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Biomedical subjects

P I Fujiwara

Publications and source records attributed to P I Fujiwara.

At least 19 recordsLinked to original sources
PubMed2006

Ensuring accountability: the contribution of the cohort review method to tuberculosis control in New York City.

SETTING: In 1993, the New York City (NYC) Bureau of Tuberculosis Control developed the cohort review process as a quality assurance method to track and improve patient outcomes. METHODS: The Bureau Director reviews every tuberculosis (TB) case quarterly in a multi-disciplinary staff meeting. In 2004 we also began collecting details on issues identified at cohort review to quantify how this process directly impacts TB control efforts. RESULTS: From 1992 to 2004, NYC TB cases decreased by 72.7% and treatment success rates significantly increased by 26.7%. Implementing the cohort review was key to improving case management, thus leading to these results. For the 1039 patients in 2004, 596 issues were identified among 424 patients; 55.0% were incorrect, unclear or unknown patient information, 13.8% were treatment issues, 12.4% were case management issues and 10.6% were incomplete contact investigations. Most (76.5%) issues were addressed within 30 days of the cohort reviews. CONCLUSION: A systematic review of every TB case improves the quality of patient information, enhances patient treatment and ensures accountability at all levels of the TB control program.

Case Management↗
PubMed2005

Should tuberculosis treatment and control be addressed differently in HIV-infected and -uninfected individuals?

Infection with HIV drives the tuberculosis epidemic, especially in sub-Saharan Africa, where up to 75% of individuals with tuberculosis are co-infected with HIV. This article reviews the epidemiological link between the conditions, how tuberculosis diagnosis and treatment differ between HIV-infected versus -uninfected individuals and the span of additional measures required to prevent and control HIV-related tuberculosis. Tuberculosis chemotherapy using standard short-course regimens is highly effective in both groups, and treatment follows the same principles. It differs in certain aspects, such as when antiretroviral treatment should be started in HIV-infected individuals with tuberculosis and consideration of drug-drug interactions between the rifamycins and certain antiretroviral drugs. Control of HIV-related tuberculosis requires, fundamentally, control of HIV transmission. Meanwhile, it is necessary to make concentrated efforts to intensify high-quality tuberculosis services employing the directly observed treatment, short-course (DOTS) strategy, carry out extensive research towards an evidence-based model for the expanded scope of collaborative tuberculosis and HIV/AIDS interventions, and ensure efficient implementation of the findings and recommended policies. The challenge is gigantic, and both robust within-country and international leadership and competent management capabilities will be required, in addition to substantial human and financial resources.

HIV Infections↗
PubMed2005

Management of adults living with HIV/AIDS in low-income, high-burden settings, with special reference to persons with tuberculosis.

Because of the increasing availability of antiretroviral (ARV) agents for HIV in low-income countries, many clinicians now need training on their use. This is especially true for clinicians caring for individuals with tuberculosis (TB), given its close relationship with HIV/AIDS. This article summarizes the key decisions facing clinicians who manage HIV-infected persons, with particular reference to issues regarding those dually infected with TB. Health care provider-initiated diagnostic testing using rapid HIV tests should be offered to all individuals with symptoms and signs suggesting HIV infection, including all persons with TB. Issues to be included in pre- and post-test counseling sessions are discussed. HIV-infected patients should be evaluated to determine clinical staging of HIV; certain laboratory examinations should ideally be performed to assess the degree of immunosuppression and to aid decisions about when best to start ARV therapy and preventive therapies. The recommended ARV regimens and guidance on proposed patient follow-up are presented. Good adherence to ARVs is required and factors that induce and reinforce compliance are suggested. The treatment of TB is a high priority, and follows the same principles whether the patient is HIV-infected or not. Suggestions are made about ARV use in patients with TB. A standardized and complementary information system should be developed to monitor management of HIV-TB patients and performance of joint TB and HIV care efforts. By diagnosing and managing additional HIV cases detected through the portal of the TB control programme, clinicians will contribute to diminishing the burden of HIV, and thus, TB.

AIDS-Related Opportunistic Infections↗
PubMed2003

Differential decline in tuberculosis incidence among US- and non-US-born persons in New York City.

SETTING: A large urban tuberculosis control program. OBJECTIVES: To examine changes in tuberculosis incidence and characteristics of cases in New York City (NYC), and assess the epidemiology of tuberculosis among non-US-born persons. DESIGN: Tuberculosis surveillance data (1995-1999) for NYC were analyzed. RESULTS: Tuberculosis incidence decreased by 56.6% in US-born and 19.6% in non-US-born persons (age-adjusted) over the study period. The decline in tuberculosis incidence among US-born persons was more substantial in the first half of the study period (23-24%) than in the second half (13-15%). The greatest decline in incidence was among US-born Hispanic or Black males aged 25-64. However, although there was an overall decline in incidence among non-US-born persons, there was no significant change in any sex or racial/ethnic subgroup. The percent of multidrug-resistant (MDR) cases among non-US-born patients remained stable, but recent arrivals accounted for 79% of non-US-born MDR-TB patients in 1999, a significant increase from 16% in 1997. CONCLUSIONS: Continuing current tuberculosis control efforts and treatment of immigrants with latent tuberculosis infection are of highest priority for reducing incident cases in NYC. Global collaboration towards earlier detection and treatment of active tuberculosis cases in high incidence countries is also essential.

Adult↗
PubMed2003

Finding contacts of homeless tuberculosis patients in New York City.

OBJECTIVE: To determine factors associated with no contacts identified for homeless patients in New York City. DESIGN: Culture-confirmed pulmonary tuberculosis cases in persons >18 years old diagnosed in 1997-1999 were included. Demographic and clinical characteristics of tuberculosis patients associated with the number of contacts identified according to homeless status were analyzed using unconditional logistic regression. RESULTS: Homeless patients (n = 152) had a significantly lower median number of contacts than non-homeless patients (n = 2836) (1 vs. 4, P < 0.001). Among homeless patients, having AFB smear-positive sputum with cavitary lesions reduced the likelihood of having no contacts identified. Homeless patients who lived on the street at the time of diagnosis were more likely to have no contacts identified compared to those with contacts identified (61.4% vs. 56.1%); however, the difference was not statistically significant (P = 0.506). Unlike non-homeless patients, being hospitalized at the time of tuberculosis diagnosis was not associated with having contacts identified in homeless patients. CONCLUSIONS: Homelessness independently predicted the likelihood of having no contacts identified. Strategies such as interviews that focus on location rather than persons may be more effective for identifying contacts. Furthermore, being homeless at the time of diagnosis should be used as an indicator for prioritizing prompt contact evaluation.

Adult↗
PubMed2002

Yield of continued monthly sputum evaluation among tuberculosis patients after culture conversion.

SETTING: New York City. OBJECTIVE: To evaluate the yield of continued monthly sputum monitoring after culture conversion. DESIGN: A retrospective review of tuberculosis patients verified between 1 January 1995 and 31 December 1996 who had: 1) pulmonary tuberculosis with organisms susceptible to isoniazid and rifampin; 2) culture conversion; and 3) completed therapy. We assessed time to smear and culture conversion and number of persons who developed a positive culture after culture conversion (culture reversion). RESULTS: Of 1440 patients, 379 were cared for by tuberculosis control program providers and 1061 were cared for by other providers; 813 (56%) were initially smear-positive. After the fifth month, 44 (5.3%) were smear-positive; four of these were culture-positive. Eighteen (1.3%) had culture reversions; eight were smear-positive. Excluding one specimen per patient collected at treatment completion, 7967 sputum samples were collected after culture conversion. The minimum estimated cost per culture reversion detected was $26,557. CONCLUSION: Continued monthly monitoring of sputum after culture conversion identified a very small number of patients who had culture reversion. However, patients who cannot tolerate or adhere to a standard regimen may need continued monitoring to assess response to treatment. For all patients a specimen should be collected at the end of treatment to document cure.

Adolescent↗
PubMed2000

Rates and risk factors for discontinuation of rifampicin.

SETTING: All patients with culture-confirmed, rifampin-susceptible Mycobacterium tuberculosis diagnosed during a 20-month period in New York City, who were started on a rifampin-containing regimen and received > or =60 days of treatment. OBJECTIVE: To identify rates of and reasons for rifampin discontinuation. DESIGN: Retrospective case-control study using surveillance data and medical record reviews. Discontinuation due to thrombocytopenia, creatinine >2.0 mg/dl, bilirubin >2.0 mg/dl or severe reactions (generalized rash, persistent drug fever, or severe interference with methadone metabolism) were defined as appropriate for discontinuation of rifampin. All other reactions were classified as inappropriate. RESULTS: Of 3,520 patients, rifampin was discontinued in 68 (1.9%); of these, 57% had rifampin discontinued unnecessarily. Treatment by an inexperienced provider (adjusted odds ratio [ORadj] 4.0; 95% confidence interval [CI] 1.9-8.5), race (ORadj 3.1; 95%CI 1.4-6.9), history of previous treatment (ORadj 4.8; 95%CI 1.9-12.5), and history of methadone drug treatment (ORadj 12.6; 95%CI 5.3-29.9) were all associated with inappropriate rifampin discontinuation. CONCLUSION: True intolerance was rare, even among those patients infected with the human immunodeficiency virus. Most patients with minor reactions can successfully complete treatment with rifampin, particularly if managed by a physician experienced in the treatment of tuberculosis.

Adolescent↗
PubMed1999

The use of legal action in New York City to ensure treatment of tuberculosis.

BACKGROUND AND METHODS: After an increase in the number of cases of tuberculosis, New York City passed regulations to address the problem of nonadherence to treatment regimens. The commissioner of health can issue orders compelling a person to be examined for tuberculosis, to complete treatment, to receive treatment under direct observation, or to be detained for treatment. On the basis of a review of patients' records, we evaluated the use of these legal actions between April 1993 and April 1995. RESULTS: Among more than 8000 patients with tuberculosis, regulatory orders were issued for less than 4 percent. Among patients with a variety of social problems, only a minority required regulatory intervention: 10 percent of those with injection-drug use, 16 percent of those with alcohol abuse, 17 percent of those who were homeless, 29 percent of those who used "crack" cocaine, and 38 percent of those with a history of incarceration. A total of 150 patients were ordered to undergo directly observed therapy, 139 patients to be detained during therapy, 12 patients to be examined for tuberculosis, and 3 patients to complete treatment. These 304 patients had a median of three prior hospitalizations related to tuberculosis and one episode of leaving the hospital against medical advice. Repeatedly noncompliant patients and those who left the hospital against medical advice were more likely than others to be detained. The median length of detention was 3 weeks for infectious patients and 28 weeks for noninfectious patients. As compared with patients ordered to receive directly observed therapy, the patients who were detained remained infectious longer, had left hospitals against medical advice more often, and were less likely to accept directly observed therapy voluntarily. Altogether, excluding those who died or moved, 96 percent of the patients completed treatment, and 2 percent continued to receive treatment for multidrug-resistant tuberculosis. CONCLUSIONS: For most patients with tuberculosis, even those with severe social problems, completion of treatment can usually be achieved without regulatory intervention. Patients were detained on the basis of their history of tuberculosis, rather than on the basis of their social characteristics, and the less restrictive measure of mandatory directly observed therapy was often effective.

Adolescent↗
PubMed1999

Extrapulmonary tuberculosis among foreign-born patients, New York City, 1995 to 1996.

In New York City both the proportion of total tuberculosis cases that are extrapulmonary and the proportion of total tuberculosis cases that are foreign-born have increased since 1992. We examined the association of region of birth and site of extrapulmonary tuberculosis among 3982 persons confirmed to have tuberculosis in 1995 or 1996, while controlling for age, gender, culture result, reporting facility, and HIV status. Patients born in the Middle East (odds ratio; 3.9, p = .0001), India (odds ratio = 2.5, p = .0007), other Asian countries (excluding China, Japan and countries of the former Soviet Union) (odds ratio = 2.7, p = .0001), sub-Saharan Africa (odds ratio = 2.6, p = .0001), and the Caribbean (odds ratio = 2.0, p = .0001) were more likely to have extrapulmonary disease than patients born in the United States. The proportion of total cases with extrapulmonary involvement is likely to increase in areas where the foreign-born comprise a growing proportion of all cases of tuberculosis. Although reasons for regional differences in tuberculosis disease site are not known, these findings should alert health care providers to maintain a high index of suspicion for extrapulmonary tuberculosis among some foreign-born groups.

Journal Article↗
PubMed1999

Prevalence and factors associated with tuberculosis infection among new school entrants, New York City, 1991-1993.

SETTING: New York City public (or state-run) and private schools-elementary and secondary. OBJECTIVE: To describe the prevalence and determine factors associated with positive tuberculin skin tests (TSTs) in school children. DESIGN: Mandatory TST surveys among cohorts of new school entrants for the 1991, 1992 and 1993 school years, of whom birthplace was known for 81%. A positive tuberculin skin test defined as > or =10 mm induration. RESULTS: Of the 298506 new school entrants, 2.1% (6326) were tuberculin test positive. The proportion that was tuberculin test positive was 0.5% (931/199 728) among US-born and 9.2% (3794/41 346) among foreign-born students. Foreign-born (FB) students with a history of BCG vaccination were much more likely to have a positive tuberculin test than US-born students (13.6% vs. 0.5%, odds ratio [OR] = 33.6, 95% confidence interval [CI] 31.7, 35.6), and were more likely to have a positive tuberculin test than FB students with no history of BCG (13.6% vs. 4.4%, OR = 3.4, 95% CI 2.5, 4.6). Older age was independently associated with tuberculin test positivity, except among foreign-born BCG-vaccinated children, in whom the youngest were more likely to have a positive tuberculin test. CONCLUSIONS: Even in the midst of a tuberculosis resurgence such as that experienced by New York City, where tuberculosis cases nearly tripled from 1978 to 1992, the risk of tuberculosis infection among school children remained quite low. Given the reduced predictive value of the tuberculin test among low risk children and the effects of BCG vaccination, many children (especially younger children) with positive tuberculin test results are probably not infected with Mycobacterium tuberculosis. To reduce unnecessary evaluation and treatment, routine tuberculin tests should be administered only to high risk groups such as older children from countries with high rates of tuberculosis.

Adolescent↗
PubMed1999

Patient and health care system delays in the diagnosis and treatment of tuberculosis.

SETTING: All culture-positive tuberculosis patients without previous treatment for tuberculosis (n = 184), New York City, April 1994. OBJECTIVE: To examine factors associated with delays in presenting to a health care provider (patient delay) and in starting antituberculosis treatment (health care system delay). DESIGN: Retrospective medical record review and patient interviews. RESULTS: Median total delay was 57 days (range 4-764), 35 for acid-fast bacilli smear-positive patients and 79 for smear-negative patients (P < 0.001). Median patient delay was 25 (range 0-731). Median health care system delay was 15 days, 6 for smear-positive patients and 31 for smear-negative patients (P < 0.001). In logistic regression, age 55-64 years (adjusted odds ratio [OR(adj)] 10.6, 95% confidence interval [CI] 1.3-86.9), and primary language other than English (OR(adj) 2.5, 95%CI 1.0-5.8), were associated with longer patient delays. Homelessness (OR(adj) 7.1, 95%CI 1.05-33.5), not having a chest radiograph at the first medical visit (OR(adj) 2.4, 95%CI 1.0-5.4), negative smear (OR(adj) 10.2, 95%CI 4.4-23.3) and absence of cough (OR(adj) 2.9, 95%CI 1.2-6.8) were associated with longer health care system delays. CONCLUSION: To reduce delays, patients should be educated to seek care more quickly, and should be provided with culturally appropriate health care and language services. Physicians should maintain a high index of suspicion for tuberculosis and perform appropriate diagnostic tests.

Adolescent↗
PubMed1998

A continuing outbreak of multidrug-resistant tuberculosis, with transmission in a hospital nursery.

We investigated an increase in cases of multidrug-resistant tuberculosis (MDRTB) at a large urban facility where a prior nosocomial outbreak of MDRTB had occurred. Nosocomial transmission appeared to account for this outbreak as well, including a cluster of cases in a newborn nursery. Seven of 24 patients (29%) described in this investigation may have been exposed in the hospital nursery during an approximately 2-week period. We believe this to be the first documented outbreak of MDRTB in a hospital nursery. The transmission in the nursery demonstrates that the possibility of exposure to unrecognized active tuberculosis in nursery and hospital personnel is always present. Infection and active disease in the infants developed after a relatively short period of exposure. These findings underscore the need for adherence to published infection control guidelines in health care settings.

Antitubercular Agents↗
PubMed1998

Cross-contamination with Mycobacterium tuberculosis: an epidemiological and laboratory investigation.

OBJECTIVE: To investigate possible cross-contamination of laboratory specimens, as suggested by an increased incidence of newly diagnosed patients with tuberculosis, many of whom had all negative smears for acid-fast bacilli and only one positive Mycobacterium tuberculosis culture referred to as "negative smears, one positive" or NSOP. METHODS: Medical-record reviews were performed for all patients with NSOP results diagnosed at this facility within a 9-month period. Laboratory logbooks were reviewed for all isolates processed; DNA fingerprinting was performed on available isolates. RESULTS: Of 80 patients with NSOP results, 45 (56%) were found to have false-positive cultures resulting from laboratory contamination with H37Ra, an avirulent stock strain of Mycobacterium tuberculosis. CONCLUSION: Laboratory cross-contamination resulted in the false diagnosis of tuberculosis in at least 45 individuals. Use of the Mycobacteria Growth Indicator Tube may have contributed to these contamination incidents by detecting small numbers of contaminating mycobacteria that may not have been detected with less sensitive media.

Diagnostic Errors↗
PubMed1997

A continuing survey of drug-resistant tuberculosis, New York City, April 1994.

BACKGROUND: A 1991 survey showed high levels of drug resistance among tuberculosis patients in New York, NY. As a result, the tuberculosis control program was strengthened, including expanded use of directly observed therapy and improved infection control. METHODS: We collected isolates from every patient in New York City with a positive culture for Mycobacterium tuberculosis during April 1994; results were compared with those in the April 1991 survey. RESULTS: From 1991 to 1994, the number of patients decreased from 466 to 332 patients. The percentage with isolates resistant to 1 or more antituberculosis drugs decreased from 33% to 24% (P < .01); with isolates resistant to at least isoniazid decreased from 26% to 18% (P < .05); and with isolates resistant to both isoniazid and rifampin decreased from 19% to 13% (P < .05). The number of patients with isolates resistant to both isoniazid and rifampin decreased by more than 50%. Among never previously treated patients, the percentage with resistance to 1 or more drugs decreased from 22% in 1991 to 13% in 1994 (P < .05). The number of patients with consistently positive culture results for more than 4 months decreased from 130 to 44. A history of antituberculosis treatment was the strongest predictor of drug resistance (odds ratio = 3.1; P < .001). Human immunodeficiency virus infection was associated with drug resistance among patients who never had been treated for tuberculosis. CONCLUSIONS: Drug-resistant tuberculosis declined significantly in New York City from 1991 to 1994. Measures to control and prevent tuberculosis were associated with a 29% decrease in the proportion of drug resistance and a 52% decrease in the number of patients with multidrug-resistant tuberculosis.

AIDS-Related Opportunistic Infections↗