Using Reports of Latent Tuberculosis Infection Among Young Children to Identify Tuberculosis Transmission in New York City, 2006-2012.

The presence of latent tuberculosis infection (LTBI) in young children indicates recent tuberculosis (TB) transmission. We reviewed surveillance reports of children with LTBI to assess whether more follow-up is needed to prevent TB in this high-risk population. Data on all children under 5 years of age who were reported by health-care providers or laboratories to the New York City Department of Health during 2006-2012 were abstracted from the TB surveillance and case management system, and those with LTBI were identified. Potential source cases, defined as any infectious TB case diagnosed in the 2 years before a child was reported and whose residence was within 0.5 miles (0.8 km) of the child's residence, were identified. Neighborhood risk factors for TB transmission were examined. Among 3,511 reports of children under age 5 years, 1,722 (49%) had LTBI. The children were aged 2.9 years, on average, and most (64%) had been born in the United States. A potential source case was identified for 92% of the children; 27 children lived in the same building as a TB patient. Children with potential source cases were more likely to reside in neighborhoods with high TB incidence, poverty, and population density. The high proportion of children born in the United States and the young average age of the cases imply that undetected TB transmission occurred. Monitoring reports could be used to identify places where transmission occurred, and additional investigation is needed to prevent TB disease.

Epidemiology of Pediatric Multidrug-Resistant Tuberculosis in the United States, 1993-2014.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) is an important global public health threat, but accurate estimates of MDR-TB burden among children are lacking. METHODS: We analyzed demographic, clinical, and laboratory data for newly diagnosed pediatric (age <15 years) TB cases reported to the US National TB Surveillance System during 1993-2014. MDR-TB was defined as culture-confirmed TB disease with resistance to at least isoniazid and rifampicin. To ascertain potential underestimation of pediatric MDR-TB, we surveyed high-burden states for clinically diagnosed cases treated for MDR-TB. RESULTS: Of 20789 pediatric TB cases, 5162 (24.8%) had bacteriologically confirmed TB. Among 4826 (93.5%) with drug susceptibility testing, 82 (1.7%) had MDR-TB. Most pediatric MDR-TB cases were female (n = 51 [62%]), median age was 5 years (interquartile range, 1-12 years), one-third were Hispanic (n = 28 [34%]), and two-thirds (n = 55 [67%]) were born in the United States. Most cases had additional resistance to ≥1 other first-line drug (n = 66 [81%]) and one-third had resistance to ≥1 second-line drug (24/73 tested). Of 77 who started treatment prior to 2013, 66 (86%) completed treatment and 4 (5%) died. Among the 4 high-TB-burden states/jurisdictions surveyed, there was 42%-55% underestimation of pediatric MDR-TB cases when using only culture-confirmed case definitions. CONCLUSIONS: Only one-quarter of pediatric TB cases had culture-confirmed TB, likely resulting in underestimation of true pediatric MDR-TB burden in the United States using strictly bacteriologic criteria. Better estimates of pediatric MDR-TB burden in the United States are needed and should include clinical diagnoses based on epidemiologic criteria.

Reportable Bacterial Infections among New York City-Born Infants, 2001-2009.

OBJECTIVE: To determine rates of reportable bacterial infections among infants in New York City and identify populations at risk and preventable causes of morbidity. STUDY DESIGN: This retrospective cohort study matched live births in New York City from 2001-2009 to reported cases of bacterial infections among infants less than 1 year of age. Characteristics recorded on birth certificates were compared between infants with bacterial enteric infection, bacterial nonenteric infection, and no reportable bacterial infection. Multinomial logistic regression and multivariable logistic regression were used to identify risk factors for infection. RESULTS: Bacterial infection was reported in 4.6 cases per 1000 live births. Of 4524 infants with a reportable infection, the majority (2880, 63%) had an enteric infection. Asian/Pacific Islanders in Brooklyn were the borough-level race/ethnic group with the highest enteric infection rate (8.5 per 1000 live births). Citywide, infants with enteric infections were disproportionately male, from higher poverty neighborhoods, born to foreign-born mothers, and enrolled in Special Supplemental Food Program for Women, Infants, and Children or Medicaid. In contrast, infants with nonenteric infections were more likely to have low birthweight and mothers characterized by US birth and black race or white Hispanic race/ethnicity. CONCLUSIONS: Distinct patterns of risk factors for enteric and nonenteric bacterial infections among infants were identified. The results suggest that infants born to Asian/Pacific Islander mothers residing in Brooklyn should be a focus of enteric disease prevention. More research is necessary to better understand what behaviors increase the risk of enteric disease in this population.

Contact Investigations Around Mycobacterium tuberculosis Patients Without Positive Respiratory Culture.

OBJECTIVE: To evaluate the yield and effectiveness of contact investigations conducted around potentially infectious tuberculosis (TB) patients with no positive respiratory culture for Mycobacterium tuberculosis in New York City (NYC). DESIGN: All TB patients without a positive respiratory culture from 2003 to 2012 were extracted from the NYC TB registry, and all patients eligible for contact investigation and their contacts were evaluated. Patients without a positive respiratory culture were defined as eligible for contact investigation if they had a respiratory nucleic acid amplification result positive for M tuberculosis, a cavitary chest radiograph, or a positive respiratory acid-fast bacilli smear. SETTING: NYC, New York. MAIN OUTCOME MEASURES: To evaluate the yield of the investigations, the number of contacts identified and the outcome of testing was quantified. Potential transmission was defined on the basis of whether active TB patients were detected among the contacts and if a contact had a TB test conversion. RESULTS: From 2003 to 2012, there were 2191 TB patients without a positive respiratory culture in NYC, 374 (17%) of which were considered eligible for contact investigation. A total of 11 096 contacts were identified around 300 (80%) eligible patients, 136 of whom had a diagnosis of TB infection; of those with TB infection who initiated preventive treatment, 66% completed treatment. Potential transmission was identified around 14 patients, with the identification of 2 additional cases of active TB and 15 contacts with TB infection test conversion. CONCLUSIONS: Conducting contact investigations around patients without a positive respiratory culture yielded evidence of possible transmission and led to the identification and treatment of new TB cases and those with TB infection. These findings suggest that these investigations should be conducted in settings where resources permit.

Moxifloxacin Prophylaxis against MDR TB, New York, New York, USA.

Contacts of persons infected with multidrug-resistant tuberculosis (MDR TB) have few prophylaxis options. Of 50 contacts of HIV- and MDR TB-positive persons who were treated with moxifloxacin, 30 completed treatment and 3 discontinued treatment because of gastrointestinal symptoms. Moxifloxacin was generally well-tolerated; further research of its efficacy against MDR TB is needed.

Risk for Tuberculosis Disease Among Contacts with Prior Positive Tuberculin Skin Test: A retrospective Cohort Study, New York City.

BACKGROUND: Patients with prior positive tuberculin skin test (TST) results may benefit from prophylaxis after repeat exposure to infectious tuberculosis (TB). OBJECTIVE: To evaluate factors associated with active TB disease among persons with prior positive TST results named as contacts of persons with infectious TB. DESIGN: Population-based retrospective cohort study. PARTICIPANTS: A total of 2,933 contacts with prior positive TST results recently exposed to infectious TB identified in New York City's TB registry during the period from January 1, 1997 through December 31, 2003. MAIN MEASUREMENTS: Contacts developing active TB disease ≤ 4 years after exposure were identified and compared with those who did not, using Poisson regression analysis. Genotyping was performed on selected Mycobacterium tuberculosis-positive isolates. KEY RESULTS: Among contacts with prior positive TST results, 39 (1.3 %) developed active TB disease ≤ 4 years after exposure (≤ 2 years: 34). Risk factors for contacts that were independently associated with TB were age < 5 years (adjusted prevalence ratio [aPR] = 19.48; 95 % confidence interval [CI] = 7.15-53.09), household exposure (aPR = 2.60;CI = 1.30-5.21), exposure to infectious patients (i.e., cavities on chest radiograph, acid-fast bacilli on sputum smear; aPR = 1.9 3; CI = 1.01-3.71), and exposure to a U.S.-born index patient (aPR = 4.04; CI = 1.95-8.38). Receipt of more than 1 month of treatment for latent TB infection following the current contact investigation was found to be protective (aPR = 0.27; CI = .08-0.93). Genotype results were concordant with the index patients among 14 of 15 contacts who developed active TB disease and had genotyping results available. CONCLUSIONS: Concordant genotype results and a high proportion of contacts developing active TB disease within 2 years of exposure indicate that those with prior positive TST results likely developed active TB disease from recent rather than remote infection. Healthcare providers should consider prophylaxis for contacts with prior TB infection, especially young children and close contacts of TB patients (e.g., those with household exposure).

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.

Using QuantiFERON-TB Gold In-Tube for field-based tuberculosis contact investigations in congregate settings.

Contact investigations are crucial to controlling tuberculosis in the United States. In these investigations, the tuberculin skin test has been the primary test to detect tuberculosis infection. Interferon-γ release assays, such as the QuantiFERON-TB Gold In-Tube test, were recently introduced and are intended to address limitations of the tuberculin skin test. However, there are limited data on the use of these tests in contact investigations in congregate settings. We present 2 field-based investigations to highlight potential advantages, limitations, and feasibility of using the QuantiFERON-TB Gold In-Tube test in congregate setting investigations.

Cohort study of the mortality among patients in New York City with tuberculosis and COVID-19, March 2020 to June 2022.

Both tuberculosis (TB) and COVID-19 can affect the respiratory system, and early findings suggest co-occurrence of these infectious diseases can result in elevated mortality. A retrospective cohort of patients who were diagnosed with TB and COVID-19 concurrently (within 120 days) between March 2020 and June 2022 in New York City (NYC) was identified. This cohort was compared with a cohort of patients diagnosed with TB-alone during the same period in terms of demographic information, clinical characteristics, and mortality. Cox proportional hazards regression was used to compare mortality between patient cohorts. One hundred and six patients with concurrent TB/COVID-19 were identified and compared with 902 patients with TB-alone. These two cohorts of patients were largely demographically and clinically similar. However, mortality was higher among patients with concurrent TB/COVID-19 in comparison to patients with TB-alone, even after controlling for age and sex (hazard ratio 2.62, 95% Confidence Interval 1.66-4.13). Nearly one in three (22/70, 31%) patients with concurrent TB/COVID-19 aged 45 and above died during the study period. These results suggest that TB patients with concurrent COVID-19 were at high risk for mortality. It is important that, as a high-risk group, patients with TB are prioritized for resources to quickly diagnose and treat COVID-19, and provided with tools and information to protect themselves from COVID-19.

COVID-19 Case Investigation and Contact Tracing in New York City, June 1, 2020, to October 31, 2021.

Importance: Contact tracing is a core strategy for preventing the spread of many infectious diseases of public health concern. Better understanding of the outcomes of contact tracing for COVID-19 as well as the operational opportunities and challenges in establishing a program for a jurisdiction as large as New York City (NYC) is important for the evaluation of this strategy. Objective: To describe the establishment, scaling, and maintenance of Trace, NYC's contact tracing program, and share data on outcomes during its first 17 months. Design, Setting, and Participants: This cross-sectional study included people with laboratory test-confirmed and probable COVID-19 and their contacts in NYC between June 1, 2020, and October 31, 2021. Trace launched on June 1, 2020, and had a workforce of 4147 contact tracers, with the majority of the workforce performing their jobs completely remotely. Data were analyzed in March 2022. Main Outcomes and Measures: Number and proportion of persons with COVID-19 and contacts on whom investigations were attempted and completed; timeliness of interviews relative to symptom onset or exposure for symptomatic cases and contacts, respectively. Results: Case investigations were attempted for 941 035 persons. Of those, 840 922 (89.4%) were reached and 711 353 (75.6%) completed an intake interview (women and girls, 358 775 [50.4%]; 60 178 [8.5%] Asian, 110 636 [15.6%] Black, 210 489 [28.3%] Hispanic or Latino, 157 349 [22.1%] White). Interviews were attempted for 1 218 650 contacts. Of those, 904 927 (74.3%) were reached, and 590 333 (48.4%) completed intake (women and girls, 219 261 [37.2%]; 47 403 [8.0%] Asian, 98 916 [16.8%] Black, 177 600 [30.1%] Hispanic or Latino, 116 559 [19.7%] White). Completion rates were consistent over time and resistant to changes related to vaccination as well as isolation and quarantine guidance. Among symptomatic cases, median time from symptom onset to intake completion was 4.7 days; a median 1.4 contacts were identified per case. Median time from contacts' last date of exposure to intake completion was 2.3 days. Among contacts, 30.1% were tested within 14 days of notification. Among cases, 27.8% were known to Trace as contacts. The overall expense for Trace from May 6, 2020, through October 31, 2021, was approximately $600 million. Conclusions and Relevance: Despite the complexity of developing a contact tracing program in a diverse city with a population of over 8 million people, in this case study we were able to identify 1.4 contacts per case and offer resources to safely isolate and quarantine to over 1 million cases and contacts in this study period.

Tuberculosis rates among HIV-infected persons in New York City, 2001-2005.

We calculated population-based tuberculosis (TB) rates among HIV-infected persons in New York City from 2001 through 2005 using data from the city's TB and HIV/AIDS surveillance registries, and we examined those rates using linear trend tests and incidence rate ratios (IRRs). HIV-infected individuals had 16 times the TB rate of a "non-HIV" population (HIV status negative or unknown; IRR = 16.0; 95% confidence interval = 14.9, 17.2). TB rates declined significantly among the US-born HIV-infected population (P (trend) < .001) but not among the foreign-born HIV-infected population (P (trend) = .355). Such disparities must be addressed if further declines are to be achieved.

Motor vehicle occupant injury and related hospital expenditures in children aged 3 years to 8 years covered versus uncovered by booster seat legislation.

BACKGROUND: Although most states have infant restraint laws, booster seat legislation for older children has not been implemented universally despite evidence of effectiveness. We examined injury and expenditures for motor vehicle traffic (MV) occupant injury among 3 year to 8 year olds covered versus uncovered by booster seat legislation. METHODS: Age, state of residence/hospitalization, and month of injury were used to examine injury, deaths, and expenditures due to MV occupant injury in children covered versus uncovered by booster seat legislation. Data sources included Kids Inpatient Database 2003 and Web-based Injury Statistics Query and Reporting System. Statistical analyses used chi, Fisher's exact, and analysis of variance. Odds ratios were calculated with 95% confidence intervals (CI). RESULTS: Children covered by booster seat legislation were less likely to be hospitalized for MV occupant injury than uncovered children (odds ratio, 0.78; 95% CI, 0.69-0.88). MV occupant injury constituted a smaller proportion of total injury expenditures in children covered (4.9%) versus uncovered (6.9%) by booster seat legislation. Covered children residing in areas with zip code incomes above the median had 26% lower MV occupant/total injury (p = 0.001) compared with 13% lower MV occupant/total injury for those below the median income (p = 0.0712). The proportion of injury dollars spent for MV occupant injury was higher in self-pay children for covered (7.8%) and uncovered (8.9%) children. CONCLUSIONS: This study suggests that booster seat laws are associated with a lower proportion of injury expenditures for MV occupant injuries in booster seat-aged children. Observed income disparities raise questions regarding whether access to booster seats, quality of affordable seats, and proper use and/or enforcement strategies impede legislative effectiveness.

Motor vehicle injury, mortality, and hospital charges by strength of graduated driver licensing laws in 36 States.

BACKGROUND: To assess the relation between strength of graduated driver licensing (GDL) laws and motor vehicle (MV) injury burden, this study examined injury mortality, hospitalizations and related charges for 15 year to 17 year olds in 36 states by strength of GDL legislation. METHODS: Data sources include the CDC's Web-Based Injury Statistics Query and Reporting System (WISQARS) and the 2003 Healthcare Cost and Utilization Kids' Inpatient database (KID). Hospital admissions for injuries in 15 year to 17 year olds (n = 49,520) are unweighted. Injury severity was assessed using ICDMAP-90 and International Classification of Injury Severity Scores. The Insurance Institute for Highway Safety rating system was used to categorize legislative strength: good, fair, marginal/poor, and none. Logistic regression was used to assess independent predictors of MV injury. RESULTS: MV injury accounted for 14.6% of all-cause injury-related hospital admissions with 47.7% classified as drivers. Total MV occupant mortality was 14.6% lower after enactment of GDL with greater improvement observed in the good law category (26.0%). In multivariate models for hospitalized injury, all GDL law categories were protective for MV driver injury in 16 year olds. Compared with whites, black and Hispanic teens were more frequently injured as passengers than drivers. The contribution of MV occupant to all-cause injury-related hospital charges was 16.0% lower in good versus no-GDL categories and 39.5% lower for MV drivers. CONCLUSIONS: These findings suggest that the presence of any GDL legislation is associated with a lower burden of MV-related injury and expenditures with the largest differences observed for 16-year-old drivers.

Factors Associated With Sputum Culture-Negative vs Culture-Positive Diagnosis of Pulmonary Tuberculosis.

Importance: Recognition of active tuberculosis (TB) in its earliest stages could reduce morbidity and prevent advancement to transmissible disease. Little is published about the occurrence and presentation of sputum culture-negative pulmonary TB (PTB), an early paucibacillary but often underrecognized disease state. Objective: To assess differences between culture-negative and culture-positive PTB regarding occurrence, clinical presentation, radiographic findings, demographics, and comorbidities. Design, Setting, and Participants: Cross-sectional study in which surveillance data of adult patients with PTB reported to the New York City Department of Health in New York, New York, from 2011 through 2013, ie, years for which demographic, clinical, and radiographic data were collected. Patients were aged 18 years or older, had signs of pulmonary disease, and had mycobacterial sputum culture results; those with HIV coinfection or a TB diagnosis within 2 years prior to presentation were excluded. Culture-negative PTB was defined as clinical and radiographic presentation consistent with TB, 3 negative results on sputum culture, and improvement with antituberculous treatment. The analyses were performed between 2015 and 2016; notably, the proportion of reported patients with culture-negative PTB has remained consistent during the past 2 decades. Main Outcomes and Measures: The occurrence of culture-negative PTB among all patients with PTB was calculated, and demographics, comorbidities, symptoms, and radiographic findings were compared between culture-negative and culture-positive PTB. Results: Of the 796 patients with PTB (median [interquartile range] age, 41 [29-54] years; 499 [63%] men) who met criteria for analysis, 116 (15%) had negative results on sputum culture. Patients with culture-negative PTB compared with culture-positive PTB were less frequently male (53% vs 64%; P = .03) and presented with a significantly lower frequency of cough (68% vs 89%; P < .001), weight loss (39% vs 51%; P = .03), and cavitation on both chest radiograph (7% vs 28%; P < .001) and chest computed tomographic scan (26% vs 59%; P < .001). Conclusions and Relevance: Given the lack of criterion-standard test confirmation and the relative paucity of symptoms and radiological abnormalities, culture-negative PTB is likely underdiagnosed and its occurrence underestimated globally. Awareness of these findings, enhanced diagnostic approaches, and, ideally, better biomarkers could improve detection and treatment of this early disease and reduce the development of transmissible TB.

National injury-related hospitalizations in children: public versus private expenditures across preventable injury mechanisms.

BACKGROUND: Examination of expenditures in areas where more universal application of effective injury prevention approaches is indicated could identify specific mechanisms and age groups where effective intervention may impact public injury-related expenditures. METHODS: The Healthcare Cost and Utilization Project 2003 (KID-HCUP) contains acute care hospitalization data for U.S. children and adolescents residing in 36 states. The study population includes 240,248 unweighted (397,943 weighted) injury-related hospital discharges for ages 0 to 19 years. Injury severity was assessed using ICDMAP-90 and International Classification of Injury Severity Scores (ICISS). SUDAAN was employed to adjust variances for stratified sampling. Expenditures were weighted to represent the U.S. population. RESULTS: Injury-related hospitalizations (mean $28,137 +/- 64,420, median $10,808) were more costly than non-injury discharges, accounting for approximately 10% of all persons hospitalized (unweighted), but more than one-fifth of expenditures. Public sources were the primary payor for 37.7% of injured persons. Incidence and cost per case variations across specific injury mechanisms heavily influenced total mechanism specific expenditures. Motor vehicle crashes were the largest expenditures for private and public payors with two thirds of expenditures in teenagers - more than 40% for drivers. Medicaid covered 45.6% ($192 million) of burn expenditures and 59.2% in 0-4 year olds. Expenditures per case (mean +/- SD, median) were: firearm ($36,196 +/- 58,052, $19,020), motor vehicle driver ($33,731 +/- 50,583, $18,431), pedestrian ($31,414 +/- 57,103, $16,552); burns ($29,242 +/- 64,271, $10,739); falls ($13,069 +/- 20,225, $8,610); and poisoning ($8,290 +/- $15,462, $5,208). CONCLUSIONS: More universal application of proven injury prevention has the potential to decrease both the public and private health expenditure burden among several modifiable injury mechanisms.

Increasing the efficiency and yield of a tuberculosis contact investigation through electronic data systems matching.

BACKGROUND: Electronic health data may improve the timeliness and accuracy of resource-intense contact investigations (CIs) in healthcare settings. METHODS: In September 2013, we initiated a CI around a healthcare worker (HCW) with infectious tuberculosis (TB) who worked in a maternity ward. Two sources of electronic health data were employed: hospital-based electronic medical records (EMRs), to identify patients exposed to the HCW, and an electronic immunization registry, to obtain contact information for exposed infants and their providers at two points during follow-up. RESULTS: Among 954 patients cared for in the maternity ward during the HCW's infectious period, the review of EMRs identified 285 patients (30%) who interacted with the HCW and were, thus, exposed to TB. Matching infants to the immunization registry offered new provider information for 52% and 30% of the infants in the first and second matches. Providers reported evaluation results for the majority of patients (66%). CONCLUSION: Data matching improved the efficiency and yield of this CI, thereby demonstrating the usefulness of enhancing CIs with electronic health data.

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.