Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
Records 1-18 (of 18 Records) |
Query Trace: Armstrong LR[original query] |
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Use of Nucleic Acid Amplification Testing for Rapid Detection of Mycobacterium tuberculosis Complex Among US Tuberculosis Patients, 2011‒2017.
Kumar V , Dalton TL , Armstrong LR , Whitesell A , Li R , Starks AM . Open Forum Infect Dis 2021 8 (11) ofab528 ![]() ![]() BACKGROUND: Nucleic acid amplification (NAA) tests rapidly detect Mycobacterium tuberculosis complex directly from clinical specimens, providing valuable results for those evaluated for tuberculosis. METHODS: We analyzed characteristics of cases with NAA testing performed, compared cases with positive and negative NAA test results, and calculated turnaround time and time to treatment for all verified cases reported to the National Tuberculosis Surveillance System in the United States during 2011-2017. RESULTS: Among 67082 verified tuberculosis cases with NAA testing information, 30820 (45.9%) were reported as not having an NAA test performed; the proportion without NAA testing declined annually, from 60.5% in 2011 to 33.6% in 2017. Of 67082 verified cases, 27912 (41.6%) had positive, 8215 (12.2%) had negative, and 135 (0.2%) had indeterminate NAA test results. Among the 33937 cases with an acid-fast bacilli (AFB) smear-positive result, 24093 (70.9%) had an NAA test performed; 11490 of the 30244 (38.0%) with an AFB smear-negative result had an NAA test performed. Although sputum was the most common specimen type tested, 79.8% (7023/8804) of nonsputum specimen types had a positive NAA test result. Overall, 63.7% of cases with laboratory testing had NAA test results reported <6 days following specimen collection; for 13891 cases not yet on treatment, median time to treatment after the laboratory report date was 2 days. CONCLUSIONS: Our analyses demonstrate increased NAA test utilization between 2011 and 2017. However, a large proportion of cases did not have an NAA test performed, reflecting challenges in broader uptake, suggesting an opportunity to expand use of this diagnostic methodology. |
Diabetes mellitus among adults with tuberculosis in the USA, 2010-2017
Armstrong LR , Kammerer JS , Haddad MB . BMJ Open Diabetes Res Care 2020 8 (1) INTRODUCTION: To describe diabetes trends among adults with incident tuberculosis (TB) disease and examine diabetes-associated TB characteristics and patient outcomes in the USA. RESEARCH DESIGN AND METHODS: We examined all 71 855 persons aged >/=20 years with incident TB disease reported to the National Tuberculosis Surveillance System during 2010-2017. We performed multivariable logistic regression, comparing characteristics and outcomes among patients with TB reported to have diabetes and those whose diabetes status was unknown. RESULTS: An overall 18% (n=13 281) of the 71 855 adults with incident TB disease were reported as also having diabetes; the annual proportion increased from 15% in 2010 to 22% in 2017. Among patients aged >/=45 years with both TB and diabetes, the adjusted OR for cavitary or sputum smear-positive TB was 1.7 and 1.5, respectively (95% CIs 1.5 to 1.8 and 1.4 to 1.6). Patients with TB and diabetes had 30% greater odds of dying and took longer to achieve negative Mycobacterium tuberculosis cultures and complete treatment. CONCLUSIONS: The prevalence of reported diabetes among adults with TB disease has increased. Having diabetes as a comorbidity negatively affects patient outcomes. In accordance with national recommendations, all patients aged >/=45 years and all younger patients who have risk factors for diabetes should be screened for diabetes at the start of TB treatment. |
Risk factors for and trends in isoniazid monoresistance at diagnosis of tuberculosis - United States, 1993-2016
Iqbal SA , Armstrong LR , Kammerer JS , Truman BI . J Public Health Manag Pract 2019 27 (4) E162-E172 CONTEXT: Resistance to isoniazid (INH) only (monoresistance), with drug susceptibility to rifampin, pyrazinamide, and ethambutol at diagnosis of tuberculosis (TB) disease, can increase the length of treatment. OBJECTIVE: To describe US trends in INH monoresistance and associated patient characteristics. DESIGN: We performed trend and cross-sectional analyses of US National Tuberculosis Surveillance System surveillance data. We used Joinpoint regression to analyze annual trends in INH monoresistance and logistic regression to identify patient characteristics associated with INH monoresistance. PARTICIPANTS: Culture-positive cases reported to National Tuberculosis Surveillance System during 1993-2016 with drug susceptibility test results to INH, rifampin, pyrazinamide, and ethambutol. MAIN OUTCOME MEASURES: (1) Trends in INH monoresistance; (2) odds ratios for factors associated with INH monoresistance. RESULTS: Isoniazid monoresistance increased significantly from 4.1% of all TB cases in 1993 to 4.9% in 2016. Among US-born patients, INH monoresistance increased significantly from 2003 onward (annual percentage change = 2.8%; 95% confidence interval: 1.4-4.2). During 2003-2016, US-born persons with INH-monoresistant TB were more likely to be younger than 65 years; to be Asian; to be human immunodeficiency virus-infected; or to be a correctional facility resident at the time of diagnosis. Among non-US-born persons, INH resistance did not change significantly during 1993-2016 (annual percentage change = -0.3%; 95% confidence interval: -0.7 to 0.2) and was associated with being aged 15 to 64 years; being Asian, black, or Hispanic; or having a previous history of TB. CONCLUSIONS: INH-monoresistant TB has been stable since 1993 among non-US-born persons; it has increased 2.8% annually among US-born persons during 2003-2016. Reasons for this increase should be further investigated. |
Changes in tuberculosis epidemiology, United States, 1993-2017
Armstrong LR , Winston CA , Stewart B , Tsang CA , Langer AJ , Navin TR . Int J Tuberc Lung Dis 2019 23 (7) 797-804 BACKGROUND: After 20 years of steady decline, the pace of decline of tuberculosis (TB) incidence in the United States has slowed.METHODS: Trends in TB incidence rates and case counts since 1993 were assessed using national US surveillance data. Patient characteristics reported during 2014-2017 were compared with those for 2010-2013.RESULTS: TB rates and case counts slowed to an annual decline of respectively 2.2% (95%CI -3.4 to -1.0) and 1.5% (95%CI -2.7 to -0.3) since 2012, with decreases among US-born persons and no change among non-US-born persons. Overall, persons with TB diagnosed during 2014-2017 were older, more likely to have combined pulmonary and extra-pulmonary disease than extra-pulmonary disease alone, more likely to be of non-White race, and less likely to have human immunodeficiency virus infection, or cavitary pulmonary disease. During 2014-2017, non-US-born persons with TB were more likely to have diabetes mellitus, while the US-born were more likely to have smear-positive TB and use non-injecting drugs.CONCLUSION: Changes in epidemiologic trends are likely to affect TB incidence in the coming decades. The Centers for Disease Control and Prevention has called for increased attention to TB prevention through the detection and treatment of latent tuberculous infection. |
Eligibility for a shorter treatment regimen for multidrug-resistant tuberculosis in the United States, 2011-2016
Tsang CA , Shah N , Armstrong LR , Marks SM . Clin Infect Dis 2019 70 (5) 907-916 BACKGROUND: In 2016, the World Health Organization (WHO) recommended a shorter (9-12 month) multidrug-resistant tuberculosis (MDR-TB) treatment regimen (as compared to the conventional 18-24 month regimen) for patients without extrapulmonary TB, pregnancy, previous second-line TB medication exposure, or drug resistance to pyrazinamide, ethambutol, kanamycin, moxifloxacin, ethionamide, or clofazimine. The recommendation was based on successful clinical trials conducted in Asia and Africa, but studies, using mainly European data, have shown few patients in higher resource settings would meet WHO eligibility criteria. METHODS: We assessed eligibility for the shorter regimen among U.S. MDR-TB cases that had full drug susceptibility testing (DST) results and were reported during 2011-2016 to the U.S. National TB Surveillance System. We estimated costs by applying the eligibility criteria for the shorter regimen, and proportional inpatient/outpatient costs from a previous population-based study to all MDR-TB patients reported to NTSS. RESULTS: Of 586 reported MDR cases, 10% (59) were eligible for the shorter regimen. Of 527 ineligible patients, 386 had full DST, of which 246 were resistant to ethambutol and 217 resistant to pyrazinamide. Compared with conventional MDR-TB treatment, implementing the shorter regimen would reduce the U.S. annual societal MDR-TB cost burden by 4%, but the cost burden for eligible individuals would be reduced by 37-46%. CONCLUSIONS: Relying on full DST use, our analysis found a minority of U.S. MDR-TB patients would be eligible for the shorter regimen. Cost reductions would be minimal for society, but large for eligible individuals. |
Age-period-cohort analyses of tuberculosis incidence rates by nativity, United States, 1996-2016
Iqbal SA , Winston CA , Bardenheier BH , Armstrong LR , Navin TR . Am J Public Health 2018 108 S315-s320 OBJECTIVES: To assess changes in US tuberculosis (TB) incidence rates by age, period, and cohort effects, stratified according to race/ethnicity and nativity. METHODS: We used US National Tuberculosis Surveillance System data for 1996 to 2016 to estimate trends through age-period-cohort models. RESULTS: Controlling for cohort and period effects indicated that the highest rates of TB incidence occurred among those 0 to 5 and 20 to 30 years of age. The incidence decreased by age for successive birth cohorts. There were greater estimated annual percentage decreases among US-born individuals (-7.3%; 95% confidence interval [CI] = -7.5, -7.1) than among non-US-born individuals (-4.3%; 95% CI = -4.5, -4.1). US-born individuals older than 25 years exhibited the largest decreases, a pattern that was not reflected among non-US-born adults. In the case of race/ethnicity, the greatest decreases by nativity were among US-born Blacks (-9.3%; 95% CI = -9.6, -9.1) and non-US-born Hispanics (-5.7%; 95% CI = -6.0, -5.5). CONCLUSIONS: TB has been decreasing among all ages, races and ethnicities, and consecutive cohorts, although these decreases are less pronounced among non-US-born individuals. |
Factors associated with all-cause mortality among patients with multidrug-resistant tuberculosis - United States, 1993-2013
Salinas JL , Armstrong LR , Silk BJ , Haddad MB , Cegielski JP . Clin Infect Dis 2017 65 (11) 1924-1926 We assessed characteristics associated with all-cause mortality among U.S. patients with multidrug-resistant tuberculosis. Mortality decreased from 31% during 1993-2002 to 11% during 2003-2013. Directly observed therapy coverage increased from 74% to 95% and was protective against all-cause mortality after accounting for demographics, clinical characteristics, HIV status, and period of treatment. |
Delayed and unreported drug-susceptibility testing results in the US National Tuberculosis Surveillance System, 1993-2014
Jones JM , Armstrong LR . Public Health Rep 2017 132 (4) 33354917708989 OBJECTIVES: Drug-susceptibility testing (DST) of Mycobacterium tuberculosis is necessary for identifying drug-resistant tuberculosis, administering effective treatment regimens, and preventing the spread of drug-resistant tuberculosis. DST is recommended for all culture-confirmed cases of tuberculosis. We examined trends in delayed and unreported DST results in the Centers for Disease Control and Prevention's National Tuberculosis Surveillance System. METHODS: We analyzed culture-confirmed tuberculosis cases reported to the National Tuberculosis Surveillance System during 1993-2014 for annual trends in initial DST reporting for first-line antituberculosis drugs and trends in on-time, delayed, and unreported results. We defined on-time reporting as DST results received during the same calendar year in which the patient's case was reported or ≤4 months after the calendar year ended and delayed reporting as DST results received after the calendar year. We compared cases with on-time, delayed, and unreported DST results by patient and tuberculosis program characteristics. RESULTS: The proportion of cases with reported results for all first-line antituberculosis drugs increased during 1993-2011. Reporting of pyrazinamide results was lower than reporting of other drugs. However, during 2000-2012, of 134 787 tuberculosis cases reported to the National Tuberculosis Surveillance System, reporting was on time for 125 855 (93.4%) cases, delayed for 5332 (4.0%) cases, and unreported for 3600 (2.7%) cases. CONCLUSIONS: Despite increases in the proportion of cases with on-time DST results, delayed and unreported results persisted. Carefully assessing causes for delayed and unreported DST results should lead to more timely reporting of drug-resistant tuberculosis. |
Tuberculosis among foreign-born persons diagnosed ≥10 years after arrival in the United States, 2010-2015
Tsang CA , Langer AJ , Navin TR , Armstrong LR . MMWR Morb Mortal Wkly Rep 2017 66 (11) 295-298 The majority of tuberculosis (TB) cases in the United States are attributable to reactivation of latent TB infection (LTBI). LTBI refers to the condition when a person is infected with Mycobacterium tuberculosis without signs and symptoms, or radiographic or bacteriologic evidence of TB disease. CDC and the U.S. Preventive Services Task Force (USPSTF) recommend screening populations at increased risk for LTBI, including persons who have lived in congregate settings at high risk and persons who were born in, or are former residents of countries with TB incidence ≥20 cases per 100,000 population. In 2015, foreign-born persons constituted 66.2% of U.S. TB cases. During the past 30 years, screening of persons from countries with high TB rates has focused on overseas screening for immigrants and refugees, and domestic screening for persons who have newly arrived in the United States. However, since 2007, an increasing number and proportion of foreign-born patients receiving a diagnosis of TB first arrived in the United States ≥10 years before the development and diagnosis of TB disease. To better understand how this group of patients differs from persons who developed TB disease and received a diagnosis <10 years after U.S. arrival, CDC analyzed data for all reported TB cases in the United States since 1993 in the National TB Surveillance System (NTSS). After adjusting for age and other characteristics, foreign-born persons who arrived in the United States ≥10 years before diagnosis were more likely to be residents of a long-term care facility or to have immunocompromising conditions other than human immunodeficiency virus (HIV) infection. These findings support using the existing CDC and USPSTF recommendations for TB screening of persons born in countries with high TB rates regardless of time since arrival in the United States. |
Tuberculosis among incarcerated Hispanic persons in the United States, 1993-2014
Mindra G , Wortham JM , Haddad MB , Salinas JL , Powell KM , Armstrong LR . J Immigr Minor Health 2016 19 (4) 982-986 We examined the National tuberculosis surveillance system to describe Hispanic persons who were incarcerated at time of tuberculosis (TB) diagnosis and to compare their characteristics with those of non-Hispanic incarcerated TB patients. After declines between 1993 and 2002, the annual proportion of Hispanic TB patients who were incarcerated grew from 4.9% in 2003 to 8.4% in 2014. During 2003-2014, 19% of incarcerated US-born TB patients were Hispanic, and 86% of the foreign-born were Hispanic. Most incarcerated TB patients were in local jails, but about a third of all foreign-born Hispanics were in the facility category that includes Immigration and Customs Enforcement detention centers. Foreign birth and recent U.S. arrival characterized many Hispanic persons receiving a TB diagnosis while incarcerated. Hispanic patients had twice the odds of being in federal prisons. Systematic efforts to identify TB infection and disease might lead to early diagnoses and prevention of future cases. |
Tuberculosis in jails and prisons: United States, 2002-2013
Lambert LA , Armstrong LR , Lobato MN , Ho C , France AM , Haddad MB . Am J Public Health 2016 106 (12) e1-e7 OBJECTIVES: To describe cases and estimate the annual incidence of tuberculosis in correctional facilities. METHODS: We analyzed 2002 to 2013 National Tuberculosis Surveillance System case reports to characterize individuals who were employed or incarcerated in correctional facilities at time they were diagnosed with tuberculosis. Incidence was estimated with Bureau of Justice Statistics denominators. RESULTS: Among 299 correctional employees with tuberculosis, 171 (57%) were US-born and 82 (27%) were female. Among 5579 persons incarcerated at the time of their tuberculosis diagnosis, 2520 (45%) were US-born and 495 (9%) were female. Median estimated annual tuberculosis incidence rates were 29 cases per 100 000 local jail inmates, 8 per 100 000 state prisoners, and 25 per 100 000 federal prisoners. The foreign-born proportion of incarcerated men 18 to 64 years old increased steadily from 33% in 2002 to 56% in 2013. Between 2009 and 2013, tuberculosis screenings were reported as leading to 10% of diagnoses among correctional employees, 47% among female inmates, and 42% among male inmates. CONCLUSIONS: Systematic screening and treatment of tuberculosis infection and disease among correctional employees and incarcerated individuals remain essential to tuberculosis prevention and control. (Am J Public Health. Published online ahead of print September 15, 2016: e1-e7. doi:10.2105/AJPH.2016.303423). |
The US National Tuberculosis Surveillance System: A descriptive assessment of the completeness and consistency of data reported from 2008 to 2012
Yelk Woodruff RS , Pratt RH , Armstrong LR . JMIR Public Health Surveill 2015 1 (2) e15 BACKGROUND: In 2009, the Tuberculosis (TB) Information Management System transitioned into the National TB Surveillance System to allow use of 4 different types of electronic reporting schemes: state-built, commercial, and 2 schemes developed by the Centers for Disease Control and Prevention. Simultaneously, the reporting form was revised to include additional data fields. OBJECTIVE: Describe data completeness for the years 2008-2012 and determine the impact of surveillance changes. METHODS: Data were categorized into subgroups and assessed for completeness (eg, the percentage of patients dead at diagnosis who had a date of death reported) and consistency (eg, the percentage of patients alive at diagnosis who erroneously had a date of death reported). Reporting jurisdictions were grouped to examine differences by reporting scheme. RESULTS: Each year less than 1% of reported cases had missing information for country of origin, race, or ethnicity. Patients reported as dead at diagnosis had death date (a new data field) missing for 3.6% in 2009 and 4.4% in 2012. From 2010 to 2012, 313 cases (1%) reported as alive at diagnosis had a death date and all of these were reported through state-built or commercial systems. The completeness of reporting for guardian country of birth for pediatric patients (a new data field) ranged from 84% in 2009 to 88.2% in 2011. CONCLUSIONS: Despite major changes, completeness has remained high for most data elements in TB surveillance. However, some data fields introduced in 2009 remain incomplete; continued training is needed to improve national TB surveillance data. |
Mind the gap: TB trends in the USA and the UK, 2000-2011
Nnadi CD , Anderson LF , Armstrong LR , Stagg HR , Pedrazzoli D , Pratt R , Heilig CM , Abubakar I , Moonan PK . Thorax 2016 71 (4) 356-63 BACKGROUND: TB remains a major public health concern, even in low-incidence countries like the USA and the UK. Over the last two decades, cases of TB reported in the USA have declined, while they have increased substantially in the UK. We examined factors associated with this divergence in TB trends between the two countries. METHODS: We analysed all cases of TB reported to the US and UK national TB surveillance systems from 1 January 2000 through 31 December 2011. Negative binominal regression was used to assess potential demographic, clinical and risk factor variables associated with differences in observed trends. FINDINGS: A total of 259 609 cases were reported. From 2000 to 2011, annual TB incidence rates declined from 5.8 to 3.4 cases per 100 000 in the USA, whereas in the UK, TB incidence increased from 11.4 to 14.4 cases per 100 000. The majority of cases in both the USA (56%) and the UK (64%) were among foreign-born persons. The number of foreign-born cases reported in the USA declined by 15% (7731 in 2000 to 6564 in 2011) while native-born cases fell by 54% (8442 in 2000 to 3883 in 2011). In contrast, the number of foreign-born cases reported in the UK increased by 80% (3380 in 2000 to 6088 in 2011), while the number of native-born cases remained largely unchanged (2158 in 2000 to 2137 in 2011). In an adjusted negative binomial regression model, significant differences in trend were associated with sex, age, race/ethnicity, site of disease, HIV status and previous history of TB (p<0.01). Among the foreign-born, significant differences in trend were also associated with time since UK or US entry (p<0.01). INTERPRETATION: To achieve TB elimination in the UK, a re-evaluation of current TB control policies and practices with a focus on foreign-born are needed. In the USA, maintaining and strengthening control practices are necessary to sustain the progress made over the last 20 years. |
Enhanced identification and characterization of non-O157 shiga toxin-producing Escherichia coli: a six-year study
Mingle LA , Garcia DL , Root TP , Halse TA , Quinlan TM , Armstrong LR , Chiefari AK , Schoonmaker-Bopp DJ , Dumas NB , Limberger RJ , Musser KA . Foodborne Pathog Dis 2012 9 (11) 1028-36 ![]() Non-O157 Shiga toxin-producing Escherichia coli (STEC) are emerging pathogens with the potential to cause serious illness and impact public health due to diagnostic challenges. Between 2005 and 2010, the Wadsworth Center (WC), the public health laboratory of the New York State (NYS) Department of Health, requested that Shiga toxin enzyme immunoassay (EIA)-positive stool enrichment broths and/or stool specimens be submitted by clinical and commercial reference laboratories testing NYS patient specimens. A total of 798 EIA-positive specimens were received for confirmation and serotyping, and additionally a subset of STEC was assessed for the presence of six virulence genes (stx1, stx2, eaeA, hlyA, nleA, and nleB) by real-time polymerase chain reaction. We confirmed 591 specimens as STEC, 164 (28%) as O157 STEC, and 427 (72%) as non-O157 STEC. Of the non-O157 STEC serogroups identified, over 70% were O103, O26, O111, O45, O121, or O145. During this time period, WC identified and characterized a total of 1282 STEC received as E. coli isolates, stool specimens, or EIA broths. Overall, the STEC testing identified 59% as O157 STEC and 41% as non-O157 STEC; however, out of 600 isolates submitted to the WC as E. coli cultures, 543 (90%) were identified as O157 STEC. This report summarizes a 6-year study utilizing enhanced STEC testing that resulted in increased identification and characterization of non-O157 STEC in NYS. Continued utilization of enhanced STEC testing may lead to effective and timely outbreak response and improve monitoring of trends in STEC disease epidemiology. |
Tuberculosis among healthcare workers, United States, 1995-2007
Lambert LA , Pratt RH , Armstrong LR , Haddad MB . Infect Control Hosp Epidemiol 2012 33 (11) 1126-32 OBJECTIVE: We examined surveillance data to describe the epidemiology of tuberculosis (TB) among healthcare workers (HCWs) in the United States during the period 1995-2007. DESIGN: Cross-sectional descriptive analysis of existing surveillance data. SETTING AND PARTICIPANTS: TB cases reported to the Centers for Disease Control and Prevention from the 50 states and the District of Columbia from 1995 through 2007. RESULTS: Of the 200,744 reported TB cases in persons 18 years of age or older, 6,049 (3%) occurred in individuals who were classified as HCWs. HCWs with TB were more likely than other adults with TB to be women (unadjusted odds ratio [95% confidence interval], 4.1 [3.8-4.3]), be foreign born (1.3 [1.3-1.4]), have extrapulmonary TB (1.6 [1.5-1.7]), and complete TB treatment (2.5 [2.3-2.8]). CONCLUSIONS: Healthcare institutions may benefit from intensifying TB screening of HCWs upon hire, especially persons from countries with a high incidence of TB, and encouraging treatment for latent TB infection among HCWs to prevent progression to TB disease. |
Unexpected decline in tuberculosis cases coincident with economic recession -- United States, 2009
Winston CA , Navin TR , Becerra JE , Chen MP , Armstrong LR , Jeffries C , Yelk Woodruff RS , Wing J , Starks AM , Hales CM , Kammerer JS , Mac Kenzie WR , Mitruka K , Miner MC , Price S , Scavotto J , Cronin AM , Griffin P , Lobue PA , Castro KG . BMC Public Health 2011 11 (1) 846 BACKGROUND: Since 1953, through the cooperation of state and local health departments, the U.S. Centers for Disease Control and Prevention (CDC) has collected information on incident cases of tuberculosis (TB) disease in the United States. In 2009, TB case rates declined -11.4%, compared to an average annual -3.8% decline since 2000. The unexpectedly large decline raised concerns that TB cases may have gone unreported. To address the unexpected decline, we examined trends from multiple sources on TB treatment initiation, medication sales, and laboratory and genotyping data on culture-positive TB. METHODS: We analyzed 142,174 incident TB cases reported to the U. S. National Tuberculosis Surveillance System (NTSS) during January 1, 2000-December 31, 2009; TB control program data from 59 public health reporting areas; self-reported data from 50 CDC-funded public health laboratories; monthly electronic prescription claims for new TB therapy prescriptions; and complete genotyping results available for NTSS cases. Accounting for prior trends using regression and time-series analyses, we calculated the deviation between observed and expected TB cases in 2009 according to patient and clinical characteristics, and assessed at what point in time the deviation occurred. RESULTS: The overall deviation in TB cases in 2009 was -7.9%, with -994 fewer cases reported than expected (P <.001). We ruled out evidence of surveillance underreporting since declines were seen in states that used new software for case reporting in 2009 as well as states that did not, and we found no cases unreported to CDC in our examination of over 5400 individual line-listed reports in 11 areas. TB cases decreased substantially among both foreign-born and U.S.-born persons. The unexpected decline began in late 2008 or early 2009, and may have begun to reverse in late 2009. The decline was greater in terms of case counts among foreign-born than U.S.-born persons; among the foreign-born, the declines were greatest in terms of percentage deviation from expected among persons who had been in the United States less than 2 years. Among U.S.-born persons, the declines in percentage deviation from expected were greatest among homeless persons and substance users. Independent information systems (NTSS, TB prescription claims, and public health laboratories) reported similar patterns of declines. Genotyping data did not suggest sudden decreases in recent transmission. CONCLUSIONS: Our assessments show that the decline in reported TB was not an artifact of changes in surveillance methods; rather, similar declines were found through multiple data sources. While the steady decline of TB cases before 2009 suggests ongoing improvement in TB control, we were not able to identify any substantial change in TB control activities or TB transmission that would account for the abrupt decline in 2009. It is possible that other multiple causes coincident with economic recession in the United States, including decreased immigration and delayed access to medical care, could be related to TB declines. Our findings underscore important needs in addressing health disparities as we move towards TB elimination in the United States. |
Tuberculosis in older adults in the United States, 1993-2008
Pratt RH , Winston CA , Kammerer JS , Armstrong LR . J Am Geriatr Soc 2011 59 (5) 851-7 OBJECTIVES: To describe older adults with tuberculosis (TB) and compare demographic, diagnostic, and disease characteristics and treatment outcomes between older and younger adults with TB. DESIGN: Descriptive analysis of all confirmed people with TB aged 21 and older. SETTING: The National Tuberculosis Surveillance System (NTSS) for the 50 United States and the District of Columbia from 1993 to 2008. PARTICIPANTS: A total of 250,784 adult TB cases were reported, including 61,119 people with TB aged 65 and older. MEASUREMENTS: TB case count and rates and proportion of TB cases in older adults. RESULTS: Older adults had consistently higher incidence rates of TB than younger adults. In 2008, the rate of TB in older adults was 6.4 per 100,000, compared with 5.0 per 100,000 for younger adults. A lower percentage of older adults had TB diagnostic test results (tuberculin skin test, sputum smear, sputum culture) or human immunodeficiency virus (HIV) infection status reported. TB risk factors (substance use, homelessness, HIV infection) and multidrug-resistant TB were less prevalent in older than younger adults. Seven percent of older adults were dead at diagnosis, and 21% died during therapy, compared with 2% and 7%, respectively, of younger adults. Sputum culture conversion percentages were similar for people who did not die. Older adults also completed therapy in a timely manner, similar to younger adults. CONCLUSION: Although older adults had higher rates of TB and mortality, for older adults who survived therapy, successful treatment outcomes were similar to those of younger adults. |
Epidemiology of extrapulmonary tuberculosis in the United States, 1993-2006
Peto HM , Pratt RH , Harrington TA , Lobue PA , Armstrong LR . Clin Infect Dis 2009 49 (9) 1350-7 BACKGROUND: Almost one-fifth of United States tuberculosis cases are extrapulmonary; unexplained slower annual case count decreases have occurred in extrapulmonary tuberculosis (EPTB), compared with annual case count decreases in pulmonary tuberculosis (PTB) cases. We describe the epidemiology of EPTB by means of US national tuberculosis surveillance data. METHODS: US tuberculosis cases reported from 1993 to 2006 were classified as either EPTB or PTB. EPTB encompassed lymphatic, pleural, bone and/or joint, genitourinary, meningeal, peritoneal, and unclassified EPTB cases. We excluded cases with concurrent extrapulmonary-pulmonary tuberculosis and cases of disseminated (miliary) tuberculosis. Demographic characteristics, drug susceptibility test results, and risk factors, including human immunodeficiency virus (HIV) status, were compared for EPTB and PTB cases. RESULTS: Among 253,299 cases, 73.6% were PTB and 18.7% were EPTB, including lymphatic (40.4%), pleural (19.8%), bone and/or joint (11.3%), genitourinary (6.5%), meningeal (5.4%), peritoneal (4.9%), and unclassified EPTB (11.8%) cases. Compared with PTB, EPTB was associated with female sex (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.7-1.8) and foreign birth (OR, 1.5; CI, 1.5-1.6), almost equally associated with HIV status (OR, 1.1; CI, 1.1-1.1), and negatively associated with multidrug resistance (OR, 0.6; CI, 0.5-0.6) and several tuberculosis risk factors, especially homelessness (OR, 0.3; CI, 0.3-0.3) and excess alcohol use (OR, 0.3; CI, 0.3-0.3). Slower annual decreases in EPTB case counts, compared with annual decreases in PTB case counts, from 1993 through 2006 have caused EPTB to increase from 15.7% of tuberculosis cases in 1993 to 21.0% in 2006. CONCLUSIONS: EPTB epidemiology and risk factors differ from those of PTB, and the proportion of EPTB has increased from 1993 through 2006. Further study is needed to identify causes of the proportional increase in EPTB. |
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