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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 events.

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, CDC.

—Reported by Cathyn Fan, MPH, Jennifer Flood, MD, Sarah Royce, MD
California Dept of Health Services
and Evalyn Horowitz, MD, California Department of Corrections

References

  1. CDC. Tuberculosis outbreaks in prison housing units for HIV-infected inmates, California, 1995-1996. MMWR 1999; 48: 79-82.
  2. 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.
  3. CDC. Reported Tuberculosis in the United States, 2001. Atlanta, GA: U.S. Department of Health and Human Services, CDC, September 2002.
  4. 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.
  5. California Health and Safety Code, Sections 121361 and 121362.
  6. California Code of Regulations, Title 17, Section 2500.
  7. 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.
  8. California Department of Corrections. TB Control Guidelines. Sacramento, California, 1995.
  9. California Department of Corrections, Public Health Infectious Disease Advisory Committee. Tuberculosis protocols for HIV-infected inmates. Sacramento, California: California Department of Corrections, 1998.
  10. 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).
  11. 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.
  12. 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.
  13. 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.
  14. US Dept of Health and Human Services. Healthy People 2010. From www.health.gov/healthypeople.

Table. Treatment Outcomesa of Verified Casesb Identified in the Prison Public Health Interface Project Prisons

 

Treatment Outcome

 

Verified Cases Identified in the PPHIP Prisons (%)

 

Completed Treatment within 12 months

 

34 (49)

Completed Treatment after 12 months

8 (11)

Moved

16 (23)

Lost

4 (6)

Refused

1 (1)

Diedc

2 (3)

No Information

5 (7)

Total

70

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 therapy.3

 

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 investigation responsibilities.

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 HIV infected.

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 Alaska Natives

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.

Image of Percentage of Cases in AI/AM, U.S.-born Patients Only. United States, 1993-2001
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 TB controllers.

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

References

  1. CDC. Trends in tuberculosis morbidity — United States, 1992-2002. MMWR 2002; 52:11.
  2. 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.
  3. Jereb J. Advancing Tuberculosis Control for American Indians and Alaska Natives: Developing a DTBE Plan. Atlanta, GA: CDC; 2002.

 

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 contact investigations.

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 Health
New Jersey Medical School National Tuberculosis Center
University of Medicine & Dentistry of New Jersey – New Jersey Medical School


References

  1. 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.
  2. 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.
  3. 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.

 


Released October 2008
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