Congenital tuberculosis and management of exposure in three neonatal intensive care units.

Congenital tuberculosis (TB) is uncommon, and diagnosis may be delayed. We report a case of congenital TB and the management of exposure in three different neonatal intensive care units. This case demonstrates the need for a high index of suspicion, active communication among maternal and neonatal medical providers, and timely provider reporting of maternal disease, and emphasizes the relatively greater risk of transmission to health care workers versus infants in this setting.

Molecular epidemiology of tuberculosis after declining incidence, New York City, 2001-2003.

Tuberculosis incidence in New York City (NYC) declined between 1992 and 2000 from 51.1 to 16.6 cases per 100,000 population. In January 2001, universal real-time genotyping of TB cases was implemented in NYC. Isolates from culture-confirmed tuberculosis cases from 2001 to 2003 were genotyped using IS6110 and spoligotype to describe the extent and factors associated with genotype clustering after declining TB incidence. Of 2408 (91.8%) genotyped case isolates, 873 (36.2%) had a pattern indistinguishable from that of another study period case, forming 212 clusters; 248 (28.4%) of the clustered cases had strains believed to have been widely transmitted during the epidemic years in the early 1990s in NYC. An estimated 27.4% (873 minus 212) of the 2408 cases were due to recent infection that progressed to active disease during the study period. Younger age, birth in the United States, homelessness, substance abuse and presence of TB symptoms were independently associated with greater odds of clustering.

Public-private collaboration for multidrug-resistant tuberculosis control in New York City.

SETTING: An urban tuberculosis control program where an enhanced multidrug-resistant tuberculosis (MDR-TB) management plan coordinated care with multiple providers. OBJECTIVE: To evaluate treatment outcomes of primary MDR-TB patients treated by multiple providers. DESIGN: Retrospective cohort study of tuberculosis patients from 1992-1997 provided that 1) their Mycobacterium tuberculosis isolates were resistant to at least isoniazid and rifampin, and 2) they had had < or = 30 days of anti-tuberculosis treatment prior to the collection of the first MDR-TB specimen. RESULTS: More than 100 facilities and providers reported 856 MDR-TB patients. Treatment completion reached 70% among non-HIV-infected and 30% among HIV-infected persons; 57.2% of the cohort died prior to treatment completion, 26.5% completed treatment, 16.0% transferred out, refused treatment or were lost to follow-up and 0.2% are still in care. Diagnosis in the later years of the study or cavitation on chest radiograph was independently associated with increased completion among HIV-infected patients. Eight of the 227 (3.5%) patients who completed treatment relapsed (relapse rate 1.01/100 person-years), two with drug-susceptible strains. CONCLUSION: A comprehensive MDR-TB control program improved the outcomes of both HIV-infected and non-infected individuals, despite management by multiple providers. Relapse was infrequent among patients who completed the recommended regimens.

Risk factors for drug-resistant tuberculosis among non-US-born persons in New York City.

SETTING: New York City (NYC). OBJECTIVES: To examine the extent to which prior tuberculosis (TB) treatment, length of residence in the United States and other factors are associated with the occurrence of drug resistance among non-US-born persons in NYC. DESIGN: Cases were non-US-born persons diagnosed with TB in NYC from 1998-1999 and from 2001-2002, with an initial Mycobacterium tuberculosis isolate resistant to any first-line anti-tuberculosis drug. Controls were randomly selected from non-US-born persons whose isolates were susceptible to all first-line anti-tuberculosis drugs. RESULTS: Overall, cases with multidrug-resistant (MDR) TB were more likely to have had prior TB treatment; other drug resistance was not associated with prior TB treatment. In a multivariate model, the relationship between MDR-TB and prior treatment remained significant for non-US-born persons regardless of length of time in the U.S. CONCLUSIONS: The findings underscore the utility of monitoring trends in drug resistance among the non-US-born by time in the US and prior treatment to determine where or when drug resistance may be occurring.

Finding contacts of homeless tuberculosis patients in New York City.

OBJECTIVE: To determine factors associated with no contacts identified for homeless patients in New York City. DESIGN: Culture-confirmed pulmonary tuberculosis cases in persons >18 years old diagnosed in 1997-1999 were included. Demographic and clinical characteristics of tuberculosis patients associated with the number of contacts identified according to homeless status were analyzed using unconditional logistic regression. RESULTS: Homeless patients (n = 152) had a significantly lower median number of contacts than non-homeless patients (n = 2836) (1 vs. 4, P < 0.001). Among homeless patients, having AFB smear-positive sputum with cavitary lesions reduced the likelihood of having no contacts identified. Homeless patients who lived on the street at the time of diagnosis were more likely to have no contacts identified compared to those with contacts identified (61.4% vs. 56.1%); however, the difference was not statistically significant (P = 0.506). Unlike non-homeless patients, being hospitalized at the time of tuberculosis diagnosis was not associated with having contacts identified in homeless patients. CONCLUSIONS: Homelessness independently predicted the likelihood of having no contacts identified. Strategies such as interviews that focus on location rather than persons may be more effective for identifying contacts. Furthermore, being homeless at the time of diagnosis should be used as an indicator for prioritizing prompt contact evaluation.

Contact investigations in congregate settings, New York City.

SETTING: Large urban tuberculosis control program. OBJECTIVE: To evaluate results of procedures implemented for systematic investigation of tuberculosis exposures in congregate settings. DESIGN: Between October 1995 and December 2000, a unit consisting of epidemiologists, health educators and tuberculin screening staff investigated exposures in sites with >15 persons. Transmission at the site was defined as likely, possible, unlikely or unknown. RESULTS: Among 100 investigations, 12 were tuberculosis case clusters, five were source case investigations, and 83 were exposures to single infectious cases. Transmission was likely in 24 (21%), possible in eight (8%), unlikely in 62 (62%), and could not be assessed in four (4%). Among the 83 exposures to single infectious cases, 2740 contacts were tested; 502 (18%) were infected. Among 1202 close contacts, 996 (82%) were tested, 197 (20%) were infected and started treatment of latent tuberculosis infection (LTBI) and 102/197 (52%) completed treatment. Sites with likely transmission had index patients with longer duration of cough (13 vs. 6 weeks, P = 0.01) and cavitary lesions (84% vs. 44%, P = 0.01) compared to sites with unlikely transmission. CONCLUSION: A systematic approach for conducting contact investigations in congregate settings is useful for assessing transmission. As such investigations are resource intensive and transmission is not common, performing tuberculin skin testing after most persons would have converted should be considered in low-risk groups. Additional efforts are needed to increase completion of treatment for LTBI in contacts identified in these settings.

Differential decline in tuberculosis incidence among US- and non-US-born persons in New York City.

SETTING: A large urban tuberculosis control program. OBJECTIVES: To examine changes in tuberculosis incidence and characteristics of cases in New York City (NYC), and assess the epidemiology of tuberculosis among non-US-born persons. DESIGN: Tuberculosis surveillance data (1995-1999) for NYC were analyzed. RESULTS: Tuberculosis incidence decreased by 56.6% in US-born and 19.6% in non-US-born persons (age-adjusted) over the study period. The decline in tuberculosis incidence among US-born persons was more substantial in the first half of the study period (23-24%) than in the second half (13-15%). The greatest decline in incidence was among US-born Hispanic or Black males aged 25-64. However, although there was an overall decline in incidence among non-US-born persons, there was no significant change in any sex or racial/ethnic subgroup. The percent of multidrug-resistant (MDR) cases among non-US-born patients remained stable, but recent arrivals accounted for 79% of non-US-born MDR-TB patients in 1999, a significant increase from 16% in 1997. CONCLUSIONS: Continuing current tuberculosis control efforts and treatment of immigrants with latent tuberculosis infection are of highest priority for reducing incident cases in NYC. Global collaboration towards earlier detection and treatment of active tuberculosis cases in high incidence countries is also essential.

Yield of continued monthly sputum evaluation among tuberculosis patients after culture conversion.

SETTING: New York City. OBJECTIVE: To evaluate the yield of continued monthly sputum monitoring after culture conversion. DESIGN: A retrospective review of tuberculosis patients verified between 1 January 1995 and 31 December 1996 who had: 1) pulmonary tuberculosis with organisms susceptible to isoniazid and rifampin; 2) culture conversion; and 3) completed therapy. We assessed time to smear and culture conversion and number of persons who developed a positive culture after culture conversion (culture reversion). RESULTS: Of 1440 patients, 379 were cared for by tuberculosis control program providers and 1061 were cared for by other providers; 813 (56%) were initially smear-positive. After the fifth month, 44 (5.3%) were smear-positive; four of these were culture-positive. Eighteen (1.3%) had culture reversions; eight were smear-positive. Excluding one specimen per patient collected at treatment completion, 7967 sputum samples were collected after culture conversion. The minimum estimated cost per culture reversion detected was $26,557. CONCLUSION: Continued monthly monitoring of sputum after culture conversion identified a very small number of patients who had culture reversion. However, patients who cannot tolerate or adhere to a standard regimen may need continued monitoring to assess response to treatment. For all patients a specimen should be collected at the end of treatment to document cure.

Relapse in persons treated for drug-susceptible tuberculosis in a population with high coinfection with human immunodeficiency virus in New York City.

The optimal duration of tuberculosis treatment for persons infected with human immunodeficiency virus (HIV) has been debated. A cohort of 4571 culture-positive drug-susceptible patients who received > or =24 weeks of standard 4-drug tuberculosis treatment were assessed to determine the incidence of tuberculosis relapse. Tuberculosis "recurrence" was defined as having a positive culture < 30 days after the last treatment date and "relapse" as having a positive culture > or =30 days after the last treatment. Patients infected with HIV were more likely than those who were uninfected to have recurrence or relapse (2.0 vs. 0.4 per 100 person-years, P< .001). Patients infected with HIV who received < or =36 weeks of treatment were more likely than those who received > 36 weeks to have a recurrence (7.9% vs. 1.4%, P< .001). Clinicians should be aware of the possibility of recurrence of tuberculosis 6-9 months after the start of treatment. Sputum evaluation to ensure cure or assessment 3 months after completion of treatment should be performed among persons infected with HIV who receive the shorter regimen.

Rising number of tuberculosis cases among Tibetans in New York City.

Tuberculosis among Tibetans increased in New York City between 1995 and 1999. We examined characteristics of 68 Tibetan patients compared to 702 non-Tibetan patients from Nepal, India, or China, diagnosed between January 1995 and December 1999. The number of Tibetan patients increased each year after 1995 whereas non-Tibetans remained stable during the same period. Tibetans were younger (27 vs. 44 years), more likely to be infectious (63% vs. 46%), have multidrug resistance (7% vs. 2%) and shorter time to diagnosis after arrival (9 vs. 79 months, p < 0.01). For Tibetan patients, 68% of identified contacts were evaluated. The prevalence of tuberculosis infection was 65%. In contrast, among non-Tibetan patients 88.8% of contacts were evaluated and 45.2% were infected. Outreach efforts with community leaders and educational presentations at community events have been implemented in an effort to ensure continuity of care and completion of treatment.

Tuberculin skin test screening in schoolchildren in the United States.

OBJECTIVE: To determine the current practices and results of tuberculin skin test (TST) screening of schoolchildren in the United States. METHODS: Tuberculosis program staff in all states and the District of Columbia were asked about current requirements, practices, and results of school-based TST screening. RESULTS: Thirty-four states and the District of Columbia (69%) reported no current statewide statutes or policies for tuberculin screening of schoolchildren, and 10 (19%) reported having statewide requirements. In 6 states (12%), requirements were instituted at the local level, and 24 localities in these states were known to require screening. Of the 34 areas requiring screening, 18 (53%) screened all new entrants, 7 (21%) screened children in specific grades, and 9 (26%) used other criteria for screening. TST results were collected for 26 (76%) of 34 areas, and 6 areas collected results of follow-up evaluation of tuberculin-positive children. Additionally, 8 localities in 7 states with no screening requirements conducted tuberculin surveys. Sixteen areas provided results. In 7 of the 8 areas that collected information about birthplace, less than 2% of US-born children were tuberculin positive; foreign-born children had rates 6 to 24 times higher than US-born children. TST screening identified new cases of tuberculosis, less than 0.02% of the children screened. CONCLUSIONS: School-based tuberculin screening identified low rates of positive TST results in US-born children. Resources should be directed toward screening children at high risk for tuberculous infection, as recommended by the American Academy of Pediatrics and the Advisory Committee for Elimination of Tuberculosis.

Completeness of tuberculosis case reporting, San Juan and Caguas Regions, Puerto Rico, 1992.

Completeness of tuberculosis case reporting in Puerto Rico was assessed. Cases diagnosed among hospitalized, tuberculosis, and human immunodeficiency virus clinic patients during 1992 were retrospectively reviewed. Hospital discharge diagnoses, pharmacy listings of patients receiving anti-tuberculous medications, laboratory and acquired immunodeficiency syndrome registry data were used for case finding in selected hospitals and clinics. Identified cases were matched to the health department TB case registry to determine previous reporting through routine surveillance. Records of unreported cases were reviewed to verify tuberculosis diagnoses. Of 159 patients with tuberculosis, 31 (19.5%) were unreported. A case was defined according to the Centers for Disease Control and Prevention definition. Unreported cases were less likely than previously reported cases to have specimens that were culture positive for M. tuberculosis, 14 of 31 (45.2%) compared with 111 of 128 (86.7%). Excluding the laboratory, tuberculosis diagnoses in acquired immunodeficiency syndrome registry patients had the highest predictive value of finding tuberculosis (94.1%), followed by tuberculosis clinic records (71.7%), and pharmacy listings (45.6%). Tuberculosis discharge diagnoses, however, yielded the largest number of unreported cases (14). Health care providers should be educated regarding the importance of promptly reporting all suspected TB cases regardless of results of laboratory testing.

Tuberculosis in a day-care center, Kentucky, 1993.

In November, 1993, a 33-month-old child in a day-care center was diagnosed with tuberculosis (TB). To identify her source of infection, close contacts, other day-care children and staff were screened by tuberculin skin test (TST). TB registry and medical/laboratory records were reviewed. The only 2 community TB cases reported in the past 3 years were investigated. Of 164 children 2 were diagnosed with TB; their TSTs were > or = 10 mm but no specimens were obtained. Six children had TSTs > or = 5 mm. Of these 4 had TST conversions between December, 1993, and March, 1994. There were no additional positive TST children in June, 1994. No TB case was identified among staff or parents. A possible epidemiologic link with the index case was found for 1 community case. No source of infection was found for the other children. Possible explanations for not finding a source are: an as yet unidentified case in the day-care center or community; or false positive TST results in children related to low community prevalence of TB infection.

Tuberculosis in children younger than five years old: New York City.

We examined medical and health department records for children < 5 years of age with suspected or confirmed tuberculosis reported to the New York City Health Department from January, 1992, through June, 1992, in order to describe the epidemiology of tuberculosis in young children and identify prevention strategies. Forty-seven children were treated for suspected or confirmed tuberculosis. Sixty-two percent (21 of 34) were foreign-born (n = 11) or had foreign-born caretakers (n = 10). A source case was found for 10 of 47 (21%) children; for 8 the adult source was diagnosed before the child. One child was human immunodeficiency virus-seropositive, however, 83% of children and 70% of adult source cases did not have human immunodeficiency virus test results available. Health care providers should test children at high risk for tuberculosis infection as recommended by the American Academy of Pediatrics and improve contact tracing to identify children exposed to adults with tuberculosis. Because most cases of tuberculosis in children are diagnosed clinically rather than by isolating Mycobacterium tuberculosis, identification of the source case is important for selecting appropriate treatment.

Transmission of Mycobacterium tuberculosis associated with air travel.

OBJECTIVE: To investigate potential transmission of Mycobacterium tuberculosis in aircraft from a crew member with tuberculosis. DESIGN: Retrospective cohort study and survey. SETTING: A large US airline carrier. PARTICIPANTS: A total of 212 crew members and 59 passengers who were exposed to a crew member with tuberculosis during a potentially infectious period (May through October 1992). Comparison volunteer sample of 247 unexposed crew members. MAIN OUTCOME MEASURES: Positive tuberculin skin test (TST) result or tuberculosis. RESULTS: Rates of positive TST results were higher among foreign-born persons in all study groups. Among US-born comparisons and contacts, rates of positive TST results did not differ between comparisons and contacts exposed from May through July (5.3% vs 5.9%, respectively). However, contacts exposed from August through October had significantly higher rates of positive TST results than did contacts exposed from May through July (30% vs 5.8%, respectively; P < .001); two had documented TST conversions between September 1992 and February 1993. The risk of infection increased with increasing hours of exposure to the index case. Four (6.7%) of 59 frequent flyers were TST-positive; all flew in October. CONCLUSIONS: Data support the conclusion that M tuberculosis was transmitted from an infectious crew member to other crew members on an aircraft. Because of the clustering of TST-positive frequent flyers in October when the index patient was most infectious, transmission of M tuberculosis to passengers cannot be excluded.

Drug resistance among tuberculosis patients, New York City, 1991 and 1992.

The authors assessed drug susceptibility patterns among tuberculosis patients reported to the New York City Department of Health in the first quarters of 1991 and 1992. Resistance to one or more drugs was seen in 26 percent (137 divided by 520) in 1991 and 24 percent (122 divided by 517) in 1992. Resistance to isoniazid was seen in 22 percent and 19 percent of patients in 1991 and 1992, respectively; resistance to rifampin in 15 percent and 14 percent; and to both isoniazid and rifampin in 15 percent and 14 percent. Combined resistance to four first line drugs (isoniazid, rifampin, streptomycin, and ethambutol) was seen in 6 percent (1991) and 8 percent (1992). Patients with organisms resistant to both isoniazid and rifampin were as likely among U.S. born as among foreign born, and younger patients were more likely than older patients to have isoniazid and rifampin resistant organisms. These findings underscore the importance of obtaining susceptibility testing in all patients who have cultures positive for Mycobacterium tuberculosis.

Nationwide survey of drug-resistant tuberculosis in the United States.

OBJECTIVE: To determine antituberculosis drug resistance patterns, geographic distribution, demographic characteristics, and risk factors of reported tuberculosis (TB) patients in the United States. DESIGN: Survey of reported TB cases in the United States. For culture-positive cases reported to the Centers for Disease Control and Prevention, we asked health departments to provide drug susceptibility test results from initial Mycobacterium tuberculosis isolates. STUDY POPULATION: Culture-positive TB cases in the United States reported during the first quarter of 1991. MAIN OUTCOME MEASURES: Individual TB case reports submitted to the Centers for Disease Control and Prevention and drug susceptibility test results. RESULTS: Resistance to one or more antituberculosis drugs was found in 14.2% of cases. Resistance to isoniazid and/or rifampin was found in 9.5% of cases whose isolates were tested against one or both drugs; such cases were found in 107 counties in 33 states. Resistance to both isoniazid and rifampin (multidrug-resistant [MDR] TB) was found in 3.5% of cases whose isolates were tested against both drugs; such cases were found in 35 counties in 13 states. New York City accounted for 61.4% of the nation's MDR TB cases. The 3-month population-based incidence rate of MDR TB in New York City was 52.4 times (95% confidence interval [CI], 35.5 to 78.3) that of the rest of the nation (9.559 vs 0.182 cases per million population). Compared with the rate in non-Hispanic whites in the rest of the nation (0.032 cases per million), the relative risk of MDR TB in New York City non-Hispanic whites was 39.0 (95% CI, 8.1 to 164.5), 299.3 (95% CI, 112.5 to 927.1) in Hispanics, 420.9 (95% CI, 121.0 to 1515.8) in Asian/Pacific Islanders, and 701.0 (95% CI, 296.4 to 2018.1) in non-Hispanic blacks. CONCLUSIONS: With nearly 10% of TB patients resistant to isoniazid and/or rifampin, greater use of four-drug regimens and directly observed therapy is indicated. Aggressive intervention to prevent the further spread of MDR TB is needed to find every TB patient and to provide optimal patient management to ensure completion of chemotherapy.