INT J TUBERC LUNG DIS 12(4):436–440

© 2008 The Union

Incidence of tuberculosis among health care workers at

a private university hospital in South Korea

K-W. Jo,* J. H. Woo,† Y. Hong,* C-M. Choi,* Y-M. Oh,* S. D. Lee,* W. S. Kim,* D. S. Kim,* W. D. Kim,*
T. S. Shim*
* Division of Pulmonary and Critical Care Medicine, † Department of Infection Control and Division of Infectious Diseases,
University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Korea

SUMMARY

SETTING: A private university hospital in South Korea.
OBJECTIVE: To investigate the incidence of tuberculosis
(TB) among health care workers (HCWs) employed at a
university hospital in South Korea.
D E S I G N : The occurrence of TB cases among HCWs over
a 6-year period (2001–2006) was reviewed. The preva-
lence of TB was compared with that of the general pop-
ulation using a prevalence ratio (PR) adjusted by age
and sex.
R E S U L T S : The study involved 8433 people. TB devel-
oped in 61 HCWs (0.72%). The prevalence ratio among
all HCWs was 1.05 (95%CI 0.80–1.35). In occupational
subgroups, the PRs for doctors, nurses and employees in
other departments were respectively 0.58 (95%CI
0.30–1.01), 1.81 (95%CI 1.21–2.59) and 0.95 (95%
CI 0.58–1.46). For nurses working in TB-related depart-
ments, the relative risk of developing TB was 3.4 times
higher (95%CI 1.52–8.25) than for employees in other
departments (P  0.005). The PR for nurses working in
TB-related department was 5.1 (95%CI 3.23–8.42).
C O N C L U S I O N : Among HCWs, nurses working in TB-
related departments were at increased risk of developing
TB. This suggests that some TB develops via in-hospital
infection.
K E Y W O R D S : tuberculosis; health care workers; hospital-
acquired infection

DESPITE RECENT PROGRESS in global control ef-
forts, tuberculosis (TB) remains a major public health
burden in many countries. TB is an established occu-
pational disease of health care workers (HCWs),1–3
and those infected may transmit the disease to suscep-
tible individuals.4,5 Recent reports suggest that HCWs
in high-prevalence countries have an increased ten-
dency to develop nosocomial TB infection.6–11 In con-
trast, where the prevalence of TB is low, the risk of
HCWs acquiring TB is likely to be small.12
The TB burden in South Korea was assessed na-
tionwide using TB prevalence surveys at 5-year inter-
vals from 1965 to 1995. These nationwide surveys re-
vealed that there has been a marked decrease in the
prevalence of smear- and/or culture-positive TB, from
940 per 100 000 population in 1965 to 219/100 000
in 1995.13 While these surveys provide reliable infor-
mation on the prevalence of TB and its trend over the
last 30 years, there were difficulties in surveying a
random sample large enough to accurately measure
the declining prevalence of TB.14,15 As a result, an
internet-based routine reporting system for TB, the
Korean TB Surveillance System (KTBS), was developed
and launched in June 2000. Physicians completed and
sent the standardised reporting form for all TB cases
to the KTBS via the internet. Based on the data col-
lected following the implementation of the KTBS, it
was presumed that TB incidence in South Korea was
in the intermediate range (92/100 000).
There has been no study of the risk of TB among
HCWs in South Korea, with the exception of a single
study restricted to laboratory technicians.16 The ob-
jective of the present study was thus to assess the oc-
cupational risk of TB among HCWs employed at a
private university hospital in South Korea, an interme-
diate TB burden country.
STUDY POPULATION AND METHODS
Subjects
The study involved a retrospective analysis of the
medical records of all HCWs employed at the Asan
Medical Centre, Seoul, South Korea, from January
2001 to December 2006. All employees who worked
at the centre for least 6 months during the study pe-
riod were investigated for the development of TB. A
list of HCWs with TB was obtained from data reported
to the Department of Infection Control at the Asan

Correspondence to: Tae Sun Shim, Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Med-
icine, Asan Medical Centre, 388-1 Pungnap-Dong, Songpa-Ku, Seoul 138-736, South Korea. Tel: (82) 2 3010 3892. Fax:
(82) 2 3010 6968. e-mail: shimts@amc.seoul.kr
Article submitted 26 November 2007. Final version accepted 21 December 2007.
 TB among Korean health care workers 437

Medical Centre and the KTBS. To obtain the list of included 5610 doctors and nurses (2389 and 3221,
HCWs with TB, the resident registration number was respectively) and 2823 persons employed in other de-
cross-matched between the lists of all HCWs and KTBS. partments, including paramedics, pharmacists, labo-
One of the several objectives of this study was to ratory technicians and office workers. The mean age
assess the incidence of active TB disease among HCWs. was 29.3  16.1 years and the male:female ratio was
In this study, TB therefore refers to active TB disease 0.52:1.
and not latent TB infection. As the tuberculin skin test TB developed in 61 HCWs (0.72%) during the
(TST) was not performed routinely at start of employ- study period. The overall incidence of TB among
ment in South Korea, we do not have previous records HCWs was therefore 723.3/100 000 and the PR was
of TST. TB was diagnosed by bacteriological culture, 1.05 (95% confidence interval [CI] 0.80–1.35). The
histological evidence of granuloma with caseation ne- mean age of the 61 tuberculous HCWs was 29.8 
crosis or clinical findings consistent with active TB. 5.9 years, females predominated (49/61, 80.3%), 41
This study was approved by the Institutional Re- were doctors or nurses (0.73%, 41/5610) and the
view Board of the Asan Medical Centre. other 20 were from other departments (0.71%, 20/
2823). The characteristics of TB occurrence among the
Bacteriological examinations HCWs are shown in the Table.
Mycobacterium tuberculosis was cultured on Ogawa TB developed in 8/5610 doctors, in 8/263 nurses
medium and identified by hybridisation methods using working in TB-related departments and in 25/2958
a commercial molecular probe (AccuProbe, Gen-Probe nurses working in other departments. There was no
Inc., San Diego, USA) or duplex PCR (Molecules and significant difference in TB prevalence between doctors
Diagnostics Inc., Wonju, South Korea). Drug suscep- (0.58, 95%CI 0.30–1.01) and nurses (1.81, 95%CI
tibility testing (DST) was carried out by the Korean 1.21–2.59). The combined prevalence ratio for doc-
Institute of Tuberculosis, a Supranational TB Refer- tors and nurses was 1.12 (95%CI 0.8–1.52), and for
ence Laboratory. personnel in other departments it was 0.95 (95%CI
0.58–1.46).
Statistical analysis Nurses comprised the only occupational subgroup
All analyses were performed using SPSS software (ver- with a high PR, with 29/3221 developing TB (0.9%,
sion 12.0, SPSS Inc., Chicago, IL, USA). Comparisons 900.3/100 000). The relative risk of developing TB
between the study and control groups were made
using Student’s t-test for continuous variables, and the
2 and Fisher’s exact tests for categorical variables. Table Clinical characteristics of health care workers with
All tests of significance were two sided; P  0.05 was tuberculosis
considered statistically significant. Occupational subgroups
The objective of this study was to assess the inci-
Doctors
dence of TB among HCWs. However, because there and nurses Others*
were more young people and females among HCWs (n  41) (n  20)
compared with the general population, it was difficult n (%) n (%) P value
to compare the results of the incidence of TB between Age, years, mean  SD 27.9  3.9 33.6  7.5 0.08
HCWs and the general population. We therefore used Sex 0.09
the prevalence ratio (PR) as a statistical technique. Male 6 (14.6) 7 (35.0)
Female 35 (85.4) 13 (65.0)
The PR was calculated as follows:
Height, cm, mean  SD 162.8  6.6 164.4  8.1 0.55
PR  (observed number of TB cases in HCWs)/ Weight, kg, mean  SD 54.5  9.2 55.2  9.3 0.27
(expected number of TB cases among South BMI, kg/m2, mean  SD 20.4  2.5 20.3  1.60 0.38
Koreans). Previous TB history 2 (4.9) 1 (5.0) 1
Smoking 4 (9.8) 4 (20.0) 0.42
As the PR was adjusted for age and sex, it was pos-
Site of TB 0.49
sible to estimate the TB incidence from the PR. (The Pulmonary TB 33 (80.5) 16 (80)
PR of the general population is always 1.) The expected TB lymphadenitis 4 (9.8) 2 (10)
number of TB cases among the South Korean popula- TB pleurisy 4 (9.8) 1 (5)
TB peritonitis 0 1 (5)
tion was derived from data from nationwide TB prev-
Comorbidity 0.95
alence surveys conducted in 1995.13 None 39 (95.1) 18 (90)
Present 2 (4.9) 2 (10)
Bronchial asthma 2 (4.9) 0
RESULTS Thyroid cancer 0 1 (5)
Gallbladder stone 0 1 (5)
Incidence of TB among HCWs
Previous TB history 2 (4.9) 1 (5) 1
Between January 2001 and December 2006, the work
force comprising those employed for 6 months at * Personnel in other departments (such as paramedics, pharmacists and
office workers).
the Asan Medical Centre was 8433 individuals. This SD  standard deviation; BMI  body mass index; TB  tuberculosis.
438 The International Journal of Tuberculosis and Lung Disease
Figure The PR of tuberculosis according to occupational sub-
groups. The PR of the general population is 1. TB  tuberculosis;
PR  prevalence ratio.
was 3.4 times higher (95%CI 1.52–8.15) for those
working in TB-related departments (medical intensive
care unit, respiratory department ward and emergency
room) compared with those working in other depart-
ments (P  0.005). The PR for nurses working in
TB-related departments was 5.1 (95%CI 3.23–8.42)
(Figure).
Clinical characteristics of HCWs who developed TB
Of the 61 HCWs who developed TB, 49 (79%) had
pulmonary TB, six (9.8%) had TB lymphadenitis and
five (8.2%) had TB pleurisy. Sputum acid-fast bacilli
(AFB) smear and bacteriological culture were per-
formed for 45 of the 49 HCWs with pulmonary TB;
positive sputum smears and cultures were obtained
from respectively seven (15.6%) and 20 (44.4%) cases.
Of 12 M. tuberculosis isolates for which DST was
carried out, 11 (91.7%) were susceptible to all avail-
able anti-tuberculosis drugs. The remaining isolate
was multidrug-resistant (MDR, defined as resistance
to both isoniazid and rifampicin). However, this MDR-
TB individual was cured with first-line drugs only.
The median period from employment at hospital
to development of TB was 894 days (range 35–6030).
All patients were cured by first-line drugs and one
(1.6%) patient had recurrence of the disease 4 years
after treatment completion.
DISCUSSION
In the present study, we determined the occupational
risk of TB in the work force of a private university
hospital in South Korea, a country with an intermedi-
ate TB burden. This is the first study to investigate the
incidence of TB in HCWs in Korea. The most impor-
tant finding was that TB developed much more fre-
quently in nurses working in TB-related departments
compared to the general population or HCWs in other
departments, suggesting occupational acquisition of
TB rather than reactivation of latent TB. Because em-
ployees did not undergo TSTs to detect TB infection
when they were hired, we do not know whether HCWs
with TB disease are already infected before starting
work at this hospital or whether they were newly in-
fected with M. tuberculosis afterwards. However, the
finding that more TB patients were detected in TB-
related departments than in other departments sug-
gests that some of the HCWs developed the disease
via hospital infection.
There was no significant difference in the PR be-
tween HCWs and the general population. However,
among occupational subgroups, the PR for nurses was
higher than that of doctors and employees in other
departments (including office workers), and was no-
tably higher among nurses working in TB-related de-
partments (medical intensive care unit, respiratory
department ward and emergency room). This finding
is consistent with previous reports showing that TB
risk among medical nurses employed in specialised
lung disease institutions is higher than among those in
non-exposed institutions.6,7,17
The reported rates of TB in different groups of
HCWs in TB-endemic countries have varied widely,
with a higher risk of TB in HCWs reported by some
studies and a lower risk by others. For example,
Kruuer et al. showed that the TB risk among HCWs
in Estonia was higher than in the general population.9
Similar results have been obtained in studies in Serbia8
and Japan,18 while opposite results were obtained in
two other studies.19,20 There is a general trend for TB
risk among HCWs to be related to the TB incidence in
the country concerned. As South Korea is an interme-
diate TB burden country, our result is consistent with
previous studies.
To stop the spread of TB in hospitals, several pre-
ventive strategies should be implemented: administra-
tive, engineering and personal respiratory protection.21
In the hospital used for this study, infectious TB pa-
tients are placed in isolation rooms equipped with
ultraviolet germicidal irradiation (UVGI) and negative
pressure ventilation. HCWs or visitors who enter the
isolation room are required to wear N-95 respirators.
All HCWs undergo an annual chest X-ray, but annual
TSTs are performed only in nurses working in TB-
related wards. The results of this study suggest that
stricter preventive strategies, such as contact investi-
gations of active TB disease, the installation of an iso-
lation room in the emergency room, and latent TB in-
fection screening by TST at the time of hiring should
be implemented for all HCWs.
The present study had several limitations. The in-
cidence of TB in HCWs in the hospital was determined
from reports to the Department of Infection Control
at the Asan Medical Centre and the KTBS. It is there-
fore possible that the incidence of TB was underesti-
mated due to incomplete reporting. Second, when

calculating the PR, the expected number of TB cases
in the general population was derived from data from
the last nationwide TB prevalence survey, performed
in 1995. However, as the incidence of TB has been de-
creasing over the past 10 years in South Korea, it is
likely that there were fewer TB patients in the study
period than in 1995, resulting in an underestimation
of PR for HCWs. Third, this study was carried out in
only one hospital and may not represent the situation
in South Korean medical institutions in general. How-
ever, the hospital in which this study was performed is
the biggest and one of the best equipped in Korea,
which suggests that the situation in Korean hospitals
may be more serious than this study concludes.
In conclusion, among HCWs in a hospital in South
Korea, only nurses, particularly those working in TB-
related departments, were more likely to develop TB
than individuals in the general population. Stricter pre-
ventive strategies against the spread of TB in hospitals
need to be implemented.
Acknowledgement
The authors acknowledge the support of the Department of Infec-
tion Control at the Asan Medical Centre.
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RÉSUMÉ
les infirmières et les autres types d’HCW a été respective-
ment de 0,58 (IC95% 0,30–1,01), 1,81 (IC95% 1,21–
2,59) et 0,95 (IC95% 0,58–1,46). Pour les infirmières
travaillant dans des départements en relation avec la TB,
le risque relatif de développer une TB a été 3,4 fois
supérieur (IC95% 1,52–8,25) à celui des employés d’au-
tres départements (P  0,005). Le PR pour les in-
firmières travaillant dans un département en relation
avec la TB a été de 5,1 (IC95% 3,23–8,42).
C O N C L U S I O N : Parmi les HCW, les infirmières travail-
lant dans des départements en relation avec la TB en-
courent un risque accru de développer la TB. Ceci sug-
gère qu’un certain nombre de cas de TB apparaissent à
la suite d’une infection hospitalière.
440 The International Journal of Tuberculosis and Lung Disease
MARCO DE REFERENCIA : Un hospital universitario pri-
vado en Corea del Sur.
O B J E T I V O : Investigar la incidencia de tuberculosis (TB)
en los profesionales de la salud empleados en un hospital
universitario en Corea del Sur.
M É T O D O S : Se analizó la ocurrencia de casos de TB du-
rante un periodo de 6 años (2001–2006) en los profe-
sionales de la salud. La prevalencia de TB se comparó
con la prevalencia en la población general mediante el co-
ciente de prevalencia (PR) ajustado según la edad y el sexo.
R E S U L T A D O S : En el estudio se incluyeron 8433 perso-
nas. Sesenta y un profesionales de la salud presentaron
TB (0,72%). El PR en todos los proveedores de salud fue
1,05 (IC95% 0,80–1,35). En subgrupos por ocupaciones,
RESUMEN
el PR fue 0,58 (IC95% 0,30–1,01) para los médicos,
1,81 (IC95% 1,21–2,59) para el personal de enfermería
y 0,95 (IC95% 0,58–1,46) para los empleados en otros
departamentos. El riesgo relativo de TB en el personal
de enfermería de departamentos relacionados con la TB
fue 3,4 veces mayor (IC95% 1,52–8,25) que el de los
empleados en otros departamentos (P  0,005). El PR
en el personal de enfermería de departamentos relacio-
nados con la TB fue 5,1 (IC95% 3,23–8,42).
C O N C L U S I Ó N : En los profesionales de la salud, el per-
sonal de enfermería que trabaja en departamentos rela-
cionados con la TB presentó un riesgo más alto de TB.
Esto indica que parte de los casos de TB se adquiere por
infección intrahospitalaria.