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Central nervous system tuberculosis (TB) was identified in 20 cases of unexplained encephalitis referred to the California Encephalitis Project. Atypical features (encephalitic symptoms, rapid onset, age) and diagnostic challenges (insensitive cerebrospinal fluid [CSF] TB PCR result, elevated CSF glucose levels in patients with diabetes, negative result for tuberculin skin test) complicated diagnosis.

The Funding section is incorrect. The complete, correct Funding statement is: TCP acknowledges support of the MIDAS study NIH NIGMS U01-{"type":"entrez-nucleotide","attrs":{"text":"GM087728","term_id":"221567427","term_text":"GM087728"}}GM087728. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Background The Centers for Disease Control and Prevention (CDC) convened a workgroup to revise the tuberculosis (TB) case report in the United States of America (U.S.). The group proposed substantial revisions. Study objectives were to systematically assess the validity and completeness of reported TB case surveillance data in California and to inform TB case report revision process. Methods A sample of 594 cases was retrospectively selected from the cohort of all TB cases reported during 6/1/96-5/31/97 to the State TB Registry. Cases, stratified by treatment outcome, were randomly sampled within each outcome category. Data for 53 variables were abstracted from each case's public health medical record and compared to data recorded on the TB case report. Using the medical record as the "gold standard," estimates were developed for 1) concordance, sensitivity, and positive predictive value of reported data for categorical variables; 2) the absolute mean difference between the two information source for date variables; and 3) the completeness of data on the case report and in medical record. Results At least 90% of the values for 35 (79.5%) categorical variables submitted on the TB case report form were identical to values in the medical record. Concordance between data on the case report and medical record was lower for the remaining nine (20.5%) categorical variables: status of abnormal chest x-ray (46.8%); directly observed therapy (48.6%); smear result for tissue or body fluid other than sputum (49.2%); type(s) of tissue or body fluid for smears and cultures other than sputum (76.4% and 73.9% respectively); provider type (73.4%); occupation (84.4%); sputum culture conversion (85.4%); and sputum smear result (89.6%). Case report data were more complete than data in the medical record; 2.9% versus 9.8% of data were missing/unknown, respectively. Conclusion For most variables examined on the TB case report, data validity was excellent, indicating a robust surveillance system. However, lower data quality was noted for a small number of variables primarily impacting treatment adherence, including assessment and planning; advocacy; allocation and garnering of resources; and research. The study provides compelling evidence supporting the CDC workgroup's proposed revisions to the TB case report.

Background Immigrants to the U.S. are required to undergo overseas screening for tuberculosis (TB), but the value of evaluation and treatment following entry to the U.S. is not well understood. We determined the cost-effectiveness of domestic follow-up of immigrants identified as tuberculosis suspects through overseas screening. Methods Using a stochastic simulation for tuberculosis reactivation, transmission, and follow-up for a hypothetical cohort of 1000 individuals, we calculated the incremental cost-effectiveness of follow-up and evaluation interventions. We utilized published literature, California Reports of Verified Cases of Tuberculosis (RVCTs), demographic estimates from the California Department of Finance, Medicare reimbursement, and Medi-Cal reimbursement rates. Our target population was legal immigrants to the United States, our time horizon is twenty years, and our perspective was that of all domestic health-care payers. We examined the intervention to offer latent tuberculosis therapy to infected individuals, to increase the yield of domestic evaluation, and to increase the starting and completion rates of LTBI therapy with INH (isoniazid). Our outcome measures were the number of cases averted, the number of deaths averted, the incremental dollar cost (year 2004), and the number of quality-adjusted life-years saved. Results Domestic follow-up of B-notification patients, including LTBI treatment for latently infected individuals, is highly cost-effective, and at times, cost-saving. B-notification follow-up in California would reduce the number of new tuberculosis cases by about 6–26 per year (out of a total of approximately 3000). Sensitivity analysis revealed that domestic follow-up remains cost-effective when the hepatitis rates due to INH therapy are over fifteen times our best estimates, when at least 0.4 percent of patients have active disease and when hospitalization of cases detected through domestic follow-up is no less likely than hospitalization of passively detected cases. Conclusion While the current immigration screening program is unlikely to result in a large change in case rates, domestic follow-up of B-notification patients, including LTBI treatment, is highly cost-effective. If as many as three percent of screened individuals have active TB, and early detection reduces the rate of hospitalization, net savings may be expected.

Objectives. We evaluated the association between ecological factors and rates of tuberculosis within California, using pediatric tuberculosis as an indicator of new transmission. Methods. Ecological variables such as racial/ethnic distribution, immigration level, education, employment, poverty, and crowding were obtained from the United States Census for each census tract in California. These data were incorporated into a negative binomial regression model with the rate of pediatric tuberculosis disease in each census tract as an outcome variable. Disease rates were obtained by geocoding reported cases. Subsections of the state (San Francisco and Los Angeles) were examined independently. Results. Census tracts with lower median incomes, more racial/ethnic minorities, and more immigrants had higher rates of pediatric tuberculosis. Other frequently cited risk factors such as overcrowding and unemployment were not associated with increased disease after adjusting for other measures. Risks were comparable across regions, but subtle differences were noted. Conclusions. The techniques used in this work provide a way to examine a disease within its social context. The results confirmed that tuberculosis in California continues to be a disease of poverty and racial/ethnic minorities.

We conducted a population-based study to assess demographic and risk-factor correlates for the most frequently occurring Mycobacterium tuberculosis genotypes from tuberculosis (TB) patients. The study included all incident, culture-positive TB patients from seven sentinel surveillance sites in the United States from 1996 to 2000. M. tuberculosis isolates were genotyped by IS6110-based restriction fragment length polymorphism and spoligotyping. Genotyping was available for 90% of 11,923 TB patients. Overall, 48% of cases had isolates that matched those from another patient, including 64% of U.S.-born and 35% of foreign-born patients. By logistic regression analysis, risk factors for clustering of genotypes were being male, U.S.-born, black, homeless, and infected with HIV; having pulmonary disease with cavitations on chest radiograph and a sputum smear with acid-fast bacilli; and excessive drug or alcohol use. Molecular characterization of TB isolates permitted risk correlates for clusters and specific genotypes to be described and provided information regarding cluster dynamics over time.

Surveillance by the Unexplained Deaths and Critical Illnesses Project (UNEX) uncovered a novel presentation of adenovirus type 3 infection that satisfied the criteria for toxic shock-like syndrome in a 28-year-old immunocompetent man. Adenovirus may be a cause of toxic shock syndrome; surveillance systems such as UNEX may uncover additional causes of this and other clinically defined infectious syndromes.

Background: Evidence of an STD-HIV interaction and the availability of noninvasive urine-based screening tests have resulted in an increased focus on chlamydial infections in men. Goal: To evaluate the prevalence of chlamydial infections among men with urethritis at the San Francisco City Clinic (SFCC). Study Design: In 1997, male SFCC patients diagnosed with urethritis were tested for chlamydia using urine-based ligase chain reaction and for gonorrhea using urethral culture. Results: Gonorrhea was identified in 45% of men who have sex with men (MSM) versus 26% of men who have sex with women (MSW). Among men with gonorrhea, chlamydia coinfection was found among 15.2% of MSM and 8.4% of MSW. Among men with nongonococcal urethritis, 18% and 20% of MSM and MSW had chlamydial infection, respectively. Young age was associated with chlamydial infection in MSM. Conclusion: After a period of low chlamydial infection rates in MSM during the pre-AIDS era, infection rates are increasing among this population. SFCC's revised clinical practice guidelines include chlamydia testing of MSM with urethritis.

Striking differences in Kaposi's sarcoma (KS) risk for AIDS patients who acquire HIV via homosexual activity and those whose HIV infections derive from blood product exposure suggest the presence of a sexually transmitted agent other than HIV in the development of KS. Using an immunofluorescence assay, we examined serum samples from 913 patients for the presence of antibody specific for infection by human herpesvirus 8 (HHV8), an agent whose genome is regularly found in KS tissue. The distribution of HHV8 seropositivity conforms to that expected for a sexually transmitted pathogen and tracks closely with the risk for KS development. Our data support the inference that this virus is the etiologic cofactor predicted by the epidemiology of KS.

ContextBetween 1994 and 2003, tuberculosis (TB) cases in California declined 33% (4834 to 3224). However, in 2003 California reported the largest number of cases in the nation, and over the past decade the proportion of cases with multidrug-resistant tuberculosis (MDR-TB) has not decreased.ObjectiveTo describe the magnitude, trends, geographic distribution, clinical characteristics, risk factors, and outcomes of MDR-TB cases reported to the California registry of Reports of Verified Cases of TB.Design, Setting, and CasesAnalysis of 38 291 TB cases reported from all 61 local health jurisdictions in California during 1994-2003. Multidrug-resistant TB was defined as resistance to at least isoniazid and rifampin.Main Outcome MeasuresResults of univariate and multivariable analyses of MDR-TB magnitude, trends, geographic distribution, clinical characteristics, associated factors, and outcomes.ResultsOf 38 291 reported TB cases, 28 712 (75%) were tested for resistance to at least isoniazid and rifampin; of these, 407 MDR-TB cases (1.4%) were reported from 38 of 61 California health jurisdictions (62%); the proportion of MDR-TB cases did not significantly change over the study period (P = .87). Cases of MDR-TB were twice as likely to have cavitary lesions compared with non–MDR-TB cases (P

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This review of tuberculosis epidemiology is intended to provide a historical perspective on the public health approach to tuberculosis (TB) control in California. This historical context offers a lens through which to view current epidemiologic trends and insight into how new therapeutic tools can be applied. Since 1993, the year detailed case reporting was instituted, California has had a decrease in recent TB transmission as evidenced by a reduction in pediatric cases and an increased percentage of cases attributable to progression of latent infection to TB disease in the foreign-born population. Overall, there has been a dramatic decline in the annual TB case count, but the speed of the decline has slowed over the last several years. At the current pace and case count of 2137 in 2015, California will not achieve TB elimination (

2,392 (6%) of 39,718 TB cases during the study period were matched in the state AIDS registry. From 1996 to 2006, annual TB incidence among persons with HIV declined from 368/100,000 to 73/100,000, and without HIV declined from 12.7/100,000 to 7.3/100,000. Comparing the period 1996-2000 with 2001-2007, the proportion of TB/HIV cases increased among Hispanics (48% to 57%; p < .001), foreign born (46% to 63%; p< .001), and women (14% to 18%; p=. 06), and decreased among Blacks (28% to 21%; p < .001). Maleto-male sexual contact (44% to 41%; p < .01) and injection drug use (21% to 15%; p < .01) decreased, and high-risk heterosexual contact (9% to 16%; p < .01) increased as HIV transmission routes. 77% of all foreign born patients with TB/HIV co-infection originated from Mexico or Central America; the median time from immigration to TB diagnosis was 10.7 (IQR 4-19) years. CD4 count at TB diagnosis (median 78 (IQR 30-167)) was available for 54% of patients. Patients with HIV coinfection were more likely to be sputum smear-positive (OR 1.17 (95% CI 1.08-1.28). Both isoniazid resistance (5% to 7%; p=. 07) and pyrazinamide monoresistance (6% to 8%; p = .01) increased over time in TB/HIV cases but not in cases without HIV. In multivariate analysis, Hispanic ethnicity, older age, and injection drug use were inversely associated with treatment success among TB/HIV cases. Discussion In California, the epidemiology of TB/HIV co-infection in the post-HAART era has shifted towards persons of foreign birth, women, Hispanics, and those who acquired HIV through heterosexual sex. In addition, drug resistance has increased in TB/AIDS cases. These changes should be considered in focusing TB and HIV disease prevention and treatment efforts.