key: cord-353988-xoxmugi8
authors: Saleiro, Sandra; Santos, Ana Rosa; Vidal, Otília; Carvalho, Teresa; Costa, José Torres; Marques, José Agostinho
title: Tuberculose em profissionais de saúde de um serviço hospitalar
date: 2007-12-31
journal: Revista Portuguesa de Pneumologia
DOI: 10.1016/s0873-2159(15)30376-7
sha: 
doc_id: 353988
cord_uid: xoxmugi8

Abstract Introduction: Tuberculosis (TB) is considered an occupational disease in health care workers (HCW) and its transmission in health care facilities is an important concern. Some hospital departments are at higher risk of infection. Objective: To describe TB cases detected after TB screening in HCW from a hospital department (Ear, Nose and Throat – ENT) who had had contact with active TB cases. Material and methods: All HCW (73) from Hospital São João’s ENT Unit who had been in contact with two in-patients with active TB underwent TB screening. Those who had symptoms underwent chest X-ray and mycobacteriological sputum exam. Results: Of 73 HCW who underwent TB screening, TB diagnosis was established in 9 (8 female; median age: 30 years; 1 doctor, 6 nurses, 2 nursing auxiliaries). Pulmonary TB was found in 8 and extra-pulmonary TB in 1. Microbiology diagnosis was obtained in 7 cases by sputum smear, n=2; culture exam in bronchial lavage, n=4 and histological exam of pleural tissue, n=1. In 4 cases, Mycobacterium tuberculosis genomic DNA was extracted from cultures and molecular typing was done. All cases had identical MIRU types, which allowed identification of the epidemiological link. Conclusion: Nosocomial TB is prominent and efforts should be made to implement successful infection control measures in health care facilities and an effective TB screening program in HCW. Molecular typing of Mycobacterium tuberculosis facilitates cluster identification. Rev Port Pneumol 2007; XIII (6): 789-799

Introdução: A tuberculose é considerada uma doença ocupacional nos profissionais de saúde e a sua transmissão, nas instituições de saúde, constitui um problema importante. Alguns serviços hospitalares estão particularmente expostos a risco de infecção. Objectivo: Caracterizar os casos de tuberculose detectados na sequência de um rastreio efectuado aos profissionais de saúde de um serviço hospitalar (otorrinolaringologia) que contactaram com casos de tuberculose activa. Material e métodos: Procedeu-se à realização de rastreio de tuberculose a todos os funcionários (73) do serviço de Otorrinolaringologia do Hospital de São João que contactaram com dois doentes internados com tuberculose activa.

Introduction: Tuberculosis (TB) is considered an occupational disease in health care workers (HCW) and its transmission in health care facilities is an important concern. Some hospital departments are at higher risk of infection. Objective: To describe TB cases detected after TB screening in HCW from a hospital department (Ear, Nose and Throat -ENT) who had had contact with active TB cases. Material and methods: All HCW (73) from Hospital São João's ENT Unit who had been in contact with two in-patients with active TB underwent TB screening. Those who had symptoms underwent chest X-ray and mycobacteriological sputum exam.

A todos aqueles que referiram sintomas foi realizada radiografia torácica e exame micobacteriológico de expectoração. Resultados: Dos 73 profissionais de saúde submetidos ao rastreio, foi estabelecido o diagnóstico de tuberculose em 9 (8 do sexo feminino; idade mediana: 30 anos; uma médica, seis enfermeiros e dois auxiliares de acção médica). Em 8 profissionais de saúde foi diagnosticada tuberculose pulmonar, tratando-se o outro caso de tuberculose extra-pulmonar. O diagnóstico microbiológico foi obtido em 7 casos pelos seguintes métodos: exame micobacteriológico directo de expectoração, n=2; exame cultural de lavado brônquico, n=4; exame histológico de tecido pleural, n=1. Em 4 casos, o DNA do Mycobacterium tuberculosis foi extraído das culturas, tendo sido efectuada tipagem molecular. Todos estes casos apresentaram tipagem idêntica, o que permite a identificação de uma ligação epidemiológica. Conclusão: A tuberculose nosocomial é relevante, sendo necessário efectuar um esforço para implementar, com sucesso, medidas de controlo de infecção nas instituições de saúde, assim como um programa eficaz de rastreio de tuberculose entre os profissionais de saúde. A tipagem molecular do Mycobacterium tuberculosis facilita a identificação de clusters de infecção.

Palavras-chave: Tuberculose, profissionais de saúde, nosocomial.

Results: Of 73 HCW who underwent TB screening, TB diagnosis was established in 9 (8 female; median age: 30 years; 1 doctor, 6 nurses, 2 nursing auxiliaries). Pulmonary TB was found in 8 and extra--pulmonary TB in 1. Microbiology diagnosis was obtained in 7 cases by sputum smear, n=2; culture exam in bronchial lavage, n=4 and histological exam of pleural tissue, n=1. In 4 cases, Mycobacterium tuberculosis genomic DNA was extracted from cultures and molecular typing was done. All cases had identical MIRU types, which allowed identification of the epidemiological link. Conclusion: Nosocomial TB is prominent and efforts should be made to implement successful infection control measures in health care facilities and an effective TB screening program in HCW. Molecular typing of Mycobacterium tuberculosis facilitates cluster identification.

While the last thirty years have seen a decline in the rate of tuberculosis in Portugal, there is still a high incidence (33.7 new cases/100000 inhabitants in 2004) 1 Esta prova foi executada através da injecção in-concern. It is also a matter for concern for HCW exposed to the risk of contagion through their jobs, such as via exposure to aerosols or poorly ventilated spaces. Nosocomially transmitted tuberculosis is a very real problem 2,3,4,5 and one which demands a consideration of the infection control mechanisms adopted as part of HCW daily working practices 6 

Seventy three ENT HCW were screened for TB. Of these, 24 (32.8%) were referred for a Pulmonology appointment for suspected TB, as they were positive in the tuberculin test (all) with one patient in addition having a dry cough. The HCW with suspected TB were evaluated via chest X-ray, mycobacteriological sputum smear, bronchofibroscopy with bronchial lavage, diagnostic thoracocentesis and pleural biopsy. All 24 HCW underwent chest X-ray, which showed abnormalities in 10 cases. Six had expectoration and underwent mycobacteriological smear sputum exam and culture, which was positive in 2. Seven underwent bronchofibroscopy with bronchial lavage. In 2 cases, this was performed as the mycobacteriological sputum smear was negative and in the other 5 as they did not (Fig.1 ). Sete dos 9 doentes apresentavam sintomas sugestivos de tuberculose present expectoration. Diagnosis was made in 4 cases. One patient, with chest X-ray showing left pleural effusion, underwent diagnostic thoracocentesis and pleural biopsy. The latter method was conclusive in diagnosing TB. The evaluation and study allowed the diagnosis of 9 cases of TB (12.3%) and 3 cases of latent tuberculosis (4.1%). Eight of the 9 new TB cases were female and 1 male. Mean age of the patients was 30 years old (23-61 years). Six were nurses, 2 nursing auxiliaries and I a doctor (Fig.1) . Seven of the 9 patients presented symptoms suggesting TB (Fig. 2 ). X-rays showed pulmonary infiltrates (Fig. 2) . A apresentação radiológica dos casos distribuiu-se da seguinte forma: infiltrado pulmonar em 6 doentes; nódulo pulmonar em 2 casos e derrame pleural em 1 doente (Fig. 3) . O diagnóstico de tuberculose foi confirmado microbiologicamente através da identificação de Mycobacterium tuberculosis em 6 casos; num caso houve confirmação histológica, pela presença de granulomas epitelióides com necrose caseosa em retalhos de pleura parietal; em 2 casos foi assumido o diagnóstico de presunção (Fig. 4) . Um dos 9 casos de tuberculose apresentava derrame pleural esquerdo, que foi estudado, tendo para esse efeito sido realizada toracocentese diagnóstica (ADA: 119 U/L; exame directo e cul-in 6 patients, pulmonary nodules in 2 and pleural effusion in 1 (Fig. 3) . TB diagnosis was confirmed microbiologically via identification of Mycobacterium tuberculosis in 6 cases. Histological diagnosis was used to confirm one case, identifying epithelioid granulomas with caseous necrosis in sections of parietal pleura. Two cases had a presumed diagnosis only (Fig. 4) . One of the 9 TB cases presented left pleural effusion. Diagnostic thoracocentesis ADA: 119 U/L was performed to study this. Smear and culture exam of the pleural liquid was negative. Mycobacterium tuberculosis study of the pleural liquid using the polymerase chain reaction molecular biology technique was negative. Pleural biopsy was performed as histological exam of the pleura fragments (Table I) .

A presumed diagnosis was made in 2 cases as the mycobacteriological exams (smear, culture and polymerase chain reaction) of the bronchial lavage were negative. One patient had respiratory (chest pain) and bodily (fever) symptoms, a pos- Assim, verificou-se que em 2 casos os exames micobacteriológicos (directo, cultural e polymerase chain reaction) do lavado brônquico foram negativos, tendo sido assumido um diagnóstico de presunção. Um dos doentes apresentava sintomas respiratórios (toracalgia) e constitucionais (febre), prova de tuberculina positiva e alteração radiológica (nódulo pulmonar no lobo superior direito), pelo que efectuou tratamento com anti--bacilares de primeira linha durante seis meses, tendo ficado assintomático. Por outro lado, a tomografia computadorizada torácica de controlo, realizada 8 meses depois do início do trata-itive reactive to the tuberculin test and X--ray abnormalities (pulmonary nodule of the right upper lobe) and so was prescribed first line anti-bacillary treatment for six months, after which symptoms disappeared. In addition, a control chest CT scan made 8 months after start of treatment showed the nodular lesion on the right upper lobe had decreased in size. While the other patient had no symptoms, there was a positive reactive to the tuberculin test and X-ray abnormalities (pulmonary infiltrates in both upper lobes). Anti--bacillary treatment was prescribed for six months, after which a control chest CT scan showed resolution of the abovementioned pulmonary infiltrates, with patient remaining asymptomatic. Mycobacterium tuberculosis genomic DNA was extracted from cultures in 4 of the 9 patients. In 3 cases the culture was of bronchial lavage and in one case sputum. Molecular typing was then carried out, using Three cases of latent TB were also identified, one in a 54 year old nurse, one in a 50 year old nurse and one in a 32 year old nursing auxiliary. These were diagnosed due to positive reaction to the tuberculin test as patients did not present any symptoms of TB and chest X-rays did not show any abnormalities suggesting the disease. These 3 health care workers were prescribed chemo-prophylaxis with isoniazid, rifampicin and pyrazinamide for 2 months.

Seventy three HCW from the HSJ ENT department were studied. They had been in probable contact with 2 ENT in-patients with active pulmonary TB who had undergone tracheotomy and were infectious. Evaluation revealed TB disease in 9 and TB infection in 3, corresponding to a TB rate of 12328.8 per 100000 persons. This high rate of TB in HCW as compared to the population at large is a matter of concern, and has been documented in other studies 4, 5, 7, 8, 9, 10, 11 . Our results underline the importance of and the need to abide by hospital-wide infection control measures 12 . We stress the higher rate usually seen in nurses, perhaps due to their closer and more prolonged contact with the 4, 5, 7, 8, 9, 10, 11 . Os resultados apresentados neste trabalho alertam para a importância e a necessidade do cumprimento de medidas de controlo de infecção a nível hospitalar 12 . De referir que o grupo profissional de enfermagem, talvez porque tenha um contacto mais próximo e prolongado com o doente infectante durante a realização de actividades, com exposição a aerossóis, apresenta, habitualmente, valores de incidência de tuberculose mais elevados 3,7,8 . As técnicas de tipagem molecular, nomeadamente a de mycobacterial interspersed repetitive unit (MIRU) ou a de restriction fragment length polymorphism (RFLP), facilitam a identificação de clusters de infecção 13, 14, 15, 16, 17 . O rastreio da tuberculose é essencial para a detecção da doença e seu tratamento precoce 18 .

infectious patients during activities with exposure to aerosols 3, 7, 8 . Molecular typing techniques, particularly Mycobacterial Interspersed Repetitive Unit (MIRU) or Restriction Fragment Length Polymorphism (RFLP), make it easier to identify infection clusters 13, 14, 15, 16, 17 . Screening for TB is vital in the early detection and treatment of this disease 18 . 

Ponto da situação epidemiológica e indicadores de desempenho

Divisão de Doenças Transmissíveis

Tuberculosis in health care personnel in a general hospital

Risk of tuberculosis among healthcare workers: can tuberculosis be considered as an occupational disease

Increased risk of tuberculosis among health care workers in Samara Oblast, Russia: analysis of notification data

Occupational risk of tuberculosis among health care workers at the Institute for Pulmonary Diseases of Serbia

Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities

Tuberculosis among health care workers in a short working period

Tuberculosis among health care workers at King Chulalongkorn Memorial Hospital

Tuberculosis in health care workers in a central hospital in Malawi

Risk of Mycobacterium tuberculosis infection and disease among health care workers

Increased risk of tuberculosis in health care workers: a retrospective survey at a teaching hospital in Istanbul, Turkey

Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings

Mycobacterial Interspersed Repetitive Unit Typing of Mycobacterium tuberculosis Compared to IS6110-Based Restriction Fragment Length Polymorphism Analysis for Investigation of Apparently Clustered Cases of Tuberculosis

Van Soolingen D. Molecular typing of Mycobacterium tuberculosis by Mycobacterial Interspersed Repetitive Unit-Variable-Number Tandem Repeat Analysis, a More Accurate Method for Identifying Epidemiological Links between Patients with Tuberculosis

Sensitivities and Specificities of Spoligotyping and Mycobacterial Interspersed Repetitive Unit-Variable-Number Tandem Repeat Typing Methods for Studying Molecular Epidemiology of Tuberculosis

Molecular Epidemiology of Tuberculosis

Outbreak of multiple drug--resistant tuberculosis in Lisbon: detection by restriction fragment length polymorphism analysis

Nosocomial transmission of Mycobacterium tuberculosis found through screening for severe acute respiratory syndrome -Taipei