Admissions to jails and prisons in the United States number 10 million yearly; persons entering locked correctional facilities have high prevalence of sexually transmitted infections (STIs). These individuals come disproportionately from communities of color, with lower access to care and prevention, compared with the United States as a whole. Following PRISMA guidelines, the authors present results of a systematic review of literature published since 2012 on STIs in US jails, prisons, Immigration and Customs Enforcement detention centers, and juvenile facilities. This updates an earlier review of STIs in short-term facilities. This current review contributed to new recommendations in the Centers for Disease Control and Prevention 2021 treatment guidelines for STIs, advising screening for Trichomonas in women entering correctional facilities. The current review also synthesizes recommendations on screening: in particular, opt-out testing is superior to opt-in protocols. Carceral interventions-managing diagnosed cases and preventing new infections from occurring (eg, by initiating human immunodeficiency virus preexposure prophylaxis before release)-can counteract structural racism in healthcare.

Human behaviour will continue to play an important role as the world grapples with public health threats. In this paper, we draw from the emerging evidence on behaviour adoption during diverse public health emergencies to develop a framework that contextualises behaviour adoption vis-à-vis a combination of top-down, intermediary and bottom-up approaches. Using the COVID-19 pandemic as a case study, we operationalise the contextual framework to demonstrate how these three approaches differ in terms of their implementation, underlying drivers of action, enforcement, reach and uptake. We illustrate how blended strategies that include all three approaches can help accelerate and sustain protective behaviours that will remain important even when safe and effective vaccines become more widely available. As the world grapples with the COVID-19 pandemic and prepares to respond to (re)emerging public health threats, our contextual framework can inform the design, implementation, tracking and evaluation of comprehensive public health and social measures during health emergencies.

MANY EARLY EPIDEMIOLOGIC STUDIES of | tuberculosis (TB) infection and disease examined | health care workers (HCWs) specifically because of | their known elevated risk of exposure to patients with | infectious TB. Efforts to mitigate this occupational risk | have translated into well-established practices that are | recommended for health care settings: managerial | activities (e.g., TB surveillance among HCWs), administrative controls (e.g., separation of patients with | presumptive or confirmed TB), environmental controls | (e.g., ventilation systems), and personal protective | equipment (e.g., use of particulate respirators).1 | The study by Shin et al. in this issue of the Journal | reports that approximately 50% of HCWs at facilities | in Botswana reported daily exposure to patients with | infectious TB, regardless of the HCW’s human | immunodeficiency virus (HIV) status.2 In particular, it | appears that HIV-infected HCWs were not reassigned | to non-clinical areas, despite the recommendations of | both the World Health Organization (WHO) and the | Botswana Ministry of Health. As the authors acknowledge, reassignment of HCWs with HIV faces numerous | challenges, including stigma against revealing one’s | HIV status, a frequent need for staff to work across | departments, and limited space for clinical activities.

Objective: To assess scale-up of recommended tuberculosis (TB)/HIV activities in Guyana and to identify specific strategies for further expansion. Methods: Medical records and clinic registers were reviewed at nine TB clinics and 10 HIV clinics. At TB clinics, data were collected on HIV testing and antiretroviral therapy (ART) for patients with TB/HIV; at HIV clinics, data were collected on intensified case finding (ICF), tuberculin skin test (TST) results, and provision of isoniazid preventive therapy (IPT). Results: At TB clinics, among 461 patients newly diagnosed with TB, 419 (90.9%) had a known HIV status and 121 (28.9%) were HIV-infected. Among the 63 patients with TB/HIV, 33 (52.4%) received ART. Among the 45 patients with TB/HIV for whom dates of HIV diagnosis were available, 38 (84.4%) individuals knew their HIV status prior to TB diagnosis. At HIV clinics, among 127 patients eligible to receive a TST, 87 (68.5%) received a TST, 66 (75.9%) had a TST result, seven (10.6%) had a newly positive result, two had a previously positive result, and six of nine patients with positive results (66.7%) received IPT. ICF could not be assessed because of incomplete or discrepant documentation. Conclusions: An in-depth evaluation of TB/HIV activities successfully identified areas of success and remaining challenges. At TB clinics, HIV testing rates are high; further scale-up of ART for persons with TB/HIV is needed. At HIV clinics, use of TST to focus IPT is a feasible and efficient strategy; improving rates of annual TST screening will allow for further expansion of IPT.

While the number of reported tuberculosis (TB) cases in the United States has declined over the past two decades, TB morbidity among foreign-born persons has remained persistently elevated. A recent unexpected decline in reported TB cases among foreign-born persons beginning in 2007 provided an opportunity to examine contributing factors and inform future TB control strategies. We investigated the relative influence of three factors on the decline: 1) changes in the size of the foreign-born population through immigration and emigration, 2) changes in distribution of country of origin among foreign-born persons, and 3) changes in the TB case rates among foreign-born subpopulations. Using data from the U.S. National Tuberculosis Surveillance System and the American Community Survey, we examined TB case counts, TB case rates, and population estimates, stratified by years since U.S. entry and country of origin. Regression modeling was used to assess statistically significant changes in trend. Among foreign-born recent entrants (<3 years since U.S. entry), we found a 39.5% decline (-1,013 cases) beginning in 2007 (P<0.05 compared to 2000-2007) and ending in 2011 (P<0.05 compared to 2011-2014). Among recent entrants from Mexico, 80.7% of the decline was attributable to a decrease in population, while the declines among recent entrants from the Philippines, India, Vietnam, and China were almost exclusively (95.5%-100%) the result of decreases in TB case rates. Among foreign-born non-recent entrants (≥3 years since U.S. entry), we found an 8.9% decline (-443 cases) that resulted entirely (100%) from a decrease in the TB case rate. Both recent and non-recent entrants contributed to the decline in TB cases; factors contributing to the decline among recent entrants varied by country of origin. Strategies that impact both recent and non-recent entrants (e.g., investment in overseas TB control) as well as those that focus on non-recent entrants (e.g., expanded targeted testing of high-risk subgroups among non-recent entrants) will be necessary to achieve further declines in TB morbidity among foreign-born persons.

In the 4 August 2014 issue of Clinical Infectious Diseases, Chaisson et al [1] demonstrated that a single GeneXpert MTB/RIF assay (Xpert) could assist in discontinuing isolation for patients with suspected tuberculosis. These results are tremendously helpful in further establishing the clinical utility of nucleic acid amplification tests (such as Xpert), which are already considered “standard practice in the United States to aid in the initial diagnosis of patients with suspected [tuberculosis]” [2]. However, because of the small sample size and low prevalence of paucibacillary (eg, smear-negative, culture-positive) disease in the study population, we believe that the results may have underestimated some of the important clinical benefits of Xpert implementation.

We thank Dr. Griffith for his insightful commentary (1) on our recent analysis (2) and would like to address and expand on his remarks. More than two-thirds of all tuberculosis cases in the United States are among foreign-born persons, and it is estimated that most tuberculosis cases among these individuals are a result of the reactivation of latent tuberculosis infection. Testing and treatment of latent tuberculosis infection is a key strategy of tuberculosis prevention, and national guidelines are currently being jointly updated as part of a collaborative effort among the Centers for Disease Control and Prevention, the American Thoracic Society, and the Infectious Diseases Society of America. | The findings of our analysis and those of a recently published study (3) support Griffith's proposal to remove the variable “years since United States entry” as a criterion for testing and treatment of foreign-born persons. Griffith speculates that “reluctance to change this recommendation is due to concern about drug toxicity in older individuals” and suggests that limiting testing and treatment to those younger than 35 years might minimize concerns about drug toxicity. However, an examination of American Community Survey estimates from 2010 shows that among the 10.2 million Mexico-born persons living in the United States for more than 5 years, 6.3 million (65%) were aged 35 years or older (4). Therefore, if an age cutoff of younger than 35 years were adopted, it would greatly limit the potential effect of testing and treatment on tuberculosis morbidity among Mexico-born persons.

In early 2013, the Los Angeles County Department of Public Health learned of two patients diagnosed with tuberculosis (TB) who had received care at the same outpatient health care facility (facility A). Facility A is a center for infusions of chemotherapeutic and biologic agents and serves a large number of immunocompromised persons who were potentially exposed to infectious TB. If infected, immunocompromised persons are at elevated risk for progression to TB disease. The two patients (patient A and patient B) both had pulmonary TB, with acid-fast bacilli found on sputum-smear microscopy, and had visited facility A multiple times during their infectious periods. Despite initial concerns that these two cases could be the result of person-to-person transmission at facility A, genotyping of the Mycobacterium tuberculosis isolates from these two patients showed that they were infected with unrelated strains.

BACKGROUND: In 2010, Mexico was the most common (22.9%) country of origin for foreign-born persons with tuberculosis in the United States, and overall trends in tuberculosis morbidity are substantially influenced by the Mexico-born population. OBJECTIVES: To determine the risk of tuberculosis disease in the United States among the Mexico-born population. METHODS: Utilizing data from the United States National Tuberculosis Surveillance System and American Community Survey, we examined tuberculosis case counts and case rates stratified by years since United States entry and geographic proximity to the United States-Mexico border. We calculated trends in case rates over time measured by average annual percent change. RESULTS: The total tuberculosis case count (-14.5%) and annual tuberculosis case rate (average annual percent change -5.1%) declined among Mexico-born persons. Among newly arrived persons (tuberculosis diagnosis <1 year since United States entry), there was a decrease in tuberculosis cases (-60.4%), no change in tuberculosis case rate (average annual percent change 0.0%), and a decrease in population (-60.7%). Among non-recently arrived persons (>5 years since United States entry), there was an increase in tuberculosis cases (+3.4%), a decrease in tuberculosis case rate (average annual percent change -4.9%), and an increase in population (+62.7%). In 2010, 66.7% of Mexico-born cases were among non-recently arrived persons, compared to 51.1% in 2000. While border states reported the highest proportions (>15%) of tuberculosis cases that were Mexico-born, the highest Mexico-born-specific tuberculosis case rates (>20 per 100,000 population) were in states in the eastern and southeastern regions of the United States. CONCLUSIONS: The decline in tuberculosis cases among Mexico-born persons may be attributed to a decline in newly arrived persons from Mexico and a decreased tuberculosis case rate among non-recently arrived persons; the extent of the decline was dampened by an unchanged tuberculosis case rate among newly arrived persons from Mexico and a large increase in the non-recently arrived Mexico-born population. If current trends continue, tuberculosis morbidity among Mexico-born persons in the United States will be increasingly driven by the non-recently arrived population.

We examined the growth of tuberculosis (TB) genotype clusters during 2005-2010 in the United States, categorized by country of origin and ethnicity of the index case and geographic proximity to the US-Mexico border at the time of TB diagnosis. Nationwide, 38.9% of cases subsequent to Mexico-born index cases were US-born. Among clusters following US-born Hispanic and USborn non-Hispanic index cases, respectively 29.2% and 5.3% of subsequent cluster members were Mexicoborn. In border areas, the majority of subsequent cases were Mexico-born following US-born Hispanic (56.4%) and US-born non-Hispanic (55.6%) index cases. These findings suggest that TB transmission commonly occurs between US-born and Mexico-born persons. Along the US-Mexico border, prioritizing TB genotype clusters following US-born index cases for investigation may prevent subsequent cases among both US-born and Mexico-born persons.