Sunday, 6 December 2015

NUH recalls 178 children for TB tests

Nurse who cared for them confirmed to have disease; patients include 131 under age of two
By Salma Khalik, Senior Health Correspondent, The Straits Times, 4 Dec 2015

The National University Hospital (NUH) is recalling 178 paediatric patients - including 131 under the age of two years - who had been cared for by a nurse now confirmed to have tuberculosis.

They include 34 children who have received a transplanted organ. These children are on immunosuppression drugs and therefore at higher risk than normal children.

A nurse at our children’s Ward 47 was diagnosed with Tuberculosis (TB) last Friday. She is receiving treatment and...
Posted by National University Hospital on Thursday, December 3, 2015

Associate Professor Daniel Goh, head of paediatrics at NUH, said the risk of any of the children contracting TB from the nurse is "very low", especially as she had donned a mask while working.

But the hospital is not taking any chances and is recalling patients who had been in ward 47 since July.

The nurse was treated at a GP clinic for her cough in July, but despite having a chest X-ray, was not diagnosed with TB. She was given antibiotics and seemed to get better.

But the cough persisted, and last Wednesday she sought treatment again and was given a CT scan which showed a possible TB patch in her lung the size of a 50-cent coin. She told the hospital on the same day and was tested for TB. Last Friday, the results confirmed she had TB.

Fortunately, it is the normal and not multi-drug-resistant variety.

Dr Goh said his team spent the weekend trawling through the patient database to identify patients who might have had long exposure to her while warded, as well as those who are deemed at higher risk because of their age or disease.

Mr Joe Sim, NUH's chief executive officer, said: "We fully understand the anxiety of the parents and are taking this matter seriously."

Professor Paul Tambyah , a senior infectious disease expert at NUH, said TB transmission depends on the amount of exposure, the bacterial load of the carrier and the individual's immune system.

He said there is a one in 10 chance of people getting the bug if a person with TB coughs at them for two hours. Of those who get the bacteria, one in 10 would get the disease in his lifetime. This doubles for those with low immunity.

The first patients were at NUH for screening on Tuesday and more will be screened over the coming weeks.

They will have a chest X-ray to check for TB, and blood tests if aged five or older, and/or skin tests to see if they have the bug latent in them.

Any child diagnosed to have caught the latent bug will be given treatment, which has a greater than 90 per cent chance of preventing TB. For those with TB, chances of a cure are very high with treatment.

Madam Crystal Lim, 28, whose two-year-old son was in ward 47 for three weeks in August, was shocked when his doctor called to ask her to bring her son back for tests.

Her son had a liver transplant in October last year, but was back in hospital for treatment for a 3cm abscess on his buttocks. The doctor had explained that because of his transplant, he was at a higher risk.

She is worried, but not angry.

"I would be angry if the hospital did not do anything and the patients started getting TB. But they are doing something," she said.

As for the nurse, Madam Lim said: "She did not do it purposely. All the nurses look after the children very well. I hope the doctors can help her get well."

The nurse, who is on medical leave for two weeks, will be able to resume work as being on treatment means she is not contagious. Her colleagues in the ward have all been tested and found negative.

So far this year, 1,252 new TB cases have been diagnosed in Singapore.

How the disease is spread
By Tan Weizhen, The Straits Times, 4 Dec 2015

Tuberculosis is an airborne disease transmitted through fine respiratory droplets from an infected person.

It usually affects the lungs but can also hit other parts of the body such as the brain, lymph nodes, kidneys, bones and joints.

Persons with TB are most likely to spread it to people who have close and prolonged contact with them, such as family members, friends and colleagues.

It is not spread through sharing drinks, utensils, cigarettes or kissing.

There were 1,454 new TB cases among residents here last year, 34 more than in 2013. In the past 30 years, Singapore had more than 1,000 new cases a year.

According to the Health Ministry, there has been a resurgence of TB cases in recent years.

TB can be cured with a combination of different drugs taken over six to nine months.

However, if the treatment is incomplete, TB germs may develop a resistance to the drugs.

Second-line TB drugs must then be taken for a longer period, but chances of a cure will be significantly reduced.

Healthcare workers at higher risk of infections

Last Friday's report highlighted what the National University Hospital did to screen for any tuberculosis infection from the infected nurse to the patients she had cared for ("NUH recalls 178 children for TB tests").

We also ought to view this incident from the perspective of healthcare workers.

Pre-employment medical screening for medical personnel often includes tests for infective illnesses like TB, hepatitis B and HIV.

So, the nurse involved was unlikely to have had TB when she joined the hospital.

Most likely, she acquired TB infection during the course of her work.

Medical studies have shown that healthcare workers are indeed more likely to suffer from TB infection than the general public.

While precautions like isolating infective patients or wearing protective gear may reduce the risk of infection transmission, some transmission still occurs, as some illnesses like TB may have silent incubation periods.

As I am also a healthcare worker, I can sympathise with the nurse.

Most (if not all) of us have contact with patients with infective diseases on a daily basis.

Besides TB, there are also diseases such as hepatitis B, hepatitis C, HIV and the common cold.

If we pick up infection from our patients, we put other patients, our colleagues and our families at risk, too.

The nurse involved did all the right things, including seeking medical consultation when she had a recurrent cough, and taking medication once diagnosis was made.

She ought to be hailed as a role model for nurses.

Desmond Wai (Dr)
ST Forum, 8 Dec 2015

* 80 children screened after NUH nurse found to have TB

This comes after the hospital asked 178 children to be tested, after discovering that a nurse working in a paediatric ward had been diagnosed with lung tuberculosis. Channel NewsAsia understands one child was found to have latent TB.
By Hetty Musfirah Abdul Khamid, Channel NewsAsia, 9 Dec 2015

More than 80 children have been screened for tuberculosis as of Wednesday (Dec 9) and none of them were found to have active tuberculosis, according to the National University Hospital. This comes after the hospital asked 178 children to be tested, after discovering that a nurse working in a paediatric ward had been diagnosed with lung tuberculosis.

According to an update from NUH, more than 120 patients - who stayed at NUH's ward 47 since July - have been contacted thus far.

A total of 131 children of the 178 included in the recall are under the age of two, and were cared for by the nurse. The 178 also includes 34 children who had received a transplanted organ, and are on immunosuppression drugs.

Channel NewsAsia understands that a child who stayed at the affected ward has been diagnosed with latent tuberculosis, which is not contagious. A caller to Mediacorp's hotline said his baby had stayed in the affected ward between Aug 23 and Sep 5 this year. The child has undergone screening, and results revealed that he has latent TB.

The caller said his child has been prescribed medication and is recuperating at home.

When asked, NUH said it is aware of the case.


Dr Leong Hoe Nam, Infectious Diseases Physician from Rophi Clinic at Mount Elizabeth Hospital said it is difficult to ascertain if the nurse was the actual source of the infection.

"It is extremely difficult to find the source of this latent tuberculosis, simply because TB is endemic in Singapore," said Dr Leong.

"The person whom you had lunch with, the person who looked after you as a child minder or a person who plays every day at the field - any one of them could have passed you tuberculosis. Similarly, if you look at the nurse, she could have picked it up at work or picked it up from anybody else," he said.

Dr Leong added that DNA finger-printing would be the only way to find out whether the nurse was the one who passed tuberculosis on to the affected child.

"To be really exact on whether the nurse passed it on to the child, you will need to isolate the tuberculosis from the nurse - which may be difficult. You may also have to isolate it from the child, which is going to be extremely difficult. Between the two, you need to do DNA finger-printing, and it is technically impossible," said Dr Leong. "It is practically impossible because it is latent TB, which means the germ is sleeping and you have very, very small quantities."


NUH said cases of latent tuberculosis can be effectively treated to prevent them from progressing to active tuberculosis.

"Current treatment options reduce the risk of developing active TB by more than 90 per cent," NUH said.

According to the Health Ministry's website, individuals with latent tuberculosis infection do not have symptoms and are not infectious. They cannot spread the tuberculosis germs to other people. Tuberculosis disease develops in about 10 per cent of those infected with latent tuberculosis.

Dr Leong explained that tuberculosis can be briefly classified into either latent or active.

"Latent - in other words - means sleeping. Let's say I have been exposed to tuberculosis; I breathe it in and it goes into my lungs. My body tries to 'wall it off' and contain it. If I am able to wall it off and contain it, it goes into a sleeping mode, and that's latent. But if I can't, then it will break out of the wall and then stop proliferating and start growing. In that case it becomes active tuberculosis," he said.

"(Tuberculosis) is in essence, a sleeping bacteria. So it is easy, because you can kill it off with one or two drug regimens, for about six months, and the bacteria can die with a very high success rate. If the person has TB, the immunity of the person will determine the risk of the TB coming out," Dr Leong added.

The doctor also said there is at most a four per cent chance of a relapse even after treatment, and should the person's immune system weaken. "TB masks itself very well, to the extent that a person may have active lung TB and not show any signs at all, and sometimes only an X-ray will show TB."

NUH said treatment given will not protect one from acquiring a new infection in the future, as TB occurs in the general community.

* More kids found with latent TB in NUH screening

They had been patients in ward where nurse was found to have the disease
By Salma Khalik, Senior Health Correspondent, The Straits Times, 23 Dec 2015

Four more children who were warded at the National University Hospital (NUH) between July and late last month have been found to have latent tuberculosis (TB).

The hospital has been recalling 178 children who had been long- stay patients in Ward 47 for TB screening since it found out on Nov 27 that one of its nurses working there had the disease.

The children were hospitalised between July, when the nurse sought treatment for a bad cough, and November, when she was confirmed to have TB.

NUH doctors had earlier said the recall of its patients from the paediatric ward was a precaution as the nurse had been wearing a mask when in the ward.

But earlier this month, a four-month-old boy became the first child patient found to have the bug.

So far, tests have been carried out on more than 130 of the children who stayed in Ward 47 at the time, of whom four others have now been diagnosed with latent TB, which means they harbour the bacteria but do not yet have the disease. They are therefore not infectious.

Without treatment, about 5 per cent to 10 per cent of people with latent TB will develop the disease some time in their lives, with half doing so within the first two years of infection. Treatment can further reduce their risk of getting the disease. There is a high rate of cure for people who have the disease, which usually affects the lungs, but can also affect the brain, kidneys or spine.

TB is spread through air droplets, usually when an infected person coughs, sneezes, laughs or even speaks. It usually requires significant exposure for someone to catch the bacteria.

However, because these were sick children - including 131 infants who are under the age of two and 34 who have received transplanted organs - their resistance may be lower, making them more prone to infection.

Transplanted patients are at higher risk of infection as their immune systems are weak due to the drugs they need to take to prevent rejection of the new organ. It is not known if any of the infected children are transplant patients.

An NUH spokesman said the children with latent TB will be treated with antibiotics for nine months. She added: "As with all medications, the antibiotic may have side effects which can be monitored. The patient will be advised by his or her doctor and monitored closely."

The nurse is receiving treatment and no longer infectious.

TB is endemic here and 1,252 people here have been diagnosed with it this year.

Symptoms include persistent coughing, fever, fatigue, chills, loss of appetite and weight loss. Left untreated, it can be fatal.

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