AEGiS-GMHC: Outbreak of Drug-Resistant TB

Important note: Information in this article was accurate in 1991. The state of the art may have changed since the publication date.

Outbreak of Drug-Resistant TB

Gay Men's Health Crisis Treatment Issues, Vol. 5, No. 7 - October, 1991
Gabriel Torres, M.D.

The Centers for Disease Control (CDC) reported several outbreaks of multi-drug-resistant tuberculosis (TB) among both patients with ANDS and HIV-positive health care workers (HCWs). The report was printed in the August 30th issue of Morbidity and Mortality Weekly Report (MMWR). In the first outbreak in a New York City hospital, 29 patients were diagnosed with TB, which was resistant to two common antibiotics used for treatment (isoniazid and rifampin). Nine of these patients also had resistance to ethambutol. Of the 29 patients, 93% were HIV-infected and 23 had AIDS. Within seven weeks of diagnosis, 72% of the patients with TB died. A year later, another 36 patients were diagnosed with resistant TB, 35 of whom were HIV-positive. Eighteen patients had TB strains resistant to isoniazid and streptomycin, and 12 patients were also resistant to rifampin and ethambutol. Strikingly similar incidences of drug-resistant TB cases have occurred in three other hospitals, two in New York and one in Miami, according to reports by the MMWR.

Genetic typing identified that the TB strains were similar among many of the patients, suggesting that the tuberculosis was transmitted from one patient to another in the same ward. In all four hospitals, patients were not placed in isolation until they were already uninfectious. Of all the cases reported, eight were HCWs, five of whom had known exposure to TB-infected patients. Because TB was not detected during its infectious stage, most HCWs and hospital visitors did not wear masks.

These outbreaks confirm that HIV-infected patients with advanced immunosuppression are more susceptible to tuberculosis. The CDC has recommended that patients who are suspected of having TB should be placed under respiratory isolation until they are treated and become non-infectious. Additionally, increased infection control precautions such as the use of tight-fitting masks, air exchanges in patients' rooms, and ultraviolet lights should be enforced. Routine screening of health care workers with skin tests and prophylactic therapy should be conducted to curb transmission in the workplace.

The alarming report of TB outbreaks does not come as a surprise to many in New York , who have witnessed the emergence of drug resistance in the past several years among persons with HIV and tuberculosis. In fact, many on the front-lines have urged city officials to wage a more serious and effective preventive campaign. It is hoped that the publicity of these cases will strengthen the argument and urge local health officials to enforce stricter infection control in hospitals, clinics and other setting in New York City where patients with HIV congregate. Homelessness must be addressed as well, since non-compliancy with TB therapies is closely linked to unstable living situations. Transmission of TB is also well-documented within shelters for the homeless. These controls will ensure better treatment for HIV-infected individuals with TB, as well as protection for others.

Screening with skin tests provides one mechanism to detect the infection prior to illness and should be utilized more often among patients, visitors, and others in close contact.

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