Latent Tuberculosis and Active Tuberculosis Disease Rates among the Homeless, New York, New York, USA, 1992�C2006

We conducted a retrospective study to examine trends in latent tuberculosis infection (LTBI) and TB disease rates among homeless persons in shelters in New York, NY, 1992–2006. Although TB case rates fell from 1,502/100,000 population to 0, a 31% LTBI rate in 2006 shows the value of identifying and treating TB in the homeless.     

Use of DNA fingerprinting to investigate a multiyear,multistate tuberculosis outbreak

In 1998-1999, the Baltimore TB control program detected a cluster of 21 tuberculosis (TB) cases. Patients reported frequent travel to various East Coast cities. An investigation was conducted to determine whether transmission of the same Mycobacterium tuberculosis strain was occurring in these other localities. A collaborative investigation among federal, state, and local TB controllers included TB record reviews, interviews of patients, and restriction fragment length polymorphism (RFLP) analysis of selected M. tuberculosis isolates from diagnosed TB patients in several cities in 1996-2001. A national TB genotyping database was searched for RFLP patterns that matched the outbreak pattern. Eighteen additional outbreak-related cases were detected outside of Baltimore-the earliest diagnosed in New Jersey in 1996, and the most recent in New York City in late 2001. The outbreak demonstrates the need for strategies to detect links among patients diagnosed with TB across multiple TB control jurisdictions.     

Latent Tuberculosis Infection Among Immigrant and Refugee Children Arriving in the United States: 2010

Immigrants and refugees age 2–14 years entering the United States from countries with estimated tuberculosis (TB) incidence rate ≥20 per 100,000 population are screened for TB. Children with TB disease are treated before US arrival. Children with positive tuberculin skin tests (TST), but negative TB evaluation during their pre-immigration examination, are classified with latent TB infection (LTBI) and are recommended for re-evaluation post-arrival. We examined post-immigration TB evaluation and therapy for children arriving with LTBI. We reviewed medical exam data from immigrant children with medical conditions and all refugee children arriving during 2010. Medical examination data were available for 67,334 children. Of these, 8231 (12 %) had LTBI pre-immigration; 5749 (70 %) were re-evaluated for TB post-immigration, and 64 % were retested by TST or IGRA. The pre-immigration LTBI diagnosis was changed for 38 % when retested by TST and for 71 % retested by IGRA. Estimated LTBI therapy initiation and completion rates were 68 and 12 %. In this population, testing with IGRA may limit the number of children targeted for therapy. Increased pre-immigration TB screening with post-immigration follow-up evaluation leading to completion of LTBI therapy should be encouraged to prevent TB reactivation.     

Practices and Policies of Providers Testing School-Aged Children for Tuberculosis,Connecticut, 2008

This study identified current practices and policies related to testing school children for latent tuberculosis infection (LTBI) in Connecticut. A cross-sectional survey was mailed to a random sample of community pediatricians and family practitioners in Connecticut who provide health care services to children aged 4–18 years. The main outcome measure was adherence to national guidelines for tuberculosis (TB) testing of school-aged children. The response rate was 66.3% (345 of 520), 258 of whom provided services to children. Responses showed that 60% (152 of 252) of replying providers read the American Academy of Pediatrics (AAP) published guidelines, and 85% routinely assess children for TB risk before skin testing although only a minority (22%) use a written questionnaire. Of 153 responding providers, 130 (85%) report that schools require formal TB risk assessments at mandated school physical examinations or at school entry. Results also showed providers who read AAP-published guidelines and who are trained in the United States are more likely to follow the national guidelines for TB testing of children. The majority of health care providers reported following AAP-published guidelines for screening school-aged children for LTBI and TB disease; however, an important number of providers still do not follow recommended guidelines. Public health officials should make efforts to increase provider awareness of, and adherence to, guidelines. School districts also should take steps to ensure the appropriate level of testing of children for TB disease and LTBI.     

Tuberculosis outbreak associated with a homeless shelter - Kane County, Illinois, 2007-2011

Despite the overall decline in tuberculosis (TB) incidence in the United States to a record low, outbreaks of TB among homeless persons continue to challenge TB control efforts. In January 2010, public health officials recognized an outbreak of TB after three overnight guests at a homeless shelter in Illinois received diagnoses of TB disease caused by Mycobacterium tuberculosis isolates with matching genotype patterns. As of September 2011, a total of 28 outbreak-associated cases involving shelter guests, dating back to 2007, had been recognized, indicating ongoing M. tuberculosis transmission. The subsequent investigation found that all patients were homeless and had been overnight shelter guests. Excess alcohol use was common (82%), and two bars emerged as additional sites of potential transmission. Patients with outbreak-associated TB were treated successfully for TB disease. To prevent future cases of TB, public health officials are implementing a program to offer 12 once-weekly doses of isoniazid and rifapentine under direct observation for treatment of latent tuberculosis infection (LTBI) in this high-risk population. Although the United States has made progress toward TB elimination, this outbreak demonstrates the vulnerability of homeless persons to outbreaks of TB, highlighting the need for aggressive and sustained TB control efforts.     

Workplace-based investigation of contacts of a patient with highly infectious tuberculosis--Maryland, District of Columbia, and Virginia, 2006

In late April 2006, the Maryland Department of Health and Mental Hygiene (DHMH) was notified by a local health department of a case of pulmonary tuberculosis (TB) in a patient with cavitary lung lesions and numerous acid-fast bacilli (AFB) observed on a sputum smear. The patient worked for an office furniture installation company at multiple sites in Maryland, the District of Columbia (DC), and Virginia. An investigation was conducted to 1) determine the extent of TB transmission, including identifying and screening the exposed cohort of contacts, and 2) provide treatment, if indicated, to contacts with latent TB infection (LTBI) or TB disease. This report describes the multijurisdictional contact investigation and summarizes its results. The findings underscore the importance of prompt diagnosis of TB, the value of interjurisdictional cooperation during large contact investigations, and the effectiveness of workplace-based methods for rapidly identifying and screening contacts.     

Latent tuberculosis infection among sailors and civilians aboard U.S.S. Ronald Reagan--United States, January-July 2006

Crews aboard ships live and work in crowded, enclosed spaces. Historically, large tuberculosis (TB) outbreaks and extensive transmission of Mycobacterium tuberculosis have occurred on U.S. Navy ships. On July 13, 2006, smear- and culture-positive, cavitary, pulmonary TB was diagnosed in a sailor aboard the aircraft carrier U.S.S. Ronald Reagan; the patient, aged 32 years, had a negative human immunodeficiency virus test. The M. tuberculosis strain cultured was susceptible to all first-line TB medications. The sailor was born in the Philippines, had latent tuberculosis infection (LTBI) diagnosed in 1995 shortly after enlisting in the U.S. Navy, and completed the 6-month daily isoniazid course that was standard treatment at that time (current treatment standard is 9 months). This report describes the contact investigation conducted by the U.S. Navy and CDC and demonstrates the importance of timely diagnosis of TB, identification and treatment of new LTBI, and cooperation among local, state, and federal agencies during large contact investigations.     

The status of tuberculosis control in New York City.

Problems in tuberculosis control still exist in New York City. They range from an increase in the incidence of the disease to the discovery of new cases in children under 5 years of age. Ninety-three percent (1,395) of the cases reported in 1980 were verified by cultures positive for tuberculosis. The rest of the cases in the 1980 tuberculosis disease count were verified by histology or a physician''s recommendation for treatment with two or more antituberculosis drugs. Of the tuberculosis at extrapulmonary sites, pleural meningeal and miliary tuberculosis, as well as genitourinary tuberculosis, ranked high in incidence in 1980. New tuberculosis cases occurred in all age groups, but the 37 cases in the age group 0-4 years is alarming and indicates a high rate of transmission of tuberculosis from parents to children. Performance indicators of the Centers for Disease Control show that in terms of drug continuity, completion of treatment, and bacteriological conversions to negative, a great deal needs to be done in New York City. The tuberculosis mortality rate for the city has been showing a steady decline over the years; it was 1.8 per 100,000 population in 1980.     

Language Discordance and Testing for Latent Tuberculosis Infection Among Recent Asian and Latino Immigrants

The foreign-born population is disproportionately affected by tuberculosis (TB). Testing to identify persons with latent TB infection is critical. The aim of this study was to assess clinic-based testing for latent tuberculosis infection among recent Asian and Latino immigrants. A randomized controlled trial of interpreting methods and their impact on medical outcomes was conducted at the primary care clinic of a New York City municipal hospital. This study is a nested cohort of recruited patients with an indication to receive tuberculin testing, based on recent migration to the US from endemic areas. Medical record data were abstracted to determine referral for, and completion of, tuberculin testing. Bivariate analyses were used to test for differences in tuberculin testing between language concordant and discordant groups. Seven hundred and eighty-two patients were enrolled. One hundred and ninety-one had migrated within 5 years of enrollment from endemic areas. None spoke English as a primary language. Seventy percentage of patient-provider encounters were language discordant. Seventeen of 191 were referred for testing. Fifteen (88%) completed testing. Six (40%) had positive results. There were no significant differences between language concordant and discordant patients. In this at-risk population, every patient in clinical care should be considered for testing if indicated by country of origin.     

To TST or not to TST: Is tuberculin skin testing necessary before BCG immunisation in children?

Bacille Calmette-Guérin (BCG) vaccine is one of the most commonly administered vaccines worldwide. In countries with high tuberculosis (TB) prevalence, it is generally given shortly after birth. In a number of low TB prevalence countries, BCG is used as a travel vaccine, typically given to children outside the neonatal period prior to visiting regions where TB is common. In this setting, it is recommended that latent TB infection (LTBI) resulting from prior exposure to Mycobacterium tuberculosis is excluded by a tuberculin skin test (TST) before BCG immunisation. This is to avoid the risk of an accelerated local reaction that is more common in individuals who have LTBI. In addition, BCG immunisation in individuals with LTBI is unnecessary, as it does not provide protection against progression to active TB disease. We review and discuss current international guidelines and recommendations on the need to screen children for LTBI prior to BCG immunisation. Guidelines vary significantly regarding age-related cut-offs and additional selection criteria. This variation primarily reflects the lack of evidence on which to base recommendations. We suggest an alternative strategy using a risk assessment questionnaire to identify children who should have a TST before BCG immunisation. This targeted approach will reduce the number of children unnecessarily screened, whilst allowing the identification of those with LTBI, who need further evaluation and treatment.     

HIV-related tuberculosis in a transgender network--Baltimore, Maryland, and New York City area, 1998-2000

During June-August 1998, the Tuberculosis (TB) Control Program of the Baltimore City Health Department (BCHD) identified four cases of TB among young black men. Three of these men also had human immunodeficiency virus (HIV) infection. The four reported belonging to a social network of transgender persons (i.e., persons who identify with or express a gender and/or sex different from their biologic sex) (1). By October 1998, test results on Mycobacterium tuberculosis isolates from the four men demonstrated a matching 11-band DNA fingerprint pattern (2), suggesting that these case-patients were epidemiologically linked. This report describes the public health investigation of these TB case-patients to identify contacts in Baltimore and the New York City area (NYC); the findings suggest that an interstate outbreak of TB has occurred within a social network that includes transgender persons.     

Prevalence and associated risk factors of latent tuberculosis infection among undergraduate and postgraduate dental students: A retrospective study

To estimate the prevalence of latent tuberculosis (TB) infection (LTBI) in Italian dental students exposed to the same occupational risks as dental health care personnel and to evaluate potential risk factors, a cross-sectional study was conducted on undergraduate and postgraduate students. After clinical evaluation, students were given a tuberculin skin test; in those found positive, an interferon-γ release assay (IGRA) was conducted. Of the 281 students enrolled, 10 were only TST positive; 8 were TST or/and IGRA positive. We found that participants testing positive at TST and/or IGRA, a group in which the risk of false LTBI positives is minimal, were older and had been studying longer. Although the prevalence of LTBI among dental students in our study was low, a risk of acquiring a work-related infection exists even in a country with a low incidence of TB. Thus, dental students should be screened to catch LTBI early on.     

Could a tuberculosis epidemic occur in London as it did in New York?

In early 1999, more than 160 senior physicians, public health officials, and nurses met to discuss London's tuberculosis (TB) control program. The program was examined against the public health response of New York City's Bureau of Tuberculosis Control during a 1988 to 1992 epidemic. This article outlines TB epidemiology and control in New York City 10 years ago and in London today to assess whether the kind of epidemic that occurred in New York could occur in London.     

Hospital care of tuberculosis patients referred for directly observed therapy in New York City: identifying factors in prolonged stays.

Individuals hospitalized and treated for tuberculosis (TB) who were then enrolled into TB directly observed therapy at four study hospitals in New York City (NYC) were identified. Review of hospital medical records determined whether the hospitalizations were warranted and whether lengths of stay were prolonged. Most hospitalizations were appropriate but over 70 percent of cases analyzed had prolonged stays. Of these, almost half were to document bacteriologic response to anti-TB treatment. Some were prolonged due to misunderstanding of state recommendations. Focused educational efforts could significantly reduce lengths of stay and save up to $9.7 million annually in NYC hospitalization costs.     

Temporal trends in tuberculosis hospitalization rates before and after implementation of directly observed therapy: New York City, 1988-1995.

New York City hospitalization rates were analyzed to investigate whether tuberculosis (TB) hospitalizations declined after implementation of directly observed therapy (DOT) for TB. TB hospitalization rates mirrored incidence rates in pattern but not in magnitude. Rates have declined significantly following widespread implementation of DOT in 1993.     

Completeness of pediatric TB reporting in New York City

OBJECTIVE: Accurate surveillance of tuberculosis (TB) in children is critical because such cases represent recent transmission, but surveillance is difficult as only 10% to 50% of cases are culture-confirmed. Hospital-based sources were used to develop alternative surveillance to assess completeness of reporting for pediatric TB in northern Manhattan and Harlem from 1993 through 1995. METHODS: Alternative surveillance sources included ICD-9-CM hospital discharge codes for active TB and gastric aspirate reports. Cases identified by alternative surveillance were compared with cases previously reported to the New York City Department of Health (NYC DOH). RESULTS: Alternative surveillance detected 25 cases of possible pediatric TB, of which four (16%) had never been reported to the NYC DOH and three (12%) had been reported as suspect cases, but had not fulfilled the criteria for a reportable case of pediatric TB. Of these seven newly counted cases, three were detected by ICD-9-CM codes, three by a gastric aspirate log book, and one by both. In contrast, 13 other cases had been reported to the NYC DOH, but were undetected by our alternative surveillance; eight of these could be verified with available medical records. Thus, the demographic and clinical characteristics of the 25 detected and the eight undetected cases with available medical records were evaluated in this study. CONCLUSION: Alternative surveillance proved effective, was complementary to the NYC DOH surveillance efforts, and increased the number of pediatric TB cases identified during the study period by 21%.     

Universal genotyping in tuberculosis control program, New York City, 2001-2003

In 2001, New York City implemented genotyping to its tuberculosis (TB) control activities by using IS6110 restriction fragment length polymorphism (RFLP) and spoligotyping to type isolates from culture-positive TB patients. Results are used to identify previously unknown links among genotypically clustered patients, unidentified sites of transmission, and potential false-positive cultures. From 2001 to 2003, spoligotype and IS6110-based RFLP results were obtained for 90.7% of eligible and 93.7% of submitted isolates. Fifty-nine (2.4%) of 2,437 patient isolates had false-positive culture results, and 205 genotype clusters were identified, with 2-81 cases per cluster. Cluster investigations yielded 57 additional links and 17 additional sites of transmission. Four additional TB cases were identified as a result of case finding initiated through cluster investigations. Length of unnecessary treatment decreased among patients with false-positive cultures.     

HIV Testing of Tuberculosis Patients by Public and Private Providers in New York City

Thirty percent of tuberculosis (TB) patients in New York City in 2007 were not tested for HIV, which may be attributable to differential testing behaviors between private and public TB providers. Adult TB cases in New York City from 2001 to 2007 (n = 5,172) were evaluated for an association between TB provider type (private or public) and HIV testing. Outcomes examined were offers of HIV tests and patient refusal of HIV testing, using multivariate logistic and binomial regression, respectively. HIV test offers were less frequent among patients who visited only private providers than patients who visited only public providers [males: adjusted odds ratio (aOR) 0.33, 95 % confidence interval (CI) 0.15–0.74; females: aOR 0.26, 95 % CI 0.12–0.57]. Changing from private to public providers was associated with an increase in HIV tests offered among male patients (aOR 1.96, 95 % CI 1.04–3.70). Among patients who did not use substances, those who visited only private providers were more likely to refuse HIV testing than those who visited only public providers [males: adjusted prevalence ratio (aPR) 1.26, 95 % CI 0.99–1.60; females: aPR 1.78, 95 % CI 1.43–2.22]. Patients of private providers were less likely to have an HIV test performed during their TB treatment. Education of TB providers should emphasize HIV testing of all TB patients, especially among patients who are traditionally considered low-risk.