Biomedical subjects

Cynthia R Driver

Publications and source records attributed to Cynthia R Driver.

13 recordsLinked to original sources

PubMed2006

Which patients' factors predict the rate of growth of Mycobacterium tuberculosis clusters in an urban community?

Factors influencing tuberculosis cluster growth are poorly understood. The authors examined clusters of two or more culture-confirmed Mycobacterium tuberculosis cases between January 1, 2001, and December 31, 2003, that had insertion sequence 6110 (IS6110) restriction fragment length polymorphism and spoligotype patterns identical to those of another study case. Genotypes first seen in New York, New York, before or during 1993 were considered historical; recent strains were those first seen after 1993. The authors examined the effect of the combined characteristics of infectiousness of the first two cases in a cluster on the rate of cluster growth. Genotyping was performed for 2,408 (91.8%) of the 2,623 tuberculosis cases diagnosed; 873 cases were in 212 clusters. Thirty-one clusters had historical strains, 153 were recent, and 28 were of unknown period. Patients' infectiousness was not associated with the rate of cluster growth among historical strain clusters. Among recent strain clusters, infectiousness of both of the initial cases was associated with a higher rate of cluster growth compared with clusters in which neither initial case was infectious, upon adjustment for male sex (rate ratio = 2.62, 95% confidence interval: 1.19, 5.78). The rate of genotype cluster growth should be monitored regardless of how long the strain has been present in the community. However, infectiousness in the first two cases may be useful to prioritize genotype cluster investigations.

AIDS-Related Opportunistic Infections↗

PubMed2006

Tuberculosis prevention for non-US-born pregnant women.

OBJECTIVE: The purpose of this study was to evaluate whether non-US-born pregnant women receiving prenatal care are targeted for treatment of latent tuberculosis (TB) infection (LTBI) with isoniazid (INH) to prevent active TB. STUDY DESIGN: This was a retrospective chart review study of 730 non-US-born pregnant women receiving care at 5 New York City prenatal clinics from 1999 to 2000. RESULTS: Among 678 women with known tuberculin skin test (TST) status, 341 (50.3%) had a TST-positive result, including 200 who were newly diagnosed. Of 291 TST-positive women with no previous LTBI treatment or history of TB, 27 (9.3%) completed > or =6 months of INH. In a subset with detailed follow-up, the most important reasons for not completing treatment were nonreferral for evaluation of a TST-positive result (30.9%), not keeping the appointment (17.9%), and nonadherence with prescribed treatment (34.6%). CONCLUSION: The prenatal setting represents a missed opportunity to link TST-positive non-US-born women with LTBI treatment and support for treatment completion.

Adult↗

PubMed2006

Strain-specific differences in two large Mycobacterium tuberculosis genotype clusters in isolates collected from homeless patients in New York City from 2001 to 2004.

We studied two large Mycobacterium tuberculosis genotype clusters associated with recent outbreaks in homeless persons to determine factors associated with these tuberculosis (TB) strains. Isolates from all culture-positive TB cases diagnosed from 1 January 2001 to 31 December 2004 were genotyped. Patients whose isolates had identical restriction fragment length polymorphism patterns and spoligotypes were considered clustered. Health department records were reviewed and reinterviews attempted for clustered cases. Patients with the Cs30 and BEs75 strains were compared to other genotypically clustered cases and to each other. The two largest genotype clusters among homeless persons were the Cs30 strain (n = 105) and the BEs75 strain (n = 47). Fifty-one (49%) patients with the Cs30 strain and 28 (60%) with the BEs75 strain were homeless. Compared to patients with the BEs75 strain, patients with the Cs30 strain were less likely to be respiratory acid-fast bacillus smear positive (51% versus 72%). Furthermore, patients with the BEs75 strain were more likely to be HIV infected (74% versus 42%), which suggests that most patients with this strain advanced to disease after recent infection. Cases in clusters of strains that have been circulating in the community over a long time period, such as the Cs30 strain, require additional investigation to determine whether clustering is a result of recent transmission or reactivation of remote infection.

Adolescent↗

PubMed2006

Universal genotyping in tuberculosis control program, New York City, 2001-2003.

In 2001, New York City implemented genotyping to its tuberculosis (TB) control activities by using IS6110 restriction fragment length polymorphism (RFLP) and spoligotyping to type isolates from culture-positive TB patients. Results are used to identify previously unknown links among genotypically clustered patients, unidentified sites of transmission, and potential false-positive cultures. From 2001 to 2003, spoligotype and IS6110-based RFLP results were obtained for 90.7% of eligible and 93.7% of submitted isolates. Fifty-nine (2.4%) of 2,437 patient isolates had false-positive culture results, and 205 genotype clusters were identified, with 2-81 cases per cluster. Cluster investigations yielded 57 additional links and 17 additional sites of transmission. Four additional TB cases were identified as a result of case finding initiated through cluster investigations. Length of unnecessary treatment decreased among patients with false-positive cultures.

Bacterial Typing Techniques↗

PubMed2005

Relapse and acquired rifampin resistance in HIV-infected patients with tuberculosis treated with rifampin- or rifabutin-based regimens in New York City, 1997-2000.

BACKGROUND: The relationship between rifamycin use and either relapse or treatment failure with acquired rifampin resistance (ARR) among human immunodeficiency virus (HIV)-infected patients with tuberculosis (TB) is not well understood. METHODS: We conducted a retrospective cohort study of HIV-infected and HIV-uninfected persons with rifampin-susceptible TB, (1) to compare relapse rates, ARR, and treatment failure, according to HIV serostatus; and (2) to examine whether and how use of rifamycin was associated with clinical outcomes of interest among HIV-infected patients with TB. RESULTS: HIV-infected patients were more likely to have ARR than were HIV-uninfected patients (0.9% vs. 0.1%; P = .007), and the association remained significant in multivariate analysis (adjusted odds ratio [OR], 5.5; 95% confidence interval [CI], 1.4-21.5). Among HIV-infected patients with TB, none of 57 patients treated with rifabutin-based regimens alone had ARR, and only 1 of 395 patients treated with rifabutin given in combination with a rifampin-based regimen had ARR, whereas 6 of 355 patients treated with a rifampin-based regimen alone had relapse and ARR. HIV-infected patients treated with rifampin-based regimens alone had a higher risk for relapse and development of rifampin resistance if intermittent dosing of rifampin was started during the intensive phase of treatment, compared with patients who did not receive intermittent dosing (hazard ratio [HR] for relapse, 6.7 [95% CI, 1.1-40.1]; HR for ARR, 6.4 [95% CI, 1.1-38.4]). This association remained when confined to patients with a CD4+ T lymphocyte count of < 100 lymphocytes/mm3. Intermittent dosing started only after the intensive phase of treatment did not increase the risks of relapse and ARR among HIV-infected patients with TB. CONCLUSION: The risk for ARR among HIV-infected persons with TB did not depend on the rifamycin used but, rather, on the rifampin dosing schedule in the intensive phase of treatment.

AIDS-Related Opportunistic Infections↗

PubMed2005

Tuberculosis in health care workers during declining tuberculosis incidence in New York State.

BACKGROUND: Nosocomial tuberculosis (TB) transmission has decreased dramatically in New York State since 1992; however, health care workers (HCWs) still compose >3% of TB cases. METHODS: Aggregate surveillance data on incident TB cases from 1994 to 2002 were examined for trends among HCWs. Additional information was available for HCW cases from 1998 to 2002, including facility type, tuberculin skin test (TST) result at hire, and treatment of latent TB infection (TLTBI). RESULTS: In New York State, 2.5% of TB cases in 1994 and 4.0% in 2002 were in HCWs (P value for trend <.001). Fifty percent of HCWs TB cases in 1994 and 77.6% in 2002 were in non-US born (P = .002) HCWs. Multidrug-resistant TB in HCWs decreased from 15.6% in 1994 to 6.9% in 2002 (P = .001). Of 297 HCWs TB cases in 1998-2002, 54.9% were TST positive at hire, and 21.2% had unknown TST result; 50.2% of 221 HCWs who were TST positive at or after hire met guidelines for TLTBI, and 23.4% received treatment. The highest proportion with unknown TST at hire and the lowest proportion receiving TLTBI were in ambulatory facilities. CONCLUSION: Many HCWs who developed TB were either TST positive at hire and did not receive TLTBI or did not receive TST at hire. Facilities should encourage treatment for HCWs who meet criteria for TLTBI. Provider education should focus on ambulatory facilities.

Adolescent↗

PubMed2004

Use of therapeutic drug monitoring for multidrug-resistant tuberculosis patients.

STUDY OBJECTIVES: Therapeutic drug monitoring (TDM) is the process of obtaining the serum concentration of a medication and modifying the dose based on the results. Little is known about the application of TDM in the treatment of patients with multidrug-resistant (MDR) tuberculosis (TB) in clinical practice. This study characterized how TDM was applied in the management of MDR TB patients, and examined the clinical indications for ordering TDM, the process for obtaining drug concentrations, and the clinician response to the drug concentrations. DESIGN: In a retrospective study, we compared the clinical and demographic characteristics of MDR TB patients who received TDM with those who did not. The clinical application of TDM also was described in patients who received TDM. SETTING: A municipal TB control program. PATIENTS OR PARTICIPANTS: Patients in whom TB was diagnosed that was caused by an isolate resistant to at least isoniazid and rifampin, and who received treatment for TB in one of the health department chest clinics between July 1, 1993, and August 31, 1997, were studied. RESULTS: Forty-nine patients receiving TDM had a longer time to culture conversion and treatment duration, more pulmonary TB in combination with an extrapulmonary site, drug resistance, and visits to the health department clinics (p < 0.05) than the 60 patients without TDM. Of the 49 patients who had initial TDM, 73.5% of them had the reason for being tested specified. A total of 85.7% of initial TDM results were collected at the appropriate time of blood sampling. Clinician response to TDM results varied with the drug that was being tested. CONCLUSIONS: The use of TDM depended largely on the patient's clinical presentation. Site-specific guidelines on the use of TDM for managing TB patients may maximize the benefit of TDM.

Adult↗

PubMed2003

Effectiveness of isoniazid treatment for latent tuberculosis infection among human immunodeficiency virus (HIV)-infected and HIV-uninfected injection drug users in methadone programs.

Injection drug users (IDUs) were heavily affected by the tuberculosis (TB) resurgence in New York City in the 1990s. We assessed the effectiveness of screening for latent TB infection in methadone users and of selective treatment with isoniazid. Risk for future TB was classified as low or high on the basis of tuberculin, anergy, and HIV test results. The cohort of 2212 IDUs was followed up for a median of 4.2 years; 25 IDUs, of whom 20 (80%) were infected with human immunodeficiency virus (HIV), developed TB. In an adjusted Cox proportional hazards model of high-risk IDUs, the risk of TB was associated with HIV infection (HR 10.3; 95% CI, 3.4-31.3); receipt of <6 months of isoniazid therapy (HR 7.6; 95% CI, 1.02-57.1); a CD4+ T lymphocyte count of <200 cells/mm3 (HR 6.6; 95% CI, 1.7-25.9); and tuberculin positivity (HR 4.0; 95% CI, 1.6-10.2). Treatment with isoniazid was beneficial in HIV-infected, tuberculin-positive IDUs.

AIDS-Related Opportunistic Infections↗

PubMed2003

Tuberculosis control: past 10 years and future progress.

The number of countries implementing directly observed therapy short-course (DOTS) has grown rapidly in the past decade and more than 10 million patients have now been treated under DOTS. While global case detection rates increased slightly, from 35% to 40% between 1995 and 2000, the proportion attributable to DOTS grew from less than one-third to more than two-thirds. DOTS is replacing inferior treatment but still treating fewer than 40% of estimated new TB cases. Misconceptions threaten to undermine continued success in tuberculosis control. The first misconception is that treatment observation is unnecessary. Treatment observation needs to be made more patient-friendly, but must not be abandoned. The second misconception is that health care reform will strengthen tuberculosis control. TB control is essentially a management problem. Greater accountability of governments, donors and providers is essential. A third misconception is to focus on treating multi-drug-resistant tuberculosis (MDRTB) cases without addressing the root causes of MDRTB. While it is important, on a clinical basis and epidemiologically in some contexts, to care optimally for patients with MDRTB, it is more important to address the cause of MDRTB and to fix the program generating MDRTB. The fourth misconception is an inordinate concern for sustainability. Delaying assistance will make implementation and sustainability in the future more difficult. Tuberculosis control is remarkably inexpensive and cost-effective, but efforts will fail unless programs have the ability to hire staff, purchase supplies, and contract for services efficiently. Critical issues for the future of tuberculosis control are sustained funding, technical rigor, and good management.

Attitude of Health Personnel↗

PubMed2003

Tuberculin testing and risk of tuberculosis infection among New York City schoolchildren.

OBJECTIVES: To assess adherence to a 1996 health policy change, which discontinued mandatory tuberculin skin testing (TST) of new entrants to NYC primary schools and continued mandatory testing of new entrants to secondary schools. METHODS: The proportion tested before (1991-1995) and after (1996-1998) the change in health policy was determined. Factors associated with TST positivity and the cost of continued testing were assessed. RESULTS: A total of 76.6% of 551 636 new entrants to primary schools were tested in 1991-1995; slightly fewer, 71.1% of 339 958, were tested in 1996- 1998. Among new entrants to secondary schools, 31.0% of 106 463 were tested in 1991-1995 and 51.4% of 53 762 were tested in 1996-1998. The proportion who were TST-positive continued to decrease after 1996 to 1.2% among primary and 9.7% among secondary schoolchildren in 1998. Older age and birth outside the United States were associated with TST positivity. The estimated minimum cost of continued testing in primary schools was $123 152 per tuberculosis case prevented. CONCLUSION: An approach aimed at reducing testing of children at low risk for latent tuberculosis infection did not decrease testing of younger children. More important, older children who were more likely to be born in countries of high tuberculosis incidence were not tested. Additional efforts are needed to increase awareness among medical and school personnel to decrease testing among children who do not have risk factors for latent tuberculosis infection and to increase tuberculin testing of children who are entering school for the first time at the secondary level and do have risk factors for tuberculosis infection.

Adolescent↗

PubMed2002

Use of DNA fingerprinting to investigate a multiyear, multistate tuberculosis outbreak.

In 1998-1999, the Baltimore TB control program detected a cluster of 21 tuberculosis (TB) cases. Patients reported frequent travel to various East Coast cities. An investigation was conducted to determine whether transmission of the same Mycobacterium tuberculosis strain was occurring in these other localities. A collaborative investigation among federal, state, and local TB controllers included TB record reviews, interviews of patients, and restriction fragment length polymorphism (RFLP) analysis of selected M. tuberculosis isolates from diagnosed TB patients in several cities in 1996-2001. A national TB genotyping database was searched for RFLP patterns that matched the outbreak pattern. Eighteen additional outbreak-related cases were detected outside of Baltimore-the earliest diagnosed in New Jersey in 1996, and the most recent in New York City in late 2001. The outbreak demonstrates the need for strategies to detect links among patients diagnosed with TB across multiple TB control jurisdictions.

Adolescent↗

PubMedDate not supplied

Targeting tuberculosis testing: the yield of source case investigations for young children with reactive tuberculin skin tests.

OBJECTIVE: This study was designed to determine the yield of investigations whose aim is to identify a source case for tuberculosis infection among tuberculin reactors 3 years of age or younger. METHODS: The authors describe the results of associate investigations conducted for child tuberculin reactors reported from January 1, 1996, through June 30, 1998. Associates were defined as individuals who live with or spend significant time with a child reactor. An associate investigation was defined as evaluation of at least one associate. A source case was an associate older than 10 years of age who had culture-positive, pulmonary tuberculosis during a period when the child could have been exposed. RESULTS: Two hundred seven children had an associate investigation performed with a median of four associates investigated per child (range 1-21). Birthplace was known for 187 (90%); 128 were U.S.-born. Of 1,222 associates identified, 980 (80%) were evaluated. Among 452 (46%) associates for whom birthplace was known, 250 (55%) were non-U.S.-born. Of 980 associates, 668 were household contacts; 198 (30%) were infected, three had prior tuberculosis disease, and three had active tuberculosis. Two active cases met source case criteria; the yield was 0.9 (2 of 207) source cases per 100 children investigated. Of 312 non-household contacts, 57 (18%) were infected and none had the disease. CONCLUSIONS: Although few source cases were identified for young tuberculin skin test reactors in New York City, investigations identified a proportion of cases and infection in associates similar to that identified among contacts to pulmonary tuberculosis cases. Such investigations may be identifying a high-risk group and should be considered, depending on program resources.

Child, Preschool↗

PubMedDate not supplied

Factors associated with tuberculosis treatment interruption in New York City.

SETTING: Large urban tuberculosis control program. OBJECTIVES: To determine the frequency and characteristics of treatment interruptions, and the factors associated with the different types of treatment interruptions. DESIGN: This was a case-control study using culture-positive tuberculosis (TB) patients verified in 1998-1999. Case patients included those in whom any of the following mutually exclusive categories of treatment interruption: default with return to therapy, directly observed therapy nonadherence, default without return to therapy, or multiple types of interruptions. Controls were selected randomly from the cohort. RESULTS: Overall, 6.0 percent of patients had treatment interruptions. All types of treatment interruption were associated with prolonged treatment course and decreased treatment completion rates. The median number of months to treatment interruption was 4.0 (range, 0.5-28.9 months). Two factors were significantly associated with every type of interruption: homelessness and lack of awareness of the severity of TB disease. In multivariate analysis, only lack of awareness of the severity of disease remained independently associated with all interruption types. CONCLUSION: Efforts to improve patients' understanding of TB disease and related treatment issues may be an important TB control program strategy and should be emphasized at the initiation of therapy and at intervals throughout the treatment course to minimize treatment interruption.

Adult↗