High Rate of Treatment Completion in Program Settings With 12-Dose Weekly Isoniazid and Rifapentine for Latent Mycobacterium tuberculosis Infection

Background

Randomized controlled trials have demonstrated that the newest latent tuberculosis (LTBI) regimen, 12 weekly doses of directly observed isoniazid and rifapentine (3HP), is as efficacious as 9 months of isoniazid, with a greater completion rate (82% vs 69%); however, 3HP has not been assessed in routine healthcare settings.

Methods

Observational cohort of LTBI patients receiving 3HP through 16 US programs was used to assess treatment completion, adverse drug reactions, and factors associated with treatment discontinuation.

Results

Of 3288 patients eligible to complete 3HP, 2867 (87.2%) completed treatment. Children aged 2-17 years had the highest completion rate (94.5% [155/164]). Patients reporting homelessness had a completion rate of 81.2% (147/181). In univariable analyses, discontinuation was lowest among children (relative risk [RR], 0.44 [95% confidence interval {CI}, .23-.85]; P = .014), and highest in persons aged ≥65 years (RR, 1.72 [95% CI, 1.25-2.35]; P < .001). In multivariable analyses, discontinuation was lowest among contacts of patients with tuberculosis (TB) disease (adjusted RR [ARR], 0.68 [95% CI, .52-.89]; P = .005) and students (ARR, 0.45 [95% CI, .21-.98]; P = .044), and highest with incarceration (ARR, 1.43 [95% CI, 1.08-1.89]; P = .013) and homelessness (ARR, 1.72 [95% CI, 1.25-2.39]; P = .001). Adverse drug reactions were reported by 1174 (35.7%) patients, of whom 891 (76.0%) completed treatment.

Conclusions

Completion of 3HP in routine healthcare settings was greater overall than rates reported from clinical trials, and greater than historically observed using other regimens among reportedly nonadherent populations. Widespread use of 3HP for LTBI treatment could accelerate elimination of TB disease in the United States.

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 in Jails and Prisons: United States, 2002-2013

OBJECTIVES

To describe cases and estimate the annual incidence of tuberculosis in correctional facilities.

METHODS

We analyzed 2002 to 2013 National Tuberculosis Surveillance System case reports to characterize individuals who were employed or incarcerated in correctional facilities at time they were diagnosed with tuberculosis. Incidence was estimated with Bureau of Justice Statistics denominators.

RESULTS

Among 299 correctional employees with tuberculosis, 171 (57%) were US-born and 82 (27%) were female. Among 5579 persons incarcerated at the time of their tuberculosis diagnosis, 2520 (45%) were US-born and 495 (9%) were female. Median estimated annual tuberculosis incidence rates were 29 cases per 100 000 local jail inmates, 8 per 100 000 state prisoners, and 25 per 100 000 federal prisoners. The foreign-born proportion of incarcerated men 18 to 64 years old increased steadily from 33% in 2002 to 56% in 2013. Between 2009 and 2013, tuberculosis screenings were reported as leading to 10% of diagnoses among correctional employees, 47% among female inmates, and 42% among male inmates.

CONCLUSIONS

Systematic screening and treatment of tuberculosis infection and disease among correctional employees and incarcerated individuals remain essential to tuberculosis prevention and control.

Civil Surgeon Tuberculosis Evaluations for Foreign-Born Persons Seeking Permanent U.S. Residence

Foreign-born persons in the United States seeking to adjust their status to permanent resident must undergo screening for tuberculosis (TB) disease. Screening is performed by civil surgeons (CS) following technical instructions by the Centers for Disease Control and Prevention. From 2011 to 2012, 1,369 practicing CS in California, Texas, and New England were surveyed to investigate adherence to the instructions. A descriptive analysis was conducted on 907 (66%) respondents. Of 907 respondents, 739 (83%) had read the instructions and 565 (63%) understood that a chest radiograph is required for status adjustors with TB symptoms; however, only 326 (36%) knew that a chest radiograph is required for immunosuppressed status adjustors. When suspecting TB disease, 105 (12%) would neither report nor refer status adjustors to the health department; 91 (10%) would neither start treatment nor refer for TB infection. Most CS followed aspects of the technical instructions; however, educational opportunities are warranted to ensure positive patient outcomes.

Assessment of postarrival tuberculosis examinations among immigrants and refugees screened overseas

BACKGROUND

Immigrants and refugees screened overseas and found to have Mycobacterium tuberculosis infection (TB arrivers) are either treated fortuberculosis (TB) or, if disease is not found these arrivers are given a TB classification of latent TB infection (LTBI) and are referred for reexamination after arriving in the United States.

METHODS

A retrospective cohort analysis was performed of TB arrivers in Connecticut to determine the proportion of TB arrivers documentedwith their postarrival domestic medical examination and to determine the proportion of TB arriverswho started and completed LTBI treatment.

RESULTS

Of 184TB arrivers, 109 (59%) were evaluated for TB after arrival and four (4%) were diagnosed withTB. Of 105 personswith LTBI,49 (47%) started treatment, and of those 15(30%) completedtreatment.

CONCLUSION

The majority of TB cases in Connecticut are among foreign-born individuals. Improving TB control overseas is a crucial step in the reduction of TB in the United States. Improvements are still needed to ensure timely, postarrival medical examinations that ensure treatment for high-risk persons with LTBI to reduce TB in Connecticut's foreign-born populations.

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.

HIV status among patients with tuberculosis and HIV testing practices by Connecticut health care providers

Knowing the human immunodeficiency virus (HIV) status of persons infected with Mycobacterium tuberculosis is important for individual treatment and preventing transmission. This evaluation analyzed surveillance data and surveyed health care providers who care for patients with HIV and tuberculosis (TB) to understand the factors contributing to suboptimal levels of Connecticut patients with TB having a known HIV status. During 2008 to 2010, 208 (76.2%) of 273 patients had a known HIV status; 12 (5.8%) were HIV-positive. Patients who were more likely to have a known HIV status were younger (40.5 vs 54.6 years, P < .001) or received care in a TB clinic (risk ratio, 1.26; 95% confidence interval, 1.12-1.42). Among 77 providers, 48 (62.3%) completed the survey, 42 (87.5%) reported routinely offering HIV testing to patients with TB, and 26 (54.2%) reported routinely offering HIV testing to patients with latent TB infection (LTBI). We conclude that interventions for improving HIV testing should focus on non-TB clinic providers and patients with LTBI.

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.

Practices and policies of providers testing school-aged children for tuberculosis, Connecticut, 2008

This study identified current practices and policies related to testing school children for latent tuberculosis infection (LTBI) in Connecticut. A cross-sectional survey was mailed to a random sample of community pediatricians and family practitioners in Connecticut who provide health care services to children aged 4-18 years. The main outcome measure was adherence to national guidelines for tuberculosis (TB) testing of school-aged children. The response rate was 66.3% (345 of 520), 258 of whom provided services to children. Responses showed that 60% (152 of 252) of replying providers read the American Academy of Pediatrics (AAP) published guidelines, and 85% routinely assess children for TB risk before skin testing although only a minority (22%) use a written questionnaire. Of 153 responding providers, 130 (85%) report that schools require formal TB risk assessments at mandated school physical examinations or at school entry. Results also showed providers who read AAP-published guidelines and who are trained in the United States are more likely to follow the national guidelines for TB testing of children. The majority of health care providers reported following AAP-published guidelines for screening school-aged children for LTBI and TB disease; however, an important number of providers still do not follow recommended guidelines. Public health officials should make efforts to increase provider awareness of, and adherence to, guidelines. School districts also should take steps to ensure the appropriate level of testing of children for TB disease and LTBI.

Tuberculosis control: lessons for outbreak preparedness in correctional facilities

Correctional facilities typically house large numbers of persons in close and crowded conditions for long periods. Clusters of communicable diseases ranging from simple viral upper respiratory infections to more serious threats, such as tuberculosis (TB), infections with methicillin-resistant Staphylococcus aureus, and influenza, often emerge in these surroundings. The recent H1N1 influenza pandemic highlights the importance of outbreak prevention and containment preparedness, particularly in congregate settings. In this commentary, the authors propose that the TB control model can provide valuable lessons for infection control practitioners to prepare for, identify, investigate, and control outbreaks of communicable diseases to prevent transmission in correctional facilities and to the surrounding community.

Two tuberculosis genotyping clusters, one preventable outbreak

In 2006, eight community tuberculosis (TB) cases and a ninth incarceration-related case were identified during an outbreak investigation, which included genotyping of all Mycobacterium tuberculosis isolates. In 1996, the source patient had pulmonary TB but completed only two weeks of treatment. From February 2005 to May 2006, the source patient lived in four different locations while contagious. The outbreak cases had matching isolate spoligotypes; however, the mycobacterial interspersed repetitive unit (MIRU) patterns from isolates from two secondary cases differed by one tandem repeat at a single MIRU locus. The source patient's isolates showed a mixed mycobacterial population with both MIRU patterns. Traditional and molecular epidemiologic methods linked eight secondary TB cases to a single source patient whose incomplete initial treatment, incarceration, delayed diagnosis, and housing instability resulted in extensive transmission. Adequate treatment of the source patient's initial TB or early diagnosis of recurrent TB could have prevented this outbreak.

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.

Unintended consequences: mandatory tuberculin skin testing and severe isoniazid hepatotoxicity

After mandatory school-enrollment tuberculin skin testing, a 4-year-old girl who was at low risk for Mycobacterium tuberculosis infection had severe isoniazid hepatotoxicity that was managed with a liver transplant. Although severe isoniazid hepatotoxicity is very uncommon in children, this case emphasizes the need to limit skin testing to persons who have a risk factor for infection and to educate parents on how to monitor for adverse effects during treatment.

Underuse of effective measures to prevent and manage pediatric tuberculosis in the United States

OBJECTIVE

To characterize problems with prevention and management of pediatric tuberculosis (TB) and latent TB infection (LTBI).

DESIGN

A multisite, cross-sectional study using data from medical records and public health logs to categorize and define use of routine prevention practices in managing pediatric TB and LTBI.

SETTING

Four areas of the United States.

PARTICIPANTS

Children younger than 5 years diagnosed with TB from January 1, 2002, through December 31, 2004, and children with LTBI reported during a continuous 12-month period in 2003 to 2004. Main Exposure Mycobacterium tuberculosis.

MAIN OUTCOME MEASURES

Underuse or nonuse of standard medical and public health interventions.

RESULTS

Almost 40% of children had a TB risk factor related to their country of birth, parental origin, or travel to a country with a high incidence of TB. Children having LTBI were less likely than those having TB to complete treatment (53.7% vs 88.6%, respectively). Almost half (46.3%) of the children with TB came to medical attention late in their course when they already had symptoms. Among 63 adult source patients, 19 (30.2%) previously had LTBI but were not treated, and none of the 40 foreign-born source patients were known to have been evaluated for TB before entry into the United States.

CONCLUSIONS

Prevention efforts are unsatisfactory to prevent TB in children. Effective interventions such as treatment of LTBI and TB evaluation of adult immigrants remain less than optimal.

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.

Tuberculosis behind bars in Israel: policy making within a dynamic situation

BACKGROUND

The crowded environment of correctional facilities may enhance infectious diseases transmission, such as tuberculosis.

OBJECTIVES

To define the tuberculosis burden in prisons in Israel, a country of low TB incidence (7.9 cases:100,000 population in 2004), in which about 13,000 inmates are being incarcerated annually, and to recommend policy adaptations for TB control.

METHODS

All prison clinic lung records from 1998 through 2004 in Israel were reviewed to identify pulmonary TB patients. Additionally, we reviewed TB epidemiological investigation files from one northern prison (years 2002 through 2005) to evaluate possible transmission of the disease.

RESULTS

During the study period 23 Israeli inmates had pulmonary TB (25 cases/100,000 prisoners), which was 3.5 times higher than in the general population. Of those, 18 (78%) were born in the Former Soviet Union and immigrated to Israel after 1990. Four pulmonary TB cases in the evaluated prison were reported, and 22% (149/670) of all inmates and staff were referred for treatment of latent TB infection.

CONCLUSIONS

To prevent future TB cases, we recommend new prevention measures, including a symptom questionnaire for all new inmates and selective tuberculin skin testing for inmates infected with human immunodeficiency virus/AIDS, those who inject drugs, and those who emigrated from the former Soviet Union after 1990. New staff should be screened by the two-step tuberculin skin test and annual symptoms questionnaire thereafter. Incarceration may be used as a point of detection for TB and a window of opportunity for treatment in this hard-to-reach population.

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.

Impact of Hurricane Katrina on newborn screening in Louisiana

OBJECTIVE

The Louisiana Office of Public Health and the Centers for Disease Control and Prevention assessed the extent to which newborn screening was disrupted from August 15 to September 21, 2005, the immediate period before and after Hurricane Katrina.

METHODS

A list of hospitals with labor and delivery services was obtained from the Louisiana Hospital Association. A survey sent to hospitals on October 17, 2005, asked about the number of live births during the assessment period, disruption in hospital services, the number of specimens sent to alternative laboratories, and the number of children without screening results.

RESULTS

Among 64 Louisiana hospitals with labor and delivery units, 6 remained closed at the time of the survey. Of the 58 open hospitals, 53 (91.4%) completed the questionnaire. Twenty-one (36.2%) of 58 hospitals experienced disruption of newborn screening services. Respondents from 31 (58.5%) of the 53 open hospitals acknowledged receiving the advisory from the Office of Public Health regarding resumption of newborn screening laboratory services. Hospitals stated that of 5958 specimens submitted, reports had not been received for 1207 (20.3%) newborns. The Office of Public Health laboratory reviewed the names of 2828 newborns received from hospitals and determined that no specimen was received within 14 days of collection for 631 (22.3%). Thirty percent of the specimens received from infants who were born between August 15 and September 21 were rejected as a result of having been received >14 days after collection. Ten children had confirmed positive screening results during the assessment period; all were located, and treatment was initiated.

CONCLUSIONS

Collaboration between the Office of Public Health and the Centers for Disease Control and Prevention was essential to increase awareness of changes in laboratory procedures after the hurricane and to help identify infants who might be in need of screening or rescreening.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

SETTING

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

STUDY OBJECTIVES

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

DESIGN

Observational cohort study.

SETTING

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

PATIENTS

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

INTERVENTIONS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

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

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

Public health and correctional collaboration in tuberculosis control

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of tuberculosis screening and management practices of large jail systems

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of tuberculosis screening and management practices of large jail systems

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mouse Models of Human Chromosomal Translocations and Approaches to Cancer Therapy

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Tuberculosis in children and adolescents: California, 1985 to 1995

OBJECTIVES

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

DESIGN

Retrospective population-based study.

SETTING

California, 1984 through 1993.

POPULATION

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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