More than 3,700 face tests for TB
Risk called higher for hospital staff
More than 3,700 hospital patients and workers started receiving notices yesterday that they should be tested for tuberculosis after possibly being exposed to a junior doctor who rotated through four Massachusetts hospitals while she had a contagious form of the disease for six months.
But during a press conference yesterday, infectious-disease specialists sought to reassure the public that the prospect of anyone becoming ill was remote. The threat, physicians said, was especially low for patients who only had a fleeting encounter with the surgeon-in-training. And when operating on patients, the doctor would have been clad in protective covering head to foot.
Co-workers are at slightly greater risk. They would have had more prolonged, repeated exposure to the Boston University surgical resident and to her coughs, sneezes, and even laughter, which might have sent the bacteria into the surrounding air.
The doctor treated patients at Boston Medical Center, the veterans's hospital in West Roxbury, Brockton Hospital, and Cape Cod Hospital.
Dr. John Rich, medical director of the Boston Public Health Commission, said at a press conference that disease investigators had determined that the woman was potentially contagious from Dec. 1, 2004, until June 2, when she was removed from treating patients. During that period, authorities said, she may have had contact with thousands of patients and healthcare workers, creating, they said, an unprecedented opportunity to spread TB in hospitals.
Most people who become infected with the TB bacteria do not develop symptoms, and only people with symptoms are infectious.
In a typical year in Massachusetts, the state Department of Public Health receives reports of four or five healthcare workers with active, contagious cases of TB, said Sue Etkind, director of the state's TB division.
''There have been other cases like this, but not with this level of exposure," Etkind said. ''It is a rare, rare occurrence."
A document obtained yesterday by The Boston Globe shows that the woman contracted TB between June 2003 and June 2004. According to the document, Boston Medical Center authorities became aware in summer 2004 that the woman was potentially infected, but tests determined only Monday that she had an active, infectious case of illness.
That memo was prepared by the US Department of Veterans Affairs for House and Senate committees on veterans affairs.
The memo states that once the woman's potential TB infection was identified by a skin test in 2004, Boston Medical Center referred her for a chest X-ray to a TB clinic run by the Boston Public Health Commission. The X-ray, which is one of the tests typically performed to ascertain whether a patient has an infectious case of TB, was scheduled for July 15, 2004, but, the document states, the doctor did not show up for the appointment.
The memo does not indicate whether anyone at the hospital followed up to make sure that the woman had, in fact, gone for her July medical visit. Nor does it say how she became infected.
In January 2005, the memo reports, the woman first developed symptoms and was diagnosed with pneumonia. It is unclear whether her primary-care physician was aware of her previous positive skin test for TB. If he had known that, it might have led to a quicker diagnosis of contagious tuberculosis.
But three sputum tests for the disease were negative at the time, the document says, suggesting that her case of TB was not especially infectious at that time.
Dr. Eric Rubin, an infectious-disease physician not involved in this case, said in an interview that making a diagnosis of TB is tricky, all the more so if the patient has pneumonia.
The woman was treated with a powerful antibiotic, and symptoms did not reemerge until the middle of May, when she developed a cough and other classic symptoms of TB, the document said. A chest X-ray June 2 showed the telltale signs of TB, and laboratory tests completed Monday confirmed the diagnosis.
Authorities with Boston Medical Center and the Boston Public Health Commission declined to confirm the contents of the memo, citing federal privacy laws preventing the disclosure of medical information about patients.
Dr. Keith Lewis, leader of quality initiatives at Boston Medical Center, and hospital spokeswoman Ellen Berlin said that it is standard procedure for healthcare workers who are screened annually for TB and who test positive to be sent for further evaluation by the hospital's occupational health department.
Workers who test positive on the skin test but don't have symptoms make an appointment with the TB clinic run by the Public Health Commission. Workers with a positive test result and symptoms are sent for a chest X-ray.
''If the person was seen in the hospital's occupational health department, it would be their responsibility in that department to follow up" to make certain the patient had shown up for the examination, Berlin said.
The hospital, Lewis and Berlin said, is conducting what they called an ''incident analysis" of everything that happened in the woman's case and what issues need to be addressed.
Rubin said that healthcare workers who have a positive skin test for TB should not return to their jobs without having an X-ray and a thorough exam.
''There was a systemic problem if she came back to work without a chest X-ray" after a positive skin test, said Rubin, a specialist in infectious disease at Harvard School of Public Health and Brigham and Women's Hospital.
The woman is receiving a regimen of TB medications, public health authorities said.
Rich, as well as top physicians from Boston Medical Center and the VA, emphasized that few people exposed to someone with an active case of tuberculosis become ill.
''Most people infected will not get sick, and the tuberculosis is diagnosable, treatable, and curable," he said. ''The highest risk of infection would be to co-workers of the healthcare worker who would have spent the most time with this individual. The risk to patients that the healthcare worker had contact with was lower, but it's still important to identify these people to ensure that they have not been infected."
That's why all four hospitals continued yesterday to scour records to identify patients who might have had contact with the woman and send them letters urging them to be tested for TB.
Identifying patients has proved laborious: It entails figuring out the wards where the trainee worked and the patients on those wards at that time. Boston Medical administrators said they had so far identified 890 patients; at the VA, 700 patients; Brockton, 150; and Cape Cod, 200.
Hospital administrators said they had adopted a liberal approach in identifying patients, but preferred inconveniencing patients rather than potentially overlooking people who might have been exposed.
Patients and workers will not be charged for the TB skin test, known as a PPD. The test involves using a specially designed syringe to inject a small amount of a substance called tuberculin under the skin of the forearm.
Tuberculin, which is harmless, is designed to provoke a response from the immune system that would indicate whether the patient's body has been exposed to TB. Patients return two to three days after the test is administered so a healthcare worker can examine the injection spot. If a bump the size of a pencil eraser is evident, that's a sign that the patient may have been infected with TB.
Having a TB infection does not mean a patient is contagious. About 90 percent of people with positive skin tests for TB are not infectious.
Stephen Smith can be reached at stsmith@globe.com. Alice Dembner can be reached at dembner@globe.com. 