[Impact of COVID-19 on mortality in Peru using triangulation of multiple data sourcesImpacto da COVID-19 na mortalidade no Peru por meio da triangulação de várias fontes de dados]. / Impacto de la COVID-19 en la mortalidad en Perú mediante la triangulación de múltiples fuentes de datos.

An analytic cross-sectional study was conducted to quantify the impact of COVID-19 on mortality in Peru. Total excess mortality due to natural and external causes was calculated. The direct and indirect impact of COVID-19 was estimated at two points: when COVID-19 deaths were confirmed by a laboratory test and when they were confirmed by broader criteria (reclassified deaths). This comparison was made in general and by sex, age, and geographical location. The sensitivity of laboratory testing and of death certificates as criteria for confirmation of a COVID-19 death was calculated using reclassified deaths as the gold standard.From epidemiological week (EW) 10 of 2020 to EW 23 of 2021, 349 756 deaths occurred, for an excess of 183 237 deaths, mainly due to natural causes. A total of 100 955 deaths corresponded to deaths confirmed by laboratory tests; however, the reclassification criterion brought this figure to 188 708. Laboratory tests had 53.3% sensitivity; this was lower at the onset of the pandemic (10.6%) and during the first wave (37.8%). The sensitivity of death certificates was higher than laboratory tests (41.7% vs 23.9%) only during the months when little testing was available. These data showed that the impact of COVID-19 on mortality in Peru was mainly direct. Also, in periods with limited access to laboratory testing, death certificates were a useful source for determining deaths directly caused by COVID-19.

Um estudo transversal analítico foi realizado com o objetivo de quantificar o impacto da COVID-19 na mortalidade no Peru. Foi calculada a sobremortalidade total, por causas naturais e externas. O impacto direto e indireto da COVID-19 foi estimado em dois momentos: quando as mortes por COVID-19 foram confirmadas por teste laboratorial e quando foram confirmadas por critérios mais amplos (óbitos reclassificados). Essa comparação foi feita na população geral, por sexo, idade e geografia. Calculou-se a sensibilidade dos critérios laboratoriais e dos atestados de óbito para a confirmação de morte por COVID-19, utilizando os óbitos reclassificados como padrão-ouro.Da semana epidemiológica 10 de 2020 até a 23 de 2021, ocorreram 349.756 óbitos, o que configura um excesso de 183.237 óbitos, principalmente por causas naturais. Considerando os óbitos confirmados por exames laboratoriais, foram encontrados 100.955 óbitos; no entanto, com os critérios de reclassificação, esse número subiu para 188.708. Os exames laboratoriais tiveram uma sensibilidade de 53,3%, sendo menor no início da pandemia (10,6%) e durante a primeira onda (37,8%). A sensibilidade do atestado de óbito foi maior que a do exame laboratorial (41,7% vs 23,9%) apenas nos meses de baixa disponibilidade de exames. Esses dados evidenciaram que, no Peru, o impacto da COVID-19 na mortalidade foi principalmente direto. Além disso, em períodos com acesso limitado a exames laboratoriais, as declarações de óbito foram uma fonte de informação útil para determinar as mortes causadas diretamente pela COVID-19.

Impacto de la COVID-19 en la mortalidad en Perú mediante la triangulación de múltiples fuentes de datos / Impact of COVID-19 on mortality in Peru using triangulation of multiple data sources / Impacto da COVID-19 na mortalidade no Peru por meio da triangulação de várias fontes de dados

RESUMEN Se realizó un estudio transversal analítico, con el objetivo de cuantificar el impacto de la COVID-19 en la mortalidad del Perú. Se calculó el exceso de mortalidad total, por causas naturales y externas. El impacto directo e indirecto de la COVID-19 fue estimado en dos momentos: cuando las muertes por COVID-19 eran confirmadas mediante una prueba de laboratorio y cuando eran confirmadas por criterios más amplios (muertes reclasificadas). Esta comparación se hizo en general, por sexo, edad y geografía. Se calculó la sensibilidad de los criterios de laboratorio y certificado de defunción para la confirmación de una muerte por COVID-19 utilizando las muertes reclasificadas como estándar de oro. Desde la semana epidemiológica 10 del 2020 hasta la 23 del 2021 ocurrieron 349 756 muertes, determinando un exceso de 183 237 muertes, principalmente por causas naturales. Considerando aquellas muertes confirmadas por pruebas de laboratorio se encontró 100 955 muertes; sin embargo, con los criterios de la reclasificación subieron a 188 708. Las pruebas de laboratorio tuvieron una sensibilidad del 53,3%, siendo menor al inicio de la pandemia (10.6%) y durante la primera ola (37,8%). La sensibilidad del certificado de defunción fue mayor que la prueba de laboratorio (41,7% vs 23,9%) solo durante los meses de baja disponibilidad de pruebas. Estos datos evidenciaron que en Perú el impacto de la COVID-19 en la mortalidad fue principalmente directo. Asimismo, en períodos con acceso limitado de pruebas de laboratorio, los certificados de defunción fueron una fuente de información útil para determinar las muertes causadas directamente por la COVID-19.

ABSTRACT An analytic cross-sectional study was conducted to quantify the impact of COVID-19 on mortality in Peru. Total excess mortality due to natural and external causes was calculated. The direct and indirect impact of COVID-19 was estimated at two points: when COVID-19 deaths were confirmed by a laboratory test and when they were confirmed by broader criteria (reclassified deaths). This comparison was made in general and by sex, age, and geographical location. The sensitivity of laboratory testing and of death certificates as criteria for confirmation of a COVID-19 death was calculated using reclassified deaths as the gold standard. From epidemiological week (EW) 10 of 2020 to EW 23 of 2021, 349 756 deaths occurred, for an excess of 183 237 deaths, mainly due to natural causes. A total of 100 955 deaths corresponded to deaths confirmed by laboratory tests; however, the reclassification criterion brought this figure to 188 708. Laboratory tests had 53.3% sensitivity; this was lower at the onset of the pandemic (10.6%) and during the first wave (37.8%). The sensitivity of death certificates was higher than laboratory tests (41.7% vs 23.9%) only during the months when little testing was available. These data showed that the impact of COVID-19 on mortality in Peru was mainly direct. Also, in periods with limited access to laboratory testing, death certificates were a useful source for determining deaths directly caused by COVID-19.

RESUMO Um estudo transversal analítico foi realizado com o objetivo de quantificar o impacto da COVID-19 na mortalidade no Peru. Foi calculada a sobremortalidade total, por causas naturais e externas. O impacto direto e indireto da COVID-19 foi estimado em dois momentos: quando as mortes por COVID-19 foram confirmadas por teste laboratorial e quando foram confirmadas por critérios mais amplos (óbitos reclassificados). Essa comparação foi feita na população geral, por sexo, idade e geografia. Calculou-se a sensibilidade dos critérios laboratoriais e dos atestados de óbito para a confirmação de morte por COVID-19, utilizando os óbitos reclassificados como padrão-ouro. Da semana epidemiológica 10 de 2020 até a 23 de 2021, ocorreram 349.756 óbitos, o que configura um excesso de 183.237 óbitos, principalmente por causas naturais. Considerando os óbitos confirmados por exames laboratoriais, foram encontrados 100.955 óbitos; no entanto, com os critérios de reclassificação, esse número subiu para 188.708. Os exames laboratoriais tiveram uma sensibilidade de 53,3%, sendo menor no início da pandemia (10,6%) e durante a primeira onda (37,8%). A sensibilidade do atestado de óbito foi maior que a do exame laboratorial (41,7% vs 23,9%) apenas nos meses de baixa disponibilidade de exames. Esses dados evidenciaram que, no Peru, o impacto da COVID-19 na mortalidade foi principalmente direto. Além disso, em períodos com acesso limitado a exames laboratoriais, as declarações de óbito foram uma fonte de informação útil para determinar as mortes causadas diretamente pela COVID-19.

Neighborhood contributions to psychological distress among Latino New York City adults.

OBJECTIVE: Neighborhood-level factors such as ethnic densities and social cohesion have been negatively associated with psychological distress among Latino Americans. Yet, existing evidence is based on either specific neighborhood factors or particular Latino subgroups. The objective of the study was to assess difference in psychological distress between each of four Latino subgroups (Puerto Ricans, Dominicans, Mexicans, other Latinos) and non-Latino white adults in New York City, and quantify total neighborhood-level influence on these differences. DESIGN: We used the combined Community Health Survey data from 2009, 2010, and 2012 surveys. We estimated the odds ratios (ORs) for self-reported non-specific psychological distress (Kessler-6 questions scale ≥ 13) by race/ethnicity using logistic regression models. We further adjusted these estimates for both observed and unobserved neighborhood-level confounding using the conditional pseudolikelihood method for complex survey data. RESULTS: Puerto Ricans were more likely to be psychologically distressed (OR = 1.58, 95% CI = 1.18, 2.12) compared with non-Latino whites, whereas the opposite was seen in other Latino subgroups. Accounting for full neighborhood-level confounding increased the disparity for Puerto Ricans (OR = 1.79, 95% CI = 1.26-2.54). For the other subgroups, lower odds of psychological distress were no longer observed or attenuated after accounting for neighborhood-level confounding. Overall neighborhood-level factors were associated with lower psychological distress at greater extent among all Latinos subgroups versus non-Latino whites in New York City. CONCLUSION: Despite substantial variations of psychological distress across Latino subgroups, the study shows evidence that neighborhood-level factors might play a protective role in all Latino subgroups.

Parental Age and Autism Spectrum Disorders Among New York City Children 0-36 Months of Age.

We examined trends in autism spectrum disorders (ASD) and the association of ASD with parental age among young New York City (NYC) children. Children born in NYC to resident mothers from 1994-2001 were identified through vital statistics records (N = 927,003). Records were linked to data from NYC Early Intervention (EI) Program through 2004. The independent parental age-specific odds of having an ASD before 36 months of age were estimated using multiple logistic regression controlling for risk factors. The increase in ASD attributable to changes in parental age at birth was examined. Births to mothers and fathers 35 years or older increased 14.9 and 11.5 %, respectively, between 1994 and 2001. ASD prevalence in EI increased significantly from 1 in 3,300 children born in 1994 to 1 in 233 children born in 2001. Children born to mothers ages 25-29, 30-34 and 35 or older had significantly greater odds of being diagnosed with ASD than children of mothers younger than 25 years (OR 1.5, 1.6, and 1.9, respectively). Children born to fathers ages 35 or older (OR 1.4) had greater odds of ASD than children of fathers younger than 25. The change in parental age accounted for only 2.7 % of the increase in ASD prevalence. Older paternal age and maternal age were independently associated with increased risk of ASD. However, while parental age at birth increased between the 1994 and 2001 birth cohorts in NYC, it did not explain the increase in number of ASD cases.

Illnesses and deaths among persons attending an electronic dance-music festival - New York City, 2013.

Outdoor electronic dance-music festivals (EDMFs) are typically summer events where attendees can dance for hours in hot temperatures. EDMFs have received increased media attention because of their growing popularity and reports of illness among attendees associated with recreational drug use. MDMA (3,4-methylenedioxymethamphetamine) is one of the drugs often used at EDMFs. MDMA causes euphoria and mental stimulation but also can cause serious adverse effects, including hyperthermia, seizures, hyponatremia, rhabdomyolysis, and multiorgan failure. In this report, MDMA and other synthetic drugs commonly used at dance festivals are referred to as "synthetic club drugs." On September 1, 2013, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) received reports of two deaths of attendees at an EDMF (festival A) held August 31-September 1 in NYC. DOHMH conducted an investigation to identify and characterize adverse events resulting in emergency department (ED) visits among festival A attendees and to determine what drugs were associated with these adverse events. The investigation identified 22 cases of adverse events; nine cases were severe, including two deaths. Twenty-one (95%) of the 22 patients had used drugs or alcohol. Of 17 patients with toxicology testing, MDMA and other compounds were identified, most frequently methylone, in 11 patients. Public health messages and strategies regarding adverse health events might reduce illnesses and deaths at EDMFs.

Incidence of self-reported diabetes in New York City, 2002, 2004, and 2008.

INTRODUCTION: Prevalence and incidence of diabetes among adults are increasing in the United States. The purpose of this study was to estimate the incidence of self-reported diabetes in New York City, examine factors associated with diabetes incidence, and estimate changes in the incidence over time. METHODS: We used data from the New York City Community Health Survey in 2002, 2004, and 2008 to estimate the age-adjusted incidence of self-reported diabetes among 24,384 adults aged 18 years or older. Multiple logistic regression analysis was performed to examine factors associated with incident diabetes. RESULTS: Survey results indicated that the age-adjusted incidence of diabetes per 1,000 population was 9.4 in 2002, 11.9 in 2004, and 8.6 in 2008. In multivariable-adjusted analysis, diabetes incidence was significantly associated with being aged 45 or older, being black or Hispanic, being overweight or obese, and having less than a high school diploma. CONCLUSION: Our results suggest that the incidence of diabetes in New York City may be stabilizing. Age, black race, Hispanic ethnicity, elevated body mass index, and low educational attainment are risk factors for diabetes. Large-scale implementation of prevention efforts addressing obesity and sedentary lifestyle and targeting racial/ethnic minority groups and those with low educational attainment are essential to control diabetes in New York City.

Tracking diabetes: New York City's A1C Registry.

CONTEXT: In December 2005, in characterizing diabetes as an epidemic, the New York City Board of Health mandated the laboratory reporting of hemoglobin A1C laboratory test results. This mandate established the United States' first population-based registry to track the level of blood sugar control in people with diabetes. But mandatory A1C reporting has provoked debate regarding the role of public health agencies in the control of noncommunicable diseases and, more specifically, both privacy and the doctor-patient relationship. METHODS: This article reviews the rationale for adopting the rule requiring the reporting of A1C test results, experience with its implementation, and criticisms raised in the context of the history of public health practice. FINDINGS: For many decades, public health agencies have used identifiable information collected through mandatory laboratory reporting to monitor the population's health and develop programs for the control of communicable and noncommunicable diseases. The registry program sends quarterly patient rosters stratified by A1C level to more than one thousand medical providers, and it also sends letters, on the provider's letterhead whenever possible, to patients at risk of diabetes complications (A1C level >9 percent), advising medical follow-up. The activities of the registry program are similar to those of programs for other reportable conditions and constitute a joint effort between a governmental public health agency and medical providers to improve patients' health outcomes. CONCLUSIONS: Mandatory reporting has proven successful in helping combat other major epidemics. New York City's A1C Registry activities combine both traditional and novel public health approaches to reduce the burden of an epidemic chronic disease, diabetes. Despite criticism that mandatory reporting compromises individuals' right to privacy without clear benefit, the early feedback has been positive and suggests that the benefits will outweigh the potential harms. Further evaluation will provide additional information that other local health jurisdictions may use in designing their strategies to address chronic disease.

Human immunodeficiency virus counseling, testing, and referral of close contacts to patients with pulmonary tuberculosis: feasibility and costs.

BACKGROUND: We aimed to increase human immunodeficiency virus (HIV) counseling, testing, referral (CTR), and knowledge of HIV serostatus of close contacts of tuberculosis patients and improve tuberculosis screening and treatment of HIV-infected contacts. METHODS: Of close contacts to infectious tuberculosis patients reported from December 2002 to November 2003, investigators (1) offered HIV CTR, (2) identified factors associated with HIV testing, and (3) assessed study costs. RESULTS: Of 614 contacts, 569 (93%) were provided HIV information and offered HIV CTR. Of the 569, 58 (10%) were previously HIV tested; 165 (29%) were newly HIV tested; and 346 (61%) were not tested. None of the 165 newly HIV tested contacts were HIV infected. Contacts more likely to be newly HIV tested (vs not tested) included those aged 18-24, Hispanic, or non-Hispanic Black. Of 24 HIV-infected contacts, 71 percent received chest-radiograph screening for tuberculosis disease; 56 percent of 18 eligible for latent-tuberculosis-infection treatment started and half completed. It cost $1 per patient to provide HIV information and $5-$8 to offer HIV CTR. CONCLUSION: The project increased HIV CTR of close contacts of infectious tuberculosis patients. The important factor for success in knowing contacts' HIV serostatus was simply for TB program staff to ask about it and offer the test to those who did not know their status.

Strain-specific differences in two large Mycobacterium tuberculosis genotype clusters in isolates collected from homeless patients in New York City from 2001 to 2004.

We studied two large Mycobacterium tuberculosis genotype clusters associated with recent outbreaks in homeless persons to determine factors associated with these tuberculosis (TB) strains. Isolates from all culture-positive TB cases diagnosed from 1 January 2001 to 31 December 2004 were genotyped. Patients whose isolates had identical restriction fragment length polymorphism patterns and spoligotypes were considered clustered. Health department records were reviewed and reinterviews attempted for clustered cases. Patients with the Cs30 and BEs75 strains were compared to other genotypically clustered cases and to each other. The two largest genotype clusters among homeless persons were the Cs30 strain (n = 105) and the BEs75 strain (n = 47). Fifty-one (49%) patients with the Cs30 strain and 28 (60%) with the BEs75 strain were homeless. Compared to patients with the BEs75 strain, patients with the Cs30 strain were less likely to be respiratory acid-fast bacillus smear positive (51% versus 72%). Furthermore, patients with the BEs75 strain were more likely to be HIV infected (74% versus 42%), which suggests that most patients with this strain advanced to disease after recent infection. Cases in clusters of strains that have been circulating in the community over a long time period, such as the Cs30 strain, require additional investigation to determine whether clustering is a result of recent transmission or reactivation of remote infection.

Universal genotyping in tuberculosis control program, New York City, 2001-2003.

In 2001, New York City implemented genotyping to its tuberculosis (TB) control activities by using IS6110 restriction fragment length polymorphism (RFLP) and spoligotyping to type isolates from culture-positive TB patients. Results are used to identify previously unknown links among genotypically clustered patients, unidentified sites of transmission, and potential false-positive cultures. From 2001 to 2003, spoligotype and IS6110-based RFLP results were obtained for 90.7% of eligible and 93.7% of submitted isolates. Fifty-nine (2.4%) of 2,437 patient isolates had false-positive culture results, and 205 genotype clusters were identified, with 2-81 cases per cluster. Cluster investigations yielded 57 additional links and 17 additional sites of transmission. Four additional TB cases were identified as a result of case finding initiated through cluster investigations. Length of unnecessary treatment decreased among patients with false-positive cultures.

Which patients' factors predict the rate of growth of Mycobacterium tuberculosis clusters in an urban community?

Factors influencing tuberculosis cluster growth are poorly understood. The authors examined clusters of two or more culture-confirmed Mycobacterium tuberculosis cases between January 1, 2001, and December 31, 2003, that had insertion sequence 6110 (IS6110) restriction fragment length polymorphism and spoligotype patterns identical to those of another study case. Genotypes first seen in New York, New York, before or during 1993 were considered historical; recent strains were those first seen after 1993. The authors examined the effect of the combined characteristics of infectiousness of the first two cases in a cluster on the rate of cluster growth. Genotyping was performed for 2,408 (91.8%) of the 2,623 tuberculosis cases diagnosed; 873 cases were in 212 clusters. Thirty-one clusters had historical strains, 153 were recent, and 28 were of unknown period. Patients' infectiousness was not associated with the rate of cluster growth among historical strain clusters. Among recent strain clusters, infectiousness of both of the initial cases was associated with a higher rate of cluster growth compared with clusters in which neither initial case was infectious, upon adjustment for male sex (rate ratio = 2.62, 95% confidence interval: 1.19, 5.78). The rate of genotype cluster growth should be monitored regardless of how long the strain has been present in the community. However, infectiousness in the first two cases may be useful to prioritize genotype cluster investigations.

Tuberculosis prevention for non-US-born pregnant women.

OBJECTIVE: The purpose of this study was to evaluate whether non-US-born pregnant women receiving prenatal care are targeted for treatment of latent tuberculosis (TB) infection (LTBI) with isoniazid (INH) to prevent active TB. STUDY DESIGN: This was a retrospective chart review study of 730 non-US-born pregnant women receiving care at 5 New York City prenatal clinics from 1999 to 2000. RESULTS: Among 678 women with known tuberculin skin test (TST) status, 341 (50.3%) had a TST-positive result, including 200 who were newly diagnosed. Of 291 TST-positive women with no previous LTBI treatment or history of TB, 27 (9.3%) completed > or =6 months of INH. In a subset with detailed follow-up, the most important reasons for not completing treatment were nonreferral for evaluation of a TST-positive result (30.9%), not keeping the appointment (17.9%), and nonadherence with prescribed treatment (34.6%). CONCLUSION: The prenatal setting represents a missed opportunity to link TST-positive non-US-born women with LTBI treatment and support for treatment completion.

Tuberculosis in health care workers during declining tuberculosis incidence in New York State.

BACKGROUND: Nosocomial tuberculosis (TB) transmission has decreased dramatically in New York State since 1992; however, health care workers (HCWs) still compose >3% of TB cases. METHODS: Aggregate surveillance data on incident TB cases from 1994 to 2002 were examined for trends among HCWs. Additional information was available for HCW cases from 1998 to 2002, including facility type, tuberculin skin test (TST) result at hire, and treatment of latent TB infection (TLTBI). RESULTS: In New York State, 2.5% of TB cases in 1994 and 4.0% in 2002 were in HCWs (P value for trend <.001). Fifty percent of HCWs TB cases in 1994 and 77.6% in 2002 were in non-US born (P = .002) HCWs. Multidrug-resistant TB in HCWs decreased from 15.6% in 1994 to 6.9% in 2002 (P = .001). Of 297 HCWs TB cases in 1998-2002, 54.9% were TST positive at hire, and 21.2% had unknown TST result; 50.2% of 221 HCWs who were TST positive at or after hire met guidelines for TLTBI, and 23.4% received treatment. The highest proportion with unknown TST at hire and the lowest proportion receiving TLTBI were in ambulatory facilities. CONCLUSION: Many HCWs who developed TB were either TST positive at hire and did not receive TLTBI or did not receive TST at hire. Facilities should encourage treatment for HCWs who meet criteria for TLTBI. Provider education should focus on ambulatory facilities.

Factors associated with tuberculosis treatment interruption in New York City.

SETTING: Large urban tuberculosis control program. OBJECTIVES: To determine the frequency and characteristics of treatment interruptions, and the factors associated with the different types of treatment interruptions. DESIGN: This was a case-control study using culture-positive tuberculosis (TB) patients verified in 1998-1999. Case patients included those in whom any of the following mutually exclusive categories of treatment interruption: default with return to therapy, directly observed therapy nonadherence, default without return to therapy, or multiple types of interruptions. Controls were selected randomly from the cohort. RESULTS: Overall, 6.0 percent of patients had treatment interruptions. All types of treatment interruption were associated with prolonged treatment course and decreased treatment completion rates. The median number of months to treatment interruption was 4.0 (range, 0.5-28.9 months). Two factors were significantly associated with every type of interruption: homelessness and lack of awareness of the severity of TB disease. In multivariate analysis, only lack of awareness of the severity of disease remained independently associated with all interruption types. CONCLUSION: Efforts to improve patients' understanding of TB disease and related treatment issues may be an important TB control program strategy and should be emphasized at the initiation of therapy and at intervals throughout the treatment course to minimize treatment interruption.

Relapse and acquired rifampin resistance in HIV-infected patients with tuberculosis treated with rifampin- or rifabutin-based regimens in New York City, 1997-2000.

BACKGROUND: The relationship between rifamycin use and either relapse or treatment failure with acquired rifampin resistance (ARR) among human immunodeficiency virus (HIV)-infected patients with tuberculosis (TB) is not well understood. METHODS: We conducted a retrospective cohort study of HIV-infected and HIV-uninfected persons with rifampin-susceptible TB, (1) to compare relapse rates, ARR, and treatment failure, according to HIV serostatus; and (2) to examine whether and how use of rifamycin was associated with clinical outcomes of interest among HIV-infected patients with TB. RESULTS: HIV-infected patients were more likely to have ARR than were HIV-uninfected patients (0.9% vs. 0.1%; P = .007), and the association remained significant in multivariate analysis (adjusted odds ratio [OR], 5.5; 95% confidence interval [CI], 1.4-21.5). Among HIV-infected patients with TB, none of 57 patients treated with rifabutin-based regimens alone had ARR, and only 1 of 395 patients treated with rifabutin given in combination with a rifampin-based regimen had ARR, whereas 6 of 355 patients treated with a rifampin-based regimen alone had relapse and ARR. HIV-infected patients treated with rifampin-based regimens alone had a higher risk for relapse and development of rifampin resistance if intermittent dosing of rifampin was started during the intensive phase of treatment, compared with patients who did not receive intermittent dosing (hazard ratio [HR] for relapse, 6.7 [95% CI, 1.1-40.1]; HR for ARR, 6.4 [95% CI, 1.1-38.4]). This association remained when confined to patients with a CD4+ T lymphocyte count of < 100 lymphocytes/mm3. Intermittent dosing started only after the intensive phase of treatment did not increase the risks of relapse and ARR among HIV-infected patients with TB. CONCLUSION: The risk for ARR among HIV-infected persons with TB did not depend on the rifamycin used but, rather, on the rifampin dosing schedule in the intensive phase of treatment.

Use of therapeutic drug monitoring for multidrug-resistant tuberculosis patients.

STUDY OBJECTIVES: Therapeutic drug monitoring (TDM) is the process of obtaining the serum concentration of a medication and modifying the dose based on the results. Little is known about the application of TDM in the treatment of patients with multidrug-resistant (MDR) tuberculosis (TB) in clinical practice. This study characterized how TDM was applied in the management of MDR TB patients, and examined the clinical indications for ordering TDM, the process for obtaining drug concentrations, and the clinician response to the drug concentrations. DESIGN: In a retrospective study, we compared the clinical and demographic characteristics of MDR TB patients who received TDM with those who did not. The clinical application of TDM also was described in patients who received TDM. SETTING: A municipal TB control program. PATIENTS OR PARTICIPANTS: Patients in whom TB was diagnosed that was caused by an isolate resistant to at least isoniazid and rifampin, and who received treatment for TB in one of the health department chest clinics between July 1, 1993, and August 31, 1997, were studied. RESULTS: Forty-nine patients receiving TDM had a longer time to culture conversion and treatment duration, more pulmonary TB in combination with an extrapulmonary site, drug resistance, and visits to the health department clinics (p < 0.05) than the 60 patients without TDM. Of the 49 patients who had initial TDM, 73.5% of them had the reason for being tested specified. A total of 85.7% of initial TDM results were collected at the appropriate time of blood sampling. Clinician response to TDM results varied with the drug that was being tested. CONCLUSIONS: The use of TDM depended largely on the patient's clinical presentation. Site-specific guidelines on the use of TDM for managing TB patients may maximize the benefit of TDM.

Effectiveness of isoniazid treatment for latent tuberculosis infection among human immunodeficiency virus (HIV)-infected and HIV-uninfected injection drug users in methadone programs.

Injection drug users (IDUs) were heavily affected by the tuberculosis (TB) resurgence in New York City in the 1990s. We assessed the effectiveness of screening for latent TB infection in methadone users and of selective treatment with isoniazid. Risk for future TB was classified as low or high on the basis of tuberculin, anergy, and HIV test results. The cohort of 2212 IDUs was followed up for a median of 4.2 years; 25 IDUs, of whom 20 (80%) were infected with human immunodeficiency virus (HIV), developed TB. In an adjusted Cox proportional hazards model of high-risk IDUs, the risk of TB was associated with HIV infection (HR 10.3; 95% CI, 3.4-31.3); receipt of <6 months of isoniazid therapy (HR 7.6; 95% CI, 1.02-57.1); a CD4+ T lymphocyte count of <200 cells/mm3 (HR 6.6; 95% CI, 1.7-25.9); and tuberculin positivity (HR 4.0; 95% CI, 1.6-10.2). Treatment with isoniazid was beneficial in HIV-infected, tuberculin-positive IDUs.

Tuberculosis control: past 10 years and future progress.

The number of countries implementing directly observed therapy short-course (DOTS) has grown rapidly in the past decade and more than 10 million patients have now been treated under DOTS. While global case detection rates increased slightly, from 35% to 40% between 1995 and 2000, the proportion attributable to DOTS grew from less than one-third to more than two-thirds. DOTS is replacing inferior treatment but still treating fewer than 40% of estimated new TB cases. Misconceptions threaten to undermine continued success in tuberculosis control. The first misconception is that treatment observation is unnecessary. Treatment observation needs to be made more patient-friendly, but must not be abandoned. The second misconception is that health care reform will strengthen tuberculosis control. TB control is essentially a management problem. Greater accountability of governments, donors and providers is essential. A third misconception is to focus on treating multi-drug-resistant tuberculosis (MDRTB) cases without addressing the root causes of MDRTB. While it is important, on a clinical basis and epidemiologically in some contexts, to care optimally for patients with MDRTB, it is more important to address the cause of MDRTB and to fix the program generating MDRTB. The fourth misconception is an inordinate concern for sustainability. Delaying assistance will make implementation and sustainability in the future more difficult. Tuberculosis control is remarkably inexpensive and cost-effective, but efforts will fail unless programs have the ability to hire staff, purchase supplies, and contract for services efficiently. Critical issues for the future of tuberculosis control are sustained funding, technical rigor, and good management.

Tuberculin testing and risk of tuberculosis infection among New York City schoolchildren.

OBJECTIVES: To assess adherence to a 1996 health policy change, which discontinued mandatory tuberculin skin testing (TST) of new entrants to NYC primary schools and continued mandatory testing of new entrants to secondary schools. METHODS: The proportion tested before (1991-1995) and after (1996-1998) the change in health policy was determined. Factors associated with TST positivity and the cost of continued testing were assessed. RESULTS: A total of 76.6% of 551 636 new entrants to primary schools were tested in 1991-1995; slightly fewer, 71.1% of 339 958, were tested in 1996- 1998. Among new entrants to secondary schools, 31.0% of 106 463 were tested in 1991-1995 and 51.4% of 53 762 were tested in 1996-1998. The proportion who were TST-positive continued to decrease after 1996 to 1.2% among primary and 9.7% among secondary schoolchildren in 1998. Older age and birth outside the United States were associated with TST positivity. The estimated minimum cost of continued testing in primary schools was $123 152 per tuberculosis case prevented. CONCLUSION: An approach aimed at reducing testing of children at low risk for latent tuberculosis infection did not decrease testing of younger children. More important, older children who were more likely to be born in countries of high tuberculosis incidence were not tested. Additional efforts are needed to increase awareness among medical and school personnel to decrease testing among children who do not have risk factors for latent tuberculosis infection and to increase tuberculin testing of children who are entering school for the first time at the secondary level and do have risk factors for tuberculosis infection.

Targeting tuberculosis testing: the yield of source case investigations for young children with reactive tuberculin skin tests.

OBJECTIVE: This study was designed to determine the yield of investigations whose aim is to identify a source case for tuberculosis infection among tuberculin reactors 3 years of age or younger. METHODS: The authors describe the results of associate investigations conducted for child tuberculin reactors reported from January 1, 1996, through June 30, 1998. Associates were defined as individuals who live with or spend significant time with a child reactor. An associate investigation was defined as evaluation of at least one associate. A source case was an associate older than 10 years of age who had culture-positive, pulmonary tuberculosis during a period when the child could have been exposed. RESULTS: Two hundred seven children had an associate investigation performed with a median of four associates investigated per child (range 1-21). Birthplace was known for 187 (90%); 128 were U.S.-born. Of 1,222 associates identified, 980 (80%) were evaluated. Among 452 (46%) associates for whom birthplace was known, 250 (55%) were non-U.S.-born. Of 980 associates, 668 were household contacts; 198 (30%) were infected, three had prior tuberculosis disease, and three had active tuberculosis. Two active cases met source case criteria; the yield was 0.9 (2 of 207) source cases per 100 children investigated. Of 312 non-household contacts, 57 (18%) were infected and none had the disease. CONCLUSIONS: Although few source cases were identified for young tuberculin skin test reactors in New York City, investigations identified a proportion of cases and infection in associates similar to that identified among contacts to pulmonary tuberculosis cases. Such investigations may be identifying a high-risk group and should be considered, depending on program resources.