Tuberculosis in physicians: compliance with surveillance and treatment

Physicians have historically shown poor compliance with tuberculosis (TB) skin testing and treatment after infection. Studies showed that nearly one half of physicians had positive skin test results, but one half to two thirds of physicians with negative tuberculin skin test results did not undergo annual skin testing despite significant exposure to patients with TB. Compliance with chemoprophylaxis after skin test conversion was worse; only 8% to 10% of physicians with a positive tuberculin skin test result received antituberculous therapy. The Centers for Disease Control and Prevention published guidelines on prevention of tuberculosis transmission recommending that all health care workers (including physicians) comply with regular skin testing and get appropriate follow-up care. The Occupational Safety and Health Administration has adopted the guidelines as part of its strategy to prevent occupationally acquired TB. OSHA's requirement provided the opportunity to study the effect on physicians of hospital-wide attempts to apply those guidelines. No previous study has looked at the differences in compliance between physicians in training, full-time staff physicians, and part-time staff (associate physicians). Understanding these differences will enable the hospital's administration to target efforts to improve compliance with TB surveillance and medical therapy after skin test conversion.

Two hundred eighty-four physicians (189 staff physicians, 65 resident physicians, and 30 associate physicians) responded to a questionnaire that asked about demographic and professional characteristics, current status of tuberculin skin test results, and follow-up of physicians with positive skin test results.

We found that 71% of resident and full-time physicians were current in their tuberculin skin test status, whereas 66% of associate physicians were up to date. Thirteen percent of the resident and full-time physicians had positive TB skin test results, compared with 20% of associate physicians. Female physicians had a lower prevalence of positive skin test results than did male physicians. The departments of pathology, surgery, and pediatrics had the highest prevalence of positive test results, followed by radiology, emergency medicine, and obstetrics and gynecology. Family practice and internal medicine were among the departments with the lowest prevalence of positive skin test results. Physicians obtained their skin tests from multiple sources and had their test results interpreted in multiple facilities; hence, the test procedure was not uniform. Compliance with disease prophylaxis was 55% among the resident physicians with positive Mantoux test results, 44% among the full-time staff physicians, and only 17% among the associate physicians. More than half of the physicians with positive Mantoux test results remained untreated.

Physicians have unique issues in complying with TB surveillance that need to be specifically addressed by hospitals in light of guidelines enforceable by the Occupational Safety and Health Administration. Resident physicians were the most compliant with TB surveillance and treatment after infection. Staff and associate staff physicians had poor compliance with treatment. Although this study shows some improvement when compared with prior studies on physician compliance, hospital follow-up and enforcement may be necessary to bring about significant behavioral change among physicians.