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

Recent outbreaks of syphilis among men who have sex with men (MSM) in major cities in the United States and reported increases in sexual risk behavior have raised concerns about potential increases in human immunodeficiency virus (HIV) transmission. The majority of MSM who have early syphilis are HIV infected; in preliminary studies, rates of recent HIV infection among them are also high. Data from San Francisco, Los Angeles, and Seattle-King County, however, suggest no temporal increases in HIV incidence among MSM seeking HIV testing at select large public sites during the syphilis outbreaks. Because most HIV incidence and behavioral data are from large metropolitan areas with large gay populations and well-established HIV epidemics, we do not know whether, nationally, incidence of HIV infection among MSM has been increasing, decreasing, or stable during syphilis outbreaks. Further studies of HIV incidence in larger and smaller cities with different maturities of HIV epidemic are warranted. Comprehensive and integrated HIV/STD prevention and control efforts are also needed to halt the spread of syphilis and reduce HIV transmission among gay and bisexual men.

Objectives.Accurate surveillance of tuberculosis (TB) in children is critical because such cases represent recent transmission, but surveillance is difficult as only 10% to 50% of cases are culture-confirmed. Hospital-based sources were used to develop alternative surveillance to assess completeness of reporting for pediatric TB in northern Manhattan and Harlem from 1993 through 1995.Methods.Alternative surveillance sources included ICD-9-CM hospital discharge codes for active TB and gastric aspirate reports. Cases identified by alternative surveillance were compared with cases previously reported to the New York City Department of Health (NYC DOH).Results.Alternative surveillance detected 25 cases of possible pediatric TB, of which four (16%) had never been reported to the NYC DOH and three (12%) had been reported as suspect cases, but had not fulfilled the criteria for a reportable case of pediatric TB. Of these seven newly counted cases, three were detected by ICD-9-CM codes, three by a gastric aspirate log book, and one by both. In contrast, 13 other cases had been reported to the NYC DOH, but were undetected by our alternative surveillance; eight of these could be verified with available medical records. Thus, the demographic and clinical characteristics of the 25 detected and the eight undetected cases with available medical records were evaluated in this study.Conclusions.Alternative surveillance proved effective, was complementary to the NYC DOH surveillance efforts, and increased the number of pediatric TB cases identified during the study period by 21%.

The use of rifamycins is limited by drug interactions in human immunodeficiency virus (HIV)-infected persons who are receiving highly active antiretroviral therapy (HAART). During a tuberculosis (TB) outbreak at a prison housing HIV-infected inmates, rifabutin was used to treat 238 men (13 case patients and 225 contacts). Steady-state peak plasma rifabutin concentrations were obtained after rifabutin dosages were adjusted for men receiving single-interacting HAART (with either 1 protease inhibitor [PI] or efavirenz), multi-interacting HAART (with either 2 PIs or > or =1 PI with efavirenz), and for noninteracting HAART (>1 nucleoside reverse-transcriptase inhibitor or no HAART) without rifabutin dose adjustments. Low rifabutin concentrations occurred in 9% of those receiving noninteracting HAART, compared with 19% of those receiving single-interacting and 29% of those receiving multi-interacting HAART (chi2, 3.76; P=.05). Of 225 contacts treated with rifabutin-pyrazinamide, 158 (70%) completed treatment while incarcerated. Rifabutin-pyrazinamide therapy was difficult to implement, because of the need for dosage adjustments and expert clinical management.

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

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

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

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

Background: Tuberculosis (TB) control activities are contingent on the timely identification and reporting of cases to public health authorities to ensure complete assessment and appropriate treatment of contacts and identification of secondary cases. We report the results of a multistate evaluation of completeness and timeliness of reporting of TB cases in the United States during 1993 and 1994. Methods: To determine completeness of TB reporting, laboratory log books, death certificates, hospital discharge, Medicaid databases, and pharmacy databases were reviewed in seven states to identify possible unreported cases. Timeliness of TB reporting was calculated using the number of days between date of TB diagnosis and date of report to the local or state health department. Cases reported >7 days after diagnosis were considered to have delayed reporting. Results: Of 2711 cases identified through review of secondary data sources, 14 (0.5%) were previously unreported to public health. The largest yield of unreported cases was identified through review of laboratory records; 13 of the 14 unreported cases were identified, of which eight were found only through this method. Timeliness of reporting varied between sites from a median of 7 days to a median of 38 days. The number of cases with delayed reporting varied from 5% to 53% between sites. Factors associated with delayed reporting included infectiousness, type of provider, diagnosing provider, and reporting source. Conclusions: Through a review of several different secondary data sources, few unreported TB cases were detected; however, timeliness of reporting was poor among the reported cases.

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

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

Strain W, a highly drug-resistant strain of Mycobacterium tuberculosis, was responsible for large nosocomial outbreaks in New York in the early 1990s. To describe the spread of strain W outside New York, we reviewed data from epidemiologic investigations, national tuberculosis surveillance, regional DNA fingerprint laboratories, and the Centers for Disease Control and Prevention Mycobacteriology Laboratory to identify potential cases of tuberculosis due to strain W. From January 1992 through February 1997, 23 cases were diagnosed in nine states and Puerto Rico; 8 were exposed to strain W in New York before their diagnosis; 4 of the 23 transmitted disease to 10 others. Eighty-six contacts of the 23 cases are presumed to be infected with strain W; 11 completed alternative preventive therapy. Strain W tuberculosis cases will occur throughout the United States as persons infected in New York move elsewhere. To help track and contain this strain, health departments should notify the Centers for Disease Control and Prevention of cases of tuberculosis resistant to isoniazid, rifampin, streptomycin, and kanamycin.

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

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

Use of rifampin is required for short-course treatment regimens for tuberculosis. Tuberculosis caused by isolates of M. tuberculosis with resistance to rifampin and susceptibility to isoniazid is unusual, but it has been recognized through surveillance. Patients with tuberculosis (cases) with rifampin monoresistance were compared with HIV-matched controls with tuberculosis caused by a drug-susceptible isolate. A total of 77 cases of rifampin mono-resistant tuberculosis were identified in this multicenter study. Three were determined to be laboratory contaminants, and 10 cases had an epidemiologic link to a case with rifampin mono-resistant tuberculosis, suggesting primary acquisition of rifampin-resistant isolates. Of the remaining 64 cases and 126 controls, there was no difference between cases and controls with regard to age, sex, race, foreign birth, homelessness, or history of incarceration. Cases were more likely to have a history of prior tuberculosis than were controls. Of the 38 cases and 74 controls with HIV infection, there was no difference between cases and controls with regard to age, sex, race, foreign birth, homelessness, history of incarceration, or prior tuberculosis. Cases were more likely to have histories of diarrhea, rifabutin use, or antifungal therapy. Laboratory analysis of available isolates showed that there was no evidence of spread of a single clone of M. tuberculosis. Further studies are needed to identify the causes of the development of rifampin resistance in HIV-infected persons with tuberculosis and to develop strategies to prevent its emergence. Ridzon R, Whitney CG, McKenna MT, Taylor JP, Ashkar SH, Nitta AT, Harvey SM, Valway S, Woodley C, Cooksey R, Onorato IM. Risk factors for rifampin mono-resistant tuberculosis. AM J RESPIR CRIT CARE MED 1998;157:1881‐1884.

Despite the long-standing observation that tuberculosis (TB) case rates are higher among racial and ethnic minorities than whites in the United States (U.S.), the proportion of this increased risk attributable to socioeconomic status (SES) has not been determined. Values for six SES indicators (crowding, income, poverty, public assistance, unemployment, and education) were assigned to U.S. TB cases reported from 1987-1993 by ZIP code- and demographic-specific matching to 1990 U.S. Census data. TB risk between racial/ethnic groups was then evaluated by quartile for each SES indicator utilizing univariate and Poisson multivariate analyses. Relative risk (RR) of TB increased with lower SES quartile for all six SES indicators on univariate analysis (RRs 2.6-5.6 in the lowest versus highest quartiles). The same trend was observed in multivariate models containing individual SES indicators (RRs 1.8-2.5) and for three SES indicators (crowding, poverty, and education) in the model containing all six indicators. Tuberculosis risk increased uniformly between SES quartile for each indicator except crowding, where risk was concentrated in the lowest quartile. Adjusting for SES accounted for approximately half of the increased risk of TB associated with race/ethnicity among U.S.-born blacks, Hispanics, and Native Americans. Even more of this increased risk was accounted for in the final model, which also adjusted for interaction between crowding and race/ethnicity. SES impacts TB incidence via both a strong direct effect of crowding, manifested predominantly in overcrowded settings, and a TB-SES health gradient, manifested at all SES levels. SES accounts for much of the increased risk of TB previously associated with race/ethnicity.

Background and Methods From 1994 to 1996, there was a large outbreak of tuberculosis in a small, rural community with a population at low risk for tuberculosis. Twenty-one patients with tuberculosis (15 with positive cultures) were identified; the DNA fingerprints of the 13 isolates available for testing were identical. To determine the extent of transmission, we investigated both the close and casual contacts of the patients. Using a mouse model, we also studied the virulence of the strain of Mycobacterium tuberculosis that caused the outbreak. Results The index patient, in whom tuberculosis was diagnosed in 1995; the source patient, in whom the disease was diagnosed in 1994; and a patient in whom the disease was diagnosed in 1996 infected the other 18 persons. In five, active disease developed after only brief, casual exposure. There was extensive transmission from the three patients to both close and casual contacts. Of the 429 contacts, 311 (72 percent) had positive skin tests, including 86 with docum...

Background: In spring 1993, four students in a high school were diagnosed with tuberculosis resistant to isoniazid, streptomycin, and ethionamide. Methods: To investigate potential transmission of drug-resistant tuberculosis, a retrospective cohort study with case investigation and screening by tuberculin skin tests and symptom checks was conducted in a high school of approximately 1400 students. Current and graduated high-school students were included in the investigation. DNA fingerprinting of available isolates was performed. Results: Eighteen students with active tuberculosis were identified, Through epidemiologic and laboratory investigation, 13 cases were linked; 8 entered 12th grade in fall 1993; 9 of 13 had positive cultures for Mycobacterium tuberculosis with isoniazid, streptomycin, and ethionamide resistance, and all 8 available isolates had identical DNA fingerprints. No staff member had tuberculosis. One student remained infectious for 29 months, from January 1991 to June 1993, and was the source case for the outbreak. Another student was infectious for 5 months before diagnosis in May 1993 and was a treatment failure in February 1994 with development of rifampin and ethambutol resistance in addition to isoniazid, streptomycin, and ethionamide. In the fall 1993 screening, 292 of 1263 (23%) students tested had a positive tuberculin skin test. Risk of infection was highest among 12th graders and classroom contacts of the two students with prolonged infectiousness. An additional 94 of 928 (10%) students tested in spring 1994 had a positive tuberculin skin test; 22 were classroom contacts of the student with treatment failure and 21 of these had documented tuberculin skin test conversions. Conclusion: Extensive transmission of drug-resistant tuberculosis was documented in this high school, along with missed opportunities for prevention and control of this outbreak. Prompt identification of tuberculosis cases and timely interventions should help reduce this public health problem. (J Pediatr 1997;131:863-8)

Epidemiologic relatedness of Mycobacterium tuberculosis isolates from Arkansas residents diagnosed with tuberculosis in 1992-1993 was assessed using IS6110- and pTBN12-based restriction fragment length polymorphism (RFLP) and epidemiologic investigation. Patients with isolates having similar IS6110 patterns had medical records reviewed and were interviewed to identify epidemiologic links. Complete RFLP analyses were obtained for isolates of 235 patients; 78 (33%) matched the pattern of > or = 1 other isolate, forming 24 clusters. Epidemiologic connections were found for 33 (42%) of 78 patients in 11 clusters. Transmission of M. tuberculosis likely occurred many years in the past for 5 patients in 2 clusters. Of clusters based only on IS6110 analyses, those with > or = 6 IS6110 copies had both a significantly greater proportion of isolates that matched by pTBN12 analysis and patients with epidemiologic connections, indicating IS6110 patterns with few bands lack strain specificity. Secondary RFLP analysis increased specificity, but most clustered patients still did not appear to be epidemiologically related. RFLP clustering in rural areas may not represent recent transmission.

After a dramatic increase in the incidence of TB in the United States from 1985 to 1992, the epidemiology of TB changed, with both the number of cases and the incidence of TB decreasing since 1992. The decreases have been focal, however, affecting only certain geographic areas (e.g., New York, California, and New Jersey) and certain populations (e.g., 25-44 year age group and people born in the United States). The factors responsible for the decrease in those areas and populations are multiple but the most important are thought to be improvements in TB control and treatment programs in communities serving populations at greatest risk for TB. Despite the overall decline in TB cases, the numbers of foreign-born people with TB continue to increase. Factors contributing to the increase in TB among foreign-born people include the prevalence of TB in the country of origin, duration of residence in the United States after immigration, inadequate screening for or treatment of TB before entering the United States, and inadequate follow-up of those who have entered the United States with noninfectious TB (i.e., abnormal chest radiograph with negative sputum smears). Control of TB among the foreign-born population is essential if the current downward trend in reported TB cases in the United States is to be maintained. The HIV epidemic had a significant impact on the increase in TB incidence in the United States in the late 1980s but improvements in measures to control transmission of TB appear to have been effective in reversing that trend. The current national decrease trend in TB morbidity can be sustained through organized efforts by federal and private agencies and state and local health departments to ensure that all people with TB are identified and treated promptly. Such efforts must be aimed at areas and populations identified as high risk for TB, especially foreign-born people and people who are infected with HIV.

Objective. To determine the current practices and results of tuberculin skin test (TST) screening of schoolchildren in the United States. Methods. Tuberculosis program staff in all states and the District of Columbia were asked about current requirements, practices, and results of school-based TST screening. Results. Thirty-four states and the District of Columbia (69%) reported no current statewide statutes or policies for tuberculin screening of schoolchildren, and 10 (19%) reported having statewide requirements. In 6 states (12%), requirements were instituted at the local level, and 24 localities in these states were known to require screening. Of the 34 areas requiring screening, 18 (53%) screened all new entrants, 7 (21%) screened children in specific grades, and 9 (26%) used other criteria for screening. TST results were collected for 26 (76%) of 34 areas, and 6 areas collected results of follow-up evaluation of tuberculin-positive children. Additionally, 8 localities in 7 states with no screening requirements conducted tuberculin surveys. Sixteen areas provided results. In 7 of the 8 areas that collected information about birthplace, less than 2% of US-born children were tuberculin positive; foreign-born children had rates 6 to 24 times higher than US-born children. TST screening identified few cases of tuberculosis, less than 0.02% of the children screened. Conclusion. School-based tuberculin screening identified low rates of positive TST results in US-born children. Resources should be directed toward screening children at high risk for tuberculous infection, as recommended by the American Academy of Pediatrics and the Advisory Committee for Elimination of Tuberculosis.

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

Many clinicians and laboratory personnel are unaware that a culture positive for Mycobacterium tuberculosis may represent contamination. Laboratory cross-contamination with the M. tuberculosis laboratory control strain (H37Ra) occurs infrequently and therefore demands heightened awareness and recognition. We report 3 occurrences of laboratory cross-contamination from the same laboratory. These occurrences illustrate the importance of interpreting laboratory results in conjunction with the patient's clinical presentation. Failure to recognize laboratory cross-contamination with M. tuberculosis leads to both erroneous administration of unnecessary medications and expenditure of resources required to conduct contact investigations.

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

In November, 1993, a 33-month-old child in a day-care center was diagnosed with tuberculosis (TB). To identify her source of infection, close contacts, other day-care children and staff were screened by tuberculin skin test (TST). TB registry and medical/laboratory records were reviewed. The only 2 community TB cases reported in the past 3 years were investigated. Of 164 children 2 were diagnosed with TB; their TSTs were > or = 10 mm but no specimens were obtained. Six children had TSTs > or = 5 mm. Of these 4 had TST conversions between December, 1993, and March, 1994. There were no additional positive TST children in June, 1994. No TB case was identified among staff or parents. A possible epidemiologic link with the index case was found for 1 community case. No source of infection was found for the other children. Possible explanations for not finding a source are: an as yet unidentified case in the day-care center or community; or false positive TST results in children related to low community prevalence of TB infection.

We examined medical and health department records for children5 years of age with suspected or confirmed tuberculosis reported to the New York City Health Department from January, 1992, through June, 1992, in order to describe the epidemiology of tuberculosis in young children and identify prevention strategies. Forty-seven children were treated for suspected or confirmed tuberculosis. Sixty-two percent (21 of 34) were foreign-born (n = 11) or had foreign-born caretakers (n = 10). A source case was found for 10 of 47 (21%) children; for 8 the adult source was diagnosed before the child. One child was human immunodeficiency virus-seropositive, however, 83% of children and 70% of adult source cases did not have human immunodeficiency virus test results available. Health care providers should test children at high risk for tuberculosis infection as recommended by the American Academy of Pediatrics and improve contact tracing to identify children exposed to adults with tuberculosis. Because most cases of tuberculosis in children are diagnosed clinically rather than by isolating Mycobacterium tuberculosis, identification of the source case is important for selecting appropriate treatment.

Objective: To investigate possible transmission of multidrug-resistant tuberculosis (MDR-TB) in a dental setting. Design: A retrospective, descriptive study of dental workers (DWs), patients, and practice characteristics. Patients: Two dental workers (DW1 and DW2) with acquired immunodeficiency syndrome and MDR-TB. Setting: A hospital-based (Hospital X) human immunodeficiency virus (HIV) dental clinic in New York City. Methods: To identify dental patients with tuberculosis (TB), patients treated in the dental clinic at Hospital X during 1990 were cross-matched with those listed in the New York City Department of Health Tuberculosis Registry Mycobacterium tuberculosis isolates from both DWs and from dental patients with TB were tested for antimicrobial susceptibility and typed by restriction fragment length polymorphism (RFLP) analysis. Infection control practices were reviewed. Results: M tuberculosis isolates infecting DW1 and DW2 were resistant to isoniazid and rifampin and had identical RFLP patterns. DW1 and DW2 worked in close proximity to each other in a small HIV dental clinic in Hospital X during 1990. Of 472 patients treated in the dental clinic in 1990, 41 (8.7%) had culture-proven M tuberculosis infection. Of these 41, 5 had isolates with resistance patterns similar to both DWs; however, for four available isolates, the RFLP patterns were different from the patterns of the DWs. Sixteen of the 41 patients received dental treatment while potentially infectious. Dental patients were not routinely questioned about TB by dental staff, nor were all dental staff screened routinely for TB. No supplemental environmental measures for TB were employed in the dental clinic in 1990. Conclusions: Our investigation suggests that MDR-TB transmission may have occurred between two DWs in an HIV dental clinic. Opportunities for transmission of TB among dental staff and patients were identified. TB surveillance programs for DWs and appropriate infection control strategies, including worker education, are needed to monitor and minimize exposure to TB in dental settings providing care to patients at risk for TB.

Objective To evaluate the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) among pregnant women in Puerto Rico. Methods An anonymous serosurvey was conducted in four prenatal clinics in San Juan, Puerto Rico, involving women presenting consecutively for their first prenatal visit. Results Nineteen of 997 pregnant women (1.9%, 95% confidence interval [CI] 1.2–3.0) tested positive for HCV antibody (anti-HCV), and eight (0.8%, 95% CI 0.4–1.6) were HIV seropositive. Of the 992 women for whom serum samples were tested for HBV markers, 91 (9.2%, 95% CI 7.5–11.2) had evidence of past or current HBV infection, and four (0.4%, 95% CI 0.1–1.1) were HBV carriers. The agespecific HBV prevalence ranged from 4.1% among women 15–19 years old to 18.5% among those at least 30 years old ( P χ 2 test for trend). Anti-HCV prevalence was also higher among women at least 30 years old compared to younger women (3.1 versus 1.9%; prevalence ratio 1.6, 95% CI 0.6–4.9), although the difference was not statistically significant. Anti-HCV prevalence was higher among women with past or current HBV infection than among women who were not infected (7.7 versus 1.3%; prevalence ratio 5.8, 95% CI 2.3–14.3). Conclusions The prevalence of chronic HBV and HCV infection among pregnant women tested in San Juan, Puerto Rico, is comparable to that among pregnant women in the United States. The prevalence of HIV infection among pregnant women in San Juan is higher than among childbearing women in the United States.

ObjectivesHomeless persons have an increased risk of HIV infection because of a high prevalence of HlV-related risk behaviors. These include drug use, sexual contact with persons at risk for HIV infection, and the exchange of sex for drugs. The objectives of this investigation were to describe HIV s

OBJECTIVE To describe HIV seroprevalence among non-injecting drug users (non-IDU) entering sentinel drug treatment centers in the United States. DESIGN Anonymous, blinded (unlinked) HIV seroprevalence surveys. SETTING Sixty-eight sentinel drug treatment centers in 37 United States metropolitan areas. PARTICIPANTS Consecutive sample of clients admitted to sentinel drug treatment centers from January 1989 through December 1992. Of 84,617 clients, 37,633 (44.5%) had used illicit drugs but reported no injecting drug use since 1978. MAIN OUTCOME MEASURES Center-specific, metropolitan area-specific, and national median HIV seroprevalence rates. RESULTS National median center-specific HIV seroprevalence among non-IDU was 3.2% (range, 0-15.2%). Rates varied widely by geographic area. Median rates were highest in the northeast (5.6%; range, 0-15.2%), intermediate in the south (3.4%; range, 0.6-8.0%), and generally lower throughout the rest of the country: midwest (1.3%; range, 0-3.1%) and west (1.8%; range, 0-14.5%). When stratified by treatment center, there were few statistically significant differences in seroprevalence among African Americans, Hispanics and whites. The median rate was 3.4% among men and 2.7% among women. Rates among non-IDU were lower than among IDU attending the same drug treatment centers, but consistently higher than among heterosexual patients attending sexually transmitted disease clinics in the same metropolitan areas. CONCLUSIONS HIV seroprevalence among non-IDU entering drug treatment is high in many metropolitan areas. HIV prevention and education efforts in drug treatment centers should target sexual as well as drug-use risk reduction for all clients.

Following an initial negative Mantoux tuberculin skin test, a second test, given as soon as 1 wk later, has been shown to elicit markedly larger reactions (boosting) in 20 to 40% of refugees tested in the United States. We conducted a study to determine the explanation for this phenomenon. Using the Mantoux method of intradermal skin testing, 2,469 refugees from Southeast Asia were initially tested with tuberculin followed by sequential retesting 7 and/or 90 d later. They were also tested initially with nontuberculous mycobacterial antigens. A high proportion (35.5%) of Southeast Asian refugees had reactions (> or = 10 mm induration) to an initial tuberculin test, and 30.9% of the nonreactors exhibited boosting on a subsequent tuberculin test. Boosting, unlike reactivity to the initial tuberculin test, was not associated with exposure to a person with tuberculosis. However, boosting was associated with reactivity to nontuberculous mycobacterial antigens and a history of bacille Calmette-Guerin (BCG) vaccination. Boosting in this population is therefore attributable to environmental exposure to nontuberculous mycobacteria that are endemic in Southeast Asia or to BCG vaccination, rather than to remote infection with Mycobacterium tuberculosis. Sequential tuberculin screening and preventive therapy of persons with boosted reactions is not recommended as a tuberculosis prevention strategy in this population.

La reinfection exogene par Mycobacterium tuberculosis est un phenomene important qui se produit a une frequence inconnue a la fois chez des sujets immunodeprimes et immunocompetents. Puisque des investigations anterieures suggerent que la reinfection exogene peut survenir dans ces deux populations, nous avons revu les donnees de 40 cas de suspicion de rechute de tuberculose afin d'essayer de determiner la frequence de ce phenomene chez les patients traites a l'Unite de Recherche de Tuberculose de Kampala en Ouganda. Nos observations suggerent que, alors que la reinfection exogene par M. tuberculosis peut survenir chez des patients immunocompetents, son risque est probablement plus eleve chez les sujets en etat d'immunodepression.

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

In 1988-1989, surveillance for human immunodeficiency virus (HIV) infection was conducted in 20 clinics providing medical care for patients with suspected and confirmed tuberculosis (TB) in 14 cities. A total of 3077 specimens from consecutive patients were tested for HIV after patient identifiers were removed. The median clinic seroprevalence rate was 3.4%, (range, 0-46.3%). The highest rates were found in the Northeast and Atlantic coastal areas. Rates by clinic were highest for persons born in the United States (median, 11.2%) and in the Caribbean region (Haitians, 36%-40%, and Cubans, 16%). Most HIV-infected patients had pulmonary TB, but HIV infections were more frequent in patients with extrapulmonary TB than in pulmonary TB patients (19.8% vs. 10.2%, P less than .0002). For US-born patients, rates did not differ by race or sex. These serosurveillance data indicate widespread HIV infection among TB patients and have important implications for clinical management of TB patients and for TB and AIDS prevention programs. Testing all HIV-infected persons and all TB patients for dual infection is essential to control the interrelated epidemics of AIDS and TB.

The human serologic response to several envelope-associated proteins and adenylate cyclase toxin of Bordetella pertussis was examined using immunoblot techniques. Antigens recognized by sera from individuals with culture-confirmed pertussis and by sera from infants immunized with three doses of conventional whole-cell pertussis vaccine included a 63,000-Da protein that was shown to be antigenically related to a mycobacterial heat-shock protein. A 29,000-Da protein reacted with sera from convalescent individuals, whereas a 91,000-Da protein reacted with sera from vaccinated individuals. Antibodies to adenylate cyclase toxin were common in sera from individuals diagnosed with pertussis. B. pertussis lipooligosaccharide was also recognized by antibodies in some of these sera. These data suggest that some of these antigens may play a role in immunity to pertussis.

The Centers for Disease Control and Prevention, in collaboration with 25 state and local health departments, began the National HIV Behavioral Surveillance System (NHBS) in 2003. The system focuses on people at risk for HIV infection and surveys the three populations at highest risk for HIV in the United States: men who have sex with men, injecting drug users, and high-risk heterosexuals. The project collects information from these three populations during rotating 12-month cycles. Methods for recruiting participants vary for each at-risk population, but NHBS uses a standardized protocol and core questionnaire for each cycle. Participating health departments tailor their questionnaire to collect information about specific prevention programs offered in their geographic area and to address local data needs. Data collected from NHBS will be used to describe trends in key behavioral risk indicators and evaluate current HIV prevention programs. This information in turn can be used to identify gaps in prevention services and target new prevention activities with the goal of reducing new HIV infections in the United States.

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

Extraordinary progress has beenmade since the first few cases of acquired immune deficiency syndrome (AIDS) were identified in the United States in 1981. More than 20 years of intense research has yielded invaluable information about human immunodeficiency virus (HIV), the virus that causes AIDS, how it is transmitted, how infection can be prevented, and how at-risk persons can be motivated to protect themselves from HIV (Wolitski et al., 2004). Remarkable advances in the detection and treatment of HIV have significantly improved the quality of life for persons living withHIV and have reducedAIDS-related deaths (Karon et al., 2001). These successes have ushered in a new era in the AIDS epidemic. In this era, HIV infection that is detected early can be successfully managed with proper medical care, allowing the majority of HIV-seropositive persons to lead active and productive lives that may extend for decades (Egger et al., 2002; Porter et al., 2003). Working effectively with people living with HIV to reduce the risk of HIV transmission has become even more important in this new era. As a result of treatment advances, the number of people living with HIV has grown considerably. It is estimated that there are now 850,000 to 950,000 persons living with HIV in the US (Fleming et al., 2002). This number is

The most effective means of preventing human immunodeficiency virus (HIV) infection is preventing exposure. The provision of antiretroviral drugs to prevent HIV infection after unanticipated sexual or injection-drug--use exposure might be beneficial. The U.S. Department of Health and Human Services (DHHS) Working Group on Nonoccupational Postexposure Prophylaxis (nPEP) made the following recommendations for the United States. For persons seeking careor =72 hours after nonoccupational exposure to blood, genital secretions, or other potentially infectious body fluids of a person known to be HIV infected, when that exposure represents a substantial risk for transmission, a 28-day course of highly active antiretroviral therapy (HAART) is recommended. Antiretroviral medications should be initiated as soon as possible after exposure. For persons seeking careor =72 hours after nonoccupational exposure to blood, genital secretions, or other potentially infectious body fluids of a person of unknown HIV status, when such exposure would represent a substantial risk for transmission if the source were HIV infected, no recommendations are made for the use of nPEP. Clinicians should evaluate risks and benefits of nPEP on a case-by-case basis. For persons with exposure histories that represent no substantial risk for HIV transmission or who seek care72 hours after exposure, DHHS does not recommend the use of nPEP. Clinicians might consider prescribing nPEP for exposures conferring a serious risk for transmission, even if the person seeks care72 hours after exposure if, in their judgment, the diminished potential benefit of nPEP outweighs the risks for transmission and adverse events. For all exposures, other health risks resulting from the exposure should be considered and prophylaxis administered when indicated. Risk-reduction counseling and indicated intervention services should be provided to reduce the risk for recurrent exposures.

Reducing new HIV infections in the United States requires allocating public resources to interventions that will have the greatest impact on reducing the number of new infections. We report on the organizational experience of a federal agency's efforts to align its HIV prevention resources to reflect the specific priorities of a five-year strategic plan that has as its goal a fifty percent reduction in the number of annual HIV infections nationwide. Structural and other impediments encountered during the alignment process, and the steps taken to minimize their impact are described, adding to the empirical data base of strategic planning experiences in the public sector.

This chapter reviews concerns about immunizing HIV-infected persons, the safety of the vaccines, potential adverse effects on the progression of HIV infection, the indications for vaccines, and the immunogenicity and efficacy of vaccines in this population. This chapter also focuses on recommendations for adults. The American College of Physicians and the Advisory Committee on Immunization Practices (ACIP) have published recommendations for immunization of adults, including those who are HIV-infected. As the number of HIV-infected persons continues to increase, as more patients are identified earlier in their disease, and as survival is increasing, there is more opportunity for acquisition of vaccine-preventable diseases. Current vaccines are most likely to be effective when HIV-infected persons are immunized before the onset of immune compromise. Experiences with adult immunizations indicate that provision of recommended vaccines and immuno- and chemoprophylaxis to HIV-infected persons needs to be much more aggressive. Additional techniques to improve responses to immunization are necessary. Research should include modifications of vaccination schedules including higher vaccine doses, booster or multiple dose schedules, vaccination concurrent with anti-HIV therapy, and development of more immunogenic vaccines.