Published online by Cambridge University Press: 02 January 2015
To investigate a cluster of newly identified tuberculosis infections.
A field study was conducted including interviews; medical record reviews; checking of bills and invoices, pharmacy records, and drug manufacturer information; and clinical retesting.
Community residential facilities providing comprehensive services to retarded adults.
Twenty residential facility staff (not previously known to be purified protein derivative [PPD] positive).
Staff had been tested with 250 TU of PPD, and 9 of 20 were tuberculin positive. Retesting with 5 TU yielded no reaction.
Reactions were attributable to testing with a product not recommended for routine PPD screening. Healthcare workers planting PPD Mantoux tests always should check the vials to ensure that the appropriate strength solution is being used.