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Introduction: Diabetes might confer a modestly increased risk of latent tuberculosis infection, which without treatment can progress to active tuberculosis disease. Three recent analyses of the National Health and Nutrition Examination Survey found a positive association between diabetes and a positive test for Mycobacterium tuberculosis infection. This study examines whether prevalence of a positive test still varies by diabetes status after stratifying by race/ethnicity., Methods: This cross-sectional analysis used the public-use National Health and Nutrition Examination Survey 2011-2012 data sets and was conducted in 2018-2019. Interview and examination results for 5,560 adult participants yielded estimates for 219 million U.S. adults in the 4 largest race/ethnicity groups. The weighted prevalence of positive tuberculin skin test or interferon-gamma release assay by diabetes status was ascertained in each group., Results: Among white and black adults, diabetes was associated with no difference in positive skin test prevalence and little difference in positive interferon-gamma release assay prevalence. The positive assay prevalence difference was +14.5% (95% CI=2.3%, 26.7%) among Hispanic and +9.9% (95% CI=1.2%, 18.6%) among Asian adults, when comparing those with diabetes with those with neither diabetes nor prediabetes. Based on assay results, 23.6% (95% CI=14.0%, 36.9%) of Hispanic and 27.2% (95% CI=19.6%, 36.5%) of Asian adults with diabetes also had latent tuberculosis infection., Conclusions: Hispanic and Asian subpopulation results drove much of the previously reported positive association between diabetes and a positive test for M. tuberculosis infection. Hispanic and Asian adults with diabetes might particularly benefit from screening and treatment for latent tuberculosis infection., (Published by Elsevier Inc.)

Background: A single 2-year National Health and Nutrition Examination Survey (NHANES) cycle is designed to provide accurate and stable estimates of conditions with prevalence of at least 10%. Recent NHANES-based estimates of a tuberculin skin test (TST) ≥10 mm in the noninstitutionalized US civilian population are at most 6.3%., Methods: NHANES included a TST in 1971-1972, 1999-2000, and 2011-2012. We examined the robustness of NHANES-based estimates of the US population prevalence of a skin test ≥10 mm with a bias analysis that considered the influence of non-US birth distributions and within-household skin test results, reclassified borderline-positive results, and adjusted for TST item nonresponse., Results: The weighted non-US birth distribution among NHANES participants was similar to that in the overall US population; further adjustment was unnecessary. We found no evidence of bias due to sampling multiple participants per household. Prevalence estimates changed 0.3% with reclassification of borderline-positive TST results and 0.2%-0.3% with adjustment for item nonresponse., Conclusions: For estimating the national prevalence of a TST ≥10 mm during these three survey cycles, a conventional NHANES analysis using the standard participant weights and masked design parameters that are provided in the public-use datasets appears robust. See video abstract at, http://links.lww.com/EDE/B636.

We used tuberculosis genotyping results to derive estimates of prevalence of latent tuberculosis infection in the United States. We estimated <1% prevalence in 1,981 US counties, 1%-<3% in 785 counties, and >3% in 377 counties. This method for estimating prevalence could be applied in any jurisdiction with an established tuberculosis surveillance system.

Background: Reexamining the prevalence of persons infected with tuberculosis (TB) is important to determine trends over time. In 2011-2012 a TB component was included in the National Health and Nutrition Examination Survey (NHANES) to estimate the reservoir of persons infected with TB., Methods: Civilian, noninstitutionalized U.S. population survey participants aged 6 years and older were interviewed regarding their TB history and eligibility for the tuberculin skin test (TST) and interferon gamma release assay (IGRA) blood test. Once eligibility was confirmed, both tests were conducted. Prevalence and numbers of TST positive (10 mm or greater), IGRA positive, and both TST and IGRA positive were calculated by adjusting for the complex survey design after applying corrections for item nonresponse and digit preference in TST induration measurements. To examine TST positivity over time, data from NHANES 1999-2000 were reanalyzed using the same statistical methods. The TST was performed using Tubersol, a commercially available purified protein derivative (PPD), rather than PPD-S, which was the antigen used in NHANES 1999-2000. Prior patient history of TB vaccination was not collected in this study nor were patients examined for the presence of a Bacillus of Calmette and Guerin (BCG) vaccine scar., Results: For NHANES 2011-2012, TST and IGRA results were available for 6,128 (78.4%) and 7,107 (90.9%) eligible participants, respectively. There was no significant difference between the percentage of the U.S. population that was TST positive in 2011-2012 (4.7% [95% CI 3.4-6.3]; 13,276,000 persons) compared with 1999-2000 (4.3%; 3.5-5.3). In 2011-2012 the percentage that was IGRA positive was 5.0% (4.2-5.8) and double TST and IGRA positivity was 2.1% (1.5-2.8). The point estimate of IGRA positivity prevalence in foreign-born persons (15.9%; 13.5-18.7) was lower than for TST (20.5%; 16.1-25.8) in 2011-2012. The point estimate of IGRA positivity prevalence in U.S.-born persons (2.8%; 2.0-3.8) was higher than for TST (1.5%; 0.9-2.6)., Conclusions: No statistically significant decline in the overall estimated prevalence of TST positivity was detected from 1999-2000 to 2011-2012. The prevalence of TB infection, whether measured by TST or IGRA, remains lower among persons born in the United States compared with foreign-born persons.

We present a mathematical transmission model of tuberculosis in the USA. The model is calibrated to recent trends of declining incidence in the US-born and foreign-born populations and is used in assessing relative impacts of treatment of latently infected individuals on elimination time, where elimination is defined as annual incidence <1 case/million. Provided current control efforts are maintained, elimination in the US-born population can be achieved before the end of this century. However, elimination in the foreign-born population is unlikely in this timeframe even with higher rates of targeted testing and treatment of residents of and immigrants to the USA with latent tuberculosis infection. Cutting transmission of disease as an interim step would shorten the time to elimination in the US-born population but foreign-born rates would remain above the elimination target.

Infectious respiratory pathogens were the suspected cause of 480 outbreaks investigated by the Centers for Disease Control and Prevention's Epidemic Intelligence Service officers during 1946-2005. All epidemic-assistance investigation reports and associated articles from scientific journals were reviewed. Investigations identified 25 different infectious respiratory pathogens including, most frequently, tuberculosis, influenza, and legionellosis. Other bacterial-, viral-, and fungal-related pathogens also were identified. Epidemic-assistance investigations were notable for first identifying Legionnaires disease and Pontiac fever, hantavirus pulmonary syndrome, and new strains of human and avian influenza, as well as emerging challenges (e.g., multidrug-resistant tuberculosis and pneumococcus). The investigations provided clinical insights into such diseases as pulmonary anthrax and identified high risks of serious respiratory illnesses for persons infected with human immunodeficiency virus, other immunocompromised persons, and persons with diabetes. They identified settings placing persons at high risk of acquiring disease, including nursing homes, prisons, homeless shelters, and hospitals. Travel also placed persons at risk. Key environmental factors related to spread of diseases and occupational risks for brucellosis and psittacosis were identified. The outbreak investigations constitute a wealth of prevention experience and provide the basis for recommendations to mitigate outbreaks and reduce future risks.

Background: Since 1953, through the cooperation of state and local health departments, the U.S. Centers for Disease Control and Prevention (CDC) has collected information on incident cases of tuberculosis (TB) disease in the United States. In 2009, TB case rates declined -11.4%, compared to an average annual -3.8% decline since 2000. The unexpectedly large decline raised concerns that TB cases may have gone unreported. To address the unexpected decline, we examined trends from multiple sources on TB treatment initiation, medication sales, and laboratory and genotyping data on culture-positive TB., Methods: We analyzed 142,174 incident TB cases reported to the U. S. National Tuberculosis Surveillance System (NTSS) during January 1, 2000-December 31, 2009; TB control program data from 59 public health reporting areas; self-reported data from 50 CDC-funded public health laboratories; monthly electronic prescription claims for new TB therapy prescriptions; and complete genotyping results available for NTSS cases. Accounting for prior trends using regression and time-series analyses, we calculated the deviation between observed and expected TB cases in 2009 according to patient and clinical characteristics, and assessed at what point in time the deviation occurred., Results: The overall deviation in TB cases in 2009 was -7.9%, with -994 fewer cases reported than expected (P < .001). We ruled out evidence of surveillance underreporting since declines were seen in states that used new software for case reporting in 2009 as well as states that did not, and we found no cases unreported to CDC in our examination of over 5400 individual line-listed reports in 11 areas. TB cases decreased substantially among both foreign-born and U.S.-born persons. The unexpected decline began in late 2008 or early 2009, and may have begun to reverse in late 2009. The decline was greater in terms of case counts among foreign-born than U.S.-born persons; among the foreign-born, the declines were greatest in terms of percentage deviation from expected among persons who had been in the United States less than 2 years. Among U.S.-born persons, the declines in percentage deviation from expected were greatest among homeless persons and substance users. Independent information systems (NTSS, TB prescription claims, and public health laboratories) reported similar patterns of declines. Genotyping data did not suggest sudden decreases in recent transmission., Conclusions: Our assessments show that the decline in reported TB was not an artifact of changes in surveillance methods; rather, similar declines were found through multiple data sources. While the steady decline of TB cases before 2009 suggests ongoing improvement in TB control, we were not able to identify any substantial change in TB control activities or TB transmission that would account for the abrupt decline in 2009. It is possible that other multiple causes coincident with economic recession in the United States, including decreased immigration and delayed access to medical care, could be related to TB declines. Our findings underscore important needs in addressing health disparities as we move towards TB elimination in the United States.

Context: Worldwide emergence of extensively drug-resistant tuberculosis (XDR-TB) has raised global public health concern, given the limited therapy options and high mortality., Objectives: To describe the epidemiology of XDR-TB in the United States and to identify unique characteristics of XDR-TB cases compared with multidrug-resistant TB (MDR-TB) and drug-susceptible TB cases., Design, Setting, and Patients: Descriptive analysis of US TB cases reported from 1993 to 2007. Extensively drug-resistant TB was defined as resistance to isoniazid, a rifamycin, a fluoroquinolone, and at least 1 of amikacin, kanamycin, or capreomycin based on drug susceptibility test results from initial and follow-up specimens., Main Outcome Measures: Extensively drug-resistant TB case counts and trends, risk factors for XDR-TB, and overall survival., Results: A total of 83 cases of XDR-TB were reported in the United States from 1993 to 2007. The number of XDR-TB cases declined from 18 (0.07% of 25 107 TB cases) in 1993 to 2 (0.02% of 13 293 TB cases) in 2007, reported to date. Among those with known human immunodeficiency virus (HIV) test results, 31 (53%) were HIV-positive. Compared with MDR-TB cases, XDR-TB cases were more likely to have disseminated TB disease (prevalence ratio [PR], 2.06; 95% confidence interval [CI], 1.19-3.58), less likely to convert to a negative sputum culture (PR, 0.55; 95% CI, 0.33-0.94), and had a prolonged infectious period (median time to culture conversion, 183 days vs 93 days for MDR-TB; P < .001). Twenty-six XDR-TB cases (35%) died during treatment, of whom 21 (81%) were known to be HIV-infected. Mortality was higher among XDR-TB cases than among MDR-TB cases (PR, 1.82; 95% CI, 1.10-3.02) and drug-susceptible TB cases (PR, 6.10; 95% CI, 3.65-10.20)., Conclusion: Although the number of US XDR-TB cases has declined since 1993, coinciding with improved TB and HIV/AIDS control, cases continue to be reported each year.

This overview of tuberculosis elimination in the United States consists of three parts. First I will briefly overview the neglect and related factors during 1970's and early 80's which resulted in the 1985-1992 unprecedented resurgence of tuberculosis following thirty years of a steady decline in the United States. Second, I will review what we did in response and the resulting trends. Third, I will focus on the Institute of Medicine (IOM) report entitled "Ending Neglect", and identify the challenges to elimination and what will it take to finishing the job. The IOM report recommends the United States to pursue and accelerate the elimination of tuberculosis, addressing the following; 1) maintain control while adapting to declining incidence of tuberculosis, 2) speed the decline through the increased treatment of persons with latent infection, 3) invest in research and development to develop new tools needed for ultimate elimination, with a focus on new reliable and rapid diagnostic tools for latent infection, new drug regimens, especially in light of the emergence of extensively drug-resistant tuberculosis, and a safe and effective vaccine for tuberculosis, 4) increase the United States engagement in global efforts, recognizing that the global reality is directly reflected in the United States, 5) mobilize support and measure progress towards elimination. Each of these recommendations will be translated into the agenda for action with the illustrations for the real situations of the United States. It is important to recognize that in spite of all this progress much work needs to be done and in order to finish the job on tuberculosis elimination we have the blueprints, we have the partners, and we must keep working to make the effective use of our resources. I would like to close by quoting one of the favorite phrases in "Ending Neglect"; "The issue now confronting the nation, that is the United States, is whether we will allow another cycle of neglect to begin or instead whether we will take decisive action to eliminate tuberculosis."

Rationale: 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., Objectives: To estimate the prevalence of LTBI in the U.S. population., Methods and Measurements: 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., Measurements and Main Results: 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., Conclusions: 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.

Background: To our knowledge, this is the first assessment of trends in tuberculosis (TB)/human immunodeficiency virus (HIV) comorbidity in the United States based on national TB surveillance data., Methods: We analyzed all incident TB cases reported to the Centers for Disease Control and Prevention national TB surveillance system from all 50 states and the District of Columbia from 1993 through 2004. Trends in TB/HIV cases were examined according to selected demographic and clinical characteristics., Results: Cases of TB/HIV decreased from 3681 (15% of 25,108 TB cases) in 1993 to 1187 (8% of 14,515 TB cases) in 2004, accounting for 23% of the overall decrease in TB cases during this period. The TB/HIV case rate decreased from 1.4/100,000 in 1993 to 0.4/100,000 in 2004. The highest TB/HIV comorbidity rates persisted in persons aged 25 to 44 years (13.8%), males (9.7%), US-born persons (10.7%), non-Hispanic blacks (17.8%), and persons from the Northeast (11.0%) and the South (10.1%). Propensity stratification, used to account for the unequal probability of patients with TB being tested for HIV during the study period, did not show important differences in TB/HIV comorbidity trends., Conclusions: Comorbidity due to TB/HIV decreased substantially between 1993 and 2004, primarily in US-born persons in states that experienced a TB resurgence between 1985 and 1992. These decreases coincide with improvements in TB control and advances in HIV treatment and diagnosis. The overall decreases obscure the wide variation in comorbidity that exists among some demographic groups and the recent slowing in the decline over the past 3 years.

Rationale: In the United States, the number of annual reported cases of tuberculosis (TB) among U.S.-born persons declined by 62% from 1993 to 2004, but increased by 5% among foreign-born persons. Over half of all reported cases of TB in the United States occur among foreign-born persons, most of these due to activation of latent TB infection (LTBI). Current guidelines recommend targeting only foreign-born persons who entered the United States within the previous 5 yr for LTBI testing., Objective: We sought to assess the epidemiologic basis for this guideline., Methods: We calculated TB case rates among foreign-born persons, stratified by duration of United States residence and world region of origin. We determined the number of cases using 2004 U.S. TB surveillance data, and calculated case rates using population data from the 2004 American Community Survey., Measurements and Main Results: In 2004, a total of 14,517 cases of TB were reported; 3,444 (24%) of these were among foreign-born persons who had entered the United States more than 5 yr previously. The rate of TB disease among foreign-born persons was 21.5/100,000, compared with 2.7/100,000 for U.S.-born persons, and varied by duration of residence and world region of origin., Conclusions: Almost one-quarter of all TB cases in the United States occur among foreign-born persons who have resided in the United States for longer than 5 yr; case rates for such persons from selected regions of origin remain substantially elevated. To eliminate TB, we must address the burden of LTBI in this high-risk group.

Objective: This study was conducted to determine whether improvements in tuberculosis (TB) program activities correlate with incident TB cases., Methods: National TB surveillance data and program data from patients with pulmonary and laryngeal TB and their contacts were collected. These data were analyzed using regression models to assess the association between changes in incident TB cases and indicators of program performance (a time series of percent changes in program indices)., Results: A total of 1,361,113 contacts exposed to 150,668 TB patients were identified through contact investigations. From 1987 to 1992 (the period of TB resurgence and antedating increased funding), there was a decline in several measures used by TB programs for outcomes of contact investigations. From 1993 to 1998 (the period after increases in TB funds), there was an observable improvement in the program indices. Four program indices for contacts and two for TB cases (directly observed therapy and completion of therapy) were statistically associated (p < or = .01) with the decline in TB incident cases., Conclusions: These analyses suggest that expanded TB program activities resulted in the reduction in national TB cases and underscore the importance of treatment completion for TB disease and latent TB infection. Based on these results, we propose that further improvements in these activities will accelerate the decline of TB in the United States.

After decades of decline, an unprecedented resurgence in tuberculosis occurred in the late 1980s and early 1990s. Deterioration of tuberculosis program infrastructure, the HIV/AIDS epidemic, drug-resistant tuberculosis, and tuberculosis among foreign-born persons contributed to the resurgence. Since then, tuberculosis case numbers have declined, but the decline in 2003 was the smallest since the resurgence. Key challenges remain, and efforts must focus on identifying and targeting interventions for high-risk populations, active involvement in the global effort against tuberculosis, developing new tools, and maintaining adequate resources.

Context: Persons with recently acquired latent tuberculosis (TB) infection and human immunodeficiency virus (HIV) co-infection are at high risk of rapid progression to TB disease., Objectives: To determine the proportion of close contacts of infectious TB patients tested for HIV, and the results of HIV testing for this group., Design, Setting and Subjects: Review of health department records for all close contacts of 349 patients with culture-positive pulmonary TB aged 15 years or older reported from five study areas in the United States in 1996., Main Outcome Measures: Proportion of close contacts of TB patients tested for HIV, and rate of HIV infection among close contacts of TB patients., Results: A total of 1169 close contacts were identified for 349 patients with active pulmonary TB. HIV test results were available for 224 (64%) TB patients and 220 (19%) close contacts. Of the TB patients tested, 164 (73%) were HIV-negative and 60 (27%) were HIV-positive. An equal proportion of close contacts of HIV-positive and -negative TB patients were tested (21% vs. 24%). Of the close contacts tested, 201 (91%) were HIV-negative and 19 (9%) were HIV-positive. Compared with close contacts of HIV-negative TB patients, close contacts of HIV-positive TB patients were more likely to be HIV-positive (53% vs. 2%; P < 0.01). This association was observed for contacts residing in the TB patient household (70% vs. none; P < 0.01), not residing in the TB patient household (20% vs. 4%; P < 0.05), 25-44 years of age (88% vs. 8%; P < 0.01), and > 44 years of age (22% vs. 2%; P < 0.05)., Conclusions: HIV-positive TB patients and their close contacts may share some of the same risk factors for HIV infection. These findings suggest that the HIV status of the TB patient, in addition to established risk factors for HIV infection, may be an important consideration for prioritizing voluntary HIV counseling and testing efforts among close contacts of infectious TB patients.

In the United States, many people erroneously think that tuberculosis (TB) is a disease of the past--an illness that no longer constitutes a public health threat. In reality, TB is one of the leading global causes of morbidity and mortality. According to the World Health Organization, which compiles annual country profiles of reported TB cases using standardized case definitions, 2.4 million cases were reported in 2001. However, because of underreporting, the number of new TB cases is estimated to be 8.3 million, including 1.8 million deaths. In the United States, after more than 3 decades of steady downward trends, an unprecedented resurgence of TB occurred between 1985 and 1992. This increase was associated with deficient infrastructure, the human immunodeficiency virus (HIV) epidemic, immigration, outbreaks in congregate settings, and widespread occurrence of multidrug resistant TB strains. The resultant increased concerns provided the impetus for the development of a national action plan to combat MDR and the mobilization of new resources. Consequently, the incidence of TB cases has decreased from 1992 through 2002. New challenges are evident and must be addressed to achieve the agreed-on goal of eliminating TB in the United States. This report describes the global epidemiology of TB and the epidemiology in the United States, and outlines future challenges to the elimination of TB in the United States.

At the time of the last world congress on tuberculosis (TB) in 1992, the United States (US) was experiencing an unprecedented resurgence of TB. Since the mid-1950s, TB incidence had been steadily decreasing, until 1984 when this longstanding trend was reversed. The annual national total of TB cases continued to increase and peaked in 1992 with 26,673 TB cases reported (10.5 TB cases per 100,000 population). A prompt and formidable response from local, state, and federal governments helped curb the resurgence. From 1992 to 2001, total TB incidence decreased by 40% to an all-time low of 15,989 TB cases reported in 2001. The decrease in TB cases from 2000 to 2001, however, was the smallest (2.4%) since the resurgence a decade ago. This report will briefly review the trends and factors associated with the TB resurgence in the late 1980s and early 1990s, and provide a detailed description of specific TB trends in the US between 1992 and 2001.

Our understanding of tuberculosis (TB) transmission dynamics has been refined by genotyping of Mycobacterium tuberculosis strains. The National Tuberculosis Genotyping and Surveillance Network was designed and implemented to systematically evaluate the role of genotyping technology in improving TB prevention and control activities. Genotyping proved a useful adjunct to investigations of outbreaks, unusual clusters, and laboratory cross-contamination.

After a 20% increase in tuberculosis (TB) cases between 1986 and 1992, TB cases in the United States have declined from 1993 through 1997, an average of 5 to 7 per cent per year. In this paper, we review trends and the current epidemiology of TB in the US, present a brief history of TB control efforts in the country, and present the key strategies for TB control in the US. We describe the current organizational structure of TB services in the US, the role of the private sector in TB control, and how TB control is funded. Finally we discuss the mechanisms by which TB policy is developed. The US model represents a categorical disease program that combines a centralized role of the national government in development of policy, funding, and in the maintenance of national surveillance, and a decentralized role of state and local jurisdictions, which adapt and implement national guidelines and which are responsible for day-to-day program activities. Given the relative success of this combined approach, other countries facing the challenge of maintaining an effective TB control program in the face of increased decentralization of health services may find this description useful.

Setting: The highest priority for tuberculosis (TB) control is to ensure patients complete therapy. However, standardized, detailed evaluation of national performance on completion of therapy in the United States has been lacking. Since 1982, the Centers for Disease Control and Prevention (CDC) has had a program objective that at least 90% of TB cases complete therapy. Since 1986, the standard of practice for patients with drug-susceptible TB has been 6 months of therapy., Objective: To determine completion of therapy rates and duration of therapy for US TB patients reported in 1993., Design: Expanded TB surveillance data on all US TB patients reported to the CDC in 1993 with initial therapy of two or more drugs were analyzed with respect to completion and duration of therapy., Results: A disposition (reason therapy stopped) was obtained on 98.7% of 23 489 treated patients. Overall, 91.2% of evaluable patients completed therapy. The overall completion rate at 12 months of therapy was 66.8%, and 90% completion was reached at 23 months. For patients with initially drug-susceptible TB, completion was 7.1% at 6 months, 66.5% at 12 months, and reached 90% at 22 months., Conclusion: While completion rates ultimately exceeded 90% nationwide, there was considerable delay in reaching this objective, especially in patients with drug-susceptible TB. It is critical that health departments and health care providers identify and remedy any deficiencies responsible for prolonged therapy.

Objectives: Factors associated with decreases in tuberculosis cases observed in the United States in 1993 and 1994 were analyzed., Methods: Changes in case counts reported to the national surveillance system were evaluated by dividing the number of incident cases of TB reported in 1993 and 1994 by the number of cases reported in 1991 and 1992 and stratifying these ratios by demographic factors, AIDS incidence, and changes in program performance., Results: Case counts decreased from 52,956 in 1991 and 1992 to 49,605 in 1993 and 1994 (case count ratio = 0.94, 95% confidence interval [CI] = 0.93, 0.95). The decrease, confined to US-born patients, was generally associated with AIDS incidence and improvements in completion of therapy, conversion of sputum, and increases in the number of contacts identified per case., Conclusions: Recent TB epidemiology patterns suggest that improvements in treatment and control activities have contributed to the reversal in the resurgence of this disease in US-born persons. Continued success in preventing the occurrence of active TB will require sustained efforts to ensure appropriate treatment of cases.

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 foreign-born compared with US-born patients [corrected] 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.

The number of reported cases of tuberculosis (TB) in foreign-born persons in the United States during 1995 was 8,042, 36% of the national total. The overseas screening of immigrants and refugee visa applicants, which relies on a chest radiograph and smear microscopy, is designed to identify future U.S. residents who have active TB or who are at high risk for TB. In this commentary, we summarize current policies and review retrospective evaluations of the screening system currently in place. The system appears to detect most persons who have active TB at the time of screening. However, active TB is actually diagnosed in < 15% of persons who are identified by screening as having suspected TB and who are evaluated in the United States. To improve the system, more sensitive and specific techniques as well as improved means of data transmission to state and local health departments are needed.

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.

Background: In April 1994, a passenger with infectious multi-drug resistant tuberculosis traveled on commercial-airline flights from Honolulu to Chicago and from Chicago to Baltimore and returned one month later. We sought to determine whether she had infected any of her contacts on this extensive trip., Methods: Passengers and crew were identified from airline records and were notified of their exposure, asked to complete a questionnaire, and screened by tuberculin skin tests., Results: Of the 925 people on the airplanes, 802 (86.7 percent) responded. All 11 contacts with positive tuberculin skin tests who were on the April flights and 2 of 3 contacts with positive tests who were on the Baltimore-to-Chicago flight in May had other risk factors for tuberculosis. More contacts on the final, 8.75-hour flight from Chicago to Honolulu had positive skin tests than those on the other three flights (6 percent, as compared with 2.3, 3.8, and 2.8 percent). Of 15 contacts with positive tests on the May flight from Chicago to Honolulu, 6 (4 with skin-test conversion) had no other risk factors; all 6 had sat in the same section of the plane as the index patient (P=0.001). Passengers seated within two rows of the index patient were more likely to have positive tuberculin skin tests than those in the rest of the section (4 of 13, or 30.8 percent, vs. 2 of 55, or 3.6 percent; rate ratio, 8.5; 95 percent confidence interval, 1.7 to 41.3; P=0.01)., Conclusions: The transmission of Mycobacterium tuberculosis that we describe aboard a commercial aircraft involved a highly infectious passenger, a long flight, and close proximity of contacts to the index patient.

In order to examine differences in the prevalence of AIDS-defining conditions by race/ethnicity, we analyzed U.S. surveillance data for 203,470 adolescents and adults diagnosed with AIDS from 1988 through 1992. A number of AIDS-indicator conditions were more common among certain racial/ethnic groups. The prevalence of extrapulmonary tuberculosis was higher among blacks, Hispanics, Asians/Pacific Islanders, and American Indians/Alaskan Natives than among whites. The prevalence of isosporiasis and toxoplasmosis was higher among Hispanics than among blacks or whites. Furthermore, the likelihood of being diagnosed with extrapulmonary tuberculosis (TB), toxoplasmosis, or isosporiasis was generally higher among foreign-born than among U.S.-born persons of all racial/ethnic groups. The prevalence of all malignancies was higher among whites than among blacks or Hispanics. However, the magnitude of prevalence differences by race/ethnicity was reduced when we controlled for other demographic and exposure risk categories. Although race/ethnicity was significantly associated with the prevalence of a number of conditions, the relative frequency and patterns of AIDS-indicator conditions in different populations are probably most influenced by differences in (1) underlying prevalence or exposure to various etiologic agents causing these conditions, (2) diagnosis and reporting of conditions, and (3) access to care and therapy for HIV-related conditions.

Tuberculosis, a bacterial disease caused by the Mycobacterium tuberculosis complex, is becoming an increasingly common opportunistic disease in persons infected with the human immunodeficiency virus (HIV). M. tuberculosis is transmitted from person-to-person by airborne droplet nuclei. Persons who are exposed to these droplet nuclei in poorly ventilated environments are at risk of becoming infected with M. tuberculosis. HIV infection is probably the most significant risk factor associated with progression from latent M. tuberculosis infection to active disease. Thus, HIV-infected persons should avoid exposure to M. tuberculosis, they should be screened for evidence of latent infection with the tuberculin skin test, and they should be offered preventive therapy. Because many severely immunosuppressed anergic HIV-infected persons have been found to have an increased risk of developing active tuberculosis, decisions to use preventive therapy should be individualized on the basis of the local prevalence of tuberculosis and drug-resistance patterns. Persons with active tuberculosis should receive at least 6 months of treatment with recommended regimens, preferably with directly observed therapy, to ensure adequate bacteriologic response, completion of therapy, and cure. Chronic suppressive therapy after completion of therapy is currently not recommended.

Tuberculosis (TB) remains an important public health problem worldwide, resulting in a estimated 8 to 10 million new cases and 2 to 3 million deaths each year. Between 1953 and 1985, the number of TB cases in the US declined by an average of 6% per year. However, since 1985, TB has been increasing in the US. Approximately 64,000 additional cases of the disease have been reported beyond the number expected had the rate of decline observed from 1980 to 1984 continued from 1985 through 1993. Increases in the number of TB cases have been significant in racial and ethnic minorities, in persons born outside the US, and in children less than 15 years of age. Infection with the human immunodeficiency virus (HIV) has also been recognized as a major risk factor for the development of active TB in persons with latent Mycobacterium tuberculosis infection. The unusual radiographic findings and the increased likelihood of extrapulmonary TB in HIV-infected persons make diagnosis of the disease problematic. Lastly, concomitant with the resurgence of TB has been the emergence of drug resistance. All of these factors make successful control of TB in the US difficult.

Objective: To evaluate the effect of human immunodeficiency virus (HIV) infection and tuberculosis on hospitalizations and the cost of care., Design: National Hospital Discharge Survey, a nationally representative survey of discharges from U.S. nonfederal short-stay hospitals, and statewide billing information., Patients: Patients 15 to 44 years of age with a listed diagnosis of HIV infection (n = 418,200) or active tuberculosis (n = 77,700) during 1985-1990., Results: During 1985-1990, hospitalizations related to HIV infection increased sixfold, from 18 to 102 per 100,000 persons; during 1988-1990, hospitalizations related to tuberculosis increased twofold, from 8 to 16 per 100,000 persons. The prevalence of tuberculosis among HIV-infected patients increased from 2.4% in 1985-1988 to 5.1% in 1989-1990 (P = 0.003). The prevalence of HIV infection among patients with tuberculosis increased from 11% in 1985-1988 to 28% in 1989 to 39% in 1990 (P < 0.001). Infection with HIV was more prevalent among patients with extrapulmonary tuberculosis (31%) than among those with pulmonary tuberculosis (18%) (P = 0.01). An increase in the duration of hospital stay was associated with both tuberculosis and HIV infection. From 1985 to 1990, inpatient care costs increased 7.7-fold and 3.2-fold for HIV and tuberculosis hospitalizations, respectively. During this period, HIV and tuberculosis hospitalizations resulted in 5,793,000 and 1,107,900 days of care, respectively, with an estimated direct cost of $5.7 to $7.4 billion and $0.89 to $1.07 billion, respectively. Estimated national costs of inpatient care for HIV infection or tuberculosis or both totaled $6.4 to $8.1 billion, 5% of which was for patients with both HIV infection and tuberculosis., Conclusions: This is the first study to use a nationally representative sample of hospitals, combined with cost data, to estimate hospitalizations and their costs for HIV and tuberculosis care. Our findings suggest that the convergence of the HIV and tuberculosis epidemics has had an increasing effect on morbidity and the cost of care among young adults in the United States. The increasing prevalence of comorbidity of HIV infection and tuberculosis in inpatients underscores the need for strict infection control of tuberculosis on the part of hospitals, increased attention to prevention, and early identification and treatment of HIV infection, and tuberculosis to reduce morbidity, hospitalizations, and the cost of care.

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.

Objectives: In 1991 the incidence of acquired immunodeficiency syndrome (AIDS) in the United States was 31.6 per 100,000 population among Hispanics and 11.8 per 100,000 among non-Hispanic Whites. The purpose of this study was to further describe the AIDS epidemic among Hispanics by examining differences in risk factors among different Hispanic groups (as defined by birthplace)., Methods: AIDS cases reported to the Centers for Disease Control and Prevention from 1988 through 1991 were reviewed., Results: For men, except for those born in Puerto Rico, the predominant exposure category was male-male sex. The proportion of cases due to injection drug use was 35% among Hispanic men born in the United States, 27% among men born in the Dominican Republic, and 61% among men born in Puerto Rico, but < 10% among other Hispanic men and non-Hispanic White men. For women the predominant exposure category was injection drug use among Hispanics born in the United States (56%) and Puerto Rico (46%) and among non-Hispanic Whites (42%). The proportion of cases associated with injection drug use was significantly lower (< 30%) among other Hispanic women., Conclusions: AIDS prevention strategies must be geared toward different exposure categories among different Hispanic groups.

AIDS surveillance data reported to the Centers for Disease Control from January 1981 through December 1991 were analyzed in a study characterizing persons with human immunodeficiency virus (HIV) infection and extrapulmonary tuberculosis (EPTB) in the United States. Among 206,392 persons reported to have AIDS, 4,751 (2.3%) were also reported to have EPTB; of these cases, 4,257 (90%) were reported after September 1987, when the case definition for AIDS was revised to include EPTB. Seventy-six percent of persons in whom AIDS and EPTB were reported after this revision were born in the United States; among these persons, the annual percentage with EPTB in 1988-1991 ranged from 2.3% to 2.5%. The South and the Northeast accounted for 73% of EPTB cases in U.S.-born persons. U.S.-born non-Hispanic blacks (odds ratio [OR], 3.3) and U.S.-born Hispanics (OR, 2.1) were more likely than U.S.-born non-Hispanic whites to be reported as having EPTB. Intravenous drug users were at higher risk (OR, 2.9) than men who reported having had sex with other men. With the resurgence of tuberculosis and the continued expansion of the HIV epidemic, these data provide a useful basis for the targeting of efforts to control tuberculosis and to prevent HIV infection.

Background: Since 1985, donors of organs or tissues for transplantation in the United States have been screened for human immunodeficiency virus type 1 (HIV-1), and more than 60,000 organs and 1 million tissues have been transplanted. We describe a case of transmission of HIV-1 by transplantation of organs and tissues procured between the time the donor became infected and the appearance of antibodies. The donor was a 22-year-old man who died 32 hours after a gunshot wound; he had no known risk factors for HIV-1 infection and was seronegative., Methods: We reviewed the processing and distribution of all the transplanted organs and tissues, reviewed the medical histories of the donor and HIV-1-infected recipients, tested stored donor lymphocytes for HIV-1 by viral culture and the polymerase chain reaction, and tested stored serum samples from four organ recipients for HIV-1 antigen and antibody., Results: HIV-1 was detected in cultured lymphocytes from the donor. Of 58 tissues and organs obtained from the donor, 52 could be accounted for by the hospitals that received them. Of the 48 identified recipients, 41 were tested for HIV-1 antibody. All four recipients of organs and all three recipients of unprocessed fresh-frozen bone were infected with HIV-1. However, 34 recipients of other tissues--2 receiving corneas, 3 receiving lyophilized soft tissue, 25 receiving ethanol-treated bone, 3 receiving dura mater treated with gamma radiation, and 1 receiving marrow-evacuated, fresh-frozen bone--tested negative for HIV-1 antibody. Despite immunosuppressive chemotherapy, HIV-1 antibody appeared between 26 and 54 days after transplantation in the three organ recipients who survived more than four weeks., Conclusions: Although rare, transmission of HIV-1 by seronegative organ and tissue donors can occur. Improvements in the methods used to screen donors for HIV-1, advances in techniques of virus inactivation, prompt reporting of HIV infection in recipients, and accurate accounting of distributed allografts would help to reduce further this already exceedingly low risk.

Prevalence of antibody to the human immunodeficiency virus type 1 (HIV-1) was assessed among 10,994 consecutive male and female entrants to 10 correctional systems in the United States. The HIV-1 seroprevalence for the 10 systems ranged from 2.1% to 7.6% for men and 2.5% to 14.7% for women; seroprevalence among women was higher than among men across nine of 10 systems. Using age 25 years to divide the population, HIV-1 prevalence among young women (5.2%) was significantly higher than among young men (2.3%), but similar to that in both older women (5.3%) and older men (5.6%). Overall, HIV-1 rates for nonwhites (4.8%) were higher than those for whites (2.5%). Although categories were identified across correctional systems, which may serve to focus prevention programs, variability in rates among correctional systems indicates that program planning must take local conditions into consideration.

By the end of 1989, 18,518 cases of Pneumocystis carinii infection and 5,614 cases of Toxoplasma gondii infection were reported to the Centers for Disease Control as the AIDS indicator disease. Pneumocystosis did not vary according to gender, race or risk factors; whereas toxoplasmosis was more common in black males with no known risk factors. Immigrants to the USA from Africa, Latin America and Haiti are three to four times more likely to develop toxoplasmic encephalitis than American-born patients with AIDS. The implications of this epidemiologic data for the predictive value of serology and clinical trials are discussed.

The transmission of tuberculosis is a recognized risk in health-care settings. Several recent outbreaks of tuberculosis in health-care settings, including outbreaks involving multidrug-resistant strains of Mycobacterium tuberculosis, have heightened concern about nosocomial transmission. In addition, increases in tuberculosis cases in many areas are related to the high risk of tuberculosis among persons infected with the human immunodeficiency virus (HIV). Transmission of tuberculosis to persons with HIV infection is of particular concern because they are at high risk of developing active tuberculosis if infected. Health-care workers should be particularly alert to the need for preventing tuberculosis transmission in settings in which persons with HIV infection receive care, especially settings in which cough-inducing procedures (e.g., sputum induction and aerosolized pentamidine [AP] treatments) are being performed. Transmission is most likely to occur from patients with unrecognized pulmonary or laryngeal tuberculosis who are not on effective antituberculosis therapy and have not been placed in tuberculosis (acid-fast bacilli [AFB]) isolation. Health-care facilities in which persons at high risk for tuberculosis work or receive care should periodically review their tuberculosis policies and procedures, and determine the actions necessary to minimize the risk of tuberculosis transmission in their particular settings. The prevention of tuberculosis transmission in health-care settings requires that all of the following basic approaches be used: a) prevention of the generation of infectious airborne particles (droplet nuclei) by early identification and treatment of persons with tuberculous infection and active tuberculosis, b) prevention of the spread of infectious droplet nuclei into the general air circulation by applying source-control methods, c) reduction of the number of infectious droplet nuclei in air contaminated with them, and d) surveillance of health-care-facility personnel for tuberculosis and tuberculous infection. Experience has shown that when inadequate attention is given to any of these approaches, the probability of tuberculosis transmission is increased. Specific actions to reduce the risk of tuberculosis transmission should include a) screening patients for active tuberculosis and tuberculous infection, b) providing rapid diagnostic services, c) prescribing appropriate curative and preventive therapy, d) maintaining physical measures to reduce microbial contamination of the air, e) providing isolation rooms for persons with, or suspected of having, infectious tuberculosis, f) screening health-care-facility personnel for tuberculous infection and tuberculosis, and g) promptly investigating and controlling outbreaks. Although completely eliminating the risk of tuberculosis transmission in all health-care settings may be impossible, adhering to these guidelines should minimize the risk to persons in these settings.