False-positive tuberculin skin tests in a state prison system

OBJECTIVE

To assess the existence and extent of false-positive tuberculin skin test (TST) results in a regularly tested population subsequent to switching to a different skin testing product.

METHOD

Over 9300 state prison inmates were tuberculin skin tested as part of a routine annual testing program. A shortage of Tubersol caused the prison system to purchase and test with Aplisol. Prison health services staff reported an apparent increase in skin test positivity using Aplisol compared to Tubersol. Record reviews were conducted in 34 prisons where inmates read as positive (> or = 5 mm) were retested with Tubersol.

RESULTS

Among 368 inmates recorded as positive (> or = 5 mm) with Aplisol who were retested with Tubersol, 150 (40.8%) were read as negative (0-4 mm).

CONCLUSION

The tuberculin skin test is a valuable tool in evaluating patients for TB infection. However, variations in planting and reading the test, and in the consistency between lots and manufacturers, can contribute to errors in determining an individual's infection status. The entire clinical and epidemiological picture for each patient must always be evaluated using the TST as a tool, and not an indisputable answer.

A pseudo-outbreak of purified protein derivative skin-test conversions caused by inappropriate testing materials

OBJECTIVE

To investigate a cluster of newly identified tuberculosis infections.

DESIGN

A field study was conducted including interviews; medical record reviews; checking of bills and invoices, pharmacy records, and drug manufacturer information; and clinical retesting.

SETTING

Community residential facilities providing comprehensive services to retarded adults.

PARTICIPANTS

Twenty residential facility staff (not previously known to be purified protein derivative [PPD] positive).

RESULTS

Staff had been tested with 250 TU of PPD, and 9 of 20 were tuberculin positive. Retesting with 5 TU yielded no reaction.

CONCLUSIONS

Reactions were attributable to testing with a product not recommended for routine PPD screening. Healthcare workers planting PPD Mantoux tests always should check the vials to ensure that the appropriate strength solution is being used.

The role of young children in a community-wide outbreak of hepatitis A

An Hasidic Jewish community has experienced recurrent hepatitis A outbreaks since 1980. To assess risk factors for illness during a 1985-6 outbreak, the authors reviewed case records and randomly selected 93 households for an interview and serologic survey. In the outbreak, 117 cases of hepatitis A were identified, with the highest attack rate (4.2%) among 3-5 year olds. Among the survey households, the presence of 3-5 year olds was the only risk factor that increased a household's risk of hepatitis A (indeterminant relative risk, P = 0.02). Furthermore, case households from the outbreak were more likely to have 3-5 years olds than were control households from the survey (odds ratio = 16.4, P < 0.001). Children 3-5 years old were more likely to have hepatitis A and may have been the most frequent transmitters of hepatitis A in this community. Hepatitis A vaccination of 3-5 year olds can protect this age group and might prevent future outbreaks in the community.

Measles vaccination levels of children enrolled in WIC during the 1991 measles epidemic in New York City

OBJECTIVES

This study assessed measles vaccination rates and risk factors for lack of vaccination among preschool children enrolled in the Special Supplemental Food Program for Women, Infants, and Children (WIC) during the 1991 measles epidemic in New York City.

METHODS

Children aged 12 to 59 months presenting for WIC certification between April 1 and September 30, 1991, at six volunteer WIC sites in New York City were surveyed.

RESULTS

Of the 6181 children enrolled in the study, measles immunization status was ascertained for 6074 (98%). Overall measles coverage was 86% (95% confidence interval [CI] = +/- 1%) and at least 90% by 21 months of age (95% CI = +/- 1%). Young age of the child, use of a private provider, and Medicaid as a source of health care payment were risk factors for lack of vaccination (P < .001).

CONCLUSIONS

During the peak of a measles epidemic, measles immunization rates were more than 80% by 24 months of age in a sample of WIC children. The ease of ascertaining immunization status and the size of the total WIC population underscore the importance of WIC immunization initiatives.

The immunization of children enrolled in the Special Supplemental Food Program for Women, Infants, and Children (WIC). The impact of different strategies

OBJECTIVE

To assess the impact of different interventions to increase measles vaccination coverage among preschool children enrolled in the Special Supplemental Food Program for Women, Infants, and Children (WIC).

DESIGN

Public health intervention trial.

SETTING

Six volunteer WIC sites in New York City.

STUDY PARTICIPANTS

Children aged 12 to 59 months presenting for WIC certification between April 1 and September 30, 1991, who were eligible for measles vaccination.

INTERVENTIONS

Two WIC sites were assigned at random to one of three immunization strategies: (1) escort: child was escorted to a nearby pediatric clinic for immunization; (2) voucher incentive: the family returned monthly, rather than every 2 months, to pick up WIC food vouchers until the child was immunized; or (3) referral: the family was passively referred for immunization.

MAIN OUTCOME MEASURE

Proportion of eligible children receiving measles vaccination.

RESULTS

Of children eligible for measles immunization, 74% (618/836) were immunized. Children at escort sites were 5.5 times (relative risk [RR] = 5.5; 95% confidence interval [CI], 3.7 to 8.1) and those at voucher incentive sites were 2.9 times (RR = 2.9; 95% CI, 1.9 to 4.5) more likely to be immunized than children at referral sites. Children were immunized more rapidly at escort sites (median, 14 days) and voucher incentive sites (median, 26 days) than at referral sites (median, 45 days; P < .001).

CONCLUSIONS

Both escort and voucher incentive models resulted in more children being immunized more rapidly than passive referral. Because of ease of administration, voucher incentives may be a more suitable immunization intervention for use at WIC sites, with addition of escort where feasible.

False positive tuberculosis skin test results

The re-emergence of tuberculosis as a significant public health threat has led to greatly renewed activity in tuberculin skin testing to identify infected persons. However, even use of the preferred skin test technique (intradermal injection of purified protein derivative via the Mantoux method) can lead to either false positive or false negative results. Interpretation of a Mantoux test can be influenced by cross reactions with other mycobacteria, intertester variation, host-response variation, and product related problems. At least 25 apparent false positive purified protein derivative skin test reactions in New York State in 1992 appeared to be associated with lots of the derivative produced by one manufacturer. These unexpected skin test results led to examination of a product with an altered appearance that may have caused the unanticipated responses. After announcement of these false positive results to the press, the company removed the product from the market. Food and Drug Administration analysis later revealed particulate matter in vials of the suspected lots of purified protein derivative.

Characteristics of HIV-infected adults in acute care hospitals in New York State, 1984-1986

The New York State acute care, hospital discharge database was used to create a longitudinal case history file for all adult inpatients infected with the human immunodeficiency virus (HIV). From 1984 through 1986, 12,958 individuals with HIV-related diseases were treated in acute care hospitals throughout the state. Approximately 80% of those people resided in New York City, and nearly half of them were between ages 30 and 39 years. Over the three-year period, the proportion of females increased from 11.8% to 16.6%. The per diem charge increased slightly, although the total length of stay for the first year of HIV illness declined sufficiently to decrease the total charge for the year. Examination of the pattern of inpatient stays and intercurrent days shows the first and last hospital stays to be longer than those in between, although the days between stays decreased as the number of admissions increased. The hospital stay in which a patient died was typically of longer duration than earlier stays. The average charge for HIV-related hospital care among inpatients during their first year of illness was approximately $20,000.

HIV infected hospital patients in New York State. The development of longitudinal information from a hospital discharge data system

Abstracted records of all patients discharged from New York State acute care hospitals from January 1, 1983, through October 1, 1987, containing a diagnosis of HIV infection (N = 36,664) were linked into a longitudinal file of 20,005 patient-specific case histories. A validation study utilizing Medicaid patient-specific discharge information for calendar year 1985 showed that, on the average, each case history of the longitudinal file contained 85% (+/- 5%) of the expected discharges. The number of patients present in the longitudinal file was 10% (+/- 4%)--too large a percentage, due to a failure to link all the discharges to the appropriate case histories. The number of patients with a diagnosis of Pneumocystis carinii pneumonia (PCP) found in the longitudinal file was found to be consistent with the number reported to the New York State AIDS Registry. The longitudinal file appears to be sufficiently accurate and complete to use in evaluating HIV-related acute care in hospitals.

AIDS behind bars. Epidemiology of New York State prison inmate cases, 1980-1988

During the last five years, AIDS has become the preeminent health care problem in New York State correctional facilities. Through December 31, 1988, 915 cases of AIDS had been diagnosed among inmates. This represented approximately 1% of the cumulative AIDS cases in the United States, 4% of those in New York State, and 40% of those reported in state correctional systems nationwide. An analysis of epidemiologic data on these cases showed an annual increase in cases from 3 in 1981 to 227 in 1988, with an incidence greater than 400 per 100,000 inmates per year over the past four years. While most cases occurred in males (96%), females had the same high incidence rates (compared to the general population, in which female rates are one-eight of males). Forty-seven percent of infected inmates were Hispanic, 38% black, and 13% white. Pneumocystis carinii pneumonia was the most common diagnosis (65%), while Kaposi's sarcoma was rare (3%). Previous intravenous drug use has been the major risk factor, seen in 95% of cases. A comparison of 54 inmate AIDS cases with 107 matched and 196 unmatched controls showed that inmates in whom AIDS developed had significantly lower white blood cell counts on entry into prison, lower hematocrits and serum albumin levels, and higher serum glutamic oxaloacetic transaminase and globulin counts. Through July 1989, 643 (70%) of these 915 inmates had died of AIDS, and HIV infection and AIDS account for 68% of recent inmate deaths.

Widespread outbreaks of clam- and oyster-associated gastroenteritis. Role of Norwalk virus

Consumption of raw shellfish has long been known to be associated with individual cases and sporadic outbreaks of enteric illness. However, during 1982, outbreaks of gastroenteritis associated with eating raw shellfish reached epidemic proportions in New York State. Between May 1 and December 31, there were 103 well-documented outbreaks in which 1017 persons became ill: 813 cases were related to eating clams, and 204 to eating oysters. The most common symptoms were diarrhea, nausea, abdominal cramps, and vomiting. Incubation periods were generally 24 to 48 hours long, and the duration of illness was 24 to 48 hours. Bacteriologic analyses of stool and shellfish specimens did not reveal a causative agent. Norwalk virus was implicated as the predominant etiologic agent by clinical features of the illness and by seroconversion and the formation of IgM antibody to Norwalk virus in paired serum samples from persons in five (71 percent) of seven outbreaks in which testing was done. In addition, Norwalk virus was identified by radioimmunoassay in clam and oyster specimens from two of the outbreaks. Determining the source of the shellfish was not always possible, but northeastern coastal waters were implicated. The magnitude, persistence, and widespread nature of these outbreaks raise further questions about the safety of consuming raw shellfish.

Tuberculin conversions in Indochinese refugees. An assessment of boosting and anergy

Indochinese refugees entering the United States have a high rate of tuberculosis and tuberculin reactivity. In addition, several investigators have noted that a large number of refugees with initial tuberculin tests that are "not significant" change to "significant" reactions when retested within 8 wk. This "conversion" phenomenon has been reported in 21 to 43% of refugees and has been unexplained by antigen, testing, demographic, or exposure risk factors. A prospective evaluation of 218 refugees, conducted to assess the role of anergy and boosting, confirmed earlier findings, with 52% of 118 persons with initial tuberculin reactions that were "not significant" developing "significant" reactions on subsequent testing. Anergy, as measured by nonreactivity to mumps and candida skin tests, was not found to be a contributing factor, as few refugees were anergic and as rates of anergy did not differ significantly among refugees with different responses to tuberculin. Boosting, however, played a major role in explaining the "conversions," as 59% of persons who changed to "significant" tuberculin tests did so when retested with tuberculin at 1 to 3 wk. "Delayed" boosting rather than incubating disease or anergy appeared to be the most likely explanation for the remaining "conversions" that occurred on a third PPD test conducted at approximately 8 wk. If the "conversion" phenomenon is due to boosting, it remains to be seen whether the boosting is a result of previous exposure to Mycobacterium tuberculosis or to other, nontuberculous mycobacteria.

Epidemiologic features of Lyme disease in New York

During 1982, surveillance identified 207 cases of Lyme disease in New York State. Cases were clustered in two geographic areas, eastern Long Island and northern Westchester counties. Symptoms and signs of Lyme disease in cases were consistent with previous reports, with erythema chronicum migrans (ECM) being the most frequently (77 percent) reported sign of disease. Facial palsy was reported in a surprisingly high 18 percent of cases. Of 160 cases whose sera were submitted for Lyme spirochete specific IgG antibody testing, 112 (70 percent) had titers greater than or equal to 64, while 88 (55 percent) had titers greater than or equal to 128. Positive titers were not associated with any single sign or symptom of disease, but were significantly associated with symptom onset or tick bite occurring during the three-month period of June, July, and August. We conclude that the incidence of Lyme disease in New York is much higher than previously recognized. In addition, our data suggest that a serologic test for Lyme-spirochete IgG antibody lacks sensitivity, but can be useful in confirming the diagnosis of Lyme disease when antibody titers are high.

High rate of tuberculin conversion in Indochinese refugees

From January 1979 through December 1980, a total of 664 Indochinese refugees were screened for tuberculosis in Monroe County, New York; 307 (46%) had positive 5-tuberculin unit PPD Mantoux tests. When 217 refugees with initially negative tests were retested at 60 days, 94 (43%) had converted from a negative to a positive test. Although none of the converters had evidence of active tuberculosis disease, 90 (96%) were given isoniazid preventive therapy. This conversion phenomenon has continued over time, discounting an effect of local, national, or international policy changes. The conversions do not seem to be a function of antigen, tester, or reader; criteria for testing, retesting, or reading; home country, camp country, or length of time in camp; or history of prior BCG vaccination, tuberculosis, or immunization exposure, current illness, or testing intervals since arrival in the United States and subsequent testing. Further studies to evaluate boosting or anergy are in progress to assess this potential public health problem.

Symptomatology in head and neck cancer: a quantitative review of 385 cases

Symptom durations in head and neck cancer patients analyzed as a function of tumor stage suggest a reversal of the "common sense" notion that patients with early disease generally present with a shorter symptomatic period. A possible explanation is that variation in stage at diagnosis is primarily due to intrinsic differences in tumor aggressiveness rather than patient delay. This would imply that early detection programs may be incapable of realizing the potential for improved survival commonly ascribed to them.

A public education program in self-examination for orofacial cancer

Instruction in self-examination for early signs of orofacial cancer was given to over 450 persons attending a large county fair in western New York State. Participants received one-on-one instruction from dentists or specially trained dental hygienists according to a protocol designed to detect abnormalities of the oral cavity, cervical lymph nodes, and major salivary glands, as well as facial skin cancers. This method of personal instruction was judged feasible for large-scale application.