mobile and had a persistent, spraying cough. Investigators also found that laboratory tests for possible tuberculosis were ordered but not performed during one of the resident’s several hospital stays (Kevin Ijaz, Arkansas Department of Health, personal communication, August 23, 2000). In addition, investigators determined that an air intake for the air-conditioning system was located outside the resident’s nursing home room.

The committee located one report of a skin test conversion in an employee of a residential substance abuse facility in Michigan following diagnosis of multidrug-resistant tuberculosis in a resident of the facility (Hoch and Wilcox, 1991). The facility had no health screening program for patients and a high attrition rate.

Individual Reports: Other Settings

Homeless Shelters The committee located only one published report on transmission of tuberculosis to workers in a homeless shelter. That report involved a 1987–1988 outbreak in a Syracuse, New York, shelter for men (Curtis et al., 2000). Investigators found that 70 percent of 257 clients and staff had positive tuberculin skin test results. Although skin test conversions were documented in 2 of 8 previously tuberculin skin test negative staff members, 52 other staff members who might have been exposed were not available for skin testing. Shelter workers are often previous shelter clients. They tend to be more transient and less available for follow-up than workers in many of the other settings reviewed in this chapter.

Hospice and Home Care Although the advent of effective treatment for people with HIV infection or AIDS has reduced their need for hospice care, hospice workers still care for many people at higher than average risk of tuberculosis. One outbreak of tuberculosis in a hospital-based hospice has been reported (Pierce et al., 1992). Eleven of 65 workers converted their skin tests after exposure to an AIDS patient with a delayed diagnosis of tuberculosis.

Ambulatory Care Setting The committee located one report of an outbreak in an ambulatory care setting. It occurred in 1988 among workers in a Florida clinic that reported skin test conversions for 17 of 30 (57 percent) workers with previously negative test results (Howell et al., 1989). Investigators identified four possible sources of transmission including 1 nurse with noncavitary pulmonary tuberculosis, 39 clinic patients with pulmonary tuberculosis (14 with at least one positive smear), sputum inductions for 13 culture-positive patients, and aerosolized pentamidine treatments for 2 culture-positive patients. The investigation identified ventilation problems in the facility that could have contributed to transmission.

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