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					Table 1: Detailed description of each study

 #          Article              Objectives              Study Design                      Main Findings                                     Discussion
     Rosenberg T et al.        To describe the       Prospective                490 (82%) of 596 eligible subjects        The authors concluded that the prevalence of
 4                              prevalence and         observational study.        were tested with 5 TU of purified         TB reactions was significantly related to a
     “Two-step tuberculin       determinants of TB    Setting: Nursing home       protein derivative (PPD-S).               history of BCG vaccination and foreign birth.
     testing in staff and       reactions.             in Manitoba, Canada.       Subjects with an induration of >          However the association with foreign birth
     residents of a nursing    To assess the         Time period:                10mm were classified as initial           was only seen among staff members. The
     home”                      booster response       September 1990 to           reactors; those with < 10mm               authors hypothesized that this may be related
                                in staff and           January 1991.               induration were retested 1 week later     to the fact that foreign-born residents spent a
     American Review of         residents of a        Study population:           to assess for a booster response.         longer time in Canada and their positive TB
     Respiratory Disease        nursing home          Staff:                     There were a total of 137 initial         tests reverted to negative over time.
                                facility.               Size: N=218.              reactors and 20 booster responses.
     1993;148(6 pt 1):1537-                             Mean age: 41  13        275 (56%) of the subjects were            Two-step tuberculin testing should be
     40.                                                  years.                   foreign-born, with the majority being     conducted for all staff and residents if
                                                                                   from Eastern Europe.                      resources permit.
                                                      Residents                  Prior BCG vaccination was
                                                        Size: N=272.              significantly associated with a           Because as many as 75% of the BCG-
                                                                                                                             vaccinated population may have a positive TB
                                                        Mean age: 85  8          positive initial reaction (OR: 7.8, 95%
                                                                                   CI: 4.6-13.5) as well as a positive       reaction, the authors do no recommend
                                                                                   booster reaction (OR: 6.7, 95% CI:        chemoprophylaxis for isolated BCG-
                                                                                   2.1-21).                                  vaccinated reactors unless the reaction can
                                                                                  Foreign-born staff members were           be linked to an infectious cause.
                                                                                   significantly more likely to have
                                                                                   positive reactions compared to            These results should be interpreted with
                                                                                   Canadian born staff (OR: 5.3, 95%         caution since greater than 50% of the study
                                                                                   CI: 2.5-11.4); this association with      population was foreign born, there were a
                                                                                   foreign birth was not seen among the      relatively small number of booster cases, and
                                                                                   residents.                                a self-administered questionnaire was used to
                                                                                  Staff members were twice as likely to     collect medical information
                                                                                   have a positive reaction compared to
                                                                                   residents (OR: 2.0, 95% CI:1.3-3.0).
                                                                                  Stepwise multiple regression
                                                                                   analysis revealed that only a history
                                                                                   of BCG (adjusted OR: 4.8, 95% CI:
                                                                                   2.1-11.3) and foreign birth (adjusted
                                                                                   OR: 1.7, 95% CI: 1.1-2.6) were
                                                                                   significant predictors of a positive
                                                                                  Age was not significantly associated
                                                                                   with the booster response.
Table 1: Detailed description of each study

 #          Article                Objectives               Study Design                         Main Findings                                    Discussion
     Sherman RA, Shimoda        To define the           Prospective                    39 (6.3%) of the 619 staff members      Overall, the two-step testing method
 5   KJ                          frequency of the         surveillance study.             had an initial positive PPD test.       successfully identified 13% of PPD reactive
                                 booster                 Setting: Veterans              102 (17.6%) of the nonreactive staff    staff members and 14% of PPD reactive
     “Tuberculosis tracking:     phenomenon               Affairs medical center in       members returned for their second       patients. Accordingly, the authors support the
     Determining the             among hospital           California.                     test, but 5 were excluded from          use this testing method for all non-reactive
     frequency of the            staff members and       Time period: February           further analysis due to inappropriate   skin test responders.
     booster effect in           LTC patients.            1994 to November                (too short or too long) retesting
     patients and staff”        To identify specific     1995.                           intervals.                              The results of this study support the findings
                                 factors associated      Study population:              6 (6.2%) of the remaining 97 staff      of earlier studies that demonstrated a link
     American Journal of         with the booster          Staff: N=619.                 members demonstrated a booster          between foreign birth and a positive TB
     Infection Control           effect.                   Patients: N=88.               response.                               response. Immigrants from Vietnam and
                                                                                         Birth outside the US (foreign birth)    Southeast Asia were more likely to
     2001;29(1):7-12.                                    All patients on chronic         was significantly associated with the   demonstrate a booster response. The
                                                          care wards and staff            booster response (Fisher exact test,    authors hypothesized that this association
                                                          members not tested in           p < 0.05) in staff members.             may be related to “the common practice of
                                                          the previous two years         Prior BCG vaccination was               BCG immunization in Southeast Asia.”
                                                          were tested with the            significantly associated with foreign
                                                          two-step testing method.        birth (p < 0.01).                       Among the chronic care patients, anemia was
                                                                                         12 (13.6%) of the 88 chronic care       the only factor significantly associated with a
                                                         Induration was                  patients had an initial positive PPD    booster response. Anemia may be an
                                                          measured by the “ball           test.                                   indicator of other clinical conditions
                                                          point pen” method.             Of the remaining 76 patients, only 37   (malnutrition, chronic disease,
                                                                                          were retested appropriately and 2       immunosuppression) rather than a causal
                                                                                          (5.4%) had a positive booster           factor.
                                                                                         Anemia was significantly associated
                                                                                          with the booster response in patients
                                                                                          (p = 0.05).
Table 1: Detailed description of each study

 #          Article               Objectives              Study Design                        Main Findings                                     Discussion
     Naglie G et al.           To identify the TB      Telephone survey using      55 of the 59 facilities completed         Overall, 31% of the facilities surveyed did not
 8                              testing practices of     a 25-item                    surveys.                                  have a formal TB testing program.
     “Tuberculosis              LTC facilities.          questionnaire.              The average bed size among the 55
     surveillance practices    To determine if the     Setting: 29 nursing          facilities was 181 (range 25 to 437).     Surveillance practices were better at the
     in long-term care          existing                 homes(NHs) and 26           20% of the responding facilities          HFAs compared to NHs. This can be
     institutions”              surveillance             homes for the aged           reported at least one case of TB in       attributed to the fact that HFAs in Toronto are
                                practices would          (HFAs) in Toronto,           the previous 5 years.                     subject to government legislation with respect
     Infection Control and      permit the               Ontario.                    2 (8%) of 26 HFAs and 15 (52%) of         to TB testing practices while NHs are not.
     Hospital Epidemiology      identification of       Time period: February        29 NHs did not have formal TB skin-
                                new TB infections        1992.                        testing programs.                         The results of this study showed that, in
     1995;16(3):148-51.         among residents.                                     Admission and annual skin testing         general, the quality of TB testing practices
                                                                                      were performed at 42% of the HFAs         among all of the facilities was poor. This led
                                                                                      and 14% of the NHs.                       the authors to conclude that the surveillance
                                                                                     Of the facilities that did perform skin   programs were “inadequate for the
                                                                                      testing, 64% of HFAs and 32% of           determination of infection rates in residents
                                                                                      NHs measured the size of induration       and for the assessment of individual
                                                                                      to identify a positive reaction.          exposures to active disease.” They stressed
                                                                                     Only 28% of respondents from HFAs         the need for educational and quality
                                                                                      and 21% from NHs correctly defined        assurance programs related to testing policies
                                                                                      a positive TB skin test.                  and procedures.

                                                                                                                                The results may have been biased by the fact
                                                                                                                                that the authors could not ensure that the
                                                                                                                                person interviewed provided an accurate
                                                                                                                                representation of the facility’s surveillance
Table 1: Detailed description of each study

 #          Article              Objectives              Study Design                        Main Findings                                     Discussion
     Schluter WW et al.       To use an               Cross-sectional              This study measured the results of        This study provides a useful review of the
 9                            educational              retrospective chart           an educational intervention (i.e.,        importance of educational interventions and
     “Increasing influenza    intervention to          review.                       information about TB screening            written policies regarding influenza and
     and pneumococcal         increase:               Setting: Randomly             recommendations, a public service         pneumococcal pneumonia vaccinations as
     vaccination and           The rate of annual     selected residents from       announcement, information sheets,         well as TB screening in elderly nursing home
     tuberculosis screening      immunization for      191 Colorado LTC              posters, description of project goals)    residents.
     among residents of          influenza and         facilities.                   after baseline measurement to
     Colorado long-term          pneumococcal         Time period: 1995 to          determine if vaccination uptake and       This study, however, suffered from several
     care facilities”            vaccinations.         early 1998.                   TB screening increased.                   methodological flaws. Most importantly was
                               Tuberculosis          Study population             The researchers assessed the              the response rate. Not all facilities
     Evaluation & The            screening.            (tuberculosis):               number of facilities, presumably at       responded. Secondly, it does not seem that
     Health Professions                                 Sample size: N=349          baseline, that had a TB screening         the authors followed the “intention to treat”
                                                          (baseline).                policy:                                   basis when calculating statistics. This has the
     1999;22(4):466-83.                                 Sample size: N=221           142 of 191 (74.5%) facilities           potential for overestimating the impact of the
                                                          (first                         responded to a policy checklist.      intervention. A control arm would have
                                                          remeasurement).             All of the facilities reported having   provided a more robust examination of
                                                        Sample size: N=557              a screening policy.                   changes over time.
                                                          (second                   The researchers also requested that
                                                          remeasurement).            medical directors use a standardized      “In conclusion, it was possible to significantly
                                                                                     data collection tool to provide a         increase vaccination and tuberculosis
                                                                                     history of TB screening rates:            screening rates by partnering with health care
                                                     Note: Sample sizes have          204 of 349 (59%) residents were         providers in developing an interventional
                                                     been corrected to account           screened at baseline.                 program that focused on educating long-term
                                                     for excluded subjects.           Screening increased to 77% at           care staff, residents, and the community using
                                                                                         the first remeasurement and 83%       a multimedia approach.”
                                                                                         at the second remeasurement
                                                                                         (two years after baseline) (2 =
                                                                                         62.4; p < 0.001).
                                                                                      “Residents receiving a 2-step
                                                                                         tuberculosis screening test (PPD)
                                                                                         on admission” was ranked as the
                                                                                         most important preventative
                                                                                         health measure among medical
                                                                                         directors responding to the
Table 2: Guideline, Recommendation or Review
 #                             Article                              Guidelines or Recommendations
      Centers for Disease Control and Prevention                 These recommendations were developed through
 1                                                                the collaborative efforts of the Advisory Committee
      “Prevention and control of tuberculosis in facilities       for Elimination of Tuberculosis, CDC staff members,
      providing long-term care to the elderly:                    and public health consultants.
      Recommendations of the advisory committee for              It provides guidance on developing policies to control
      elimination of tuberculosis”                                TB in nursing homes and other LTC facilities.
                                                                 It covers the following areas:
      Morbidity and Mortality Weekly Report                        General guideline considerations.
                                                                   Surveillance/diagnosis.
      1990;39(RR-10):7-20.                                         Containment/isolation.
                                                                   Treatment.
                                                                   Assessment.
                                                                   Role of the health department.

      Centers for Disease Control and Prevention                 This report is a result of a joint statement from the
 2                                                                American Thoracic Society and the CDC. It was
      “Targeted tuberculin testing and treatment of latent        endorsed by the Council of the Infectious Diseases
      tuberculosis infection”                                     Society of America.
                                                                 It provides updated, evidence-based
      Morbidity and Mortality Weekly Report                       recommendations for testing and treatment of latent
                                                                  TB infection.

      Dutt AK, Stead WW                                          This article reviews the epidemiology and
 3                                                                management of TB with particular emphasis on the
      “Tuberculosis in the elderly”                               nursing home population.
                                                                 It covers risk factors, clinical manifestations
      Medical Clinics of North America                            diagnosis, treatment, and surveillance.
                                                                 The authors published similar reviews in 1991 and
      1993;77(6):1353-68.                                         1992 in the Annual Review of Medicine and Clinics of
                                                                  Geriatric Medicine, respectively.

      Rajagopalan S, Yoshikawa TT                                This review provides a brief summary of the
 6                                                                epidemiology and clinical manifestations of TB in the
      “Tuberculosis in long-term-care facilities”                 elderly.
                                                                 It reiterates the 1990 CDC recommendations for
      Infection Control and Hospital Epidemiology                 prevention and control but updates the treatment

      Martin G, Lazarus A                                        This article is one part of a four-article symposium on
 7                                                                tuberculosis.
      “Epidemiology and diagnosis of tuberculosis:               This portion of the review covers the current
      Recognition of at-risk patients is key to prompt            diagnostic techniques, as well as the clinical and
      detection”                                                  radiographic findings associated with TB.

      Postgraduate Medicine


      Means-Markwell M, O’Neil KM.                               This is the final article of a four-article symposium on
 10                                                               tuberculosis.
      “Prevention of tuberculosis: Vigilance and infection       This portion of the review covers the components of
      control strategies are mainstays of efforts”                an effective occupational control program,
                                                                  identification of high-risk individuals,
      Postgraduate Medicine                                       recommendations for prophylactic therapy, and the
                                                                  role of BCG vaccinations.

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