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Volume 12, Number 5—May 2006

Volume 12, Number 5—May 2006   PDF Version [PDF - 6.58 MB - 167 pages]

Tuberculosis Special Section


  • Universal Genotyping in Tuberculosis Control Program, New York City, 2001–2003 PDF Version [PDF - 129 KB - 6 pages]
    C. M. Clark et al.
    View Summary

    Real-time universal genotyping decreased unnecessary treatment.

        View Abstract

    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.


  • Tuberculin Skin Testing in Children PDF Version [PDF - 62 KB - 2 pages]
    M. Reznik and P. O. Ozuah
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    Skin testing is recommended for children at risk for this disease.

        View Abstract

    In 1996, the American Academy of Pediatrics (AAP) recommended targeted tuberculin skin testing (TST) of children while discouraging routine TST of children without risk factors for tuberculosis (TB). Recent studies have provided evidence in support of the targeted TST and recommendations that favor risk assessment over universal screening with TST. While evidence for targeted TB testing exists and benefits of screening programs are clear, administrative logistics could be a greater issue. The challenge for public health and school officials is to develop a screening program that avoids stigmatization of the at-risk group. Until then, pediatric healthcare providers will continue to have a key role in identifying children at risk for latent TB infection by using the AAP-endorsed risk-assessment questionnaire and should screen children with TST only when >1 risk factor is present.


  • Tuberculosis Transmission Attributable to Close Contacts and HIV Status, Malawi PDF Version [PDF - 188 KB - 7 pages]
    A. C. Crampin et al.
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    In this population, ≈90% of M. tuberculosis infections were transmitted by casual contact, and nearly half from HIV-positive patients.

        View Abstract

    We conducted the first molecular study of tuberculosis (TB) to estimate the role of household contact and transmission from HIV-positive putative source contacts (PSCs) in a high HIV-prevalence area. TB patients in a long-term population-based study in Malawi were asked about past contact with TB. DNA fingerprinting was used to define clusters of cases with identical strains. Among 143 epidemiologically defined PSC-case pairs, fingerprinting confirmed transmission for 44% of household and family contacts and 18% of other contacts. Transmission was less likely to be confirmed if the PSC were HIV positive than if he or she was HIV negative (odds ratio 0.32, 95% confidence interval [CI] 0.14–0.74). Overall, epidemiologic links were found for 11% of 754 fingerprint-clustered cases. We estimate that 9%–13% of TB cases were attributable to recent transmission from identifiable close contacts and that nearly half of the TB cases arising from recent infection had acquired the infection from HIV-positive patients.

  • Beijing/W Genotype Mycobacterium tuberculosis and Drug Resistance PDF Version [PDF - 228 KB - 8 pages]
    View Summary

    The genotype, endemic in some areas and emerging in others, may be associated with drug-resistance.

        View Abstract

    Beijing/W genotype Mycobacterium tuberculosis is widespread, may be increasing, and may have a predilection for drug resistance. Individual-level data on >29,000 patients from 49 studies in 35 countries were combined to assess the Beijing genotype’s prevalence worldwide, trends over time and with age, and associations with drug resistance. We found 4 patterns for Beijing/W genotype tuberculosis (TB): 1) endemic, not associated with drug resistance (high level in most of East Asia, lower level in parts of the United States); 2) epidemic, associated with drug resistance (high level in Cuba, the former Soviet Union, Vietnam, and South Africa, lower level in parts of Western Europe); 3) epidemic but drug sensitive (Malawi, Argentina); and 4) very low level or absent (parts of Europe, Africa). This study confirms that Beijing/W genotype TB is an emerging pathogen in several areas and a predominant endemic strain in others; it is frequently associated with drug resistance.

  • Isoniazid Preventive Therapy and Risk for Resistant Tuberculosis PDF Version [PDF - 223 KB - 8 pages]
    M. Balcells et al.
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    Preventive therapy may increase risk for drug resistance.

        View Abstract

    In the context of tuberculosis (TB) resurgence, isoniazid preventive therapy (IPT) is increasingly promoted, but concerns about the risk for development of isoniazid-resistant tuberculosis may hinder its widespread implementation. We conducted a systematic review of data published since 1951 to assess the effect of primary IPT on the risk for isoniazid-resistant TB. Different definitions of isoniazid resistance were used, which affected summary effect estimates; we report the most consistent results. When all 13 studies (N = 18,095 persons in isoniazid groups and N = 17,985 persons in control groups) were combined, the summary relative risk for resistance was 1.45 (95% confidence interval 0.85–2.47). Results were similar when studies of HIV-uninfected and HIV-infected persons were considered separately. Analyses were limited by small numbers and incomplete testing of isolates, but findings do not exclude an increased risk for isoniazid-resistant TB after IPT. The diagnosis of active TB should be excluded before IPT. Continued surveillance for isoniazid resistance is essential.

  • Mycobacterium tuberculosis and Rifampin Resistance, United Kingdom PDF Version [PDF - 233 KB - 8 pages]
    I. Sam et al.
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    A national diagnostic service identified M. tuberculosis and rifampin resistance in primary clinical specimens faster than conventional techniques.

        View Abstract

    The United Kingdom Health Protection Agency Mycobacterium Reference Unit offers a national "Fastrack" molecular service for detecting Mycobacterium tuberculosis complex (MTBC) and rifampin resistance by using the INNO-LiPA Rif.TB assay. We analyzed the service in a routine, nontrial context of 1,997 primary clinical specimens, including 658 nonrespiratory specimens. The overall adjusted concordance, sensitivity, specificity, positive predictive value, and negative predictive value for detecting MTBC were 91.2%, 85.2%, 96.2%, 95.7%, and 86.7%, respectively (unadjusted, 86.7%, 85.2%, 88.2%, 86.9%, and 86.7%), when false-positive samples from patients (n = 83) with a known microbiologic diagnosis of MTBC or patients receiving current or recent antituberculous treatment were excluded. The parameters for detecting rifampin resistance were 99.1%, 95.0%, 99.6%, 92.7%, and 99.7%, respectively. The assay enabled earlier diagnosis of MTBC and rifampin resistance (15.2 days) compared with culture-based techniques (30.7 days).


Volume 12, Number 5—May 2006 - Continued


  • Coronavirus HKU1 Infection in the United States PDF Version [PDF - 189 KB - 5 pages]
    F. Esper et al.
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    Virus is associated with respiratory tract disease in children <5 years of age.

        View Abstract

    In 2005, a new human coronavirus, HCoV-HKU1, was identified in Hong Kong. We screened respiratory specimens collected from December 16, 2001, to December 15, 2002, from children <5 years of age who tested negative for respiratory syncytial virus, parainfluenza viruses, influenza virus, and adenovirus for HCoV-HKU1 by reverse transcription–polymerase chain reaction. Overall, 1,048 respiratory specimens from 851 children were tested, and 9 HCoV-HKU1–positive children (1%) were identified, 2 of whom had 2 positive specimens. Children who had HCoV-HKU1 infection had evidence of either upper or lower respiratory tract infection or both. Two patients had disease beyond the respiratory tract. HCoV-HKU1 was identified from December 2001 to February 2002. Sequence analyses suggest that a single strain was circulating. HCoV-HKU1 is therefore likely circulating in the United States and is associated with upper and lower respiratory tract disease.

  • Novel Swine Influenza Virus Subtype H3N1, United States PDF Version [PDF - 294 KB - 8 pages]
    P. Lekcharoensuk et al.
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    A new subtype H3N1 may have arisen from reassortment of a H3N2 turkey isolate, a human H1N1 isolate, and currently circulating swine viruses.

        View Abstract

    Influenza A virus infects various animal species and transmits among different hosts, especially between humans and swine. Swine may serve as a mixing vessel to create new reassortants that could infect humans. Thus, monitoring and characterizing influenza viruses in swine are important in preventing interspecies transmission. We report the emergence and characterization of a novel H3N1 subtype of swine influenza virus (SIV) in the United States. Phylogenetic analysis showed that the H3N1 SIVs may have acquired the hemagglutinin gene from an H3N2 turkey isolate, the neuraminidase gene from a human H1N1 isolate, and the remaining genes from currently circulating SIVs. The H3N1 SIVs were antigenically related to the turkey virus. Lung lesions and nasal shedding occurred in swine infected with the H3N1 SIVs, suggesting the potential to transmit among swine and to humans. Further surveillance will help determine whether this novel subtype will continue to circulate in swine populations.

  • Aedes aegypti Larval Indices and Risk for Dengue Epidemics PDF Version [PDF - 354 KB - 7 pages]
    L. Sanchez et al.
    View Summary

    Entomologic indices can identify areas at high risk for disease transmission.

        View Abstract

    We assessed in a case-control study the test-validity of Aedes larval indices for the 2000 Havana outbreak. "Cases" were blocks where a dengue fever patient lived during the outbreak. "Controls" were randomly sampled blocks. Before, during, and after the epidemic, we calculated Breteau index (BI) and house index at the area, neighborhood, and block level. We constructed receiver operating characteristic (ROC) curves to determine their performance as predictors of dengue transmission. We observed a pronounced effect of the level of measurement. The BImax (maximum block BI in a radius of 100 m) at 2-month intervals had an area under the ROC curve of 71%. At a cutoff of 4.0, it significantly (odds ratio 6.00, p<0.05) predicted transmission with 78% sensitivity and 63% specificity. Analysis of BI at the local level, with human-defined boundaries, could be introduced in control programs to identify neighborhoods at high risk for dengue transmission.

Historical Review

  • Spatial Analysis of Sleeping Sickness, Southeastern Uganda, 1970–2003 PDF Version [PDF - 432 KB - 8 pages]
    L. Berrang-Ford et al.
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    Disease will likely spread into central Uganda.

        View Abstract

    Sleeping sickness reemerged in southeastern Uganda in the 1970s and remains a public health problem. It has continued to spread north into new districts, and gaps remain in the understanding of the causes of its spread and distribution. We report the distribution and magnitude of sleeping sickness in southeastern Uganda from 1970 to 2003. Data were collected from records of the Ugandan Ministry of Health, individual sleeping sickness treatment centers, and interviews with public health officials. Data were used to develop incidence maps over time, conduct space-time cluster detection analyses, and develop a velocity vector map to visualize spread of sleeping sickness over time in southeastern Uganda. Results show rapid propagation of sleeping sickness from its epicenter in southern Iganga District and its spread north into new districts and foci.


  • Shiga-toxigenic Escherichia coli O157 in Agricultural Fair Livestock, United States PDF Version [PDF - 296 KB - 7 pages]
    J. E. Keen et al.
    View Summary

    Organisms were common in ruminants, swine, and pest flies.

        View Abstract

    Agricultural fairs exhibiting livestock are increasingly implicated in human Shiga-toxigenic Escherichia coli O157:H7 (STEC O157:H7) outbreaks. To estimate livestock STEC O157:H7 prevalence at US fairs, we collected 2,919 fecal specimens at 29 county fairs in 2 states and at 3 state fairs in 2002. Fly pools were also collected. STEC O157:H7 was isolated from livestock at 31 (96.9%) of 32 fairs, including 11.4% of 1,407 cattle, 1.2% of 1,102 swine, 3.6% of 364 sheep and goats, and 5.2% of 154 fly pools. Cattle, swine, and flies at some fairs shared indistinguishable STEC O157:H7 isolate subtypes. In 2003, a total of 689 ambient environmental samples were collected at 20 fairgrounds 10–11 months after 2002 livestock sampling while fairgrounds were livestock-free. Four beef barn environmental samples at 3 fairgrounds yielded STEC O157:H7. These data suggest that STEC O157 is common and transmissible among livestock displayed at agricultural fairs and persists in the environment after the fair.

  • The Trojan Chicken Study, Minnesota PDF Version [PDF - 271 KB - 5 pages]
    S. R. Olson and G. C. Gray
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    County fairs are a possible venue for animal-to-human pathogen transmission.

        View Abstract

    We conducted a study in the summer of 2004 at county fairs in the Midwest to investigate the role poultry exhibits have in spreading avian pathogens to humans. A nearly invisible powder (pathogen surrogate) that fluoresces under UV light was surreptitiously sprinkled each day on 1 show bird at each of 2 fairs. A UV light box was used to daily examine the hands of 94 poultry-exhibit participants (blinded regarding UV box results) for up to 4 days during the poultry shows. Enrollment and end-of-study questionnaires collected data on pathogen risk factors. Eight (8.5%) of 94 participants had evidence of fluorescent powder contamination (95% confidence interval 2.76%–14.26%). This contamination and infrequent handwashing practices suggest that county fairs are a possible venue for animal-to-human pathogen transmission.

  • Enterobacter cloacae Outbreak and Emergence of Quinolone Resistance Gene in Dutch Hospital PDF Version [PDF - 187 KB - 6 pages]
    A. Paauw et al.
    View Summary

    Plasmid-mediated qnrA1 is an emerging resistance trait.

        View Abstract

    An outbreak of Enterobacter cloacae infections with variable susceptibility to fluoroquinolones occurred in the University Medical Center Utrecht in the Netherlands in 2002. Our investigation showed that a qnrA1 gene was present in 78 (94%) of 83 outbreak isolates and that a qnrA1-encoding plasmid transferred to other strains of the same species and other species. The earliest isolate carrying this same plasmid was isolated in 1999. qnrA1 was located in a complex integron consisting of the intI1, aadB, qacEΔ1, sul1, orf513, qnrA1, ampR, qacEΔ1, and sul1 genes that were not described previously. On the same plasmid, 2 other class 1 integrons were present. One was a new integron associated with the blaCTX-M-9 extended-spectrum β-lactamase.

  • Mycobacterium intermedium Granulomatous Dermatitis from Hot Tub Exposure PDF Version [PDF - 199 KB - 3 pages]
    R. S. Edson et al.
        View Abstract

    Nontuberculous mycobacteria, which are widespread in the environment, frequently cause opportunistic infections in immunocompromised patients. We report the first case of a patient with chronic granulomatous dermatitis caused by a rarely described organism, Mycobacterium intermedium. The infection was associated with exposure in a home hot tub.

  • Molecular Characterization of Rotavirus Gastroenteritis Strains, Iraqi Kurdistan PDF Version [PDF - 127 KB - 3 pages]
    H. M. Ahmed et al.
        View Abstract

    Of 260 children with acute diarrhea in Erbil, Iraqi Kurdistan, 96 (37%) were infected with rotavirus. Reverse transcription–polymerase chain reaction identified G1, G4, G2, G9, P[8], P[6], and P[4] as the most common genotypes. Eight G/P combinations were found, but P[8]G1 and P[4]G2 accounted for >50% of the strains.

  • Clostridium difficile Ribotype 027, Toxinotype III, the Netherlands PDF Version [PDF - 143 KB - 4 pages]
    E. J. Kuijper et al.
        View Abstract

    Outbreaks due to Clostridium difficile polymerase chain reaction (PCR) ribotype 027, toxinotype III, were detected in 7 hospitals in the Netherlands from April 2005 to February 2006. One hospital experienced at the same time a second outbreak due to a toxin A–negative C. difficile PCR ribotype 017 toxinotype VIII strain. The outbreaks are difficult to control.

  • Costs of Surgical Site Infections That Appear after Hospital Discharge PDF Version [PDF - 145 KB - 4 pages]
    N. Graves et al.
        View Abstract

    Data were collected from surgical patients in the hospital and on 4 occasions postdischarge. The incidence of postdischarge surgical site infection was 8.46%. Strong evidence showed that these infections caused minor additional costs, which contradicts existing literature. We discuss why previous studies might have overstated costs.

  • Historical Lassa Fever Reports and 30-year Clinical Update PDF Version [PDF - 103 KB - 3 pages]
    A. M. Macher and M. S. Wolfe
        View Abstract

    Five cases of Lassa fever have been imported from West Africa to the United States since 1969. We report symptoms of the patient with the second imported case and the symptoms and long-term follow-up on the patient with the third case. Vertigo in this patient has persisted for 30 years.

  • Hantavirus in African Wood Mouse, Guinea PDF Version [PDF - 78 KB - 3 pages]
    B. Klempa et al.
        View Abstract

    Hantaviruses are rodentborne, emerging viruses that cause life-threatening human diseases in Eurasia and the Americas. We detected hantavirus genome sequences in an African wood mouse (Hylomyscus simus) captured in Sangassou, Guinea. Sequence and phylogenetic analyses of the genetic material demonstrate a novel hantavirus species, which we propose to name "Sangassou virus."

  • Rickettsia felis in Fleas, Western Australia PDF Version [PDF - 118 KB - 3 pages]
    D. Schloderer et al.
        View Abstract

    This study is the first confirmation of Rickettsia felis in Australia. The organism was identified from 4 species of fleas obtained from dogs and cats in Western Australia, by using polymerase chain reaction amplification and DNA sequencing of the citrate synthase and outer membrane protein A genes.

  • Heterogeneity among Mycobacterium ulcerans Isolates from Africa PDF Version [PDF - 241 KB - 4 pages]
    P. Stragier et al.
        View Abstract

    Mycobacterium ulcerans causes Buruli ulcer, an ulcerative skin disease in tropical and subtropical areas. Despite restricted genetic diversity, mycobacterial interspersed repetitive unit–variable-number tandem repeat analysis on M. ulcerans revealed 3 genotypes from different African countries. It is the first time this typing method succeeded directly on patient samples.

  • Human Bocavirus Infection, Canada PDF Version [PDF - 133 KB - 3 pages]
    N. Bastien et al.
        View Abstract

    Human Bocavirus was detected in 18 (1.5%) of 1,209 respiratory specimens collected in 2003 and 2004 in Canada. The main symptoms of affected patients were cough (78%), fever (67%), and sore throat (44%). Nine patients were hospitalized; of these, 8 (89%) were <5 years of age.

  • Lymphocytic Choriomeningitis in Michigan PDF Version [PDF - 70 KB - 3 pages]
    E. S. Foster et al.
        View Abstract

    We summarize the first reported case of acquired lymphocytic choriomeningitis virus (LCMV) infection in Michigan to be investigated by public health authorities and provide evidence of the focal nature of LCMV infection in domestic rodents. Results of serologic and virologic testing in rodents contrasted, and negative serologic test results should be confirmed by tissue testing.

  • Second Human Case of Cache Valley Virus Disease PDF Version [PDF - 117 KB - 3 pages]
    G. L. Campbell et al.
        View Abstract

    We document the second known case of Cache Valley virus disease in a human. Cache Valley virus disease is rarely diagnosed in North America, in part because laboratories rarely test for it. Its true incidence, effect on public health, and full clinical spectrum remain to be determined.


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