HIV counseling and testing in tuberculosis contact investigations in the United States and Canada.

BACKGROUND: Determining the human immunodeficiency virus (HIV) status of tuberculosis (TB) patients and contacts is important. Despite existing guidelines, not all patients are tested, and testing of contacts is rarely performed. METHODS: In a study conducted at nine US/Canadian sites, we introduced formal procedures for offering HIV testing to TB patients and contacts. Data were collected via interviews and medical record review. Characteristics associated with offering and accepting HIV testing were examined. RESULTS: Of 651 TB patients, 601 (92%) were offered testing, 511 (85%) accepted, and 51 (10%) were HIV-infected. Of 4152 contacts, 3099 (75%) were offered testing, 1202 (39%) accepted, and 24 (2%) were HIV-infected. Contacts aged 15-64 years, non-Whites, foreign-born persons, smokers, those with positive TB screening, and household contacts were more likely to be offered testing, whereas contacts exposed to HIV-negative patients were less likely to be offered testing. Contacts aged 15-64 years, smokers, drug/alcohol users, diabetics, and those with positive TB screening were more likely to accept testing. Foreign-born persons, Blacks, Hispanics, and contacts exposed to HIV-positive patients were less likely to accept testing. CONCLUSIONS: High rates of HIV were detected among patients and contacts. Despite structured procedures to offer HIV testing, some patients and most contacts did not accept testing. Strategies are needed to improve testing acceptance rates.

Risk factors for treatment default in close contacts with latent tuberculous infection.

OBJECTIVE: 1) To characterize risk factors for non-completion of latent tuberculous infection treatment (LTBIT), and 2) to assess the impact of LTBIT regimens on subsequent risk of tuberculosis (TB). METHODS: Close contacts of adults aged ⩾15 years with pulmonary TB were prospectively enrolled in a multi-center study in the United States and Canada from January 2002 to December 2006. Close contacts of TB patients were screened and cross-matched with TB registries to identify those who developed active TB. RESULTS: Of 3238 contacts screened, 1714 (53%) were diagnosed with LTBI. Preventive treatment was recommended in 1371 (80%); 1147 (84%) initiated treatment, of whom 723 (63%) completed it. In multivariate analysis, study site, initial interview sites other than a home or health care setting and isoniazid preventive treatment (IPT) were significantly associated with non-completion of LTBIT. Fourteen TB cases were identified in contacts, all of whom initiated IPT: two TB cases among persons who received ⩾6 months of IPT (66 cases/100 000 person-years [py]), and nine among those who received 0-5 months (median 2 months) of IPT (792 cases/100 000 py, P < 0.001); data on duration of IPT were not available for three cases. CONCLUSION: Only 53% (723/1371) of close contacts for whom IPT was recommended actually completed treatment. Close contacts were significantly less likely to complete LTBIT if they took IPT. Less than 6 months of IPT was associated with increased risk of active TB.

Outcomes of contact investigation among homeless persons with infectious tuberculosis.

SETTING: Homelessness is an important risk factor for tuberculosis (TB). Health departments often fail to identify contacts for homeless TB cases, but little else is known about the outcome of contact investigations for these cases. OBJECTIVE: To describe the outcomes of identification, tuberculin skin testing (TST), clinical evaluation and treatment for contacts of infectious homeless TB cases. DESIGN: Retrospective multicenter review of data of contact investigations conducted in 1996 by five health departments in the United States. RESULTS: Twenty-seven (8%) of 349 TB cases were homeless. Failure to identify contacts occurred in six (50%) of 12 cases residing in shelters vs. one (7%) of 15 non-shelter cases. Of 479 contacts identified, 297 (62%) were fully evaluated, 97 (20%) had only initial testing, and 85 (18%) were not evaluated. Of the 394 evaluated contacts, 13 (3%) had a prior positive TST. Of the remaining 381 contacts, six (1.6%) had active TB and 67 (17.6%) were TST-positive. Only 27 (44%) of 61 contacts completed treatment for latent TB infection. CONCLUSION: Despite the failure to identify contacts for some cases, contact investigations for homeless TB cases identified large numbers of contacts for whom evaluation and treatment were often not completed. Prospective studies with more complete documentation are needed to improve contact investigations for homeless TB cases.

Workplace contact investigations in the United States.

SETTING: Five state tuberculosis (TB) control programs in the United States. OBJECTIVES: To determine the prevalence of and treatment for latent TB infection (LTBI) among contacts of active TB cases identified in the workplace, and to describe TB control program policies for the initiation and conduct of workplace investigations. DESIGN: Retrospective review of health department records for all culture-positive pulmonary tuberculosis cases aged > or = 15 years reported in 1996, and their contacts. RESULTS: There were 349 cases of active TB, of whom 134 (38%) were employed. Workplace contact investigations were conducted for 42 cases, resulting in the identification of 724 contacts. The rate of LTBI was 29% overall, varying by worksite from a low of 16% to a high of 51%. LTBI estimates were higher for fully-screened contacts of smear-positive rather than of smear-negative index cases. However, fully-screened contacts of index patients with cavitary disease had lower LTBI estimates than those of index patients without cavitation. Treatment for LTBI was initiated in 45% of infected contacts. The five programs had somewhat variable policies regarding workplace contact investigations. Data on HIV co-infection and place of birth of contacts were largely missing. CONCLUSION: Factors contributing to LTBI among workplace contacts may include the presence of persons with pre-existing LTBI or a positive skin test as a result of BCG vaccination, clinical characteristics of the index case, and workplace environmental characteristics conducive to transmission. Standard guidelines for workplace investigations, written workplace investigation policies, and standard data collection practices are needed to better apportion the causes of observed infection rates in the workplace.

Results of testing for human immunodeficiency virus infection among recent contacts of infectious tuberculosis cases in the United States.

CONTEXT: Persons with recently acquired latent tuberculosis (TB) infection and human immunodeficiency virus (HIV) co-infection are at high risk of rapid progression to TB disease. OBJECTIVES: To determine the proportion of close contacts of infectious TB patients tested for HIV, and the results of HIV testing for this group. DESIGN, SETTING AND SUBJECTS: Review of health department records for all close contacts of 349 patients with culture-positive pulmonary TB aged 15 years or older reported from five study areas in the United States in 1996. MAIN OUTCOME MEASURES: Proportion of close contacts of TB patients tested for HIV, and rate of HIV infection among close contacts of TB patients. RESULTS: A total of 1169 close contacts were identified for 349 patients with active pulmonary TB. HIV test results were available for 224 (64%) TB patients and 220 (19%) close contacts. Of the TB patients tested, 164 (73%) were HIV-negative and 60 (27%) were HIV-positive. An equal proportion of close contacts of HIV-positive and -negative TB patients were tested (21% vs. 24%). Of the close contacts tested, 201 (91%) were HIV-negative and 19 (9%) were HIV-positive. Compared with close contacts of HIV-negative TB patients, close contacts of HIV-positive TB patients were more likely to be HIV-positive (53% vs. 2%; P < 0.01). This association was observed for contacts residing in the TB patient household (70% vs. none; P < 0.01), not residing in the TB patient household (20% vs. 4%; P < 0.05), 25-44 years of age (88% vs. 8%; P < 0.01), and > 44 years of age (22% vs. 2%; P < 0.05). CONCLUSIONS: HIV-positive TB patients and their close contacts may share some of the same risk factors for HIV infection. These findings suggest that the HIV status of the TB patient, in addition to established risk factors for HIV infection, may be an important consideration for prioritizing voluntary HIV counseling and testing efforts among close contacts of infectious TB patients.

Cluster survey evaluation of coverage and risk factors for failure to be immunized during the 1995 National Immunization Days in Egypt.

BACKGROUND: In 1995, Egypt continued to experience endemic wild poliovirus transmission despite achieving high routine immunization coverage with at least three doses of oral poliovirus vaccine (OPV3) and implementing National Immunization Days (NIDs) annually for several years. METHODS: Parents of 4188 children in 3216 households throughout Egypt were surveyed after the second round of the 1995 NIDs. RESULTS: Nationwide, 74% of children are estimated to have received both NID doses, 17% one NID dose, and 9% neither NID dose. Previously unimmunized (47%) or partially immunized (64%) children were less likely to receive two NID doses of OPV than were fully immunized children (76%) (P < 0.001). Other risk factors nationwide for failure to receive NID OPV included distance from residence to nearest NID site >10 minute walk (P < 0.001), not being informed about the NID at least one day in advance (P < 0.001), and residing in a household which does not watch television (P < 0.001). Based on these findings, subsequent NIDs in Egypt were modified to improve coverage, which has resulted in a marked decrease in the incidence of paralytic poliomyelitis in Egypt. CONCLUSIONS: In selected situations, surveys can provide important information that is useful for planning future NIDs.

PIP: In 1995, Egypt was experiencing endemic wild poliovirus transmission despite achieving high routine immunization coverage with at least 3 doses of oral poliovirus vaccine (OPV3) and implementing National Immunization Days (NIDs) annually for several years. The parents of 4188 children aged 0-47 months in 3216 households throughout Egypt were surveyed after the second round of the 1995 NID in an attempt to gain some insight into the extent of NID OPV coverage nationwide, why children were not immunized during the NIDs, and the effectiveness of the NID media campaign. Countrywide, an estimated 74% of children have received both NID doses, 17% 1 NID dose, and 9% neither NID dose. Previously unimmunized (47%) or partially immunized (64%) children were less likely to receive 2 NID doses of OPV than were fully immunized children (76%). Other risk factors nationwide for failing to receive NID OPV included living farther than 10 minutes by foot from the nearest NID site, not being informed about the NID at least 1 day in advance, and living in a household which does not watch television. Based upon these findings, subsequent NIDs in Egypt were changed to improve coverage, which has resulted in a marked decrease in the incidence of paralytic poliomyelitis in the country.

Emergence of antibody to capsular polysaccharides of Streptococcus pneumoniae during outbreaks of pneumonia: association with nasopharyngeal colonization.

Antibody to pneumococcal capsular polysaccharides (PPS) of Streptococcus pneumoniae plays a major role in protecting the host against pneumococcal infection. A variable proportion of healthy adults have antibody to PPS, often in the absence of recognized pneumococcal infection. To determine whether exposure to pneumococci or colonization by pneumococci, or both, stimulates the emergence of antibody to PPS, we studied outbreaks of pneumonia at two military camps. Of the men who were present at a military training camp during an outbreak of pneumonia due to S. pneumoniae serotype 1 but who did not develop pneumonia, 27.8% had IgG antibody to PPS 1, whereas only 3.6% of controls had this antibody. In another outbreak caused by S. pneumoniae serotypes 7F and 8, 35.9% of asymptomatic soldiers who had nasopharyngeal colonization by one of these strains had antibody to the relevant PPS, and another 30.8% who originally did not have antibody developed it within 30 days; thus, 66.7% of these soldiers had antibody to the relevant PPS. These data show that serotype-specific antibody promptly appears following exposure to an outbreak of pneumococcal pneumonia and is probably mediated through acquisition of nasopharyngeal pneumococcal carriage.

Progress toward poliomyelitis eradication in the Eastern Mediterranean Region of the World Health Organization.

The Eastern Mediterranean Region (EMR) of the World Health Organization has made substantial progress toward eradicating poliomyelitis. From 1988 to 1995, the number of confirmed cases of polio decreased 66%, from 2342 to 789. National immunization days were conducted in 18 (78%) of the 23 countries in 1995, representing 88% of the regional population. By 1995, 20 countries (87%) in the EMR had established systems for reporting acute flaccid paralysis (AFP), 20 (87%) were investigating AFP or polio cases epidemiologically, 18 (78%) had initiated follow-up at 60 days to confirm or discard suspected polio cases, 7 (30%) had achieved nonpolio AFP rates of > or = 1.0/100,000 children <15 years of age (a measure of the sensitivity of surveillance), and 16 (70%) had made laboratory investigations of polio cases for 1281 (74%) of the 1715 AFP cases reported in the EMR. Despite significant progress, the success of the polio eradication initiative in the EMR will depend on finding solutions to a number of technical, managerial, political, and financial challenges.

Outbreak of paralytic poliomyelitis in a highly immunized population in Jordan.

Between November 1991 and March 1992, 37 cases of paralytic poliomyelitis occurred in Jordan, where none had been reported since 1988. Of these, 17 (50%) of 34 patients had received at least three doses of oral poliovirus vaccine (OPV3). The first and 2 subsequent case-patients were children of Pakistani migrant workers, and the first 8 and a total of 27 (75%) case-patients resided in or near the Jordan Valley. A seroepidemiologic study of 987 children in all regions of Jordan was performed to assess OPV3 coverage and immune response to OPV. Although OPV3 coverage by 12 months of age was high (96%) in the general population, coverage was lower among Pakistani (21%), Bedouin (63%), and Gypsy (9%) children (P < .001). Seroprevalences for poliovirus type 3 were 71% in the Jordan Valley versus 81% in other regions after 3 doses of OPV (P < .06) and 77% in the Jordan Valley versus 98% in other regions after 5 doses of OPV (P < .001). This outbreak demonstrates the importance of achieving high seroimmunity to infection in all geographic areas to prevent the reintroduction and spread of imported strains of wild poliovirus.

Increased immunogenicity of oral poliovirus vaccine administered in mass vaccination campaigns compared with the routine vaccination program in Jordan.

To compare the immunogenicity of routine versus mass campaign doses of oral poliovirus vaccine (OPV), serum neutralizing antibodies were measured in 254 children before and after two mass vaccination campaigns in Jordan. Precampaign seroprevalences to poliovirus types 1, 2, and 3 in children who had received three, four, or five routine doses of OPV were compared with postcampaign seroprevalences in children who had received one, two, or three routine doses plus two mass campaign doses. Seroprevalences were consistently higher in subgroups that received two doses through mass campaigns than in subgroups that received all doses through the routine program, especially for poliovirus type 3. Geometric mean titers were also consistently higher for mass campaign subgroups, particularly for poliovirus type 3. The findings suggest that adding further doses of OPV to the routine schedule is unlikely to have as great an impact on the immune state of children as administering the same number of doses during mass campaigns.

Evaluation of oral poliovirus vaccine delivery during the 1994 national immunization days in Pakistan.

Pakistan conducted national immunization days (NIDs) for the first time in 1994. To estimate coverage, to evaluate risk factors for failure to be immunized, and to determine the effectiveness of mass media, parents of 1288 children in 714 households in four districts were surveyed after the first NID round. In each district, a high proportion of children (93%-96%) received oral poliovirus vaccine (OPV) during the NID. In three districts, unimmunized or partially immunized children were less likely to receive NID OPV than were fully immunized children (Kohistan, P < .001; Quetta, P < .001; and Sibi, P = .05). Although a high proportion of children in each age cohort received NID OPV, in three districts children 0-11 months of age were less likely to receive NID OPV than were older children. Television and radio reached a high proportion of survey households, but other mass media were less effectively utilized. Risk factor and media effectiveness surveys provide important information that is useful for planning future NIDs.

Spread of multidrug-resistant Streptococcus pneumoniae among hospitalized children in Slovakia.

A multidrug-resistant serotype 14 strain of Streptococcus pneumoniae was isolated from sterile-site specimens and nasopharyngeal secretions from > 200 children in Slovakia between 1985 and 1990. Nasopharyngeal culture surveys were done to determine the extent of spread and means of transmission of this strain. The resistant strain was isolated from cultures of 8 (33.0%) of 24 children at hospital A and from 1 (0.8%) of 130 children attending outpatient clinics or day care centers (P < .001). One-quarter of the initially uncolonized children at hospital A acquired the resistant strain during hospitalization. Among hospitalized children, frequent antimicrobial drug use (P < .01), prior hospitalization (P < .005), and length of hospital stay (P < .001) were associated with infection with the resistant strain. These findings support limiting broad-spectrum antimicrobial drug use and nonessential hospitalizations in settings were drug-resistant pneumococci are prevalent. Development of a pneumococcal vaccine that is immunogenic in young children is urgently needed.

Multiple antimicrobial resistance of pneumococci in children with otitis media, bacteremia, and meningitis in Slovakia.

Penicillin-resistant pneumococci have been isolated from middle ear fluid, blood, cerebrospinal fluid, and nasopharyngeal secretions of several hundred children in Slovakia since 1985; 116 of these isolates were serotyped and tested for susceptibility to antimicrobial drugs at the Centers for Disease Control and Prevention. To define the prevalence of drug-resistant pneumococci and identify risk factors for infection, laboratory and medical records were reviewed. Nearly all (96%) of the resistant strains tested were serotype 14. Of these, all were resistant to penicillin (MIC, 4-16 micrograms/mL); most were resistant to cefaclor, erythromycin, tetracycline, and chloramphenicol; and many had decreased susceptibility to trimethoprim-sulfamethoxazole and ceftriaxone. Frequent antibiotic use, prior hospitalization, and length of hospital stay (P < .001 for all 3) were associated with infection with resistant strains. These findings suggest the need for routine screening of pneumococcal isolates for penicillin resistance and highlight the importance of controlling globally the spread of resistant pneumococci.

An epidemic of pneumococcal disease in an overcrowded, inadequately ventilated jail.

BACKGROUND: In the United States many correctional facilities now operate at far over capacity, with the potential for living conditions that permit outbreaks of respiratory infections. We investigated an outbreak that was identified in an overcrowded Houston jail after two inmates died of pneumococcal sepsis on the same day. Outbreaks of pneumococcal disease have been rare in the era of antibiotics. METHODS: We assessed risk factors for pneumococcal disease in both a case-control and a cohort study. Ventilation was evaluated by measuring carbon dioxide levels and air flow to the living areas of the jail. The extent of asymptomatic infection was determined by culturing pharyngeal specimens from a random sample of inmates. Type-specific immunity was determined with an enzyme immunoassay. RESULTS: Over a four-week period, 46 inmates had either acute pneumonia or invasive pneumococcal disease due to Streptococcus pneumoniae serotype 12F. The jail's capacity had been set at 3500 inmates, but it housed 6700 at the time of the outbreak; the inmates had a median living area of only 34 ft2 (3.2 m2) (interquartile range, 28 to 56 ft2 [2.6 to 5.2 m2]) per person. There were significantly fewer cases of disease among inmates with 80 ft2 (7.4 m2) per person or more (P = 0.030). Carbon dioxide levels ranged from 1100 to 2500 ppm (acceptable, < 1000), and the ventilation system delivered a median of only 6.1 ft3 of outside air per minute per person (interquartile range, 4.4 to 8.5 ft3; recommended, > or = 20 ft3). The attack rate was highest among inmates in cells with the highest carbon dioxide levels and the lowest volume of outside air delivered by the ventilation system (relative risk, 1.94; 95 percent confidence interval, 1.08 to 3.48). Of underlying medical conditions, intravenous drug use was most strongly associated with disease (odds ratio, 4.50). The epidemic strain (serotype 12F) was cultured from 7 percent of the asymptomatic inmates. Of 11 case patients tested with the enzyme immunoassay, 9 (82 percent) lacked preexisting immunity to this strain. CONCLUSIONS: Severe overcrowding, inadequate ventilation, and altered host susceptibility all contributed to this outbreak of pneumococcal disease in a large urban jail.

The spread of multiply resistant Streptococcus pneumoniae at a day care center in Ohio.

Streptococcus pneumoniae, type 23F, resistant to penicillin (MIC, 2 micrograms/mL) and multiple other antimicrobic agents, was isolated from middle ear fluid of a child with otitis media attending a day care center in Ohio. To determine the extent of spread of this strain, nasopharyngeal culture surveys were done, and 52 carriers were identified among 250 children attending the index day care center. No carriers were found among 121 children at two other day care centers in the same urban area. Use of prophylactic doses of antibiotics (P < .001) and frequent use of antibiotics (P < 0.001) were risk factors for nasopharyngeal carriage. Carriers were more likely to have had frequent otitis media episodes (P < .02) and otitis media not responsive to antimicrobial therapy (P < .001). Strategies to limit the spread of highly resistant pneumococcal strains should include encouraging judicious use of antimicrobic agents and reevaluating indications for prophylactic use of antimicrobic agents.