Transmission of tuberculosis to close contacts of patients with multidrug-resistant tuberculosis.

Multidrug-resistant tuberculosis (MDRTB) has emerged as a major public health problem worldwide. To determine the incidence and risk factors associated with tuberculosis among contacts of MDRTB index cases, we studied human immunodeficiency virus-seronegative close contacts of 64 culture-confirmed MDRTB patients in Rio de Janeiro, Brazil. Between March 1988 and July 1992, tuberculosis developed in 17 (7.8%) of 218 previously healthy close contacts of 64 MDRTB index cases (1.6 cases per 1,000-person-months of contact). Among strains of Mycobacterium tuberculosis isolated from 13 contacts of 12 index cases, six (46%) had susceptibility patterns identical to those of their index cases, four (31%) had different patterns of resistance, and three (23%) were susceptible to all drugs. Tuberculosis developed more frequently in male contacts (p < 0.05), persons > or = 15 yr of age (p < 0.05), nonwhites (p < 0.001), and persons not previously vaccinated with bacillus Calmette-Guerin (BCG) (p < 0.05). The association of BCG vaccination with decreased risk of disease was significant even when this variable was controlled (by Cox's regression analysis) for age, sex, race, purified protein derivative (PPD) status, and isoniazid prophylaxis. BCG vaccination appears to offer protection against tuberculosis during prolonged exposures to persons with MDRTB, which identifies a novel and specific indication of BCG use.

HIV infection in 567 active pulmonary tuberculosis patients in Brazil.

We studied 567 patients with active pulmonary tuberculosis (APT) in Rio de Janeiro, Brazil, by using a standardized questionnaire and by testing blood for HIV antibodies. The rate of HIV infection was 3.9% in 1987, 4.8% in 1988, and 5.2% in 1989, and did not differ by sex. It was highest (7.4%) in the 15- to 39-year age group. There was no difference between patients infected and not infected by HIV with regard to education, income, housing, or employment. Among all patients with definite HIV risk behavior, the HIV infection rate was 23.3%, rising to 31.2% among homo/bisexual men and 36.4% among intravenous drug users, and the rate was 6.5% for blood-transfusion recipients. Among patients who denied risk behavior, the rate was 1.2%. Generalized lymphadenopathy and oral candidiasis occurred with greater frequency among HIV-infected patients (p < 0.0001). Applying the World Health Organization 1985 clinical criteria and revised case definition for AIDS, we found, respectively, sensitivities of 34% and 76.9% and specificities of 31% and 26.3%; in the Rio de Janeiro environment, these clinical criteria without HIV serology should not be adopted for tuberculosis patients. For chest radiographs, a significant association was found between HIV infection and the occurrence of atypical images (p = 0.0001), and hilar and/or mediastinal adenopathy (p = 0.0002) and absence of cavities (p = 0.0003). A PPD (purified protein derivative) skin test induration of < 5 mm was identified in 53% of the HIV-positive cases and in 31.3% of the HIV-negative cases. Only 11.5% of HIV-infected APT patients met the Centers for Disease Control 1987 AIDS criteria.