Persons age 65 and over constitute the largest reservoir of Mycobacterium tuberculosis infection in the United States today. During 1987, 6,150 tuberculosis cases were reported among this high-risk group. These cases represent 27% of the total US tuberculosis morbidity, although this age group constitutes only 12% of the US population. Tuberculosis case rates in the United States are higher among the elderly (20.6 per 100,000) than among all other age groups (average 9.3 per 100,000).

More Americans live in nursing homes than in any other type of residential institution; on any given day approximately 5% of all elderly persons are living in a nursing home. Elderly nursing home residents are at greater risk for tuberculosis than elderly persons living in the community. In a Centers for Disease Control (CDC)-sponsored survey of 15,379 routinely-reported tuberculosis cases from 29 states, 8% of the 4,919 cases that occurred among elderly persons occurred among residents of nursing homes. The incidence of tuberculosis among nursing home residents was 39.2 per 100,000 person years, whereas the incidence of tuberculosis among elderly persons living in the community was 21.5 per 100,000. The observed rate of tuberculosis among nursing home employees was three times the rate expected in employed adults of similar age, race and sex (CDC, unpublished data).

Human T-cell lymphotropic virus type-1 (HTLV-I) is a recently recognized retrovirus identified as the cause of adult T-cell leukemia-lymphoma (ATLL) and HTLV-I-associated myelopathy (TSPI HAM). HTLV-I, a member of the Retroviridae family of viruses, was first described in 1980 after the isolation of the virus from a patient with a T-cell lymphoma. These pathogenic retroviruses are typically divided into the Oncovirinae and Lentivirinae. The oncovirus group, including HTLV-I, HTLV-II and bovine leukemia virus (BLV), is generally associated with tumors. The lentiviruses are associated with immune deficiency and/or neurologic disease, and include agents such as the visna virus of sheep and the human immunodeficiency virus type-1 and -2 HIV-1 and HIV-2).

Many hospital epidemiologists (HE) and infection control practitioners (ICPs) find criticism a product of controlling infection because as change agents, these healthcare workers are often perceived as being highly critical. Criticism of epidemiologists and ICPs may appear in a number of ways. Staff may perceive the HE/ICP in a criticizing role because monitoring duties usually require investigative behavior that can be misinterpreted as spying. Staff may feel that epidemiologists do not understand the real work situation, because HEs and ICPs often do not actively care for patients and sometimes dictate that familiar routines be replaced by new procedures. This is especially true when the new procedures appear to take more time and effort than the familiar routine. In addition, the HE/ICP may be seen as picking on certain staff members when follow-up evaluation flags staff deficiencies that must be corrected.

Criticism is a subjective perception, but staff who perceive the change agent as critical may impede the change process. All too often, staff who feel criticized get angry and defensive, and become less willing to cooperate. Instead of quickly being able to modify unacceptable staff behavior, the HE/ICP may find that staff resistance and negativism will obstruct the implementation of even a minor change. Staff energy will be spent justifying the undesired behavior. Some staff even fantasize about eliminating the roles of the epidemiologist and ICPs, and may be heard to say, “We got our work done before they came. Besides, how does all this monitoring really help patient care? With this nursing shortage, the ICP could help us more by taking part in real patient care.” The ICP and HE do not generate known income for the hospital and many times they create additional work and advocate that extra monies be spent. Consequently, even an administrator might become critical of these change agents.

The goal of antimicrobial chemotherapy is to effectively eradicate pathogenic organisms while minimizing the likelihood of drug-related adverse effects. In this era of cost containment, consideration should also be given to performing this task with the smallest total dose of drug and the shortest duration of therapy. Determination of the appropriate dose and dosing interval of an antimicrobial requires knowledge and integration of both its pharmacokinetic and pharmacodynamic properties.

There are several goals of a hepatitis B immunoprophylaxis program. Prevention of clinical disease and carrier status in healthcare workers (HCW) is the primary goal. In addition, the uncommon incidence of staff transmitting hepatitis B infection (HBV) to patients should not continue with available methods of prevention. The prevention of disease is not only desirable from a public health standpoint, it is also needed to protect health centers from liability that may result from the occurrence of preventable diseases of occupational origin, such as HBV.