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In 2004, identification of patients infected with the same Mycobacterium tuberculosis strain in New York, New York, USA, resulted in an outbreak investigation. The investigation involved data collection and analysis, establishing links between patients, and forming transmission hypotheses. Fifty-four geographically clustered cases were identified during 2003-2009. Initially, the M. tuberculosis strain was drug susceptible. However, in 2006, isoniazid resistance emerged, resulting in isoniazid-resistant M. tuberculosis among 17 (31%) patients. Compared with patients with drug-susceptible M. tuberculosis, a greater proportion of patients with isoniazid-resistant M. tuberculosis were US born and had a history of illegal drug use. No patients named one another as contacts. We used patient photographs to identify links between patients. Three links were associated with drug use among patients infected with isoniazid-resistant M. tuberculosis. The photographic method would have been more successful if used earlier in the investigation. Name-based contact investigation might not identify all contacts, particularly when illegal drug use is involved.

Objective: To review outcomes of human immunodeficiency virus (HIV) positive tuberculosis (TB) patients in New York City (NYC) to determine if the World Health Organization treatment success target of 85% was met in a setting with ready access to treatment for HIV and TB., Design: Retrospective review of new TB patients diagnosed from 1995 to 2004, excluding patients with rifampin (RMP) resistance., Results: Of 9198 eligible TB patients, 83% had achieved treatment success, 8% died during treatment, 4% failed, 3% defaulted and 2% were transferred from NYC. Among 6374 HIV-negative individuals, treatment success was consistently over 85%; 5% died during treatment. Among 2824 HIV-positive individuals, treatment success was 72% overall and 66% in sputum acid-fast bacilli smear-positive patients. Mortality among the HIV-positive decreased from 26% in 1995 to 14% in 2004. HIV-positive patients achieved higher treatment success if 1) they received treatment by directly observed therapy (DOT) (82% vs. 74%, OR(adj) = 1.80, 95%CI 1.44-2.26), or 2) were administered rifabutin (RFB) in the regimen, a proxy for receiving antiretroviral therapy (ART) (84% vs. 78%, OR(adj) = 1.49, 95%CI 1.20-1.85). Treatment success of 85% was achieved in HIV-positive patients who received RFB and DOT., Conclusion: High mortality precluded achieving 85% treatment success among HIV-positive TB patients. DOT and ART remain essential for improving success among co-infected patients everywhere.

Public health departments rely on the timely receipt of tuberculosis (TB) reports to promptly initiate patient management and contact investigations. In 2003, 43% of persons in New York City with confirmed or suspected TB were reported 4 or more days late. An intervention to increase the timeliness of TB reporting was initiated in 2004. A list of patients who were reported late and had a smear positive for acid-fast bacilli, a pathology finding consistent with TB, or who initiated 2 or more anti-TB medications was generated quarterly. Health care providers and laboratories were contacted to determine the reasons for reporting late and were educated on TB reporting requirements. To assess the effectiveness of the intervention, we evaluated the trend in delayed reports between 2003 and 2006, using the Jonckheere-Terpstra test for trend. The proportion of patients who were reported late decreased from 43% (942/2183) in 2003 to 20% (386/1930) in 2006 (Ptrend < .0001). There were improvements in reporting timeliness for all 3 reporting criteria included in the evaluation and all provider types (all Ptrend < .0001); however, private providers consistently had a higher proportion of delayed reporting (22% reported late in 2006). This relatively simple intervention was very effective in improving the timeliness of TB reporting and could be utilized for other reportable diseases where prompt reporting is critical.

Background: Although highly active antiretroviral therapy (HAART) has decreased human immunodeficiency virus (HIV)-related morbidity, tuberculosis remains an important disease among HIV-infected individuals., Methods: By use of surveillance data, sociodemographic and clinical changes among HIV-infected and HIV-uninfected tuberculosis patients in New York City were evaluated using the Cochran-Armitage trend test and multivariate logistic regression across 3 periods: 1992-1995 (pre-HAART), 1996-2000 (early HAART), and 2001-2005 (late HAART)., Results: Among tuberculosis patients with known HIV status, 4345 (60%) of 7224 were HIV-infected in pre-HAART, 1943 (33%) of 5933 in early HAART, and 851 (22%) of 3815 in late HAART (P < .001 for trend). During the study period, the age of HIV-infected tuberculosis patients increased, and greater proportions were female, non-Hispanic black, Asian, and foreign born; the proportion that was non-Hispanic white decreased. The proportion that was culture-negative for Mycobacterium tuberculosis increased (from 7% pre-HAART to 21% late HAART; P < .001 for trend; early HAART vs pre-HAART adjusted odds ratio [aOR], 1.68; 95% confidence interval [CI], 1.38-2.04), and the proportion with extrapulmonary disease also increased (from 32% to 46%; P < .001 for trend). The proportion with multidrug-resistant tuberculosis decreased (from 16% to 4%; P < .001 for trend), especially from pre-HAART to early HAART (aOR, 0.31; 95% CI, 0.25-0.40). The proportion who died before tuberculosis treatment decreased (from 12% to 7%), and the proportion who died during tuberculosis treatment also decreased (from 29% to 11%) (both, P < .001 for trend). Over time, HIV-infected tuberculosis patients had AIDS longer before the diagnosis of tuberculosis (P < .001 for trend). Similar trends for culture, site of disease, and drug resistance were seen for HIV-uninfected tuberculosis patients., Conclusions: The sociodemographic and clinical characteristics changed substantially among HIV-infected tuberculosis patients in New York City. Awareness of these changes may speed diagnosis of tuberculosis. Future studies should evaluate HAART's effect on tuberculosis presentation among HIV-infected patients.

Background: Low adherence to treatment of latent tuberculosis infection (TLTBI) diminishes TB prevention efforts. This study examined the treatment completion rate among those who started TLTBI and factors associated with adherence to TLTBI., Methods: Patients who started TLTBI in New York City (NYC) Health Department chest clinics during January 2002-August 2004 were studied. TLTBI completion rate were described and compared according to patient demographic and clinical characteristics by regimen using univariate analysis and log-binomial regression., Results: A total of 15 035 patients started and 6788 (45.2%) completed TLTBI. Treatment completers were more likely than non-completers to be >or=35 years old (52.5%, adjusted relative risk (aRR)=1.2, 95% confidence interval (CI)=1.1, 1.2), contacts to pulmonary TB patients (57.4%, aRR=1.5, 95% CI=1.4, 1.7), treated by directly observed preventive therapy (DOPT) (71.4%, aRR=1.3, 95% CI=1.2, 1.3), and to have received the rifamycin-based regimen (60.0%, aRR=1.2, 95% CI=1.1, 1.3). The completion rate with an isoniazid regimen did not differ between HIV-infected and HIV-uninfected persons. Among those who failed to complete, 3748 (47.8%) failed to return for isoniazid and 59 (14.7%) for rifamycin after the first month of medication dispensing., Conclusions: Shorter regimen and DOPT increased completion rates for LTBI. Though efforts to improve TLTBI completion need to address all groups, greater focus is needed for persons who are contacts and HIV-infected, as they have higher risk of developing TB.

Unlabelled: Rationale Linezolid may be effective for the treatment of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB); however, serious adverse events are common and there is little information on the management of these toxicities., Methods: We retrospectively reviewed public health and medical records of 16 MDR TB patients, including 10 patients with XDR TB, who were treated with linezolid in New York City between January 2000 and December 2006, to determine treatment outcomes and describe the incidence, management and predictors of adverse events., Results: Linezolid was added to MDR TB regimens for a median duration of 16 months (range: 1-29). Eleven patients (69%) completed treatment, four (25%) died and one (6%) discontinued treatment without relapse. Myelosuppression occurred in 13 (81%) patients a median of 5 weeks (range: 1-11) after starting linezolid, gastrointestinal adverse events occurred in 13 (81%) patients after a median of 8 weeks (range: 1-57) and neurotoxicity occurred in seven (44%) patients after a median of 16 weeks (range: 10-111). Adverse events were managed by combinations of temporary suspension of linezolid, linezolid dose reduction and symptom management. Five (31%) patients required eventual discontinuation of linezolid. Myelosuppression was more responsive to clinical management strategies than was neurotoxicity. Leucopenia and neuropathy occurred more often in males and older age was associated with thrombocytopenia (P < 0.05)., Conclusions: The majority of MDR TB patients on linezolid had favourable treatment outcomes, although treatment was complicated by adverse events that required extensive clinical management.

Objective: To describe a 3-year effort to identify factors associated with lapses in case management (CM) and to improve CM practices by New York City Bureau of Tuberculosis Control (BTBC) staff., Design: Evaluation of the CM of TB cases reported in the second quarter of 2003 and comparison of results with the findings of a similar review conducted in 2002. Implementation of strategies to target areas in need of improvement and identification of interventions that contribute to improved work practices., Results: From 2002 to 2003, significant improvements were found in some CM indicators, such as patient education about the importance of directly observed therapy (32% vs. 74%), importance of monthly follow-up (24% vs. 51%) and potential for development of drug resistance (36% vs. 61%). Informing patients about the availability of services provided by the BTBC also improved (16% vs. 59%); however, timeliness and documentation of CM activities and implementation of supervisory activities remained poor. Supervisors largely attributed this lack of improvement to poor documentation of work actually performed., Conclusions: These evaluations identified lapses in CM practices and program supervision. The findings were used to adjust protocols, target interventions, and focus education and training to improve work practices.

Background: We aimed to increase human immunodeficiency virus (HIV) counseling, testing, referral (CTR), and knowledge of HIV serostatus of close contacts of tuberculosis patients and improve tuberculosis screening and treatment of HIV-infected contacts., Methods: Of close contacts to infectious tuberculosis patients reported from December 2002 to November 2003, investigators (1) offered HIV CTR, (2) identified factors associated with HIV testing, and (3) assessed study costs., Results: Of 614 contacts, 569 (93%) were provided HIV information and offered HIV CTR. Of the 569, 58 (10%) were previously HIV tested; 165 (29%) were newly HIV tested; and 346 (61%) were not tested. None of the 165 newly HIV tested contacts were HIV infected. Contacts more likely to be newly HIV tested (vs not tested) included those aged 18-24, Hispanic, or non-Hispanic Black. Of 24 HIV-infected contacts, 71 percent received chest-radiograph screening for tuberculosis disease; 56 percent of 18 eligible for latent-tuberculosis-infection treatment started and half completed. It cost $1 per patient to provide HIV information and $5-$8 to offer HIV CTR., Conclusion: The project increased HIV CTR of close contacts of infectious tuberculosis patients. The important factor for success in knowing contacts' HIV serostatus was simply for TB program staff to ask about it and offer the test to those who did not know their status.

Tuberculosis incidence in New York City (NYC) declined between 1992 and 2000 from 51.1 to 16.6 cases per 100,000 population. In January 2001, universal real-time genotyping of TB cases was implemented in NYC. Isolates from culture-confirmed tuberculosis cases from 2001 to 2003 were genotyped using IS6110 and spoligotype to describe the extent and factors associated with genotype clustering after declining TB incidence. Of 2408 (91.8%) genotyped case isolates, 873 (36.2%) had a pattern indistinguishable from that of another study period case, forming 212 clusters; 248 (28.4%) of the clustered cases had strains believed to have been widely transmitted during the epidemic years in the early 1990s in NYC. An estimated 27.4% (873 minus 212) of the 2408 cases were due to recent infection that progressed to active disease during the study period. Younger age, birth in the United States, homelessness, substance abuse and presence of TB symptoms were independently associated with greater odds of clustering.

Setting: In 1993, the New York City (NYC) Bureau of Tuberculosis Control developed the cohort review process as a quality assurance method to track and improve patient outcomes., Methods: The Bureau Director reviews every tuberculosis (TB) case quarterly in a multi-disciplinary staff meeting. In 2004 we also began collecting details on issues identified at cohort review to quantify how this process directly impacts TB control efforts., Results: From 1992 to 2004, NYC TB cases decreased by 72.7% and treatment success rates significantly increased by 26.7%. Implementing the cohort review was key to improving case management, thus leading to these results. For the 1039 patients in 2004, 596 issues were identified among 424 patients; 55.0% were incorrect, unclear or unknown patient information, 13.8% were treatment issues, 12.4% were case management issues and 10.6% were incomplete contact investigations. Most (76.5%) issues were addressed within 30 days of the cohort reviews., Conclusion: A systematic review of every TB case improves the quality of patient information, enhances patient treatment and ensures accountability at all levels of the TB control program.

We studied two large Mycobacterium tuberculosis genotype clusters associated with recent outbreaks in homeless persons to determine factors associated with these tuberculosis (TB) strains. Isolates from all culture-positive TB cases diagnosed from 1 January 2001 to 31 December 2004 were genotyped. Patients whose isolates had identical restriction fragment length polymorphism patterns and spoligotypes were considered clustered. Health department records were reviewed and reinterviews attempted for clustered cases. Patients with the Cs30 and BEs75 strains were compared to other genotypically clustered cases and to each other. The two largest genotype clusters among homeless persons were the Cs30 strain (n = 105) and the BEs75 strain (n = 47). Fifty-one (49%) patients with the Cs30 strain and 28 (60%) with the BEs75 strain were homeless. Compared to patients with the BEs75 strain, patients with the Cs30 strain were less likely to be respiratory acid-fast bacillus smear positive (51% versus 72%). Furthermore, patients with the BEs75 strain were more likely to be HIV infected (74% versus 42%), which suggests that most patients with this strain advanced to disease after recent infection. Cases in clusters of strains that have been circulating in the community over a long time period, such as the Cs30 strain, require additional investigation to determine whether clustering is a result of recent transmission or reactivation of remote infection.

Factors influencing tuberculosis cluster growth are poorly understood. The authors examined clusters of two or more culture-confirmed Mycobacterium tuberculosis cases between January 1, 2001, and December 31, 2003, that had insertion sequence 6110 (IS6110) restriction fragment length polymorphism and spoligotype patterns identical to those of another study case. Genotypes first seen in New York, New York, before or during 1993 were considered historical; recent strains were those first seen after 1993. The authors examined the effect of the combined characteristics of infectiousness of the first two cases in a cluster on the rate of cluster growth. Genotyping was performed for 2,408 (91.8%) of the 2,623 tuberculosis cases diagnosed; 873 cases were in 212 clusters. Thirty-one clusters had historical strains, 153 were recent, and 28 were of unknown period. Patients' infectiousness was not associated with the rate of cluster growth among historical strain clusters. Among recent strain clusters, infectiousness of both of the initial cases was associated with a higher rate of cluster growth compared with clusters in which neither initial case was infectious, upon adjustment for male sex (rate ratio = 2.62, 95% confidence interval: 1.19, 5.78). The rate of genotype cluster growth should be monitored regardless of how long the strain has been present in the community. However, infectiousness in the first two cases may be useful to prioritize genotype cluster investigations.

Background: Two drug-resistance surveys showed a very high prevalence of drug resistance among isolates obtained from patients with tuberculosis in 1991 and 1994 in New York, New York., Methods: A cross-sectional survey in April 1997 and a survey of incident cases in April-June 2003 were conducted. The trend in the proportion of drug resistance in the 4 surveys was examined separately for prevalent and incident cases. Risk factors for drug resistance in incident cases were also assessed., Results: The number of patients was 251 in the 1997 survey and 217 in the 2003 survey. Among prevalent cases, the percentage of cases with resistance to any antituberculosis drug decreased from 33.5% in 1991 to 23.8% in 1994 and to 21.5% in 1997 (P < .001, by test for trend); cases of multidrug-resistant tuberculosis also decreased significantly, from 19% in 1991 to 6.8% in 1997 (P < .001, by test for trend). Among incident cases in the 4 surveys, the decrease in resistance to any antituberculosis drugs was not statistically significant; however, the decrease in multidrug-resistant tuberculosis (from 9% in 1991 to 2.8% in 2003) was statistically significant (P = .002, by test for trend). However, in 2003, a worrisome increase in incident cases of multidrug-resistant tuberculosis (an increase of 23%) was seen among previously treated patients with pulmonary tuberculosis not born in the United States. Human immunodeficiency virus infection, a strong predictor for drug resistance in 1991 and 1994, was not associated with drug resistance in subsequent surveys., Conclusions: Intensive case management, including directly observed therapy, adherence monitoring, and periodic medical review to ensure appropriate treatment for each patient, should be sustained to prevent acquired drug resistance.

Setting: An urban tuberculosis control program where an enhanced multidrug-resistant tuberculosis (MDR-TB) management plan coordinated care with multiple providers., Objective: To evaluate treatment outcomes of primary MDR-TB patients treated by multiple providers., Design: Retrospective cohort study of tuberculosis patients from 1992-1997 provided that 1) their Mycobacterium tuberculosis isolates were resistant to at least isoniazid and rifampin, and 2) they had had < or = 30 days of anti-tuberculosis treatment prior to the collection of the first MDR-TB specimen., Results: More than 100 facilities and providers reported 856 MDR-TB patients. Treatment completion reached 70% among non-HIV-infected and 30% among HIV-infected persons; 57.2% of the cohort died prior to treatment completion, 26.5% completed treatment, 16.0% transferred out, refused treatment or were lost to follow-up and 0.2% are still in care. Diagnosis in the later years of the study or cavitation on chest radiograph was independently associated with increased completion among HIV-infected patients. Eight of the 227 (3.5%) patients who completed treatment relapsed (relapse rate 1.01/100 person-years), two with drug-susceptible strains., Conclusion: A comprehensive MDR-TB control program improved the outcomes of both HIV-infected and non-infected individuals, despite management by multiple providers. Relapse was infrequent among patients who completed the recommended regimens.

In 2001, New York City implemented genotyping to its tuberculosis (TB) control activities by using IS6110 restriction fragment length polymorphism (RFLP) and spoligotyping to type isolates from culture-positive TB patients. Results are used to identify previously unknown links among genotypically clustered patients, unidentified sites of transmission, and potential false-positive cultures. From 2001 to 2003, spoligotype and IS6110-based RFLP results were obtained for 90.7% of eligible and 93.7% of submitted isolates. Fifty-nine (2.4%) of 2,437 patient isolates had false-positive culture results, and 205 genotype clusters were identified, with 2-81 cases per cluster. Cluster investigations yielded 57 additional links and 17 additional sites of transmission. Four additional TB cases were identified as a result of case finding initiated through cluster investigations. Length of unnecessary treatment decreased among patients with false-positive cultures.

Background: Nosocomial tuberculosis (TB) transmission has decreased dramatically in New York State since 1992; however, health care workers (HCWs) still compose >3% of TB cases., Methods: Aggregate surveillance data on incident TB cases from 1994 to 2002 were examined for trends among HCWs. Additional information was available for HCW cases from 1998 to 2002, including facility type, tuberculin skin test (TST) result at hire, and treatment of latent TB infection (TLTBI)., Results: In New York State, 2.5% of TB cases in 1994 and 4.0% in 2002 were in HCWs (P value for trend <.001). Fifty percent of HCWs TB cases in 1994 and 77.6% in 2002 were in non-US born (P = .002) HCWs. Multidrug-resistant TB in HCWs decreased from 15.6% in 1994 to 6.9% in 2002 (P = .001). Of 297 HCWs TB cases in 1998-2002, 54.9% were TST positive at hire, and 21.2% had unknown TST result; 50.2% of 221 HCWs who were TST positive at or after hire met guidelines for TLTBI, and 23.4% received treatment. The highest proportion with unknown TST at hire and the lowest proportion receiving TLTBI were in ambulatory facilities., Conclusion: Many HCWs who developed TB were either TST positive at hire and did not receive TLTBI or did not receive TST at hire. Facilities should encourage treatment for HCWs who meet criteria for TLTBI. Provider education should focus on ambulatory facilities.

Setting: New York City (NYC)., Objectives: To examine the extent to which prior tuberculosis (TB) treatment, length of residence in the United States and other factors are associated with the occurrence of drug resistance among non-US-born persons in NYC., Design: Cases were non-US-born persons diagnosed with TB in NYC from 1998-1999 and from 2001-2002, with an initial Mycobacterium tuberculosis isolate resistant to any first-line anti-tuberculosis drug. Controls were randomly selected from non-US-born persons whose isolates were susceptible to all first-line anti-tuberculosis drugs., Results: Overall, cases with multidrug-resistant (MDR) TB were more likely to have had prior TB treatment; other drug resistance was not associated with prior TB treatment. In a multivariate model, the relationship between MDR-TB and prior treatment remained significant for non-US-born persons regardless of length of time in the U.S., Conclusions: The findings underscore the utility of monitoring trends in drug resistance among the non-US-born by time in the US and prior treatment to determine where or when drug resistance may be occurring.

Setting: Large urban tuberculosis control program., Objectives: To determine the frequency and characteristics of treatment interruptions, and the factors associated with the different types of treatment interruptions., Design: This was a case-control study using culture-positive tuberculosis (TB) patients verified in 1998-1999. Case patients included those in whom any of the following mutually exclusive categories of treatment interruption: default with return to therapy, directly observed therapy nonadherence, default without return to therapy, or multiple types of interruptions. Controls were selected randomly from the cohort., Results: Overall, 6.0 percent of patients had treatment interruptions. All types of treatment interruption were associated with prolonged treatment course and decreased treatment completion rates. The median number of months to treatment interruption was 4.0 (range, 0.5-28.9 months). Two factors were significantly associated with every type of interruption: homelessness and lack of awareness of the severity of TB disease. In multivariate analysis, only lack of awareness of the severity of disease remained independently associated with all interruption types., Conclusion: Efforts to improve patients' understanding of TB disease and related treatment issues may be an important TB control program strategy and should be emphasized at the initiation of therapy and at intervals throughout the treatment course to minimize treatment interruption.

Background: The relationship between rifamycin use and either relapse or treatment failure with acquired rifampin resistance (ARR) among human immunodeficiency virus (HIV)-infected patients with tuberculosis (TB) is not well understood., Methods: We conducted a retrospective cohort study of HIV-infected and HIV-uninfected persons with rifampin-susceptible TB, (1) to compare relapse rates, ARR, and treatment failure, according to HIV serostatus; and (2) to examine whether and how use of rifamycin was associated with clinical outcomes of interest among HIV-infected patients with TB., Results: HIV-infected patients were more likely to have ARR than were HIV-uninfected patients (0.9% vs. 0.1%; P = .007), and the association remained significant in multivariate analysis (adjusted odds ratio [OR], 5.5; 95% confidence interval [CI], 1.4-21.5). Among HIV-infected patients with TB, none of 57 patients treated with rifabutin-based regimens alone had ARR, and only 1 of 395 patients treated with rifabutin given in combination with a rifampin-based regimen had ARR, whereas 6 of 355 patients treated with a rifampin-based regimen alone had relapse and ARR. HIV-infected patients treated with rifampin-based regimens alone had a higher risk for relapse and development of rifampin resistance if intermittent dosing of rifampin was started during the intensive phase of treatment, compared with patients who did not receive intermittent dosing (hazard ratio [HR] for relapse, 6.7 [95% CI, 1.1-40.1]; HR for ARR, 6.4 [95% CI, 1.1-38.4]). This association remained when confined to patients with a CD4+ T lymphocyte count of < 100 lymphocytes/mm3. Intermittent dosing started only after the intensive phase of treatment did not increase the risks of relapse and ARR among HIV-infected patients with TB., Conclusion: The risk for ARR among HIV-infected persons with TB did not depend on the rifamycin used but, rather, on the rifampin dosing schedule in the intensive phase of treatment.

Setting: Large urban tuberculosis control program., Objective: To evaluate results of procedures implemented for systematic investigation of tuberculosis exposures in congregate settings., Design: Between October 1995 and December 2000, a unit consisting of epidemiologists, health educators and tuberculin screening staff investigated exposures in sites with >15 persons. Transmission at the site was defined as likely, possible, unlikely or unknown., Results: Among 100 investigations, 12 were tuberculosis case clusters, five were source case investigations, and 83 were exposures to single infectious cases. Transmission was likely in 24 (21%), possible in eight (8%), unlikely in 62 (62%), and could not be assessed in four (4%). Among the 83 exposures to single infectious cases, 2740 contacts were tested; 502 (18%) were infected. Among 1202 close contacts, 996 (82%) were tested, 197 (20%) were infected and started treatment of latent tuberculosis infection (LTBI) and 102/197 (52%) completed treatment. Sites with likely transmission had index patients with longer duration of cough (13 vs. 6 weeks, P = 0.01) and cavitary lesions (84% vs. 44%, P = 0.01) compared to sites with unlikely transmission., Conclusion: A systematic approach for conducting contact investigations in congregate settings is useful for assessing transmission. As such investigations are resource intensive and transmission is not common, performing tuberculin skin testing after most persons would have converted should be considered in low-risk groups. Additional efforts are needed to increase completion of treatment for LTBI in contacts identified in these settings.

Objective: To determine factors associated with no contacts identified for homeless patients in New York City., Design: Culture-confirmed pulmonary tuberculosis cases in persons >18 years old diagnosed in 1997-1999 were included. Demographic and clinical characteristics of tuberculosis patients associated with the number of contacts identified according to homeless status were analyzed using unconditional logistic regression., Results: Homeless patients (n = 152) had a significantly lower median number of contacts than non-homeless patients (n = 2836) (1 vs. 4, P < 0.001). Among homeless patients, having AFB smear-positive sputum with cavitary lesions reduced the likelihood of having no contacts identified. Homeless patients who lived on the street at the time of diagnosis were more likely to have no contacts identified compared to those with contacts identified (61.4% vs. 56.1%); however, the difference was not statistically significant (P = 0.506). Unlike non-homeless patients, being hospitalized at the time of tuberculosis diagnosis was not associated with having contacts identified in homeless patients., Conclusions: Homelessness independently predicted the likelihood of having no contacts identified. Strategies such as interviews that focus on location rather than persons may be more effective for identifying contacts. Furthermore, being homeless at the time of diagnosis should be used as an indicator for prioritizing prompt contact evaluation.

One multidrug-resistant Mycobacterium tuberculosis (MDRTB) strain, strain W, caused several nosocomial outbreaks in New York City (NYC) during 1 January 1990-31 July 1993. We reviewed all MDRTB cases verified during 1 August 1993-31 December 1999 that had isolates with either this DNA pattern or a variant of this strain, and we compared them to the outbreak cases. Of 427 DNA-confirmed cases from 1990-1999, 161 (37%) were from 1 August 1993-31 December 1999; these 161 cases, from 56 hospitals and 2 correctional sites, constituted 28% of all MDRTB cases in NYC during this period. Compared with those from 1 January 1990-31 July 1993, patients from 1 August 1993-31 December 1999 were less likely to be infected with human immunodeficiency virus, to have been born in the United States, to be homeless, to have been incarcerated, and to have epidemiological links; 16% of patients had nosocomial- and 9% had community-exposure links. This strain was disseminated widely in the community during the outbreaks; postoutbreak cases likely represent reactivated disease among individuals infected during the outbreak periods in the community.

Setting: A large urban tuberculosis control program., Objectives: To examine changes in tuberculosis incidence and characteristics of cases in New York City (NYC), and assess the epidemiology of tuberculosis among non-US-born persons., Design: Tuberculosis surveillance data (1995-1999) for NYC were analyzed., Results: Tuberculosis incidence decreased by 56.6% in US-born and 19.6% in non-US-born persons (age-adjusted) over the study period. The decline in tuberculosis incidence among US-born persons was more substantial in the first half of the study period (23-24%) than in the second half (13-15%). The greatest decline in incidence was among US-born Hispanic or Black males aged 25-64. However, although there was an overall decline in incidence among non-US-born persons, there was no significant change in any sex or racial/ethnic subgroup. The percent of multidrug-resistant (MDR) cases among non-US-born patients remained stable, but recent arrivals accounted for 79% of non-US-born MDR-TB patients in 1999, a significant increase from 16% in 1997., Conclusions: Continuing current tuberculosis control efforts and treatment of immigrants with latent tuberculosis infection are of highest priority for reducing incident cases in NYC. Global collaboration towards earlier detection and treatment of active tuberculosis cases in high incidence countries is also essential.

From January 1, 1995, to December 31, 1997, we reviewed records of all New York City patients who had multidrug-resistant tuberculosis (MDRTB); we performed insertion sequence (IS) 6110-based DNA genotyping on the isolates. Secondary genotyping was performed for low IS6110 copy band strains. Patients with identical DNA pattern strains were considered clustered. From 1995 through 1997, MDRTB was diagnosed in 241 patients; 217 (90%) had no prior treatment history, and 166 (68.9%) were born in the United States or Puerto Rico. Compared with non-MDRTB patients, MDRTB patients were more likely to be born in the United States, have HIV infection, and work in health care. Genotyping results were available for 234 patients; 153 (65.4%) were clustered, 126 (82.3%) of them in eight clusters of >or=4 patients. Epidemiologic links were identified for 30 (12.8%) patients; most had been exposed to patients diagnosed before the study period. These strains were likely transmitted in the early 1990 s when MDRTB outbreaks and tuberculosis transmission were widespread in New York.

The optimal duration of tuberculosis treatment for persons infected with human immunodeficiency virus (HIV) has been debated. A cohort of 4571 culture-positive drug-susceptible patients who received > or =24 weeks of standard 4-drug tuberculosis treatment were assessed to determine the incidence of tuberculosis relapse. Tuberculosis "recurrence" was defined as having a positive culture < 30 days after the last treatment date and "relapse" as having a positive culture > or =30 days after the last treatment. Patients infected with HIV were more likely than those who were uninfected to have recurrence or relapse (2.0 vs. 0.4 per 100 person-years, P< .001). Patients infected with HIV who received < or =36 weeks of treatment were more likely than those who received > 36 weeks to have a recurrence (7.9% vs. 1.4%, P< .001). Clinicians should be aware of the possibility of recurrence of tuberculosis 6-9 months after the start of treatment. Sputum evaluation to ensure cure or assessment 3 months after completion of treatment should be performed among persons infected with HIV who receive the shorter regimen.

A distinct branch of the Mycobacterium tuberculosis W phylogenetic lineage (W14 group) has been identified and characterized by various genotyping techniques. The W14 group comprises three strain variants: W14, W23, and W26, which accounted for 26 clinical isolates from the New York City metropolitan area. The W14 group shares a unique IS6110 hybridizing banding motif as well as distinct polymorphic GC-rich repetitive sequence and variable number tandem repeat patterns. All W14 group members have high levels of streptomycin resistance. When the streptomycin resistance rpsL target gene was sequenced, all members of this strain family had an identical mutation in codon 43. Patients infected with the W14 group were primarily of non- Hispanic black origin (77%); all were US-born. Including HIV positivity, 84% of the patients had at least one known risk factor for tuberculosis.

Objective: To determine whether active tuberculosis alters the rate of progression of HIV infection in dually infected patients., Methods: HIV-seropositive patients at two Bronx, New York hospitals with tuberculosis confirmed by culture from July 1992 to February 1995, who survived the initial hospitalization for tuberculosis, were matched on gender, age, CD4+ percentage, and calendar time with HIV-seropositive patients without tuberculosis participating in a study of the natural history of HIV infection. Patients received follow-up observation prospectively until May 23, 1995 to determine survival rates and development of AIDS-defining opportunistic infections (OIs)., Results: 70 patients had tuberculosis; 120 did not. Mean CD4+ percentages were 12.4% and 12.5%, respectively. At study entry, 27% of those with tuberculosis had prior AIDS-defining OIs other than tuberculosis, compared with 10% of those without tuberculosis (p = .004). In multivariate survival analysis, controlling for CD4+ level, tuberculosis was not an independent predictor of increased other causes of AIDS-related mortality. However, in a logistic regression model, independent predictors of subsequent OIs included tuberculosis (hazard ratio, 4.1; 95% confidence intervals [CI], 1.9, 8.7), CD4+ count <100/mm3 (hazard ratio, 2.4; 95% CI, 1.1, 5.0) and prior OIs (hazard ration, 3.3; 95% CI, 1.3, 8.3)., Conclusions: Tuberculosis was not an independent predictor of increased non-tuberculosis-related mortality in HIV-seropositive patients but was associated with increased risk of development of OIs.

All New York City patients whose cultures yielded Mycobacterium tuberculosis with isolated resistance to rifampin in 1993 and 1994 were included in this study. Of the 96 patients, 48 (50%) had primary resistance, 32 (33%) had acquired resistance, and 16 (17%) had unclassified resistance; 66% had histories of illicit drug use, and 79% were infected with human immunodeficiency virus (HIV). The median time to emergence of resistance was 40 weeks among the 32 patients with acquired resistance. Each of the HIV-infected patients with acquired resistance (cases, n = 29) was matched to two HIV-infected patients who had disease due to fully susceptible M. tuberculosis (controls, n = 58). In multivariate analysis, factors associated with the emergence of rifampin resistance were as follows: a sputum smear positive for acid-fast bacilli, advanced immunosuppression, and nonadherence to therapy.