Occupational transmission of Mycobacterium tuberculosis to health care workers in a university hospital in Lima, Peru.

From November 1996 through March 1997, presumptive active pulmonary tuberculosis (TB) was detected in 44 health care workers (HCWs) at a university hospital in Lima, Peru. To further assess the magnitude of the outbreak and determine risk factors for occupational Mycobacterium tuberculosis transmission, we identified HCWs in whom active pulmonary TB was diagnosed from January 1994 through January 1998, calculated rates by year and hospital work area, and conducted a tuberculin skin test (TST) survey. Thirty-six HCWs had confirmed active pulmonary TB. The rate of TB was significantly higher among the 171 HCWs employed in the laboratory than among HCWs employed in all other areas. In multivariate analysis, the only independent risk factor for HCW M. tuberculosis infection in HWCs employed in the laboratory was the use of common staff areas. Very high rates of active pulmonary TB were detected among HCWs at this hospital, and occupational acquisition in the laboratory was associated with HCW-to-HCW transmission.

Drug-resistant tuberculosis in foreign-born persons from Mexico, the Philippines, and Vietnam-United States, 1993-1997.

SETTING: Foreign-born persons in the United States represent a growing proportion of the nation's tuberculosis (TB) cases. OBJECTIVE: To characterize drug resistance patterns in foreign-born TB patients from the three most common birth countries. DESIGN: A descriptive analysis of national TB surveillance data for 1993-1997. TB case reports for foreign-born persons who were at least 15 years old and born either in Mexico (6221), the Philippines (3624), or Vietnam (3351) were included. RESULTS: Among those with no prior history of TB, the proportions with isoniazid-resistant TB and MDR-TB (resistance to at least isoniazid and rifampin) were 9.2% and 1.6% for persons from Mexico, 13.7% and 1.4% for those from the Philippines, and 17.8% and 1.4% for those from Vietnam. Levels of isoniazid resistance and MDR-TB did not change during the 5-year study period. Levels of isoniazid resistance decreased with older age for persons with no prior TB from all three countries; however, rates of MDR-TB did not vary with age. Persons with <1 year of residence in the US were more likely to have MDR-TB; however, duration of residence in the US was not associated with isoniazid resistance. CONCLUSION: Increased drug resistance in younger and more recent arrivals suggests that vigorous efforts to prevent further development of MDR-TB in the three countries are essential.

Survey of drug resistance of Mycobacterium tuberculosis in 3 Mexican states, 1997.

BACKGROUND: Drug resistance threatens global tuberculosis (TB) control efforts. Population-based estimates of drug resistance are needed to develop strategies for controlling drug-resistant TB in Mexico. OBJECTIVE: To obtain population-based data on Mycobacterium tuberculosis drug resistance in Mexico. METHODS: To obtain drug resistance data, we conducted a population-based study of TB cases in the states of Baja California, Sinaloa, and Oaxaca, Mexico. We performed cultures and drug susceptibility testing on M tuberculosis isolates from patients with newly diagnosed, smear-positive TB from April 1 to October 31, 1997. RESULTS: Mycobacterium tuberculosis was isolated from 460 (75%) of the 614 patients. Levels of resistance in new and retreatment TB cases to 1 or more of the 3 current first-line drugs used in Mexico (isoniazid, rifampin, and pyrazinamide) were 12.9% and 50.5%, respectively; the corresponding levels of multi-drug-resistant TB were 2.4% and 22.4%. Retreatment cases were significantly more likely than new cases to have isolates resistant to 1 or more of the 3 first-line drugs (relative risk [RR], 3.9; 95% confidence interval [CI], 2.8-5.5), to have isoniazid resistance (RR, 3.6; 95% CI, 2.5-5.2), and to have multi-drug-resistant TB (RR, 9.4; 95% CI, 4.3-20.2). CONCLUSIONS: This population-based study of M tuberculosis demonstrates moderately high levels of drug resistance. Important issues to consider in the national strategy to prevent M tuberculosis resistance in Mexico include consideration of the most appropriate initial therapy in patients with TB, the treatment of patients with multiple drug resistance, and surveillance or periodic surveys of resistance among new TB patients to monitor drug resistance trends.

Patterns of health seeking behavior during episodes of childhood diarrhea: a study of Tzotzil-speaking Mayans in the highlands of Chiapas, Mexico.

In Chiapas, Mexico, diarrheal disease causes the majority of all deaths in children under the age of five. Treatment of childhood diarrhea may be influenced by local beliefs and cultural practices. Few studies have attempted to quantitatively evaluate health seeking behavior (HSB) for diarrheal diseases in indigenous communities, while controlling for potential confounding factors such as parental education or socioeconomic status. A rapid ethnographic survey was conducted in Nabenchauc, Chiapas, to determine hypothetical HSB patterns for each of four major types of childhood diarrhea. Additionally, we examined the actual HSB for the last episode of childhood diarrheal illness within the household. One hundred households participated in the survey; 94 households with children < 5 years old reported a mean of 1.9 diarrheal episodes during the preceding month. Households reported using a mean of 1.3 types of in-home remedies. Oral rehydration therapy (ORT) was used in <2% of the 368 HSB patterns elicited for the four types of diarrhea. HSB patterns utilized an eclectic combination of traditional, allopathic, local and distant health care options. A mean of 2.5 outside-the-home health care options were reported for each diarrheal type; the local grocery store was reported in 245 (67%) of the hypothetical HSB patterns and as a first option in 199 (54%). Maternal and/or paternal education had little impact on hypothetical HSB. Households with lower SES were more likely to report using local grocery stores as a first option and were less likely to use options outside the village. The rapid ethnographic survey approach allows for assessment of changes in the approach to health care option utilization in cultures incorporating new health care paradigms. Public health interventions targeting local stores may lead to increased use of ORT, thereby potentially reducing early morbidity and mortality due to childhood diarrhea.

Tuberculosis among foreign-born residents of southern Florida, 1995.

OBJECTIVE: To examine the characteristics of foreign-born people with tuberculosis (TB) in Southern Florida, their contribution to the total number of TB cases, and available data on their HIV status as well as to determine the number of cases detected by the overseas medical screening of immigrants and refugees. METHODS: The authors reviewed TB cases reported by Broward, Dade, and Palm Beach counties in 1995. Case records were matched against the CDC Division of Quarantine database of immigrants and refugees suspected to have TB at the time of visa application overseas. RESULTS: Nearly half (49%) of TB cases in the three counties were among people born outside the United States--34% in Broward County, 58% in Dade County, and 40% in Palm Beach County. A high percentage (26%) were co-infected with HIV. Of those with known date of arrival, 68% had been in the United States for five or more years. Only three cases had been identified by overseas immigrant screening. CONCLUSIONS: A low percentage of TB cases in foreign-born people were identified through the overseas screening system. Controlling TB in South Florida will require efforts targeted toward high risk populations, including people with HIV infection.

Cuba's national AIDS program. The first decade.

There is a high incidence of infection with the human immunodeficiency virus (HIV) in many Caribbean nations. But by 1993 Cuba, with a population of greater than 10 million people, had fewer than 1,000 seropositive persons and less than 200 cases of the acquired immunodeficiency syndrome (AIDS). To investigate Cuba's approach to the AIDS epidemic, we visited Cuba, reviewed published statistics, spoke with health care officials, interviewed HIV-positive patients, and toured medical facilities. Cuba established an extensive HIV surveillance program in 1983, and more than 15 million HIV antibody tests have been done. The sexual contacts of all infected persons are closely observed. A national education program is evolving. Since 1986, all known HIV-positive patients have been placed in sanitariums, which is the most controversial aspect of Cuba's program. We review available information on AIDS in Cuba and describe that nation's attempt to prevent the spread of disease. We discuss how the political system and Cuba's relative isolation have influenced this approach. Strategies have been developed that may be of limited efficacy and would not be acceptable in most Western nations.