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OBJECTIVE: Approximately 6000 women deliver annually at Jackson Memorial Hospital in Miami, where 2.4% of women has human immunodeficiency virus (HIV) and 60% is foreign-born. We conducted a retrospective review of prenatal records among HIV-infected women to evaluate tuberculin skin testing (TST). STUDY DESIGN: We determined how many women had TSTs placed and read, and the TST results. RESULTS: We identified 207 HIV-infected women, 87% of such women delivering in 1995 to 1996. Most did not know their HIV status before seeking prenatal care (109, 54%) and most (176, 85%) had TSTs done. Of the women, 45 had positive TSTs, 96 had negative TSTs, and 35 were anergic. Most results were not recorded using millimeters of induration. Two women (1%) had active tuberculosis (TB) disease. CONCLUSION: Overall, 21% of all HIV-infected women had positive TSTs and 1% had active TB disease. Focused TB skin testing should be part of routine prenatal care in clinics serving populations at high-risk for TB, such as those with HIV infection and the foreign-born.

Objective:To evaluate the implementation and efficacy of selected Centers for Disease Control and Prevention guidelines for preventing spread ofMycobacterium tuberculosis.Design:Analysis of prospective observational data.Setting:Two medical centers where outbreaks of multidrug-resistant tuberculosis (TB) had occurred.Participants:All hospital inpatients who had active TB or who were placed in TB isolation and healthcare workers who were assigned to selected wards on which TB patients were treated.Methods:During 1995 to 1997, study personnel prospectively recorded information on patients who had TB or were in TB isolation, performed observations of TB isolation rooms, and recorded tuberculin skin-test results of healthcare workers. Genetic typing ofM tuberculosisisolates was performed by restriction fragment-length polymorphism analysis.Results:We found that only 8.6% of patients placed in TB isolation proved to have TB; yet, 19% of patients with pulmonary TB were not isolated on the first day of hospital admission. Specimens were ordered for acid-fast bacillus smear and results received promptly, and most TB isolation rooms were under negative pressure. Among persons entering TB isolation rooms, 44.2% to 97.1% used an appropriate (particulate, high-efficiency particulate air or N95) respirator, depending on the hospital and year; others entering the rooms used a surgical mask or nothing. We did not find evidence of transmission of TB among healthcare workers (based on tuberculin skin-test results) or patients (based on epidemiological investigation and genetic typing).Conclusions:We found problems in implementation of some TB infection control measures, but no evidence of healthcare-associated transmission, possibly in part because of limitations in the number of patients and workers studied. Similar evaluations should be performed at hospitals treating TB patients to find inadequacies and guide improvements in infection control.

Objective. Although identification and appropriate treatment of children with latent tuberculosis (TB) infection (LTBI) is considered critical to the control and elimination of TB in the United States, there are limited data on risk factors for LTBI in pediatric populations. Methods. To further improve targeted screening for LTBI, we performed a matched case–control study from September 1996 to December 1998. We actively surveyed 24 primary care clinics serving Northern Manhattan and Harlem twice monthly for case participants 1 to 5 years old with LTBI, defined as a child with a Mantoux tuberculin skin test (TST) ≥10 mm and a normal chest radiograph. Two age- and clinic-matched control participants with TSTs equal to 0 mm were enrolled per case. To determine risk factors for LTBI, a bilingual research worker reviewed the medical records of study participants and administered a questionnaire to the parents of participants. Results. We enrolled 96 cases and 192 controls whom did not differ by age, gender, ethnicity, and race; overall, the mean age of participants was 2.9 years, 51% were male, 80% were Hispanic, and 9% black. Logistic regression analysis demonstrated that contact with an adult with active TB, foreign birth, foreign travel, and a relative with a positive TST were predictive of case status. In contrast, a history of a previous negative TST proved protective and BCG immunization was not an independent risk factor for a positive TST, suggesting that boosting was not important in this population. Conclusions. We identified several risk factors for LTBI in children that can be used to refine targeted surveillance for TB among Hispanic immigrant populations in the United States.

Drug-susceptible and drug-resistant isolates of Mycobacterium tuberculosis were recovered from 2 patients, 1 with isoniazid-resistant tuberculosis (patient 1) and another with multidrug-resistant tuberculosis (patient 2). An investigation included patient interviews, record reviews, and genotyping of isolates. Both patients worked in a medical-waste processing plant. Transmission from waste was responsible for at least the multidrug-resistant infection. We found no evidence that specimens were switched or that cross-contamination of cultures occurred. For patient 1, susceptible and isoniazid-resistant isolates, collected 15 days apart, had 21 and 19 restriction fragments containing IS6110, 18 of which were common to both. For patient 2, a single isolate contained both drug-susceptible and multidrug-resistant colonies, demonstrating 10 and 11 different restriction fragments, respectively. These observations indicate that simultaneous infections with multiple strains of M. tuberculosis occur in immunocompetent hosts and may be responsible for conflicting drug-susceptibility results, though the circumstances of infections in these cases may have been unusual.

The association of human immunodeficiency virus infection (HIV) with increased rates of multidrug-resistant (MDR) tuberculosis (TB) in the United States (US) has been well-documented [1–4]. Furthermore, a number of studies conducted in the US have identified HIV infection as a risk factor for acquired drug resistance [5–6]. During the late 1980s and early 1990s, large outbreaks of MDRTB primarily involving HIV-infected patients occurred in hospitals, correctional facilities and other institutional settings in the US [7– 12]. Similar outbreaks also occurred in other established market economies during the 1990s [13–17]. In these outbreaks, active TB developed within a few weeks or months following exposure to an infectious MDRTB patient, leading to multiple transmissions in a short period of time. Furthermore, the outbreaks were characterized by delayed diagnosis, extended infectious periods, and delays in initiation of appropriate treatment, which contributed to high mortality and morbidity. More recent data have documented a decline in new MDRTB cases and improvement in clinical outcomes for HIV-infected patients [2,18–20]. This chapter describes trends in MDRTB and HIV co-infection and key characteristics of MDRTB patients with HIV infection in the US based on national surveillance data from 1993–1997, and summarizes the key findings in published outbreaks of MDRTB involving HIV-infected persons in US and other established market economies. This chapter will demonstrate that the association of HIV infection with drugresistant TB is largely attributable to nosocomial outbreaks of MDRTB in various congregate settings. However, HIV-infected patients may be at some increased risk of acquired drug resistance, particularly rifampicin monoresistance, and various plausible but unproven explanations for this association are presented.

Mycobacterium tuberculosis resistant to multiple antituberculosis drugs emerged as a serious threat to tuberculosis (TB) control efforts in the United States (US) in the late 1980s and early 1990s. The strains responsible for the extended and large outbreaks in hospitals and correctional facilities, reported primarily from New York, were resistant to at least isoniazid and rifampicin, and the term multidrug-resistant (or MDR) became used to refer selectively to resistance to at least these two key first-line drugs. The outbreaks primarily involved patients with human immunodeficiency virus (HIV) infection and were characterized by high morbidity and mortality, delayed diagnosis, extended infectious periods and multiple generations of source cases [1“5]. Although drug-resistant TB was not a new phenomenon, MDRTB had rarely been encountered in the US [6]. This chapter describes the emergence of MDRTB in the US, the steps that led to improved surveillance for drug-resistant TB, and key characteristics of MDRTB patients during 1993-1998, based on national surveillance data. In addition, a brief summary of the experience of other established market economies is also provided.

Young children rarely transmit tuberculosis. In July 1998, infectious tuberculosis was identified in a nine-year-old boy in North Dakota who was screened because extrapulmonary tuberculosis had been diagnosed in his female guardian. The child, who had come from the Republic of the Marshall Islands in 1996, had bilateral cavitary tuberculosis. Because he was the only known possible source for his female guardian's tuberculosis, an investigation of the child's contacts was undertaken. We identified family, school, day-care, and other social contacts and notified these people of their exposure. We asked the contacts to complete a questionnaire and performed tuberculin skin tests.Of the 276 contacts of the child whom we tested, 56 (20 percent) had a positive tuberculin skin test (induration of at least 10 mm), including 3 of the child's 4 household members, 16 of his 24 classroom contacts, 10 of 32 school-bus riders, and 9 of 61 day-care contacts. A total of 118 persons received preventive therapy, including 56 young children who were prescribed preventive therapy until skin tests performed at least 12 weeks after exposure were negative. The one additional case identified was in the twin brother of the nine-year-old patient. The twin was not considered infectious on the basis of a sputum smear that was negative on microscopical examination.This investigation showed that a young child can transmit Mycobacterium tuberculosis to a large number of contacts. Children with tuberculosis, especially cavitary or laryngeal tuberculosis, should be considered potentially infectious, and screening of their contacts for infection with M. tuberculosis or active tuberculosis may be required.

Objective. To identify factors contributing to a 400% increase in tuberculosis among children in San Diego County, California, from 1985 to 1993. Design. Review of medical records of reported cases in 1989, 1991, and 1993 and their source case. Results. Of 192 children with tuberculosis, the largest increase was observed in children younger than 5 years old, of whom 77.4% were born in the United States, 67.8% had a foreign-born parent, 73.1% came from a non-English-speaking household, and 46.2% were known to visit Mexico. Of 28 source cases, 82.1% were born outside the United States, primarily in Mexico (67.9%). Resistance to at least one first-line antituberculous drug was identified in 27.5% of isolates from children and in 33.3% of isolates from source cases. Conclusions. The increase in tuberculosis and high level of drug-resistance among children born in the United States may be attributed to transmission outside of the United States or within the United States from household contacts born in countries in which tuberculosis is highly endemic.

Objective: To assess tuberculin skin testing practices of physicians after community-wide screening of 1400 children exposed to a pediatrician with active tuberculosis (TB). Design: A self-administered questionnaire. Setting: Medium-sized city in eastern Pennsylvania. Participants: Pediatricians and family practitioners seeing pediatric patients. Main Outcome Measures: Percentages of physicians who followed published recommendations for placement and reading of TB skin tests published by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC). Results: Questionnaires were completed by 60/80 (75%) physicians. The 60 physicians had practiced a mean of 17 years (range 3–38 years), and only one did not do TB skin testing for pediatric patients. The 59 physicians doing TB skin testing reported routinely tuberculin testing more than 900 children per month. Only 8/59 (14%) physicians followed published guidelines for placement and reading of tuberculin tests. Those physicians screened 158 (17%) of the pediatric patients undergoing TB skin testing in a typical month. Conclusion: In this community where a highly publicized TB case prompted massive pediatric screening, most physicians seeing children in private practice do not follow standard TB skin testing guidelines. Increased understanding of how private-practice physicians learn about and decide to use recommended standards are needed if tuberculin tests are to be correctly performed and TB appropriately diagnosed.

Objective: To determine the extent of transmission of Mycobacterium tuberculosis to pediatric patients exposed to a pediatrician with smear- and culture-positive pulmonary tuberculosis (TB). Methods: Clinic billing and hospital admission records were used to identify patients seen during the pediatrician's infectious period. Patients were notified of the potential exposure and were offered screening. Results: A total of 1416 pediatric patients were identified as exposed. Of the 606 who completed screening, 12 (2%) had a skin test result ≥10 mm, 2 (0.3%) had a result 5 to 9 mm, and 592 (98%) had a negative test result (0 to 4 mm). No active TB cases were identified. Of the 14 children with a skin test result ≥5 mm, 7 were U.S.-born and had no other risk factor for a positive skin test. The remaining seven had either been exposed to another person with infectious TB or were from countries with a high prevalence of TB. Conclusion: We found evidence of limited transmission of Mycobacterium tuberculosis in the outpatient pediatric setting. Despite extensive resource dedication, only 43% of exposed children completed screening. In similar situations decisions should balance the responsibility to protect children exposed to Mycobacterium tuberculosis with other public health priorities and available resources. (J Pediatr 1998;133:108-12)

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.

Background and Objectives: From March 1989 through December 1992, the Centers for Disease Control and Prevention conducted annual, voluntary surveys of human immunodeficiency virus (HIV) risk behavior in sentinel sexually transmitted disease (STD) clinics in 25 cities in the United States. Goal: Describe behaviors of heterosexual participants who reported as their only risk for HIV infection sexual contact with persons at increased risk for HIV. Study Design: Participants responded to a standard questionnaire that collected demographic data and medical, drug use, and sexual histories. Results: Sex with an injection drug user was the most common risk behavior. Fewer than 5% of participants always used condoms in the preceding year; 38% never used condoms. Multivariate analyses identified three independent predictors of HIV infection in men: living in the Northeast (odds ratio [OR] = 3.6; P < 0.001), sex with an HIV-infected woman (OR = 3.6; P < 0.01), and black race (OR = 2.7; P < 0.01). For women, sex with an HIV-infected man was the strongest predictor (OR = 12.0; P < 0.001) followed by Northeast residence (OR = 5.4; P < 0.001) and black race (OR = 3.4; P < 0.01). Conclusion: Sexually transmitted disease clinic patients throughout the United States knowingly engaged in sexual activities with partners at increased risk for HIV infection. HIV prevention activities need to be targeted to all sexually active persons, particularly in areas where injection drug use and HIV are prevalent.

The following report describes the contact investigation of a pediatrician with tuberculosis (TB). The pediatrician's disease was discovered in late February 1993 after tuberculin skin testing (TST) of his 15-month-old son was positive (13-mm induration). Further investigation to identify the source of the child's infection revealed a positive (15-mm induration) TST in the pediatrician. The pediatrician had been symptomatic with a cough since September 1992. The pediatrician had a chest radiograph that revealed numerous cavitary lesions and a sputum smear that was positive for acid-fast bacilli. An investigation was initiated to assess whether the transmission of Mycobacterium tuberculosis had occurred in the pediatrician's office to patients, families, or other visitors. The investigation was later extended to include the hospitals and the day care center where the pediatrician worked. Methods. A letter was mailed to parents of children served by the practice, explaining the potential exposure to TB and requesting that all persons who visited the office after September 1, 1992 complete an interview and Mantoux TST. Mass interviewing, testing, and test interpretation within the practice took place seven times during March and April 1993. Results. At the completion of screening, 181 (87%) of 208 children who had close contact with the index case were reliably skin-tested and returned for interpretation. Three (1.7%) of the 181 children were TST-positive (≥5 mm). Thirty-seven (13%) of the 286 adults tested and returning for interpretations were TST-positive (≥10 mm). Thirty-two (86%) of the 37 adults who tested positive were foreign-born. Conclusion. This investigation highlighted the need for identifying childhood TB infection as a sentinel event for adult disease. It also demonstrated the difficulty associated with deciding the extent of contact investigation of a health care worker with TB. Finally, the investigation emphasized the importance of maintaining regularly scheduled and appropriate testing for TB infection in health care workers and the need for health care workers to be cognizant of their own risk and be able to identify, especially in themselves, signs and symptoms of potential TB disease.

An outbreak of seven cases (in six patients and one health care worker, all of whom had AIDS) of multidrug-resistant tuberculosis occurred in a hospital in Chicago. The hospital had a respirator-fit testing program but no acid-fast bacilli isolation rooms.To identify risk factors for transmission of Mycobacterium tuberculosis.Retrospective cohort study.Private hospital.Patients and health care workers exposed to M. tuberculosis.Analysis of M. tuberculosis isolates, tuberculin skin testing, assessment of exposure, and assessment of participant characteristics.All seven M. tuberculosis isolates had matching DNA fingerprints. Of patients exposed to M. tuberculosis, those who developed tuberculosis had lower CD4+ T-lymphocyte counts (P = 0.02) and were more likely to be ambulatory (P = 0.03) than those who did not. Of 74 exposed health care workers, the 11 (15%) who had conversion on tuberculin skin testing were no more likely than those who did not have conversion to report that they always wore a respirator with a high-efficiency particulate air filter.Transmission of M. tuberculosis occurred in a hospital that did not have recommended isolation rooms. A respirator-fit testing program did not protect health care workers in this setting.

There has been increasing interest in the potential association between occupation and the risk of tuberculosis. Therefore, we analyzed occupational information collected on all patients with clinically active tuberculosis in 29 states from 1984 to 1985. Census data were used to estimate the number of persons in each of the occupations. Information on employment and occupation was ascertained for 9,534 (99%) of the working age (16 through 64 yr) tuberculosis patients. The overall case rate of tuberculosis in this age group in the study areas was 8.4 per 100,000 persons, which was slightly lower than the national rate of 9.3 per 100,000 persons. As a group, health care workers had rates of tuberculosis similar to the general population (standardized morbidity ratio [SMR]: 1.0; 95% CI: 0.9 to 1.1). However, elevated rates were observed for inhalation therapists (SMR: 2.9; 95% CI: 1.2 to 6.0), and lower-paid health care workers (SMR: 1.3; 95% CI: 1.1 to 1.5). Elevated rates were also noted for funeral directors (SMR: 3.9; 95% CI: 2.2 to 6.1) and farm workers (SMR: 3.7; 95% CI: 3.4 to 4.1). These data suggest that even in communities with relatively low rates of tuberculosis certain occupations may be associated with an elevated risk.

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.

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.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.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).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.

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.

To determine the safety and immunogenicity of childhood vaccines in children with perinatally acquired human immunodeficiency virus type 1 (HIV-1) infection.Nonrandomized, prospective cohort study; 12-month follow-up period.Obstetric wards and outpatient pediatric clinics at two large hospitals in Kinshasa, Zaire.A total of 8108 pregnant women were screened for HIV-1 antibodies. The 474 children born to 466 seropositive women identified during screening and the 616 children born to 606 seronegative, age- and parity-matched women were vaccinated.The following vaccines were administered at the stated ages: bacille Calmette-Guérin (BCG) vaccine (2 days); trivalent oral Sabin poliomyelitis vaccine (2 days and 6, 10, and 14 weeks); and adsorbed diphtheria-tetanus-pertussis (DTP) vaccine (6, 10, and 14 weeks).Protective antibody titers to tetanus and poliovirus types 1, 2, and 3 were achieved in 95% of all children. Among children with HIV-1 infection, 70.8% had protective antibody titers to diphtheria compared with 98.5% of uninfected children (p0.05). Geometric mean antibody titers to diphtheria and poliovirus types 1, 2, and 3 were significantly lower in children with HIV-1 infection than in uninfected children. Vaccine-associated side effects were similarly low in all children.The low incidence of side effects and the high proportion of children with HIV-1 infection who achieved protective postimmunization antibody titers support the continuing use of BCG, DTP, and oral polio vaccines in childhood immunization programs in HIV-1 endemic areas.

BACKGROUND. Intravenous drug use has played a key role in the human immunodeficiency virus (HIV) epidemic. Standardized surveillance of HIV infection among intravenous drug users (IVDUs) is needed to determine HIV prevalence rates, to monitor changes in prevalence over time, and to describe behaviors associated with HIV infection. METHODS. In 1987, the Centers for Disease Control began collaborating with state and local health departments to conduct a national program of HIV seroprevalence surveys in a variety of populations and settings. This program includes unlinked HIV seroprevalence surveys in IVDUs entering sentinel drug treatment programs. RESULTS. From April 1988 through December 1989, annual studies were completed in 59 drug treatment centers in 33 US cities. Center-specific seroprevalence rates ranged from 0% to 48.2%, with a median of 4.6%. HIV seroprevalence rates varied widely by geographic area, with rates highest in the Northeast, intermediate in the Middle Atlantic cities of Baltimore and Washington, DC, and lower in other parts of the country. Median rates were 15.6% among African Americans, 3.2% among Hispanics, and 3.3% among Whites. CONCLUSIONS. Intravenous drug use is likely to remain an important factor in HIV transmission. This study supports the need to develop or expand programs to prevent the further introduction and spread of HIV among IVDUs and to prevent HIV transmission to their sexual partners.

Oral polio vaccine (OPV) is recommended for routine immunization in the United States in part because of its ability to induce intestinal and pharyngeal immunity to reinfection. Mucosal immunity produced by OPV and enhanced-potency inactivated polio vaccine (E-IPV) was compared by challenging vaccines with type 1 OPV. Fewer OPV (25%) than E-IPV (63%) vaccinees excreted OPV virus in stool after challenge. The mean stool virus titer was higher and the duration of shedding longer among E-IPV excreters. Only one E-IPV and three OPV vaccinees shed virus in the pharynx after challenge. Prechallenge serum neutralizing antibody levels were not statistically different among E-IPV vaccinees who did and did not shed virus; these levels were much higher than those of OPV vaccinees. Poliovirus-specific IgA levels in stool did not correlate with viral excretion. E-IPV was less effective than OPV in preventing and limiting intestinal infection, even though it induced higher postvaccination serum antibody levels.

• Sixty-one children who had previously received three doses of enhanced potency inactivated poliovirus vaccine (epIPV) at 2, 4, and 18 months of age and 56 children who had previously received oral poliovirus vaccine (OPV) according to the same schedule were challenged with a single dose of monovalent, type 1 oral poliovirus vaccine (OPV1)between 19 and 52 months of age. Before the OPV1 challenge, the previously epIPV-immunized recipients had a geometric mean poliovirus type 1 microneutralization antibody titer (geometric mean titer [GMT]) of 11.1 IU, which was significantly higher than the prechallenge GMT of 2.2 IU among the children who had previously received OPV. Three weeks after the OPV1 challenge, the GMTs for the epIPV-immunized recipients and the OPV-immunized recipients were 35.3 IU and 5.1 IU, respectively. For the epIPV-immunized recipients, both the prechallenge GMT and the postchallenge GMT were dependent on the D antigen content of the vaccine that they had previously received. A fourfold or greater rise in poliovirus type 1 antibody occurred after the OPV1 challenge in 50.9% of the epIPV-immunized children and in 28.6% of the OPV-immunized children; this difference was statistically significant. For both groups, antibody boosts were inversely correlated with the prechallenge serum antibody titer. However, the epIPV-immunized children consistently were more likely to boost than the OPV-immunized children at equivalent levels of prechallenge antibody. This experience indicated that OPV1 administration effectively raises the level of serum antibody in children previously immunized with three doses of epIPV, especially in children with lower levels of preexisting antibody. This booster response was superior to the booster response of children who received three doses of OPV. ( AJDC . 1990;144:480-484)

The reliability of blood cultures obtained through indwelling intravascular catheters is controversial. In this study, the results of 200 catheter blood cultures were compared with those of an equal number of peripheral blood cultures drawn at the same time. Catheter blood cultures were found to be 96% sensitive (95% confidence interval, 89% to 100%) and 98% specific (95% confidence interval, 96% to 100%) for the detection of septicemia. Factors thought to have influenced these favorable results were the relatively short duration of catheter placement and the particular emphasis given to aseptic technique.

A phlebotomist with nosocomially acquired human immunodeficiency virus infection developed tuberculosis 10 months after exposure to multidrug-resistant Mycobacterium tuberculosis during a nosocomial outbreak. Healthcare workers with immunosuppression are at increased risk of tuberculosis if infected and, if exposed, should be considered for preventive therapy regardless of tuberculin skin-test status.

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.—Concern about transmission of Mycobacterium tuberculosis on college campuses has prompted some schools to institute tuberculin skin test screening of students, but this screening has never been evaluated.Objective.—To describe tuberculin skin test screening practices and results of screening in colleges and universities in the United States.Design and Setting.—Self-administered mail and telephone questionnaire in November and December 1995 to a stratified random sample of US 2-year and 4-year colleges and universities.Main Outcome Measures.—Type of tuberculin screening required; types of schools requiring screening; number and rate of students with positive skin test results and/or diagnosed as having tuberculosis.Results.—Of the 3148 US colleges and universities, 624 (78%) of 796 schools surveyed responded. Overall, 378 schools (61%) required tuberculin screening; it was required for all new students (US residents and international students) in 161 (26%) of 624 schools, all new international students but not new US residents in 53 (8%), and students in specific academic programs in 294 (47%). Required screening was more likely in 4-year vs 2-year schools, schools that belonged to the American College Health Association vs nonmember schools, schools with immunization requirements vs schools without, and schools with a student health clinic vs those without (P

To the Editor. —We are authors of the manuscript submitted to JAMA that reported an outbreak of drug-resistant tuberculosis referred to by Dr Snider in his article.1The case reports in our manuscript contain no identifying information; even age and sex are omitted because of their limited relevance to that report. Rejected byJAMA, the same manuscript was subsequently accepted for publication (with case reports) in another peer-reviewed journal2; this journal did not require patient consent. We have recently published other case reports that have contained sensitive information without requests from the editors for patient consent.3-5Of note, one of these journals is represented in the ICMJE. In one of the manuscripts accepted for publication, the picture and name of a patient described in a case report had appeared in a major newspaper prior to publication of the manuscript.4With regard to the outbreak of drug-resistant tuberculosis,2because

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.

Objective. Between November 1994 and April 1995, more than 3300 students in 49 schools in two counties in New York were potentially exposed to five school bus drivers with tuberculosis. This investigation was carried out to determine the extent of transmission of Mycobacterium tuberculosis among students. Methods. Components of the epidemiologic investigation included tuberculin skin-test screening and collection of demographic information for students exposed to a driver with tuberculosis, chest radiography and medical evaluation of individuals with positive skin tests, and DNA fingerprinting of M tuberculosis isolates. A positive skin test was defined as ≥10 mm induration, and a converter was an individual with an increase in reaction size of ≥10 mm in the past 2 years. Results. The rates of positive skin tests were 0.8%, 0.3%, 9.9%, 1.1%, and 0.7% among US-born students exposed to drivers 1 through 5, respectively. The relative risk for a positive tuberculin skin test was significant only for students exposed to driver 3, and the only secondary case identified among students was exposed to driver 3. The DNA fingerprint patterns of isolates from drivers 3 and 4 matched. Conclusion. There was no clear evidence of transmission ofM tuberculosis to students from drivers 1, 2, 4, or 5. However, evidence suggests that driver 3 transmitted M tuberculosis to students and another driver. Routine annual tuberculin skin-test screening of drivers would not have prevented these tuberculosis exposures.

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.

Annual cross-sectional prevalence, incidence of new infection, and risks for human immunodeficiency virus type 1 (HIV-1) infection were studied in 607 women convicted of prostitution between October 1987 and December 1990 and tested for HIV under court order. Cross-sectional prevalence was stable for 4 years (23-24% positivity in 1987-1991, p = 0.6). However, the incidence of new infections (rate of seroconversion) in 264 women tested more than once increased significantly each year from 12 per 100 person-years in 1987-1988 to 19 per 100 person-years in 1991 (p < 0.03). Seroconverters were more likely to be young black women with a prior history of syphilis or gonorrhea. A new episode of syphilis or rectal gonorrhea during the follow-up period predicted HIV seroconversion in a survival analysis model. Female sex workers are at great risk of acquiring HIV infection. Although HIV prevalence in cross-sectional samples was stable, incidence was increasing. Interpretation of prevalence trends from convenience samples, such as screening programs, may be difficult because changes in incidence may not be detected.

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)

In Reply. — As correctly pointed out by Dr Bayuk, the current overseas medical examination procedures for persons applying for immigration to the United States are designed to exclude applicants with infectious TB. According to the regulations, a person is considered to have infectious TB if the CXR is compatible with active TB and one or more sputum smear examinations is positive for acid-fast bacilli (AFB). 1 The decision to define infectiousness on the results of sputum smears rather than culture is based on the lower risk of transmission among persons who are AFB smear-negative 1 and on at least two practical considerations. First, immigrants and refugees come from more than 100 countries, many of which do not have the laboratory capabilities to conduct mycobacterial culture. Also, drug susceptibility testing is rarely available, making it difficult to prescribe an appropriate regimen in countries with relatively high rates of drug resistance.

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)