Publications by authors named "Mark N Lobato"

29 Publications

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Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019.

MMWR Morb Mortal Wkly Rep 2019 May 17;68(19):439-443. Epub 2019 May 17.

The 2005 CDC guidelines for preventing Mycobacterium tuberculosis transmission in health care settings include recommendations for baseline tuberculosis (TB) screening of all U.S. health care personnel and annual testing for health care personnel working in medium-risk settings or settings with potential for ongoing transmission (1). Using evidence from a systematic review conducted by a National Tuberculosis Controllers Association (NTCA)-CDC work group, and following methods adapted from the Guide to Community Preventive Services (2,3), the 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include 1) TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement); 2) TB testing with an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for persons without documented prior TB disease or latent TB infection (LTBI); 3) no routine serial TB testing at any interval after baseline in the absence of a known exposure or ongoing transmission; 4) encouragement of treatment for all health care personnel with untreated LTBI, unless treatment is contraindicated; 5) annual symptom screening for health care personnel with untreated LTBI; and 6) annual TB education of all health care personnel.
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May 2019

High Completion Rate for 12 Weekly Doses of Isoniazid and Rifapentine as Treatment for Latent Mycobacterium tuberculosis Infection in the Federal Bureau of Prisons.

J Public Health Manag Pract 2019 Mar/Apr;25(2):E1-E6

Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia (Drs Schmit and Lobato); CDC/CSTE Applied Epidemiology Fellowship Program, Hartford, Connecticut (Ms Lang); Connecticut Department of Public Health, Hartford, Connecticut (Ms Lang); and Health Services Division, Federal Bureau of Prisons, Washington, District of Columbia (Drs Wheeler and Kendig and Ms Bur).

Context: Correctional facilities provide unique opportunities to diagnose and treat persons with latent tuberculosis infection (LTBI). Studies have shown that 12 weekly doses of isoniazid and rifapentine (INH-RPT) to treat LTBI resulted in high completion rates with good tolerability.

Objective: To evaluate completion rates and clinical signs or reported symptoms associated with discontinuation of 12 weekly doses of INH-RPT for LTBI treatment.

Setting/participants: During July 2012 to February 2015, 7 Federal Bureau of Prisons facilities participated in an assessment of 12 weekly doses of INH-RPT for LTBI treatment among 463 inmates.

Main Outcome Measures: Fisher exact test was used to assess the associations between patient sociodemographic characteristics and clinical signs or symptoms with discontinuation of treatment.

Results: Of 463 inmates treated with INH-RPT, 424 (92%) completed treatment. Reasons for discontinuation of treatment for 39 (8%) inmates included the following: 17 (44%) signs/symptoms, 9 (23%) transfer or release, 8 (21%) treatment refusal, and 5 (13%) provider error. A total of 229 (49.5%) inmates reported experiencing at least 1 sign or symptom during treatment; most frequently reported were fatigue (16%), nausea (13%), and abdominal pain (7%). Among these 229 inmates, signs/symptoms significantly associated with discontinuation of treatment included abdominal pain (P < .001), appetite loss (P = .02), fever/chills (P = .01), nausea (P = .03), sore muscles (P = .002), and elevation of liver transaminases 5× upper limits of normal or greater (P = .03).

Conclusions: The LTBI completion rates were high for the INH-RPT regimen, with few inmates discontinuing because of signs or symptoms related to treatment. This regimen also has practical advantages to aid in treatment completion in the correctional setting and can be considered a viable alternative to standard LTBI regimens.
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April 2020

A National Survey on the Use of Electronic Directly Observed Therapy for Treatment of Tuberculosis.

J Public Health Manag Pract 2018 Nov/Dec;24(6):567-570

New York City Department of Health and Mental Hygiene, Queens, New York (Dr Macaraig and Ms McGinnis Pilote); Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Lobato and Ms McGinnis Pilote); and National Tuberculosis Controllers Association, Smyrna, Georgia (Ms Wegener).

Context: An increasing number of tuberculosis (TB) programs are adopting electronic directly observed therapy (eDOT), the use of technology to supervise patient adherence remotely. Pilot studies show that treatment adherence and completion were similar with eDOT compared with the standard in-person DOT.

Objective: In December 2015, the National Tuberculosis Controllers Association administered an online survey to determine the extent to which eDOT is used in the United States.

Participants: Sixty-eight Centers for Disease Control and Prevention (CDC)-funded health department TB programs across the United States and a convenient sample of local health department TB programs.

Results: Fifty-six (82%) of 68 CDC-funded health department TB programs and an additional 57 local TB programs responded to the survey. Forty-seven (42%) of 113 TB programs are currently using eDOT, 41 (36%) are planning to implement it in the next year, and 25 (22%) have no plans to implement eDOT. Of the 47 TB programs using eDOT, 31 (66%) use synchronous video DOT, 4 (9%) asynchronous video DOT, 11 (23%) a combination of both, and 1 (2%) ingestible sensor to conduct electronic observations. Forty-one (87%) indicated that treatment adherence and 40 (85%) indicated that treatment completion were about the same or higher than in-person DOT. More than 80% indicated that eDOT resulted in program cost savings, and almost all (91%) reported benefits in patient and staff satisfaction. However, 25 (53%) of the 47 TB programs that use eDOT encountered technical challenges and 37 (79%) offer eDOT to less than a third of their patients.

Conclusions: Results from this survey indicate that eDOT is a promising tool that can be utilized to efficiently and effectively manage TB treatment. Findings will inform other TB programs interested in implementing eDOT. However, further evaluation is needed to assess eDOT acceptability to understand barriers to eDOT implementation from the patient and provider perspectives.
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November 2019

High Rate of Treatment Completion in Program Settings With 12-Dose Weekly Isoniazid and Rifapentine for Latent Mycobacterium tuberculosis Infection.

Clin Infect Dis 2017 10;65(7):1085-1093

Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: Randomized controlled trials have demonstrated that the newest latent tuberculosis (LTBI) regimen, 12 weekly doses of directly observed isoniazid and rifapentine (3HP), is as efficacious as 9 months of isoniazid, with a greater completion rate (82% vs 69%); however, 3HP has not been assessed in routine healthcare settings.

Methods: Observational cohort of LTBI patients receiving 3HP through 16 US programs was used to assess treatment completion, adverse drug reactions, and factors associated with treatment discontinuation.

Results: Of 3288 patients eligible to complete 3HP, 2867 (87.2%) completed treatment. Children aged 2-17 years had the highest completion rate (94.5% [155/164]). Patients reporting homelessness had a completion rate of 81.2% (147/181). In univariable analyses, discontinuation was lowest among children (relative risk [RR], 0.44 [95% confidence interval {CI}, .23-.85]; P = .014), and highest in persons aged ≥65 years (RR, 1.72 [95% CI, 1.25-2.35]; P < .001). In multivariable analyses, discontinuation was lowest among contacts of patients with tuberculosis (TB) disease (adjusted RR [ARR], 0.68 [95% CI, .52-.89]; P = .005) and students (ARR, 0.45 [95% CI, .21-.98]; P = .044), and highest with incarceration (ARR, 1.43 [95% CI, 1.08-1.89]; P = .013) and homelessness (ARR, 1.72 [95% CI, 1.25-2.39]; P = .001). Adverse drug reactions were reported by 1174 (35.7%) patients, of whom 891 (76.0%) completed treatment.

Conclusions: Completion of 3HP in routine healthcare settings was greater overall than rates reported from clinical trials, and greater than historically observed using other regimens among reportedly nonadherent populations. Widespread use of 3HP for LTBI treatment could accelerate elimination of TB disease in the United States.
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October 2017

Tuberculosis in Jails and Prisons: United States, 2002-2013.

Am J Public Health 2016 Dec 15;106(12):2231-2237. Epub 2016 Sep 15.

At the time of this study, all of the authors were with the Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA.

Objectives: To describe cases and estimate the annual incidence of tuberculosis in correctional facilities.

Methods: We analyzed 2002 to 2013 National Tuberculosis Surveillance System case reports to characterize individuals who were employed or incarcerated in correctional facilities at time they were diagnosed with tuberculosis. Incidence was estimated with Bureau of Justice Statistics denominators.

Results: Among 299 correctional employees with tuberculosis, 171 (57%) were US-born and 82 (27%) were female. Among 5579 persons incarcerated at the time of their tuberculosis diagnosis, 2520 (45%) were US-born and 495 (9%) were female. Median estimated annual tuberculosis incidence rates were 29 cases per 100 000 local jail inmates, 8 per 100 000 state prisoners, and 25 per 100 000 federal prisoners. The foreign-born proportion of incarcerated men 18 to 64 years old increased steadily from 33% in 2002 to 56% in 2013. Between 2009 and 2013, tuberculosis screenings were reported as leading to 10% of diagnoses among correctional employees, 47% among female inmates, and 42% among male inmates.

Conclusions: Systematic screening and treatment of tuberculosis infection and disease among correctional employees and incarcerated individuals remain essential to tuberculosis prevention and control.
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December 2016

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

J Immigr Minor Health 2016 Apr;18(2):301-7

Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, 1600 Clifton Rd. Mailstop E-10, Atlanta, GA, 30333, USA.

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.
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April 2016

Old and new approaches to diagnosing and treating latent tuberculosis in children in low-incidence countries.

Curr Opin Pediatr 2014 Feb;26(1):106-13

aDepartment of Pediatrics, Baylor College of Medicine, Houston, Texas bDivision of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Purpose Of Review: The primary purpose is to review guidance on the testing and treatment of latent tuberculosis infection (LTBI) in children. Most children and adults with LTBI have positive tuberculin skin test (TST) or interferon gamma release assay (IGRA) results, normal examinations, and normal chest radiographs. Diagnosis of and treatment completion for LTBI are critical to diminish future cases of tuberculosis (TB) disease.

Recent Findings: Children should be screened for TB risk factors, and only children with risk factors should be tested with either a TST or an IGRA. IGRAs measure interferon gamma production by lymphocytes after they are stimulated ex vivo by antigens that are primarily Mycobacterium tuberculosis-specific. The foundation of LTBI therapy in the United States has been 9 months of daily isoniazid, but shorter treatment regimens now exist, including a 12-dose regimen of weekly isoniazid and rifapentine. These shorter regimens are associated with higher completion rates.

Summary: There are two distinct modalities for LTBI diagnosis and several treatment regimens that can prevent TB disease in infected children. The selection of treatment regimen should take several factors into consideration, including adherence, drug susceptibility results of the presumed source case (if known), safety, cost, and patient preference.
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February 2014

Assessment of postarrival tuberculosis examinations among immigrants and refugees screened overseas.

Conn Med 2013 Jun-Jul;77(6):325-30

Connecticut Department of Public Health, Hartford, CT, USA.

Background: Immigrants and refugees screened overseas and found to have Mycobacterium tuberculosis infection (TB arrivers) are either treated fortuberculosis (TB) or, if disease is not found these arrivers are given a TB classification of latent TB infection (LTBI) and are referred for reexamination after arriving in the United States.

Methods: A retrospective cohort analysis was performed of TB arrivers in Connecticut to determine the proportion of TB arrivers documentedwith their postarrival domestic medical examination and to determine the proportion of TB arriverswho started and completed LTBI treatment.

Results: Of 184TB arrivers, 109 (59%) were evaluated for TB after arrival and four (4%) were diagnosed withTB. Of 105 personswith LTBI,49 (47%) started treatment, and of those 15(30%) completedtreatment.

Conclusion: The majority of TB cases in Connecticut are among foreign-born individuals. Improving TB control overseas is a crucial step in the reduction of TB in the United States. Improvements are still needed to ensure timely, postarrival medical examinations that ensure treatment for high-risk persons with LTBI to reduce TB in Connecticut's foreign-born populations.
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October 2013

HIV status among patients with tuberculosis and HIV testing practices by Connecticut health care providers.

J Int Assoc Provid AIDS Care 2013 Jul-Aug;12(4):261-5. Epub 2013 Feb 26.

Lifespan Learning Institute, Lifespan Health System, Providence, RI, USA.

Knowing the human immunodeficiency virus (HIV) status of persons infected with Mycobacterium tuberculosis is important for individual treatment and preventing transmission. This evaluation analyzed surveillance data and surveyed health care providers who care for patients with HIV and tuberculosis (TB) to understand the factors contributing to suboptimal levels of Connecticut patients with TB having a known HIV status. During 2008 to 2010, 208 (76.2%) of 273 patients had a known HIV status; 12 (5.8%) were HIV-positive. Patients who were more likely to have a known HIV status were younger (40.5 vs 54.6 years, P < .001) or received care in a TB clinic (risk ratio, 1.26; 95% confidence interval, 1.12-1.42). Among 77 providers, 48 (62.3%) completed the survey, 42 (87.5%) reported routinely offering HIV testing to patients with TB, and 26 (54.2%) reported routinely offering HIV testing to patients with latent TB infection (LTBI). We conclude that interventions for improving HIV testing should focus on non-TB clinic providers and patients with LTBI.
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September 2013

Predictors for a positive QuantiFERON-TB-Gold test in BCG-vaccinated adults with a positive tuberculin skin test.

J Infect Public Health 2012 Dec 27;5(6):369-73. Epub 2012 Oct 27.

Department of Medicine, University of Connecticut Medical Center, Farmington, CT, USA.

Background: Prevention of tuberculosis (TB) in the United States usually involves testing for latent tuberculosis infection (LTBI) with a tuberculin skin test (TST), followed by offering therapy to those who have a positive test result. QuantiFERON-TB Gold assay (QFT-G) is more specific for infection with Mycobacterium tuberculosis than the TST, especially among persons vaccinated with bacillus Calmette-Guérin, thereby reducing the number of false positive tests.

Methods: Adults referred to a pulmonary clinic for a positive TST result were tested with QFT-G. We assessed factors for having a positive QFT-G.

Results: Among 100 adults who were BCG-vaccinated and had a positive TST result, 30 (30%) had a positive result using QFT-G. Persons from high-incidence countries were 8.2 times more likely to have a positive QFT-G result compared with persons from low-incidence countries (46% versus 9%). Using logistic regression to assess QFT-G positivity, strong predictors included having an abnormal chest radiograph consistent with healed TB, a TST induration of ≥16mm, and birth in a high-incidence country.

Conclusion: Use of QFT-G assay following a positive TST result further identifies persons who would most benefit from treatment for LTBI.
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December 2012

Tuberculosis control: lessons for outbreak preparedness in correctional facilities.

J Correct Health Care 2010 Jul 12;16(3):239-42. Epub 2010 May 12.

Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Correctional facilities typically house large numbers of persons in close and crowded conditions for long periods. Clusters of communicable diseases ranging from simple viral upper respiratory infections to more serious threats, such as tuberculosis (TB), infections with methicillin-resistant Staphylococcus aureus, and influenza, often emerge in these surroundings. The recent H1N1 influenza pandemic highlights the importance of outbreak prevention and containment preparedness, particularly in congregate settings. In this commentary, the authors propose that the TB control model can provide valuable lessons for infection control practitioners to prepare for, identify, investigate, and control outbreaks of communicable diseases to prevent transmission in correctional facilities and to the surrounding community.
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July 2010

Practices and policies of providers testing school-aged children for tuberculosis, Connecticut, 2008.

J Community Health 2010 Oct;35(5):495-9

University of Connecticut Graduate Program in Public Health, 63 Stoneywood Drive, Niantic, CT 06357, USA.

This study identified current practices and policies related to testing school children for latent tuberculosis infection (LTBI) in Connecticut. A cross-sectional survey was mailed to a random sample of community pediatricians and family practitioners in Connecticut who provide health care services to children aged 4-18 years. The main outcome measure was adherence to national guidelines for tuberculosis (TB) testing of school-aged children. The response rate was 66.3% (345 of 520), 258 of whom provided services to children. Responses showed that 60% (152 of 252) of replying providers read the American Academy of Pediatrics (AAP) published guidelines, and 85% routinely assess children for TB risk before skin testing although only a minority (22%) use a written questionnaire. Of 153 responding providers, 130 (85%) report that schools require formal TB risk assessments at mandated school physical examinations or at school entry. Results also showed providers who read AAP-published guidelines and who are trained in the United States are more likely to follow the national guidelines for TB testing of children. The majority of health care providers reported following AAP-published guidelines for screening school-aged children for LTBI and TB disease; however, an important number of providers still do not follow recommended guidelines. Public health officials should make efforts to increase provider awareness of, and adherence to, guidelines. School districts also should take steps to ensure the appropriate level of testing of children for TB disease and LTBI.
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October 2010

Interferon-gamma release assays: new diagnostic tests for Mycobacterium tuberculosis infection, and their use in children.

Curr Opin Pediatr 2010 Feb;22(1):71-6

Division of Infectious Disease, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon 97239, USA.

Purpose Of Review: The testing and treatment of children at risk for Mycobacterium tuberculosis infection represents an important public health priority in the United States. Until recently, diagnosis has relied upon the tuberculin skin test (TST). New interferon-gamma release assays (IGRAs) offer improvements over TST, but these tests have not been studied in children until recently.

Recent Findings: Evidence regarding IGRA performance in children is accumulating rapidly. Overall, the findings demonstrate performance of IGRAs equivalent or superior to that of the TST. However, IGRAs have biological limitations similar to TST and some technical problems of their own, and critical gaps in our knowledge remain.

Summary: Current evidence supports usage of IGRAs in children aged 5 years or older. IGRAs are preferred over TST when specificity is paramount or wherein patients might fail to return for TST reading. Evidence for use in children aged less than 5 years is insufficient at this time: the sensitivity is poorly defined, and TST is preferred for testing these children. Future IGRA research should focus on children aged less than 5 years for informing expanded usage in this vulnerable population.
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February 2010

Two tuberculosis genotyping clusters, one preventable outbreak.

Public Health Rep 2009 Jul-Aug;124(4):490-4

Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.

In 2006, eight community tuberculosis (TB) cases and a ninth incarceration-related case were identified during an outbreak investigation, which included genotyping of all Mycobacterium tuberculosis isolates. In 1996, the source patient had pulmonary TB but completed only two weeks of treatment. From February 2005 to May 2006, the source patient lived in four different locations while contagious. The outbreak cases had matching isolate spoligotypes; however, the mycobacterial interspersed repetitive unit (MIRU) patterns from isolates from two secondary cases differed by one tandem repeat at a single MIRU locus. The source patient's isolates showed a mixed mycobacterial population with both MIRU patterns. Traditional and molecular epidemiologic methods linked eight secondary TB cases to a single source patient whose incomplete initial treatment, incarceration, delayed diagnosis, and housing instability resulted in extensive transmission. Adequate treatment of the source patient's initial TB or early diagnosis of recurrent TB could have prevented this outbreak.
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August 2009

Do we have evidence for policy changes in the treatment of children with latent tuberculosis infection?

Pediatrics 2009 Mar;123(3):902-3

Centers for Disease Control and Prevention, 1600 Clifton Rd, MS E-10, Atlanta, GA 30333, USA.

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March 2009

Tuberculosis control in a large urban jail: discordance between policy and reality.

J Public Health Manag Pract 2008 Sep-Oct;14(5):442-7

Maryland Department of Health and Mental Hygiene, Division of Tuberculosis Control, Refugee and Migrant Health, Baltimore, MD 21201, USA.

Objective: This study evaluated adherence to tuberculosis control guidelines, published by the Centers for Disease Control and Prevention in 1996, in a large urban jail. Jails are a critical locale because of high risk for tuberculosis transmission in a congregate setting.

Methods: Symptom screening at intake into the facility was systematically observed. Medical records were reviewed to measure timing of tuberculin skin testing (TST) and chest radiograph (CXR) screening. Isolation records were examined for airborne infectious isolation practices. Contact investigation practices were evaluated for ease of data retrieval and adherence to CDC guidelines.

Results: A TB symptom screening question was asked correctly during 28/97 of intake health interviews. Median time from intake to TST was 3 days for men and 2 days for women. Median time from referral to CXR was 2 days for men and 7 days for women. Delays were noted in diagnostic testing of 51 detainees isolated for suspected TB. Contact investigations lacked comprehensive procedures, data collection forms, and databases for managing information.

Conclusion: Findings were used to refine protocols for TB control. This evaluation illustrated the need for ongoing assessment of adherence to TB control protocols in short-term correctional settings to prevent the spread of TB.
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November 2008

Tuberculosis behind bars in Israel: policy making within a dynamic situation.

Isr Med Assoc J 2008 Mar;10(3):202-6

Department of Tuberculosis and AIDS, Ministry of Health, Jerusalem, Israel.

Background: The crowded environment of correctional facilities may enhance infectious diseases transmission, such as tuberculosis.

Objectives: To define the tuberculosis burden in prisons in Israel, a country of low TB incidence (7.9 cases:100,000 population in 2004), in which about 13,000 inmates are being incarcerated annually, and to recommend policy adaptations for TB control.

Methods: All prison clinic lung records from 1998 through 2004 in Israel were reviewed to identify pulmonary TB patients. Additionally, we reviewed TB epidemiological investigation files from one northern prison (years 2002 through 2005) to evaluate possible transmission of the disease.

Results: During the study period 23 Israeli inmates had pulmonary TB (25 cases/100,000 prisoners), which was 3.5 times higher than in the general population. Of those, 18 (78%) were born in the Former Soviet Union and immigrated to Israel after 1990. Four pulmonary TB cases in the evaluated prison were reported, and 22% (149/670) of all inmates and staff were referred for treatment of latent TB infection.

Conclusions: To prevent future TB cases, we recommend new prevention measures, including a symptom questionnaire for all new inmates and selective tuberculin skin testing for inmates infected with human immunodeficiency virus/AIDS, those who inject drugs, and those who emigrated from the former Soviet Union after 1990. New staff should be screened by the two-step tuberculin skin test and annual symptoms questionnaire thereafter. Incarceration may be used as a point of detection for TB and a window of opportunity for treatment in this hard-to-reach population.
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March 2008

Unintended consequences: mandatory tuberculin skin testing and severe isoniazid hepatotoxicity.

Pediatrics 2008 Jun 12;121(6):e1732-3. Epub 2008 May 12.

Connecticut Department of Public Health, 410 Capitol Ave, MS 11-TUB, PO Box 340308, Hartford, CT 06134, USA.

After mandatory school-enrollment tuberculin skin testing, a 4-year-old girl who was at low risk for Mycobacterium tuberculosis infection had severe isoniazid hepatotoxicity that was managed with a liver transplant. Although severe isoniazid hepatotoxicity is very uncommon in children, this case emphasizes the need to limit skin testing to persons who have a risk factor for infection and to educate parents on how to monitor for adverse effects during treatment.
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June 2008

Underuse of effective measures to prevent and manage pediatric tuberculosis in the United States.

Arch Pediatr Adolesc Med 2008 May;162(5):426-31

Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.

Objective: To characterize problems with prevention and management of pediatric tuberculosis (TB) and latent TB infection (LTBI).

Design: A multisite, cross-sectional study using data from medical records and public health logs to categorize and define use of routine prevention practices in managing pediatric TB and LTBI.

Setting: Four areas of the United States.

Participants: Children younger than 5 years diagnosed with TB from January 1, 2002, through December 31, 2004, and children with LTBI reported during a continuous 12-month period in 2003 to 2004. Main Exposure Mycobacterium tuberculosis.

Main Outcome Measures: Underuse or nonuse of standard medical and public health interventions.

Results: Almost 40% of children had a TB risk factor related to their country of birth, parental origin, or travel to a country with a high incidence of TB. Children having LTBI were less likely than those having TB to complete treatment (53.7% vs 88.6%, respectively). Almost half (46.3%) of the children with TB came to medical attention late in their course when they already had symptoms. Among 63 adult source patients, 19 (30.2%) previously had LTBI but were not treated, and none of the 40 foreign-born source patients were known to have been evaluated for TB before entry into the United States.

Conclusions: Prevention efforts are unsatisfactory to prevent TB in children. Effective interventions such as treatment of LTBI and TB evaluation of adult immigrants remain less than optimal.
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May 2008

Impact of Hurricane Katrina on newborn screening in Louisiana.

Pediatrics 2007 Oct;120(4):e749-55

Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, USA.

Objective: The Louisiana Office of Public Health and the Centers for Disease Control and Prevention assessed the extent to which newborn screening was disrupted from August 15 to September 21, 2005, the immediate period before and after Hurricane Katrina.

Methods: A list of hospitals with labor and delivery services was obtained from the Louisiana Hospital Association. A survey sent to hospitals on October 17, 2005, asked about the number of live births during the assessment period, disruption in hospital services, the number of specimens sent to alternative laboratories, and the number of children without screening results.

Results: Among 64 Louisiana hospitals with labor and delivery units, 6 remained closed at the time of the survey. Of the 58 open hospitals, 53 (91.4%) completed the questionnaire. Twenty-one (36.2%) of 58 hospitals experienced disruption of newborn screening services. Respondents from 31 (58.5%) of the 53 open hospitals acknowledged receiving the advisory from the Office of Public Health regarding resumption of newborn screening laboratory services. Hospitals stated that of 5958 specimens submitted, reports had not been received for 1207 (20.3%) newborns. The Office of Public Health laboratory reviewed the names of 2828 newborns received from hospitals and determined that no specimen was received within 14 days of collection for 631 (22.3%). Thirty percent of the specimens received from infants who were born between August 15 and September 21 were rejected as a result of having been received >14 days after collection. Ten children had confirmed positive screening results during the assessment period; all were located, and treatment was initiated.

Conclusions: Collaboration between the Office of Public Health and the Centers for Disease Control and Prevention was essential to increase awareness of changes in laboratory procedures after the hurricane and to help identify infants who might be in need of screening or rescreening.
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October 2007

Tuberculosis control among people in U.S. Immigration and Customs Enforcement custody.

Am J Prev Med 2007 Jul;33(1):9-14

Division of Immigration Health Services, U.S. Public Health Service, Washington, DC 20005, USA.

Background: People detained by United States Immigration and Customs Enforcement (ICE) are a high-risk population for tuberculosis (TB). Detainees are screened for TB upon intake, and TB patients are reported to the Division of Immigration Health Services (DIHS).

Methods: TB case reports were reviewed for ICE detainees reported to DIHS during 2004-2005. Case counts and frequency distributions are presented. Case counts are stratified by demographic characteristics, release status, laboratory and clinical findings, HIV/AIDS status, and drug resistance. Case rates were calculated for patients housed at facilities with DIHS staffing. Duration of treatment and of ICE custody is provided. Analyses were conducted in 2006.

Results: During 2004 and 2005, 76 and 142 TB patients were reported, respectively. The TB case rate was 82.6/100,000 in 2004 and 121.5/100,000 in 2005. The culture-confirmed case rate of 55.8/100,000 in 2005 was 2.5 times higher than the case rate in the U.S. foreign-born population. Of 218 patients, 127 (58.3%) had Mycobacterium tuberculosis-positive sputum cultures, 70 (32.1%) had acid-fast bacilli-positive sputum smears, and 36 (16.5%) were symptomatic at diagnosis. Patients from Mexico, Honduras, Guatemala, and El Salvador accounted for 184 cases (84.4%) and 184 patients (84.4%) were repatriated. TB patients spent an average 82.6 days in treatment before release or repatriation.

Conclusions: Screening at intake to ICE custody has helped DIHS staff in diagnosing TB and starting patients on treatment, but patients are usually deported before completing therapy. Because of deportation, and sometimes re-entry into the United States, unique collaborations are required to support completion of treatment.
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July 2007

Improved program activities are associated with decreasing tuberculosis incidence in the United States.

Public Health Rep 2006 Mar-Apr;121(2):108-15

Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd, Mailstop E-10, Atlanta, GA 30333, USA.

Objective: This study was conducted to determine whether improvements in tuberculosis (TB) program activities correlate with incident TB cases.

Methods: National TB surveillance data and program data from patients with pulmonary and laryngeal TB and their contacts were collected. These data were analyzed using regression models to assess the association between changes in incident TB cases and indicators of program performance (a time series of percent changes in program indices).

Results: A total of 1,361,113 contacts exposed to 150,668 TB patients were identified through contact investigations. From 1987 to 1992 (the period of TB resurgence and antedating increased funding), there was a decline in several measures used by TB programs for outcomes of contact investigations. From 1993 to 1998 (the period after increases in TB funds), there was an observable improvement in the program indices. Four program indices for contacts and two for TB cases (directly observed therapy and completion of therapy) were statistically associated (p < or = .01) with the decline in TB incident cases.

Conclusions: These analyses suggest that expanded TB program activities resulted in the reduction in national TB cases and underscore the importance of treatment completion for TB disease and latent TB infection. Based on these results, we propose that further improvements in these activities will accelerate the decline of TB in the United States.
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April 2006

Tuberculosis prevention and control in large jails: a challenge to tuberculosis elimination.

Am J Prev Med 2006 Feb;30(2):125-30

Abt Associates Inc., Cambridge, Massachusetts, USA.

Background: This study assessed the extent to which 20 large jail systems have implemented national recommendations for tuberculosis (TB) prevention and control in correctional facilities.

Methods: Data were collected through questionnaires to jail medical directors and TB control directors, observation at the jails, and abstraction of medical records of inmates with TB disease and latent TB infection.

Results: Twenty percent of jail systems (4/20) had conducted an assessment of risk for TB transmission in their facilities, and 55% (11/20) monitored tuberculin skin test conversions of inmates and staff. Sixty-five percent (13/20) of jails had an aggregate record-keeping system for tracking TB status and treatment, which was usually paper based. Forty-five percent of jails (9/20) had policies to offer HIV counseling and testing to tuberculin skin test-positive patients, and 75% (15/20) screen HIV-infected inmates with chest radiographs. Three quarters of jails (15/20) had policies to always isolate patients with suspected or confirmed pulmonary TB in an airborne infection isolation room. Half of jails with airborne infection isolation rooms (6/12) conformed to Centers for Disease Control and Prevention (CDC) guidelines for monitoring negative pressure.

Conclusions: Improvements are needed in conducting TB risk assessments and evaluations to determine priorities and reduce risk of transmission. Inadequate medical information systems are impeding TB control and evaluation efforts. Although HIV infection is the greatest cofactor for development of TB disease, jails have inadequate information on patients' HIV status to make informed decisions in screening and management of TB and latent TB infection. Jails need to improve the use of environmental controls.
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February 2006

Time for tuberculosis contact tracing in correctional facilities?

Int J Tuberc Lung Dis 2005 Nov;9(11):1179

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November 2005

An unanswered health disparity: tuberculosis among correctional inmates, 1993 through 2003.

Am J Public Health 2005 Oct;95(10):1800-5

Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Office of Communications, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail Stop E-06, Atlanta, GA 30333, USA.

Objectives: We sought to describe disparities and trends in tuberculosis (TB) risk factors and treatment outcomes between correctional inmate and noninmate populations.

Methods: We analyzed data reported to the national TB surveillance system from 1993 through 2003. We compared characteristics between inmate and non-inmate men aged 15-64 years.

Results: Of the 210976 total US TB cases, 3.8% (7820) were reported from correctional systems. Federal and state prison case rates were 29.4 and 24.2 cases per 100000 inmates, respectively, which were considerably higher than those in the noninmate population (6.7 per 100000 people). Inmates with TB were more likely to have at least 1 TB risk factor compared with noninmates (60.1% vs 42.0%, respectively) and to receive directly observed therapy (65.0% vs 41.0%, respectively); however, they were less likely to complete treatment (76.8% vs 89.4%, respectively). Among inmates, 58.9% completed treatment within 12 months compared with 73.2% of noninmates.

Conclusions: Tuberculosis case rates in prison systems remain higher than in the general population. Inmates with TB are less likely than noninmates to complete treatment.
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October 2005

Adverse events and treatment completion for latent tuberculosis in jail inmates and homeless persons.

Chest 2005 Apr;127(4):1296-303

CDC, 1600 Clifton Rd, Mailstop E-10, Atlanta, GA 30333, USA.

Background: Recently, a short-course treatment using 60 daily doses of rifampin and pyrazinamide was recommended for latent tuberculosis (TB) infection (LTBI).

Study Objectives: To determine the acceptability, tolerability, and completion of treatment.

Design: Observational cohort study.

Setting: Five county jails and TB outreach clinics for homeless populations in three cities.

Patients: Study staff enrolled 1,211 patients (844 inmates and 367 homeless persons).

Interventions: Sites used 60 daily doses of rifampin and pyrazinamide, an approved treatment regimen for LTBI.

Measurements: Types and frequency of drug-related adverse events and outcomes of treatment.

Results: Prior to treatment, 25 of 1,178 patients (2.1%) had a serum aminotransferase measurement at least 2.5 times the upper limit of normal. Patients who reported excess alcohol use in the past 12 months were more likely than other patients to have an elevated pretreatment serum aminotransferase level (odds ratio, 2.1; 95% confidence interval, 1.1 to 6.1; p = 0.03). Treatment was stopped in 66 of 162 patients (13.4%) who had a drug-related adverse event. Among 715 patients who had serum aminotransferase measured during treatment, 43 patients (6.0%) had an elevation > 5 times the upper limits of normal, including one patient who died of liver failure attributed to treatment. In multivariate analyses, increasing age, an abnormal baseline aspartate aminotransferase level, and unemployment within the past 24 months were independent risk factors for hepatotoxicity. Completion rates were similar in jail inmates (47.5%) and homeless persons (43.6%).

Conclusions: This study detected the first treatment-associated fatality with the rifampin and pyrazinamide regimen, prompting surveillance that detected unacceptable levels of hepatotoxicity and retraction of recommendations for its routine use. Completion rates for LTBI treatment using a short-course regimen exceeds historical rates using isoniazid. Efforts to identify an effective short-course treatment for LTBI should be given a high priority.
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April 2005

Public health and correctional collaboration in tuberculosis control.

Am J Prev Med 2004 Aug;27(2):112-7

Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of Tuberculosis Elimination, Atlanta, Georgia, USA.

Objective: To assess the extent that 20 large jail systems and their respective public health departments collaborate to prevent and control tuberculosis (TB).

Methods: Data were collected through questionnaires sent to jail medical directors and TB control directors, interviews, and on-site observation in each of the jails.

Results: Only 35% of jail systems and health departments reported having effective collaboration in TB prevention and control activities. Four barriers were reported by a majority of the jail systems: funding (65%), staffing (60%), staff training (55%), and communication (55%). Lack of advance notice of a patient's release was rated as the greatest barrier to discharge planning. Fifty percent of the jail systems reported that they scheduled appointments for soon-to-be released patients with TB, and 10% did so for patients being treated for latent TB infection (LTBI). Fewer patients actually received appointments: seven (39%) of 33 released patients with TB had documentation in their medical record of appointments, and one of 46 released patients on treatment for LTBI had them. Characteristics associated with increased collaboration include having designated liaisons between jail systems and health departments and holding periodic meetings of staff.

Conclusions: Health departments and jail systems in the same jurisdiction have implemented recommendations regarding collaboration to a limited extent. Such collaborations need strengthening, especially discharge planning and evaluation of TB control activities.
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August 2004

Assessment of tuberculosis screening and management practices of large jail systems.

Public Health Rep 2003 Nov-Dec;118(6):500-7

Field Services and Evaluation Branch, Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.

Objective: This descriptive study sought to explore the use and timeliness of tuberculosis (TB) screening and management activities in jail facilities.

Methods: Study personnel visited 20 large U.S. jail systems and reviewed the medical records of 56 inmates who had recently been evaluated for TB disease and 376 inmates who were diagnosed with or confirmed to have latent TB infection (LTBI). Data from these records were analyzed to determine completion and timeliness of screening, diagnostic, and treatment activities.

Results: In 14% of 56 inmates evaluated for TB disease and 24% of 376 inmates with LTBI, chest radiographs were either not performed or not documented. Of 48 inmates evaluated for TB disease who were not receiving treatment when admitted to jail, 10 had no record of sputum collection being done. A mean delay of 3.1 days occurred from symptom report to respiratory isolation. Time from tuberculin skin test reading to chest radiograph reading was a mean of 5.3 days in inmates evaluated for TB disease and a mean of 7.0 days in inmates with LTBI. Follow-up was arranged for 91% of released inmates who were on treatment for TB disease and only 17% of released inmates who were on treatment for LTBI.

Conclusions: Jail health information systems should be augmented to better document and monitor inmate health care related to TB. Completion rates and timeliness of TB screening, diagnostic, and treatment measures should be evaluated to identify areas needing improvement. Finally, mechanisms for continuity of care upon inmate release should be enhanced to promote therapy completion and prevent TB transmission in the community.
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November 2003

Treatment for latent TB in correctional facilities: a challenge for TB elimination.

Am J Prev Med 2003 Apr;24(3):249-53

Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.

Background: To eliminate tuberculosis (TB) in the United States, more information is needed on how to gain access to difficult-to-reach, high-risk populations to evaluate people who would benefit from treatment for latent TB infection (LTBI).

Methods: A field study was conducted of people at risk for co-infection with TB and the human immunodeficiency virus (HIV) and to demonstrate that treating LTBI in inmates is feasible. Inmates were tested for LTBI using the Mantoux tuberculin skin test (TST). Outcomes measured were skin test results and the start and completion of treatment for LTBI.

Results: In 49 correctional facilities in 12 states, 198102 inmates had a skin test read. The mean skin test positivity rate among inmates was 17.0%. Of those who had a known HIV test result, 14.5% tested HIV positive. Inmates with a positive TST were 4.2 times more likely than those with a negative TST to be HIV infected (95% confidence interval [CI]=3.9-4.4). Therapy for LTBI was completed in 55.9% of patients started on treatment. Patients who were HIV positive and started on a 12-month treatment regimen were less likely than HIV-negative patients (40.0% vs 68.1%, respectively) to complete treatment (odds ratio [OR]=0.24, 95% CI=0.20-0.28). Patients treated in jails were less likely than those treated in prisons (33.6% vs 57.7%, respectively) to complete treatment (OR=0.29, 95% CI=0.26-0.32).

Conclusions: Correctional facilities offer a venue for identifying and treating high-risk individuals for LTBI. However, completing treatment is more problematic in jails than in prisons.
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April 2003