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TB Notes 2, 2006
Introduction
Highlights from State and Local Programs
  An Outbreak Response in a Rural, Southwest Missouri County Jail
  No Reported TB Cases in Wyoming in 2005
  Suffolk County (New York) Targeted TB Testing and Treatment Program Among the Foreign-born, 2000–2004
  The Changing Epidemiology of TB in Connecticut, 2000-2004
  Molecular Genotyping of Mycobacterium tuberculosis in Connecticut
  Third Annual Conference on TB in the U.S. Pacific Islands: Meeting Highlights, Challenges, and Solutions for Addressing the Disparities
  "Update: Tuberculosis Nursing" Workshop in Hawaii
  Lessons Learned in the Process of Evaluation – Illinois
  TB Education and Targeted Testing of Garfield County, Colorado, WIC Clients
Laboratory Updates
TB Education and Training Network Updates
Communications, Education, and Behavioral Studies Branch Updates
Information Technology and Statistics Branch Update
SEOIB Updates
New CDC Publications
Personnel Notes
Calendar of Events
 
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TB Notes Newsletter

No. 2, 2006

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS 

The Changing Epidemiology of Tuberculosis in Connecticut, 2000–2004

Tuberculosis (TB), which is caused by the organism Mycobacterium tuberculosis, remains a serious infectious disease in Connecticut.1 Transmission of M. tuberculosis occurs with inhalation of droplet nuclei produced by a person with contagious pulmonary or laryngeal TB. In the United States, TB is reportable by both physicians and laboratories. This report reviews the epidemiology of TB in Connecticut and ongoing activities of the Connecticut Department of Public Health’s (DPH) Tuberculosis Control Program.

During 2000–2004, 543 TB cases were reported to the DPH for an average of 109 cases per year (Figure 1). The annual rate ranged from a high of 3.6 cases per 100,000 population in 2001 to a low of 3.0 cases in 2004. Overall, the annual TB rate declined 3.2% from 2000 to 2004. This rate meets the interim national goal of 3.5 cases per 100,000 population but is still short of the Healthy People 2010 goal of <1 case per 100,000 population. Tuberculosis was reported in all age groups, with the most cases (n=186) reported in persons aged 25–44 years. Of these persons, 28 (15%) tested positive for infection with human immunodeficiency virus (HIV). Cases were reported in all racial/ethnic groups except Native Americans and Hawaiians/Pacific Islanders.

Figure 1: Tuberculosis Case Rates and Number of Cases, Connecticut, 2000–2004
Figure 1: Tuberculosis Case Rates and Number of Cases, Connecticut, 2000-2004

Of the 543 cases, 62% (334) were in foreign-born persons representing 62 countries. Of these, 46% were reported in foreign-born persons from India (41), Ecuador (35), Haiti (29), Peru (25), and Mexico (22). The percentage of cases in foreign-born persons ranged from a low of 55% in 2001 to a high of 70% in 2003 (Figure 2). The increasing proportion of TB cases among foreign-born individuals is consistent with and precedes a similar national trend.2 The number of foreign-born TB patients has increased 12% over the previous 5-year period.

Figure 2: Percentage of Foreign-born Patients in the United States and in Connecticut, 2000–2004
Figure 2: Percentage of Foreign-born Patients in the United States and in Connecticut, 2000-2004

Of the 334 foreign-born TB patients reported during 2000–2004, 47% entered the United States within 5 years prior to diagnosis (Table 1). Of these, 23% were diagnosed within 1 year after arrival. This suggests that many of these individuals are not receiving adequate screening for TB or treatment for latent infection before and after entry into the United States.

Table 1: Number of years in the United States before TB diagnosis in foreign-born persons

Year
Years in
U.S.
2000 2001 2002 2003 2004 Total
No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
< 1 18 (30) 15 (23) 10 (16) 21 (27) 13 (19) 77 (23)
1-4 20 (33) 13 (20) 10 (16) 19 (24) 19 (28) 81 (24)
5-9 7 (11) 11 (17) 9 (15) 7 (9) 12 (18) 46 (14)
³ 10 11 (18) 14 (21) 7 (12) 13 (17) 17 (25) 62 (19)
Unknown 5 (8) 13 (20) 25 (41) 18 (23) 7 (10) 68 (20)
Total 61 66 61 78 68 334

Programmatic Response of the TB Control Program
In response to the changing epidemiology of TB in Connecticut, the DPH has revised or initiated the following programmatic activities aimed at increasing awareness about prevention and treatment guidelines:

  • Enhanced surveillance among foreign-born persons with TB or suspected of having TB,
  • Pediatric follow-up (for both TB and latent TB infection),
  • Revised policy reflecting the need to test and treat persons with a positive tuberculin skin test, regardless of previous bacille Calmette-Guérin (BCG) vaccination,3
  • Revised screening guidelines for Connecticut schools (in cooperation with the School Health Committee of the Connecticut Chapter of the American Academy of Pediatrics),4  and
  • Development and dissemination of educational and prevention material in various languages (in partnership with the Refugee Health Program).

In Connecticut, emphasis has been placed on enhancing TB surveillance among foreign-born persons because this population accounts for the majority of reported cases. This activity was planned with assistance from a CDC regional consultant. One area of focus in the regional approach to TB prevention is to develop strategies aimed at reducing cases in areas where the incidence is relatively low.

Enhanced surveillance of foreign-born TB patients involves collecting information that may assist the DPH in targeting prevention resources in this high-risk population. The following information is collected:

  • Type of health care provider
  • Difficulties surrounding health care access, language, and communication
  • History of previous testing and treatment for latent TB infection

These data may suggest policies related to TB standards of care that should be modified, such as expanding directly observed therapy (DOT) and strengthening provider education.

Comment
From 2000 to 2004, for the United States as well as for Connecticut, the overall incidence of TB declined; however, the percentage of cases in foreign-born persons increased. In Connecticut, the highest percentage of TB cases was in foreign-born persons originating from Asia, South America, and the Caribbean. Nationally, the majority of foreign-born patients were from Mexico.1

U.S. immigration and public health regulations require immigrants seeking permanent residence and refugees to be evaluated for TB prior to entry into the United States. Persons found to have infectious TB disease must be rendered noninfectious before entering the United States; in Connecticut, many foreign-born persons with TB do not belong to these immigrant groups and were not tested before entry. After arrival, immigrants who have noninfectious or inactive TB disease are required to report to the local health authority within 30 days for further evaluation and possible treatment. It is necessary for health care providers to integrate TB prevention into the routine care of persons from countries with a high TB prevalence. As more information becomes available on behaviors and barriers related to health care for persons from countries with a high TB prevalence, effective prevention practices can be put into effect.

In Connecticut, the local health department is responsible for ensuring the quality and completeness of TB-related services. Resources available through local health authorities include language-appropriate educational materials, culturally sensitive providers, clinical interpreter services, DOT, and contact investigation to identify and evaluate individuals potentially exposed to infectious TB. Case management is necessary for successful completion of therapy and requires a coordinated effort between the state and local health department, health care provider, and patient. The DPH conducts surveillance, analyzes data, supports and ensures treatment completion including use of DOT for all patients, oversees contact investigations, promotes prevention activities, and evaluates relevant outcomes of its activities in collaboration with health care providers and municipal health departments. The state laboratory confirms the diagnosis of TB by growing M. tuberculosis on culture, and tests the pattern of drug susceptibility for each isolate. The patient is responsible for taking the full course of TB drugs and for providing information on potentially exposed persons and venues of exposure. Health care providers should begin each new patient on a four-drug regimen of isoniazid, rifampin, pyrazinamide, and ethambutol, which may be modified once drug susceptibilities are known.5

—Reported by Tom Condren, MPH, George Raiselis,
Mukhtar Mohamed, MPH,
TB Control Program,
Connecticut Department of Public Health;
Lloyd Friedman, MD, VPMA,
Milford Hospital Clinical Professor,
Yale School of Medicine and
Chair, Connecticut Advisory Committee for the Elimination of TB;
Mark Lobato, MD, Div of TB Elimination, CDC

References

  1. CDC. Trends in Tuberculosis—United States, 1998–2003. MMWR 2004; 53:209-214.
  2. CDC. Reported Tuberculosis in the United States, 2004. Atlanta, GA: U.S. Department of Health and Human Service, CDC, Sept 2005.
  3. CDC. Fact Sheet, BCG Vaccine. CDC, Jan 2005.
  4. http://www.dph.state.ct.us/BCH/infectiousdise/tubercul.htm (Accessed 1/16/2006).
  5. CDC. Treatment of Tuberculosis. American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003: 52 (RR-11).

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

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