Abstracts Vol. 1 [International Conference on AIDS (11th: 1996: Vancouver, Canada)]

Track C: Epidemiology & Public Health
than the multidrug resistance outbreaks which have been reported in several groups of
AIDS patients.
Ernest L. Cunningham, M.D., Ceres 773, Dos Pinos, Rio Piedras, PR 00923
Tel. [phone] Fax [phone]
Mo.C.1647
NOSOCOMIAL OUTBREAK OF MULTIDRUG-RESISTANT TUBERCULOSIS (MDR-TB),
CHICAGO
KenyonThomas A, Luskin-Hawk R**, Ridzon R*, Schultz C**, Paul WP***, Lightdale J*,
Valway SE*, Onorato IM*. "Division of TB Elimination, Centers for Disease Control and
Prevention, Atlanta, GA, USA:**St. Joseph Hospital, Chicago, IL, USA;**"Chicago
Department of Health, Chicago, IL, USA
Background: From 8/94-2/95, 6 MDR-TB cases (resistant to isoniazid and rifampin) were
reported among patients with AIDS at Hospital A.
Methods: To identify extent of transmission and contributing factors, medical and laboratory
records of cases and exposed patients were reviewed.
Results: A total of 6 patients and I health care worker (HCW), all HIV-positive, developed
MDR-TB. Case I was admitted 8/94 to Ward A with suspected TB; no negative pressure
room existed and she refused to remain in her room. After 4 days exposure to Case I on
Ward A, Case 2 was admitted I 1/94 to Ward B with a febrile illness and a normal chest
radiograph. On day 3 a routine sputum smear was highly positive for acid-fast bacilli (AFB);
no negative pressure room existed and he was placed in a private room. Cases 3-6 were 2 -4 rooms away from Case 2 on Ward B for I-12 days. Case 7 (HCW) had brief close contact with Case 2 prior to isolation orders and worked on the ward <4 shifts when a case
was not in AFB isolation. Incubation periods were < 100 days for 6 cases with CD4 counts
< 100 cells/mm3 around exposure and 392 days for the HCW with CD4 count of 336
cells/mm3. No epidemiologic link apart from hospital exposure was identified. DNA fingerprints of isolates from all cases matched. HEPA filter masks were available to HCWs. Eleven
(14.9%) of 74 exposed HCWs from the outbreak floor had tuberculin skin test conversion.
Of these, 4 provided care to a case when TB was not suspected, ie, when HEPA filter masks
would not have been worn, and 7 worked on a ward when a case was not in AFB isolation.
All but I HCW passed fit-testing and 4 had no evidence of close contact to a case.
Conclusion: A patient with AIDS/MDR-TB was highly infectious in spite of having a normal
chest radiograph. For at least I case, less than I day exposure on the same hospital floor
was sufficient time to become infected by the source case. A personal respiratory protection program failed to protect HCWs when inadequate administrative and environmental
control measures contributed to airborne spread of M. tuberculosis to patients and HCWs
throughout a hospital floor.
TA. Kenyon, Division of TB Elimination, CDC, 1 600 Clifton Rd. MS El 0 Atlanta, GA 30333
Tel: [phone] Fax: [phone] email [email protected]
Mo.C. 1648
TUBERCULOSIS DISEASE AND EXPOSURE IN CHILDREN BORN TO HIV INFECTED
MOTHERS IN TEXAS
Schulte IM*, Kreitner S**, Hamaker D*, Subia L **, Caldwell MB*. *Centers for Disease
Control and Prevention (CDC), Atlanta, GA, USA:Texas Department of Health (TDH),
Austin,TX.
Objective: To assess tuberculosis (TB) disease and exposure in families of children born to
HIV+ mothers in Texas, 1989-95.
Methods: Children born to HIV + mothers and under medical care in Houston, Dallas and
San Antonio were followed by medical record review at 6-month intervals. Parent-child
pairs and some siblings (those born to the same mother and evaluated for HIV transmission) were identified through birth certificate review and cross referenced with TDH TB
registries. Children's current living arrangements were verified through medical records.
Results: The Texas Pediatric Spectrum of Disease Project (PSD) tracks I.183 children who
were either infected with HIV or perinatally exposed; 888 (75%) were born in Texas.
Among the Texas-born PSD children, we identified 30 families with 34 family members who
either had TB disease (14/34, 4 I1.2%) or had begun preventive therapy for presumptive TB
infection.The 14 family members who were TB cases included 8 mothers, 4 children and 2
fathers; 3 children were HIV+, one had HIV-indeterminate status.The children (n = 35)
from the 30 families were aged 6 years or younger when exposed to or infected with
tuberculosis. Of the 35 children, 33 (94%) were perinatally exposed to HIV; one was a
hemophiliac and one had an unknown mode of transmission. In 2 1/30 (70%) families, the
biologic parents had custody of their children. In 9 families with TB cases, the TB treatment
status of another 6 children (3 HIV+) and 3 mothers was not recorded in medical records.
In 7 families where a family member was on preventive therapy the TB status of three children (I HIV+) was not documented in medical records.
Conclusion: This is the first review of HIV and TB infection among las f;rilies, and
emphasizes that medical management of HIV+ mothers and childen must incude monitoring of TB exposure, infection, disease and compliance with drug ther:py.
Joan M. Schulte, MS El0, CDC. I 600 Clifton Rd.NE,Atlanta, Ga. 30333 Tel: [phone];
Fax [phone]
MoC. 1649
EFFECT OF HIV ON TB TRANSMISSION IN A NORTH EASTERN AMERICAN URBAN
COMMUNITY
Durante A.J.*, Merino F.L.*, Selwyn PA.*, Marino J.**, Hadler J**, Balacos K Yale
University AIDS Program, New Haven, CT* Department of Publiii Health Hartford, CT
Objective: To determine the effect of HIV on TB transmission in a smsall iii t,.n American
area <1I00 Km. from New Yorkc City (NYC) with high rates of AIDS, puaie l',,ird drug use.
Methods: Review of-TB and HIV registry data for the grea r New an '<res (NHA),
(231,000 pop). Study of PPD prevalence at drug, HIV, and primai car clii, the city welfare office and prisons. Profile of all active cases from '9 I -'95 (n: I0t2) in NI A, including
data reported to CDC, chart review, strain typing, environmentali arid cthnographic studies.

Results: Within New Haven City (125,000 pop) there are an estimated 2300 drug users
and in 5/9 neighborhoods > 10% of households earn <$5,000 per year PPD positivity was
9% in the welfare office and clinics in June-October'95 (n=720) and 12% in the city jail in
August '93.To the end of'95,the cumulative AIDS incidence was 665 per 100,000. HIV+

Mo.C.1647 - Mo.C.1651
people are offered a comprehensive care network Directly observed therapy (DOT) has
been available to all TB patients since '87 and directly observed preventive therapy (DOPT)
of PPD/HIV+s began in '9 I. An upward trend in annual TB cases (per 100,000) in the'80s
peaked at 19 in '87. Since then, the annual rate has been <1 I Three quarters of HIV/PPD+s
have completed or are still on DOPT From '9 I-95, no known TB patient has been lost
before therapy completion.The HIV rate in theseTB cases with a known status was 31%.
Hospital records of 56 cases reviewed to date show otherTB risk factors, including heavy
alcohol use (50%), drug use (29%), foreign birth (23%), and prior incarceration (2 1%).
Conclusion:. HIV has been shown to increase the risk of TB in areas with substantial drug
use and poverty such as NYC. However, high rates of poverty drug use, HIV and PPD positivity in our area have not been associated with high TB rates.The implementation of DOT
in '87, along with DOPT for PPD/HIV +s and the accessibility of primary care services for
HIV + people may have been important in limiting the TB case rate. HIV is only one of several risk factors forTB which are common in NHA.TB strain mapping and local environmental and ethnographic studies in this area will provide valuable data on the effect of HIV
infection on the dynamics ofTB transmission in a high-risk urban community.
F.L. Merino,Yale AIDS Program, 135 College Street, Suite 323, New Haven, CT 06510
Telephone: [phone] Fax: [phone] I e-mail: [email protected]
Mo.C.1650
MEETING THE HIV/TB CHALLENGE:TUBERCULOSIS-RELATED SERVICES IN HIV
HEALTH AND SUPPORT SERVICE DELIVERY SITES
McClain, Matthew*, Marla J. Gold MD*, Gloria Weissman**, Katherine Marconi PHD**,
Rebecca Hines**, Margaret DiClemente**. *=Gold & McClain Public Health **=U.S. Health
Resources and Services Administration
Issue: Although standards of HIV care include TB screening, prevention, and treatment services, little is known about factors that affect successful implementation ofTB-related standards in HIV settings.
Project Progressive immunosuppression from HIV disease contributes to the persistent
morbidity of active tuberculosis (TB) in the U.S. Eligible metropolitan areas (EMAs) qualify
for federal funds through Title I of the Ryan White CARE Act due to high rates of AIDS
incidence or prevalence.This session presents the final results of a study commissioned by
the U.S. Health Resources and Services Administration to determine the policies and procedures that best facilitate the delivery ofTB-related services in HIV care settings. Data was
gathered from 34 EMAs in theTitle I program. Site visits were conducted in 7 EMAs in 6
states with high incidence ofAIDS,TB, and co-morbid HIV/TB: Bergen-Passaic Counties NJ,
Chicago IL, DallasTX, Miami FL, Los Angeles CA, NewYork NY and San Francisco CA.
Results: Discussion will focus on the principal factors uncovered by the study that affected
delivery ofTB-related services in HIV care systems. Service delivery recommendations from
the study will be reviewed, including how collaborative relationships between public health
officials in HIV and TB prevention and control programs impact on delivery ofTB-related
services and ways in which HIV-related health and support service providers can best
mplementTB-related services. Policy recommendations at the Federal, State, local, and
community levels will conclude the presentation.
Lessons Learned: Through the implementation of appropriate policies and procedures, public health systems and private sectors health and support services providers can integrate
the delivery of screening, prevention, and treatment of tuberculosis in HIV care settings,
enhance the quality of care delivered to persons with HIV/TB, and potentially reduce the
spread of pulmonaryTB and MDR-TB among the population of HIV-positive persons and
the general public.
Matthew McClain 413 Schuyler Road, Silver Spring, MD 20910
Mo.C.1651
FACTORS RELATED TO VARIATIONS IN TB TREATMENT COMPLIANCE AMONG
IDUS IMPACTED BY HIV - PRELIMINARY FINDINGS
Jimenez. A MA, Johnson,W PhD, Hershow, R, MD,Wiebel,W, PhD. School of Public Health,
University of Illinois at Chicago, Chicago, IL
Objective: To identify and examine factors that influence TB treatment regimen compliance
among injecting drug users (IDUs) with, or at risk for, HIV.
Methods: In response to a tuberculosis (TB) outbreak originating among HIV + IDUs on
the northwest side of Chicago, the University of Illinois at Chicago Community Outreach
Intervention Project joined the Chicago Department of Health in a pilot project that
applied the Indigenous Leader Outreach Model (ILOM) intervention - previously used for
HIV prevention - to targetTB-infected individuals.The ILOM enlists ex-addict outreach
workers to provide directly observed therapy (DOT), preventive prophylaxis, and case
management to IDUs, a group with low levels ofTB treatment compliance and high levels
of distrust of public health authorities. Qualitative data, in the form of observational fieldnotes and taped interviews with key informants, were collected to assess the impact of the
intervention and examine factors related toTB treatment compliance among IDUs.
Results: Preliminary findings regarding factors that influence TB treatment compliance
among IDUn, include: I) IDU residential patterns vary greatly, from stable, relatively permanent housing to living arrangements which are temporary and erratic (shelters, abandoned
buildings, family members' homes, etc.), making DOT difficult. Further, certain living spaces
also serve as a locus of drug procurement and administration (e.g.,"shooting galleries" or
"rock" houses) resulting in a pattern of congregation that promotes transmission of TB and
inhibits DOT 3) Stigma associated with havingTB can affect IDUs' ability to procure drugs
or a place to sleep, and may be viewed as more harmful than the stigma associated with
HIV. As a result, IDUs typically avoid public health measures that arouse suspicion or label
an addict as havingTB. 4) Individuals with a high level of drug addiction generally find that
these needs require more attention than other "health needs," which compromises dailyTB
treatment regimens.
Conclusion: The design of public health interventions to control TB among IDUn should
take into account drug-using lifestyle factors which may greatly influence TB treatment compliance.

Antonio D. Jimenez, UIC-School of Public Health, 2 I 2 1 West Taylor Street, Chicago, Illinois
Telephone: [phone] Fax: [phone]

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