Valerie A. Robison

Extensively Drug-Resistant Tuberculosis in the United States, 1993-2007

CONTEXT Worldwide emergence of extensively drug-resistant tuberculosis (XDR-TB) has raised global public health concern, given the limited therapy options and high mortality. OBJECTIVES To describe the epidemiology of XDR-TB in the United States and to identify unique characteristics of XDR-TB cases compared with multidrug-resistant TB (MDR-TB) and drug-susceptible TB cases. DESIGN, SETTING, AND PATIENTS Descriptive analysis of US TB cases reported from 1993 to 2007. Extensively drug-resistant TB was defined as resistance to isoniazid, a rifamycin, a fluoroquinolone, and at least 1 of amikacin, kanamycin, or capreomycin based on drug susceptibility test results from initial and follow-up specimens. MAIN OUTCOME MEASURES Extensively drug-resistant TB case counts and trends, risk factors for XDR-TB, and overall survival. RESULTS A total of 83 cases of XDR-TB were reported in the United States from 1993 to 2007. The number of XDR-TB cases declined from 18 (0.07% of 25 107 TB cases) in 1993 to 2 (0.02% of 13 293 TB cases) in 2007, reported to date. Among those with known human immunodeficiency virus (HIV) test results, 31 (53%) were HIV-positive. Compared with MDR-TB cases, XDR-TB cases were more likely to have disseminated TB disease (prevalence ratio [PR], 2.06; 95% confidence interval [CI], 1.19-3.58), less likely to convert to a negative sputum culture (PR, 0.55; 95% CI, 0.33-0.94), and had a prolonged infectious period (median time to culture conversion, 183 days vs 93 days for MDR-TB; P < .001). Twenty-six XDR-TB cases (35%) died during treatment, of whom 21 (81%) were known to be HIV-infected. Mortality was higher among XDR-TB cases than among MDR-TB cases (PR, 1.82; 95% CI, 1.10-3.02) and drug-susceptible TB cases (PR, 6.10; 95% CI, 3.65-10.20). CONCLUSION Although the number of US XDR-TB cases has declined since 1993, coinciding with improved TB and HIV/AIDS control, cases continue to be reported each year.

Broad Human Immunodeficiency Virus (HIV)–Specific T Cell Responses to Conserved HIV Proteins in HIV-Seronegative Women Highly Exposed to a Single HIV-Infected Partner

Eighteen highly exposed but persistently seronegative (HEPS) women (HW) and their human immunodeficiency virus (HIV) type 1-seropositive male partners were studied for HIV-specific T cells and other host factors. Circulating HIV-specific T cells were measured by interferon-gamma enzyme-linked immunospot assays, using recombinant vaccinia virus vectors expressing HIV proteins. Nine (50%) of the HW and all HIV-seropositive persons had HIV-specific T cell responses. Only 2 (22%) of the HEPS responders recognized Env, compared with 94% of HIV-seropositive persons. A high percentage (75%) of the HW with HIV-specific T cell responses reported recent HIV exposure. Remarkably, however, long-lived HIV-specific T cells were detected in 2 HW who had an extended period (>3.9 years) of no HIV exposure. These findings have important implications for HIV vaccine design.

Epidemiology of urban tuberculosis in the United States, 2000-2007

OBJECTIVES We investigated tuberculosis (TB) incidence rates and characteristics of patients with TB in large US cities. METHODS Using the Centers for Disease Control and Preventions National Tuberculosis Surveillance System data, we categorized 48 cities annually from 2000 to 2007 as reporting decreasing or nondecreasing rates with Joinpoint analysis. We compared demographic, clinical, and treatment characteristics of patients with TB using bivariate and multivariate analyses. RESULTS We found that 42 448 patients with TB in 48 cities accounted for 36% of all US patients with TB; these cities comprised 15% of the US population. The average TB incidence rate in the 48 cities (12.1 per 100,000) was higher than that in the US excluding the cities (3.8 per 100,000) but decreased at a faster rate. Nineteen cities had decreasing rates; 29 cities had nondecreasing rates. Patient characteristics did not conclusively distinguish decreasing and nondecreasing rate cities. CONCLUSIONS A significant TB burden occurs in large US cities. More than half (60%) of the selected cities did not show decreasing TB incidence rates. Studies of city-level variations in migration, socioeconomic status, and resources are needed to improve urban TB control.

Seroprevalence of Human Herpesvirus 8 Infection in Northern Thailand

BACKGROUND Human herpesvirus 8 (HHV-8) is associated with Kaposi sarcoma (KS) in patients with acquired immunodeficiency syndrome (AIDS) and KS, classical KS, or endemic KS. Because human immunodeficiency virus (HIV) infections and HIV/AIDS are common in Thailand but KS is very rare (only 0.2% of reported patients with AIDS in Thailand had KS), we determined the HHV-8 seroprevalence among populations who were HIV positive or at risk of HIV infection. METHODS A total of 992 persons from 2 populations underwent testing for lytic antibodies to HHV-8 using an immunofluorescence assay involving a BCBL-1 cell line at serum dilutions of 1 : 50 and 1 : 100. Serum specimens with positive results were titered to end points. Subjects included approximately 400 married couples in which the husband was HIV positive and the wife was HIV positive (200 couples) or HIV negative (200 couples). In addition, 200 HIV-negative men from a sexually transmitted diseases (STD) clinic were studied. RESULTS The antibody prevalence was 24.2% in the total population. The prevalence was higher among HIV-negative men (13.0%) but was similar among HIV-positive women (27.9%) and HIV-negative women (23.8%). The HHV-8 seroprevalence among wives whose husbands were HIV-1 positive did not differ according to their husbands HHV-8 status. There was no association between HHV-8 seroprevalence and reported sexual behavior or STD history. CONCLUSION Despite the rarity of KS among patients with AIDS in Thailand, HHV-8 infections are common and do not appear to be frequently transmitted sexually in these populations.

Eliminating tuberculosis one neighborhood at a time

OBJECTIVES We evaluated a strategy for preventing tuberculosis (TB) in communities most affected by it. METHODS In 1996, we mapped reported TB cases (1985-1995) and positive tuberculin skin test (TST) reactors (1993-1995) in Smith County, Texas. We delineated the 2 largest, densest clusters, identifying 2 highest-incidence neighborhoods (180 square blocks, 3153 residents). After extensive community preparation, trained health care workers went door-to-door offering TST to all residents unless contraindicated. TST-positive individuals were escorted to a mobile clinic for radiography, clinical evaluation, and isoniazid preventive treatment (IPT) as indicated. To assess long-term impact, we mapped all TB cases in Smith County during the equivalent time period after the project. RESULTS Of 2258 eligible individuals, 1291 (57.1%) were tested, 229 (17.7%) were TST positive, and 147 were treated. From 1996 to 2006, there were no TB cases in either project neighborhood, in contrast with the preintervention decade and the continued occurrence of TB in the rest of Smith County. CONCLUSIONS Targeting high-incidence neighborhoods for active, community-based screening and IPT may hasten TB elimination in the United States.

Tuberculosis Among Persons Born in the Philippines and Living in the United States, 2000–2007

OBJECTIVES We examined demographic, clinical, and treatment outcome characteristics of Filipinos with tuberculosis (TB) in the United States. METHODS We calculated TB case rates from US Census Bureau population estimates and National Tuberculosis Surveillance System data for US-born non-Hispanic Whites and for US residents born in the Philippines, India, China, Cambodia, Vietnam, Pakistan, and Korea--countries that are major contributors to the TB burden in the United States. We compared Filipinos with the other groups through univariate and multivariate analyses. RESULTS Of 45,504 TB patients, 15.5% were Filipinos; 43.0% were other Asian/Pacific Islander groups; and 41.6% were Whites. Per 100 000 persons in 2007, the TB rate was 73.5 among Cambodians, 54.0 among Vietnamese, 52.1 among Filipinos, and 0.9 among Whites. Filipinos were more likely than other groups to be employed as health care workers and to have used private health care providers but less likely to be HIV positive and to be offered HIV testing. CONCLUSIONS The relatively high TB rate among Filipinos indicates that TB control strategies should target this population. Providers should be encouraged to offer HIV testing to all TB patients.

Clinical oral examinations may not be predictive of dysplasia or oral squamous cell carcinoma.

Article title and bibliographic information The limitations of the clinical oral examination in detecting dysplastic oral lesions and oral squamous cell carcinoma. Epstein JB, Guneri P, Boyacioglu H, Abt E. JADA 2012;143(12);1332-42 . Reviewers Jennifer L. Cleveland, DDS, MPH, Valerie A. Robison, DDS, MPH, PhD Purpose/Question To assess the effectiveness of the clinical oral exam in predicting potentially malignant epithelial lesions or oral squamous cell carcinomas Source of funding None of the authors reported any external sources of funding to support this study Type of study/Design Systematic review with meta-analysis of data Level of evidence Level 2: Limited–quality patient-oriented evidence Strength of recommendation grade Grade B: Inconsistent or limited-quality patient-oriented evidence

Disparities in Receipt of Preventive Dental Services in Children From Low-Income Families

INTRODUCTION Healthy People 2020 includes a goal of increasing use of preventive dental care among children from low-income families. The services used to define preventive care are evidence-based services (i.e., dental sealants and professionally applied topical fluoride) and professional dental cleaning, which lacks evidence of effectiveness in preventing caries. This study examined how increasing preventive dental care use and reducing disparities by race/ethnicity among children from low-income families varied by the services included in case definitions of preventive dental care use. METHODS Three case definitions of past-year preventive dental care use were considered: (1) the Healthy People 2020 definition; (2) receipt of an evidence-based caries prevention service; and (3) dental cleaning only. Using pooled data from the 2001-2002 and 2013-2014 Medical Expenditure Panel Survey for each definition, this study conducted in 2017 used multivariate logistic regression to estimate changes in preventive dental care use among children from low-income families by race/ethnicity. RESULTS Use increased for all racial/ethnic groups for all definitions. Use of preventive dental care (Healthy People 2020 definition), however, was at least two times higher than evidence-based preventive dental use for all racial/ethnic groups in both survey periods. After controlling for insurance status and parental education, the disparity between non-Hispanic black and non-Hispanic white children in use of preventive dental care that was present in 2001-2002 was not detected in 2013-2014 whereas the disparity for evidence-based preventive dental care use persisted. CONCLUSIONS Case definitions of preventive dental care that include non-evidence-based services may overstate receipt of effective preventive dental care and reductions in certain racial/ethnic disparities.

Multilevel model to estimate county-level untreated dental caries among US children aged 6–9 years using the National Health and Nutrition Examination Survey

Because conducting population-based oral health screening is resource intensive, oral health data at small-area levels (e.g., county-level) are not commonly available. We applied the multilevel logistic regression and poststratification method to estimate county-level prevalence of untreated dental caries among children aged 6-9years in the United States using data from the National Health and Nutrition Examination Survey (NHANES) 2005-2010 linked with various area-level data at census tract, county and state levels. We validated model-based national estimates against direct estimates from NHANES. We also compared model-based estimates with direct estimates from select State Oral Health Surveys (SOHS) at state and county levels. The model with individual-level covariates only and the model with individual-, census tract- and county-level covariates explained 7.2% and 96.3% respectively of overall county-level variation in untreated caries. Model-based county-level prevalence estimates ranged from 4.9% to 65.2% with median of 22.1%. The model-based national estimate (19.9%) matched the NHANES direct estimate (19.8%). We found significantly positive correlations between model-based estimates for 8-year-olds and direct estimates from the third-grade State Oral Health Surveys (SOHS) at state level for 34 states (Pearson coefficient: 0.54, P=0.001) and SOHS estimates at county level for 53 New York counties (Pearson coefficient: 0.38, P=0.006). This methodology could be a useful tool to characterize county-level disparities in untreated dental caries among children aged 6-9years and complement oral health surveillance to inform public health programs especially when local-level data are not available although the lack of external validation due to data unavailability should be acknowledged.