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As part of the required screening process of illegal aliens applying for adjustment of status by the Immigration and Naturalization Service, 7,573 persons were evaluated for tuberculous infection by the Denver Department of Health and Hospitals from May 1987 through December 1988. Applicants were screened with tuberculin skin testing, chest radiographs, or both. Review of 6,520 charts that were available found that 4,840 applicants had tuberculin skin tests, of which 2,039 (42 percent) were > or = 10 mm and 1,528 had further evaluation at the Denver Metro Tuberculosis Clinic. Seventy-five percent of the applicants were between the ages of 15 and 34 years, and 91 percent were from Mexico. Evidence of past or current tuberculous infection on chest radiograph was present in 273 (17 percent) and 16 (7 percent) had sputum cultures obtained that identified four new cases of active tuberculosis. Isoniazid preventive therapy (IPT) was recommended to 1,029 applicants, of whom 29 (3 percent) were 35 years of age or older; 716 (70 percent) completed at least six months of treatment. We conclude that there is a high prevalence of tuberculous infection in foreign-born persons applying for adjustment of immigration status, but a low prevalence of clinically apparent tuberculosis. This population is an excellent target for IPT, which can be achieved with good success. Proactive screening and preventive therapy is likely to significantly reduce tuberculosis reactivation and morbidity, prevent secondary infection of contacts, and be cost-effective.

Study Objective: To evaluate the efficacy and toxicity of a 62-dose, four-drug, 6-month, and directly observed regimen for treatment of pulmonary and extrapulmonary tuberculosis., Design: An open, nonblinded clinical trial, with intended follow-up of patients for 36 months after the completion of therapy., Setting: A metropolitan tuberculosis clinic in a public health department., Patients: From March 1981 through April 1989, we enrolled 160 patients with suspected or known tuberculosis; 35 of these patients were excluded from the analysis., Interventions: Isoniazid, rifampin, pyrazinamide, and streptomycin were administered daily for 2 weeks; these drugs were then given in higher doses twice weekly for 6 weeks, followed by isoniazid and rifampin twice weekly for 6 weeks, followed by isoniazid and rifampin twice weekly for 18 weeks. A total of 62 doses were administered, and all therapy was directly observed by a nurse or an outreach worker., Measurements and Main Results: Of the 125 evaluable patients, 101 (81%) had pulmonary tuberculosis, 7 (6%) had both pulmonary and extrapulmonary involvement, and 17 (13%) had extrapulmonary disease only. Seventy-one (57%) patients had a history of recent alcoholism. There were two relapses (1.6% +/- 2.2%), occurring 6 and 56 months after the completion of therapy. The time at which sputum samples became culture negative in pulmonary patients ranged from 1 to 19 weeks (median, 4.6 weeks); 40% +/- 9.6% of patients were culture-negative after 4 weeks of therapy, 75% +/- 8.5% after 8 weeks, 94% +/- 4.7% after 12 weeks, 97% +/- 3.3% after 16 weeks, and 100% after 20 weeks. Adverse drug reactions included hyperuricemia (greater than 178 mumol/L [3 mg/dL] above normal) secondary to pyrazinamide in 80 patients (64%), twofold or greater elevations of aspartate aminotransferase in 21 patients (17%), 1.5-fold or greater elevations of alkaline phosphatase in 33 patients (27%), cutaneous abnormalities in 8 patients (6%), nausea in five patients (4%), and dizziness in 1 patient (1%)., Conclusions: This 62-dose, largely twice-weekly tuberculosis treatment regimen is efficacious and relatively nontoxic and is especially useful for patients in whom directly observed therapy is indicated.

The long-term effectiveness of intermittent non-rifampin-containing regimens for the treatment of tuberculosis is demonstrated. The direct administration of 170 to 190 doses during an extended period of time (18 to 20 months) permits a 10 to 20% rate of missed treatment doses during the continuation phase of therapy while retaining a cost-effectiveness ratio comparable to that reported for 6-month, rifampin-containing regimens administered daily. Although 4 patients from a highly noncompliant population of 165 persons relapsed during a follow-up period of 2.5 to 12 yr, after treatment, 3 of these failures were the result of the system's inability to administer the drugs adequately. These regimens are confirmed as effective treatment alternatives that may be used in the treatment of tuberculosis in potentially unreliable patients when rifampin is contraindicated.