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The goal for tuberculosis (TB) elimination in the United States is a TB disease incidence of less than 1 per million U.S. population by 2010, which requires that the latent TB infection (LTBI) prevalence be less than 1% and decreasing.To estimate the prevalence of LTBI in the U.S. population.Interviews and medical examinations, including tuberculin skin testing (TST), of 7,386 individuals were conducted in 1999-2000 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the civilian, noninstitutionalized U.S. population. LTBI was defined as a TST measurement of/=10 mm. Associations of age, race/ethnicity, sex, poverty, and birthplace were assessed. Results among the 24- to 74-year-old subgroup were compared with NHANES 1971-1972 data.Estimated LTBI prevalence was 4.2%; an estimated 11,213,000 individuals had LTBI. Among 25- to 74-year-olds, prevalence decreased from 14.3% in 1971-1972 to 5.7% in 1999-2000. Higher prevalences were seen in the foreign born (18.7%), non-Hispanic blacks/African Americans (7.0%), Mexican Americans (9.4%), and individuals living in poverty (6.1%). A total of 63% of LTBI was among the foreign born. Among the U.S. born, after adjusting for confounding factors, LTBI was associated with non-Hispanic African-American race/ethnicity, Mexican American ethnicity, and poverty. A total of 25.5% of persons with LTBI had been previously diagnosed as having LTBI or TB, and only 13.2% had been prescribed treatment.In addition to basic TB control measures, elimination strategies should include targeted evaluation and treatment of individuals in high-prevalence groups, as well as enhanced support for global TB prevention and control.

Objectives.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.Conclusions.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%.

To estimate the incidence of and assess risk factors for occupational Mycobacterium tuberculosis transmission to health care personnel (HCP) in 5 New York City and Boston health care facilities, performance of prospective tuberculin skin tests (TSTs) was conducted from April 1994 through October 1995. Two-step testing was used at the enrollment of 2198 HCP with negative TST results. Follow-up visits were scheduled for every 6 months. Thirty (1.5%) of 1960 HCP with >/=1 follow-up evaluation had TST conversion (that is, an increase in TST induration of >/=10 mm). Independent risk factors for TST conversion were entering the United States after 1991 and inclusion in a tuberculosis-contact investigation in the workplace. These findings suggest that occupational transmission of M. tuberculosis occurred, as well as possible nonoccupational transmission or late boosting among foreign-born HCP who recently entered the United States. These results demonstrate the difficulty in interpreting TST results and estimating conversion rates among HCP, especially when large proportions of foreign-born HCP are included in surveillance.

Few data are available describing treatment completion rates among recently infected contacts of tuberculosis (TB) cases, a group at high risk for development of active TB.Health department records were reviewed for all contacts of 360 culture-positive pulmonary TB cases reported from five health departments in the United States in 1996.Of 2,267 contacts who completed screening, 630 (28%) had newly documented positive skin tests (121 with skin test conversion). Treatment of latent TB infection was documented to have been recommended for 447 (71%). Among these, treatment was documented to be initiated for 398 (89%). Of these, 203 (51%) were documented to have completed a 6-month course of treatment, and 78 (20%) received directly observed treatment. Treatment was recommended more often for contacts15 years of age, skin test converters, close contacts, and contacts of smear-positive cases. Treatment completion rates were higher for skin test converters.In this study, fewer than one third of all persons with newly documented positive skin tests detected during contact investigations were proven to have completed treatment. Achieving high rates of completion of therapy for latent TB infection in recently infected contacts of active cases of pulmonary TB is essential to maximize public health prevention efforts aimed at eliminating TB.

In 1998, a city in Indiana reported 4-fold increase in the number of cases of tuberculosis (TB). An investigation to assess the increase in cases and to identify possible epidemiologic links among persons with TB identified 41 cases of active TB. Epidemiologic links and/or matching DNA fingerprints were identified for 31 patients (76%). The majority of these patients were members of a single social network within the community. Links for most of these patients were identified after multiple interviews with patients and their contacts. TB control activities in the county were limited prior to the identification of the outbreak. At least 24 cases may have been preventable. This outbreak may have been prevented with prompt case identification and effective contact tracing and screening during the years before the outbreak. The use of social networks should be considered in the investigation of outbreaks that involve difficult-to-reach populations. TB control measures should be maintained in areas with historically low TB incidence.

Objectives.Source case finding in San Diego, California, rarely detects the source for children with tuberculosis (TB) infection or disease. One third of all pediatric TB isolates in San Diego are Mycobacterium bovis, a strain associated with raw dairy products. This study was conducted to determine risk factors for TB infection in San Diego.Design.Case-control study of children ≤5 years old screened for TB as part of routine health care visit. Asymptomatic children with a positive (≥10 mm) Mantoux skin test (TST) were matched by age to 1 to 2 children with negative TST from the same clinic. We assessed risk factors for TB infection through parental interview and chart review.Results.A total of 62 cases and 97 controls were enrolled. Eleven cases and 25 controls were excluded from analysis because of previous positive skin tests. Compared with controls, cases were more likely to have received BCG vaccine (73% vs 7%, odds ratio [OR] 44), to be foreign born (35% vs 11%, OR 4.3), and to have eaten raw milk or cheese (21% vs 8%, OR 3.76). The median time between the most recent previous TST and the current test was 12 months for cases and 25 months for controls. Other factors associated with a positive TST included foreign travel, staying in a home while out of the country, and having a relative with a positive TST. There was no association between contact with a known TB case. In a multivariable model, receipt of BCG, contact with a relative with a positive TST, and having a previous TST within the past year were independently associated with TB infection.Conclusions.We identified several new or reemerging associations with positive TST including cross border travel, staying in a foreign home, and eating raw dairy products. The strong associations with BCG receipt and more recent previous TST may represent falsely positive reactions, booster phenomena, or may be markers for a population that is truly at greater risk for TB infection. Unlike studies conducted in nonborder areas, we found no association between positive TB skin tests and contact with a TB case or a foreign visitor. Efforts to control pediatric TB in San Diego need to address local risk factors including consumption of unpasteurized dairy products and cross-border travel. The interpretation of a positive TST in a young child in San Diego who has received BCG is problematic.

Migrant farm workers (MFWs) are considered a high-risk group for tuberculosis. MFW tuberculosis cases reported to the Centers for Disease Control and Prevention represented 1 percent of all reported tuberculosis cases from 1993 to 1997. Most of these cases (70 percent) were reported from Florida, Texas, and California. MFW tuberculosis cases were more likely to be male, foreign-born, or Hispanic and to have a history of alcohol abuse and homelessness than were non-MFWs. Most (79 percent) foreign-born MFWs were from Mexico. HIV status was poorly reported, with results available for only 28 percent of MFW and 33 percent of non-MFW cases. Of the MFWs tested, 28 percent were HIV infected, whereas 34 percent of non-MFWs were HIV infected. Twenty percent of MFWs move or are lost to follow-up before completing therapy; these cases pose a management challenge for the nation's tuberculosis control efforts.

Background. Fourteen cases of tuberculosis (TB) in Puerto Rico, diagnosed from April 1993 to April 1995, had the same DNA fingerprint, documenting disease caused by the same strain of Mycobacterium tuberculosis. The 14 cases were retrospectively investigated for epidemiologic links. Methods. Records were reviewed and staffs of the TB program, hospital/clinic, and AIDS residential facilities were interviewed. Results. Half of the AIDS cases were epidemiologically related, providing evidence of TB transmission in an emergency department, an AIDS inpatient ward, and an AIDS residential facility. DNA fingerprinting allowed detection of M tuberculosis transmission, but contact investigators could have documented it sooner. Factors contributing to transmission included delayed diagnosis, prolonged infectiousness, inadequate discharge planning and infection control procedures, and poor communication between health-care facilities. Conclusions. The numbers of AIDS residential facilities are increasing and must understand proper monitoring of TB patients and infection control measures that prevent transmissions.

OBJECTIVES: Because of limited reporting of HIV status in case reports to the national tuberculosis (TB) surveillance system, the authors conducted this study to estimate the proportion of US TB cases with HIV co-infection and to describe demographic and clinical characteristics of co-infected patients. METHODS: The 50 states, New York City, and Puerto Rico submitted the results of cross-matches of TB registries and HIV-AIDS registries. The authors determined the number of TB cases reported for 1993-1994 that were listed in HIV-AIDS registries and analyzed data on demographic and clinical characteristics by match status. RESULTS: Of 49,938 TB cases reported for 1993-1994, 6863 (14%) were listed in AIDS or HIV registries. The proportions of TB-AIDS cases among TB cases varied by reporting area, from 0% to 31%. Anti-TB drug resistance was higher among TB-AIDS cases, particularly resistance to isoniazid and rifampin (multidrug resistance) and rifampin alone, In some areas with low proportions of multidrug-resistant TB cases, however, the difference in multidrug resistance between TB-AIDS patients and non-AIDS TB patients was not found. CONCLUSIONS: The proportion of TB cases with HIV co-infection, particularly in some areas, underscores the importance of the HIV-AIDS epidemic for the epidemiology of TB. Efforts to improve HIV testing as well as reporting of HIV status for TB patients should continue to ensure optimum management of coinfected patients, enhance surveillance activities, and promote judicious resource allocation and targeted prevention and control activities.

In January 1996, smear- and culture-positive tuberculosis (TB) was diagnosed for a 22-year-old black man after he had traveled on two U.S. passenger trains (29.1 hours) and a bus (5.5 hours) over 2 days. To determine if transmission had occurred, passengers and crew were notified of the potential exposure and instructed to undergo a tuberculin skin test (TST). Of the 240 persons who completed screening, 4 (2%) had a documented TST conversion (increase in induration of > or = 10 mm between successive TSTs), 11 (5%) had a single positive TST (> or = 10 mm), and 225 (94%) had a negative TST (< 10 mm). For two persons who underwent conversion, no other risk factors for a conversion were identified other than exposure to the ill passenger during train and/or bus travel. These findings support limited transmission of Mycobacterium tuberculosis from a potentially highly infectious passenger to other persons during extended train and bus travel.

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 few cases of tuberculosis, less than 0.02% of the children screened. Conclusion. 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.

Contacts exposed to tuberculosis patients with acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection were compared with contacts of HIV-negative patients for evidence of Mycobacterium tuberculosis transmission, based on a review of records of tuberculin skin tests administered during routine health department follow-up investigations in Miami/Dade County, Florida, from 1985 through 1989. After an adjusted analysis designed to balance background prevalence, tuberculin positivity was 42.0% in 2,158 contacts of HIV-negative patients compared with 28.6% and 31.3% in 363 contacts of HIV-infected patients and 732 contacts of AIDS patients, respectively. Similar results were observed in a subset of 5- to 14-year-old contacts of United States-born black or white tuberculosis patients chosen to minimize the possibility of false-negative tuberculin tests in contacts due to undiagnosed HIV infection. Analysis of contacts as sets showed a more than expected number of sets with none or all contacts infected, but this did not differ by HIV/AIDS group. In this study, tuberculosis patients with AIDS or HIV infection were less infectious to their contacts and, in this community, exposed fewer contacts than HIV-negative tuberculosis patients.

Congregate facilities for homeless persons with the acquired immunodeficiency syndrome (AIDS) are often endemic for tuberculosis. We evaluated tuberculosis screening methods at single-room-occupancy hotels housing persons with AIDS. Residents were screened by cross matching the New York City Tuberculosis Registry, interviewing for tuberculosis history, skin testing, and chest radiography. Cases were classified as either previously or newly diagnosed. Among the 106 participants, 16 (15%) previously diagnosed tuberculosis cases were identified. Participants' tuberculosis histories were identified by the questionnaire (100%) or by registry match (69%). Eight participants (50%) were noncompliant with therapy. These findings prompted the establishment of a directly observed therapy program on site.

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.

We examined medical and health department records for children5 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.

Background. The human T-cell lymphotropic virus Type I (HTLV-I) is associated with adult T-cell leukemia and myelopathy, whereas HTLV-II infection has uncertain clinical consequences. We assessed the seroprevalence of these retroviruses among intravenous drug users and among patients seen at clinics for sexually transmitted diseases (STD clinics). Methods. We used serum samples that were collected in eight cities in 1988 and 1989 during surveys of human immunodeficiency virus infection among intravenous drug users entering treatment and persons seen in STD clinics. The serum samples were tested for antibodies to HTLV, and positive specimens were tested further by a synthetic peptide-based enzyme-linked immunosorbent assay to differentiate between HTLV-I and HTLV-II. Results. Among 3217 intravenous drug users in 29 drug-treatment centers, the median seroprevalence rates of HTLV varied widely according to city (range, 0.4 percent in Atlanta to 17.6 percent in Los Angeles). Seroprevalence increased ...

The need for a new surveillance approach to understand the clinical outcomes and behaviors of people in care for HIV evolved from the new challenges for monitoring clinical outcomes in the HAART era, the impact of the epidemic on an increasing number of areas in the US, and the need for representative data to describe the epidemic and related resource utilization and needs. The Institute of Medicine recommended that the Centers for Disease Control and Prevention and the Heath Resources and Services Administration coordinate efforts to survey a random sample of HIV-infected persons in care, in order to more accurately measure the need for prevention and care services. The Medical Monitoring Project (MMP) was created to meet these needs. This manuscript describes the evolution and design of MMP, a new nationally representative clinical outcomes and behavioral surveillance system, and describes how MMP data will be used locally and nationally to identify care and treatment utilization needs, and to plan for prevention interventions and services.

Health departments in all 53 reporting areas in the United States were asked to submit the case definition they used for tuberculosis surveillance. Sixteen areas used the 1990 case definition; two areas sent 1977 guidelines; and 34 areas sent other definitions. Case reports sent to the Centers for Disease Control and Prevention (CDC) in 1992 were analyzed; 4% of cases did not meet the 1990 definition. Tuberculosis case reporting criteria are not uniformly applied in the United States. CDC, in collaboration with state and local health officials, is evaluating the current definition and will implement uniform national criteria for tuberculosis surveillance.

One third of the world's population is infected with Mycobacterium tuberculosis, and in the developed countries immigration is a major force that sustains the incidence of tuberculosis. We studied the effects of immigration on the epidemiology of tuberculosis and its recent resurgence in the United States.We analyzed data from the national tuberculosis reporting system of the Centers for Disease Control and Prevention. Since 1986 reports of tuberculosis have included the patient's country of origin. Population estimates for foreign-born persons were derived from special samples from the 1980 and 1990 censuses.The proportion of persons reported to have tuberculosis who were foreign-born increased from 21.6 percent (4925 cases) in 1986 to 29.6 percent (7346 cases) in 1993. For the entire eight-year period, most foreign-born patients with tuberculosis were from Latin America (43.9 percent; 21,115 cases) and Southeast Asia (34.6 percent; 16,643 cases). Among foreign-born persons the incidence rate was almost quadruple the rate for native residents of the United States (30.6 vs. 8.1 per 100,000 person-years), and 55 percent of immigrants with tuberculosis had the condition diagnosed in their first five years in the United States.Immigration has had an increasingly important effect on the epidemiology of tuberculosis in the United States. It will be difficult to eliminate tuberculosis without better efforts to prevent and control it among immigrants and greater efforts to control it in the countries from which they come.

ContextContact investigations are routinely conducted by health departments throughout the United States for all cases of active pulmonary tuberculosis (TB) to identify secondary cases of active TB and latent TB infection and to initiate therapy as needed in these contacts. Little is known about the actual procedures followed, or the results.ObjectivesTo evaluate contact investigations conducted by US health departments and the outcomes of these investigations.Design, Setting, and SubjectsReview of health department records for all contacts of 349 patients with culture-positive pulmonary TB aged 15 years or older reported from 5 study areas in the United States during 1996.Main Outcome MeasuresNumber of contacts identified, fully screened, and infected per TB patient; rates of TB infection and disease among contacts of TB patients; and type and completeness of data collected during contact investigations.ResultsA total of 3824 contacts were identified for 349 patients with active pulmonary TB. Of the TB patients, 45 (13%) had no contacts identified. Of the contacts, 55% completed screening, 27% had an initial but no postexposure tuberculin skin test, 12% were not screened, and 6% had a history of prior TB or prior positive tuberculin skin test. Of 2095 contacts who completed screening, 68% had negative skin test results, 24% had initial positive results with no prior test result available, 7% had documented skin test conversions, and 1% had active TB at the time of investigation. Close contacts younger than 15 years (76% screened vs 65% for older age groups; P

ContextWashington State has a relatively low incidence rate of tuberculosis (TB) infection. However, from May to September 1997, 3 cases of pulmonary TB were reported among medical waste treatment workers at 1 facility in Washington. There is no previous documentation of Mycobacterium tuberculosis transmission as a result of processing medical waste.ObjectiveTo identify the source(s) of these 3 TB infections.Design, Setting, and ParticipantsInterviews of the 3 infected patient-workers and their contacts, review of patient-worker medical records and the state TB registry, and collection of all multidrug-resistant TB (MDR-TB) isolates identified after January 1, 1995, from the facility's catchment area; DNA fingerprinting of all isolates; polymerase chain reaction and automated DNA sequencing to determine genetic mutations associated with drug resistance; and occupational safety and environmental evaluations of the facility.Main Outcome MeasuresPrevious exposures of patient-workers to TB; verification of patient-worker tuberculin skin test histories; identification of other cases of TB in the community and at the facility; drug susceptibility of patient-worker isolates; and potential for worker exposure to live M tuberculosis cultures.ResultsAll 3 patient-workers were younger than 55 years, were born in the United States, and reported no known exposures to TB. We did not identify other TB cases. The 3 patient-workers' isolates had different DNA fingerprints. One of 10 MDR-TB catchment-area isolates matched an MDR-TB patient-worker isolate by DNA fingerprint pattern. DNA sequencing demonstrated the same rare mutation in these isolates. There was no evidence of personal contact between these 2 individuals. The laboratory that initially processed the matching isolate sent contaminated waste to the treatment facility. The facility accepted contaminated medical waste where it was shredded, blown, compacted, and finally deactivated. Equipment failures, insufficient employee training, and respiratory protective equipment inadequacies were identified at the facility.ConclusionProcessing contaminated medical waste resulted in transmission of M tuberculosis to at least 1 medical waste treatment facility worker.

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 links were identified for 5 patients (Patients 1-5). However, no links were identified for the 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. —Eightpatients 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. —Patients 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.

Context. —With the resurgence of tuberculosis (TB) disease in the late 1980s and early 1990s in the United States, multidrug-resistant (MDR) TB emerged as a serious challenge to TB control. In response, the Centers for Disease Control and Prevention in 1993 added drug susceptibility test results to the information collected for the national surveillance system to monitor trends in drug resistance. Objective. —To determine the extent of drug-resistant tuberculosis (TB) in the United States. Design. —Descriptive analysis of TB surveillance data. Study Population. —Patients reported to the national TB surveillance system as confirmed TB cases with culture-positive disease from 1993 through 1996 by the 50 states, New York City, and the District of Columbia (DC). Main Outcome Measure. —Percentage of case patients with culture-positive disease whose isolates are resistant to specific anti-TB drugs. Results. —Overall resistance to at least isoniazid was 8.4%; rifampin, 3.0%; both isoniazid and rifampin (ie, MDR TB), 2.2%; pyrazinamide, 3.0%; streptomycin, 6.2%; and ethambutol hydrochloride, 2.2%. Rates of resistance were significantly higher for case patients with a prior TB episode. Among those without prior TB, isoniazid resistance of 4% or more was found in 41 states, New York City, and DC. A total of 1457 MDR TB cases were reported from 42 states, New York City, and DC; however, 38% were reported from New York City. Rates of isoniazid and streptomycin resistance were higher for cases among US-born compared with foreign-born patients, but rates of rifampin resistance and MDR TB were similar. Among US-born patients, resistance to first-line drugs, particularly rifampin monoresistance, was significantly higher among those with human immunodeficiency virus (HIV) infection. Conclusions. —Compared with recent US surveys in 1991 and 1992, isoniazid resistance has remained relatively stable. In addition, the percentage of MDR TB has decreased, although the national trend was significantly influenced by the marked decrease in New York City. Foreign-born and HIV-positive patients and those with prior TB have higher rates of resistance. The widespread extent of isoniazid resistance confirms the need for drug susceptibility testing to guide optimal treatment of patients with culture-positive disease.

Context. —Cases of tuberculosis (TB) in the United States have declined for 4 consecutive years, but cases among foreign-born persons account for an increasing percentage. Objective. —To describe the risk of tuberculosis among foreign-born persons with respect to their length of residence in the United States. Design. Cross-sectional analysis of national surveillance data. Setting. —The United States. Patients. —All verified TB cases reported to the Centers for Disease Control and Prevention between 1986 and 1994. Main Outcome Measure. —Stratum-specific incidence rates of TB by age, place of birth, length of residence, age at arrival in the United States, or combinations of these variables. Results. —Several groups of persons from countries with a high prevalence of TB had incidence rates higher than 20 per 100 000 person-years more than 20 years after arrival. Among long-term residents, those who arrived in the United States after their fifth birthday had incidence rates of TB 2 to 6 times higher than those of similar age who arrived before their fifth birthday. A total of 45% of the TB cases were among persons younger than 35 years and an additional 18% were among persons who arrived in the United States before their 35th birthday. Conclusions. —Imported Mycobacterium tuberculosis infection (active or latent) is responsible for most TB cases among foreign-born persons in the United States. Detection of active cases among recent arrivals is the main priority in these populations, but many cases were in persons who arrived in the United States before the age of 35 years that could potentially have been avoided with preventive therapy. Elimination of TB in the United States may not be feasible using available diagnostic and treatment modalities without increased efforts to address the global burden of this disease.

Background: Elucidation of the relationship between tuberculosis (TB) and the acquired immunodeficiency syndrome (AIDS) is needed to help predict the future course of these two epidemics. We examined nationwide trends in TB and AIDS occurring in the same individual. Methods: Health departments in the 50 states, District of Columbia, Puerto Rico, and Guam matched their TB and AIDS case registries to determine the number of persons diagnosed with both TB and AIDS. The number of AIDS cases, TB cases, AIDS cases that matched with a TB case on the TB registry, and TB cases that matched with an AIDS case on the AIDS registry were reported to the Centers for Disease Control and Prevention, Atlanta, Ga. Data were analyzed for the period from 1981 through 1991. The number of matched TB-AIDS cases was compared with a modeled estimate of excess TB cases during the period from 1985 through 1990. Results: From 1981 through 1991 there were 11 299 AIDS cases that matched with a TB case on the TB registry, representing 5.1% (geographic variation, 0% to 9.3%) of AIDS cases. The TB cases that matched with an AIDS case on the AIDS registry represent 4.3% (geographic variation, 0% to 15.1%) of TB cases from 1981 through 1991. Since 1981, matched TB and AIDS cases increased yearly through 1990. When examined by year of AIDS report, the percentage of AIDS cases that matched with a TB case increased from 1981 to 1982 (1.9% to 5.1%), remained fairly constant from 1983 through 1987 (range, 4.0% to 4.7%), increased in 1988 (5.4%) after extrapulmonary TB was added to the AIDS case definition, and increased slightly through 1990 (5.8%). When examined by year of TB report, the percentage of TB cases that matched with an AIDS case increased steadily from 1981 through 1990 (0.1% to 9.5%). The calculated fraction of excess TB cases during the period from 1985 through 1990 that could be accounted for by identified TB-AIDS cases was 30%. Conclusion: The risk of TB or AIDS among persons already diagnosed with one disease is much higher than among the general population. The percentage of persons with TB who are also diagnosed with AIDS has been increasing rapidly. Human immunodeficiency virus— induced immunosuppression is an important contributor to the TB epidemic and probably accounts for a minimum of 30% of excess TB cases during the period from 1985 through 1990. (Arch Intern Med. 1995;155:1281-1286)

Objective: To describe the seroprevalence of human immunodeficiency virus type 1 (HIV-1) and risk factors for HIV-1 infection among teenagers attending selected clinics. Design: Anonymous, cross-sectional serosurveys conducted in 130 clinics in 24 cities. Settings: Adolescent medicine clinics, sexually transmitted disease clinics, clinics in juvenile detention and correctional facilities, and homeless and runaway youth centers. Patients: Teenagers in whom serum samples were drawn as part of routine medical services. Main Outcome Measures: Prevalence of HIV-1 infection and reported HIV risk behaviors. Results: From January 1, 1990 through December 31, 1992, serum specimens were collected from 79 802 teenagers; 591 of these specimens were positive for HIV-1 antibody. Seropositive test results were found in all 24 cities surveyed, and in 95 (73%) of the 130 clinics surveyed. The median clinic-specific prevalence was 0.2% (range, 0% to 1.4%) in 22 adolescent medicine clinics, 0.3% (range, 0% to 6.8%) in 33 correctional facilities, 0.5% (range, 0% to 3.5%) in 70 sexually transmitted disease clinics, and 1.1% (range, 0% to 4.1%) in five homeless youth centers. Rates exceeded 1% in 37 sites (28%). Excluding sites with many men reporting sex with men, rates in women were similar or somewhat higher than rates in men. Rates were highest among young men reporting sex with men, with clinic rates ranging from 16% to 17% in two homeless youth sites and 13% to 17% in two sexually transmitted disease clinics. Most teenagers with risk information reported heterosexual activity as their only potential risk exposure to HIV-1. Conclusions: Seroprevalence of HIV was generally low but varied by type of clinic and geographic area. The highest rates were observed among young women and gay men in some settings, suggesting that targeted prevention messages are needed. (Arch Pediatr Adolesc Med. 1995;149:521-528)

Objective. —To investigate potential transmission ofMycobacterium tuberculosisin 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 Conclusions. —Data support the conclusion thatM tuberculosiswas 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 ofM tuberculosisto passengers cannot be excluded. (JAMA. 1994;272:1031-1035)

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. ( JAMA . 1994;271:665-671)

Objective. —To evaluate the efficacy of currently used whole-cell pertussis vaccines. Design. —Active surveillance to detect pertussis cases in Baltimore, Md, Denver, Colo, and Milwaukee, Wis, and investigation of secondary attack rates in 347 household contacts, aged 1 through 4 years, to estimate vaccine efficacy. Outcome Measure. —Vaccine efficacy was estimated using different case definitions for pertussis. Results. —Vaccine efficacy was 64%, 81%, and 95% for case definitions of mild cough, paroxysmal cough, and severe clinical illness, respectively. Requiring laboratory confirmation increased efficacy to 95% to 98% for culture-positive children and to 77% to 95% for culture- or serology-confirmed cases, depending on disease severity. Vaccine efficacy for typical paroxysmal cough increased from 44% for one diphtheria, tetanus, and pertussis vaccine dose to 80% for four or more doses. Conclusions. —The trend toward increasing vaccine efficacy with different case definitions may be due to improved efficacy in preventing severe illness and to case definitions that are more specific for pertussis. Whole-cell pertussis vaccine was highly effective in preventing pertussis in preschool children exposed to infection within their households. Direct side-by-side efficacy studies of whole-cell vaccine and the recently licensed acellular vaccine will be necessary to assure that comparable protection is afforded by the new vaccines if they are to be used for immunization of infants. ( JAMA . 1992;267:2745-2749)

Le point sur le cytomegalovirus, et la maladie des inclusions cytomegaliques. En pratique, la meilleure prevention pour la femme enceinte ou prevoyant de l'etre est une rigoureuse hygiene personnelle, au cas ou elle travaille en contact avec des enfants ou des nourissons