The fall after the rise: Tuberculosis in the United States, 1991 through 1994

Parallels and Mutual Lessons in Tuberculosis and COVID-19 Transmission, Prevention, and Control

The coronavirus disease (COVID-19) pandemic has had unprecedented negative effects on global health and economies, drawing attention and resources from many other public health services. To minimize negative effects, the parallels, lessons, and resources from existing public health programs need to be identified and used. Often underappreciated synergies relating to COVID-19 are with tuberculosis (TB). COVID-19 and TB share commonalities in transmission and public health response: case finding, contact identification, and evaluation. Data supporting interventions for either disease are, understandably, vastly different, given the diseases' different histories. However, many of the evolving issues affecting these diseases are increasingly similar. As previously done for TB, all aspects of congregate investigations and preventive and therapeutic measures for COVID-19 must be prospectively studied for optimal evidence-based interventions. New attention garnered by the pandemic can ensure that knowledge and investment can benefit both COVID-19 response and traditional public health programs such as TB programs.

Estimating tuberculosis cases and their economic costs averted in the United States over the past two decades

BACKGROUND

Following a concerted public health response to the resurgence of tuberculosis (TB) in the United States in the late 1980s, annual TB incidence decreased substantially. However, no estimates exist of the number and cost savings of TB cases averted.

METHODS

TB cases averted in the United States during 1995-2014 were estimated: Scenario 1 used a static 1992 case rate; Scenario 2 applied the 1992 rate to foreign-born cases, and a pre-resurgence 5.1% annual decline to US-born cases; and a statistical model assessed human immunodeficiency virus and TB program indices. We applied the cost of illness to estimate the societal benefits (costs averted) in 2014 dollars.

RESULTS

During 1992-2014, 368 184 incident TB cases were reported, and cases decreased by two thirds during that period. In the scenarios and statistical model, TB cases averted during 1995-2014 ranged from approximately 145 000 to 319 000. The societal benefits of averted TB cases ranged from US$3.1 to US$6.7 billion, excluding deaths, and from US$6.7 to US$14.5 billion, including deaths.

CONCLUSIONS

Coordinated efforts in TB control and prevention in the United States yielded a remarkable number of TB cases averted and societal economic benefits. We illustrate the value of concerted action and targeted public health funding.

Treatment Outcomes of Patients with Tuberculosis in New York City

CONTEXT

Treatment completion for tuberculosis (TB) is one of the essential components of TB prevention and control. Delays in treatment completion and incomplete treatment can result in increased transmission, development of drug resistance, and increased morbidity and mortality. Understanding the reasons for poor treatment outcomes may help improve TB control efforts.

OBJECTIVE

To identify those at highest risk and determine the reasons for poor treatment outcomes among TB cases (January 2009-June 2010).

DESIGN

Retrospective analysis.

SETTING/PARTICIPANTS

New York City TB patients eligible to complete treatment within 12 months.

MAIN OUTCOME MEASURES

Poisson regression models were used to identify risk factors associated with delayed completion and incomplete treatment compared with completion within 12 months of initiating treatment (timely completion). Reasons for delayed completion and incomplete treatment were summarized.

RESULTS

Of 1008 cases eligible to complete treatment within 12 months, 921 (91%) had timely completion, 48 (5%) had delayed completion, and 39 (4%) had incomplete treatment. Cases with delayed completion and incomplete treatment were more likely to have extrapulmonary TB (adjusted risk ratio = 3.31; 95% confidence interval, 1.79-6.14; and adjusted risk ratio = 3.34; 95% confidence interval, 1.73-6.44, respectively). Primary reasons for delayed completion were a physician's decision to extend treatment (35%) and interrupted treatment (31%), whereas those for incomplete treatment included lost to care (38%), moved (28%), and refusal to continue treatment (26%).

CONCLUSION

Overall, treatment completion in New York City was high. Patients with delayed completion and incomplete treatment had extrapulmonary disease in common. However, specific reasons suggest that delayed completion may be clinically motivated whereas incomplete treatment may result from social conditions.

Tuberculosis in pregnancy: current recommendations for screening and treatment in the USA

The main focus of this review is the management of active and latent tuberculosis in pregnancy in industrialized countries. The review is geared towards the healthcare professional taking care of the obstetric patient. The epidemiology of active and latent tuberculosis in the USA and recommendations for the screening of tuberculosis in pregnancy are considered. The history of treatment methodology and its relationship to the current treatment of active and latent tuberculosis in pregnancy is reviewed, and finally, a discussion of the best time to treat latent tuberculosis in a pregnant patient is undertaken, along with thoughts on future changes and advances in this field.

Improved outcomes found after implementing a systematic evaluation and program improvement process for tuberculosis

California's state and local tuberculosis (TB) programs collaborated to develop the Tuberculosis Indicators Project (TIP), a program evaluation and improvement process. In TIP, local and state staff review data, identify program gaps, implement plans to improve local TB program performance, and evaluate outcomes. After 10 years of project implementation, indicator performance changes and patient outcomes were measured. Eighty-seven percent of participating programs showed a performance increase in targeted indicators after three years compared with 57% of comparison groups. Statistically significant performance change was more common in the intervention local health departments (LHDs) than in comparison groups. The most notable performance changes were in the contact investigation and case management indicators. These results indicate that this systematic evaluation and program improvement project was associated with improved LHD TB control performance and may be useful to inform improvement projects in other public health programs.

Multidrug-resistant Tuberculosis

Multidrug-resistant tuberculosis (MDR-TB) threatens to become the dominant form of tuberculosis in many parts of the world because of decades of inappropriate treatment on a global scale. Infection with MDR-TB is associated with poor outcomes because of delays in treatment and the need for complex, toxic, and long medication regimens. Most cases are undetected because of technological and economic barriers to diagnosing tuberculosis and the availability of assays to test for drug resistance. Experience in treating MDR-TB is scarce. Tuberculosis was once curable, but could become a potentially untreatable infectious disease unless efforts are made to control it.

Epidemic Intelligence Service investigations of respiratory illness, 1946-2005

Infectious respiratory pathogens were the suspected cause of 480 outbreaks investigated by the Centers for Disease Control and Prevention's Epidemic Intelligence Service officers during 1946-2005. All epidemic-assistance investigation reports and associated articles from scientific journals were reviewed. Investigations identified 25 different infectious respiratory pathogens including, most frequently, tuberculosis, influenza, and legionellosis. Other bacterial-, viral-, and fungal-related pathogens also were identified. Epidemic-assistance investigations were notable for first identifying Legionnaires disease and Pontiac fever, hantavirus pulmonary syndrome, and new strains of human and avian influenza, as well as emerging challenges (e.g., multidrug-resistant tuberculosis and pneumococcus). The investigations provided clinical insights into such diseases as pulmonary anthrax and identified high risks of serious respiratory illnesses for persons infected with human immunodeficiency virus, other immunocompromised persons, and persons with diabetes. They identified settings placing persons at high risk of acquiring disease, including nursing homes, prisons, homeless shelters, and hospitals. Travel also placed persons at risk. Key environmental factors related to spread of diseases and occupational risks for brucellosis and psittacosis were identified. The outbreak investigations constitute a wealth of prevention experience and provide the basis for recommendations to mitigate outbreaks and reduce future risks.

Racial differences in tuberculosis infection in United States communities: the coronary artery risk development in young adults study

Previously reported associations between race/ethnicity and tuberculosis infection have lacked sufficient adjustment for socioeconomic factors. We analyzed race/ethnicity and self-reported tuberculosis infection data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a well-characterized cohort of 5115 black and white participants, and found that after adjusting for sociodemographic and clinical factors, black participants were more likely to report tuberculosis infection and/or disease (odds ratio, 2.0; 95% confidence interval, 1.5-2.9).

Factors associated with tuberculosis as an AIDS-defining disease in an immigration setting

Background

Immigration can affect the evolution of TB as an AIDS-defining disease (AIDS–TB).

Methods

The Barcelona AIDS register for 1994–2005 was analyzed, and the global characteristics of AIDS–TB and AIDS–non-TB cases were compared. The Mantel-Haenszel test was used in the trend analysis, and logistic regression was used in the multivariate analysis.

Results

Of the 3600 cases studied, 1130 had both AIDS and TB. A declining trend in AIDS–TB rates was observed in both sexes among both immigrants and native residents. The percentage of AIDS–TB was significantly higher among immigrants (P = 0.02). The number of cases among immigrants remained constant over the period of study, but decreased among native residents. The sociodemographic and immunological characteristics associated with TB were male sex, age younger than 36 years, inner city residence, a record of incarceration, greater than 200 CD4+ T-cells/mm³, injecting drug use, heterosexual sex, and immigration from Latin America, the Caribbean, or sub-Saharan Africa.

Conclusions

The incidence of TB as an AIDS-defining disease decreased in Barcelona during a recent 10-year period in both native and immigrant populations. However, immigrants remain a high-risk group for AIDS–TB and should be targeted for surveillance and control of both diseases.

Trends in tuberculosis mortality in the United States, 1990-2006: a population-based case-control study

OBJECTIVE

We assessed demographic and temporal trends of tuberculosis (TB)-related deaths in the United States and examined associated comorbidities listed on death certificates.

METHODS

We analyzed TB-related mortality from 1990 through 2006 by examining multiple-cause-of-death data from the National Center for Health Statistics. We assessed age-adjusted mortality rates, secular trends, associations with demographic variables, and comorbid conditions.

RESULTS

From 1990 through 2006, TB was reported as a cause of death among 53,505 people in the U.S. with a combined overall mean age-adjusted mortality rate of 1.16 per 100,000 person-years. The age-adjusted TB mortality rate declined from 2.22 per 100,000 person-years in 1990 to 0.47 per 100,000 person-years in 2006, demonstrating mean annual decline of about 10%. People aged 75 years and older; males; foreign-born people; and those of Hispanic, Asian, black, and Native American race/ethnicity had comparatively elevated TB-related mortality rates. The mortality rate in foreign-born people was more than two times higher than in U.S.-born people. About 89% of deaths among people of Asian race/ethnicity and nearly 50% among black people were foreign-born individuals. Human immunodeficiency virus and selected autoimmune diseases were more common in TB-related deaths.

CONCLUSIONS

TB mortality decreased substantially from 1990 through 2006, but remains an important cause of preventable mortality. The observed decrease was more pronounced among U.S.-born people than among foreign-born people. Disparities in TB-related mortality and the identification of important comorbid conditions can inform strategies targeting subpopulations at increased risk for fatal TB infection.

Prevalence of tuberculosis infection in the United States population: the national health and nutrition examination survey, 1999-2000

RATIONALE

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.

OBJECTIVES

To estimate the prevalence of LTBI in the U.S. population.

METHODS AND MEASUREMENTS

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.

MEASUREMENTS AND MAIN RESULTS

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.

CONCLUSIONS

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.

Enhanced killing of intracellular multidrug-resistant Mycobacterium tuberculosis by compounds that affect the activity of efflux pumps

Whereas human neutrophils are effective and efficient killers of bacteria, macrophages such as those derived from monocytes are almost devoid of killing activity. Nevertheless, monocytes can be transformed into effective killers of mycobacteria or staphylococci when exposed to clinical concentrations of a phenothiazine or to inhibitors of efflux pumps (reserpine and verapamil), or to ouabain, an inhibitor of K(+) transport. Because the rates of multidrug-resistant Mycobacterium tuberculosis (MDR-TB) continue to escalate globally, and because no new effective drug has been made available for almost 40 years, compounds that enhance the killing activity of monocytes against MDR-TB are obviously needed. This review covers the specific characteristics of MDR-TB, identifies a variety of agents that address these characteristics and therefore have potential for managing MDR-TB. Because the mechanism by which these agents enhance the killing of intracellular bacteria is important for the intelligent design of new anti-tubercular agents, the review correlates the mechanisms by which these agents manifest their effects. Lastly, a model is presented which describes the mechanisms by which distinct efflux pumps of the phagosome-lysosome complex are inhibited by agents that are known to inhibit K(+) flux. The model also predicts the existence of a K(+) activated exchange (pump) that is probably located in the membrane that delineates the lysosome. This putative pump, which is immune to inhibitors of K+ flux, is identified as being the cause for the acidification of the lysosome thereby activating its hydrolytic enzymes. Because the non-killer macrophage can be transformed into an effective killer by a variety of compounds that inhibit K(+) transport, perhaps it would be wise to develop drugs that enhance the killing activity of these cells inasmuch as this approach would not be subject to any resistance, as is the eventual case for conventional antibiotics.

Tuberculosis in pregnancy - case studies and a review of Australia's screening process

Few changes have occurred in the management of tuberculosis over the past two decades and many of the recent developments are in the area of diagnostics. The application of these to the pregnant population is not yet established. Two cases recently managed at the Royal Women's Hospital, Melbourne highlight the need for clinicians managing pregnant women to rethink this condition and, with changes in migration and epidemiology, reconsider our screening practice.

Costs and cost-effectiveness of adolescent compliance with treatment for latent tuberculosis infection: results from a randomized trial

PURPOSE

Assess the costs and cost-effectiveness of an incentive-based tuberculosis (TB) program designed to promote adolescents' compliance with treatment for latent TB infection (LTBI).

METHODS

Randomized controlled trial. Adolescents between the ages of 11 and 19 years who were referred to one of two participating clinics after being screened for TB and receiving a positive diagnosis indicating LTBI (n = 794) were assigned to one of four groups: usual care, peer counseling, contingency contracting, and combined peer counseling/contingency contracting. Primary outcome variables were completion of isoniazid preventive therapy (IPT), total treatment costs, and lifetime TB-related costs per quality-adjusted life year (QALY) in each of the four study groups (three treatment, one control). Cost effectiveness was evaluated using a five-stage Markov model and a Monte Carlo simulation with 10,000 trials.

RESULTS

Average costs were 199 dollars for usual care (UC), 277 dollars for peer counseling (PC), 326 dollars for contingency contracting (CC), and 341 dollars for PC + CC combined. The differences among these groups were all significant at the p = .001 level. Only the PC + CC group improved the rate of IPT completion (83.8%) relative to usual care (75.9%) (p = .051), with an overall incremental CE ratio of 209 dollars per QALY relative to usual care.

CONCLUSION

Incentives combined with peer counseling are a cost-effective strategy for helping adolescents to complete care when combined with peer counseling.

Low prevalence of TB on long-haul aircraft

BACKGROUND

Proximity to an infectious TB case is a potential risk in any close contact setting. However, the rapid growth in airline transportation is in stark contrast to the lack of evidence about the prevalence of TB among airline passengers and crew. The rate of ventilation in the aircraft cabin is far superior to other forms of transportation and reduces the risk of airborne transmission.

METHODS

This study calculated TB disease rates among passengers and cabin crew during the 5-year study period. The principal study outcome was the number of notifications of confirmed TB disease cases and potential under-reporting was estimated. The airline rates were compared with the WHO definition of low incidence--"a TB notification rate below 10 per 100,000 population and declining".

FINDINGS

The TB case notification rate was 0.05 per 100,000 long-haul passengers. The risk increased seven-fold on flights from TB-endemic areas in Africa or India. The aircraft cabin remains classified as a low TB incidence environment on all routes within a wide margin of error. Low occupational prevalence was observed in the cabin crew workforce.

INTERPRETATION

Airline passengers are considered to be a select group with low TB rates. This study provides important evidence that confirms the aircraft as a low-risk setting for transmission of TB and emphasizes the presence of environmental-control measures that reduce the risk as far as possible.

Tuberculosis cases in Wisconsin: documentation of treatment improvement and completion of treatment, 2000-2002

OBJECTIVE

In 2000, the Wisconsin Strategic Plan for the Elimination of Tuberculosis (TB) sets goals of 90 percent treatment completion and 95 percent documentation of treatment improvement for all reported cases of TB. This study measures the success in achieving these goals.

METHODS

Data were abstracted from charts of all 249 reported TB cases during 2000-2002. Treatment completion was considered for patients indicated for completion in 12 months or less. Documentation of treatment improvement included therapy adherence, sputum culture conversion, and chest radiograph improvement for pulmonary cases, and therapy adherence and clinical improvement for extrapulmonary cases.

RESULTS

Treatment completion was measured in 204 of 249 TB cases; 87.1 percent completed treatment in 12 months or less. There was a significant difference in completion by site of disease, 89.9 percent for pulmonary cases and 66.1 percent for extrapulmonary cases (P < .01). Documentation of treatment improvement was 61.2 percent among pulmonary cases and 83.6 percent among extrapulmonary cases (P < .01). During the study period, there was a significant decrease in documentation rates for patients with pulmonary TB (P < .01).

CONCLUSIONS

The goal of 90 percent treatment completion was nearly accomplished but the goal of 95 percent documentation of treatment improvement was not achieved. Barriers to TB treatment in Wisconsin need to be identified. Case management of TB is necessary for control and prevention of TB.

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.

American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: Controlling Tuberculosis in the United States

During 1993-2003, incidence of tuberculosis (TB) in the United States decreased 44% and is now occurring at a historic low level (14,874 cases in 2003). The Advisory Council for the Elimination of Tuberculosis has called for a renewed commitment to eliminating TB in the United States, and the Institute of Medicine has published a detailed plan for achieving that goal. In this statement, the American Thoracic Society (ATS), Centers for Disease Control and Prevention (CDC), and the Infectious Diseases Society of America (IDSA) propose recommendations to improve the control and prevention of TB in the United States and to progress toward its elimination. This statement is one in a series issued periodically by the sponsoring organizations to guide the diagnosis, treatment, control, and prevention of TB. This statement supersedes the previous statement by ATS and CDC, which was also supported by IDSA and the American Academy of Pediatrics (AAP). This statement was drafted, after an evidence-based review of the subject, by a panel of representatives of the three sponsoring organizations. AAP, the National Tuberculosis Controllers Association, and the Canadian Thoracic Society were also represented on the panel. This statement integrates recent scientific advances with current epidemiologic data, other recent guidelines from this series, and other sources into a coherent and practical approach to the control of TB in the United States. Although drafted to apply to TB-control activities in the United States, this statement might be of use in other countries in which persons with TB generally have access to medical and public health services and resources necessary to make a precise diagnosis of the disease; achieve curative medical treatment; and otherwise provide substantial science-based protection of the population against TB. This statement is aimed at all persons who advocate, plan, and work at controlling and preventing TB in the United States, including persons who formulate public health policy and make decisions about allocation of resources for disease control and health maintenance and directors and staff members of state, county, and local public health agencies throughout the United States charged with control of TB. The audience also includes the full range of medical practitioners, organizations, and institutions involved in the health care of persons in the United States who are at risk for TB.

Epidemiology of Tuberculosis in the United States

After decades of decline, an unprecedented resurgence in tuberculosis occurred in the late 1980s and early 1990s. Deterioration of tuberculosis program infrastructure, the HIV/AIDS epidemic, drug-resistant tuberculosis, and tuberculosis among foreign-born persons contributed to the resurgence. Since then, tuberculosis case numbers have declined, but the decline in 2003 was the smallest since the resurgence. Key challenges remain, and efforts must focus on identifying and targeting interventions for high-risk populations, active involvement in the global effort against tuberculosis, developing new tools, and maintaining adequate resources.

Drive-by readings: a creative strategy for tuberculosis control among immigrants

OBJECTIVES

We explored an innovative strategy for targeted testing and disease management among immigrant communities at risk for tuberculosis.

METHODS

Taxi drivers were recruited at an airport holding lot to undergo tuberculin skin testing (Mantoux). After receiving their test results in a location convenient for them, drivers with positive results were referred for evaluation and treatment. We conducted baseline and follow-up assessments.

RESULTS

Of 123 drivers who participated, two thirds (82) were at high risk for tuberculosis. Seventy-eight (63%) of the 123 returned for test readings; 62% of these drivers had positive test results. All drivers with positive results received a complete physician evaluation, but 64% of those evaluated were not treated for latent TB infection. Of the untreated drivers, 37.5% were at high risk. Systemic and physician barriers (e.g., lack of knowledge, erroneous beliefs regarding vaccines) affected adherence to evaluation and treatment.

CONCLUSIONS

Targeted testing and treatment are important to the control of tuberculosis. The results of this study highlight the need for an aggressive physician educational campaign to identify latent tuberculosis infection and to tailor service delivery to meet the unique needs of foreign-born communities.

Investigation of healthcare-associated transmission ofMycobacterium tuberculosis among patients with malignancies at three hospitals and at a residential facility

BACKGROUND

Immunocompromised patients have an increased risk of experiencing progression of latent Mycobacterium tuberculosis infection (LTBI) to active tuberculosis (TB) disease. In January 2002, 2 patients with leukemia (Patients 1 and 2) developed pulmonary TB after recent exposure at 3 hospitals (Hospital A, Hospital B, and Hospital C) and at a residential facility for patients with cancer. Neither was known to have LTBI. Within 1 year, 3 other patients with malignancy and TB disease had been identified at these facilities, prompting an investigation of healthcare facility-associated transmission of M. tuberculosis.

METHODS

The authors performed genotypic analysis of the five available M. tuberculosis isolates from patients with malignancies at these facilities, reviewed medical records, interviewed individuals who had identical M. tuberculosis genotypic patterns, and performed tuberculin skin testing (TST) and case finding for possible exposed contacts.

RESULTS

Only Patients 1 and 2 had identical genotypic patterns. Neither patient had baseline TST results available. Patient 1 had clinical evidence of infectiousness 3 months before the diagnosis of TB was ascertained. Among employee contacts of Patient 1, TST conversions occurred in 1 of 59 (2%), 2 of 34 (6%), 2 of 32 (6%), and 0 of 8 who were tested at Hospitals A, B, and C and at the residential facility, respectively. Among the others who were exposed to Patient 1, 1 of 31 (3%), 1 of 30 (3%), 0 of 40 (0%), and 12 of 136 (9%) who were tested had positive TSTs at Hospitals A, B, and C and at the residential facility, respectively.

CONCLUSIONS

Delayed TB diagnosis in 2 patients with leukemia resulted in the transmission of M. tuberculosis to 19 patients and staff at 3 hospitals and a residential facility. Baseline TB screening and earlier clinical recognition of active disease could reduce healthcare facility-associated transmission of M. tuberculosis among patients with malignancy.

Increasing Latino adolescents' adherence to treatment for latent tuberculosis infection: a controlled trial

OBJECTIVES

We sought to determine the efficacy of coaching Latino adolescents with latent tuberculosis infection to adhere to isoniazid treatment.

METHODS

Participants (n = 286) were randomly assigned to adherence coaching, attention control, or usual care groups. Adherence was measured via interviews and validated with urine assays.

RESULTS

Coaching resulted in significant increases in adherence compared with attention and usual care groups. Bicultural adolescents were more likely to be adherent than those most or least acculturated. Age and risk behavior were negatively related to adherence.

CONCLUSIONS

Coaching can increase Latino adolescents' adherence to treatment for latent tuberculosis infection and should contribute to tuberculosis control for adolescents at high risk of contracting the disease.

Tuberculosis trends in the United States, 1992-2001

At the time of the last world congress on tuberculosis (TB) in 1992, the United States (US) was experiencing an unprecedented resurgence of TB. Since the mid-1950s, TB incidence had been steadily decreasing, until 1984 when this longstanding trend was reversed. The annual national total of TB cases continued to increase and peaked in 1992 with 26,673 TB cases reported (10.5 TB cases per 100,000 population). A prompt and formidable response from local, state, and federal governments helped curb the resurgence. From 1992 to 2001, total TB incidence decreased by 40% to an all-time low of 15,989 TB cases reported in 2001. The decrease in TB cases from 2000 to 2001, however, was the smallest (2.4%) since the resurgence a decade ago. This report will briefly review the trends and factors associated with the TB resurgence in the late 1980s and early 1990s, and provide a detailed description of specific TB trends in the US between 1992 and 2001.

Tuberculosis

Tuberculosis is an infectious disease caused by bacteria in the Mycobacterium tuberculosis complex. Of these, the most common species to infect humans is M. tuberculosis. The TB bacillus is an extremely successful human pathogen, infecting two billion persons worldwide; an estimated 2 to 3 million people die from tuberculosis each year. In the United States, TB rates decreased steadily at the rate of 5% per year from 1953 until 1985 when the trend reversed, with the number of TB cases peaking in 1992. Outbreaks of multidrug-resistant TB (MDR TB) were reported, and these cases were documented to be transmitted in nosocomial and congregate settings, including hospitals and prisons. AIDS patients infected with M. tb developed disease rapidly, and case-fatality rates of >80% were noted in those infected with multidrug-resistant M. tb. Intensive intervention, at enormous cost, caused the number of TB cases to decline. This article discusses factors that led to the increase in TB cases, their subsequent decline, and measures needed in the future if TB is to be eliminated in the United States.

TB-HIV Registry Matching in Missouri, 1987-1999

Mycobacterium tuberculosis (MTB) is an important problem for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients. This study investigated whether all cases of MTB reported to the HIV/AIDS Registry (HARS) in Missouri were also reported to the Tuberculosis Information Management System (TIMS) to determine the sensitivity of TIMS and the predictive value of HARS. We found 262 total MTB cases registered in HARS. Of these, 145 (55%) were included in the TIMS. Thirty-eight of the remaining 117 were caused by mycobacteria other than TB leaving 79 for investigation. Chart review of the 79 revealed 16 cases of MTB. Sensitivities and predictive values were calculated first including unknown/unreported group as being MTB-positive and the second including this group as being MTB-negative. Sensitivities for TIMS were 83 and 90%, respectively, and predictive values for HARS were 68 and 63%, respectively. The fact that there were at least 16 unreported cases of MTB has significant public health implications for TB control in Missouri. Public health nursing could work with HARS surveillance staff to help improve the accuracy of case finding and reporting. By whatever means necessary, communications between the TB and HIV programs within the Missouri Department of Health should be enhanced.

Tuberculosis infection among young adults enlisting in the United States Navy

BACKGROUND

Tuberculosis (TB) is a re-emerging infectious disease threat worldwide. To protect the health and readiness of US military personnel, policies exist to screen for and treat latent TB infection at the time of service entrance.

RESULTS

of this screening programme have not been recently described.

METHODS

Multivariate regression techniques were used to evaluate demographic and medical data associated with TB infection among all young adults entering US Navy enlisted service between 1 October 1997 and 30 September 1998. Results A total of 44,128 adults (ages 17-35, 81% male) were screened for TB during this 12-month period. The prevalence of latent TB infection was 3.5%. Place of birth was very strongly associated with TB infection, with foreign-born recruits eight times more likely to have a reactive tuberculin skin test or history of infection. Those who reported their race as 'Asian/Pacific Island' had 3.8 times the odds of having evidence of TB infection compared with 'Caucasian' recruits, even after adjusting for place of birth.

CONCLUSIONS

The prevalence of TB infection among Navy recruits was last reported as 2.5% nearly 10 years ago. The apparent increase to 3.5% in this large cohort is likely due to a concurrent increase in the number of foreign-born recruits, and it serves to underscore the importance of comprehensive screening and treatment of latent TB infections in this population.

A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users

Substance abuse is associated with high risk for tuberculosis (TB) and poor adherence to medication regimens. This study compared completion rates for isoniazid (INH) preventive therapy for injection drug users (IDUs) randomly assigned to methadone treatment combined with directly observed preventive treatment (DOPT) versus those assigned to routine TB clinic referral without methadone treatment. One hundred and eleven opioid-dependent patients with latent TB were assigned to one of three 6-month treatment conditions: standard methadone treatment including substance abuse counseling combined with daily INH DOPT (n=37); minimal methadone treatment without counseling, also combined with daily INH DOPT (n=35); or routine care referral to TB clinic for monthly INH supplies without DOPT and without methadone treatment (n=39). INH completion rates were 77.1% for minimal methadone and 59.5% for standard methadone, as compared with only 13.5% for routine care (P<0.0001). Mean duration of INH treatment retention was 5.7, 5.0 and 1.6 months, respectively (P<0.0001). TB incidence at 4-year follow-up was 0 of 54 subjects who completed preventive therapy versus 2 of 57 who failed to complete. One of these two had been assigned to routine care, and the other to minimal methadone. In conclusion, INH retention time and completion rates were significantly improved by methadone treatment combined with observed INH, whether or not substance abuse counseling was provided. The results of this study indicate that methadone treatment offers clear public health benefits when it is used to deliver preventive medical services.

Trends in diseases reported on U.S. death certificates that mentioned HIV infection, 1987-1999

To examine trends in the proportions of deaths with various diseases among deaths with HIV infection, we analyzed multiple-cause death certificate data for all deaths in the United States from 1987 through 1999. Disease proportions were adjusted to control for demographic changes. Deaths reported with HIV infection increased from 15,331 in 1987 to 47,977 in 1995 and then decreased to 16,061 in 1999. Among these reported deaths, new trends during the period from 1995 through 1999 included decreases in the proportions with cytomegalovirus disease (from 6.8% to 2.8%), wasting/cachexia (9.8% to 6.8%), and dementia/encephalopathy (6.3% to 3.9%) and increases in the proportions with septicemia/septic shock (from 9.2% to 13.4%) and diseases of the liver (4.9% to 11.6%), kidney (6.3% to 9.1%), and heart (4.2% to 6.9%). Continuations of pre-1995 trends included decreases in the proportions with nontuberculous mycobacteriosis (7.1% to 3.1%) and Kaposi sarcoma (5.3% to 2.6%). Advances in antiretroviral therapy probably caused deaths due to HIV infection to decrease after 1995. Consequently, the proportions of deaths with HIV that were caused by other conditions increased. Improved prophylaxis or treatment of some opportunistic infections could also have reduced the proportions of deaths with those diseases, whereas antiviral drug toxicity could have contributed to increases in the proportions with noninfectious organ diseases.

Supervised preventive therapy for latent tuberculosis infection in illegal immigrants in Italy

In a multicenter, prospective, randomized, open-label study of isoniazid-preventive therapy (IPT) for latent tuberculosis infection, illegal immigrants from countries where tuberculosis is highly endemic were enrolled at two clinical sites in Northern Italy. Of 208 eligible subjects, 82 received supervised IPT at a dose of 900 mg twice weekly for 6 mo (Regimen A), 73 received unsupervised IPT 900 mg twice weekly for 6 mo (Regimen B), and 53 received unsupervised IPT 300 mg daily for 6 mo (Regimen C). Supervised IPT was delivered at either one tuberculosis clinic or one migrant clinic. The probability of completing a 26-wk regimen was 7, 26, and 41% in Regimens A, B, and C, respectively (p < 0.005, Log- rank test calculated using Kaplan-Meier plots). The mean time to dropout was 3. 8, 6, and 6.2 wk in Regimens A, B, and C, respectively (p = 0.003 for regimen A versus either Regimens B or C). Treatment was stopped in five subjects (2.4%) because of adverse events. The rate of completion of preventive therapy for latent tuberculosis infection among illegal immigrants was low. Supervised, clinic-based administration of IPT significantly reduced adherence. Alternative strategies to implement preventive therapy in illegal immigrants are clearly required.

The occupational hazards of emergency physicians

Emergency physicians are exposed to a variety of occupational hazards. Among these are infectious diseases, such the human immunodeficiency virus, hepatitis B and C viruses, and tuberculosis. Hepatitis G virus is transmissible but may not be a cause of illness. The likelihood of being exposed to these agents appears to be higher in the ED than other medical settings but estimates of the prevalence of these diseases in the ED vary, depending on the patient population served. Estimates of risk for contracting these infections are reviewed. Measures to prevent these exposures can reduce risk, but compliance is low, particularly for those involving changes in the behavior of emergency physicians (such as not recapping needles). Latex allergy is a hazard of health care workers. Its prevalence is reported to be quite high, but these findings are difficult to interpret in the absence of a universally accepted definition of the condition. Its prevalence in emergency physicians is not known. Other noninfectious hazards include workplace violence and exposure to nitrous oxide. The health effects of rotating shift work may put emergency physicians at increased risk of coronary artery disease and impaired reproductive health. Emotional stress is another hazard of emergency physicians, and may lead to burnout.

Isolation and stigma: the experience of patients with active tuberculosis

Tuberculosis treatment is an important component of community health programs. Understanding how different groups of patients experience tuberculosis can influence the completion of drug therapy. This study explored how a sample of patients with active tuberculosis experienced their illness. Guided by questions from Kleinman's (1980) explanatory model, 28 semistructured interviews were conducted in public health clinics. The analysis suggested that patients understood tuberculosis through the medical model and perceived themselves as disease vectors. After their diagnosis became known, almost all patients felt that their family and friends avoided or shunned them. Patients responded to these attitudes by isolating themselves and becoming secretive about their illness. An awareness of patients' experiences can help nurses to understand behaviors that may be labeled as noncompliant and design interventions that address these behaviors. Modifying community attitudes and behaviors poses a longer term challenge to the elimination of tuberculosis.

Recent Developments in Epidemiology, Treatment, and Diagnosis of Tuberculosis

The resurgence in cases of active tuberculosis in North America in the past decade has prompted increases in funding for tuberculosis treatment, research, and education. As a result, the number of new cases of tuberculosis has declined and cases occur in smaller pockets of well-characterized populations, such as communities of foreign-born persons and socioeconomically disadvantaged groups. New strategies for the treatment of both active and latent tuberculosis may soon include the newly licensed, long-acting rifamycin, rifapentine, but further studies are needed to determine optimal dosing regimens for this agent. Experts in tuberculosis and HIV infection have made headway in defining the optimal therapy for each current therapeutic option, and recently published guidelines are a useful document for clinicians. Rifabutin-based regimens are one approach toward achieving the optimal treatment of both diseases simultaneously. Finally, newly licensed molecular diagnostic tests for direct use on clinical specimens are intriguing, but their clinical utility remains to be defined.