Tuberculosis Surveillance Program: A Nursing Home Experience Tuberculosis surveillance in nursing homes must be organized into a system that meets the public health needs of residents, staff, and visitors. BY
BARBARA
AYN
WRIGHT/DAVID
O.
STAATS
uberculosis is a health h a z a r d in the U n i t e d States, for some age groups more than others. Persons more than 55 years of age account for 50% of new cases. Case rates are considerably higher in aged patients who reside in nursing homes than in elderly persons who live in the community. I, 2 The Advisory Committee for Elimination of Tuberculosis recently published recommendations for tuberculosis surveillance in nursing homes and disseminated this information) The recommendations are designed to meet public health needs of persons living in the nursing home, staff, and visitors. The program provides for early identification of active cases on admission of the patient, systematic monitoring for conversion, and methodology for recording results. In addition, retrieving data for the program provides a way of epidemiologic follow-up if an active case appears and the ability to create periodic reports of the status of the nursing home population as a whole. Reports of monitoring for tuberculosis 4-6 and management of outbreaks of tuberculosis 7"9 have expanded knowledge of the nature of tuberculosis in nursing home populations. We describe our experience with tuberculosis testing in a nursing home for residents admitted to that facility.
T
Purpose This descriptive study of tuberculosis surveillance in a nursing home used data from retrospective record review and reviewed periodic infection control reports from 1982
BARBARA AYN WRIGHT, RN, CFNP, CGNP, practices at the Comprehensive Rehabilitation Center, Naples Community Hospital, Naples, Florida. DAVID O. STAATS, MD, FACP, is an associate professor of clinical medicine at the University of Illinois at Chicago. 34/1/39942
to 1990. The nature of the nursing home population response to booster Mantoux testing, the nature of active tuberculosis disease presentation, and patterns of conversion are documented. Tuberculosis surveillance in this nursing home is described as a process to meet the challenges of surveillance, adapt to findings in the field of tuberculosis research, and respond to recommendations of advisory bodies for tuberculosis control and elimination of the disease. Methods Setting and sample. The nursing home is located in the Midwest. Mean, median, and mode of resident age at entry is 85 to 86 years. All residents are Jewish. Two hundred forty beds are licensed for skilled care. All rooms are single occupancy. The building opened in 1981 to residents of two other nursing homes who relocated there. Mortality averages 70 per year, with new admissions constant to maintain an average of 100% occupancy. Therefore from 1981 until 1991, 800 persons entered this nursing home and system of care. Process. In 1981 one resident transferred from one of the two other nursing homes was completing treatment for active disease. The resident's disease was no longer contagious. In 1982 active tuberculosis developed in a registered nurse working at the nursing home. Staff and residents were tested by the two-step Mantoux method. Repeated tests 3 months later showed no conversions to positive resuits. The nurse with active disease was referred to the Illinois Department of Public Health Tuberculosis Program. In 1984 a resident was found to have active tuberculosis. Treatment was begun at the hospital, and the resident returned to the nursing home when the disease was
Geriatric Nursing September/October1992 257
5 mm
~lL~)~
15 m m
0 15 mm or more induration is considered positive for:
5 or more mm induration is considered
positive for the highest risk groups= Immu0osuppressed persons HIV infection immunosuppresive therapy - - retia;Ioendotheliat disease cancer end-stage renal oqsease Recent T6 contacts Persons with abnormal chest x-ray consistent with tuberculosis
Persons who do not have any of the risk factors mentioned
,-~ c o ~ e ~ o ~ a t ~Stit~lioas, ~. ~tSj~mes ~
~mpr~ee~ ,,,-, ~.spffaT~,
Pe~.qo~~Ct ~ r ~ i ~ ~ervlc~10 h~gh.risk gmv~ ~ c r e a ~ ~ asT~ . ~ ~a_befe~ me11~s
dtrOJ~l~~[ol~r~ti0n *#d.r~nm, beI¢~ |deaI~b.o~. w~lgt~t :by 1 0 % or
FIGURE 1. Mantoux tuberculin skln test. (Videotape instruction available through The Centers for Disease Control.)
no longer contagious. The resident subsequently died of complications of his chronic disease (uncontrolled diabetes and dementia) after 3 months of treatment. Various times and methods of testing have been used in this nursing home. In 1982 baseline tests of all residents were done. In 1985 all new residents were tested by the two-step method and those known to have negative resuits were retested. In 1986 all new residents were tested by the two-step method and a new procedure of testing by the two-step method for residents at time of admission was instituted. In addition, in 1986 persons with known negative results were retested. In 1989 annual retest of those persons with known negative results was begun and continues to the present time. Testing at admission. All persons entering the nursing home are tested on entry with purified protein derivative (PPD), 5 T U in 0.1 ml solution intradermally. Excepted from testing are persons with a history of tuberculosis or history of a previous positive reaction to testing. Residents who refuse testing are not tested. Tests are read within 48 to 72 hours (Figure I). Those persons whose
258 Geriatric Nursing September/October1992
tests yield negative results are retested after 1 week and before 2 weeks with a second test with the same dose amount and method. All positive results are measured in millimeters of induration. All persons with positive resuits are given a chest x-ray. This is repeated annually or if s y m p t o m s appear. Positive persons are not retested with the intradermal test after a first positive test result or if the result is positive on the second test. The second test is called a booster. In our facility staff surveillance is accomplished by the same initial and annual testing. Documentation. A self-adhesive label is fixed to the inside cover of the chart and remains clearly in view for that patient for tuberculin test response and other vaccination records (Figure 2). The response to the initial test, response to booster test if needed, and response to annual retests are recorded to the chart label. If conversion occurs, the course of prophylactic treatment is added to the label. Concurrently a central cardfile is created for each patient on admission. This m a y be done by simple index cards or by computer entry. The status of the individual
NAME
IN!~UENZA ~ l l
=
,
Prleumo¢o¢¢at D.~e~ T~tanus DOte~ ~ r ~ r o u x tEST .....
i
FIGURE 2. Label affixed to inside cover of patient's chart.
patient test response is recorded on the card in duplicate to the adhering label in the medical record. Annual testing. Annual retesting may be done in two ways. The tests may be given to those persons who yield negative results on a revolving basis by linking the test date to date of birth, to annual history and physical examination, or to admission date. The second method would be to test all negative persons on a given day or during the course of a week. In our experience the second method is preferable because any conversions are recorded at about the same time. This way conversion rate is more easily figured and questions of active transmission in the home may be addressed. Cardfile use. The cardfile information is kept in a central location. If an active case is suspected, the cards are divided into those with positive and those with negative results. On the basis of the totals, a plan to retest the persons with negative results may be formulated to detect conversion. Needed supplies and personnel are estimated. Tuberculin test vehicle and syringes are ordered; lists of negative persons who need to be retested are created. Persons with positive results are not retested. Persons with known positive results, if retested, may react with a large cutaneous eruption, which may be painful and severe.
Should this occur, topical steroid cream may help alleviate symptoms. A case of active tuberculosis must be reported to public health authorities. Public health officials may elect to join with facility staff to participate in testing should an active case appear. The search for other active cases (or transmission) is done by looking for conversion on retest of persons with negative results. Conversion to a positive reaction does not always mean that the person has active tuberculosis: conversion most probably means recent exposure to tuberculosis bacilli. Elderly persons who convert to positive begin prophylactic treatment because the risk of active tuberculosis eventually developing is higher after the conversion to positive. Cardfile data are separated and totaled for periodic reports to assess the status of the nursing home as a whole at any given point in time. These reports render a pattern of response to tuberculin testing that may be compared with previous results at regular intervals (e.g., annually or every 6 months). In addition, the reports may be compared with published results of known results from research for normative parameters. In this way the surveillance efforts may be periodically documented in a written report that demonstrates the monitoring effort.
Geriatric Nursing September/October 1992 259
TABLE 1. COMPARISON O F POS|T[VE I ~ T E $ TO, NEGAI[IVE RATES BY YEARS
TABLE 3. CONVERSION, RATES C4nvetsion rate
~ar --.
~ -
198.2
ii ,
"
mu
1989
2_24: 38 62
201
27 73
ii
i
,,
,
,
,,,
,
1989 TESTING
5 3.4
148 5 3.4
i
HegCltivestested Positive:rtmttions Co.version rate (%)
,
1984-,1989 TESTING
!
........................................................................
Tt~ta_t~¢_ml~lesige Posmva{ ~ Negate{%)
I'
.L_l
i
1osis bacilli may continue to be viable in granulomas in the lung or in other tissue. In certain situations (e.g., cancer, poor nutritional status) this latent infection may beAge{n = 224I I come active. This is called recrudescence l°. The booster test given has produced a positive reaction in up to 38% of these elders previously tested in their first test as negative in our setting. The efficacy of the booster test for tuberculosis in a geriatric population is proved by responses T~..stt positive 39 32 T~I 2 l~Q~41i~ I~ 11 even in those older than 85 years in our setting. Age alone To,at(e.) ~ O1) a3 (35) is not a factor in ability to recognize and react to Mantoux tests. Entry testing and negative response identifies the pool of persons who could become infected if exposed to active tuberculosis. However, persons who yield negative results Results might be positive for exposure but did not recognize the challenge of the tuberculin antigen. This occurs because The data collected in periodic reports at our facility of a phenomenon called reversion. Reversion means perhave not included an outbreak of active disease. Sur- sons who previously might have tested positive lose the veillance efforts compared with previous years, for ability to respond to tuberculin testing and test as negapositive and negative reaction, are of interest (see tive. jl These persons may or may not demonstrate the Table 1). presence of granulomas on chest x-ray films. Reversion The high rate of positive reaction in 1982 falls within may occur as a natural process over time. However, these the expected range yet has been suggested as reflecting persons may be immunocompromised because of chronic possible transmission. Continued monitoring has not disease, malnutrition, chronic infection, or other factors. proved active transmission to be the case. These persons can reactivate latent infection and active Efficacy of booster testing. In 1984 we totaled data to tuberculosis may develop, even though they have negative observe the efficacy of booster testing versus age of those results, t2 elders tested. The two-step Mantoux test has demonThe effective surveillance program monitors for active strated usefulness for the geriatric population in nursing cases of tuberculosis) 3 In the elderly, clinical manifestahome regardless of the age of those persons tested. Age tions may be nonspecific and associated with progressive alone is not a factor in ability to recognize and react to changes in functional status. I Classic symptoms of weight PPD tests. Young-old and old-old both give satisfac- loss, productive cough with hemoptysis, low-grade temt o r y r e a c t i o n s to t e s t i n g in a n u r s i n g h o m e (see perature in the evenings, and anorexia may not be seen. Table 2). Chest x-ray evidence of puimonary tuberculosis is seen Conversion. Table 3 compares our conversion rate with predominantly in the upper lobes but may be seen in the the known conversion rate found in persons living in a middle and lower lung fields of elderly patients. This findnursing home (3% to 5% annually). The capability to ing mimics other common findings of disease and may algenerate these sorts of results is possible by maintaining low progression without identification of the diagnosis. TM the program and central cardfile. Such a case was described by Stead 7 wherein transmission and infection occurred in patients, staff, and others. Discussion A high index of suspicion is needed to identify an active case of tuberculosis in an elderly person) The entry testing identifies persons with positive reacIf an active case of tuberculosis is found in nursing tions. These persons are a pool of persons who could resist home patients or staff, the index cardfile system allows new disease. Persons who test positive are also a pool of quick retrieval of names and total number of persons with persons who could reactivate their old disease. Tubercu- negative results who need retesting to assess for active
260 GeriatricNursing September/October 1992
ANNUAL RETEST OF A N N U A L RESIDENTS LIVING IN NURSING HOMES 1. Retest persons with negative result annually Z If converted to positivet i Obtain chest x-ray film to exclude active disease Treat unless specific clinical reason not to treat Isoniazid, 300 rag/day for 6-9 mo Monitor for toxicity to isoniazid i Annual chest x-ray and/or as needed Consider furtherfnve~gation for active disease (e.g., sputum AFB, bronchial wash, gastric aspiration) Mark chart clearly Total and document numbers of conversionsto figure annual conversion rOte Total and document numbers of conversions who are unable to tolerate or complete prophylactic course of isoniazid and reasons
transmission. This is useful for ordering needed supplies and providing enough staff during the testing time. Concurrent staff testing of the negative pool of staff is also done at this time. The program success depends on diligence in admission testing, booster testing, and documentation. Consistency of testing media and methods is required. Training in giving the tests, reading the results, and documenting the data is of paramount importance. Persons suspected to have active disease require efforts to obtain sputum specimens. Persons who require treatment for conversion or active disease must be monitored for compliance with the treatment regimen and side effects of the medications given (see "Annual Retest" box). Preventive treatment for persons in nursing homes is now regularly given once benefit-risk considerations are reviewed. 15 If preventive regimens must be discontinued because of intolerance to the medication, a careful record of the course of treatment and the dates given must be maintained. The numbers of conversions, persons treated, and those unable to complete treatment are included in summary reports. 3 Summary Tuberculosis surveillance efforts in the nursing home for elderly persons need organization into an effective program. The ability to tally results of testing gives reliable parameters for comparison and may alert practitioners to early active disease presentation and transmission within the setting. Such efforts based on current research and recommendations ensure provision of prudent and useful standards of elderly care. Our experience during a 10-year period shows that tuberculosis may be an active problem for nursing home populations.,,
2. Stead WW. Special problems in tuberculosis: tuberculosis in the elderly and in residents of nursing homes, correctional facilities, long-term care hospitals, mental hospitals, shelters for the homeless, and jails. Clin Chest Med 1989;10(3):397-405. 3. Centers for Disease Control. Advisory Committee for Elimination of Tuberculosis. Prevention and control of tuberculosis in facilities providing long-term care to the elderly: recommendation of the MMWR. MMWR 1990;39:7-13. 4. Pattee JJ. Two-step Mantoux testing in a Minnesota nursing home. Minn Med 1987;70:647-8. 5. Aronow WS, Bloom HG. Tuberculosis screening in 1161 elderly patients [Letter]. Chest 1989;96:961-2. 6. Creditor MC. Screening for tuberculosis. Kan Med 1990;91:136-7. 7. Stead WW. Tuberculosis among elderly persons: an outbreak in a nursing home. Ann Intern Med 1981;95:606-10. 8. Creditor MC, Smith EC, Gallai JB, Baumann M, Nelson KE. Tuberculosis, tuberculin reactivity, and delayed cutaneous hypersensitivity in nursing home residents. J Gerontol 1988;43(4):M97-100. 9. Morris CDW, Nell tt. Epidemic of pulmonary tuberculosis in geriatric homes. South Afr Med J 1988;74:117-20. 10. Stead WW. Pathogenesis of a first episode of chronic pulmonary tuberculosis in man: recrudescence of residuals of the primary infection or exogenous reinfection? Am Rev Respir Dis 1967;95(5):729-45. 11. Grzybowski S, Allen EA. The challenge of tuberculosis in decline: a study based on the epidemiology of tuberculosis in Ontario, Canada. Am Rev Respir Dis 1964;90:707-20. 12. Perez-Stable E J, Flaherty D, Schecter G, Slutkin G, Hopewell PC. Conversion and reversion of tuberculin reactions in nursing home residents. Am Rev Respir Dis 1988;137:801-4. 13. Bradley AC. Pulmonary tuberculosis in geriatric homes [Letter]. South Afr Med J 1989;75:197. 14. Pitlik SD, Fainstein V, Bodey GP. Tuberculosis mimicking cancer: a reminder. Am J Ued 1984;76(5):822-5. 15. Stead WW, To T, Harrison RW, Abraham JH Ill. Benefit-risk considerations in preventive treatment for tuberculosis in elderly persons. Ann Intern Med 1987;107(6):843-5.
MOVING? GIVE US YOUR NEW ADDRESS SIX WEEKS AHEAD To ensure prompt service when you change your address or whenever you write us about your GERIATRIC NURSING subscription, please include your address label from a recent issue of GERIATRICNURSING.Address your correspondence to GERIATRIC N U R S I N G , Subscription Services, Mosby-Year Book, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318. Affix address label here when sending address change. Clearly print NEW address. The expiration date of your subscription is toward the right end of the upper portion of the label. Name
REFERENCES !. Yoshikawa TT. Tuberculosis: the intensive course in geriatric medicine and board review. Presented by American College of Physicians, UCLA Academic Geriatric Resource Center, UCLA Multi-Campus Division of Geriatric Medicine and Gerontology and American Geriatrics Society, Jan 15-20, 1990, Beverly }fills, CaliL: 265-70.
Address City State
ZIP
G e r i a t r i c N u r s i n g September/October 1992
261
BARBARA
AYN
WRIGHT/DAVID
O.
STAATS
uberculosis is a health h a z a r d in the U n i t e d States, for some age groups more than others. Persons more than 55 years of age account for 50% of new cases. Case rates are considerably higher in aged patients who reside in nursing homes than in elderly persons who live in the community. I, 2 The Advisory Committee for Elimination of Tuberculosis recently published recommendations for tuberculosis surveillance in nursing homes and disseminated this information) The recommendations are designed to meet public health needs of persons living in the nursing home, staff, and visitors. The program provides for early identification of active cases on admission of the patient, systematic monitoring for conversion, and methodology for recording results. In addition, retrieving data for the program provides a way of epidemiologic follow-up if an active case appears and the ability to create periodic reports of the status of the nursing home population as a whole. Reports of monitoring for tuberculosis 4-6 and management of outbreaks of tuberculosis 7"9 have expanded knowledge of the nature of tuberculosis in nursing home populations. We describe our experience with tuberculosis testing in a nursing home for residents admitted to that facility.
T
Purpose This descriptive study of tuberculosis surveillance in a nursing home used data from retrospective record review and reviewed periodic infection control reports from 1982
BARBARA AYN WRIGHT, RN, CFNP, CGNP, practices at the Comprehensive Rehabilitation Center, Naples Community Hospital, Naples, Florida. DAVID O. STAATS, MD, FACP, is an associate professor of clinical medicine at the University of Illinois at Chicago. 34/1/39942
to 1990. The nature of the nursing home population response to booster Mantoux testing, the nature of active tuberculosis disease presentation, and patterns of conversion are documented. Tuberculosis surveillance in this nursing home is described as a process to meet the challenges of surveillance, adapt to findings in the field of tuberculosis research, and respond to recommendations of advisory bodies for tuberculosis control and elimination of the disease. Methods Setting and sample. The nursing home is located in the Midwest. Mean, median, and mode of resident age at entry is 85 to 86 years. All residents are Jewish. Two hundred forty beds are licensed for skilled care. All rooms are single occupancy. The building opened in 1981 to residents of two other nursing homes who relocated there. Mortality averages 70 per year, with new admissions constant to maintain an average of 100% occupancy. Therefore from 1981 until 1991, 800 persons entered this nursing home and system of care. Process. In 1981 one resident transferred from one of the two other nursing homes was completing treatment for active disease. The resident's disease was no longer contagious. In 1982 active tuberculosis developed in a registered nurse working at the nursing home. Staff and residents were tested by the two-step Mantoux method. Repeated tests 3 months later showed no conversions to positive resuits. The nurse with active disease was referred to the Illinois Department of Public Health Tuberculosis Program. In 1984 a resident was found to have active tuberculosis. Treatment was begun at the hospital, and the resident returned to the nursing home when the disease was
Geriatric Nursing September/October1992 257
5 mm
~lL~)~
15 m m
0 15 mm or more induration is considered positive for:
5 or more mm induration is considered
positive for the highest risk groups= Immu0osuppressed persons HIV infection immunosuppresive therapy - - retia;Ioendotheliat disease cancer end-stage renal oqsease Recent T6 contacts Persons with abnormal chest x-ray consistent with tuberculosis
Persons who do not have any of the risk factors mentioned
,-~ c o ~ e ~ o ~ a t ~Stit~lioas, ~. ~tSj~mes ~
~mpr~ee~ ,,,-, ~.spffaT~,
Pe~.qo~~Ct ~ r ~ i ~ ~ervlc~10 h~gh.risk gmv~ ~ c r e a ~ ~ asT~ . ~ ~a_befe~ me11~s
dtrOJ~l~~[ol~r~ti0n *#d.r~nm, beI¢~ |deaI~b.o~. w~lgt~t :by 1 0 % or
FIGURE 1. Mantoux tuberculin skln test. (Videotape instruction available through The Centers for Disease Control.)
no longer contagious. The resident subsequently died of complications of his chronic disease (uncontrolled diabetes and dementia) after 3 months of treatment. Various times and methods of testing have been used in this nursing home. In 1982 baseline tests of all residents were done. In 1985 all new residents were tested by the two-step method and those known to have negative resuits were retested. In 1986 all new residents were tested by the two-step method and a new procedure of testing by the two-step method for residents at time of admission was instituted. In addition, in 1986 persons with known negative results were retested. In 1989 annual retest of those persons with known negative results was begun and continues to the present time. Testing at admission. All persons entering the nursing home are tested on entry with purified protein derivative (PPD), 5 T U in 0.1 ml solution intradermally. Excepted from testing are persons with a history of tuberculosis or history of a previous positive reaction to testing. Residents who refuse testing are not tested. Tests are read within 48 to 72 hours (Figure I). Those persons whose
258 Geriatric Nursing September/October1992
tests yield negative results are retested after 1 week and before 2 weeks with a second test with the same dose amount and method. All positive results are measured in millimeters of induration. All persons with positive resuits are given a chest x-ray. This is repeated annually or if s y m p t o m s appear. Positive persons are not retested with the intradermal test after a first positive test result or if the result is positive on the second test. The second test is called a booster. In our facility staff surveillance is accomplished by the same initial and annual testing. Documentation. A self-adhesive label is fixed to the inside cover of the chart and remains clearly in view for that patient for tuberculin test response and other vaccination records (Figure 2). The response to the initial test, response to booster test if needed, and response to annual retests are recorded to the chart label. If conversion occurs, the course of prophylactic treatment is added to the label. Concurrently a central cardfile is created for each patient on admission. This m a y be done by simple index cards or by computer entry. The status of the individual
NAME
IN!~UENZA ~ l l
=
,
Prleumo¢o¢¢at D.~e~ T~tanus DOte~ ~ r ~ r o u x tEST .....
i
FIGURE 2. Label affixed to inside cover of patient's chart.
patient test response is recorded on the card in duplicate to the adhering label in the medical record. Annual testing. Annual retesting may be done in two ways. The tests may be given to those persons who yield negative results on a revolving basis by linking the test date to date of birth, to annual history and physical examination, or to admission date. The second method would be to test all negative persons on a given day or during the course of a week. In our experience the second method is preferable because any conversions are recorded at about the same time. This way conversion rate is more easily figured and questions of active transmission in the home may be addressed. Cardfile use. The cardfile information is kept in a central location. If an active case is suspected, the cards are divided into those with positive and those with negative results. On the basis of the totals, a plan to retest the persons with negative results may be formulated to detect conversion. Needed supplies and personnel are estimated. Tuberculin test vehicle and syringes are ordered; lists of negative persons who need to be retested are created. Persons with positive results are not retested. Persons with known positive results, if retested, may react with a large cutaneous eruption, which may be painful and severe.
Should this occur, topical steroid cream may help alleviate symptoms. A case of active tuberculosis must be reported to public health authorities. Public health officials may elect to join with facility staff to participate in testing should an active case appear. The search for other active cases (or transmission) is done by looking for conversion on retest of persons with negative results. Conversion to a positive reaction does not always mean that the person has active tuberculosis: conversion most probably means recent exposure to tuberculosis bacilli. Elderly persons who convert to positive begin prophylactic treatment because the risk of active tuberculosis eventually developing is higher after the conversion to positive. Cardfile data are separated and totaled for periodic reports to assess the status of the nursing home as a whole at any given point in time. These reports render a pattern of response to tuberculin testing that may be compared with previous results at regular intervals (e.g., annually or every 6 months). In addition, the reports may be compared with published results of known results from research for normative parameters. In this way the surveillance efforts may be periodically documented in a written report that demonstrates the monitoring effort.
Geriatric Nursing September/October 1992 259
TABLE 1. COMPARISON O F POS|T[VE I ~ T E $ TO, NEGAI[IVE RATES BY YEARS
TABLE 3. CONVERSION, RATES C4nvetsion rate
~ar --.
~ -
198.2
ii ,
"
mu
1989
2_24: 38 62
201
27 73
ii
i
,,
,
,
,,,
,
1989 TESTING
5 3.4
148 5 3.4
i
HegCltivestested Positive:rtmttions Co.version rate (%)
,
1984-,1989 TESTING
!
........................................................................
Tt~ta_t~¢_ml~lesige Posmva{ ~ Negate{%)
I'
.L_l
i
1osis bacilli may continue to be viable in granulomas in the lung or in other tissue. In certain situations (e.g., cancer, poor nutritional status) this latent infection may beAge{n = 224I I come active. This is called recrudescence l°. The booster test given has produced a positive reaction in up to 38% of these elders previously tested in their first test as negative in our setting. The efficacy of the booster test for tuberculosis in a geriatric population is proved by responses T~..stt positive 39 32 T~I 2 l~Q~41i~ I~ 11 even in those older than 85 years in our setting. Age alone To,at(e.) ~ O1) a3 (35) is not a factor in ability to recognize and react to Mantoux tests. Entry testing and negative response identifies the pool of persons who could become infected if exposed to active tuberculosis. However, persons who yield negative results Results might be positive for exposure but did not recognize the challenge of the tuberculin antigen. This occurs because The data collected in periodic reports at our facility of a phenomenon called reversion. Reversion means perhave not included an outbreak of active disease. Sur- sons who previously might have tested positive lose the veillance efforts compared with previous years, for ability to respond to tuberculin testing and test as negapositive and negative reaction, are of interest (see tive. jl These persons may or may not demonstrate the Table 1). presence of granulomas on chest x-ray films. Reversion The high rate of positive reaction in 1982 falls within may occur as a natural process over time. However, these the expected range yet has been suggested as reflecting persons may be immunocompromised because of chronic possible transmission. Continued monitoring has not disease, malnutrition, chronic infection, or other factors. proved active transmission to be the case. These persons can reactivate latent infection and active Efficacy of booster testing. In 1984 we totaled data to tuberculosis may develop, even though they have negative observe the efficacy of booster testing versus age of those results, t2 elders tested. The two-step Mantoux test has demonThe effective surveillance program monitors for active strated usefulness for the geriatric population in nursing cases of tuberculosis) 3 In the elderly, clinical manifestahome regardless of the age of those persons tested. Age tions may be nonspecific and associated with progressive alone is not a factor in ability to recognize and react to changes in functional status. I Classic symptoms of weight PPD tests. Young-old and old-old both give satisfac- loss, productive cough with hemoptysis, low-grade temt o r y r e a c t i o n s to t e s t i n g in a n u r s i n g h o m e (see perature in the evenings, and anorexia may not be seen. Table 2). Chest x-ray evidence of puimonary tuberculosis is seen Conversion. Table 3 compares our conversion rate with predominantly in the upper lobes but may be seen in the the known conversion rate found in persons living in a middle and lower lung fields of elderly patients. This findnursing home (3% to 5% annually). The capability to ing mimics other common findings of disease and may algenerate these sorts of results is possible by maintaining low progression without identification of the diagnosis. TM the program and central cardfile. Such a case was described by Stead 7 wherein transmission and infection occurred in patients, staff, and others. Discussion A high index of suspicion is needed to identify an active case of tuberculosis in an elderly person) The entry testing identifies persons with positive reacIf an active case of tuberculosis is found in nursing tions. These persons are a pool of persons who could resist home patients or staff, the index cardfile system allows new disease. Persons who test positive are also a pool of quick retrieval of names and total number of persons with persons who could reactivate their old disease. Tubercu- negative results who need retesting to assess for active
260 GeriatricNursing September/October 1992
ANNUAL RETEST OF A N N U A L RESIDENTS LIVING IN NURSING HOMES 1. Retest persons with negative result annually Z If converted to positivet i Obtain chest x-ray film to exclude active disease Treat unless specific clinical reason not to treat Isoniazid, 300 rag/day for 6-9 mo Monitor for toxicity to isoniazid i Annual chest x-ray and/or as needed Consider furtherfnve~gation for active disease (e.g., sputum AFB, bronchial wash, gastric aspiration) Mark chart clearly Total and document numbers of conversionsto figure annual conversion rOte Total and document numbers of conversions who are unable to tolerate or complete prophylactic course of isoniazid and reasons
transmission. This is useful for ordering needed supplies and providing enough staff during the testing time. Concurrent staff testing of the negative pool of staff is also done at this time. The program success depends on diligence in admission testing, booster testing, and documentation. Consistency of testing media and methods is required. Training in giving the tests, reading the results, and documenting the data is of paramount importance. Persons suspected to have active disease require efforts to obtain sputum specimens. Persons who require treatment for conversion or active disease must be monitored for compliance with the treatment regimen and side effects of the medications given (see "Annual Retest" box). Preventive treatment for persons in nursing homes is now regularly given once benefit-risk considerations are reviewed. 15 If preventive regimens must be discontinued because of intolerance to the medication, a careful record of the course of treatment and the dates given must be maintained. The numbers of conversions, persons treated, and those unable to complete treatment are included in summary reports. 3 Summary Tuberculosis surveillance efforts in the nursing home for elderly persons need organization into an effective program. The ability to tally results of testing gives reliable parameters for comparison and may alert practitioners to early active disease presentation and transmission within the setting. Such efforts based on current research and recommendations ensure provision of prudent and useful standards of elderly care. Our experience during a 10-year period shows that tuberculosis may be an active problem for nursing home populations.,,
2. Stead WW. Special problems in tuberculosis: tuberculosis in the elderly and in residents of nursing homes, correctional facilities, long-term care hospitals, mental hospitals, shelters for the homeless, and jails. Clin Chest Med 1989;10(3):397-405. 3. Centers for Disease Control. Advisory Committee for Elimination of Tuberculosis. Prevention and control of tuberculosis in facilities providing long-term care to the elderly: recommendation of the MMWR. MMWR 1990;39:7-13. 4. Pattee JJ. Two-step Mantoux testing in a Minnesota nursing home. Minn Med 1987;70:647-8. 5. Aronow WS, Bloom HG. Tuberculosis screening in 1161 elderly patients [Letter]. Chest 1989;96:961-2. 6. Creditor MC. Screening for tuberculosis. Kan Med 1990;91:136-7. 7. Stead WW. Tuberculosis among elderly persons: an outbreak in a nursing home. Ann Intern Med 1981;95:606-10. 8. Creditor MC, Smith EC, Gallai JB, Baumann M, Nelson KE. Tuberculosis, tuberculin reactivity, and delayed cutaneous hypersensitivity in nursing home residents. J Gerontol 1988;43(4):M97-100. 9. Morris CDW, Nell tt. Epidemic of pulmonary tuberculosis in geriatric homes. South Afr Med J 1988;74:117-20. 10. Stead WW. Pathogenesis of a first episode of chronic pulmonary tuberculosis in man: recrudescence of residuals of the primary infection or exogenous reinfection? Am Rev Respir Dis 1967;95(5):729-45. 11. Grzybowski S, Allen EA. The challenge of tuberculosis in decline: a study based on the epidemiology of tuberculosis in Ontario, Canada. Am Rev Respir Dis 1964;90:707-20. 12. Perez-Stable E J, Flaherty D, Schecter G, Slutkin G, Hopewell PC. Conversion and reversion of tuberculin reactions in nursing home residents. Am Rev Respir Dis 1988;137:801-4. 13. Bradley AC. Pulmonary tuberculosis in geriatric homes [Letter]. South Afr Med J 1989;75:197. 14. Pitlik SD, Fainstein V, Bodey GP. Tuberculosis mimicking cancer: a reminder. Am J Ued 1984;76(5):822-5. 15. Stead WW, To T, Harrison RW, Abraham JH Ill. Benefit-risk considerations in preventive treatment for tuberculosis in elderly persons. Ann Intern Med 1987;107(6):843-5.
MOVING? GIVE US YOUR NEW ADDRESS SIX WEEKS AHEAD To ensure prompt service when you change your address or whenever you write us about your GERIATRIC NURSING subscription, please include your address label from a recent issue of GERIATRICNURSING.Address your correspondence to GERIATRIC N U R S I N G , Subscription Services, Mosby-Year Book, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318. Affix address label here when sending address change. Clearly print NEW address. The expiration date of your subscription is toward the right end of the upper portion of the label. Name
REFERENCES !. Yoshikawa TT. Tuberculosis: the intensive course in geriatric medicine and board review. Presented by American College of Physicians, UCLA Academic Geriatric Resource Center, UCLA Multi-Campus Division of Geriatric Medicine and Gerontology and American Geriatrics Society, Jan 15-20, 1990, Beverly }fills, CaliL: 265-70.
Address City State
ZIP
G e r i a t r i c N u r s i n g September/October 1992
261
