| |
TB Notes Newsletter
Return to TB Notes 2, 2006 Main Menu
This is an archived document. The links
and content are no longer being updated.
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
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
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
- CDC. Trends in Tuberculosis—United States, 1998–2003. MMWR
2004; 53:209-214.
- CDC. Reported Tuberculosis in the United States, 2004. Atlanta,
GA: U.S.
Department of Health and Human Service, CDC, Sept 2005.
- CDC. Fact Sheet, BCG Vaccine. CDC, Jan 2005.
- http://www.dph.state.ct.us/BCH/infectiousdise/tubercul.htm
(Accessed 1/16/2006).
- CDC. Treatment of Tuberculosis. American Thoracic Society, CDC,
and Infectious Diseases Society of America.
MMWR 2003: 52 (RR-11).
Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
|
