Natural ventilation reduces high TB transmission risk in traditional homes in rural KwaZulu-Natal, South Africa

Current Epidemiology of Pediatric Tuberculosis

Tuberculosis (TB) is a communicable disease that is a major cause of ill health and one of the leading causes of death worldwide. Children act as reservoirs of infection out of which future cases develop. Without the successful detection and treatment of TB infection and disease in children, elimination strategies for TB will be ineffective. India has a severe problem with TB in children, which accounts for around 31% of the global pediatric TB load. However, over the past 10 y, children have consistently made up 6-7% of all patients treated yearly under the National Tuberculosis Elimination Programme (NTEP). There is an estimated detection gap of 56% in India, which is the reason for many missed cases of TB in children. Only 3% of children less than 14 y with MDR/RR-TB, are reported from India, which again is an underestimation of the actual incident cases. Population density, housing and living conditions, environmental conditions, cultural practices, age of the child, exposure to tobacco and other environmental pollutants, the virulence of the mycobacterial strain and their genetics, host genetics, BCG vaccination, malnutrition, immunodeficiency are some of the risk factors for TB exposure, infection and disease in children. Understanding the natural history as well as the epidemiology of childhood TB is important to assess which children are the most vulnerable. It would also guide us in understanding the burden of pediatric TB on a regional, national, or global level, thus facilitating the appropriate targeting of health resources and also guiding policy-making decisions.

Individual and household risk factors for COVID-19 infection among household members of COVID-19 patients in home-based care in western Uganda, 2020

OBJECTIVE

To investigate factors associated with COVID-19 among household members of patients in home-based care (HBC) in western Uganda.

METHODS

We conducted a case-control and cohort study. Cases were reverse transcriptase-polymerase chain reaction-confirmed SARS-CoV-2 diagnosed 1-30 November 2020 among persons in HBC in Kasese or Kabarole districts. We compared 78 case-households (≥1 secondary case) with 59 control-households (no secondary cases). The cohort included all case-household members. Data were captured by in-person questionnaire. We used bivariate regression to calculate odds and risk ratios.

RESULTS

Case-households were larger than control-households (mean 5.8 vs 4.3 members, P<0.0001). Having ≥1 household member per room (adjusted odds ratio (aOR)=4.5, 95% CI 2.0-9.9), symptom development (aOR=2.3, 95% CI 1.1-5.0), or interaction with primary case-patient (aOR=4.6, 95% CI 1.4-14.7) increased odds of case-household status. Households assessed for suitability for HBC reduced odds of case-household status (aOR=0.4, 95% CI=0.2-0.8). Interacting with a primary case-patient increased the risk of individual infection among household members (adjusted risk ratio=1.7, 95% CI 1.1-2.8).

CONCLUSION

Household and individual factors influence secondary infection risk in HBC. Decisions about HBC should be made with these in mind.

Importance of ventilation and occupancy to Mycobacterium tuberculosis transmission rates in congregate settings

BACKGROUND

Ventilation rates are a key determinant of the transmission rate of Mycobacterium tuberculosis and other airborne infections. Targeting infection prevention and control (IPC) interventions at locations where ventilation rates are low and occupancy high could be a highly effective intervention strategy. Despite this, few data are available on ventilation rates and occupancy in congregate locations in high tuberculosis burden settings.

METHODS

We collected carbon dioxide concentration and occupancy data in congregate locations and public transport on 88 occasions, in Cape Town, South Africa. For each location, we estimated ventilation rates and the relative rate of infection, accounting for ventilation rates and occupancy.

RESULTS

We show that the estimated potential transmission rate in congregate settings and public transport varies greatly between different settings. Overall, in the community we studied, estimated infection risk was higher in minibus taxis and trains than in salons, bars, and shops. Despite good levels of ventilation, infection risk could be high in the clinic due to high occupancy levels.

CONCLUSION

Public transport in particular may be promising targets for infection prevention and control interventions in this setting, both to reduce Mtb transmission, but also to reduce the transmission of other airborne pathogens such as measles and SARS-CoV-2.

SARS-CoV-2 Transmission and Prevention in the Era of the Delta Variant

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) delta variant transmits much more rapidly than prior SARS-CoV-2 viruses. The primary mode of transmission is via short range aerosols that are emitted from the respiratory tract of an index case. There is marked heterogeneity in the spread of this virus, with 10% to 20% of index cases contributing to 80% of secondary cases, while most index cases have no subsequent transmissions. Vaccination, ventilation, masking, eye protection, and rapid case identification with contact tracing and isolation can all decrease the transmission of this virus.

Control and prevention of infectious diseases from a One Health perspective

The ongoing COVID-19 pandemic has caught the attention of the global community and rekindled the debate about our ability to prevent and manage outbreaks, epidemics, and pandemics. Many alternatives are suggested to address these urgent issues. Some of them are quite interesting, but with little practical application in the short or medium term. To realistically control infectious diseases, human, animal, and environmental factors need to be considered together, based on the One Health perspective. In this article, we highlight the most effective initiatives for the control and prevention of infectious diseases: vaccination; environmental sanitation; vector control; social programs that encourage a reduction in the population growth; control of urbanization; safe sex stimulation; testing; treatment of sexually and vertically transmitted infections; promotion of personal hygiene practices; food safety and proper nutrition; reduction of the human contact with wildlife and livestock; reduction of social inequalities; infectious disease surveillance; and biodiversity preservation. Subsequently, this article highlights the impacts of human genetics on susceptibility to infections and disease progression, using the SARS-CoV-2 infection as a study model. Finally, actions focused on mitigation of outbreaks and epidemics and the importance of conservation of ecosystems and translational ecology as public health strategies are also discussed.

Improving the diagnosis of pulmonary tuberculosis using line probe assay and determining the factors associated with the disease in children in Jos, Nigeria

Introduction

Diagnosing tuberculosis (TB), including pulmonary tuberculosis (PTB), in children remains a challenge, partly due to its paucibacillary nature in young children. Data on the use of line probe assay (LPA), on gastric and sputum samples, for diagnosing PTB in children are scarce. We determined the proportion of samples positive for Mycobacterium tuberculosis (MTB) by smear microscopy (SM) and LPA in presumptive PTB cases as well as the factors associated with PTB confirmed by LPA, in children in Jos, Nigeria.

Methods

An observational study in children aged 6 months-16 years. Gastric and sputum samples were examined by SM and by LPA for MTB using GenoType MTBDRplus Ver 2.0 (Hain Lifescience). Multivariate logistic regression was performed to determine the factors associated with PTB.

Results

Out of 103 children with presumptive PTB, 47 had confirmed PTB, 26 unconfirmed PTB and 30 unlikely PTB by LPA. In 67 gastric samples, MTB was identified by SM in 2 (3.0%) compared to 28 (41.8%) by LPA while in 31 sputum samples, MTB was identified by SM in 5 (16.1%) compared to 18 (58.1%) by LPA. The factors associated with pulmonary tuberculosis were an abnormal chest X-ray (adjusted odds ratio (AOR))=12.39 [3.75-40.90], p<0.001), sleeping in the same room with more than three persons (AOR=3.30 [1.23-8.85], p=0.018) and sleeping in a room with none or one window (AOR=2.86 [1.03-7.95], p=0.044).

Conclusions

Line probe assay improves the diagnosis of pulmonary TB in children, especially with gastric samples, while an abnormal chest X-ray is a useful adjunct in PTB diagnosis. Avoiding overcrowding and having windows in sleeping rooms are a necessary part of TB prevention.

Preventing tuberculosis in children: A global health emergency

It is estimated that 20 million children are exposed to tuberculosis (TB) each year, making TB a global paediatric health emergency. TB preventative efforts have long been overlooked. With the view of achieving "TB elimination" in "our lifetime", this paper explores challenges and potential solutions in the TB prevention cascade, including identifying children who have been exposed to TB; detecting TB infection in these children; identifying those at highest risk of progressing to disease; implementing treatment of TB infection; and mobilizing multiple stakeholders support to successfully prevent TB.

Prevalence of LTBI among household contacts of sputum positive TB patients receiving DOTS chemotherapy

OBJECTIVES

1. To estimate the prevalence of latent tuberculosis infection among household contacts of sputum positive pulmonary tuberculosis patient receiving DOTS chemotherapy. 2. To evaluate the risk factors among household contacts of sputum positive pulmonary tuberculosis patient receiving DOTS chemotherapy. 3. To evaluate the degree of exposure among household contacts of sputum positive pulmonary tuberculosis patient receiving DOTS chemotherapy.

METHODS

This study was a cross sectional done among 220 household contacts of age 12 years and above (male and female) of the index sputum positive patients receiving DOTS. Mantoux skin test (Tuberculin Skin Test - TST) was administered by the principal investigator along with TST reading & final diagnosis. Chi-square test was done to find out the association.

RESULTS

Out of 220 household contacts tested, 43.6% (96) tested positive for latent TB (induration ≥10mm) with 95% CI ranging from 37% to 50%. The prevalence of latent TB among men and women are 35.6% and 49.2% respectively the difference between which is found to be statistically significant (p = 0.04). Odds Ratio of 5.5 was noted among study subjects who were diabetic (p = 0.018). Household contacts of index patients taking CAT II were at a higher risk than that of CAT I.

CONCLUSION

This study clearly shows the high prevalence of latent TB infection among household contacts of sputum positive patients receiving DOTS and so RNTCP should include them in IPT along with under 6 children. The household contacts who spend most time with the index case, who sleep close to them within 5 feet, female household contacts, students, diabetic household contacts are at a significantly higher risk than others.

Baseline Assessment of Risk Factors of Presumptive Tuberculosis among under Five Children Living with an Index Client under Treatment in Mbale District, Eastern Uganda

BACKGROUND AND AIMS

Children in contact with adults having pulmonary Tuberculosis (TB) are vulnerable to TB infection and hence contact tracing and screening is important for early detection of infection. However, there are few contacts traced and the prevalence and risk factors for transmission are not well studied. The objective of this study was to determine the prevalence of infection and risk factors associated with TB transmission among under five children in household contact with adult pulmonary TB patients.

MATERIALS AND METHODS

A cross sectional study was carried out in three health facilities with a high TB burden in Mbale District, Eastern Uganda involving all under five household contacts of adults with pulmonary tuberculosis recorded in the TB register from October 2018 to March 2019 and still on treatment. Structured questionnaires were administered to the index clients to obtain their demographic and clinical data about TB, HIV as well as information on the children. Children were screened using the intensive case finding forms to identify presumptive cases.

RESULTS

The total number of index TB Clients line listed were 70. Number of clients traced was 38, 21 (%) of whom had children under five years and a total of 33 children were identified. The number of presumptive cases was 9/33 (27.27%). 77.8% of the presumptive cases were living in poorly ventilated houses.

CONCLUSION

The study identified children with presumptive TB and various risk factors for TB transmission. Intensive contact tracing can therefore help reduce TB transmission within the communities. It is recommended to undertake studies aiming at improving contact tracing and strategies to eliminate the risk factors to TB transmission.

Yield of household contact investigation of patients with pulmonary tuberculosis in southern Ethiopia

BACKGROUND

Household Contacts (HHCs) of patients with pulmonary tuberculosis (PTB) have a higher risk of developing TB. Contact investigation is recommended to reach this group and identify undiagnosed cases. In this study, we have determined the yield of contact investigation among HHCs of patients with smear-positive PTB, and estimated TB burden.

METHODS

We conducted retrospective record review for the occurrence of TB among HHCs of Index PTB+ cases treated between November 2010 and April 2013 in 12 public health facilities in Boricha district. HHCs were followed up monthly and revisited between March and June 2015. Information on additional TB cases diagnosed and treated among HHCs were documented. HHCs who were diagnosed as having TB after the index cases were diagnosed and treated were considered as 'incident cases'. Presumptive TB case was defined as those having cough for ≥2 weeks or enlarged lymph node. Diagnosis of TB among HHCs were made using smear-microscopy and/or X-rays, and clinically for Extra-pulmonary TB (EPTB).

RESULTS

One thousand five hundred and seventeenth HHCs of 344 index cases were visited and screened for TB and followed up for a median of 37 months. 77 (5.1% - 72 with PTB and 5 with EPTB) HHCs developed TB during 4713 person-years of follow-up with an estimated incidence of 1634 (95% CI: 1370-2043) per 100,000 person-years follow-up which is much higher than the estimated TB incidence for the general population in Ethiopia of 210/100,000. Half (41/77) of incident TB cases were diagnosed within the first year of diagnosis of the index cases and 88% (68/77) were adults (Hazard Ratio: 4.03; 95% CI: 2.00-8.12).

CONCLUSION

HHCs of index PTB+ cases have high risk of developing active TB. Long term follow-up of HHCs could help improve TB case finding depending on country contexts. Further studies on effectiveness and feasibility of the approach and integration in routine settings are needed.

Tuberculosis susceptibility and protection in children

Children represent both a clinically important population susceptible to tuberculosis and a key group in whom to study intrinsic and vaccine-induced mechanisms of protection. After exposure to Mycobacterium tuberculosis, children aged under 5 years are at high risk of progressing first to tuberculosis infection, then to tuberculosis disease and possibly disseminated forms of tuberculosis, with accompanying high risks of morbidity and mortality. Children aged 5-10 years are somewhat protected, until risk increases again in adolescence. Furthermore, neonatal BCG programmes show the clearest proven benefit of vaccination against tuberculosis. Case-control comparisons from key cohorts, which recruited more than 15 000 children and adolescents in total, have identified that the ratio of monocytes to lymphocytes, activated CD4 T cell count, and a blood RNA signature could be correlates of risk for developing tuberculosis. Further studies of protected and susceptible populations are necessary to guide development of novel tuberculosis vaccines that could facilitate the achievement of WHO's goal to eliminate deaths from tuberculosis in childhood.

Measuring ventilation and modelling M. tuberculosis transmission in indoor congregate settings, rural KwaZulu-Natal

SETTING: Molecular epidemiology suggests that most Mycobacterium tuberculosis transmission in high-burden settings occurs outside the home.

OBJECTIVE: To estimate the risk of M. tuberculosis transmission inside public buildings in a high TB burden community in KwaZulu-Natal, South Africa.

DESIGN: Carbon dioxide (CO₂) sensors were placed inside eight public buildings. Measurements were used with observations of occupancy to estimate infection risk using an adaptation of the Wells-Riley equation. Ventilation modelling using CONTAM was used to examine the impact of low-cost retrofits on transmission in a health clinic.

RESULTS: Measurements indicate that infection risk in the church, classroom and clinic waiting room would be high with typical ventilation, occupancy levels and visit durations. For example, we estimated that health care workers in a clinic waiting room had a 16.9–24.5% annual risk of M. tuberculosis infection. Modelling results indicate that the simple addition of two new windows allowing for cross-ventilation, at a cost of US$330, would reduce the annual risk to health care workers by 57%.

CONCLUSIONS: Results indicate that public buildings in this community have a range of ventilation and occupancy characteristics that may influence transmission risks. Simple retrofits may result in dramatic reductions in M. tuberculosis transmission, and intervention studies should therefore be considered.

Biological and Epidemiological Consequences of MTBC Diversity

Tuberculosis is caused by different groups of bacteria belonging to the Mycobacterium tuberculosis complex (MTBC). The combined action of human factors, environmental conditions and bacterial virulence determine the extent and form of human disease. MTBC virulence is a composite of different clinical phenotypes such as transmission rate and disease severity among others. Clinical phenotypes are also influenced by cellular and immunological phenotypes. MTBC phenotypes are determined by the genotype, therefore finding genotypes responsible for clinical phenotypes would allow discovering MTBC virulence factors. Different MTBC strains display different cellular and clinical phenotypes. Strains from Lineage 5 and Lineage 6 are metabolically different, grow slower, and are less virulent. Also, at least certain groups of Lineage 2 and Lineage 4 strains are more virulent in terms of disease severity and human-to-human transmission. Because phenotypic differences are ultimately caused by genotypic differences, different genomic loci have been related to various cellular and clinical phenotypes. However, defining the impact of specific bacterial genomic loci on virulence when other bacterial determinants, human and environmental factors are also impacting the phenotype would contribute to a better knowledge of tuberculosis virulence and ultimately benefit tuberculosis control.

Infectious Diseases of Poverty in Children: A Tale of Two Worlds

"Infectious diseases of poverty" (IDoP) describes infectious diseases that are more prevalent among poor and vulnerable populations, namely human immunodeficiency virus (HIV) infection, tuberculosis (TB), malaria, and neglected tropical diseases (NTDs). In 2013, 190,000 children died of HIV-related causes and there were 550,000 cases and 80,000 TB deaths in children. Children under age 5 account for 78% of malaria deaths annually. NTDs remain a public health challenge in low- and middle-income countries. This article provides an overview of the major IDoP that affect children. Clinicians must be familiar with the epidemiology and clinical manifestations to ensure prompt diagnosis and treatment.

Stopping tuberculosis: a biosocial model for sustainable development

Tuberculosis transmission and progression are largely driven by social factors such as poor living conditions and poor nutrition. Increased standards of living and social approaches helped to decrease the burden of tuberculosis before the introduction of chemotherapy in the 1940s. Since then, management of tuberculosis has been largely biomedical. More funding for tuberculosis since 2000, coinciding with the Millennium Development Goals, has yielded progress in tuberculosis mortality but smaller reductions in incidence, which continues to pose a risk to sustainable development, especially in poor and susceptible populations. These at-risk populations need accelerated progress to end tuberculosis as resolved by the World Health Assembly in 2015. Effectively addressing the worldwide tuberculosis burden will need not only enhancement of biomedical approaches but also rebuilding of the social approaches of the past. To combine a biosocial approach, underpinned by social, economic, and environmental actions, with new treatments, new diagnostics, and universal health coverage, will need multisectoral coordination and action involving the health and other governmental sectors, as well as participation of the civil society, and especially the poor and susceptible populations. A biosocial approach to stopping tuberculosis will not only target morbidity and mortality from disease but would also contribute substantially to poverty alleviation and sustainable development that promises to meet the needs of the present, especially the poor, and provide them and subsequent generations an opportunity for a better future.

The Impact of Ventilation and Early Diagnosis on Tuberculosis Transmission in Brazilian Prisons

Prisoners have among the highest incidence of tuberculosis (TB) globally. However, the contribution of the prison environment on transmission is not well understood and structural characteristics have received little attention as effective epidemiological interventions in TB control. We evaluated architectural characteristics and estimated ventilation rates in 141 cells in three prisons in central west Brazil using steady-state exhaled carbon dioxide (CO2) levels. We used a modified Wells-Riley equation to estimate the probability of infection for inmates sharing a cell with an infectious case and projected the impact of interventions, including early diagnosis and improved ventilation. Overall, prison cells were densely populated (mean 2.1 m(2) per occupant) and poorly ventilated, with only three cells meeting World Health Organization (WHO) standards for per-person ventilation (60 L/s) applied in infection control settings. In the absence of interventions, projected mean risk of infection was 78.0% during a 6-month period. Decreasing time-to-diagnosis by 25% reduced transmission risk by 8.3%. Improving ventilation to WHO standards decreased transmission by 38.2%, whereas optimizing cross-ventilation reduced transmission by 64.4%. Prison environments promote high infection risk over short-time intervals. In this context, enhanced diagnostics have a limited impact on reducing transmission. Improving natural ventilation may be required to effectively control TB in prisons.

Modelling the risk of airborne infectious disease using exhaled air

In this paper we develop and demonstrate a flexible mathematical model that predicts the risk of airborne infectious diseases, such as tuberculosis under steady state and non-steady state conditions by monitoring exhaled air by infectors in a confined space. In the development of this model, we used the rebreathed air accumulation rate concept to directly determine the average volume fraction of exhaled air in a given space. From a biological point of view, exhaled air by infectors contains airborne infectious particles that cause airborne infectious diseases such as tuberculosis in confined spaces. Since not all infectious particles can reach the target infection site, we took into account that the infectious particles that commence the infection are determined by respiratory deposition fraction, which is the probability of each infectious particle reaching the target infection site of the respiratory tracts and causing infection. Furthermore, we compute the quantity of carbon dioxide as a marker of exhaled air, which can be inhaled in the room with high likelihood of causing airborne infectious disease given the presence of infectors. We demonstrated mathematically and schematically the correlation between TB transmission probability and airborne infectious particle generation rate, ventilation rate, average volume fraction of exhaled air, TB prevalence and duration of exposure to infectors in a confined space.

Trained community volunteers improve tuberculosis knowledge and attitudes among adults in a periurban community in southwest Nigeria

Nigeria has the world's 10th largest tuberculosis (TB) burden. Targeted community-based interventions can potentially help reduce TB incidence. We designed an intervention in a periurban community where 10 community volunteers were trained to provide community TB education and also detect and refer TB suspects to a nearby clinic. To determine the effect of the intervention on knowledge, attitude, and preventive practices of TB, we compared results from a pre-intervention survey with those of a post-intervention survey. Pre-intervention, respondents had a mean knowledge score of 10.6 ± 7.0 of a possible 34, a mean attitude score of 5.8 ± 3.3 of a possible 10, and a mean practice score of 5.3 ± 1.4 of a possible 7. The intervention significantly increased the mean knowledge score to 16 ± 5.4 (P < 0.001) and mean attitude score to 7.0 ± 1.8 (P < 0.001); however, there was no statistically significant difference in the mean practice score. Eight TB suspects were referred to the clinic, and one suspect was subsequently diagnosed with TB. The use of trained community volunteers to share information on TB improved the overall knowledge and attitudes of respondents. Continued empowerment of the community should be encouraged to promote TB prevention and care.

Consequences of genomic diversity in Mycobacterium tuberculosis

The causative agent of human tuberculosis, Mycobacterium tuberculosis complex (MTBC), comprises seven phylogenetically distinct lineages associated with different geographical regions. Here we review the latest findings on the nature and amount of genomic diversity within and between MTBC lineages. We then review recent evidence for the effect of this genomic diversity on mycobacterial phenotypes measured experimentally and in clinical settings. We conclude that overall, the most geographically widespread Lineage 2 (includes Beijing) and Lineage 4 (also known as Euro-American) are more virulent than other lineages that are more geographically restricted. This increased virulence is associated with delayed or reduced pro-inflammatory host immune responses, greater severity of disease, and enhanced transmission. Future work should focus on the interaction between MTBC and human genetic diversity, as well as on the environmental factors that modulate these interactions.

Epidemiology and disease burden of tuberculosis in children: a global perspective

Our understanding of the tuberculosis (TB) epidemic in children is incomplete due to challenges in diagnosis and reporting. Children have also been largely excluded from research and advocacy. However, the tide appears to be turning and interest in pediatric TB is increasing. In this article, we explore the epidemiology of childhood TB by first reviewing the natural history of TB in children and the factors that impact on each of the stages from exposure to disease. We then discuss how these factors affect what we see at a country and regional level. Finally, we assess the burden of childhood TB globally.

Shared air: a renewed focus on ventilation for the prevention of tuberculosis transmission

Background

Despite an improvement in the overall TB cure rate from 40–74% between 1995 and 2011, TB incidence in South Africa continues to increase. The epidemic is notably disquieting in schools because the vulnerable population is compelled to be present. Older learners (age 15–19) are at particular risk given a smear-positive rate of 427 per 100,000 per year and the significant amount of time they spend indoors. High schools are therefore important locations for potential TB infection and thus prevention efforts.

Methods and Findings

Using portable carbon dioxide monitors, we measured CO₂ in classrooms under non-steady state conditions. The threshold for tuberculosis transmission was estimated using a carbon dioxide-based risk equation. We determined a critical rebreathed fraction of carbon dioxide () of 1·6%, which correlates with an indoor CO₂ concentration of 1000 ppm. These values correspond with a ventilation rate of 8·6 l/s per person or 12 air exchanges per hour (ACH) for standard classrooms of 180 m³.

Conclusions

Given the high smear positive rate of high-school adolescents in South Africa, the proposal to achieve CO₂ levels of 1000ppm through natural ventilation (in the amount 12 ACH) will not only help achieve WHO guidelines for providing children with healthy indoor environments, it will also provide a low-cost intervention for helping control the TB epidemic in areas of high prevalence.

Transmission of tuberculosis in resource-limited settings

Unrecognized transmission is a major contributor to ongoing TB epidemics in high-burden, resource-constrained settings. Limitations in diagnosis, treatment, and infection control in health-care and community settings allow for continued transmission of drug-sensitive and drug-resistant TB, particularly in regions of high HIV prevalence. Health-care facilities are common sites of TB transmission. Improved implementation of infection control practices appropriate for the local setting and in combination, has been associated with reduced transmission. Community settings account for the majority of TB transmission and deserve increased focus. Strengthening and intensifying existing high-yield strategies, including household contact tracing, can reduce onward TB transmission. Recent studies documenting high transmission risk community sites and strategies for community-based intensive case finding hold promise for feasible, effective transmission reduction. Infection control in community settings has been neglected and requires urgent attention. Developing and implementing improved strategies for decreasing transmission to children, within prisons and of drug-resistant TB are needed.