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1.
MMWR Morb Mortal Wkly Rep ; 72(35): 957-960, 2023 Sep 01.
Article in English | MEDLINE | ID: mdl-37651293

ABSTRACT

An outbreak of multidrug-resistant (MDR) tuberculosis (TB) involved 13 persons in four households in a low-income, under-resourced urban Kansas community during November 2021-November 2022. A majority of the seven adults identified in the Kansas outbreak were born outside the United States in a country that had experienced an MDR TB outbreak with the same genotype during 2007-2009, whereas most of the six children in the Kansas outbreak were U.S.-born. Prompt identification, evaluation, and treatment of persons with MDR TB and their contacts is essential to limiting transmission.


Subject(s)
Disease Outbreaks , Tuberculosis, Multidrug-Resistant , Adult , Child , Humans , Kansas/epidemiology , Genotype , Poverty , Tuberculosis, Multidrug-Resistant/epidemiology
2.
J Clin Tuberc Other Mycobact Dis ; 11: 37-46, 2018 May.
Article in English | MEDLINE | ID: mdl-31720390

ABSTRACT

Background : Optimal screening and management of latent tuberculosis infection (LTBI) and active tuberculosis (TB) in solid organ transplant (SOT) candidates and recipients is necessary to prevent morbidity and mortality. Methods : We conducted a cross-sectional survey of TB and transplant experts across the United States reviewing the clinical practice preferences on key management issues related to LTBI and TB in SOT candidates and recipients. Results : Thirty TB and 13 SOT experts were surveyed (response rate = 53.8%). Both groups agreed that tuberculin skin test (TST) and chest x-ray screening in SOT candidates was useful (78.6% and 84.6%, respectively). TST after SOT was not useful for most transplant experts and TB experts (0% vs. 32.1%, respectively), but both groups were split on usefulness of interferon gamma release assays (IGRA) in SOT recipients (42.9% TB experts vs. 46.2% SOT experts). Most experts recommend LTBI treatment prior to SOT if close monitoring is assured (82.1% TB experts vs. 76.9% transplant experts). LTBI treatment with isoniazid was preferred for patients on calcineurin inhibitors. Evaluation for suspected TB in SOT recipients varied, but most TB experts favored sputum testing (88.9%) whereas most transplant experts favored bronchoscopic testing (69.2%). Preferred TB treatment regimens in SOT recipients were similar to regimens recommended for immunocompetent patients. Conclusions : Most TB and transplant experts recommend evaluation and treatment for LTBI in SOT candidates. Liver transplant candidates, however, should only be treated if close monitoring can be assured and after consulting with a hepatologist. Practice preferences varied regarding the initial diagnostic approach for suspected TB in SOT recipients; however, most experts agreed that SOT recipients should receive similar treatments as immunocompetent patients.

3.
Microbiol Spectr ; 5(2)2017 03.
Article in English | MEDLINE | ID: mdl-28361737

ABSTRACT

The global epidemic of multidrug-resistant tuberculosis (MDR-TB) caused by Mycobacterium tuberculosis strains resistant to at least isoniazid and rifampin was recently reported as larger than previously estimated, with at least 580,000 new cases reported in 2015. Extensively drug-resistant tuberculosis (XDR-TB), MDR-TB with additional resistance to a second-line fluoroquinolone and injectable, continues to account for nearly 10% of MDR cases globally. Cases in India, China, and the Russian Federation account for >45% of the cases of MDR-TB. Molecular testing helps identify MDR more quickly, and treatment options have expanded across the globe. Despite this, only 20% are in treatment, and treatment is challenging due to the toxicity of medications and the long duration. In 2016 the World Health Organization updated guidelines for the treatment of MDR-TB. A new short-course regimen is an option for those who qualify. Five effective drugs, including pyrazinamide (PZA) when possible, are recommended during the initial treatment phase and four drugs thereafter. Revised drug classifications include the use of linezolid and clofazimine as key second-line drugs and the option to use bedaquiline and delamanid to complete a five-drug regimen when needed due to poor medication tolerance or extensive resistance. Despite multiple drugs and long-duration treatment regimens, the outcomes for MDR and especially XDR-TB are much worse than for drug-susceptible disease. Better management of toxicity, prevention of transmission, and identification and appropriate management of infected contacts are important challenges for the future.


Subject(s)
Antitubercular Agents/therapeutic use , Drug Therapy, Combination/methods , Tuberculosis, Multidrug-Resistant/drug therapy , Global Health , Humans , Practice Guidelines as Topic , Tuberculosis, Multidrug-Resistant/diagnosis , Tuberculosis, Multidrug-Resistant/epidemiology , World Health Organization
4.
Ann Am Thorac Soc ; 11(3): 286-95, 2014 Mar.
Article in English | MEDLINE | ID: mdl-24673692

ABSTRACT

Healthcare and humanitarian workers who travel to work where the incidence of multidrug-resistant tuberculosis (MDR TB) is high and potential transmission may occur are at risk of infection and disease due to these resistant strains. Transmission occurs due to inadequate transmission control practices and the inability to provide timely and accurate diagnosis and treatment of persons with MDR TB. Patients risk exposure if active TB is unrecognized in workers after they return to lower-risk settings. Guidance for risk reduction measures for workers in high-risk areas is limited, and no studies confirm the efficacy of treatment regimens for latent TB infection due to MDR TB. Bacille Calmette-Guérin (BCG) vaccination decreases the risk of active TB and possibly latent infection. IFN-γ release assays differentiate TB infection from BCG vaccination effect. A series of risk reduction measures are provided as a potential strategy. These measures include risk reductions before travel, including risk assessment, TB screening, education, respirator fit testing, and BCG vaccination. Measures during travel include use of respirators in settings where this may not be common practice, transmission control practices, triaging of patients with consistent symptoms, providing education for good cough etiquette, and provision of care in well-ventilated areas, including open air areas. Risk reduction measures after return include TB screening 8 to 10 weeks later and recommendations for management of latent TB infection in areas where the likelihood of MDR TB exposure is high.


Subject(s)
Altruism , Communicable Disease Control/organization & administration , Health Personnel , Risk Reduction Behavior , Travel , Tuberculosis, Multidrug-Resistant/prevention & control , BCG Vaccine , Health Knowledge, Attitudes, Practice , Humans , Respiratory Protective Devices , Risk Assessment , Tuberculosis, Multidrug-Resistant/diagnosis , Tuberculosis, Multidrug-Resistant/transmission
6.
Infect Control Hosp Epidemiol ; 34(6): 625-30, 2013 Jun.
Article in English | MEDLINE | ID: mdl-23651895

ABSTRACT

On June 13, 2012, a group of key stakeholders, leaders, and national experts on tuberculosis (TB), occupational health, and laboratory science met in Atlanta, Georgia, to focus national discussion on the higher than expected positive results occurring among low-risk, unexposed healthcare workers undergoing serial testing with interferon-γ release assays (IGRAs). The objectives of the meeting were to present the latest clinical and operational research findings on the topic, to discuss evaluation and treatment algorithms that are emerging in the absence of national guidance, and to develop a consensus on the action steps needed to assist programs and physicians in the interpretation of serial testing IGRA results. This report summarizes its proceedings.


Subject(s)
Interferon-gamma Release Tests/standards , Occupational Health , Practice Guidelines as Topic , Tuberculosis/diagnosis , Health Care Sector , Humans , ROC Curve , Tuberculosis/drug therapy , Tuberculosis/prevention & control , United States
7.
Clin Infect Dis ; 51(11): 1298-305, 2010 Dec 01.
Article in English | MEDLINE | ID: mdl-21039283

ABSTRACT

With the recent emphasis on funding and training opportunities for global health and humanitarian aid and the increased interest in the field, many health care workers and medical researchers are traveling from resource-replete to resource-limited settings. This type of travel brings unique disease risks not routinely considered for the business or vacationing traveler. This review provides practical advice for this special population of travelers, targeted to specific health care-related risks (needlestick, hemorrhagic fever viruses, severe viral respiratory disease, and tuberculosis), with suggestions for risk mitigation.


Subject(s)
Communicable Disease Control/methods , Communicable Diseases/transmission , Health Personnel , Research Personnel , Travel , Developing Countries , Humans
8.
Expert Rev Anti Infect Ther ; 3(6): 995-1010, 2005 Dec.
Article in English | MEDLINE | ID: mdl-16307511

ABSTRACT

Tuberculosis remains one of the top two causes of death caused by a single infectious disease worldwide, despite curative therapy. Children with tuberculosis are especially difficult to detect, since acid fast bacilli smears and cultures are usually negative and clinical signs are nonspecific or lacking. Multidrug-resistant tuberculosis, or tuberculosis resistant to at least isoniazid and rifampin, has emerged in most areas of the world over the past 20 years. Treatment of multidrug-resistant tuberculosis is more expensive and difficult. The second-line tuberculosis medications required for treatment are more toxic and less efficacious than standard treatment. These medications are not readily available in many areas of the world where drug resistance is most common. Fluoroquinolones are one of the most promising classes of second-line medications, but are not generally recommended for use in children. Ethambutol is recommended in the initial treatment of tuberculosis in children treated in areas where there is a risk of drug-resistant disease and the susceptibility of the source case is not known. Some experts have been hesitant to use ethambutol due to the risk of visual impairment associated with the drug and the difficulties in monitoring vision in young children. Pediatric drug formulations are not available for most antituberculosis medications, even the first-line tuberculosis drugs. Treatment of children exposed, infected or ill with multidrug-resistant tuberculosis is reviewed with special emphasis on second-line drugs, including recommended dosage, available formulations and necessary monitoring. While new cases of multidrug-resistant tuberculosis have decreased in most developed countries over the past 10 years, cases continue to increase in many developing countries and among immigrants from high-risk areas. Tuberculosis and multidrug-resistant tuberculosis are serious threats requiring worldwide strategies to control and treat. Better diagnostic tests, medications, public health strategies and vaccines will all be needed to eliminate tuberculosis.


Subject(s)
Antitubercular Agents/therapeutic use , Tuberculosis, Multidrug-Resistant/drug therapy , Animals , Antitubercular Agents/adverse effects , Antitubercular Agents/pharmacology , Child , Humans , Tuberculosis/drug therapy , Tuberculosis/epidemiology , Tuberculosis, Multidrug-Resistant/epidemiology
10.
J Clin Microbiol ; 40(8): 2716-24, 2002 08.
Article in English | MEDLINE | ID: mdl-12149319

ABSTRACT

To examine the transmission of drug-resistant (DR) tuberculosis between Texas and Mexico, Mycobacterium tuberculosis isolates resistant to one or more of the first-line antimycobacterial drugs were obtained from 606 patients who resided in Texas and 313 patients who resided in Mexico, primarily within the state of Tamaulipas. The isolates were genotyped by IS6110-based restriction fragment length polymorphism (RFLP) analysis and spoligotyping. Of the 919 isolates genotyped, 413 (45%) grouped into 105 clusters containing 2 or more isolates with identical genotypes. In addition to having identical genotypes, identical drug resistance patterns were identified in 250 isolates in 78 clusters (DR clusters). Twenty DR clusters, containing isolates from 32% of the total number of patients infected with DR strains, were geographically distributed across Mexico and Texas. Within this population of 919 patients infected with DR isolates, the probability of being in a DR cluster was the same for residents of Mexico and Texas. In Texas, the significant independent predictors of clustering within DR clusters as opposed to genotype clusters were found to be race, age, country of birth, human immunodeficiency virus (HIV) infection status, and resistance to more than one drug. Specifically, isolates from African Americans, individuals under age 65, individuals born in the United States, and HIV-positive individuals were each more likely to be associated with a DR cluster. By contrast, no significant independent predictors of clustering in a DR cluster were identified in Mexico. Although some DR M. tuberculosis strains are geographically restricted, this study suggests that a number of strains are transmitted between Mexico and the United States.


Subject(s)
Antitubercular Agents/pharmacology , Drug Resistance, Bacterial , Mycobacterium tuberculosis/drug effects , Tuberculosis, Multidrug-Resistant/transmission , Tuberculosis, Pulmonary/transmission , Adolescent , Adult , DNA Transposable Elements/genetics , Female , Genotype , Humans , Male , Mexico/epidemiology , Microbial Sensitivity Tests , Middle Aged , Mycobacterium tuberculosis/classification , Mycobacterium tuberculosis/genetics , Mycobacterium tuberculosis/isolation & purification , Polymorphism, Restriction Fragment Length , Texas/epidemiology , Tuberculosis, Multidrug-Resistant/microbiology , Tuberculosis, Pulmonary/microbiology
11.
Infect Dis Clin North Am ; 16(1): 73-105, 2002 Mar.
Article in English | MEDLINE | ID: mdl-11917817

ABSTRACT

Multidrug-resistant TB is a growing public health problem. Although control of the multidrug-resistant TB epidemic has been achieved in New York City, strains of multidrug-resistant TB are found in nearly every state. Much of the world faces a growing problem with no immediate solution. The treatment habits and policies that have led to this problem persist. New drug development has been almost nonexistent. The current tremendous global interest offers hope, as does the Global Alliance for Tuberculosis Drug Development supported by the Rockefeller Foundation and the Bill and Melinda Gates Foundation. Their mission is to accelerate the discovery and development of new antituberculosis drugs and put them on the market within 10 years, at prices affordable in less-developed countries. As Dr. Reichman notes, "this action will not address the main underlying cause of almost all drug resistance, non-adherence of patients and doctors to recommended regimens." He calls for an equal commitment to improving the capacity of health care workers to use new and older agents correctly, so that they may continue to be effective in the future. Each year brings new, at-risk immigrants to the United States from all regions of the globe. They bring all the TB problems of their countries of origin with them. Foreign-born people will have a significant impact on TB control efforts in the next decade and beyond. TB elimination programs will need to incorporate systems that can adequately address TB within the United States and support national TB programs in developing countries to help them develop the capacity to successfully manage their own TB problems. A review of the drug resistance patterns isolated from foreign-born people should be adequate to convince even skeptics of the need to support global TB programs.


Subject(s)
Tuberculosis, Multidrug-Resistant , Humans , Tuberculosis, Multidrug-Resistant/drug therapy , United States/epidemiology
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