Tuberculosis control among people in U.S. Immigration and Customs Enforcement custody

BACKGROUND

People detained by United States Immigration and Customs Enforcement (ICE) are a high-risk population for tuberculosis (TB). Detainees are screened for TB upon intake, and TB patients are reported to the Division of Immigration Health Services (DIHS).

METHODS

TB case reports were reviewed for ICE detainees reported to DIHS during 2004-2005. Case counts and frequency distributions are presented. Case counts are stratified by demographic characteristics, release status, laboratory and clinical findings, HIV/AIDS status, and drug resistance. Case rates were calculated for patients housed at facilities with DIHS staffing. Duration of treatment and of ICE custody is provided. Analyses were conducted in 2006.

RESULTS

During 2004 and 2005, 76 and 142 TB patients were reported, respectively. The TB case rate was 82.6/100,000 in 2004 and 121.5/100,000 in 2005. The culture-confirmed case rate of 55.8/100,000 in 2005 was 2.5 times higher than the case rate in the U.S. foreign-born population. Of 218 patients, 127 (58.3%) had Mycobacterium tuberculosis-positive sputum cultures, 70 (32.1%) had acid-fast bacilli-positive sputum smears, and 36 (16.5%) were symptomatic at diagnosis. Patients from Mexico, Honduras, Guatemala, and El Salvador accounted for 184 cases (84.4%) and 184 patients (84.4%) were repatriated. TB patients spent an average 82.6 days in treatment before release or repatriation.

CONCLUSIONS

Screening at intake to ICE custody has helped DIHS staff in diagnosing TB and starting patients on treatment, but patients are usually deported before completing therapy. Because of deportation, and sometimes re-entry into the United States, unique collaborations are required to support completion of treatment.

A conditional model of MLL-AF4 B-cell tumourigenesis using invertor technology

MLL-AF4 fusion is the most common consequence of chromosomal translocations in infant leukaemia and is associated with a poor prognosis. MLL-AF4 is thought to be required in haematopoietic stem cells to elicit leukaemia and may be involved in tumour phenotype specification as it is only found in B-cell tumours in humans. We have employed the invertor conditional technology to create a model of MLL-AF4, in which a floxed AF4 cDNA was knocked into Mll in the opposite orientation for transcription. Cell-specific Cre expression was used to generate Mll-AF4 expression. The mice develop exclusively B-cell lineage neoplasias, whether the Cre gene was controlled by B- or T-cell promoters, but of a more mature phenotype than normally observed in childhood leukaemia. These findings show that the MLL-AF4 fusion protein does not have a mandatory role in multi-potent haematopoietic stem cells to cause cancer and indicates that MLL-AF4 has an instructive function in the phenotype of the tumour.

Improved program activities are associated with decreasing tuberculosis incidence in the United States

OBJECTIVE

This study was conducted to determine whether improvements in tuberculosis (TB) program activities correlate with incident TB cases.

METHODS

National TB surveillance data and program data from patients with pulmonary and laryngeal TB and their contacts were collected. These data were analyzed using regression models to assess the association between changes in incident TB cases and indicators of program performance (a time series of percent changes in program indices).

RESULTS

A total of 1,361,113 contacts exposed to 150,668 TB patients were identified through contact investigations. From 1987 to 1992 (the period of TB resurgence and antedating increased funding), there was a decline in several measures used by TB programs for outcomes of contact investigations. From 1993 to 1998 (the period after increases in TB funds), there was an observable improvement in the program indices. Four program indices for contacts and two for TB cases (directly observed therapy and completion of therapy) were statistically associated (p < or = .01) with the decline in TB incident cases.

CONCLUSIONS

These analyses suggest that expanded TB program activities resulted in the reduction in national TB cases and underscore the importance of treatment completion for TB disease and latent TB infection. Based on these results, we propose that further improvements in these activities will accelerate the decline of TB in the United States.

Low adherence to guidelines for preventing TB among persons with newly diagnosed HIV infection, United States

SETTING

Persons infected with human immunodeficiency virus (HIV) are at risk for developing tuberculosis (TB) if latent TB infection remains untreated.

OBJECTIVE

To assess missed opportunities for preventing TB by selecting a population-based sample of 1093 persons diagnosed with HIV from June 1995 to June 1997 in Seattle, WA, New Orleans, LA, and Jersey City, NJ.

DESIGN

To determine the proportion of persons receiving a tuberculin skin test (TST) following HIV diagnosis, we conducted record reviews at providers and local TB control.

RESULTS

An estimated 53.7% (95% CI 49.9-57.4) had a TST following HIV diagnosis; 6.6% (95% CI 4.3-8.9%) of TST-tested patients were reactive. Median time between HIV diagnosis and TST was 1 month (mean 5.7 months, 95% CI 4.8-6.5). Factors associated with TST included additional risk factors for TB (OR 1.76, 95% CI 1.17-2.63), history of HIV-related preventive treatment (OR 5.84, 95% CI 3.74-8.75), higher number of clinic visits (OR 4.16, 95% CI 2.01-8.02), and attendance at facilities with a written policy to provide TST for all persons with HIV (OR 2.54, 95% CI 1.28-4.88).

CONCLUSION

About half of persons newly diagnosed with HIV infection had a TST following HIV diagnosis, with little variation by demographics, signaling a general need to improve interventions to prevent TB.

Tuberculosis prevention and control in large jails: a challenge to tuberculosis elimination

BACKGROUND

This study assessed the extent to which 20 large jail systems have implemented national recommendations for tuberculosis (TB) prevention and control in correctional facilities.

METHODS

Data were collected through questionnaires to jail medical directors and TB control directors, observation at the jails, and abstraction of medical records of inmates with TB disease and latent TB infection.

RESULTS

Twenty percent of jail systems (4/20) had conducted an assessment of risk for TB transmission in their facilities, and 55% (11/20) monitored tuberculin skin test conversions of inmates and staff. Sixty-five percent (13/20) of jails had an aggregate record-keeping system for tracking TB status and treatment, which was usually paper based. Forty-five percent of jails (9/20) had policies to offer HIV counseling and testing to tuberculin skin test-positive patients, and 75% (15/20) screen HIV-infected inmates with chest radiographs. Three quarters of jails (15/20) had policies to always isolate patients with suspected or confirmed pulmonary TB in an airborne infection isolation room. Half of jails with airborne infection isolation rooms (6/12) conformed to Centers for Disease Control and Prevention (CDC) guidelines for monitoring negative pressure.

CONCLUSIONS

Improvements are needed in conducting TB risk assessments and evaluations to determine priorities and reduce risk of transmission. Inadequate medical information systems are impeding TB control and evaluation efforts. Although HIV infection is the greatest cofactor for development of TB disease, jails have inadequate information on patients' HIV status to make informed decisions in screening and management of TB and latent TB infection. Jails need to improve the use of environmental controls.

An unanswered health disparity: tuberculosis among correctional inmates, 1993 through 2003

OBJECTIVES

We sought to describe disparities and trends in tuberculosis (TB) risk factors and treatment outcomes between correctional inmate and noninmate populations.

METHODS

We analyzed data reported to the national TB surveillance system from 1993 through 2003. We compared characteristics between inmate and non-inmate men aged 15-64 years.

RESULTS

Of the 210976 total US TB cases, 3.8% (7820) were reported from correctional systems. Federal and state prison case rates were 29.4 and 24.2 cases per 100000 inmates, respectively, which were considerably higher than those in the noninmate population (6.7 per 100000 people). Inmates with TB were more likely to have at least 1 TB risk factor compared with noninmates (60.1% vs 42.0%, respectively) and to receive directly observed therapy (65.0% vs 41.0%, respectively); however, they were less likely to complete treatment (76.8% vs 89.4%, respectively). Among inmates, 58.9% completed treatment within 12 months compared with 73.2% of noninmates.

CONCLUSIONS

Tuberculosis case rates in prison systems remain higher than in the general population. Inmates with TB are less likely than noninmates to complete treatment.

Adverse Events and Treatment Completion for Latent Tuberculosis in Jail Inmates and Homeless Persons*

BACKGROUND

Recently, a short-course treatment using 60 daily doses of rifampin and pyrazinamide was recommended for latent tuberculosis (TB) infection (LTBI).

STUDY OBJECTIVES

To determine the acceptability, tolerability, and completion of treatment.

DESIGN

Observational cohort study.

SETTING

Five county jails and TB outreach clinics for homeless populations in three cities.

PATIENTS

Study staff enrolled 1,211 patients (844 inmates and 367 homeless persons).

INTERVENTIONS

Sites used 60 daily doses of rifampin and pyrazinamide, an approved treatment regimen for LTBI.

MEASUREMENTS

Types and frequency of drug-related adverse events and outcomes of treatment.

RESULTS

Prior to treatment, 25 of 1,178 patients (2.1%) had a serum aminotransferase measurement at least 2.5 times the upper limit of normal. Patients who reported excess alcohol use in the past 12 months were more likely than other patients to have an elevated pretreatment serum aminotransferase level (odds ratio, 2.1; 95% confidence interval, 1.1 to 6.1; p = 0.03). Treatment was stopped in 66 of 162 patients (13.4%) who had a drug-related adverse event. Among 715 patients who had serum aminotransferase measured during treatment, 43 patients (6.0%) had an elevation > 5 times the upper limits of normal, including one patient who died of liver failure attributed to treatment. In multivariate analyses, increasing age, an abnormal baseline aspartate aminotransferase level, and unemployment within the past 24 months were independent risk factors for hepatotoxicity. Completion rates were similar in jail inmates (47.5%) and homeless persons (43.6%).

CONCLUSIONS

This study detected the first treatment-associated fatality with the rifampin and pyrazinamide regimen, prompting surveillance that detected unacceptable levels of hepatotoxicity and retraction of recommendations for its routine use. Completion rates for LTBI treatment using a short-course regimen exceeds historical rates using isoniazid. Efforts to identify an effective short-course treatment for LTBI should be given a high priority.

Intracellular antibodies as specific reagents for functional ablation: future therapeutic molecules

The use of antibodies in medicine and research depends on their specificity and affinity in the recogniton and binding of individual molecules. However, these applications are limited to the extracellular targets. Advances in antibody engineering has allowed the manipulation of the antibody segments containing the antigen-binding regions and generation of small fragments that can be stably expressed in cells. These entities are called intracellular antibodies or intrabodies and have being successfully applied, mainly in the scFv format, to inhibit the function of intracellular target proteins in specific cellular compartments. As new techniques to select and isolate intrabody fragments have been developed, intrabodies are beginning to be used to interfere with the function of a greater number of relevant disease targets. Just as monoclonal antibodies are opening a new era in human therapeutics, intrabodies promise a new prospective for antibody tools for therapy and research. Their varied mode of action gives intrabodies great potential in different approaches in the treatment of human diseases, as well as in the area of functional genomics for characterisation of novel gene products and subsequent validation as potential drug targets. While techniques for identifying functional intrabodies have improved, there are still many significant problems to be overcome before intrabodies can actually be used in treatment of diseases such as cancer, AIDS or neuro-degenerative disorders.

Public health and correctional collaboration in tuberculosis control

OBJECTIVE

To assess the extent that 20 large jail systems and their respective public health departments collaborate to prevent and control tuberculosis (TB).

METHODS

Data were collected through questionnaires sent to jail medical directors and TB control directors, interviews, and on-site observation in each of the jails.

RESULTS

Only 35% of jail systems and health departments reported having effective collaboration in TB prevention and control activities. Four barriers were reported by a majority of the jail systems: funding (65%), staffing (60%), staff training (55%), and communication (55%). Lack of advance notice of a patient's release was rated as the greatest barrier to discharge planning. Fifty percent of the jail systems reported that they scheduled appointments for soon-to-be released patients with TB, and 10% did so for patients being treated for latent TB infection (LTBI). Fewer patients actually received appointments: seven (39%) of 33 released patients with TB had documentation in their medical record of appointments, and one of 46 released patients on treatment for LTBI had them. Characteristics associated with increased collaboration include having designated liaisons between jail systems and health departments and holding periodic meetings of staff.

CONCLUSIONS

Health departments and jail systems in the same jurisdiction have implemented recommendations regarding collaboration to a limited extent. Such collaborations need strengthening, especially discharge planning and evaluation of TB control activities.

Yield of source-case and contact investigations in identifying previously undiagnosed childhood tuberculosis

OBJECTIVE

To determine the extent to which source-case investigations, in which a child was the index tuberculosis (TB) case, and contact investigations of adult pulmonary cases, identified children and adults with previously undiagnosed TB or latent tuberculosis infection (LTBI).

METHODS

We reviewed records of 111 source-case investigations and 38 contact investigations involving 164 TB cases among children <5 years of age from eight California health jurisdictions with a case rate greater than the state average for this age group (9.6/100000).

RESULTS

In source-case investigations, 141 children <5 years and 113 children 5-14 years of age were evaluated for TB disease and LTBI. Fourteen previously undiagnosed TB cases were found, including seven children <5 years of age. Source-case investigations also identified persons who might benefit from treatment for LTBI (45% had a positive tuberculin reaction). In contact investigations of adult TB cases, 202 children <5 years and 122 children 5-14 years of age were evaluated. In addition to 46 children with TB <5 years of age, the basis on which these contact investigations were selected for study, four children 5-14 years of age and 10 adults were found to have TB disease. A high percentage (41%) of contacts with a positive tuberculin reaction was found, especially among household contacts.

CONCLUSIONS

Source-case investigations and contact investigations are effective for finding previously undiagnosed cases of TB. They are also useful for identifying children and adults who would possibly benefit from treatment for LTBI. Earlier detection and treatment of adults with TB could interrupt transmission and be a step toward eliminating childhood TB.

Assessment of tuberculosis screening and management practices of large jail systems

OBJECTIVE

This descriptive study sought to explore the use and timeliness of tuberculosis (TB) screening and management activities in jail facilities.

METHODS

Study personnel visited 20 large U.S. jail systems and reviewed the medical records of 56 inmates who had recently been evaluated for TB disease and 376 inmates who were diagnosed with or confirmed to have latent TB infection (LTBI). Data from these records were analyzed to determine completion and timeliness of screening, diagnostic, and treatment activities.

RESULTS

In 14% of 56 inmates evaluated for TB disease and 24% of 376 inmates with LTBI, chest radiographs were either not performed or not documented. Of 48 inmates evaluated for TB disease who were not receiving treatment when admitted to jail, 10 had no record of sputum collection being done. A mean delay of 3.1 days occurred from symptom report to respiratory isolation. Time from tuberculin skin test reading to chest radiograph reading was a mean of 5.3 days in inmates evaluated for TB disease and a mean of 7.0 days in inmates with LTBI. Follow-up was arranged for 91% of released inmates who were on treatment for TB disease and only 17% of released inmates who were on treatment for LTBI.

CONCLUSIONS

Jail health information systems should be augmented to better document and monitor inmate health care related to TB. Completion rates and timeliness of TB screening, diagnostic, and treatment measures should be evaluated to identify areas needing improvement. Finally, mechanisms for continuity of care upon inmate release should be enhanced to promote therapy completion and prevent TB transmission in the community.

Assessment of tuberculosis screening and management practices of large jail systems

OBJECTIVE

This descriptive study sought to explore the use and timeliness of tuberculosis (TB) screening and management activities in jail facilities.

METHODS

Study personnel visited 20 large U.S. jail systems and reviewed the medical records of 56 inmates who had recently been evaluated for TB disease and 376 inmates who were diagnosed with or confirmed to have latent TB infection (LTBI). Data from these records were analyzed to determine completion and timeliness of screening, diagnostic, and treatment activities.

RESULTS

In 14% of 56 inmates evaluated for TB disease and 24% of 376 inmates with LTBI, chest radiographs were either not performed or not documented. Of 48 inmates evaluated for TB disease who were not receiving treatment when admitted to jail, 10 had no record of sputum collection being done. A mean delay of 3.1 days occurred from symptom report to respiratory isolation. Time from tuberculin skin test reading to chest radiograph reading was a mean of 5.3 days in inmates evaluated for TB disease and a mean of 7.0 days in inmates with LTBI. Follow-up was arranged for 91% of released inmates who were on treatment for TB disease and only 17% of released inmates who were on treatment for LTBI.

CONCLUSIONS

Jail health information systems should be augmented to better document and monitor inmate health care related to TB. Completion rates and timeliness of TB screening, diagnostic, and treatment measures should be evaluated to identify areas needing improvement. Finally, mechanisms for continuity of care upon inmate release should be enhanced to promote therapy completion and prevent TB transmission in the community.

Treatment for latent TB in correctional facilities: a challenge for TB elimination

BACKGROUND

To eliminate tuberculosis (TB) in the United States, more information is needed on how to gain access to difficult-to-reach, high-risk populations to evaluate people who would benefit from treatment for latent TB infection (LTBI).

METHODS

A field study was conducted of people at risk for co-infection with TB and the human immunodeficiency virus (HIV) and to demonstrate that treating LTBI in inmates is feasible. Inmates were tested for LTBI using the Mantoux tuberculin skin test (TST). Outcomes measured were skin test results and the start and completion of treatment for LTBI.

RESULTS

In 49 correctional facilities in 12 states, 198102 inmates had a skin test read. The mean skin test positivity rate among inmates was 17.0%. Of those who had a known HIV test result, 14.5% tested HIV positive. Inmates with a positive TST were 4.2 times more likely than those with a negative TST to be HIV infected (95% confidence interval [CI]=3.9-4.4). Therapy for LTBI was completed in 55.9% of patients started on treatment. Patients who were HIV positive and started on a 12-month treatment regimen were less likely than HIV-negative patients (40.0% vs 68.1%, respectively) to complete treatment (odds ratio [OR]=0.24, 95% CI=0.20-0.28). Patients treated in jails were less likely than those treated in prisons (33.6% vs 57.7%, respectively) to complete treatment (OR=0.29, 95% CI=0.26-0.32).

CONCLUSIONS

Correctional facilities offer a venue for identifying and treating high-risk individuals for LTBI. However, completing treatment is more problematic in jails than in prisons.

Mouse Models of Human Chromosomal Translocations and Approaches to Cancer Therapy

Cancer arises because of genetic changes in somatic cells, eventually giving rise to overt malignancy. Principle among genetic changes found in tumor cells are chromosomal translocations which give rise to fusion genes or enforced oncogene expression. These mutations are tumor-specific and result in production of tumor-specific mRNAs and proteins and are attractive targets for therapy. Also, in acute leukemias, many of these molecules are transcription regulators which involve cell-type-specific complexes, offering an alternative therapy via interfering with protein-protein interaction. We are studying these various features of tumor cells to evaluate new therapeutic methods. We describe a mouse model of de novo chromosomal translocations using the Cre-loxP system in which interchromosomal recombination occurs between the Mll and Af9 genes. We are also developing other in vivo methods designed, like the Cre-loxP system, to emulate the effects of these chromosomal abnormalities in human tumors. In addition, we describe new technologies to facilitate the intracellular targeting of fusion mRNAs and proteins resulting from such chromosomal translocations. These include a masked antisense RNA method with the ability to discriminate between closely related RNA targets and the selection and use of intracellular antibodies to bind to target proteins in vivo and cause cell death. These approaches should also be adaptable to targeting point mutations or to differentially expressed tumor-associated proteins. We hope to develop therapeutic approaches for use in cancer therapy after testing their efficacy in our mouse models of human cancer.

Missed opportunities for preventing tuberculosis among children younger than five years of age

OBJECTIVES

Childhood tuberculosis (TB) is an important indicator of public health success in interrupting and preventing TB transmission. To determine the frequency and types of missed opportunities for preventing TB among children <5 years of age.

METHODS

We collected data from the public health records of child TB cases and their adult source cases. These children were from health jurisdictions where TB case rates in children were higher than the California average for this age group.

RESULTS

We reviewed the records for 165 children reported with TB (20% confirmed by culture). These children were evaluated for TB because of signs or symptoms of illness (32%), a contact investigation (26%), screening (22%), a source case investigation (4%), and unknown reasons (16%). Excluding 4 children infected by Mycobacterium bovis, only 59 of 161 children (37%) had a source case found. Children found in a contact investigation, born in the United States, <1 year of age, or who were black were more likely to have a source case found than children who did not have one of these characteristics. Of 43 children found in a contact investigation, improvements in contact investigations may have prevented TB in 17 of these children (40%). Among the 43 adult source cases, factors that may have facilitated transmission include delayed reporting in 23%, a delayed contact investigation in 21%, and delayed or nondocumented bacteriologic sputum conversion in 42% of culture-positive cases.

CONCLUSIONS

Important missed opportunities to prevent TB in children include the failure to find and appropriately manage adult source cases and failure to completely evaluate and properly treat children exposed to TB. Improvements in case detection, case management, and contact investigations are necessary to eliminate TB in children.

Functional analysis of four CYP21 mutations from spanish patients with congenital adrenal hyperplasia

Deleterious mutations in the CYP21 (steroid 21-hydroxylase) gene cause congenital adrenal hyperplasia (CAH). These mutations usually result from recombinations between CYP21 and an adjacent pseudogene, CYP21P, including deletions and transfers of deleterious mutations from CYP21P to CYP21 (gene conversions). Additional rare mutations that are not gene conversions account for 5-10% of 21-hydroxylase deficiency alleles. Recently, four novel CYP21 point mutations leading to amino acid changes were identified in a population of 57 Spanish families with CAH. A nonsense mutation, K74X, was also identified. The enzymatic activities of 21-hydroxylase mutants G90V, G178A, G291C, and R354H were examined in transiently transfected CHOP cells using progesterone and 17alpha-hydroxyprogesterone as substrates. The G90V, G291C, and R354H mutations effectively eliminated 21-hydroxylase activity. However, the G178A mutant retained significant activity when 17alpha-hydroxyprogesterone was the substrate. These results correlate well with the identification of G90V, G291C, and R354H in patients with severe "salt-wasting" disease and G178A in a patient with the milder simple virilizing form.

Unreported AIDS-defining opportunistic illnesses in persons reported with HIV-related severe immunosuppression

To better estimate the distribution of AIDS cases after the 1993 change in the case definition, we assessed the proportion of persons whose AIDS diagnosis was based on laboratory criteria for severe immunosuppression (CD4 count <200 cells/microl or <14%) and who also had an unreported opportunistic illness (OI) at the time of the CD4 report. Five U.S. reporting sites (Arizona; Los Angeles County, California; New Jersey; Oregon; and Washington State) reviewed AIDS cases reported between January 1 and June 30, 1993. From these sites, 3289 immunologic cases were reported; of these cases, 322 (9.8%; range, 1.6%-16.1%) were in persons who had an unreported OI. More of those who had an unreported OI were male, members of racial groups other than white, injection drug users, and had a CD4 count of <50 cells/microl at AIDS diagnosis. Because of recent advances in OI prophylaxis and treatment of HIV infection, studies monitoring HIV-related morbidity should assess the occurrence of OIs in a sample of persons reported with HIV and severe immunosuppression. Such assessment will ensure representative ascertainment of initial AIDS-defining OIs and thus improve the usefulness of the data for public health planning and the allocation of resources for patient care.

Mutation analysis in patients with congenital adrenal hyperplasia in the Spanish population: identification of putative novel steroid 21-hydroxylase deficiency alleles associated with the classic form of the disease

Steroid 21-hydroxylase deficiency, due to the genetic impairment of the CYP21 gene, is a major cause of congenital adrenal hyperplasia (CAH). In about 80% of the cases, the defect is related with the transfer of deleterious point mutations from the CYP21P pseudogene to the active CYP21 gene. Sixteen different point mutations have been searched for in 60 Spanish patients with the classic form of CAH and 171 unaffected family members, using selective amplification of the CYP21 gene followed by allele-specific oligonucleotide hybridization (PCR-ASOH) and sequencing analysis. While 31.9% of the disease alleles carry CYP21 deletions or large gene conversions, around 58% of the alleles carry single point mutations. Corresponding segregation of mutations was found in every case indicating that none of them has apparently appeared de novo. The most frequent mutations found in our sample are i2G, V281L, R356W, Q318X, P453S and F306+t, with rates of 30, 14.2, 10, 9.2, 9.2 and 7. 5%, respectively. We found similar frequencies for the A and C polymorphism at position 656 (40 and 31.5%, respectively) in wild-type alleles for the i2G mutation. Around 10% of the alleles, for which no mutations were identified by searching for the sixteen previously known mutations, are currently being sequenced and new possible mutations and polymorphisms have been identified.

Mycobacterium tuberculosis infection after travel to or contact with visitors from countries with a high prevalence of tuberculosis

To assess whether there is increased risk of tuberculous infection in children who traveled to or had a household visitor from a country having a high prevalence of tuberculosis, we conducted a case-control study. Children younger than 6 yr of age who had a tuberculin skin test read at public health clinics in areas of California that have a high prevalence of tuberculosis were enrolled. Of the 953 children who had a skin test read, 72 (7.6%) had a positive reaction. By multiple logistic regression analysis, children who had traveled in the 12 mo before the skin test were 3.9 times more likely to have a positive skin test than were children who had not traveled (95% confidence interval [CI], 1.9 to 7.9). Among children born in the United States, those who had traveled were 4.7 times more likely to have a positive skin test (95% CI, 2.0 to 11.2). Children who had a household visitor from a country having a high prevalence of tuberculosis were 2.4 times more likely to have a positive skin test than were those who did not have a visitor (95% CI, 1.0 to 5.5). These data indicate that travel to a country that has a high prevalence of tuberculosis or having a visitor from such countries increase the risk of tuberculous infection among young children. Physicians and tuberculosis control programs should incorporate questions about travel and visitors into their evaluations, and children with a history of extended travel should have a tuberculin skin test.

Detection of Mycobacterium tuberculosis in gastric aspirates collected from children: hospitalization is not necessary

OBJECTIVE

To compare the yields of gastric aspirates collected for culture of Mycobacterium tuberculosis from children evaluated as outpatients versus inpatients and to determine factors associated with a positive culture.

METHODS

Retrospective study of 100 children <12 years of age with tuberculosis diagnosed at a pediatric referral hospital or in one of two tuberculosis control programs in California.

RESULTS

Of the 100 children who had tuberculosis, 80 had at least one gastric aspirate collected. M tuberculosis was isolated from 33 (41%) of the 80 children who had a gastric aspirate; 4 children had a positive culture from an aspirate subsequent to the first. Inpatients had a higher proportion of positive gastric aspirates than that of children who had aspirates collected as outpatients (48% vs 37%); however, this difference was not statistically significant. Resistance to isoniazid was found in three isolates (9%) of children all of whose presumptive source case had a susceptible strain of M tuberculosis. Characteristics that were associated with an approximately 50% yield from gastric aspirates were identification of a source case, age <2 years, birth in the United States, symptomatic tuberculosis, and pulmonary disease.

CONCLUSIONS

The culture of M tuberculosis from gastric aspirates of children in the outpatient setting has a yield comparable to aspirates collected from hospitalized children. Collection of gastric aspirates in the outpatient setting will reduce both the cost and the inconvenience of the procedure. Although the yield from gastric aspirates is relatively low, important information including drug susceptibility patterns may be obtained. tuberculosis, gastric aspirate, children.

High variability of CYP21 gene rearrangements in Spanish patients with classic form of congenital adrenal hyperplasia

Mutations that cause deficiency of the 21-hydroxylase (21-OH) appear as a result of recombinations between the CYP21B coding gene and the highly homologous CYP21A pseudogene, which are tandemly arranged with the C4A and C4B genes. We report a detailed analysis of a major chromosomic rearrangement by Southern blot using 21-OH and complement C4 cDNA probes, in a wide sample of classic Spanish congenital adrenal hyperplasia (CAH) patients. This study made it possible to observe that 50% of the patients carried at least one allele with gross abnormalities and that the frequencies of alleles with large deletions (16.66%) and gene conversions (14.16%) in the CYP21B gene were very similar. Moreover, our analysis revealed the existence of sixteen different restriction patterns of C4/CYP21 genes. Besides the detection of a new haplotype, which does not seem to appear from unequal crossing-over mechanisms, we observed the highest frequency on CYP21A duplications reported, as well as no duplications of the CYP21B gene. We also observed that although gross abnormalities of the CYP21A pseudogene did not affect 21-OH activity, alleles carrying deleterious point mutations had more rearrangements of the CYP21A gene than normal alleles. Even though the 21-OH deficiency is an autosomic trait, boys in our sample carried 2.6 times more deletions than girls. In contrast, conversion alleles were found equally frequently.

Tuberculosis in children and adolescents: California, 1985 to 1995

OBJECTIVES

To describe the epidemiology and clinical characteristics of tuberculosis (TB) among children and adolescents and to define children at risk for TB.

SETTING

4607 children 0 to 14 years of age and 1615 adolescents 15 to 19 years of age reported with TB in California.

METHODS

We analyzed surveillance data reported to the California Department of Health Services TB Control Branch from 1985 through 1995.

RESULTS

TB cases increased 22% among children 0 to 4 years of age and 66% among children 5 to 14 from 1985 through 1995. Case rates were highest among children 0 to 4 years of age (13/ 100000 children), but declined from 1993 to 1995, except for black children 0 to 4 years of age. Minority children 0 to 14 years of age had case rates 6- to 34-fold higher than did white children. Pulmonary TB was the most common site of disease in all age groups (71 to 82%). TB meningitis was most common in children 0 to 4 years of age (5%). Most children (64%) did not have cultures done; however, among culture-proved cases isoniazid-resistant Mycobacterium tuberculosis was isolated in 7%. Adolescents were more likely to have cavitary pulmonary disease (24%), to be foreign-born (78%) or homeless (4%) and to have an isoniazid-resistant strain isolated (13%) than were children 0 to 14 years of age (P < 0.05).

CONCLUSIONS

TB in children and adolescents increased substantially in the mid-1980s and early 1990s. Pediatric TB remains a serious health problem, especially among minority children and adolescents. Our findings indicate that TB control programs need improved strategies to prevent infection and detect disease in this population.

Tinea capitis in California children: a population-based study of a growing epidemic

OBJECTIVE

To describe trends in tinea capitis incidence among California children and to determine subpopulations at increased risk.

DESIGN

Retrospective population-based study.

SETTING

California, 1984 through 1993.

POPULATION

Children < 10 years of age enrolled in Medi-Cal.

OUTCOME MEASURES

California Medi-Cal provider data for first-time prescriptions of oral griseofulvin suspension were used to estimate annual incidence of tinea capitis and calculate risk ratios.

RESULTS

From 1984 through 1993, the incident rate for prescriptions of oral griseofulvin suspension increased by 84.2% for all children, 140.4% for white children, and 209.7% for African-American children. In 1993, incidence rates (per 10,000 enrolled) were 252.1 claimants for African-American children, 23.1 for white, 17.5 for Hispanic, and 14.3 for Asian/Pacific Islander. The highest rate by location was San Francisco County (172.2). In age groups < 5 years and 5 to 9 years, African-American children were 13.1 and 17.6 times more likely to be prescribed griseofulvin than Hispanic children. Since 1987, incidence rates for children 5 to 9 years of age were higher compared with children ages < 5 years.

CONCLUSIONS

Tinea capitis is epidemic among California children with higher rates in the northern counties studied. African-American children are the most affected by this epidemic; however, white children have also experienced increased rates.