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The prevalence of latent tuberculosis infection (LTBI) in the various populations of New York City (NYC), a city with a high density of non-US-born persons, is unknown. We examined the prevalence of TST positivity in patients who received a tuberculin skin test (TST) between 1/2002 and 8/2004 at any of 10 NYC health department chest centers. A positive TST was defined as an induration reaction to tuberculin of ≥10 mm. In the study population of 41,022 individuals, prevalence of TST positivity was 24.4% (95%CI = 24.0, 24.8); four times higher among non-US-born persons than US-born (39.5% vs. 8.8%, Prevalence ratio (PR) = 4.5; 95%CI = 4.4, 4.6). Prevalence of TST positivity increased with age in both US and non-US-born persons. Persons from countries with a TB case rate >100/100,000 population had higher prevalence of TST positivity (47% vs. ≤39%), even after controlling for BCG (PR = 1.3, 95%CI = 1.2, 1.4). These findings provide insight into current prevalence of TST positivity in many immigrant populations and will help both clinicians and health departments to target patients for LTBI treatment. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Rationale: Moxifloxacin has promising preclinical activity against Mycobacterium tuberculosis, but has not been evaluated in multidrug treatment of tuberculosis in humans. Objective: To compare the impact of moxifloxacin versus ethambutol, both in combination with isoniazid, rifampin, and pyrazinamide, on sputum culture conversion at 2 mo as a measure of the potential sterilizing activity of alternate induction regimens. Methods: Adults with smear-positive pulmonary tuberculosis were randomized in a factorial design to receive moxifloxacin (400 mg) versus ethambutol given 5 d/wk versus 3 d/wk (after 2 wk of daily therapy). All doses were directly observed. Measurements: The primary endpoint was sputum culture status at 2 mo of treatment. Results: Of 336 patients enrolled, 277 (82%) were eligible for the efficacy analysis, 186 (67%) were male, 175 (63%) were enrolled at African sites, 206 (74%) had cavitation on chest radiograph, and 60 (22%) had HIV infection. Two-month cultures were negative in 71% of patients (99 of 139) treated with moxifloxacin versus 71% (98 of 138) treated with ethambutol (p = 0.97). Patients receiving moxifloxacin, however, more often had negative cultures after 4 wk of treatment. Patients treated with moxifloxacin more often reported nausea (22 vs. 9%, p = 0.002), but similar proportions completed study treatment (88 vs. 89%). Dosing frequency had little effect on 2-mo culture status or tolerability of therapy. Conclusions: The addition of moxifloxacin to isoniazid, rifampin, and pyrazinamide did not affect 2-mo sputum culture status but did show increased activity at earlier time points. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The purpose of this study was to evaluate whether non-US-born pregnant women receiving prenatal care are targeted for treatment of latent tuberculosis (TB) infection (LTBI) with isoniazid (INH) to prevent active TB. STUDY DESIGN: This was a retrospective chart review study of 730 non-US-born pregnant women receiving care at 5 New York City prenatal clinics from 1999 to 2000. RESULTS: Among 678 women with known tuberculin skin test (TST) status, 341 (50.3%) had a TST-positive result, including 200 who were newly diagnosed. Of 291 TST-positive women with no previous LTBI treatment or history of TB, 27 (9.3%) completed > or =6 months of INH. In a subset with detailed follow-up, the most important reasons for not completing treatment were nonreferral for evaluation of a TST-positive result (30.9%), not keeping the appointment (17.9%), and nonadherence with prescribed treatment (34.6%). CONCLUSION: The prenatal setting represents a missed opportunity to link TST-positive non-US-born women with LTBI treatment and support for treatment completion. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

STUDY OBJECTIVES: Therapeutic drug monitoring (TDM) is the process of obtaining the serum concentration of a medication and modifying the dose based on the results. Little is known about the application of TDM in the treatment of patients with multidrug-resistant (MDR) tuberculosis (TB) in clinical practice. This study characterized how TDM was applied in the management of MDR TB patients, and examined the clinical indications for ordering TDM, the process for obtaining drug concentrations, and the clinician response to the drug concentrations. DESIGN: In a retrospective study, we compared the clinical and demographic characteristics of MDR TB patients who received TDM with those who did not. The clinical application of TDM also was described in patients who received TDM. SETTING: A municipal TB control program.Patients or participants: Patients in whom TB was diagnosed that was caused by an isolate resistant to at least isoniazid and rifampin, and who received treatment for TB in one of the health department chest clinics between July 1, 1993, and August 31, 1997, were studied. RESULTS: Forty-nine patients receiving TDM had a longer time to culture conversion and treatment duration, more pulmonary TB in combination with an extrapulmonary site, drug resistance, and visits to the health department clinics (p < 0.05) than the 60 patients without TDM. Of the 49 patients who had initial TDM, 73.5% of them had the reason for being tested specified. A total of 85.7% of initial TDM results were collected at the appropriate time of blood sampling. Clinician response to TDM results varied with the drug that was being tested. CONCLUSIONS: The use of TDM depended largely on the patient's clinical presentation. Site-specific guidelines on the use of TDM for managing TB patients may maximize the benefit of TDM. [ABSTRACT FROM AUTHOR]

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. Copyright © 2003 Infectious Diseases Society of America [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study was designed to determine the yield of investigations whose aim is to identify a source case for tuberculosis infection among tuberculin reactors 3 years of age or younger. METHODS: The authors describe the results of associate investigations conducted for child tuberculin reactors reported from January 1, 1996, through June 30, 1998. Associates were defined as individuals who live with or spend significant time with a child reactor. An associate investigation was defined as evaluation of at least one associate. A source case was an associate older than 10 years of age who had culture-positive, pulmonary tuberculosis during a period when the child could have been exposed. RESULTS: Two hundred seven children had an associate investigation performed with a median of four associates investigated per child (range 1-21). Birthplace was known for 187 (90%); 128 were U.S.-born. Of 1,222 associates identified, 980 (80%) were evaluated. Among 452 (46%) associates for whom birthplace was known, 250 (55%) were non-U.S.-born. Of 980 associates, 668 were household contacts; 198 (30%) were infected, three had prior tuberculosis disease, and three had active tuberculosis. Two active cases met source case criteria; the yield was 0.9 (2 of 207) source cases per 100 children investigated. Of 312 non-household contacts, 57 (18%) were infected and none had the disease. CONCLUSIONS: Although few source cases were identified for young tuberculin skin test reactors in New York City, investigations identified a proportion of cases and infection in associates similar to that identified among contacts to pulmonary tuberculosis cases. Such investigations may be identifying a high-risk group and should be considered, depending on program resources. [ABSTRACT FROM AUTHOR]

Tuberculosis among Tibetans increased in New York City between 1995 and 1999. We examined characteristics of 68 Tibetan patients compared to 702 non-Tibetan patients from Nepal, India, or China, diagnosed between January 1995 and December 1999. The number of Tibetan patients increased each year after 1995 whereas non-Tibetans remained stable during the same period. Tibetans were younger (27 vs. 44 years), more likely to be infectious (63% vs. 46%), have multidrug resistance (7% vs. 2%) and shorter time to diagnosis after arrival (9 vs. 79 months, p < 0.01). For Tibetan patients, 68% of identified contacts were evaluated. The prevalence of tuberculosis infection was 65%. In contrast, among non-Tibetan patients 88.8% of contacts were evaluated and 45.2% were infected. Outreach efforts with community leaders and educational presentations at community events have been implemented in an effort to ensure continuity of care and completion of treatment. [ABSTRACT FROM AUTHOR]

Background: Respiratory isolation of people with pulmonary tuberculosis (TB), including after treatment initiation, is used to prevent community-based transmission; yet guidelines on duration are limited and implementation is heterogeneous. This systematic review synthesized evidence on respiratory isolation for TB to inform National TB Coalition of America guidelines., Methods: After searching six databases, eight reviewers screened and extracted data in duplicate on effects of respiratory isolation compared to no isolation or masking. Studies were stratified by outcomes: TB infection or disease in contacts, mortality, hospitalization duration, patient and health system costs, and impact on mental health or stigma. We used a convergent integrated approach to synthesize quantitative and qualitative findings and assess limitations., Results: Seventeen studies were included. There were limited data directly comparing isolation to non-isolation interventions, including effects after treatment initiation. One randomized controlled trial suggested treatment in a sanatorium versus at home did not affect TB incidence in contacts. Modelling studies suggest isolation may reduce transmission, but relied on various assumptions, and isolation was implemented alongside other interventions. Descriptive, mixed-methods, and qualitative studies described adverse impacts of isolation on employment, education, food/housing security, and mental health due to transmission fears, stigma and social isolation. Impacts were compounded in marginalized groups including indigenous and incarcerated persons., Conclusion: Data to support current isolation practices, particularly after effective treatment initiation, to reduce TB transmission in communities are limited. Public health guidance should weigh the negative impacts on people with TB against decreased community transmission to make evidence-based decisions about respiratory isolation., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Data regarding ocular tuberculosis (OTB) in the United States have not been previously reported. We evaluated trends of OTB compared with other extrapulmonary TB (EPTB)., Methods: We estimated the proportion of all EPTB cases (with or without concurrent pulmonary involvement) with OTB reported to the National Tuberculosis Surveillance System during 1993-2019. We compared demographics and clinical characteristics of people with OTB and other EPTB during 2010-2019. P values were calculated by chi-square test for categorical variables and Kruskal-Wallis for continuous variables., Results: During 1993-2019, 1766 OTB cases were reported, representing 1.6% of 109 834 all EPTB cases: 200 (0.5% of 37 167) during 1993-1999, 395 (1.0% of 41 715) during 2000-2009, and 1171 (3.8% of 30 952) during 2010-2019. In contrast to persons with other EPTB, persons with OTB were older (median, 48 vs 44 years; P < .01), more likely to be US-born (35% vs 28%; P < .01), more likely to have diabetes (17% vs 13%; P < .01), and less likely to have HIV (1% vs 8%; P < .01). OTB was less likely to be laboratory confirmed (5% vs 75%; P < .01), but patients were more likely to be tested by interferon gamma release assay (IGRA; 84% vs 56%; P < .01) and to be IGRA positive (96% vs 80%; P < .01)., Conclusions: Reported OTB increased during 1993-2019 despite decreasing TB, including EPTB; the largest increase occurred during 2010-2019. OTB was rarely laboratory confirmed and was primarily diagnosed in conjunction with IGRA results. More research is needed to understand the epidemiology of OTB to inform clinical and diagnostic practices., Competing Interests: Potential conflicts of interest. The authors declare no conflicts of interest related to the content of this manuscript., (Published by Oxford University Press on behalf of Infectious Diseases Society of America 2024.)

Background: Managing the complex needs of outpatient parenteral antibiotic therapy (OPAT) patients is challenging and time-consuming. We describe development of multimodal interventions to facilitate patient management within an Epic® (Epic Systems Corporation)-based electronic health record (EHR) platform., Methods: During 2016-2018, a multidisciplinary team created several modifications in our local EHR to improve gaps in OPAT care, including shared note templates, shared patient lists, automatically triggered notifications, and comprehensive order sets. A SmartForm was created, allowing collection of discrete, self-contained extractable data about each OPAT episode. We reviewed OPAT episodes from January 2019 through December 2022., Results: The multimodal EHR interventions culminated in the creation of a patient report, the "OPAT Monitoring View" collating OPAT-relevant data from multiple sections of the chart onto 1 screen display. This view is accessible both within the patient chart and from multiple list-based, in-basket, and snapshot-anchored preview functions in the EHR. Implementation of the EHR bundle facilitated management of 3402 OPAT episodes from 2019 to 2022 (850 episodes/year), about 50% higher than anticipated based on 540 OPAT courses in 2016. The OPAT EHR bundle allowed efficient (<3 hours) multidisciplinary rounds for management of 130-145 patients each week, streamlining of care transitions, and increasing staff satisfaction., Conclusions: Bundled multimodal modifications to the local EHR increased patient care efficiency and staff satisfaction and facilitated data collection to support a large OPAT program. These modifications apply commonly available EHR functionalities to OPAT care and could be adapted to other settings with different EHR platforms., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: We evaluated our SARS-CoV-2 prefusion spike recombinant protein vaccine (CoV2 preS dTM) with different adjuvants, unadjuvanted, and in a one-injection and two-injection dosing schedule in a previous phase 1-2 study. Based on interim results from that study, we selected a two-injection schedule and the AS03 adjuvant for further clinical development. However, lower than expected antibody responses, particularly in older adults, and higher than expected reactogenicity after the second vaccination were observed. In the current study, we evaluated the safety and immunogenicity of an optimised formulation of CoV2 preS dTM adjuvanted with AS03 to inform progression to phase 3 clinical trial., Methods: This phase 2, randomised, parallel-group, dose-ranging study was done in adults (≥18 years old), including those with pre-existing medical conditions, those who were immunocompromised (except those with recent organ transplant or chemotherapy) and those with a potentially increased risk for severe COVID-19, at 20 clinical research centres in the USA and Honduras. Women who were pregnant or lactating or, for those of childbearing potential, not using an effective method of contraception or abstinence, and those who had received a COVID-19 vaccine, were excluded. Participants were randomly assigned (1:1:1) using an interactive response technology system, with stratification by age (18-59 years and ≥60 years), rapid serodiagnostic test result (positive or negative), and high-risk medical conditions (yes or no), to receive two injections (day 1 and day 22) of 5 7mu;g (low dose), 10 7mu;g (medium dose), or 15 7mu;g (high dose) CoV2 preS dTM antigen with fixed AS03 content. All participants and outcome assessors were masked to group assignment; unmasked study staff involved in vaccine preparation were not involved in safety outcome assessments. All laboratory staff performing the assays were masked to treatment. The primary safety objective was to describe the safety profile in all participants, for each candidate vaccine formulation. Safety endpoints were evaluated for all randomised participants who received at least one dose of the study vaccine (safety analysis set), and are presented here for the interim study period (up to day 43). The primary immunogenicity objective was to describe the neutralising antibody titres to the D614G variant 14 days after the second vaccination (day 36) in participants who were SARS-CoV-2 naive who received both injections, provided samples at day 1 and day 36, did not have protocol deviations, and did not receive an authorised COVID-19 vaccine before day 36. Neutralising antibodies were measured using a pseudovirus neutralisation assay and are presented here up to 14 days after the second dose. As a secondary immunogenicity objective, we assessed neutralising antibodies in non-naive participants. This trial is registered with ClinicalTrials.gov (NCT04762680) and is closed to new participants for the cohort reported here., Findings: Of 722 participants enrolled and randomly assigned between Feb 24, 2021, and March 8, 2021, 721 received at least one injection (low dose=240, medium dose=239, and high dose=242). The proportion of participants reporting at least one solicited adverse reaction (injection site or systemic) in the first 7 days after any vaccination was similar between treatment groups (217 [91%] of 238 in the low-dose group, 213 [90%] of 237 in the medium-dose group, and 218 [91%] of 239 in the high-dose group); these adverse reactions were transient, were mostly mild to moderate in intensity, and occurred at a higher frequency and intensity after the second vaccination. Four participants reported immediate unsolicited adverse events; two (one each in the low-dose group and medium-dose group) were considered by the investigators to be vaccine related and two (one each in the low-dose and high-dose groups) were considered unrelated. Five participants reported seven vaccine-related medically attended adverse events (two in the low-dose group, one in the medium-dose group, and four in the high-dose group). No vaccine-related serious adverse events and no adverse events of special interest were reported. Among participants naive to SARS-CoV-2 at day 36, 158 (98%) of 162 in the low-dose group, 166 (99%) of 168 in the medium-dose group, and 163 (98%) of 166 in the high-dose group had at least a two-fold increase in neutralising antibody titres to the D614G variant from baseline. Neutralising antibody geometric mean titres (GMTs) at day 36 for participants who were naive were 2189 (95% CI 1744-2746) for the low-dose group, 2269 (1792-2873) for the medium-dose group, and 2895 (2294-3654) for the high-dose group. GMT ratios (day 36: day 1) were 107 (95% CI 85-135) in the low-dose group, 110 (87-140) in the medium-dose group, and 141 (111-179) in the high-dose group. Neutralising antibody titres in non-naive adults 21 days after one injection tended to be higher than titres after two injections in adults who were naive, with GMTs 21 days after one injection for participants who were non-naive being 3143 (95% CI 836-11 815) in the low-dose group, 2338 (593-9226) in the medium-dose group, and 7069 (1361-36 725) in the high-dose group., Interpretation: Two injections of CoV2 preS dTM-AS03 showed acceptable safety and reactogenicity, and robust immunogenicity in adults who were SARS-CoV-2 naive and non-naive. These results supported progression to phase 3 evaluation of the 10 7mu;g antigen dose for primary vaccination and a 5 7mu;g antigen dose for booster vaccination., Funding: Sanofi Pasteur and Biomedical Advanced Research and Development Authority., Competing Interests: Declaration of interests SSr, MIB, A-LC, AC, RMC, BF, HJ, YM, ER, NR, DvB, GdB, RC, M-HG, DL, RM, SM, CM, CAD, and SSa are Sanofi Pasteur employees. SSr, MIB, HJ, CM, and SSa own stock or stock options; A-LC, NR, and M-HG hold shares or restricted shares; and RMC reports owning shareholder and vesting options in Sanofi Pasteur. SSr, RMC, GdB, CAD, and SSa are inventors on a pending patent application filed by Sanofi Pasteur and GlaxoSmithKline (GSK) for the development of the CoV-2 dTM vaccine. LS, MK, MAC, and FT-D-S are employed by, and hold restricted shares in, the GSK group of companies. AJ was contracted by Sanofi Pasteur. DD received funding from Sanofi Pasteur for his institution, George Washington University, to serve as a clinical site for the vaccine trial. NG reports receiving funding and study materials from Sanofi and funding from the National Institute of Allergy and Infectious Diseases (NIAID) through the COVID-19 Prevention Network (CoVPN), which provides research grants to her institution, the Fred Hutchinson Cancer Research Center. MCK received NIAID funding support for the current study, paid to the clinical trials site for the CoVPN and HIV vaccine trials network; Sanofi Pasteur contracted the site to do this clinical trial. DMRM received a research grant from Sanofi Pasteur for this study. OO received a Gilead Sciences grant paid to Yale, and consulting fees from Gilead Sciences. OO also reports that Gilead, Integrity CE, and Medscape paid for lectures, presentations, manuscript writing, or educational events and that Gilead and ViiV Healthcare paid for their participation on a data safety monitoring or advisory board. VNR received funding from Sanofi for the CoVPN and Vaccine Treatment and Evaluation Units for COVID-19 vaccine clinical trials, and payments from Pfizer to her institution for the conduct of COVID-19 vaccine clinical trials. RS received clinical trial investigator site contracts with AES Synexus. NGR received a grant from Sanofi Pasteur to do this study and received grants from Sanofi, Merck, Pfizer, Quidel, and Lilly in the past 36 months. NGR received a payment from the Infectious Disease Association of California and participated on advisory or safety monitoring boards for Micron, ICON, and The Emmes Company; NGR also reports having a leadership or fiduciary role (paid or unpaid) for the Infectious Diseases Society of America, the Vaccine Treatment and Evaluation Unit and Antibacterial Resistance Leadership Group. LDS received a research grant from Sanofi Pasteur and SRW and JW were contracted by Sanofi Pasteur. AB, BJE, NLM, SSM, MKJ, SR, JS, TT, and JT declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Broad-spectrum antibiotics with once-daily dosing are often chosen for outpatient parenteral antibiotic therapy (OPAT) due to convenience even when narrower-spectrum antibiotics are appropriate. At our institution, up to 50% of select broad-spectrum OPAT regimens had potential to be narrowed, highlighting the need to re-evaluate regimens for de-escalation prior to discharge., (© The Author(s) 2021.)

Non-tuberculous mycobacteria are increasingly recognized as a cause of infection in both immunocompromised and immunocompetent hosts. Mycobacterium heraklionense is a recently described member of the Mycobacterium terrae complex. Herein we report a case of M. heraklionense chronic flexor tenosynovitis in the hand, managed with surgery and antibiotics., (Copyright © 2016 Asian-African Society for Mycobacteriology. Published by Elsevier Ltd. All rights reserved.)

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.

Congenital tuberculosis (TB) is uncommon, and diagnosis may be delayed. We report a case of congenital TB and the management of exposure in three different neonatal intensive care units. This case demonstrates the need for a high index of suspicion, active communication among maternal and neonatal medical providers, and timely provider reporting of maternal disease, and emphasizes the relatively greater risk of transmission to health care workers versus infants in this setting.

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.

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.

Background: A diagnosis of tuberculosis (TB) relies on acid-fast bacilli (AFB) smear and culture results. Two rapid tests that use nucleic acid amplification (NAA) have been approved by the US Food and Drug Administration for the diagnosis of TB based on detection of Mycobacterium tuberculosis from specimens obtained from the respiratory tract. We evaluated the performance of NAA testing under field conditions in a large urban setting with moderate TB prevalence., Methods: The medical records of patients with suspected TB during 2000-2004 were reviewed. Analysis was restricted to the performance of NAA on specimens collected within 7 days after the initiation of treatment for TB. The assay's sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) were evaluated., Results: The proportion of patients with confirmed or suspected TB whose respiratory tract specimens were tested by use of NAA increased from 429 (12.9%) of 3334 patients in 2000 to 527 (15.6%) of 3386 patients in 2004; NAA testing among patients whose respiratory tract specimens tested positive for AFB increased from 415 (43.6%) of 952 patients in 2000 to 487 (55.5%) of 877 patients in 2004 (P < .001 for both trends). Of the 16,511 patients being evaluated for pulmonary TB, 4642 (28.1%) had specimens that tested positive for AFB on smear. Of those 4642 patients, 2241 (48.3%) had NAA performed on their specimens. Of those 2241 patients, 1279 (57.1%) had positive test results. Of those 1279 patients, 1262 (98.7%) were confirmed to have TB. For 1861 (40.1%) of the 4642 patients whose specimens tested positive for AFB on smear, the NAA test had a sensitivity of 96.0%, a specificity of 95.3%, a PPV of 98.0%, and an NPV of 90.9%. For 158 patients whose specimens tested negative for AFB on smear, the NAA test had a sensitivity of 79.3%, a specificity of 80.3%, a PPV of 83.1%, and an NPV of 76.0%, respectively. For the 215 specimens that tested positive for AFB by smear, we found a sensitivity, specificity, PPV, and NPV of 97.5%, 93.6%, 95.1%, and 96.8%, respectively. A high-grade smear was associated with a better test performance., Conclusion: NAA testing was helpful for determining whether patients whose specimens tested positive for AFB on smear had TB or not. This conclusion supports the use of this test for early diagnosis of pulmonary and extrapulmonary TB.

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.

Rifapentine is a recently approved antituberculosis drug that has not yet been widely used in clinical settings. Clinical data support intermittent use of rifapentine with isoniazid during the continuation phase of tuberculosis treatment. Patients with culture-positive, noncavitary, pulmonary tuberculosis whose sputum smear is negative for acid-fast bacilli at the end of the 2-month intensive treatment phase are eligible for rifapentine therapy. Rifapentine should not be used in human immunodeficiency virus-infected patients, given their increased risk of developing rifampin resistance with currently recommended dosages. Rifapentine is not currently recommended for children aged <12 years, pregnant or lactating women, or individuals with culture-negative or extrapulmonary tuberculosis. Rifapentine (600 mg) is administered once weekly with isoniazid (900 mg) during the continuation phase of treatment. This combination should only be given under direct observation. As with rifampin, drug-drug interactions are common, and regular patient monitoring is required. Ease of administration makes this regimen attractive both for tuberculosis-control programs and for patients.

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.

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.

This article reviews the principles, scientific basis, and experience with implementation of the directly observed treatment strategy, short course (DOTS) for tuberculosis. The relevance of DOTS in the context of multidrug-resistant tuberculosis and the HIV epidemic also is discussed.

Injection drug users (IDUs) were heavily affected by the tuberculosis (TB) resurgence in New York City in the 1990s. We assessed the effectiveness of screening for latent TB infection in methadone users and of selective treatment with isoniazid. Risk for future TB was classified as low or high on the basis of tuberculin, anergy, and HIV test results. The cohort of 2212 IDUs was followed up for a median of 4.2 years; 25 IDUs, of whom 20 (80%) were infected with human immunodeficiency virus (HIV), developed TB. In an adjusted Cox proportional hazards model of high-risk IDUs, the risk of TB was associated with HIV infection (HR 10.3; 95% CI, 3.4-31.3); receipt of <6 months of isoniazid therapy (HR 7.6; 95% CI, 1.02-57.1); a CD4+ T lymphocyte count of <200 cells/mm3 (HR 6.6; 95% CI, 1.7-25.9); and tuberculin positivity (HR 4.0; 95% CI, 1.6-10.2). Treatment with isoniazid was beneficial in HIV-infected, tuberculin-positive IDUs.

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.