An outbreak of tuberculosis among adults with mental illness

摘要

In August 2008, a resident at a Florida assisted living facility for adults with mental illness was diagnosed with infectious pulmonary tuberculosis (TB). From October 2008 to May 2009, 14 additional residents and three nonresidents were diagnosed with TB. The index patient was contagious for approximately 8 months before he was diagnosed in August 2008. He first sought medical attention for a cough and general malaise in April 2008, at a local psychiatric hospital where he felt comfortable receiving care because of his frequent previous hospitalizations there, He was evaluated by an internist and admitted for acute psychiatric decompensation for 8 days to a locked ward that held approximately 25 patients. Although cough was documented on admission, medical records did not reveal any detail on how the patient described his symptoms, and further evaluation was not performed at that time. During the course of his infectious period, the patient did not seek treatment at a medical facility for his worsening TB symptoms. He was held for one night in a one-person cell at the county jail and was hospitalized three more times at the psychiatric hospital for stays ranging from 2 to 8 days. He was assessed by an internist at each admission, and a cough was documented in each admission note. When the patient was hospitalized for the fourth time at the psychiatric facility in August 2008, a provider noted that his cough had persisted and ordered chest radiography, which revealed evidence of a cavitary lesion suggestive of pulmonary TB. The patient was transferred to a medical hospital, where sputum smear microscopy was positive for acid-fast bacilli, and confirmatory testing revealed Mycobacteritim tuberculosis. After 2 weeks of TB treatment, the patient left against medical advice and returned to the assisted living facility. Three days later, supervisors from the assisted living facility brought him to another medical hospital for admission under direct one-to-one observation. He attempted to leave the hospital multiple times, requiring transfer to an isolation unit at the local jail and then to the A.G. Holley State Hospital, a Department of Health facility specializing in tuberculosis, in accordance with Florida state law permitting the involuntary examination and treatment of persons with mental illness who may be a harm to others, such as patients who have dangerous infectious diseases like tuberculosis. The assisted living facility had an average census of 84 residents each month and the capacity to hold up to 91 at any one time. Each month, approximately four to five residents departed and a similar number of new residents arrived. Residents slept three or four to a room, but they did not have a curfew and were not required to sleep at the facility. Hence, despite stable housing, residents were sometimes transient, often sleeping at locations outside of the facility. The facility did not provide medical care; residents were not routinely screened for TB on admission, and those who developed TB symptoms could not be evaluated on-site. Medications were disbursed by facility staff, but staff did not enforce adherence.