Extensive transmission of Mycobacterium tuberculosis among congregated, HIV-infected prison inmates in South Carolina, United States.

BACKGROUND: In August 1999, a prison inmate infected with the human immunodeficiency virus (HIV) was diagnosed with pulmonary tuberculosis (TB). This source patient lived in a prison dormitory housing over 300 HIV-infected men, and was symptomatic for at least 2 months prior to diagnosis. We report a large outbreak of TB in HIV-infected prison inmates with subsequent transmission of Mycobacterium tuberculosis outside the prison. METHODS: Exposed inmates were screened by symptom review, chest radiograph and tuberculin skin test (TST) in September and December 1999. We recorded CD4 cell counts, viral loads and receipt of highly active antiretroviral therapy (HAART). RESULTS: The source patient lived on the right side of a two-sided dormitory exclusively housing HIV-infected men. Of 114 men tested from the right side, 75 (66%) had documented TST conversions. Of 96 converters overall, 82 (85%) had TSTs measuring > or = 15 mm. Within 6 months of diagnosis of TB in the source patient, 30 additional inmates and a healthcare worker who cared for the source patient developed TB disease. Two other inmates developed TB disease in spring of 2001. CONCLUSIONS: We describe extensive transmission of M. tuberculosis in a group of HIV-infected prison inmates with high TST conversion rates and subsequent transmission in the community. In settings where HIV-infected persons are congregated, the consequences of TB outbreaks are magnified.

Drug-drug interactions in inmates treated for human immunodeficiency virus and Mycobacterium tuberculosis infection or disease: an institutional tuberculosis outbreak.

The use of rifamycins is limited by drug interactions in human immunodeficiency virus (HIV)-infected persons who are receiving highly active antiretroviral therapy (HAART). During a tuberculosis (TB) outbreak at a prison housing HIV-infected inmates, rifabutin was used to treat 238 men (13 case patients and 225 contacts). Steady-state peak plasma rifabutin concentrations were obtained after rifabutin dosages were adjusted for men receiving single-interacting HAART (with either 1 protease inhibitor [PI] or efavirenz), multi-interacting HAART (with either 2 PIs or > or =1 PI with efavirenz), and for noninteracting HAART (>1 nucleoside reverse-transcriptase inhibitor or no HAART) without rifabutin dose adjustments. Low rifabutin concentrations occurred in 9% of those receiving noninteracting HAART, compared with 19% of those receiving single-interacting and 29% of those receiving multi-interacting HAART (chi2, 3.76; P=.05). Of 225 contacts treated with rifabutin-pyrazinamide, 158 (70%) completed treatment while incarcerated. Rifabutin-pyrazinamide therapy was difficult to implement, because of the need for dosage adjustments and expert clinical management.

Spread of strain W, a highly drug-resistant strain of Mycobacterium tuberculosis, across the United States.

Strain W, a highly drug-resistant strain of Mycobacterium tuberculosis, was responsible for large nosocomial outbreaks in New York in the early 1990s. To describe the spread of strain W outside New York, we reviewed data from epidemiologic investigations, national tuberculosis surveillance, regional DNA fingerprint laboratories, and the Centers for Disease Control and Prevention Mycobacteriology Laboratory to identify potential cases of tuberculosis due to strain W. From January 1992 through February 1997, 23 cases were diagnosed in nine states and Puerto Rico; 8 were exposed to strain W in New York before their diagnosis; 4 of the 23 transmitted disease to 10 others. Eighty-six contacts of the 23 cases are presumed to be infected with strain W; 11 completed alternative preventive therapy. Strain W tuberculosis cases will occur throughout the United States as persons infected in New York move elsewhere. To help track and contain this strain, health departments should notify the Centers for Disease Control and Prevention of cases of tuberculosis resistant to isoniazid, rifampin, streptomycin, and kanamycin.

Correlates of hepatotoxicity and antituberculosis therapy in South Carolina.

This study revealed that 20-30 percent of TB patients who were taking antituberculosis therapy developed elevated liver function tests. Half of the elevation in liver enzyme values occurred within the first two months of treatment. No statistically significant differences between sex, race and liver toxicity was found in this study. The time from initiation of treatment for TB to development of hepatotoxicity was shorter for females and whites. Physicians and public health workers should monitor the liver function tests of TB patients who are taking antituberculosis treatment. Recommendations for monitoring hepatotoxicity vary depending on the age of the patients. For patients less than 35 years old, monthly symptom review for jaundice, acholic stools, fever, anorexia, nausea and vomiting, may be adequate. For older patients, liver function tests are recommended monthly or every one to two months.

Transmission of a highly drug-resistant strain (strain W1) of Mycobacterium tuberculosis. Community outbreak and nosocomial transmission via a contaminated bronchoscope.

CONTEXT: Nosocomial transmission of multidrug-resistant tuberculosis (MDR TB) has been reported primarily in New York State and has generally been presumed to occur via respiratory aerosols. OBJECTIVE: To assess nosocomial transmission of MDR TB. In 1995, 8 patients with MDR TB were identified in South Carolina; all were resistant to 7 drugs and had matching DNA fingerprints (strain W1). Community linkswere identified for 5 patients (Patients 1-5). However, no links were identified forthe other 3 patients (Patients 6-8) except being hospitalized at the same hospital as 1 community patient. DESIGN: Outbreak investigation. SETTING: Community and hospital. PATIENTS: Eight patients whose MDR TB isolates had DNA fingerprint patterns matching strain W1. MAIN OUTCOME MEASURES: Clinical characteristics of patients with strain W1 Mycobacterium tuberculosis isolates. RESULTS: Patient 5 (community patient) and Patient 8, diagnosed April 1995 and November 1995, respectively, had clinical courses consistent with MDR TB, with smear-positive and culture-positive specimens and cavitary lesions on chest radiograph; both died of MDR TB less than 1 month after diagnosis. Patients 6 and 7 (diagnosed May 1995) each had 1 positive culture for MDR TB; specimens were collected during bronchoscopy. Patient 6 had a skin test conversion after bronchoscopy. Neither Patient 6 nor Patient 7 had a clinical course consistent with MDR TB, neither was treated for MDR TB, and both are alive and well. No evidence of laboratory contamination of specimens, transmission on inpatient wards, or contact among patients was found. All 4 received bronchoscopies in May 1995; Patients 6, 7, and 8 had bronchoscopies 1, 12, and 17 days, respectively, after Patient 5. Observations revealed that bronchoscope cleaning was inadequate, and the bronchoscope was never immersed in disinfectant. CONCLUSIONS: Inadequate cleaning and disinfection of the bronchoscope after the procedure performed on Patient 5 led to subsequent false-positive cultures in Patients 6 and 7 and transmission of infection to Patient 6 and active MDR TB to Patient 8.

Tuberculous pleurisy is more common in AIDS than in non-AIDS patients with tuberculosis.

OBJECTIVE: To investigate the incidence, clinical features, and treatment of tuberculous pleurisy in AIDS patients. METHODS: We reviewed all cases of pleural tuberculosis in AIDS patients in South Carolina from 1988 through 1994. Clinical findings, test results, treatment, and outcome were analyzed. MAIN RESULTS: Twenty-two (11%) of the 202 AIDS patients with tuberculosis had pleural involvement compared to 6% (169/2,817) pleural involvement in non-AIDS patients (p=0.01). Associated features of AIDS tuberculous pleurisy included substantial weight loss (7.65+/-1.35 kg) and lower lobe infiltrates (12/22; 55%). No difference in pleural fluid characteristics was found when comparing AIDS patients with a serum CD4 count > or =200/microL to patients with CD4 count <200/microL. Two (9%) of the 22 patients died of tuberculosis. Chest radiograph follow-up of 20 patients showed complete resolution in 7, improvement in 10, and no improvement in 3. CONCLUSIONS: In South Carolina, pleural involvement is more common in AIDS patients than in non-AIDS patients with tuberculosis. Tuberculous pleurisy has several atypical features in AIDS patients such as substantial weight loss and lower lobe infiltrates. The outcome of treatment is good for most patients.

Compliance with tuberculosis therapy.

The treatment experience in TB control can be a very rewarding time for both the patient and the provider. If the patient is made to feel that the provider cares for him as a person, a meaningful relationship can develop and can have a positive influence on the patient's behavior in taking medications and perhaps even in the direction of his life. Noncompliance with medications unfortunately has been a "given" in the TB control program. The successful program must be patient centered and include the following components: (1) fair and equal treatment of all patients, (2) patient involvement in the plan of care, (3) the most current patient treatment and services, including the availability of DOT for patients with TB infection and disease, and (4) rewards for patients and staff for positive behavior in the completion of treatment. Given current levels of staffing and other resources, some noncompliance will continue even in the best TB programs. Caring and knowledgeable staff members who support the patient-centered approach can make TB treatment a positive experience for both the patient and themselves.

Tuberculosis and AIDS in South Carolina: a case-control study.

The epidemiologic features of tuberculosis patients with AIDS or HIV infection in this study do not appear to be different from those reported from previous studies. Tuberculosis patients with AIDS or HIV positive antibody in South Carolina are predominantly black males who live in the urban areas and are 25 to 44 years old. They have more extrapulmonary sites and more anergic reactions to tuberculin tests. Physicians and other public health workers should be aware of the abnormal clinical and laboratory manifestations of tuberculosis patients with AIDS and HIV infection. It is also imperative for tuberculosis control programs to offer counseling and HIV antibody testing to tuberculosis patients.

Tuberculosis today in South Carolina: a partnership between DHEC and local physicians.

The DHEC TB Control Division staff in both the central office in Columbia, and in local county health departments are in place to provide the best services for diagnosis, treatment, prevention and control of the disease. Physicians are encouraged to contact either unit to report suspected cases and/or receive consultation. In the future, the partnership to maintain effective tuberculosis control in South Carolina will depend upon the continuing cooperation of local physicians and DHEC.