Tuberculosis contact investigation: two years of experience in New York City correctional facilities

Contact investigation for tuberculosis: a systematic review and meta-analysis

Investigation of contacts of patients with tuberculosis (TB) is a priority for TB control in high-income countries, and is increasingly being considered in resource-limited settings. This review was commissioned for a World Health Organization Expert Panel to develop global contact investigation guidelines. We performed a systematic review and meta-analysis of all studies reporting the prevalence of TB and latent TB infection, and the annual incidence of TB among contacts of patients with TB. After screening 9,555 titles, we included 203 published studies. In 95 studies from low- and middle-income settings, the prevalence of active TB in all contacts was 3.1% (95% CI 2.2-4.4%, I(2)=99.4%), microbiologically proven TB was 1.2% (95% CI 0.9-1.8%, I(2)=95.9%), and latent TB infection was 51.5% (95% CI 47.1-55.8%, I(2)=98.9%). The prevalence of TB among household contacts was 3.1% (95% CI 2.1-4.5%, I(2)=98.8%) and among contacts of patients with multidrug-resistant or extensively drug-resistant TB was 3.4% (95% CI 0.8-12.6%, I(2)=95.7%). Incidence was greatest in the first year after exposure. In 108 studies from high-income settings, the prevalence of TB among contacts was 1.4% (95% CI 1.1-1.8%, I(2)=98.7%), and the prevalence of latent infection was 28.1% (95% CI 24.2-32.4%, I(2)=99.5%). There was substantial heterogeneity among published studies. Contacts of TB patients are a high-risk group for developing TB, particularly within the first year. Children <5 yrs of age and people living with HIV are particularly at risk. Policy recommendations must consider evidence of the cost-effectiveness of various contact tracing strategies, and also incorporate complementary strategies to enhance case finding.

American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: Controlling Tuberculosis in the United States

During 1993-2003, incidence of tuberculosis (TB) in the United States decreased 44% and is now occurring at a historic low level (14,874 cases in 2003). The Advisory Council for the Elimination of Tuberculosis has called for a renewed commitment to eliminating TB in the United States, and the Institute of Medicine has published a detailed plan for achieving that goal. In this statement, the American Thoracic Society (ATS), Centers for Disease Control and Prevention (CDC), and the Infectious Diseases Society of America (IDSA) propose recommendations to improve the control and prevention of TB in the United States and to progress toward its elimination. This statement is one in a series issued periodically by the sponsoring organizations to guide the diagnosis, treatment, control, and prevention of TB. This statement supersedes the previous statement by ATS and CDC, which was also supported by IDSA and the American Academy of Pediatrics (AAP). This statement was drafted, after an evidence-based review of the subject, by a panel of representatives of the three sponsoring organizations. AAP, the National Tuberculosis Controllers Association, and the Canadian Thoracic Society were also represented on the panel. This statement integrates recent scientific advances with current epidemiologic data, other recent guidelines from this series, and other sources into a coherent and practical approach to the control of TB in the United States. Although drafted to apply to TB-control activities in the United States, this statement might be of use in other countries in which persons with TB generally have access to medical and public health services and resources necessary to make a precise diagnosis of the disease; achieve curative medical treatment; and otherwise provide substantial science-based protection of the population against TB. This statement is aimed at all persons who advocate, plan, and work at controlling and preventing TB in the United States, including persons who formulate public health policy and make decisions about allocation of resources for disease control and health maintenance and directors and staff members of state, county, and local public health agencies throughout the United States charged with control of TB. The audience also includes the full range of medical practitioners, organizations, and institutions involved in the health care of persons in the United States who are at risk for TB.

Unrecognised transmission of tuberculosis in prisons

BACKGROUND

Tuberculosis (TB) is a public health concern in correctional facilities. High turnover of inmate populations may preclude timely diagnosis of TB, so that unrecognised transmission may be common.

OBJECTIVE

To determine the proportion of inmates with new skin test conversions who had identifiable exposure to diagnosed cases of TB in the correctional system, and to test the hypothesis that source cases of TB may be undiagnosed during incarceration.

SETTING

Maryland Division of Corrections, USA.

SUBJECTS

All inmates whose skin test converted from negative to positive at annual screening.

DESIGN

All cases of TB in inmates, diagnosed in the prisons during the relevant time period, were identified. Movements of skin test converters and potential source cases within the prisons were matched. We then matched all inmates discharged from the prison system with all new cases of tuberculosis notified to the Maryland Department of Health & Mental Hygiene tuberculosis registry in 1994.

RESULTS

The inmate turnover was 21% per year. Probable exposure to a diagnosed source case was found in 13% of converters, possible exposure in 10% and no exposure in 72%. In a further 5% exposure status could not be determined. We identified four cases of pulmonary tuberculosis notified to the state in 1994, within 3 months of discharge in released inmates, who were not known to have tuberculosis whilst incarcerated.

CONCLUSIONS

Significant transmission of TB due to undiagnosed index cases may occur in prisons due to high population turnover. New skin test conversions in inmates should be treated as new infection, even in the absence of identifiable exposure to TB.

Inner-city tuberculosis in the USA

Tuberculosis (TB) has become more common during the past five years in several areas of the USA. Occurrence has been facilitated by the increasing number of patients with concurrent HIV infection, by cases due to multiple-drug-resistant strains, by incomplete TB therapy among homeless and non-compliant patients, and by cases in immigrants from other countries where TB prevalence is high. These features mean that the major burden of TB today is being borne by inner-city health care facilities that care for the poor. This is illustrated by data from Atlanta, Georgia, where a large proportion of the new cases recognized in the metropolitan area are reported by Grady Memorial Hospital, the public hospital serving the indigent and working poor of the inner city. Similar patterns are recognized in the other USA cities where TB has again become a blight. In view of these epidemiological features, minimizing inner-city TB will require careful attention to diagnosis and isolation procedures in the hospital. Engineering changes at hospitals providing acute care of TB have recently been ordered by the federal government. These promise to be very expensive, and primarily affect the public hospitals, which can least afford them. Innovative treatment programmes are essential, as follow-up after acute care is difficult in this setting. Directly observed therapy can help, but for some cases the era of the TB hospital may have returned. Current attention focuses on legal and ethical issues associated with detaining non-compliant and recalcitrant patients to complete their therapy. Bacille Calmette Guerin (BCG) vaccine is not a priority for this setting at this time.(ABSTRACT TRUNCATED AT 250 WORDS)