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Tuberculosis and AIDS -- Connecticut

Until 1983, the incidence of tuberculosis in Connecticut had steadily declined for several decades. In 1982, it reached its lowest point, 5.0 cases per 100,000 population. Since then, tuberculosis incidence in Connecticut has fluctuated above that level, with a rate of 6.2 in 1983, 5.6 in 1984, and 5.1 in 1985. A rate of 6.0 is projected for 1986. This would be an 18% increase over 1985. Concern about a possible association between human immunodeficiency virus (HIV) infection and the rise in tuberculosis morbidity led to an evaluation of data on acquired immuno-deficiency syndrome (AIDS) and tuberculosis in Connecticut.

The entire AIDS register was confidentially linked to the tuberculosis case register dating back to 1970 to determine the proportion of tuberculosis patients with a diagnosis of AIDS, the proportion of AIDS patients with tuberculosis, and the interval between the diagnosis of tuberculosis and AIDS. The following selected characteristics of those with both diagnoses were also studied: age, sex, race and ethnicity, geographic location by city size, and risk factors for a diagnosis of AIDS. Patients were placed in subgroups by each of these characteristics, and the incidence rate of tuberculosis in individuals with and without AIDS in each subgroup was calculated and compared. A 3-year incidence rate of tuberculosis was used for these comparisons because most diagnoses of tuberculosis in AIDS patients occurred in the 3-year period beginning 30 months before and ending 6 months after the diagnosis of AIDS.

As of September 1, 1986, 18 cases of tuberculosis had been diagnosed among the 299 cumulatively reported AIDS cases in Connecticut. The 18 tuberculosis patients with AIDS (TB/AIDS) ranged from 24 to 53 years of age, with a median of 33 years. Fourteen (78%) were male; 11 (61%) were black; 13 (72%) came from the six cities in Connecticut with a population of 100,000 or greater; and seven (39%) were intravenous drug abusers. One of the 18 cases of tuberculosis was diagnosed in 1973 and another in 1980. The remaining 16 cases were diagnosed after January 1, 1982, and represent 5.4% of all AIDS cases reported to date and 2.0% of all 816 tuberculosis cases diagnosed and reported from 1982 through 1986. When these 16 cases are analyzed by year of diagnosis, there appears to be no significant rise or fall in the frequency of tuberculosis patients with AIDS (TB/AIDS) for the years 1982 through 1986.

Compared with tuberculosis patients without AIDS in Connecticut, TB/AIDS patients were younger and more likely to be male, black, and from a large city. Compared with AIDS patients without tuberculosis, TB/AIDS patients were more likely to be black and from a large city and to have intravenous drug abuse as an AIDS risk factor. Age and sex distribution were similar in both groups.

Among the 18 TB/AIDS patients, the diagnosis of tuberculosis occurred from 10 years before to 19 months after the diagnosis of AIDS, with a median of 4 months before the diagnosis of AIDS. Fourteen (78%) of TB/AIDS patients were diagnosed as having tuberculosis within 3 years of their diagnosis of AIDS (2.5 years before to 0.5 years after).

Table 4 shows the crude 3-year incidence rate of tuberculosis in AIDS patients and in the general population without AIDS according to sex, race, and city size as well as the incidence rate adjusted for these three factors and age. In all groups, the rate of tuberculosis (risk ratio) in AIDS patients was more than 100 times the incidence in the general population. Reported by JL Hadler, MD, MPH, State Epidemiologist, R Burger, Pulmonary Diseases and AIDS Programs, Connecticut State Dept of Health Svcs; Div of Tuberculosis Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The demographic characteristics of TB/AIDS patients in Connecticut are similar to those found elsewhere; individuals are most likely to come from groups that have a higher incidence of tuberculosis and are at risk for AIDS (1-3).

The following factors suggest an association between tuberculosis and AIDS in Connecticut: the 5.4% incidence of tuberculosis in AIDS cases, the clustering of the development of tuberculosis and AIDS within a distinct time period (within 3 years of diagnosis of AIDS), and the 100-fold or greater risk of tuberculosis among AIDS patients than among the general population. The risk that persons with latent tuberculous infection who develop AIDS will develop clinically active tuberculosis cannot be determined from these data. However, to the extent that individuals with AIDS are representative of the general population in prevalence and incidence of tuberculous infection, this risk could be as much as 100- to 200-fold greater than that of their non-HIV-infected counterparts.

The total number of AIDS patients in the United States meeting the CDC surveillance case definition represents only a fraction of the number of persons with HIV infection. It has been estimated that, in 1985, for every diagnosed case of AIDS, there were 50 to 100 persons with HIV infection (4). The number of tuberculosis patients with HIV infection but without AIDS in Connecticut may also exceed the number who have overt AIDS.

These data further support recently published guidelines that risk factors for HIV should be identified as part of the evaluation of persons with tuberculous infection (5). HIV antibody testing should be offered, and, where there is both tuberculous infection and HIV infection, isoniazid preventive therapy should be offered. Conversely, persons who are positive for HIV antibody should be offered tuberculin skin testing, and isoniazid preventive therapy should be offered to reactors (5).

References

  1. CDC. Tuberculosis and acquired immunodeficiency syndrome--Florida. MMWR 1986;35:587-90.

  2. Sunderam G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB. Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS). JAMA 1986;256:362-6.

  3. Stoneburner RL, Kristal A. Increasing tuberculosis incidence and its relationship to acquired immunodeficiency syndrome in New York City. Atlanta, Georgia: International Conference on Acquired Immunodeficiency Syndrome (AIDS). April 14-17, 1985.

  4. Curran JW, Morgan WM, Hardy AM, Jaffe HW, Darrow WW, Dowdle WR. The epidemiology of AIDS: current status and future prospects. Science 1985;229:1352-7.

  5. CDC. Diagnosis and management of mycobacterial infection and disease in persons with human T-lymphotropic virus type III/lymphadenopathy-associated virus infection. MMWR 1986;35:448-52.



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