COVID-19 Case Investigations Among Federally Quarantined Evacuees From Wuhan, China, and Exposed Personnel at a US Military Base, United States, February 5-21, 2020.

In February 2020, during the early days of the COVID-19 pandemic, 232 evacuees from Wuhan, China, were placed under federal 14-day quarantine upon arrival at a US military base in San Diego, California. We describe the monitoring of evacuees and responders for symptoms of COVID-19, case and contact investigations, infection control procedures, and lessons learned to inform future quarantine protocols for evacuated people from a hot spot resulting from a novel pathogen. Thirteen (5.6%) evacuees had COVID-19-compatible symptoms and 2 (0.9%) had laboratory-confirmed SARS-CoV-2. Two case investigations identified 43 contacts; 3 (7.0%) contacts had symptoms but tested negative for SARS-CoV-2 infection. Daily symptom and temperature screening of evacuees and enacted infection control procedures resulted in rapid case identification and isolation and no detected secondary transmission among evacuees or responders. Lessons learned highlight the challenges associated with public health response to a novel pathogen and the evolution of mitigation strategies as knowledge of the pathogen evolves.

Performance of the Xpert MTB/RIF assay for the diagnosis of pulmonary tuberculosis and rifampin resistance in a low-incidence, high-resource setting.

Performance of the Xpert MTB/RIF assay, designed to simultaneously detect Mycobacterium tuberculosis complex (MTBC) and rifampin (RIF) resistance, has been well documented in low-resource settings with high TB-incidence. However, few studies have assessed its accuracy in low TB incidence settings. We evaluated the performance of Xpert MTB/RIF using clinical sputum specimens routinely collected from suspect pulmonary TB patients over a 4-year time period in San Diego County, California. Xpert MTB/RIF results were compared to acid-fast bacilli (AFB) smear microscopy, mycobacterial culture, and phenotypic drug susceptibility testing (DST). Of 751 sputum specimens, 134 (17.8%) were MTBC culture-positive and 2 (1.5%) were multidrug-resistant (MDR). For the detection of MTBC, Xpert MTB/RIF sensitivity was 89.6% (97.7% and 74.5% in smear-positive and -negative sputa, respectively) and specificity was 97.2%; while AFB smear sensitivity and specificity were 64.9% and 77.8%, respectively. Xpert MTB/RIF detected 35 of 47 smear-negative culture-positive specimens, and excluded 124 of 137 smear-positive culture-negative specimens. Xpert MTB/RIF also correctly excluded 99.2% (121/122) of nontuberculous mycobacteria (NTM) specimens, including all 33 NTM false-positives by smear microscopy. For the detection of RIF resistance, Xpert MTB/RIF sensitivity and specificity were 100% and 98.3%, respectively. Our findings demonstrate that Xpert MTB/RIF is able to accurately detect MTBC and RIF resistance in routinely collected respiratory specimens in a low TB-incidence setting, with comparable performance to that achieved in high-incidence settings; and suggest that under these conditions the assay has particular utility in detecting smear-negative TB cases, excluding smear-positive patients without MTBC disease, and differentiating MTBC from NTM.

Civil Surgeon Tuberculosis Evaluations for Foreign-Born Persons Seeking Permanent U.S. Residence.

Foreign-born persons in the United States seeking to adjust their status to permanent resident must undergo screening for tuberculosis (TB) disease. Screening is performed by civil surgeons (CS) following technical instructions by the Centers for Disease Control and Prevention. From 2011 to 2012, 1,369 practicing CS in California, Texas, and New England were surveyed to investigate adherence to the instructions. A descriptive analysis was conducted on 907 (66%) respondents. Of 907 respondents, 739 (83%) had read the instructions and 565 (63%) understood that a chest radiograph is required for status adjustors with TB symptoms; however, only 326 (36%) knew that a chest radiograph is required for immunosuppressed status adjustors. When suspecting TB disease, 105 (12%) would neither report nor refer status adjustors to the health department; 91 (10%) would neither start treatment nor refer for TB infection. Most CS followed aspects of the technical instructions; however, educational opportunities are warranted to ensure positive patient outcomes.

Factors associated with genotype clustering of Mycobacterium tuberculosis isolates in an ethnically diverse region of southern California, United States.

Mycobacterium tuberculosis (Mtb) isolates with identical genotypes, found in different patients, are most likely the result of recent transmission. Mtb strains with closely related genotypes, called clonal complexes, are most likely derived from one another. We examined Mtb genotypes from southern California TB patients from 2005 through 2008 to complete the first comprehensive molecular epidemiology analysis of this complicated and ethnically diverse region. Mtb genotypes were characterized with spoligotype and MIRU-12 typing. MIRU-VNTRplus was utilized to assign genotypes to global lineages and complete cluster analyses. Associations between patient characteristics and genotype clustering and clonal complexes were evaluated using logistic regression and frequency analysis. Of 832 Mtb isolates analyzed, 480 (58%) fell into 94 strain clusters. The majority of isolates were identified as being in the EA1 (31%), LAM (17%) and Haarlem (15%) lineages, but 13 different lineages were found in this region. TB patients with clustered isolates were more likely to be homeless (AOR 3.44, 95% CI 1.65, 7.18) and male (AOR 1.57, 95% CI 1.17, 2.10). Of the 480 clustered strains, 388 aggregated into six clonal complexes. Over 45% of reported TB cases were clustered and likely resulted from recent transmission events. Patients with clustered Mtb isolates that were grouped into clonal complexes had unique socio-demographic characteristics. These data suggest that TB is being transmitted in relatively insular community networks defined by race/ethnicity and country of origin. The addition of clonal complex analysis to simple cluster analysis provides important public health insights into the local transmission of TB in ethnically diverse regions with diverse Mtb genotypes.

Evaluation of an Interferon Gamma Release Assay to Detect Tuberculosis Infection in Children in San Diego, California.

QuantiFERON-TB Gold In-Tube (QFT-GIT) and tuberculin skin test (TST) results are reported in 23 children with active tuberculosis due to Mycobacterium tuberculosis and Mycobacterium bovis. Overall QFT-GIT (96%) was more sensitive than TST (74%) for detecting tuberculosis infection in these patients.

Under- and over-nutrition among refugees in San Diego County, California.

Resettled refugees often arrive in their host country with little knowledge of nutrition or available food choices. We explored nutrition-related issues of recent refugee arrivals to San Diego County-the second largest California resettlement site. In-depth interviews (n = 40) were conducted with refugees, health care practitioners, and refugee service organizations. Content analysis identified nutrition-related themes. Unhealthy weight gain after arrival was the most common concern and was attributed to social pressures among adolescents, food choices and a more sedentary lifestyle. Conversely, undernutrition remained a concern due to poor diets. Factors influencing nutritional problems included continuation of past habits, acculturation, unfamiliarity with available foods and socio-economic influences. The nutritional concerns encountered by resettled refugees in San Diego are not unique to this group but are aggravated by their past experiences, and abrupt changes to food choices and behavior. Addressing contextual factors of poor food choices may prevent some of the long term health consequences of poor nutrition.

Tuberculosis due to Mycobacterium bovis in patients coinfected with human immunodeficiency virus.

We reviewed 86 cases of human immunodeficiency virus and tuberculosis coinfection; 34.9% were caused by Mycobacterium bovis. Patients with M. bovis infection were more likely to have advanced immunosuppression (CD4 T cell counts ≤200 cells/µL). Hispanic ethnicity, male sex, and abdominal disease were strongly associated with M. bovis disease.

HIV-tuberculosis coinfection in Southern California: evaluating disparities in disease burden.

OBJECTIVES: We sought to understand tuberculosis (TB) and HIV coinfection trends in San Diego County, California, and to identify associations between sociodemographic risk factors and TB and HIV coinfection. METHODS: We analyzed TB surveillance data from 1993 through 2007. TB cases were grouped by HIV status: positive, negative, or unknown. We used Poisson regression to estimate trends and tested associations between TB and HIV coinfection and sociodemographic risk factors with polychotomous logistic regression. RESULTS: Of 5172 TB cases, 8.8% were also infected with HIV. Incidence of coinfected cases did not change significantly over the period studied, but the proportion of cases among Hispanics increased significantly, whereas cases among non-Hispanic Whites and Blacks decreased. TB cases with HIV coinfection were significantly more likely to be Hispanic, male, injection drugs users, and aged 30 to 49 years, relative to cases with TB disease only. CONCLUSIONS: The burden of TB and HIV in San Diego has shifted to Hispanics in the last decade. To address this health disparity, binational TB and HIV prevention efforts are needed.

Influences of cross-border mobility on tuberculosis diagnoses and treatment interruption among injection drug users in Tijuana, Mexico.

OBJECTIVES: We sought to identify correlates of reported lifetime diagnoses of TB among injection drug users in the border city of Tijuana, Mexico. METHODS: Injection drug users in Tijuana were recruited into a prospective cohort study during 2006 and 2007. We used weighted multivariate logistic regression to identify correlates of TB diagnoses. RESULTS: Of the 1056 participants, 103 (9.8%) reported a history of TB, among whom 93% received anti-TB medication and 80% were diagnosed in the United States. Treatment was prematurely halted among 8% of patients; deportation from the United States was the cause of half of these treatment interruptions. History of travel to (odds ratio [OR] = 6.44; 95% confidence interval [CI] = 1.53, 27.20) or deportation from (OR = 1.83; 95% CI = 1.07, 3.12) the United States and incarceration (OR = 2.20; 95% CI = 1.06, 4.58) were independently associated with a reported lifetime diagnosis of TB. CONCLUSIONS: Mobility and migration are important factors in identifying and treating TB patients diagnosed in the US-Mexico border region. Strengthening capacity on both sides of the border to identify, monitor, and treat TB is a priority.

Tuberculosis from Mycobacterium bovis in binational communities, United States.

The epidemiology of tuberculosis (TB) in the United States is changing as the incidence of disease becomes more concentrated in foreign-born persons. Mycobacterium bovis appears to be contributing substantially to the TB incidence in some binational communities with ties to Mexico. We conducted a retrospective analysis of TB case surveillance data from the San Diego, California, region from 1994 through 2005 to estimate incidence trends, identify correlates of M. bovis disease, and evaluate risk factors for deaths during treatment. M. bovis accounted for 45% (62/138) of all culture-positive TB cases in children (<15 years of age) and 6% (203/3,153) of adult cases. M. bovis incidence increased significantly (p = 0.002) while M. tuberculosis incidence declined (p<0.001). Almost all M. bovis cases from 2001 through 2005 were in persons of Hispanic ethnicity. Persons with M. bovis were 2.55x (p = 0.01) as likely to die during treatment than those with M. tuberculosis.

Screening of immigrants and refugees for pulmonary tuberculosis in San Diego County, California.

STUDY OBJECTIVES: To evaluate the outcomes of a tuberculosis (TB) screening program for recent immigrants to San Diego County, CA, and to compare the demographic and clinical characteristics of pulmonary TB cases occurring in recently arrived foreign-born persons detected through this screening with those of similar cases found through routine surveillance. DESIGN: Retrospective review of computer databases and medical records. SETTING: Local public health department. PATIENTS: Recent immigrants and refugees classified as TB suspects in their country of departure and foreign-born patients with active TB detected through routine surveillance. RESULTS: Five hundred seventy-one of 658 immigrants and refugees (87%) of completed screening. Thirty-nine subjects (7%) were found to have active TB, and 433 subjects (76%) were found to have latent TB. A diagnosis of active TB was associated with age of 25 to 44 years (odds ratio, 3.6; 95% confidence interval, 1.1 to 11.6) and A (odds ratio, 25.7; 95% confidence interval, 1.3 to 512.2) or B1 classifications (odds ratio, 4.3; 95% confidence interval, 1.5 to 12.5). Cases detected through screening comprised 12% of all reported foreign-born persons with active TB. Compared to other recently arrived foreign-born persons with active TB, those detected through immigrant screening were more likely to be Asian and born in the Philippines and less likely to have advanced disease. CONCLUSIONS: Most immigrants and refugees classified as TB suspects by foreign screening completed the US screening process, which had a high yield for detecting active and latent TB. Only a minority of foreign-born persons (12%) with active TB were discovered through this program, however, and additional measures are needed to facilitate early case finding in other foreign-born populations.

Use of isoniazid for latent tuberculosis infection in a public health clinic.

Isoniazid is an efficacious treatment for latent tuberculosis. Concerns remain, however, regarding hepatotoxicity associated with this medication. In addition, adherence may be suboptimal because at least 6 months of treatment is required. We extracted information from our latent tuberculosis treatment database to determine adverse effects and treatment completion rates associated with the use of isoniazid at a county tuberculosis clinic. Outcomes were available for 3,788 patients started on isoniazid between 1999 and 2002. Six hundred seventy-two patients (18%) experienced one or more adverse effects, including 10 (0.3%) determined to have isoniazid-associated liver injury. No hospitalizations or deaths occurred in patients experiencing an adverse effect. A higher incidence of adverse effects was associated with increasing age. Sixty-four percent of patients completed at least 6 months of isoniazid. Higher completion rates were associated with younger age, Hispanic ethnicity, and non-U.S. country of birth. Lower completion rates were associated with being homelessness, using excess alcohol, and having experienced an adverse effect. In summary, we conclude that in our clinic population isoniazid is a safe therapy for latent tuberculosis, but its effectiveness is limited by modest completion rates.

Tuberculosis screening among foreign-born persons applying for permanent US residence.

OBJECTIVES: This study sought to determine adherence of physicians to tuberculosis (TB) screening guidelines among foreign-born persons living in the United States who were applying for permanent residency. METHODS: Medical forms of applicants from 5 geographic areas were reviewed, along with information from a national physician database on attending physicians. Applicant and corresponding physician characteristics were compared among those who were and were not correctly screened. RESULTS: Of 5739 applicants eligible for screening via tuberculin skin test, 75% were appropriately screened. Except in San Diego, where 11% of the applicants received no screening, most of the inappropriate screening resulted from the use of chest x-rays as the initial screening tool. CONCLUSIONS: Focused physician education and periodic monitoring of adherence to screening guidelines are warranted.