By Annette M. Boyle

Brooke Decker, MD, director of infection prevention at the VA Pittsburgh Health System

Brooke Decker, MD, director of infection prevention at the VA Pittsburgh Health System

PALO ALTO, CA— In February, five U.S. representatives from California blasted the VA in a letter to Secretary Robert McDonald, alleging the Palo Alto Medical Center failed to follow public health protocol regarding potential tuberculosis (TB) exposure. The letter contends that a VA employee waited four months to notify management of a TB diagnosis, endangering co-workers, veterans and other visitors to the facility.

Reps. Jerry McNerney (D-CA ), Mark DeSaulnier (D-CA), Zoe Lofgren (D-CA), Jeff Denham (R-CA) and Mike Honda (D-CA) expressed “disappointment and concern,” noting that VA facilities in Pittsburgh and Loma Linda, CA, have also dealt with TB exposure, “underscoring the need for a uniform policy and training across the system.”

Information provided by the affected medical centers, however, indicate the letter could have been an overreaction because the legislators might not have had a clear understanding of the risk to patients, staff and visitors or the timelines of the specific incidents.

It also demonstrates how different an issue portrayed by Congress or in the media can look from the perspective of the VAMCs under attack, according to medical professionals involved in those cases.

Tuberculosis is not a trivial disease; until the discovery in the 1940s of antibiotics used in its cure, it was the leading cause of death in the United States, according to the University of Maryland.

TB remains a top killer worldwide and is even on a modest upswing in the United States: Following a steady drop in infections from 1992 to 2014, 2015 saw a small uptick in cases in 29 states and the District of Columbia, according to the national Centers for Disease Control and Prevention in Atlanta.

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While it is contagious, however, tuberculosis is not easy for people to contract through casual contact. About 30% of people exposed to Mycobacterium tuberculosis will develop latent TB infection, and if not treated, 5% to 10% of those with latent infection will develop active disease at some point in their lives, according to the U.S. Preventive Services Task Force. Rates are highest in individuals with compromised immune systems.

In the Palo Alto case, a VA employee started to exhibit respiratory symptoms in October 2015, for which she sought care by her primary care provider at a non-VA facility in the winter. On Jan. 7, 2016, the employee received notification that she had tested positive for tuberculosis. The next day, her supervisor contacted the facility’s Infection Prevention and Control team, who notified the chief of Occupational Health, according to Rodney Copley, director of the VA Palo Alto’s Quality and Safety Section. The Santa Clara County TB Control Officer also was notified and assumed monitoring and oversight for the employee.

The VAMC’s Occupational Health Department contacted all potentially exposed employees during the week of Jan. 11, 2016, and initiated calls to 171 potentially exposed patients. The calls reached 122 patients, and notification letters went out to the remaining 49 patients, Copley told U.S. Medicine.

“Two employees and four patients had positive blood tests for tuberculosis and were diagnosed with latent TB, which is not communicable,” said Copley. “All underwent follow-up clinical evaluations and no cases of active tuberculosis were diagnosed.”

In the Pennsylvania case, the VA Pittsburgh Healthcare System diagnosed an outpatient veteran with tuberculosis based on positive test results on Nov. 17, 2015.

“Infection prevention officials determined that, between two VA Pittsburgh sites, more than 400 patients may have been exposed to the affected veteran,” said Brooke Decker, MD, director of infection prevention at the VA Pittsburgh Health System. The patient had sought treatment in the previous two months at both the VA Community Based Outpatient Clinic in Beaver County, PA, and the VA Pittsburgh’s University Drive campus in Oakland, PA.

The VA contacted every potentially affected veteran between Nov. 17 and Dec. 1 and instructed them to obtain additional testing as a routine precaution. The Pittsburgh VA also notified all employees, congressional partners, other stakeholders, the Allegheny County health department, and the news media to advise those potentially exposed that they were at minimal risk for developing an infection.

“The chance of developing tuberculosis from this level of exposure is very, very low,” said Decker in communications at the time. “While it is unlikely anyone exposed in this incident will become ill, out of an abundance of caution we are recommending veterans who receive a letter be tested.”

“It is important to know that infection prevention officials classify the event as a potential exposure and not an outbreak, as no other tuberculosis cases were suspected or confirmed,” Decker told U.S. Medicine. 

The Loma Linda incident, meanwhile, began when an employee at the Jerry L. Pettis Memorial VAMC notified a supervisor of a TB diagnosis on Oct. 27, 2015. Following CDC guidelines, the hospital contacted 1,727 patients and employees who might have come in contact with the infected employee back to June 1, 2015. Veterans, employees and visitors were encouraged to come to the facility for a free blood test or to contact their primary care physician, if they thought they might have TB symptoms.

The letter to veterans sent by Michael Ing, MD, chief of the infectious disease section of the Loma Linda VA on Nov. 2 noted that “we have every reason to believe that your contact with the TB case is unlikely to have infected you.”

His prediction proved right. In December, Susan Strong, NP, TB controller with the San Bernardino County Department of Public Health announced that no new infections were associated with the case.