Published Date: 2005-10-28 23:50:00
Subject: PRO/EDR> Tuberculosis, school - Sweden (Stockholm)
Archive Number: 20051028.3140
TUBERCULOSIS, SCHOOL - SWEDEN (STOCKHOLM)
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases
Sponsored in part by Elsevier, publisher of
Date: Thu, 27 Oct 2005
From: ProMED-mail <email@example.com>
Source: Eurosurveillance Weekly [edited]
A female assistant at a nursery in a wealthy suburb of Stockholm was
diagnosed with smear-positive advanced pulmonary tuberculosis in August
2005. She had lost weight and been coughing for several months before
diagnosis. The chest x-ray showed bilateral cavitary lesions. Infection
with an isoniazid-resistant strain of _Mycobacterium tuberculosis_ was
confirmed on culture.
All children and adults with a presumed exposure at the nursery were listed
and examined. A 3-year-old boy was found to be ill with fever, admitted to
hospital immediately, and diagnosed with primary tuberculosis with hilar
adenopathy. All children below 3 years of age were also sent directly to
the hospital for clinical examination. Children 3 years and over underwent
a tuberculin skin test (TST) at the nursery. All children with a TST of [10
mm induration or greater - Mod.LL] were referred to the hospital for chest
x ray and clinical evaluation.
In total, 141 children were exposed and of these, 35 (25 percent) had a TST
of 10 mm or more and/or an abnormal chest x-ray. Out of 20 children with an
abnormal chest x-ray, 8 had bronchoalveolar infiltrates with hilar
adenopathy and 12 hilar adenopathy only. A 7-year-old girl had a
disseminated tuberculosis. No child required prolonged hospitalization, and
all are recovering well. None of 61 children from nearby nurseries with
sporadic short contacts were infected. 45 children had no observable
reaction to their first TST. Another round of TSTs will be performed.
Children with chest x rays showing signs of tuberculosis were put on full
anti-tuberculous medication, while children with only a positive TST were
prescribed chemoprophylactic therapy.
11 of 25 permanent staff members at the nursery had a TST of 10 mm or
greater. One assistant at a nearby nursery who had had only temporary
contact developed tuberculosis pleuritis. Another 9 adults with sporadic
contact showed a TST of 10 mm or greater.
46 parents were considered exposed and 6 possibly infected. No parent has
developed disease. Infected adults were prescribed prophylactic treatment,
determined on an individual basis.
The strain was resistant to isoniazid and the chemoprophylaxis was adjusted
correspondingly. In children, rifampicin [another name for rifampin -
Mod.LL] only was used, although in the adults rifampicin was used in
combination, for example, with a fluoroquinolone.
9 of the non-infected children and 3 of the infected children had been
vaccinated with BCG. No source of infection other than the index case was
[Reported by: Berggren Palme I (<firstname.lastname@example.org>), Larsson
L-O, Zedenius I, et al]
[Elsevier on-line reference:
Challenges and hope for the diagnosis of tuberculosis in infants and young
children.Lancet, January 2005,
[This outbreak, at an earlier stage, was pointed out to ProMED by Dr. Peter
Valverius in late August 2005 for which we are grateful.
Clusters of tuberculosis such as this one continue to point out that _M.
tuberculosis_, which has been referred to as the "white plague," is still a
threat in the developed world, even the "wealthy" part of it. The amount
of transmission in this outbreak suggests prolonged, relatively close
exposure of many children to the index case.
It is not stated in the posting whether the index case was known to be
TST-reactive prior to the illness or was from a higher endemic
area. Routine tuberculosis screening programs in environments where
transmission can be more problematic (exposure to small children,
hospitals, nursing homes) can be quite useful in minimizing risk. In this
case, if the index case had been known to be TST-positive prior to becoming
ill, tuberculosis chemopreventive therapy might have been utilized, and/or
the individual could have been counseled regarding immediately seeking
medical attention upon becoming ill with symptoms such as cough lasting
more than a week or so -- especially when associated with constitutional
symptoms such as night sweats and weight loss. - Mod.LL]