De la Torre Romero, P.(*); Garay Pelegrín, V.; Sarasqueta Eizaguirre, C.; Lobo Beristain, JL.; Dorronsoro Quintana, S.; Bermejo Navas, MC.
Tuberculosis, Prevention and control, Transmission and health care workers.
Tuberculosis is a contagious disease and the danger of transmission in hospitals relates to the prevalence of this disease in the community in question and to the prevention and control means in place in each individual centre.
Determine the scope of nosocomial tuberculosis at this moment in time, the most effective means to avoid this disease and the situation in the Autonomous Community of the Basque Country.
Review of literature in the form of bibliographical searches in Medline from 1966 2000, Health Star (1975-1999), Cochrane Library and Best Evidence (1991-1999), websites referring to U.S. general practice guidelines (National Guidelines Clearinghouse, ATS, CDC, OSHA, NIOSH), Canadian guidelines and INAHTA. Expert opinion is included (CDC-94 regulations, Canadian and British guidelines)
Survey among hospitals in the Basque Autonomous Community.
No economic analyses were made although an assessment was made of the cost effectiveness of some prevention means.
From a review of the literature on this subject, it can be deduced that nosocomial tuberculosis is a fact but that in countries such as Great Britain, with a tuberculosis rate of under 10 in every 100,000 inhabitants, this is not considered to be problem.
The period reviewed does not contain any description of an outbreak of tuberculosis, nor any significant increase in tuberculin conversion in hospitals compliant with the CDC-94 regulation or even those for 1990.
The measures contained in any prevention programme are structured hierarchically in accordance with their effectiveness. In first place, there are administrative measures such as operational protocols and isolation criteria, which are also the cheapest. Other administrative measures such as tuberculin controls and the treatment of the latent tuberculous infection of health care personnel, are less important. Structural and technical controls, would come in second place. These refer basically to negative pressure isolation rooms which must be kept in accordance with the appropriate technical conditions as otherwise, they might even contribute to spreading the tuberculous bacillus.
Individual protection systems are considered to be the most cost-effective although their real contribution to the prevention of nosocomial tuberculosis is unknown. The bibliography reviewed includes, fundamentally, higher-cost equipment than those currently accepted as correct (N-95 or P1-P2 of European Regulations).
At the time the survey was made, in the Basque Autonomous Community there was a very acceptable tuberculosis suspicion level and there were written protocols in most hospitals, but there were only isolation rooms in 4 of the 14 hospitals in the public health system, and most of these were insufficient in number and incorrectly used.
Compliance with CDC-94 regulations ensures the prevention of nosocomial tuberculosis. Administrative measures are the most important within the efficiency hierarchy. A correct maintenance of isolation rooms is essential. N-95 respirators are cost-effective at least in places with a moderate or high prevalence of tuberculosis. In workers, tuberculin is essential from the point of view of monitoring risk levels, but the poor behaviour of the retest and subsequent treatment of the latent tuberculous infection, reduce the efficiency of this measure. The role of the BCG among health workers may be worth considering.
The test validation conditions of the European Regulations are different to those for the N-95 units stipulated in the American regulations and masks typified such as FPP1, FPP2 and FPP3 according to the European regulations, may be used in our environment, depending on the risk levels.
(*) Correspondence: Hospital Donostia. Pneumology Service. Paseo Dr. Begiristain s/n . 20014 Donostia - San Sebastián (Gipuzkoa)