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TB Notes 3, 2003
HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS
World TB Day and TB Awareness
Fortnight in Missouri
The Missouri Department of Health and Senior
Services’ TB Control Program annually commemorates World TB Day
on March 24 and TB Awareness Fortnight in Missouri for a period
of 2 weeks during the latter part of March each year. During this
time, the TB Control Program promotes awareness throughout Missouri
concerning the signs and symptoms of TB, the availability of treatment,
and the importance of being examined by your local health department
or private physician if you have symptoms and signs of disease or
have come in contact with someone who has TB disease. From March
17 through March 31, 2003, the following activities were carried
out in Missouri:
- On March 13, Governor Holden signed a proclamation declaring
the period of March 17 through 31, 2003, as TB Awareness Fortnight
in Missouri. Representatives from the state health department
attended this ceremony.
- On March 18, a seminar entitled "Knowing Tuberculosis"
was held at the Missouri Baptist Hospital in Sullivan, Missouri,
for health professionals in the private and public sectors.
- On March 20, Grand Rounds were held at Washington University
in St. Louis for health professionals. Dr. Joseph Malone, an EIS
officer with the Missouri Department of Health and Senior Services,
conducted the session. (Dr. Michael Iseman from the National Jewish
Center in Denver had been scheduled to conduct Grand Rounds but
had to cancel owing to inclement weather.)
- On March 21, a seminar entitled "TB in the Colleges and
Universities" was held in Kansas City for health professionals
in student health centers. It was sponsored by the Kansas City
Metro TB Coalition.
- On March 24, a reception was held to commemorate World TB Day
in the state TB program’s central office in Jefferson City for
Missouri Department of Health and Senior Services employees and
Missouri Advisory Committee for the Elimination of TB (MACET)
members. A meeting of MACET followed the reception.
- On March 25, a nurses’ seminar entitled "Advance Topics
in TB Control" was held at the Jefferson County Health Department,
Arnold Branch. Over 60 health professionals from the public and
private sectors attended the seminar. The American Lung Association
of Eastern Missouri sponsored the program.
- On March 27, a seminar entitled "Whip That Ole TB"
was held at the University of Missouri, Reynolds Alumni Center,
in Columbia, Missouri. Over 50 health professionals from the public
and private sectors attended this seminar. The American Lung Association
of Eastern Missouri sponsored the program.
The Missouri Department of Health and Senior Services issued a
news release during March regarding World TB Day and TB Awareness
Fortnight. As a result of this release, six media interviews were
conducted across the state.
Activities such as these noted above are conducted each year in
Missouri to raise awareness about this important public health problem
that some people think has virtually disappeared.
—Submitted by Vic Tomlinson, Lynelle Phillips,
RN, MPH, and David Oeser
Missouri Department of Health and Senior Services
TB Control Program
The Prison Public Health Interface Project
for Tuberculosis Control, California, 1998-2000
Tuberculosis (TB) outbreaks among HIV-infected inmates in California
correctional facilities in 1995 and 1996 resulted in transmission
of Mycobacterium tuberculosis inside and outside these facilities
and revealed gaps in TB control practices.1 The Prison
Public Health Interface Project (PPHIP), a collaboration between
the California Department of Corrections (DC) and the California
Department of Health Services (DHS), was a joint response to the
outbreaks. This programmatic intervention, supported by unobligated
federal TB cooperative agreement funds, began in March 1998 and
ended in June 2000. A retrospective review of PPHIP records, which
is summarized here, confirmed that incarceration creates opportunities
for TB case finding and treatment. The review also showed that TB
notifications sometimes were delayed and that frequent relocations
of inmates jeopardized continuity of care for TB, as corroborated
by a low treatment-completion rate.
PPHIP targeted the nine California state correctional facilities
housing 100 or more HIV-infected inmates because HIV-infected persons
are highly susceptible to TB.2 The target prisons were
in five counties, and together had a daily census of approximately
48,500 inmates, 31% of the state’s inmate population. PPHIP placed
a nurse liaison in each of the five county health departments during
the 28 months of the project, and these nurses used telephone contacts
and medical records in prisons and health departments to coordinate
information about TB diagnosis, notifications, and case management.
DHS epidemiologists subsequently reviewed PPHIP records and tallied
project events: an event was counted as each time that an inmate
with suspected or confirmed TB entered a project prison or when
TB was suspected or confirmed during a stay. Suspected TB was noted
in patient medical records by health care workers when a diagnostic
evaluation was suggestive of TB but insufficient for confirmation,
and confirmed TB was defined in accordance with U.S. surveillance
instructions.3 Individual inmates could have multiple
During the 28-month project period, 312 individual inmates accounted
for 410 project events of suspected or confirmed TB, an average
of 1.6 events per facility per month. Of the 410 events, 342 (83%)
involved suspected TB, 64 (16%) involved confirmed TB, and 4 (1%)
could not be classified. Of the 342 events of suspected TB, 21 (6%)
led to confirmation of TB after full diagnostic evaluation. Retrospective
review of the 64 project events originally recorded as confirmed
cases found that 5 could have been registered 2 to 6 weeks earlier
as suspected cases, but were not notified to the health department
until confirmatory diagnostic results were obtained. One of these
five was discounted subsequently because laboratory cross-contamination
with M. tuberculosis was strongly suspected.4
Timing of notifications. In 202 (49%) of the 410 project
events, suspected or confirmed TB was recorded for the first time,
that is, the diagnostic evaluation for TB began at the time of entry
to a prison or during a stay at that facility. Prison health care
providers notified local health department staff in 147 (73%) of
these 202 project events, while in 47 (23%) events, the local health
department notified the prison because PPHIP nurses were first to
receive reports from laboratories, hospitals, or other local health
departments. In eight (4%) events, the direction of reporting could
not be determined.
California public health code and policies stipulate that suspect
or confirmed TB be reported within 1 day.5-9 For the
record review, timing of notification for cases and suspected cases
detected in prisons was defined as the period between the date of
the earliest marker for possible TB (start of antituberculosis therapy,
first abnormal chest radiograph consistent with active TB, or first
smear with acid-fast bacilli or culture with M. tuberculosis)
and a report to the local health department. In 46 (31%) of 147
newly diagnosed TB events in which the prison notified the health
department, notification occurred within 1 working day of the date
of detection. The timing ranged from 2 to 7 days for 33 (22%) notifications
and exceeded 7 days for 36 (25%). Information about timing was missing
for 32 (22%). The extent to which late receipt of diagnostic test
results might have contributed to delays was not determined – prison
health care providers relied on reports from external sources (e.g.,
radiology services from contractors) and some reports were mailed
rather than telephoned.
Inmate relocations. Evaluation of suspected TB or treatment
of confirmed TB was temporarily interrupted by inmate relocation
in 185 (45%) of the 410 total project events: 157 (46%) of the 342
events related to suspected TB and 41 (48%) of the 85 events related
to confirmed TB. In 39 (21%) of the 185 total events ending in relocation,
the inmate was paroled or released into the community. In 22 (56%)
of these returns to the community, the destination local health
department located the patient.
Completion of therapy. The project included 70 unique
confirmed cases. Final treatment outcomes for these cases were derived
from the California TB registry (table). Completion of therapy (excludes
death from the denominator3) for these 70 cases was 50%
within 12 months and 62% ever. The outcome was recorded as moved
(without follow-up results) or lost for 29%.
Commentary. This project highlighted several challenges
for correctional and public health care workers: TB case finding
among prison inmates, notifications, follow-up of suspect cases,
relocations of inmates, and completion of treatment for TB. The
project nurses facilitated notifications, but half of the new events
of suspected or confirmed TB were notified to the health department
later than 1 working day, and a quarter were reported later than
1 week. Prompt notification facilitates curative treatment for TB,
isolation of contagious patients, and contact investigations both
inside and outside prisons, all of which helps prevent further cases.
Nearly half of the events that were registered in PPHIP occurred
when suspected or confirmed TB cases were detected by prison health
care providers, which suggests a significant contribution from case-finding
efforts in these facilities. While incarceration presents a unique
opportunity for TB control, the additional effort that is required
increases the workload for prison health care providers. After entry
screening of all inmates, each inmate with a suspected case must
be evaluated and observed in order to exclude or confirm TB. Sometimes
extensive contact investigations for preventing or finding secondary
TB cases, activities that were not recorded systematically in PPHIP,
must be started while results for case confirmation are pending.10
Standard TB surveillance, upon which funding and resource-allocation
decisions are made, reflects only confirmed TB cases. In PPHIP,
342 of the events involving suspected TB yielded 21 confirmed cases,
a suspect-to-case ratio of 16:1. In recognition of the workload
of finding cases and subsequent interventions, it is crucial to
allocate sufficient systems and personnel in correctional facilities
to find and cure TB patients.
Relocation of inmates who have TB, especially undetected cases,
has contributed to multiple-site outbreaks.1,11 Inmates
are moved mostly for security and also because of court arrangements
or a need for special medical care. Although no suggestion of undetected
TB was found through PPHIP, each move potentially disrupts continuity
of care, which creates a chance for a contagious patient to enter
a facility or a community.
Only 50% of the TB patients in this project were reported into
the state TB registry as having completed therapy within 12 months,
similar to rates measured in epidemiological studies of TB patients
who relocate during treatment.12,13 This completion rate
falls below the 1999 U.S. rate of 80% and the national objective
of 90%.3,14 Furthermore, 23% moved without having follow-up
results reported. It suggests the need for improved case tracking
in the corrections system and statewide, to diminish the risks associated
with interruption of treatment.
PPHIP did not include information about why the destination health
departments did not locate inmates for 44% of project events ending
in parole or release. Once returned to the community, these patients
can be difficult to reach, or their social circumstances can present
barriers to health care. The collaboration between correctional
facilities and health departments must be focused on this critical
transition to ensure that care is not disrupted.
PPHIP documented some of the TB control challenges faced by both
health departments and correctional facilities. It underscored their
shared responsibilities, and validated the role of systematic communication
and collaboration between health care staff at these agencies in
the prevention and control of TB.10
The following individuals contributed to this report: D Grice,
S Minkin, MD, Kings County Health Department; J Zaslav, R Gelber,
MD, F Schwartz, MD, Marin County Health Department; E Snyder, T
Prendergast, MD, San Bernardino County Health Department; T Salter,
G Thomas, MD, San Luis Obispo Health Department; L Padilla, E Lopez,
MD, T Charron, MD, Solano County Health Department; S Petrillo,
J Young, D Chin, MD, D Vugia, MD, Acting State Epidemiologist, California
Dept of Health Services; J Jereb, MD, Division of TB Elimination,
—Reported by Cathyn Fan, MPH, Jennifer Flood,
MD, Sarah Royce, MD
California Dept of Health Services
and Evalyn Horowitz, MD, California Department of Corrections
- CDC. Tuberculosis outbreaks in prison housing units for HIV-infected
inmates, California, 1995-1996. MMWR 1999; 48: 79-82.
- Markowitz N, Hansen N, Hopewell PC, et al. Incidence of tuberculosis
in the United States among HIV-infected patients. Ann Intern
Med 1997; 126: 123-132.
- CDC. Reported Tuberculosis in the United States, 2001.
Atlanta, GA: U.S. Department of Health and Human Services, CDC,
- Braden CR, Templeton GL, Stead WW, Bates JH, Cave MD, Valway
SE. Retrospective detection of laboratory cross-contamination
of Mycobacterium tuberculosis cultures with use of DNA fingerprint
analysis. Clin Infect Dis 1997;24:35-40.
- California Health and Safety Code, Sections 121361 and 121362.
- California Code of Regulations, Title 17, Section 2500.
- California Department of Health Services, California TB Controllers
Association. Joint Guidelines for TB Treatment and Control
in California. Berkeley, California: California Department
of Health Services, 2000. www.ctca.org.
- California Department of Corrections. TB Control Guidelines.
Sacramento, California, 1995.
- California Department of Corrections, Public Health Infectious
Disease Advisory Committee. Tuberculosis protocols for HIV-infected
inmates. Sacramento, California: California Department of Corrections,
- CDC. Prevention and control of tuberculosis in correctional
facilities: recommendations of the Advisory Council for the Elimination
of Tuberculosis. MMWR 1996; 45 (No. RR-8).
- Valway S, Greifinger R, Papania M, et al. Multidrug-resistant
TB in the New York State prison system, 1990-1991. J Infect
Dis 1994: 170: 151-156.
- Cummings K, Mohle-Boetani J, Royce S, et al. Movement of TB
patients and the failure to complete antituberculosis treatment.
Am J Respir Crit Care Med 1998: 157; 1249-1252.
- Chin DP, Cummings KC, Sciortino S, et al. Progress and problems
in achieving the US national target for completion of antituberculosis
treatment. Int J Tuberc Lung Dis 2000: 4(8): 744-751.
- US Dept of Health and Human Services. Healthy People 2010. From
Table. Treatment Outcomesa of Verified Casesb
Identified in the Prison Public Health Interface Project Prisons
Verified Cases Identified
in the PPHIP Prisons (%)
Completed Treatment within
Treatment after 12 months
aBased on the most recent follow-up information submitted
to the TB Registry as of December 2000.
bCompletion data are reported for patients alive at
diagnosis and started on treatment.3
cThe outcome category of "Died [during treatment]"
is excluded from the standard U.S. calculation for completion of
An Outbreak of Tuberculosis Among Homeless Persons
in Seattle & King County - Washington State, 2002-2003
The Seattle & King County TB Control Program continues to investigate
an outbreak of TB among homeless persons in Seattle. High suspicion
of an outbreak was confirmed in October 2002 when four cases were
proven to have an identical strain type, with a 15-band RFLP DNA
fingerprint. That month, seven additional homeless cases were diagnosed,
mostly associated with two service centers for homeless persons.
Site contact investigations at these facilities, performed at the
time of each case diagnosis and at 3-month follow-up, resulted in
83% (179/216) testing of identified contacts, with 68% (122/179)
of skin tests read and 23% (28/122) positive. One new case was found
as a direct result of these screening efforts.
Once the outbreak was recognized, the TB program quickly received
support from other programs within the county health department
and from the Washington State Department of Health TB Program. In
December, early observations and the public health response were
presented to the Division of TB Elimination. By the end of 2002,
TB had been diagnosed in 30 homeless persons. This was more than
twice that reported during each of the previous 6 years, except
for 1998, when another smaller outbreak had occurred. An Epi-Aid
investigation was requested through the Washington State Department
of Health to determine the extent of the outbreak and to identify
contacts at highest risk of exposure. The Epi-Aid investigation
and ongoing State TB Program support also enabled local public health
staff resources to be focused on treatment of their increased burden
of difficult active cases, by relieving them of some of the contact
Medical records of patients with active TB were reviewed, and the
duration and degree of infectiousness were estimated. To identify
sites of transmission, homeless facility registries were reviewed
to document the presence of infectious patients, and staff and client
tuberculin skin test (TST) results from homeless facilities were
analyzed. Named contacts were identified by TB patients and health
care providers at homeless facilities; site contacts were identified
by review of logbooks at homeless facilities that TB patients frequented
and where transmission likely occurred.
From January 2002 to January 2003, 20 of 33 homeless TB patients
were determined to be outbreak-associated. Outbreak-associated TB
patients had M. tuberculosis isolates with a matching 15-band
RFLP pattern (n=20) or an epidemiologic link to a patient whose
isolate matched the 15-band RFLP pattern (n=0). Of the outbreak-associated
homeless TB patients, 11 (55%) were Native American and 13 (65%)
were sputum smear positive at diagnosis. Six outbreak-associated
patients (30%), including four Native Americans, were coinfected
with HIV. During the previous 5 years only 11% (9/80) of homeless
TB cases in King County were Native American and 20% (16/80) were
Three homeless facilities (one sleeping facility and two daytime
facilities) were identified as probable sites of M. tuberculosis
transmission, including the two previously investigated during 2002.
These facilities were frequented by a total of 16 infectious outbreak-associated
patients. TST-positivity rates in clients from these facilities
were more than three times the rate normally seen in this community.
Eighty-five named contacts and 300 site contacts from these facilities
were identified for aggressive screening.
Extensive screening of high-risk contacts (e.g., symptom review,
chest radiograph, sputum smear and culture, TST and HIV counseling
and testing) began at the end of January 2003. Screening of high-risk
contacts is conducted both in the TB clinic and on-site at homeless
facilities using a mobile x-ray unit. In addition, high-risk homeless
persons are being screening during county emergency room visits
and county jail incarcerations. Monetary incentives are being offered
to those who complete screening.
On-site enhanced screening has found 132 additional site contacts
who were not found by the homeless facility registries, bringing
the total high-risk contacts to 517. Of these, 301 (58%) have been
evaluated with a chest radiograph or AFB sputum examination. As
of April 18, 2003, 33 outbreak-associated patients have been identified.
Of the 16 outbreak-associated patients diagnosed in 2003, 10 (63%)
were on the original named or site contact lists and 8 (50%) were
diagnosed through health department screening efforts. Two additional
homeless TB patients without known epidemiologic links to an outbreak
patient were also diagnosed through screening efforts. Five (1.9%)
of 269 contacts tested for HIV infection were seropositive. A total
of 242 contacts without a history of a prior positive TST have had
at least one TST placed and read. Of these, 95 have tested positive,
86 (91%) of whom received a chest radiograph. Treatment of latent
TB infection has been initiated for approximately 28 infected homeless
persons so far during 2003, mostly directly observed.
In summary, a large, ongoing outbreak of TB is occurring in Seattle
and King County. An extensive and enhanced screening effort, carefully
focused on identified segments of King County’s homeless community,
with significant support from numerous institutions, has combined
screening for infection and for disease, and has accomplished effective
case finding. After ensuring completion of therapy for new cases
of TB disease, the most effective approaches need to be determined
to ensure completion of therapy for new cases of TB infection.
—Reported by Kathryn Lofy, MD, Epidemic Intelligence
Service OfficerWashington State Department of Health
and Masa Narita, MD, Director
Stefan Goldberg, MD, Senior Staff Physician
Linda Lake, MBA, TB Outbreak Coordinator
TB Control Program, Public Health – Seattle & King County
Advancing TB Control Among American Indians and
American Indians and Alaska Natives contributed 177 (2.4%) of 7,252
cases in U.S.-born persons in 2002. This count is deceptively low:
American Indians and Alaska Natives constitute only 0.7% of U.S.
total population, but have a TB rate of 7.0/100,000, compared to
1.3/100,000 for white, non-Hispanic persons. TB in the United States
is a reflection of the nation’s racial health disparities. Among
racial/ ethnic groups, American Indians and Alaska Natives have
the lowest rates of decline in TB cases since 1992.1
A closer look at cases in U.S.-born persons for the period 1993-2001
demonstrates that American Indians and Alaska Natives contribute
greater than 5% of the TB cases in 15 states. Two thirds of these
states are low-incidence (<3.5 TB cases /100,000 population)
states: Idaho, Montana, North Dakota, Nebraska, New Mexico, Oregon,
South Dakota, Utah, Wisconsin and Wyoming. Because of their low-incidence
status, they face distinctive challenges in maintaining a TB control
infrastructure.2 Bolstering partnerships between the
Indian Health Service (IHS) and CDC, and especially between tribal
and state TB control programs, will be essential for achieving TB
elimination in these states.
In May 2001, DTBE convened an internal meeting for the purpose of
assessing TB control efforts directed toward American Indians and
Alaska Natives. Representatives from the Indian Health Service (IHS)
participated as advisors. At the meeting, recommendations were developed
for a specific TB control strategy. The goal of the strategy is
to build systems that will improve TB control.
The procedings of the meeting, Advancing Tuberculosis Control
for American Indians and Alaska Natives: Developing a DTBE Plan,3
were mailed to all state TB control directors in 2002. Copies were
also sent to the IHS Epidemiology Program, to FSB field staff, and
to members of the Advisory Council for the elimination of TB (ACET).
Over the last 6 months DTBE staff have been moving forward on the
following recommendations that were made at the meeting:
- Prepare for a meeting in the area of the Great Plains States
for Northern Plains tribes. Activities have included holding a
teleconference with the state TB Controllers in the Northern Plains
states of Montana, Wyoming, North Dakota, South Dakota, Nebraska,
and Iowa; meeting with area Tribal Leaders through the Aberdeen
Area Tribal Chairman Health Board and the Montana – Wyoming Tribal
Leaders Council Subcommittee on Health; and holding a teleconference
with Indian Health Service Chief Medical Officers and TB controllers
from the Aberdeen and Billings IHS Area.
- Train key IHS personnel at the DTBE Program Managers Course
in October 2003. The Aberdeen Area IHS TB controller plans to
attend this fall course. Nominations can be made through state
In addition, a longer-term strategy is to explore Cooperative Agreement
options for increasing technical and financial TB control assistance
to health departments that have memoranda of understanding or agreement
with tribal governments.
—Submitted by Jennifer Giroux, MD
Div of TB Elimination
- CDC. Trends in tuberculosis morbidity — United States, 1992-2002.
MMWR 2002; 52:11.
- CDC. Progressing toward tuberculosis elimination in low-incidence
areas of the United States: recommendations of the Advisory Council
for the Elimination of Tuberculosis. MMWR 2002; 51:RR-5.
- Jereb J. Advancing Tuberculosis Control for American Indians
and Alaska Natives: Developing a DTBE Plan. Atlanta, GA: CDC;
Rethinking the Socioeconomics and Geography of
Tuberculosis Among Foreign-Born Residents of New Jersey, 1994–1999
The following is abstracted from a
previously published article (Am J Public Health 2003;93: 1007-1012).1
Tuberculosis has long been noted as a disease of the poor. Explanations
for this notion have traditionally included crowded living quarters
associated with an increased risk of transmission. Poverty-related
co-morbid conditions such as HIV infection, intravenous drug use,
alcoholism, and nutritional deficiencies increase one’s susceptibility
to progressing from latent TB infection to active disease. However,
clinicians at the New Jersey Medical School National Tuberculosis
Center anecdotally observed an increasing number of foreign-born
patients who did not fit the archetypical profile of a tuberculosis
patient burdened with multiple social and medical problems. For
the most part employed and educated, these patients presented no
exceptional risk factors except for being born in one of the 22
nations that comprise the World Health Organization’s list of high
TB burden countries. In aggregate, these 22 countries contain 80%
of the world’s TB.
These observations led us to conduct an analysis of TB cases by
place of birth reported to New Jersey’s tuberculosis registry in
the years 1994-1999. To get a sense of each TB patient’s individual
socioeconomic status, we examined the variables "occupation"
and "medical supervision" as recorded by the TB registry.
As per the examination, foreign-born subjects were more likely than
U.S.-born subjects to be working within the 2 years prior to diagnosis
and to have their entire treatment managed exclusively by a private
physician. In addition, linkage of case-level tuberculosis records
with Census data showed that foreign-born TB patients were more
likely than US-born TB patients to live in areas where (1) a greater
percentage of persons aged 25 years or older had some college education
and (2) a smaller percentage of persons lived in homes with more
than one person per room (a measure of crowding used by the Census).
We also found that the per-capita income was higher on average in
zip codes where foreign-born patients resided as compared to zip
codes where US-born patients resided.
It is important to note that there was tremendous heterogeneity
among the foreign-born patient population. The relationships observed
overall were driven in large part by the substantial number of foreign-born
TB patients of relatively high socioeconomic circumstances born
in South Asia (Bangladesh, India, Pakistan: n=437) and East Asia
(China, Korea, Philippines, Taiwan, Viet Nam: n=437). Among persons
aged 25-65 years, 46% of the Asians and 55% of the South Asians
were treated exclusively by private providers and, respectively,
65% and 62% of them were employed in the 2 years prior to diagnosis.
Nevertheless, there remain a substantial number of foreign-born
patients whose socioeconomic status is as low as that which characterizes
the average US-born TB patient.
These findings have important implications for TB control. First,
if a large portion of foreign-born patients are being treated exclusively
by private providers, efforts will have to be made to ensure that
private providers are ensuring proper public health follow-up (as
noted by the Institute of Medicine Report2), and providing
correct TB treatment regimens (as noted in Liu et al.3).
Second, clinic hours, directly observed therapy programs, and incentives
will need to accommodate patients who are employed. Third, resources
may need to be allocated for TB control in localities that heretofore
were not considered to be at high risk for tuberculosis. This will
include resources for the conduct of increasing numbers of workplace
We have shown that, at least in New Jersey, the long-established
link between TB and lower socioeconomic status may have been altered
by the arrival of large numbers of TB patients from regions of high
TB endemicity. In order to make progress towards TB elimination
in the United States, it will be important to conduct similar analyses
in other US states and regions that are likewise experiencing a
rising proportion of TB cases among the foreign-born.
—Submitted by Amy L. Davidow, PhD
Assistant Professor, Department of Preventive Medicine & Community
New Jersey Medical School National Tuberculosis Center
University of Medicine & Dentistry of New Jersey – New Jersey
- Davidow AL, Mangura BT, Napolitano EC, Reichman LB. Rethinking
the socioeconomics and geography of tuberculosis among foreign-born
residents of New Jersey, 1994-1999. American Journal of Public
Health Jun 2003;93(6):1007-1012.
- Ending Neglect. The Elimination of Tuberculosis in the United
States. Lawrence Geiter, Editor. Committee
on the Elimination of Tuberculosis in the United States. Division
of Health Promotion and Disease Prevention, Institute of Medicine.
Washington, DC: National Academy Press; 2000.
- Liu Z, Shilkret KL, Finelli L. Initial drug regimens for the
treatment of tuberculosis: evaluation of physician prescribing
practices in New Jersey, 1994 to 1995. Chest 1998;113:1446-1451.