OBJECTIVES: To evaluate the cost-effectiveness of testing and treatment for Mycobacterium tuberculosis (Mtb) infection among Asian and Hispanic persons with diagnosed diabetes in the United States. METHODS: We estimated population size and Mtb infection prevalence for Asian and Hispanic persons aged ≥15 years with diagnosed, non-gestational diabetes, by age and US-born-status. We assumed a one-time test for Mtb infection intervention, with positive-testing persons offered treatment. Using a deterministic, transmission-dynamic model of TB in the United States, we estimated costs, TB cases and deaths averted, and quality-adjusted life-years (QALY) gained under the intervention compared to no-intervention. We estimated incremental cost-effectiveness ratios (ICERs), calculated as costs per QALY-gained, from a TB health services perspective, including diagnosis and treatment for TB infection and disease. We also assessed health services and societal perspectives. We estimated 95% uncertainty intervals via probabilistic sensitivity analysis. RESULTS: TB cases averted per 100,000 persons tested ranged from 7.5 (95% uncertainty interval: 6.9-8.1) among US-born Hispanic persons to 238.9 (225.2-254.3) among non-US-born Asian persons. TB deaths averted per 100,000 persons tested ranged from 1.3 (1.2-1.4) among US-born Hispanic persons to 53.7 (51.4-56.1) among non-US-born Asian persons. ICERs for US-born Asian and Hispanic populations were $856,671 ($533,506-$1,234,032) and $1,081,646 ($673,142-$1,551,264), respectively. ICERs for non-US-born Asian and Hispanic populations were lower: $66,664 ($41,456-$93,625) and $68,749 ($43,136-$97,044), respectively. ICERs were 2-19% higher under a societal perspective. CONCLUSIONS: While the intervention produced health benefits for all populations assessed, health benefits were greater-and ICERs more favorable-for non-US-born Asian and Hispanic populations with diagnosed-diabetes.

BACKGROUND: People with chronic kidney disease (CKD) have a higher risk for progression to tuberculosis disease following infection with Mycobacterium tuberculosis. We produced a nationwide incidence estimate and description of tuberculosis among people with kidney failure. METHODS: We completed a cross-sectional descriptive analysis of people with a reported case of tuberculosis in the United States between 2010 and 2021. We stratified all people with tuberculosis by reported kidney failure status. The primary outcome was tuberculosis incidence among people with kidney failure. We also compared characteristics of people with tuberculosis by reported kidney failure status. RESULTS: Approximately 3% of people (2,892 of 111,155) diagnosed with tuberculosis between 2010 and 2021 also had kidney failure. Annual tuberculosis incidence ranged from 26.1 to 45.4 per 100,000 people with kidney failure and 2.1 to 3.5 per 100,000 people without kidney failure. Among people with kidney failure, 924 (32%) had extrapulmonary tuberculosis only, and nearly 40% died: 286 were diagnosed with tuberculosis after death, and 792 died during treatment. People with tuberculosis and kidney failure had approximately twice the prevalence of a false-negative tuberculin skin test result (39%) compared to people with tuberculosis alone (20%). CONCLUSIONS: Tuberculosis incidence among people with kidney failure between 2010 and 2021 in the United States was 10-fold that among people without kidney failure.

BACKGROUND: Early identification of outbreaks remains a key component in continuing to reduce the burden of infectious disease in the United States. Previous studies have applied statistical methods to detect unexpected cases of disease in space or time. The objectives of our study were to assess the ability and timeliness of three spatio-temporal methods to detect known outbreaks of tuberculosis. METHODS: We used routinely available molecular and surveillance data to retrospectively assess the effectiveness of three statistical methods in detecting tuberculosis outbreaks: county-based log-likelihood ratio, cumulative sums, and a spatial scan statistic. RESULTS: Our methods identified 8 of the 9 outbreaks, and 6 outbreaks would have been identified 1-52 months (median=10 months) before local public health authorities identified them. Assuming no delays in data availability, 46 (59.7%) of the 77 patients in the 9 outbreaks were identified after our statistical methods would have detected the outbreak but before local public health authorities became aware of the problem. CONCLUSIONS: Statistical methods, when applied retrospectively to routinely collected tuberculosis data, can successfully detect known outbreaks, potentially months before local public health authorities become aware of the problem. The three methods showed similar results; no single method was clearly superior to the other two. Further study to elucidate the performance of these methods in detecting tuberculosis outbreaks will be done in a prospective analysis.

BACKGROUND: In the United States, over 80% of tuberculosis (TB) disease cases are estimated to result from reactivation of latent TB infection (LTBI) acquired more than 2 years previously ("reactivation TB"). We estimated reactivation TB rates for the US population with LTBI, overall, by age, sex, race-ethnicity, and US-born status, and for selected comorbidities (diabetes, end-stage renal disease, and HIV). METHODS: We collated nationally representative data for 2011-2012. Reactivation TB incidence was based on TB cases reported to the National TB Surveillance System that were attributed to LTBI reactivation. Person-years at risk of reactivation TB were calculated using interferon-gamma release assay (IGRA) positivity from the National Health and Nutrition Examination Survey, published values for interferon-gamma release assay sensitivity and specificity, and population estimates from the American Community Survey. RESULTS: For persons aged ≥6 years with LTBI, the overall reactivation rate was estimated as 0.072 (95% uncertainty interval: 0.047, 0.12) per 100 person-years. Estimated reactivation rates declined with age. Compared to the overall population, estimated reactivation rates were higher for persons with diabetes (adjusted rate ratio [aRR] = 1.6 [1.5, 1.7]), end-stage renal disease (aRR = 9.8 [5.4, 19]), and HIV (aRR = 12 [10, 13]). CONCLUSIONS: In our study, individuals with LTBI faced small, non-negligible risks of reactivation TB. Risks were elevated for individuals with medical comorbidities that weaken immune function.

During July 7-11, 2023, CDC received reports of two patients in different states with a tuberculosis (TB) diagnosis following spinal surgical procedures that used bone allografts containing live cells from the same deceased donor. An outbreak associated with a similar product manufactured by the same tissue establishment (i.e., manufacturer) occurred in 2021. Because of concern that these cases represented a second outbreak, CDC and the Food and Drug Administration worked with the tissue establishment to determine that this product was obtained from a donor different from the one implicated in the 2021 outbreak and learned that the bone allograft product was distributed to 13 health care facilities in seven states. Notifications to all seven states occurred on July 12. As of December 20, 2023, five of 36 surgical bone allograft recipients received laboratory-confirmed TB disease diagnoses; two patients died of TB. Whole-genome sequencing demonstrated close genetic relatedness between positive Mycobacterium tuberculosis cultures from surgical recipients and unused product. Although the bone product had tested negative by nucleic acid amplification testing before distribution, M. tuberculosis culture of unused product was not performed until after the outbreak was recognized. The public health response prevented up to 53 additional surgical procedures using allografts from that donor; additional measures to protect patients from tissue-transmitted M. tuberculosis are urgently needed.

An outbreak of multidrug-resistant (MDR) tuberculosis (TB) involved 13 persons in four households in a low-income, under-resourced urban Kansas community during November 2021-November 2022. A majority of the seven adults identified in the Kansas outbreak were born outside the United States in a country that had experienced an MDR TB outbreak with the same genotype during 2007-2009, whereas most of the six children in the Kansas outbreak were U.S.-born. Prompt identification, evaluation, and treatment of persons with MDR TB and their contacts is essential to limiting transmission.

A systematic approach to contact investigations has long been a cornerstone of interrupting transmission of tuberculosis (TB) in community settings. This paper describes the implementation of a systematic 10-step contact investigation within an acute care setting during a multistate outbreak of healthcare-associated TB. A systematic approach to contact investigations might have applicability to the prevention of other communicable infections within healthcare settings.

U.S. clinical practice guidelines recommend directly observed therapy (DOT) as the standard of care for tuberculosis (TB) treatment (1). DOT, during which a health care worker observes a patient ingesting the TB medications, has typically been conducted in person. Video DOT (vDOT) uses video-enabled devices to facilitate remote interactions between patients and health care workers to promote medication adherence and clinical monitoring. Published systematic reviews, a published meta-analysis, and a literature search through 2022 demonstrate that vDOT is associated with a higher proportion of medication doses being observed and similar proportions of cases with treatment completion and microbiologic resolution when compared with in-person DOT (2-5). Based on this evidence, CDC has updated the recommendation for DOT during TB treatment to include vDOT as an equivalent alternative to in-person DOT. vDOT can assist health department TB programs meet the U.S. standard of care for patients undergoing TB treatment, while using resources efficiently.

A nationwide tuberculosis outbreak linked to a viable bone allograft product contaminated with Mycobacterium tuberculosis was identified in June 2021. Our subsequent investigation identified 73 healthcare personnel with new latent tuberculosis infection following exposure to the contaminated product, product recipients, surgical instruments, or medical waste.

Until COVID-19, the greatest national public health crisis was the 1918 influenza pandemic, which was covered extensively by Public Health Reports.1 -6 Extrapolating from their knowledge of tuberculosis, public health authorities at that time exhorted ill people to remain home to break the chain of respiratory transmission. 7 Other contemporaneous appeals that reverberate a century later include “avoid needless crowding,” “stay in the open air,” “wear a gauze mask over the nose and mouth,” and “keep away from houses where there are influenza cases.” 2

OBJECTIVE: This study describes characteristics of large tuberculosis (TB) outbreaks in the United States detected using novel molecular surveillance methods during 2014-2016 and followed for 2 years through 2018. METHODS: We developed 4 genotype-based detection algorithms to identify large TB outbreaks of ≥10 cases related by recent transmission during a 3-year period. We used whole-genome sequencing and epidemiologic data to assess evidence of recent transmission among cases. RESULTS: There were 24 large outbreaks involving 518 cases; patients were primarily U.S.-born (85.1%) racial/ethnic minorities (84.1%). Compared with all other TB patients, patients associated with large outbreaks were more likely to report substance use, homelessness, and having been diagnosed while incarcerated. Most large outbreaks primarily occurred within residences among families and nonfamilial social contacts. A source case with a prolonged infectious period and difficulties in eliciting contacts were commonly reported contributors to transmission. CONCLUSION: Large outbreak surveillance can inform targeted interventions to decrease outbreak-associated TB morbidity.

BACKGROUND: Mycobacterium tuberculosis transmission through solid organ transplantation has been well described, but transmission through transplanted tissues is rare. We investigated a tuberculosis outbreak in the USA linked to a bone graft product containing live cells derived from a single deceased donor. METHODS: In this outbreak report, we describe the management and severity of the outbreak and identify opportunities to improve tissue transplant safety in the USA. During early June, 2021, the US Centers for Disease Control and Prevention (CDC) worked with state and local health departments and health-care facilities to locate and sequester unused units from the recalled lot and notify, evaluate, and treat all identified product recipients. Investigators from CDC and the US Food and Drug Administration (FDA) reviewed donor screening and tissue processing. Unused product units from the recalled and other donor lots were tested for the presence of M tuberculosis using real-time PCR (rt PCR) assays and culture. M tuberculosis isolates from unused product and recipients were compared using phylogenetic analysis. FINDINGS: The tissue donor (a man aged 80 years) had unrecognised risk factors, symptoms, and signs consistent with tuberculosis. Bone was procured from the deceased donor and processed into 154 units of bone allograft product containing live cells, which were distributed to 37 hospitals and ambulatory surgical centres in 20 US states between March 1 and April 2, 2021. From March 3 to June 1, 2021, 136 (88%) units were implanted into 113 recipients aged 24-87 years in 18 states (some individuals received multiple units). The remaining 18 units (12%) were located and sequestered. 87 (77%) of 113 identified product recipients had microbiological or imaging evidence of tuberculosis disease. Eight product recipients died 8-99 days after product implantation (three deaths were attributed to tuberculosis after recognition of the outbreak). All 105 living recipients started treatment for tuberculosis disease at a median of 69 days (IQR 56-81) after product implantation. M tuberculosis was detected in all eight sequestered unused units tested from the recalled donor lot, but not in lots from other donors. M tuberculosis isolates from unused product and recipients were more than 99·99% genetically identical. INTERPRETATION: Donor-derived transmission of M tuberculosis via bone allograft resulted in substantial morbidity and mortality. All prospective tissue and organ donors should be routinely assessed for tuberculosis risk factors and clinical findings. When these are present, laboratory testing for M tuberculosis should be strongly considered. FUNDING: None.

Objectives. To understand the frequency, magnitude, geography, and characteristics of tuberculosis outbreaks in US state prisons. Methods. Using data from the National Tuberculosis Surveillance System, we identified all cases of tuberculosis during 2011 to 2019 that were reported as occurring among individuals incarcerated in a state prison at the time of diagnosis. We used whole-genome sequencing to define 3 or more cases within 2 single nucleotide polymorphisms within 3 years as clustered; we classified clusters with 6 or more cases during a 3-year period as tuberculosis outbreaks. Results. During 2011 to 2019, 566 tuberculosis cases occurred in 41 state prison systems (a median of 3 cases per state). A total of 19 tuberculosis genotype clusters comprising 134 cases were identified in 6 state prison systems; these clusters included a subset of 5 outbreaks in 2 states. Two Alabama outbreaks during 2011 to 2017 totaled 20 cases; 3 Texas outbreaks during 2014 to 2019 totaled 51 cases. Conclusions. Only Alabama and Texas reported outbreaks during the 9-year period; only Texas state prisons had ongoing transmission in 2019. Effective interventions are needed to stop tuberculosis outbreaks in Texas state prisons. (Am J Public Health. 2022;112(8):1170-1179. https://doi.org/10.2105/AJPH.2022.306864).

On May 25, 2021, a Delaware acute care hospital notified the Delaware Division of Public Health (DPH) of seven patients who developed tuberculosis after spinal surgery during March–April 2021. Hospital staff members identified a single common exposure: implantation of bone allograft material (product A) from a single product lot. DPH notified CDC, requested a field investigation, and issued a nationwide call for cases. In collaboration with the Food and Drug Administration, a CDC team was deployed to Delaware on June 2 to investigate the epidemiology of cases and opportunities for transmission and to provide prevention and treatment recommendations. On the same day, another state health department notified CDC about a person who developed tuberculosis after surgery involving the same product A lot, and the manufacturer issued a voluntary nationwide recall (1).

INTRODUCTION: In the U.S., universal genotyping of culture-confirmed tuberculosis cases facilitates cluster detection. Early recognition of the small clusters more likely to become outbreaks can help prioritize public health resources for immediate interventions. METHODS: This study used national surveillance data reported during 2009-2018 to describe incident clusters (≥3 tuberculosis cases with matching genotypes not previously reported in the same county); data were analyzed during 2020. Cox proportional hazards regression models were used to examine the patient characteristics associated with clusters doubling in size to ≥6 cases. RESULTS: During 2009-2018, a total of 1,516 incident clusters (comprising 6,577 cases) occurred in 47 U.S. states; 231 clusters had ≥6 cases. Clusters of ≥6 cases disproportionately included patients who used substances, who had recently experienced homelessness, who were incarcerated, who were U.S. born, or who self-identified as being of American Indian or Alaska Native race or of Black race. A median of 54 months elapsed between the first and the third cases in clusters that remained at 3-5 cases compared with a median of 9.5 months in clusters that grew to ≥6 cases. The longer time between the first and third cases and the presence of ≥1 patient aged ≥65 years among the first 3 cases predicted a lower hazard for accumulating ≥6 cases. CONCLUSIONS: Clusters accumulating ≥3 cases within a year should be prioritized for intervention. Effective response strategies should include plans for targeted outreach to U.S.-born individuals, incarcerated people, those experiencing homelessness, people using substances, and individuals self-identifying as being of American Indian or Alaska Native race or of Black race.

INTRODUCTION: Preventing tuberculosis (TB) disease requires treatment of latent TB infection (LTBI) as well as prevention of person-to-person transmission. We estimated the LTBI prevalence for the entire United States and for each state by medical risk factors, age, and race/ethnicity, both in the total population and stratified by nativity. METHODS: We created a mathematical model using all incident TB disease cases during 2013-2017 reported to the National Tuberculosis Surveillance System that were classified using genotype-based methods or imputation as not attributed to recent TB transmission. Using the annual average number of TB cases among US-born and non-US-born persons by medical risk factor, age group, and race/ethnicity, we applied population-specific reactivation rates (and corresponding 95% confidence intervals [CI]) to back-calculate the estimated prevalence of untreated LTBI in each population for the United States and for each of the 50 states and the District of Columbia in 2015. RESULTS: We estimated that 2.7% (CI: 2.6%-2.8%) of the U.S. population, or 8.6 (CI: 8.3-8.8) million people, were living with LTBI in 2015. Estimated LTBI prevalence among US-born persons was 1.0% (CI: 1.0%-1.1%) and among non-US-born persons was 13.9% (CI: 13.5%-14.3%). Among US-born persons, the highest LTBI prevalence was in persons aged ≥65 years (2.1%) and in persons of non-Hispanic Black race/ethnicity (3.1%). Among non-US-born persons, the highest LTBI prevalence was estimated in persons aged 45-64 years (16.3%) and persons of Asian and other racial/ethnic groups (19.1%). CONCLUSIONS: Our estimations of the prevalence of LTBI by medical risk factors and demographic characteristics for each state could facilitate planning for testing and treatment interventions to eliminate TB in the United States. Our back-calculation method feasibly estimates untreated LTBI prevalence and can be updated using future TB disease case counts at the state or national level.

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.

INTRODUCTION: Diabetes might confer a modestly increased risk of latent tuberculosis infection, which without treatment can progress to active tuberculosis disease. Three recent analyses of the National Health and Nutrition Examination Survey found a positive association between diabetes and a positive test for Mycobacterium tuberculosis infection. This study examines whether prevalence of a positive test still varies by diabetes status after stratifying by race/ethnicity. METHODS: This cross-sectional analysis used the public-use National Health and Nutrition Examination Survey 2011-2012 data sets and was conducted in 2018-2019. Interview and examination results for 5,560 adult participants yielded estimates for 219 million U.S. adults in the 4 largest race/ethnicity groups. The weighted prevalence of positive tuberculin skin test or interferon-gamma release assay by diabetes status was ascertained in each group. RESULTS: Among white and black adults, diabetes was associated with no difference in positive skin test prevalence and little difference in positive interferon-gamma release assay prevalence. The positive assay prevalence difference was +14.5% (95% CI=2.3%, 26.7%) among Hispanic and +9.9% (95% CI=1.2%, 18.6%) among Asian adults, when comparing those with diabetes with those with neither diabetes nor prediabetes. Based on assay results, 23.6% (95% CI=14.0%, 36.9%) of Hispanic and 27.2% (95% CI=19.6%, 36.5%) of Asian adults with diabetes also had latent tuberculosis infection. CONCLUSIONS: Hispanic and Asian subpopulation results drove much of the previously reported positive association between diabetes and a positive test for M. tuberculosis infection. Hispanic and Asian adults with diabetes might particularly benefit from screening and treatment for latent tuberculosis infection.

BACKGROUND: A single 2-year National Health and Nutrition Examination Survey (NHANES) cycle is designed to provide accurate and stable estimates of conditions with prevalence of at least 10%. Recent NHANES-based estimates of a tuberculin skin test >/=10 mm in the noninstitutionalized U.S. civilian population are at most 6.3%. METHODS: NHANES included a tuberculin skin test in 1971-1972, 1999-2000, and 2011-2012. We examined the robustness of NHANES-based estimates of the U.S. population prevalence of a skin test >/=10 mm with a bias analysis that considered the influence of non-U.S. birth distributions and within-household skin test results, reclassified borderline-positive results, and adjusted for tuberculin skin test item nonresponse. RESULTS: The weighted non-U.S. birth distribution among NHANES participants was similar to that in the overall U.S. population; further adjustment was unnecessary. We found no evidence of bias due to sampling multiple participants per household. Prevalence estimates changed 0.3% with reclassification of borderline-positive tuberculin skin test results and 0.2%-0.3% with adjustment for item nonresponse. CONCLUSIONS: For estimating the national prevalence of a tuberculin skin test >/=10 mm during these three survey cycles, a conventional NHANES analysis using the standard participant weights and masked design parameters that are provided in the public-use datasets appears robust.

To refine estimates of how many persons in the United States are candidates for treatment of latent tuberculosis, we removed from analysis persons who self-reported prior treatment on the National Health and Nutrition Examination Survey 2011-2012. We estimate that 12.6 million persons could benefit from treatment to prevent active tuberculosis.

Mycobacterium bovis bacillus Calmette-Guerin (BCG) is used as a vaccine to protect against disseminated tuberculosis (TB) and as a treatment for bladder cancer. We describe characteristics of US TB patients reported to the National Tuberculosis Surveillance System (NTSS) whose disease was attributed to BCG. We identified 118 BCG cases and 91,065 TB cases reported to NTSS during 2004-2015. Most patients with BCG were US-born (86%), older (median age 75 years), and non-Hispanic white (81%). Only 17% of BCG cases had pulmonary involvement, in contrast with 84% of TB cases. Epidemiologic features of BCG cases differed from TB cases. Clinicians can use clinical history to discern probable BCG cases from TB cases, enabling optimal clinical management. Public health agencies can use this information to quickly identify probable BCG cases to avoid inappropriately reporting BCG cases to NTSS or expending resources on unnecessary public health interventions.

The National Health and Nutrition Examination Survey (NHANES) has tested for Mycobacterium tuberculosis infection three times: in 1971–1972, 1999–2000, and 2011–2012. Based on tuberculin skin test results, the estimated national prevalence of latent tuberculosis infection (LTBI) among adults was 11–18% in 1971–1972 but has remained less than or equal to 6% in subsequent NHANES cycles (1–4). A single 2-year NHANES cycle is designed to produce accurate and stable estimates for conditions with at least 10% prevalence in the noninstitutionalized civilian U.S. population (5–7), suggesting that NHANES might no longer be as nationally representative for LTBI as it is for more common health conditions. Approximately 30 counties were selected for each 2-year cycle (5). We wished to examine whether persons in selected counties might have been systematically more or less likely to have a positive tuberculin skin test result than their counterparts in the approximately 3,100 counties that were not selected for NHANES participation.

We used tuberculosis genotyping results to derive estimates of prevalence of latent tuberculosis infection in the United States. We estimated <1% prevalence in 1,981 US counties, 1%-<3% in 785 counties, and >3% in 377 counties. This method for estimating prevalence could be applied in any jurisdiction with an established tuberculosis surveillance system.

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.

OBJECTIVES: Our objective was to describe and determine the factors contributing to a recent drug-resistant tuberculosis (TB) outbreak in Georgia. METHODS: We defined an outbreak case as TB diagnosed from March 2008 through December 2015 in a person residing in Georgia at the time of diagnosis and for whom (1) the genotype of the Mycobacterium tuberculosis isolate was consistent with the outbreak strain or (2) TB was diagnosed clinically without a genotyped isolate available and connections were established to another outbreak-associated patient. To determine factors contributing to transmission, we interviewed patients and reviewed health records, homeless facility overnight rosters, and local jail booking records. We also assessed infection control measures in the 6 homeless facilities involved in the outbreak. RESULTS: Of 110 outbreak cases in Georgia, 86 (78%) were culture confirmed and isoniazid resistant, 41 (37%) occurred in people with human immunodeficiency virus coinfection (8 of whom were receiving antiretroviral treatment at the time of TB diagnosis), and 10 (9%) resulted in TB-related deaths. All but 8 outbreak-associated patients had stayed overnight or volunteered extensively in a homeless facility; all these facilities lacked infection control measures. At least 9 and up to 36 TB cases outside Georgia could be linked to this outbreak. CONCLUSIONS: This article highlights the ongoing potential for long-lasting and far-reaching TB outbreaks, particularly among populations with untreated human immunodeficiency virus infection, mental illness, substance abuse, and homelessness. To prevent and control TB outbreaks, health departments should work with overnight homeless facilities to implement infection control measures and maintain searchable overnight rosters.

OBJECTIVES: The Centers for Disease Control and Prevention provides on-site epidemiologic assistance for outbreak response when the health capacity of state, tribal, local, and territorial health departments has been exceeded. We examined recent outbreaks of tuberculosis (TB) for which health departments needed assistance. METHODS: We defined a TB outbreak as detection of ≥3 TB cases related by transmission, as suggested by routine genotyping and epidemiologic linkages. We conducted retrospective reviews of documentation from all 21 TB outbreak investigations in the United States for which the Centers for Disease Control and Prevention provided on-site assistance during 2009-2015. We abstracted data on patients' demographic characteristics and TB risk factors, as well as factors contributing to the outbreak from trip reports written by on-site investigators, and we compared these with outbreaks investigated during 2002-2008. RESULTS: The 21 TB outbreaks during 2009-2015 involved 457 outbreak patients (range, 3-99 patients per outbreak). Of the 21 outbreaks, 16 were first identified through genotype data. In sum, 118 (26%) patients were identified through contact investigations of other patients in the outbreak. Most outbreak patients (n = 363, 79%) were US born. Ninety-two (26%) patients had a mental illness, 204 (45%) had been homeless in the year before diagnosis, and 379 (83%) used alcohol excessively or used illicit substances. The proportion of patients experiencing homelessness doubled between 2002-2008 and 2009-2015; other characteristics were similar between the 2 periods. Delayed TB diagnosis contributed to unmitigated transmission in all but 1 outbreak. CONCLUSIONS: TB outbreaks challenge frontline public health resources. Genotyping and contact investigations are important strategies for detecting and controlling TB outbreaks, particularly among people experiencing homelessness or those with mental illness.

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.

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).

After 2 decades of progress toward tuberculosis (TB) elimination with annual decreases of ≥0.2 cases per 100,000 persons (1), TB incidence in the United States remained approximately 3.0 cases per 100,000 persons during 2013-2015. Preliminary data reported to the National Tuberculosis Surveillance System indicate that TB incidence among foreign-born persons in the United States (15.1 cases per 100,000) has remained approximately 13 times the incidence among U.S.-born persons (1.2 cases per 100,000). Resuming progress toward TB elimination in the United States will require intensification of efforts both in the United States and globally, including increasing U.S. efforts to detect and treat latent TB infection, strengthening systems to interrupt TB transmission in the United States and globally, accelerating reductions in TB globally, particularly in the countries of origin for most U.S. CASES: