Tuberculosis screening at a diabetes clinic in the Republic of the Marshall Islands.

SETTING: Tuberculosis (TB) and diabetes mellitus (DM) are prominent public health problems in the Republic of the Marshall Islands, a small island nation with high rates of tuberculosis and diabetes. OBJECTIVE: Evaluate the rate of active and latent TB in a Pacific Island DM clinic. DESIGN: In one DM clinic on the island of Ebeye, 213 adult patients aged 27-86 years completed tuberculin skin testing and TB work-up between April 2010 and March 2012. RESULTS: Screening for TB led to the diagnosis of 77 patients with TB infection and 11 patients with TB disease. From these data, the prevalence of TB disease among DM patients in the clinic exceeded 5% (95% CI 2.2%-8.1%). All patients who completed TB screening were at high risk of TB disease, and those with DM aged  ≤ 50 years had a higher risk of TB disease than those with DM over age 50 (RR 3.1, C.I. 1.0-9.7, p = 0.05). CONCLUSION: The experience at the Ebeye Diabetes Clinic demonstrates that screening DM patients for TB can identify significant rates of TB infection and TB disease, and should be considered for other settings with a high background TB incidence. Further assessment of TB risks should explore age, gender, and level of diabetes control.

Treatment for LTBI in contacts of MDR-TB patients, Federated States of Micronesia, 2009-2012.

SETTING: Few studies have shown the operational feasibility, safety, tolerability, or outcomes of multidrug-resistant latent tuberculous infection (MDR LTBI) treatment. After two simultaneous multidrug-resistant tuberculosis (MDR-TB) outbreaks in Chuuk, Federated States of Micronesia, infected contacts were offered a 12-month fluoroquinolone (FQ) based MDR LTBI treatment regimen. DESIGN: Between January 2009 and February 2012, 119 contacts of MDR-TB patients were followed using a prospective observational study design. After MDR-TB disease was excluded, 12 months of daily FQ-based preventive treatment of MDR LTBI was provided by directly observed therapy. RESULTS: Among the 119 infected contacts, 15 refused, while 104 began treatment for MDR LTBI. Of the 104 who initiated treatment, 93 (89%) completed treatment, while 4 contacts discontinued due to adverse effects. None of the 104 contacts who undertook MDR LTBI treatment of any duration developed MDR-TB disease; however, 3 of 15 contacts who refused and 15 unidentified contacts developed MDR-TB disease. CONCLUSION: Providing treatment for MDR LTBI can be accomplished in a resource-limited setting, and contributed to preventing MDR-TB disease. The Chuuk TB program implemented treatment of MDR LTBI with an 89% completion rate. The MDR LTBI regimens were safe and well tolerated, and no TB cases occurred among persons treated for MDR LTBI.

Multi-drug resistant tuberculosis in Chuuk State Federated States of Micronesia, 2008-2009.

Multi-drug resistant tuberculosis (MDR TB) is a growing public health concern, particularly for the Pacific, where rates of tuberculosis infection are extremely high. In May 2008, a cluster of patients with MDR TB were identified in Chuuk State, Federated States of Micronesia. A multi-agency investigation led to the eventual discovery of 21 cases, and over 100 latent TB infections. Incomplete implementation of Directly Observed Therapy (DOT) and contact investigation were major contributors to the outbreak. The problem of MDR TB in Chuuk was controlled only after a concerted effort on the part of multiple agencies coupled with the highest level of political commitment.

Disparities in tuberculosis between Asian/Pacific Islanders and non-Hispanic Whites, United States, 1993-2006.

SETTING: The United States (US) National Tuberculosis Surveillance System (NTSS), including 50 states, District of Columbia, and New York City. OBJECTIVE: To examine disparities in characteristics and rates of Asian/Pacific Islander (API) and non-Hispanic White tuberculosis (TB) patients. DESIGN: Descriptive analysis and logistic regression of selected 1993-2006 NTSS data. US Census Bureau Zip Code Tabulation Areas and geographic information system were used to compare API and non-Hispanic White TB patients by population density. RESULT: Of 253,299 TB cases, 19.8% were APIs and 23.2% were Whites; 94.2% APIs and 11.9% Whites were foreign-born. Factors that were most often associated with APIs were being female, age 15-24 years, extra-pulmonary TB, and drug resistance. APIs were less likely than Whites to be human immunodeficiency virus (HIV) positive, homeless, substance abusers, or on directly observed therapy. From 1993 to 2006, the API TB case rate declined by 42.9% vs. 66.6% in Whites (P < 0.01). Being foreign-born was the strongest risk factor for TB, regardless of population densities, but APIs were more likely to have TB than foreign-born Whites at lower population densities. CONCLUSION: Disparities in TB exist among US APIs and non-Hispanic Whites. TB program officials should allocate programs appropriately for foreign-born APIs in lower population density areas.