National trends in the concurrence of tuberculosis and acquired immunodeficiency syndrome.

BACKGROUND: Elucidation of the relationship between tuberculosis (TB) and the acquired immunodeficiency syndrome (AIDS) is needed to help predict the future course of these two epidemics. We examined nationwide trends in TB and AIDS occurring in the same individual. METHODS: Health departments in the 50 states, District of Columbia, Puerto Rico, and Guam matched their TB and AIDS case registries to determine the number of persons diagnosed with both TB and AIDS. The number of AIDS cases, TB cases, AIDS cases that matched with a TB case on the TB registry, and TB cases that matched with an AIDS case on the AIDS registry were reported to the Centers for Disease Control and Prevention, Atlanta, Ga. Data were analyzed for the period from 1981 through 1991. The number of matched TB-AIDS cases was compared with a modeled estimate of excess TB cases during the period from 1985 through 1990. RESULTS: From 1981 through 1991 there were 11,299 AIDS cases that matched with a TB case on the TB registry, representing 5.1% (geographic variation, 0% to 9.3%) of AIDS cases. The TB cases that matched with an AIDS case on the AIDS registry represent 4.3% (geographic variation, 0% to 15.1%) of TB cases from 1981 through 1991. Since 1981, matched TB and AIDS cases increased yearly through 1990. When examined by year of AIDS report, the percentage of AIDS cases that matched with a TB case increased from 1981 to 1982 (1.9% to 5.1%), remained fairly constant from 1983 through 1987 (range, 4.0% to 4.7%), increased in 1988 (5.4%) after extrapulmonary TB was added to the AIDS case definition, and increased slightly through 1990 (5.8%). When examined by year of TB report, the percentage of TB cases that matched with an AIDS case increased steadily from 1981 through 1990 (0.1% to 9.5%). The calculated fraction of excess TB cases during the period from 1985 through 1990 that could be accounted for by identified TB-AIDS cases was 30%. CONCLUSION: The risk of TB or AIDS among persons already diagnosed with one disease is much higher than among the general population. The percentage of persons with TB who are also diagnosed with AIDS has been increasing rapidly. Human immunodeficiency virus-induced immunosuppression is an important contributor to the TB epidemic and probably accounts for a minimum of 30% of excess TB cases during the period from 1985 through 1990.

HIV infection among non-injecting drug users entering drug treatment, United States, 1989-1992. Field Services Branch.

OBJECTIVE: To describe HIV seroprevalence among non-injecting drug users (non-IDU) entering sentinel drug treatment centers in the United States. DESIGN: Anonymous, blinded (unlinked) HIV seroprevalence surveys. SETTING: Sixty-eight sentinel drug treatment centers in 37 United States metropolitan areas. PARTICIPANTS: Consecutive sample of clients admitted to sentinel drug treatment centers from January 1989 through December 1992. Of 84,617 clients, 37,633 (44.5%) had used illicit drugs but reported no injecting drug use since 1978. MAIN OUTCOME MEASURES: Center-specific, metropolitan area-specific, and national median HIV seroprevalence rates. RESULTS: National median center-specific HIV seroprevalence among non-IDU was 3.2% (range, 0-15.2%). Rates varied widely by geographic area. Median rates were highest in the northeast (5.6%; range, 0-15.2%), intermediate in the south (3.4%; range, 0.6-8.0%), and generally lower throughout the rest of the country: midwest (1.3%; range, 0-3.1%) and west (1.8%; range, 0-14.5%). When stratified by treatment center, there were few statistically significant differences in seroprevalence among African Americans, Hispanics and whites. The median rate was 3.4% among men and 2.7% among women. Rates among non-IDU were lower than among IDU attending the same drug treatment centers, but consistently higher than among heterosexual patients attending sexually transmitted disease clinics in the same metropolitan areas. CONCLUSIONS: HIV seroprevalence among non-IDU entering drug treatment is high in many metropolitan areas. HIV prevention and education efforts in drug treatment centers should target sexual as well as drug-use risk reduction for all clients.

HIV infection among homeless adults and runaway youth, United States, 1989-1992. Field Services Branch.

OBJECTIVES: Homeless persons have an increased risk of HIV infection because of a high prevalence of HIV-related risk behaviors. These include drug use, sexual contact with persons at risk for HIV infection, and the exchange of sex for drugs. The objectives of this investigation were to describe HIV seroprevalence rates in homeless adults and runaway youth. METHODS: In 1989, the Centers for Disease Control and Prevention began collaboration with state and local health departments to conduct HIV seroprevalence surveys in homeless populations. Unlinked HIV seroprevalence surveys were conducted in 16 sites; 11 provided medical services primarily to homeless adults, and five to runaway youth aged < 25 years. RESULTS: From January 1989 through December 1992, annual surveys were conducted in 16 sites in 14 cities. Site-specific seroprevalence rates ranged from 0-21.1% (median, 3.3%). Among homeless adults in three sites, rates were higher among men who had sex with other men and those who injected drugs than among persons with other risk exposures (28.9 versus 5.3%). In general, rates were higher for heterosexual men than for women and higher among African Americans than whites. In sites providing services to homeless youth, HIV seroprevalence rates ranged from 0-7.3% (median, 2.3%). CONCLUSIONS: These data indicate that HIV infection among homeless adults and runaway youth is an important public health problem. HIV prevention and treatment should be integrated into comprehensive health and medical programs serving homeless populations.

Tuberculin skin test screening in schoolchildren in the United States.

OBJECTIVE: To determine the current practices and results of tuberculin skin test (TST) screening of schoolchildren in the United States. METHODS: Tuberculosis program staff in all states and the District of Columbia were asked about current requirements, practices, and results of school-based TST screening. RESULTS: Thirty-four states and the District of Columbia (69%) reported no current statewide statutes or policies for tuberculin screening of schoolchildren, and 10 (19%) reported having statewide requirements. In 6 states (12%), requirements were instituted at the local level, and 24 localities in these states were known to require screening. Of the 34 areas requiring screening, 18 (53%) screened all new entrants, 7 (21%) screened children in specific grades, and 9 (26%) used other criteria for screening. TST results were collected for 26 (76%) of 34 areas, and 6 areas collected results of follow-up evaluation of tuberculin-positive children. Additionally, 8 localities in 7 states with no screening requirements conducted tuberculin surveys. Sixteen areas provided results. In 7 of the 8 areas that collected information about birthplace, less than 2% of US-born children were tuberculin positive; foreign-born children had rates 6 to 24 times higher than US-born children. TST screening identified new cases of tuberculosis, less than 0.02% of the children screened. CONCLUSIONS: School-based tuberculin screening identified low rates of positive TST results in US-born children. Resources should be directed toward screening children at high risk for tuberculous infection, as recommended by the American Academy of Pediatrics and the Advisory Committee for Elimination of Tuberculosis.

Tuberculosis in a day-care center, Kentucky, 1993.

In November, 1993, a 33-month-old child in a day-care center was diagnosed with tuberculosis (TB). To identify her source of infection, close contacts, other day-care children and staff were screened by tuberculin skin test (TST). TB registry and medical/laboratory records were reviewed. The only 2 community TB cases reported in the past 3 years were investigated. Of 164 children 2 were diagnosed with TB; their TSTs were > or = 10 mm but no specimens were obtained. Six children had TSTs > or = 5 mm. Of these 4 had TST conversions between December, 1993, and March, 1994. There were no additional positive TST children in June, 1994. No TB case was identified among staff or parents. A possible epidemiologic link with the index case was found for 1 community case. No source of infection was found for the other children. Possible explanations for not finding a source are: an as yet unidentified case in the day-care center or community; or false positive TST results in children related to low community prevalence of TB infection.

Tuberculosis in children younger than five years old: New York City.

We examined medical and health department records for children < 5 years of age with suspected or confirmed tuberculosis reported to the New York City Health Department from January, 1992, through June, 1992, in order to describe the epidemiology of tuberculosis in young children and identify prevention strategies. Forty-seven children were treated for suspected or confirmed tuberculosis. Sixty-two percent (21 of 34) were foreign-born (n = 11) or had foreign-born caretakers (n = 10). A source case was found for 10 of 47 (21%) children; for 8 the adult source was diagnosed before the child. One child was human immunodeficiency virus-seropositive, however, 83% of children and 70% of adult source cases did not have human immunodeficiency virus test results available. Health care providers should test children at high risk for tuberculosis infection as recommended by the American Academy of Pediatrics and improve contact tracing to identify children exposed to adults with tuberculosis. Because most cases of tuberculosis in children are diagnosed clinically rather than by isolating Mycobacterium tuberculosis, identification of the source case is important for selecting appropriate treatment.

Nosocomial transmission of human immunodeficiency virus and subsequent transmission of multidrug-resistant tuberculosis in a healthcare worker.

A phlebotomist with nosocomially acquired human immunodeficiency virus infection developed tuberculosis 10 months after exposure to multidrug-resistant Mycobacterium tuberculosis during a nosocomial outbreak. Healthcare workers with immunosuppression are at increased risk of tuberculosis if infected and, if exposed, should be considered for preventive therapy regardless of tuberculin skin-test status.

Multidrug-resistant Mycobacterium tuberculosis in an HIV dental clinic.

OBJECTIVE: To investigate possible transmission of multidrug-resistant tuberculosis (MDR-TB) in a dental setting. DESIGN: A retrospective, descriptive study of dental workers (DWs), patients, and practice characteristics. PATIENTS: Two dental workers (DW1 and DW2) with acquired immunodeficiency syndrome and MDR-TB. SETTING: A hospital-based (Hospital X) human immunodeficiency virus (HIV) dental clinic in New York City. METHODS: To identify dental patients with tuberculosis (TB), patients treated in the dental clinic at Hospital X during 1990 were cross-matched with those listed in the New York City Department of Health Tuberculosis Registry. Mycobacterium tuberculosis isolates from both DWs and from dental patients with TB were tested for antimicrobial susceptibility and typed by restriction fragment length polymorphism (RFLP) analysis. Infection control practices were reviewed. RESULTS: M tuberculosis isolates infecting DW1 and DW2 were resistant to isoniazid and rifampin and had identical RFLP patterns. DW1 and DW2 worked in close proximity to each other in a small HIV dental clinic in Hospital X during 1990. Of 472 patients treated in the dental clinic in 1990, 41 (8.7%) had culture-proven M tuberculosis infection. Of these 41, 5 had isolates with resistance patterns similar to both DWs; however, for four available isolates, the RFLP patterns were different from the patterns of the DWs. Sixteen of the 41 patients received dental treatment while potentially infectious. Dental patients were not routinely questioned about TB by dental staff, nor were all dental staff screened routinely for TB. No supplemental environmental measures for TB were employed in the dental clinic in 1990. CONCLUSIONS: Our investigation suggests that MDR-TB transmission may have occurred between two DWs in an HIV dental clinic. Opportunities for transmission of TB among dental staff and patients were identified. TB surveillance programs for DWs and appropriate infection control strategies, including worker education, are needed to monitor and minimize exposure to TB in dental settings providing care to patients at risk for TB.

Use and efficacy of tuberculosis infection control practices at hospitals with previous outbreaks of multidrug-resistant tuberculosis.

OBJECTIVE: To evaluate the implementation and efficacy of selected Centers for Disease Control and Prevention guidelines for preventing spread of Mycobacterium tuberculosis. DESIGN: Analysis of prospective observational data. SETTING: Two medical centers where outbreaks of multidrug-resistant tuberculosis (TB) had occurred. PARTICIPANTS: All hospital inpatients who had active TB or who were placed in TB isolation and healthcare workers who were assigned to selected wards on which TB patients were treated. METHODS: During 1995 to 1997, study personnel prospectively recorded information on patients who had TB or were in TB isolation, performed observations of TB isolation rooms, and recorded tuberculin skin-test results of healthcare workers. Genetic typing of M tuberculosis isolates was performed by restriction fragment-length polymorphism analysis. RESULTS: We found that only 8.6% of patients placed in TB isolation proved to have TB; yet, 19% of patients with pulmonary TB were not isolated on the first day of hospital admission. Specimens were ordered for acid-fast bacillus smear and results received promptly, and most TB isolation rooms were under negative pressure. Among persons entering TB isolation rooms, 44.2% to 97.1% used an appropriate (particulate, high-efficiency particulate air or N95) respirator, depending on the hospital and year; others entering the rooms used a surgical mask or nothing. We did not find evidence of transmission of TB among healthcare workers (based on tuberculin skin-test results) or patients (based on epidemiological investigation and genetic typing). CONCLUSIONS: We found problems in implementation of some TB infection control measures, but no evidence of healthcare-associated transmission, possibly in part because of limitations in the number of patients and workers studied. Similar evaluations should be performed at hospitals treating TB patients to find inadequacies and guide improvements in infection control.

Teenagers at risk of human immunodeficiency virus type 1 infection. Results from seroprevalence surveys in the United States.

OBJECTIVE: To describe the seroprevalence of human immunodeficiency virus type 1 (HIV-1) and risk factors for HIV-1 infection among teenagers attending selected clinics. DESIGN: Anonymous, cross-sectional serosurveys conducted in 130 clinics in 24 cities. SETTINGS: Adolescent medicine clinics, sexually transmitted disease clinics, clinics in juvenile detention and correctional facilities, and homeless and runaway youth centers. PATIENTS: Teenagers in whom serum samples were drawn as part of routine medical services. MAIN OUTCOME MEASURES: Prevalence of HIV-1 infection and reported HIV risk behaviors. RESULTS: From January 1, 1990 through December 31, 1992, serum specimens were collected from 79,802 teenagers; 591 of these specimens were positive for HIV-1 antibody. Seropositive test results were found in all 24 cities surveyed, and in 95 (73%) of the 130 clinics surveyed. The median clinic-specific prevalence was 0.2% (range, 0% to 1.4%) in 22 adolescent medicine clinics, 0.3% (range, 0% to 6.8%) in 33 correctional facilities, 0.5% (range, 0% to 3.5%) in 70 sexually transmitted disease clinics, and 1.1% (range, 0% to 4.1%) in five homeless youth centers. Rates exceeded 1% in 37 sites (28%). Excluding sites with many men reporting sex with men, rates in women were similar or somewhat higher than rates in men. Rates were highest among young men reporting sex with men, with clinic rates ranging from 16% to 17% in two homeless youth sites and 13% to 17% in two sexually transmitted disease clinics. Most teenagers with risk information reported heterosexual activity as their only potential risk exposure to HIV-1. CONCLUSIONS: Seroprevalence of HIV was generally low but varied by type of clinic and geographic area. The highest rates were observed among young women and gay men in some settings, suggesting that targeted prevention messages are needed.

Sentinel surveillance of human immunodeficiency virus infection in women seeking reproductive health services in the United States, 1988-1989. The Field Services Branch.

Cases of AIDS among women of reproductive age have increased dramatically since 1981; nearly a third of all cases among females were reported in 1990 alone. Surveillance of human immunodeficiency virus (HIV) infection among women is essential for monitoring the spread of HIV over time and identifying specific populations and geographic areas in need of HIV counseling, testing, and prevention services. Blinded (unlinked) serologic surveys were conducted in the United States and Puerto Rico in sentinel clinics providing reproductive health services to women, including family planning, prenatal care, and abortion services. Seventy-eight of 94 clinics (83%) in 30 cities conducting surveys during 1988 and 1989 detected at least one HIV-positive woman. Clinic-specific prevalence ranged from 0-2.28% (median 0.22%), with rates over 1% occurring in clinics predominantly on the East Coast and in Puerto Rico. Seroprevalence varied by primary type of service, race-ethnicity, and age group. Median rates were higher in clinics offering prenatal services and lower in abortion and family planning clinics in the same cities. In general, women 25-29 years of age showed the highest median rate of infection (0.32%), and rates were higher among black women (median 0.34%) than among Hispanic (median 0.11%) and white women (median 0%). Our data indicate the need to educate women about recognizing and reducing their risk of HIV infection. Reproductive health clinics with high seroprevalence should implement voluntary HIV counseling and testing with appropriate follow-up clinical evaluation and referral for infected women. Clinics with low prevalence should seize the opportunity to enhance HIV education and prevention efforts.

Prevalence of hepatitis B, hepatitis C, and human immunodeficiency virus infection among women attending prenatal clinics in San Juan, Puerto Rico, from 1989-1990.

OBJECTIVE: To evaluate the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) among pregnant women in Puerto Rico. METHODS: An anonymous serosurvey was conducted in four prenatal clinics in San Juan, Puerto Rico, involving women presenting consecutively for their first prenatal visit. RESULTS: Nineteen of 997 pregnant women (1.9%, 95% confidence interval [CI] 1.2-3.0) tested positive for HCV antibody (anti-HCV), and eight (0.8%, 95% CI 0.4-1.6) were HIV seropositive. Of the 992 women for whom serum samples were tested for HBV markers, 91 (9.2%, 95% CI 7.5-11.2) had evidence of past or current HBV infection, and four (0.4%, 95% CI 0.1-1.1) were HBV carriers. The age-specific HBV prevalence ranged from 4.1% among women 15-19 years old to 18.5% among those at least 30 years old (P < .001, chi 2 test for trend). Anti-HCV prevalence was also higher among women at least 30 years old compared to younger women (3.1 versus 1.9%; prevalence ratio 1.6, 95% CI 0.6-4.9), although the difference was not statistically significant. Anti-HCV prevalence was higher among women with past or current HBV infection than among women who were not infected (7.7 versus 1.3%; prevalence ratio 5.8, 95% CI 2.3-14.3). CONCLUSIONS: The prevalence of chronic HBV and HCV infection among pregnant women tested in San Juan, Puerto Rico, is comparable to that among pregnant women in the United States. The prevalence of HIV infection among pregnant women in San Juan is higher than among childbearing women in the United States.

Acute hemorrhagic conjunctivitis caused by enterovirus type 70: an epidemic in American Samoa.

From December 1981 to February 1982, an estimated 22,000 cases of acute hemorrhagic conjunctivitis (AHC) caused by enterovirus type 70 (EV 70) occurred among Samoan and non-Samoan residents of American Samoa. The overall attack rate was estimated to be 68%. Samoans of all ages resident in traditional housing and of large family size were at greatest risk of acquiring AHC, while non-Samoan adults resident in western style housing were at lowest risk. Epidemiologic aspects of AHC acquisition were also different for the Samoan and non-Samoan communities; index cases in Samoan households were frequently young adults, whereas index cases in non-Samoan households were commonly school age children, suggesting a role for school transmission in non-Samoans only. In this outbreak, subclinical AHC was rare; of 50 asymptomatic members of affected households, only 3 had neutralizing antibody to EV 70 (all with titers of 1:10). Investigation documented the highly contagious nature of AHC caused by EV 70, and the ease with which epidemic transmission may develop under conditions of crowding and frequent interpersonal contact.

Completeness and timeliness of tuberculosis case reporting. A multistate study.

BACKGROUND: Tuberculosis (TB) control activities are contingent on the timely identification and reporting of cases to public health authorities to ensure complete assessment and appropriate treatment of contacts and identification of secondary cases. We report the results of a multistate evaluation of completeness and timeliness of reporting of TB cases in the United States during 1993 and 1994. METHODS: To determine completeness of TB reporting, laboratory log books, death certificates, hospital discharge, Medicaid databases, and pharmacy databases were reviewed in seven states to identify possible unreported cases. Timeliness of TB reporting was calculated using the number of days between date of TB diagnosis and date of report to the local or state health department. Cases reported >7 days after diagnosis were considered to have delayed reporting. RESULTS: Of 2711 cases identified through review of secondary data sources, 14 (0.5%) were previously unreported to public health. The largest yield of unreported cases was identified through review of laboratory records; 13 of the 14 unreported cases were identified, of which eight were found only through this method. Timeliness of reporting varied between sites from a median of 7 days to a median of 38 days. The number of cases with delayed reporting varied from 5% to 53% between sites. Factors associated with delayed reporting included infectiousness, type of provider, diagnosing provider, and reporting source. CONCLUSIONS: Through a review of several different secondary data sources, few unreported TB cases were detected; however, timeliness of reporting was poor among the reported cases.

Tuberculosis screening in private physicians' offices, Pennsylvania, 1996.

OBJECTIVE: To assess tuberculin skin testing practices of physicians after community-wide screening of 1400 children exposed to a pediatrician with active tuberculosis (TB). DESIGN: A self-administered questionnaire. SETTING: Medium-sized city in eastern Pennsylvania. PARTICIPANTS: Pediatricians and family practitioners seeing pediatric patients. MAIN OUTCOME MEASURES: Percentages of physicians who followed published recommendations for placement and reading of TB skin tests published by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC). RESULTS: Questionnaires were completed by 60/80 (75%) physicians. The 60 physicians had practiced a mean of 17 years (range 3-38 years), and only one did not do TB skin testing for pediatric patients. The 59 physicians doing TB skin testing reported routinely tuberculin testing more than 900 children per month. Only 8/59 (14%) physicians followed published guidelines for placement and reading of tuberculin tests. Those physicians screened 158 (17%) of the pediatric patients undergoing TB skin testing in a typical month. CONCLUSION: In this community where a highly publicized TB case prompted massive pediatric screening, most physicians seeing children in private practice do not follow standard TB skin testing guidelines. Increased understanding of how private-practice physicians learn about and decide to use recommended standards are needed if tuberculin tests are to be correctly performed and TB appropriately diagnosed.

Analysis of Mycobacterium tuberculosis transmission patterns in a homeless shelter outbreak.

SETTING: From July 1997 through May 1998, ten tuberculosis (TB) cases were reported among men in a Syracuse New York homeless shelter for men. OBJECTIVE AND DESIGN: Investigation to determine extent of, and prevent further, transmission of Mycobacterium tuberculosis. RESULTS: Epidemiologic and laboratory evidence suggests that eight of the ten cases were related. Seven cases had isolates with matching six-band IS6110 DNA fingerprints; the isolate from another case had a closely related fingerprint pattern and this case was considered to be caused by a variant of the same strain. Isolates from eight cases had identical spoligotypes. The source case had extensive cavitary disease and stayed at the shelter nightly, while symptomatic, for almost 8 months before diagnosis. A contact investigation was conducted among 257 shelter users and staff, 70% of whom had a positive tuberculin skin test, including 21 with documented skin test conversions. CONCLUSIONS: An outbreak of related TB cases in a high-risk setting was confirmed through the use of IS6110 DNA fingerprinting in conjunction with spoligotyping and epidemiologic evidence. Because of the high rate of infection in the homeless population, routine screening for TB and preventive therapy for eligible persons should be considered in shelters.

Clinical findings and results of treatment in an outbreak of acute hemorrhagic conjunctivitis in southern Florida.

An epidemic of acute hemorrhagic conjunctivitis in Miami, Florida, involved approximately 800 documented cases and more than 2,500 suspected cases. This epidemic was caused by an enterovirus 70 infection affecting primarily young black people residing within a high-risk area. Acute hemorrhagic conjunctivitis is characterized by the rapid onset of swollen eyelids, foreign-body sensation, burning, watery discharge, and, usually, bilateral ocular involvement. Signs include distinctive bulbar conjunctival hemorrhages and a follicular conjunctival reaction with only mild and infrequent corneal involvement. This infection is short in duration, self-limited, and free of significant ocular sequelae. Symptomatic treatment appears to be as effective as various topical medical regimens for relief of symptoms. Secondary bacterial infections (occurring in individuals who used urine as an eyewash) and one case of a transient acute Bell's palsy were the only complications associated with this acute hemorrhagic conjunctivitis epidemic.

The epidemiology of tuberculosis in the United States.

After a dramatic increase in the incidence of TB in the United States from 1985 to 1992, the epidemiology of TB changed, with both the number of cases and the incidence of TB decreasing since 1992. The decreases have been focal, however, affecting only certain geographic areas (e.g., New York, California, and New Jersey) and certain populations (e.g., 25-44 year age group and people born in the United States). The factors responsible for the decrease in those areas and populations are multiple but the most important are thought to be improvements in TB control and treatment programs in communities serving populations at greatest risk for TB. Despite the overall decline in TB cases, the numbers of foreign-born people with TB continue to increase. Factors contributing to the increase in TB among foreign-born people include the prevalence of TB in the country of origin, duration of residence in the United States after immigration, inadequate screening for or treatment of TB before entering the United States, and inadequate follow-up of those who have entered the United States with noninfectious TB (i.e., abnormal chest radiograph with negative sputum smears). Control of TB among the foreign-born population is essential if the current downward trend in reported TB cases in the United States is to be maintained. The HIV epidemic had a significant impact on the increase in TB incidence in the United States in the late 1980s but improvements in measures to control transmission of TB appear to have been effective in reversing that trend. The current national decrease trend in TB morbidity can be sustained through organized efforts by federal and private agencies and state and local health departments to ensure that all people with TB are identified and treated promptly. Such efforts must be aimed at areas and populations identified as high risk for TB, especially foreign-born people and people who are infected with HIV.

Immunization of asymptomatic HIV-infected children with measles vaccine: assessment of risks and benefits.

Because HIV infection is associated with immunologic abnormalities, concerns have been expressed about the safety and efficacy of vaccination of infected children with live virus vaccines. The authors used decision analysis to assess the likely impacts of four alternative policies for immunization of asymptomatic HIV-infected children with measles vaccine. Probabilities for vaccine efficacy, vaccine-related adverse events, and measles complications in HIV-infected children and the prevalence of HIV infection in the birth cohort were obtained from a modified Delphi survey. Using median estimates from the Delphi survey, there were no major differences in outcomes under any proposed policy. Using the most extreme estimates, serologic testing and exclusion of seropositive children from vaccination or exclusion of all high-risk children decreased vaccine-associated adverse events without greatly increasing measles complications, primarily because of the current low incidence of measles. Under conditions assumed to exist in the United States today, alternate immunization policies have only minor differences in societal impact although costs would certainly differ.

Cross-matching TB and AIDS registries: TB patients with HIV co-infection, United States, 1993-1994.

OBJECTIVES: Because of limited reporting of HIV status in case reports to the national tuberculosis (TB) surveillance system, the authors conducted this study to estimate the proportion of US TB cases with HIV co-infection and to describe demographic and clinical characteristics of co-infected patients. METHODS: The 50 states, New York City, and Puerto Rico submitted the results of cross-matches of TB registries and HIV-AIDS registries. The authors determined the number of TB cases reported for 1993-1994 that were listed in HIV-AIDS registries and analyzed data on demographic and clinical characteristics by match status. RESULTS: Of 49,938 TB cases reported for 1993-1994, 6863 (14%) were listed in AIDS or HIV registries. The proportions of TB-AIDS cases among TB cases varied by reporting area, from 0% to 31%. Anti-TB drug resistance was higher among TB-AIDS cases, particularly resistance to isoniazid and rifampin (multidrug resistance) and rifampin alone, In some areas with low proportions of multidrug-resistant TB cases, however, the difference in multidrug resistance between TB-AIDS patients and non-AIDS TB patients was not found. CONCLUSIONS: The proportion of TB cases with HIV co-infection, particularly in some areas, underscores the importance of the HIV-AIDS epidemic for the epidemiology of TB. Efforts to improve HIV testing as well as reporting of HIV status for TB patients should continue to ensure optimum management of coinfected patients, enhance surveillance activities, and promote judicious resource allocation and targeted prevention and control activities.