Nosocomial tuberculosis exposures at a tertiary care hospital: A root cause analysis

Published:March 24, 2014DOI:


      Exposure of health care workers (HCWs) to patients with active TB continues to occur despite implementation of TB control policies.


      We conducted a root-cause analysis of TB exposures at a tertiary care hospital. Clinical and management details of all confirmed cases identified in 2011 were summarized. Cases were independently reviewed by an expert panel that determined the type (ie, delay in initiating, incorrect use of or premature removal of control measures), preventability, and root cause(s) of each error (exposure).


      Fifteen cases were reviewed. Ten errors were identified in 7 (47%) cases. Cases associated with errors were older than those without errors (68 y vs 40 y; P = .037). Most cases (12/15) were foreign born. A delay in initiating airborne precautions accounted for 70% (7/10) of the errors. The expert panel determined that 80% (8/10) of the errors were preventable or possibly preventable. The most common root causes were failure to consider TB and failure to obtain and interpret imaging. Advanced age, atypical presentation, and presence of comorbid illnesses were common among the preventable cases.


      TB control policies do not prevent all exposures. Our findings suggest that consideration of TB in elderly patients with risk factors, even if their signs and symptoms can be explained by an alternative diagnosis or are atypical, followed by a review of imaging studies, can further reduce this risk.

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        • Pearson M.L.
        • Jereb J.A.
        • Freiden T.R.
        • Crawford J.T.
        • Davis B.J.
        • Dooley S.W.
        • et al.
        Nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis: a risk to patients and health care workers.
        Ann Intern Med. 1992; 117: 191-196
        • Boudreau A.Y.
        • Baron S.L.
        • Steenland N.K.
        • Van Gilder T.J.
        • Decker J.A.
        • Galson S.K.
        • et al.
        Occupational risk of Mycobacterium tuberculosis infection in hospital workers.
        Am J Ind Med. 1997; 32: 528-534
        • Joshi R.
        • Reingold A.L.
        • Menzies D.
        • Pivetta E.
        • Bugiani M.
        • Scano F.
        Tuberculosis among health care workers in low- and middle-income countries: a systematic review.
        PLoS Med. 2006; 3: e494
        • Menzies D.
        • Joshi R.
        • Pai M.
        Risk of tuberculosis infection and disease associated with work in health care settings.
        Int J Tuberc Lung Dis. 2007; 11: 593-605
      1. ACOEM guidelines for protecting health care workers against tuberculosis.
        J Occup Environ Med. 1998; 40: 765-767
        • Jensen P.A.
        • Lambert L.A.
        • Iademarco M.F.
        • Ridzon R.
        Guidelines for preventing the transmission of Mycobacterium tuberculosis in healthcare settings, 2005.
        MMWR Recomm Rep. 2005; 54: 1-141
      2. Long R, Ellis E. Canadian Tuberculosis Standards. 6th Edition. Public Health Agency of Canada. 2007.

        • Baussano I.
        • Nunn P.
        • Williams B.
        • Pivetta E.
        • Bugiani M.
        • Scano F.
        Tuberculosis among health care workers.
        Emerg Infect Dis. 2011; 17: 488-494
        • Bailey T.C.
        • Fraser V.J.
        • Spitznagel E.L.
        • Dunagen W.C.
        Risk factors for a positive tuberculin skin test among employees of an urban, midwestern teaching hospital.
        Ann Intern Med. 1995; 122: 580-585
        • World Health Organization
        WHO policy on TB infection control in health-care facilities, congregate settings, and households.
        World Health Organization, Geneva, Switzerland2009
        • Centers for Disease Control and Prevention
        Tuberculosis outbreak in a community hospital: District of Columbia, 2002.
        MMWR Morb Mortal Wkly Rep. 2004; 53: 214-216
        • Jonsson J.
        • Kan B.
        • Berggren I.
        • Bruchfeld J.
        Extensive nosocomial transmission of tuberculosis in a low-incidence country.
        J Hosp Infect. 2013; 83: 321-326
        • Rao V.K.
        • Iademarco E.P.
        • Fraser V.J.
        • Kollef M.H.
        Delays in the suspicion and treatment of tuberculosis among hospitalized patients.
        Ann Intern Med. 1999; 130: 404-411
        • Menzies D.
        • Fanning A.
        • Yuan L.
        • Fitzgerald M.
        Tuberculosis among health care workers.
        N Engl J Med. 1995; 332: 92-98
        • Harris T.G.
        • Sullivan Meissner J.
        • Proops D.
        Delay in diagnosis leading to nosocomial transmission of tuberculosis at a New York City health care facility.
        Am J Infect Control. 2013; 41: 155-160