Spatial clusters of latent tuberculous infection, Connecticut, 2010-2014

SETTING

In the United States, tuberculosis (TB) control is increasingly focusing on the identification of persons with latent tuberculous infection (LTBI).

OBJECTIVE

To characterize the local epidemiology of LTBI in Connecticut, USA.

METHODS

We used spatial analyses 1) to identify census tract-level clusters of reported LTBI and TB disease in Connecticut, 2) to compare persons and populations in clusters with those not in clusters, and 3) to compare persons with LTBI to those with TB disease.

RESULTS

Significant census tract-level spatial clusters of LTBI and TB disease were identified. Compared with persons with LTBI in non-clustered census tracts, those in clustered census tracts were more likely to be foreign-born and less likely to be of white non-Hispanic ethnicity. Populations in census tract clusters of high LTBI prevalence had greater crowding, persons living in poverty, and persons lacking health care insurance than populations not in clustered census tracts. Persons with LTBI were less likely than those with TB disease to be of Asian ethnicity, and persons with LTBI were more likely than those with TB disease to reside in a clustered census tract.

CONCLUSIONS

Characterizing fine-scale populations at risk for LTBI supports effective and culturally accessible screening and treatment programs.

Tuberculosis mortality: death from a curable disease, Connecticut, 2007-2009

SETTING

Health Department Tuberculosis (TB) Control program, Connecticut, United States

OBJECTIVE

1) To assess TB-relatedness of deaths and missed opportunities among Connecticut patients who died with TB, and 2) to identify factors associated with death.

DESIGN

The study population consisted of all persons diagnosed with TB and reported to the Connecticut TB Control Program during 2007-2009. TB Control Program records, medical records, autopsy reports and death certificates of decedents were reviewed. A tool was used to categorize TB-relatedness of deaths and identify missed opportunities in diagnosis and medical treatment among TB-related deaths. Surveillance data regarding TB survivors were used for comparison to identify factors associated with death.

RESULTS

During 2007-2009, 20/300 (7%) persons with TB died; 14 (70%) decedents had at least one medical comorbidity and 17 (85%) deaths were TB-related. Among patients who had a TB-related death, 16 (94%) had ≥1 missed opportunity identified. Excess alcohol use (risk ratio [RR] 4.4, 95% confidence interval [CI] 1.8-11.0) and age > 64 years (RR 5.7, 95%CI 2.5-13.1) were associated with death.

CONCLUSIONS

The majority of deaths among Connecticut TB patients were TB-related. Missed opportunities were common. Excess alcohol use and older age might indicate a need for monitoring to prevent death.

Mycobacterium tuberculosis testing practices in hospital, commercial and state laboratories in the New England states

SETTING

The mycobacterial laboratory is assuming an increasingly important role in tuberculosis (TB) control in the United States today.

OBJECTIVE

To assess mycobacterial laboratory capacity and practices in the New England states, USA.

DESIGN

We surveyed 143 hospital and commercial laboratories and five of the six state public health laboratories in New England that offer testing services for Mycobacterium tuberculosis. The survey captured information on types of services offered and volume of testing, use of state laboratories for testing, and promptness of reporting results to TB control programs.

RESULTS

State laboratories perform the majority of testing services, particularly for more specialized tests. All state laboratories surveyed perform species identification of acid-fast isolates, culture and first-line drug susceptibility testing. Less than 20% of hospital and commercial laboratories offer these services, and 78.6% of hospitals and commercial laboratories refer specimens to state laboratories for culture.

CONCLUSION

Surveys of M. tuberculosis testing capacities in a region can help decision makers ensure maintenance of essential services. Hospital and commercial laboratories with lower testing volume might increase efficiency by referring more specimens to state laboratories. State health departments might consider organizing regional laboratory service networks to monitor the provision of services, improve efficiency and oversee quality improvement initiatives.

Missed opportunities to prevent tuberculosis in foreign-born persons, Connecticut, 2005-2008

SETTING

Factors that influence testing for latent tuberculosis infection (LTBI) among foreign-born persons in Connecticut are not well understood.

OBJECTIVE

To identify predictors for LTBI testing and challenges related to accessing health care among the foreign-born population in Connecticut.

DESIGN

Foreign-born Connecticut residents with confirmed or suspected tuberculosis (TB) disease during June 2005-December 2008 were interviewed regarding health care access and immigration status. Predictors for self-reported testing for LTBI after US entry were determined.

RESULTS

Of 161 foreign-born persons interviewed, 48% experienced TB disease within 5 years after arrival. One third (51/156) reported having undergone post-arrival testing for LTBI. Although those with established health care providers were more likely to have reported testing (aOR 4.49, 95%CI 1.48-13.62), only 43% of such persons were tested. Undocumented persons, the majority of whom lacked a provider (53%), were less likely than documented persons to have reported testing (aOR 0.20, 95%CI 0.06-0.67). Hispanic permanent residents (immigrants and refugees) and visitors (persons admitted temporarily) were more likely than non-Hispanics in the respective groups to have reported testing (OR 5.25, 95%CI 1.51-18.31 and OR 7.08, 95%CI 1.30-38.44, respectively).

CONCLUSIONS

The self-reported rate of testing for LTBI among foreign-born persons in Connecticut with confirmed or suspected TB was low and differed significantly by ethnicity and immigration status. Strategies are needed to improve health care access for foreign-born persons and expand testing for LTBI, especially among non-Hispanic and undocumented populations.

Outbreak of tuberculosis in a correctional facility: consequences of missed opportunities

In May 2006, the Department of Public Health investigated a tuberculosis (TB) outbreak at a correctional facility after two recently discharged inmates were diagnosed with TB. Based on epidemiological and genotyping data, one infectious patient was determined to be the source of infection for the other. Despite prolonged symptoms and abnormal chest radiographs, the index patient was not diagnosed while incarcerated. Among the estimated 910 exposed inmates tested, 53 (5.8%) had newly positive tuberculin skin tests (TSTs). Ten (2.1%) of 485 corrections staff tested converted their TSTs. This investigation highlights the consequences of missed TB diagnoses in prisons.

Tuberculosis in a low-incidence US area: local consequences of global disruptions

SETTING

Tuberculosis (TB) in the United States is increasingly concentrated among foreign-born persons. The northeastern states, including Connecticut, are among those with the highest proportion of foreign-born patients.

METHODS

This retrospective analysis of surveillance data from Connecticut for 1996 through 2005 compared TB case rates and risk factors among US-born and foreign-born persons.

RESULTS

Between 1996 and 2005, TB cases declined by 8.7% in foreign-born persons and by 53.6% in US-born persons. The median annual incidence rate for foreign-born persons was 19.7 cases per 100000 population compared with 1.5 for US-born persons. Refugees had the highest TB rate (116 cases/100000) in the first year of their arrival. Resistance to any drug was more common among foreign-born persons (15.0%) than among US-born persons (9.3%). Although the proportion of multidrug-resistant TB was highest among foreign-born persons with prior TB (5.6%), most cases occurred in those without prior TB. Risk factors for TB, such as human immunodeficiency virus infection, drug use, incarceration and homelessness, were more common among US-born TB patients than among foreign-born patients.

CONCLUSIONS

Although TB case rates for US-born persons in Connecticut have declined dramatically, foreign-born persons, including refugees fleeing conflict, contribute disproportionately to the TB burden. Future efforts to eliminate TB must be directed toward immigrants and refugees.

An antibody inhibitor of the LMO2-protein complex blocks its normal and tumorigenic functions

The LIM-domain protein LMO2 is a T-cell oncogenic protein first recognized by gene activation through chromosomal translocations, but it is also responsible for leukaemias arising as secondary, adverse effects in an X-SCID gene therapy trial. There are no specific reagents currently available to analyse the LMO2 multiprotein complex or to combat LMO2-dependent leukaemias. Accordingly, we have isolated an anti-LMO2 single chain Fv antibody fragment to determine if intracellular interference with LMO2-protein complexes can avert LMO2-dependent functions in normal and cancer settings. The anti-LMO2 single chain Fv, obtained using Intracellular Antibody Capture (IAC) technology, is specific for LMO2 among the LIM-only protein family and binds LMO2 through the third and fourth LIM fingers. Using vector-mediated expression of anti-LMO2 scFv, we show inhibition of Lmo2-dependent erythropoiesis but not endothelial development. We also demonstrate inhibition of Lmo2-dependent leukaemia in a mouse T-cell tumourigenesis transplantation assay with retroviral-mediated expression of anti-LMO2 scFv. Our studies establish that interference with the LMO2 multiprotein complex inhibits both normal and tumourigenic roles. The antibody fragment is a tool for dissecting LMO2 function in haematopoiesis and leukaemia and is a lead for development of therapeutics against LMO2-dependent T-ALL.

MLL gene fusions in human leukaemias: in vivo modelling to recapitulate these primary tumourigenic events

Recurrent reciprocal chromosomal translocations are frequently found in leukaemias and sarcomas as initiating events in these cancers. Mouse models of chromosomal translocations are not only important for the elucidation of the mechanism of these factors underlying the disease but are also important pre-clinical models for assessing new drug combinations, developing new rational therapeutic strategies based on new drugs and testing novel macromolecular drugs. We describe three technologies for creating chromosomal translocation mimics in mice, applied specifically to understand how the MLL-fusions contribute to leukaemia. An important finding of this work is that the lineage of the tumours can be controlled by the MLL-protein fusion. The translocation mimic methods can be applied to any human reciprocal chromosomal translocation.

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.

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.

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.

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.

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.

Attitudes, practices, and infection risks of hemophilia treatment center nurses who teach infection control for the home

OBJECTIVE

To examine the practices toward infection control training and to assess the attitudes about, and risks for, exposures to blood among hemophilia treatment center (HTC) nurses who teach home infusion therapy (HIT).

DESIGN AND POPULATION

Written and telephone interview surveys of the 153 nurses who teach HIT at federally funded HTCs.

MAIN OUTCOME MEASURES

Hemophilia treatment center nurses' teaching practices and infection control messages taught, and frequency of exposures to blood.

RESULTS

The response rate to the written nurses' survey was 60% and to the telephone interview 88%. Nurses taught patients a median of three HIT sessions totaling 4 hours of instruction. Reevaluation of patients' HIT practices took place every 6 months by 22% and every 12 months by 59% of nurses. Nurses frequently reported teaching proper use of a sharps disposal container (99%) and gloves (93%), but less often reported teaching patients to wash hands after infusions (26%) and to report needlestick injuries to HTCs (11%). The respondents identified several barriers to effective infection control as it is practiced in the home by patients. Although at least 30% of HTC nurses recalled having had percutaneous exposure to blood, they considered their risk for hepatitis B infection low but greater than for infection with the human immunodeficiency virus (HIV).

CONCLUSIONS

While some important infection control messages are stressed during HIT teaching, others may be underemphasized. Failure to instruct patients about all infection control precautions may be related to nurse educators' perception of low to moderate personal risk for hepatitis B and HIV infection. Patients receiving HIT, and those who assist them, need to be fully aware of, and to have reinforced periodically, universal infection control strategies in the home.

Infection control practices in the home: a survey of households of HIV-infected persons with hemophilia

OBJECTIVE

To assess infection control practices and risk for human immunodeficiency virus (HIV) transmission in households where home infusion for hemophilia is used.

DESIGN

Cross-sectional prospective survey from 1992 through 1994.

SETTING

Hemophilia treatment centers.

PARTICIPANTS

Human immunodeficiency virus (HIV)-infected persons with hemophilia who receive home infusions of clotting factor concentrate and their household members.

MAIN OUTCOME MEASURES

Frequency of specific infection control practices in the home and the risk of HIV transmission to household members.

RESULTS

We surveyed 235 persons from 75 families (79 HIV-infected persons with hemophilia and 156 household members) about infection control practices in the home. Forty-eight percent of household members surveyed helped with the infusion process. Of 74 members who assisted with infusion, 13 (18%) had sustained a needlestick injury, 11 of whom were injured during the past year. One hundred fifty household members tested for antibody to HIV were antibody negative. These household members had a total of 903 person-years of contact after HIV was diagnosed in the index case. Household members' adherence to recommended infection control measures was highest for washing hands after cleaning up infusion equipment and waste, and for using sharps disposal containers. Adherence was lowest for wearing gloves when helping with infusions and proper disposal of bloody waste from the infusion.

CONCLUSIONS

No HIV transmission was found among persons living with HIV-infected persons with hemophilia, although there was a high rate of needlestick injuries during home infusion. Because persons who assisted with infusions often did not wear gloves and many households did not dispose of bloody waste properly, hemophilia treatment center personnel should emphasize these areas when training for home infusion. Adherence to appropriate infection control practices should help to keep the risk of HIV transmission in households extremely low.

CD4+ T lymphocytopenia in children: lack of evidence for a new acquired immunodeficiency syndrome agent

We investigated children with CD4+ T lymphocytopenia to determine the magnitude and public health impact of this condition and to investigate possible causes. Children < 13 years old with CD4+ T lymphocyte counts below age-adjusted cutoffs (age < 24 months, 1000 cells/microliters; age > or = 24 months, 300 cells/microliters) or < 20% on 2 separate measurements were considered to have CD4+ T lymphocytopenia. We solicited information from clinicians and public health departments on these children and their families and collected blood for immunologic and retroviral testing. We identified 18 children (10 boys; 14 African-Americans) with a median age of 10 months at their first low CD4+ T lymphocyte measurement. Three children had had opportunistic infections and two still had low CD4+ T lymphocyte counts 5 and 7 years later. Of the 11 children born to human immunodeficiency virus (HIV)-infected mothers 7 were asymptomatic. Specimens from all children were negative for HIV and human T lymphotropic virus antibodies and negative for HIV by culture or polymerase chain reaction. Among 12 families interviewed no other HIV-seronegative family or household member had illnesses suggestive of immunosuppression. We conclude that negative retroviral tests and lack of illness among their family members do not support the hypothesis that a retrovirus causes CD4+ T lymphocytopenia among these children.(ABSTRACT TRUNCATED AT 250 WORDS)

Encephalopathy in children with perinatally acquired human immunodeficiency virus infection. Pediatric Spectrum of Disease Clinical Consortium

OBJECTIVE

To define the incidence, characteristics, and survival of children with perinatally acquired human immunodeficiency virus (HIV) infection and encephalopathy.

DESIGN

Cross-sectional and longitudinal data collected from 1811 HIV-infected children in a multicenter active surveillance study.

SETTING

Health departments and medical centers in six areas of the United States.

RESULTS

HIV encephalopathy was diagnosed in 178 (23%) of 766 children with perinatally acquired immunodeficiency syndrome (AIDS). The median age at diagnosis of encephalopathy was 19 months. Among infected children, the estimated risk of having HIV encephalopathy by age 12 months was 4.0% (95% confidence interval, 2.6% to 6.0%). Children with HIV encephalopathy had more hospitalizations (median, 4) than children with other AIDS-defining conditions (median, 2; p = 0.002) and lower CD4+ T-lymphocyte counts in the first year of life (median, 444 cells/mm3). Estimated median survival after diagnosis was 22 months, similar to the 20 months for children with Pneumocystis carinii pneumonia.

CONCLUSION

HIV encephalopathy in children with perinatally acquired AIDS is a common condition and is associated with severe morbidity evidenced by frequent hospitalizations, severe immunodeficiency, and short survival.

Fluctuating dermatoglyphic asymmetry: genetic and prenatal influences

Genetic and environmental prenatal factors influencing the fluctuating asymmetry of the a-b interdigital ridge count are examined. From the results obtained we can conclude that fluctuating asymmetry of the a-b interdigital ridge count is poorly influenced by genetic factors. We suggest that fluctuating asymmetry of dermatoglyphics provides a good measure of developmental stability in humans, especially for males. The results also indicate that random environmental factors, acting before the 19th week of embryonic development, could be related to the differential timing of maturation of the sexes.

An outbreak of Escherichia coli O157:H7 colitis associated with consumption of precooked meat patties

An outbreak of Escherichia coli O157:H7 hemorrhagic colitis at a Minnesota junior high school in October 1988 comprised 32 cases among 1562 students (attack rate, 2.0%). Four children were hospitalized; none developed hemolytic-uremic syndrome. Case children were more likely than controls to have eaten heat-processed meat patties (odds ratio, 6.2; 95% confidence interval, 2.0-20.1; P less than .001) in the school cafeteria on a specific day. The minimum estimated attack rate among students who ate these patties was 8%. The patties should have been sufficiently cooked by the manufacturer to destroy enteric pathogens before they were frozen and distributed. E. coli were cultured from frozen patties that were manufactured at the same plant on the same dates as the implicated patties, but serotype O157:H7 was not isolated. Heat-processed meat patties may serve as vehicles for E. coli O157:H7 infection, and currently there are no federal or state regulatory standards to ensure the safety of these products.