Diabetes Among People With Tuberculosis, HIV Infection, Viral Hepatitis B and C, and STDs in New York City, 2006-2010.

Matching infectious disease surveillance data has become a routine activity for many health departments. With the increasing focus on chronic disease, it is also useful to explore opportunities to match infectious and chronic disease surveillance data. To understand the burden of diabetes in New York City (NYC), adults with select infectious diseases (tuberculosis, HIV infection, hepatitis B, hepatitis C, chlamydial infection, gonorrhea, and syphilis) reported between 2006 and 2010 were matched with hemoglobin A1c results reported in the same period. Persons were considered to have diabetes with 2 or more hemoglobin A1c test results of 6.5% or higher. The analysis was restricted to persons who were 18 years or older at the time of first report, either A1c or infectious disease. Overall age-adjusted diabetes prevalence was 8.1%, and diabetes prevalence was associated with increasing age; among NYC residents, prevalence ranged from 0.6% among 18- to 29-year-olds to 22.4% among those 65 years and older. This association was also observed in each infectious disease. Diabetes prevalence was significantly higher among persons with tuberculosis born in Mexico, Jamaica, Honduras, Guyana, Bangladesh, Dominican Republic, the Philippines, and Haiti compared with those born in the United States after adjusting for age and sex. Hepatitis C virus-infected women had higher age-adjusted prevalence of diabetes compared with the NYC population as a whole. Recognizing associations between diabetes and infectious diseases can assist early diagnosis and management of these conditions. Matching chronic disease and infectious disease surveillance data has important implications for local health departments and large health system practices, including increasing opportunities for integrated work both internal to systems and with the local community. Large health systems may consider opportunities for increased collaboration across infectious and chronic disease programs facilitated through data linkages of routinely collected surveillance data.

Treatment for Tuberculosis Infection With 3 Months of Isoniazid and Rifapentine in New York City Health Department Clinics.

BACKGROUND: Completion of treatment for tuberculosis infection (TBI) with 9 months of self-administered daily isoniazid (9H) has historically been low (<50%) among New York City (NYC) Health Department tuberculosis clinic patients. Treatment of TBI with 3 months of once-weekly isoniazid and rifapentine (3HP) administered under directly observed therapy (DOT) might increase treatment acceptance and completion. METHODS: The study population included patients diagnosed with TBI at 2 NYC Health Department tuberculosis clinics from January 2013 through November 2013. Treatment acceptance and completion with 3HP were compared with historical estimates. Treatment outcomes, side effects, and reasons for refusing 3HP were described. RESULTS: Among 631 patients eligible for TBI treatment, 503 (80%) were offered 3HP; 302 (60%) accepted, 92 (18%) chose other treatment, and 109 (22%) refused treatment. The most common reason for refusing 3HP was the clinic-based DOT requirement. Forty (13%) patients treated with 3HP experienced side effects--9 were restarted on 3HP, 18 switched treatment regimens, and 13 discontinued. Although treatment acceptance did not differ from historical estimates (78% vs 79%, P = .75), treatment completion increased significantly (65% vs 34%, P < .01). CONCLUSIONS: Implementation of 3HP in 2 NYC Health Department tuberculosis clinics increased TBI treatment completion by 31 percentage points compared with historical estimates. More flexible DOT options may improve acceptance of 3HP. Wider use of 3HP may substantially improve TBI treatment completion in NYC and advance progress toward tuberculosis elimination.

Disparities in tuberculosis burden among South Asians living in New York City, 2001-2010.

OBJECTIVES: We have described the characteristics of South Asian-born tuberculosis (TB) patients living in New York City (NYC) and compared them with other foreign-born patients to explore possible explanations for the disproportionate burden of TB in the South Asian population. METHODS: We used data on demographic and clinical characteristics for TB patients identified by the NYC Bureau of Tuberculosis Control from 2001 to 2010 to compare South Asian patients with other Asian and other foreign-born patients. We reviewed genotyping and cluster investigation data for South Asian patients to assess the extent of genotype clustering and the possibility of local transmission in this population. RESULTS: The observed disparity in TB rates and burden among South Asians was not explained by social or clinical characteristics. A large amount of TB strain diversity was observed among South Asians, and they were less likely than other foreign-born patients to be infected with the same TB strain as another NYC patient. CONCLUSIONS: The majority of South Asians were likely infected with TB abroad. South Asians represent a meaningful foreign-born subpopulation for targeted detection and treatment of TB infection in NYC.

Active Monitoring of Travelers for Ebola Virus Disease-New York City, October 25, 2014-December 29, 2015.

The CDC recommended active monitoring of travelers potentially exposed to Ebola virus during the 2014 West African Ebola virus disease outbreak, which involved daily contact between travelers and health authorities to ascertain the presence of fever or symptoms for 21 days after the travelers' last potential Ebola virus exposure. From October 25, 2014, to December 29, 2015, the New York City Department of Health and Mental Hygiene (DOHMH) monitored 5,359 persons for Ebola virus disease, corresponding to 5,793 active monitoring events. Most active monitoring events were in travelers classified as low (but not zero) risk (n = 5,778; 99%). There were no gaps in contact with DOHMH of ≥2 days during 95% of active monitoring events. Instances of not making any contact with travelers decreased after CDC began distributing mobile telephones at the airport. Ebola virus disease-like symptoms or a temperature ≥100.0°F were reported in 122 (2%) active monitoring events. In the final month of active monitoring, an optional health insurance enrollment referral was offered for interested travelers, through which 8 travelers are known to have received coverage. Because it is possible that active monitoring will be used again for an infectious threat, the experience we describe might help to inform future such efforts.

Current and future trends in tuberculosis incidence in New York City: a dynamic modelling analysis.

BACKGROUND: After steady decline since the 1990s, tuberculosis (TB) incidence in New York City (NYC) and the United States (US) has flattened. The reasons for this trend and the implications for the future trajectory of TB in the US remain unclear. METHODS: We developed a compartmental model of TB in NYC, parameterized with detailed epidemiological data. We ran the model under five alternative scenarios representing different explanations for recent declines in TB incidence. We evaluated each scenario's relative likelihood by comparing its output to available data. We used the most likely scenarios to explore drivers of TB incidence and predict future trajectories of the TB epidemic in NYC. FINDINGS: Demographic changes and declining TB transmission alone were insufficient to explain recent trends in NYC TB incidence. Only scenarios that assumed contemporary changes in TB dynamics among the foreign-born - a declining rate of reactivation or a decrease in imported subclinical TB - could accurately describe the trajectory of TB incidence since 2007. In those scenarios, the projected decline in TB incidence from 2015 to 2025 varied from minimal [2·0%/year (95% credible interval 0·4-3·5%)] to similar to 2005 to 2009 trends [4·4%/year (2·5-6·4%)]. The primary factor differentiating optimistic from pessimistic projections was the degree to which improvements in TB dynamics among the foreign-born continued into the coming decade. INTERPRETATION: Further progress against TB in NYC requires additional focus on the foreign-born population. Absent additional intervention in this group, TB incidence may not decline further.

Bridging the gap between evidence and policy for infectious diseases: How models can aid public health decision-making.

The dominant approach to decision-making in public health policy for infectious diseases relies heavily on expert opinion, which often applies empirical evidence to policy questions in a manner that is neither systematic nor transparent. Although systematic reviews are frequently commissioned to inform specific components of policy (such as efficacy), the same process is rarely applied to the full decision-making process. Mathematical models provide a mechanism through which empirical evidence can be methodically and transparently integrated to address such questions. However, such models are often considered difficult to interpret. In addition, models provide estimates that need to be iteratively re-evaluated as new data or considerations arise. Using the case study of a novel diagnostic for tuberculosis, a framework for improved collaboration between public health decision-makers and mathematical modellers that could lead to more transparent and evidence-driven policy decisions for infectious diseases in the future is proposed. The framework proposes that policymakers should establish long-term collaborations with modellers to address key questions, and that modellers should strive to provide clear explanations of the uncertainty of model structure and outputs. Doing so will improve the applicability of models and clarify their limitations when used to inform real-world public health policy decisions.

Estimated Prevalence of Tuberculosis Infection Among a New York City Clinic Population Using Interferon-gamma Release Assays.

BACKGROUND: Elimination of tuberculosis (TB) in the United States requires treating not only persons with active disease but also those infected with TB. Achieving this goal requires understanding local TB infection prevalence and identifying subgroups at increased risk for infection and disease. METHODS: The study population included all patients tested with an interferon-gamma release assay (IGRA) test at New York City (NYC) public TB clinics from October 1, 2006 to December 31, 2011. Patients who were not a case or contact at testing (general clinic patients) and who had a positive QuantiFERON-Gold In-Tube (QFT-GIT) test result were compared with those with indeterminate or negative results to identify characteristics associated with positive results. New York City TB surveillance data were used to identify clinic patients later diagnosed with active TB disease. RESULTS: A total of 69 273 IGRA tests were conducted. Among 20 066 patients tested with QFT-GIT, 16% tested positive, 83% tested negative, and <1% were indeterminate. Of 18 481 general clinic patients, 14% had a positive QFT-GIT result. Nine percent of United States-born patients compared with 19% of foreign-born patients had a positive result. Increasing age and birth in a high-incidence country were associated with a higher likelihood of having a positive result. One patient with a negative QFT-GIT result was identified as a TB case 2 years later. CONCLUSIONS: Using QFT-GIT data, the background prevalence of TB infection in NYC was estimated. Patient characteristics associated with a positive QFT-GIT result were consistent with known TB risk factors. Results suggest that IGRAs are reliable tests for TB infection.