HomeMy WebLinkAboutMINUTES - 12141993 - IO.5 TO: BOARD OF SUPERVISORS I.0:-5 Contra
INTERNAL OPERATIONS COMMITTEE f�►`\ Costa
FROM: ;•
;S
November 22, 1993 �9 County
r.%��
DATE: lSa
SUBJECT: STATUS OF COMMUNICABLE DISEASES IN CONTRA COSTA COUNTY
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDATIONS:
1 . ACCEPT the attached quarterly report from the Health Services
Director on the status of Communicable Diseases in Contra
Costa County.
2 . EXPRESS the Board' s appreciation to all of the staff from the
Health Services Department who are responsible for the
excellent and informative "HIV/AIDS EPIDEMIOLOGICAL REPORT" ,
a copy of which is attached, which has been distributed widely
to individuals and organizations concerned with AIDS,• a1d_HIV.
3 . ACKNOWLEDGE the prompt and accurate diagnostic work done on a
recent case of human rabies at Merrithew Memorial Hospital by
nursing staff from the Health Services Department.
4 . REQUEST staff from the Health Services Department to contact
staff from the Office of Oakland Mayor Elihu Harris and
explore the potential for Mayor Harris ' proposal for an East
Bay AIDS Foundation, developed jointly by Alameda County and
Contra Costa County and report their findings and
recommendations to the 1994 Internal Operations Committee.
5 . REQUEST the Health Services Director to make his next
quarterly report on the subject of communicable diseases to
the 1994 Internal Operations Committee and for this purpose
and for the purpose of receiving the report requested under
Recommendation '# 4, refer this subject to the 1994 Internal
Operations Committee.
CONTINUED ON ATTACHMENT: YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD P9199ITTEE
APPROVE OTH ER Q
SIGNATURE S: J `rFrr qMTTH
x
ACTION OF BOARD ON Derei ber Ili-, 1993 APPROVED AS RECOMMENDED L OTHER
VOTE OF SUPERVISORS
I HEREBY CERTIFY THAT THIS IS A TRUE
UNANIMOUS(ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN
AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD
ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN.
ATTESTED p t 0.I a }-g!!n, -5
Contact: PHIL BATCHELOR.CLERK OF THE BOARD OF
cc: See Page 2 SUPERVISORS AND COUNTY ADMINISTRATOR
BYDEPUTY
I.O.-5
-2-
6 . REMOVE this item as a referral to the 1993 Internal Operations
Committee.
BACKGROUND:
Our Committee has been receiving quarterly reports on the status of
communicable diseases from the Health Services Director throughout
1993 . Attached is the latest of these reports . We would
particularly call to the Board' s attention the excellent "HIV/AIDS
Epidemiology Report" , which provides a variety of statistical data
on the source of the HIV/AIDS epidemic, the characteristics of AIDS
patients, the populations which are most at risk and other
important data which needs to be studied and understood in order to
grasp the full scope of the AIDS epidemic in this County.
The Health Services Director' s report also highlights the growing
problem of tuberculosis and the steps which are being taken to try
to control the spread of the disease.
Finally, we would like to note the outstanding work done recently
by the nursing staff at Merrithew Memorial Hospital in diagnosing
a very rare case of human rabies . A man from Mexico, who had
apparently been bitten by a rabid dog in Mexico and who did not
seek treatment at that time, was visiting in the United States when
he became ill . Displaying a number of fairly common symptoms, the
man eventually came to the attention of the nursing staff at
Merrithew Memorial Hospital, who promptly diagnosed his symptoms as
a ,case of human rabies . Unfortunately, the diagnosis was too late
to safe the life of the man. It was, however, very helpful in
limiting the potential exposure of other staff and visitors to the
disease, thereby substantially limiting the number of individuals
who must undergo the preventive treatment for exposure to rabies .
cc: County Administrator
Health Services Director
Public Health Director
Francie Wise, Director, Communicable Disease Control
Contra Costa County
The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR
Tom Powers,1st District Mark Finucane,Director
Jeff Smith,2nd District .......
Gayle Bishop,3rd District =t 20 Allen Street
Sunne Wright McPeak,4th District Martinez,Ca4fornia 94553-3191
Tom Torlakson,5th District (510)370-5003
FAX(510)370-5098
County Administrator
Phil Batchelor U
County Administrator November 18, 1993
To: Internal Operations Committee
From: Mark Finucane, Director, Health Services Department
by Wendel Brunner, M.D., Assistant Health Service Director for Public Health
Subject: Quarterly Report on Communicable Diseases
AIDS
CURRENT AIDS CASES IN CONTRA COSTA COUNTY
As of November 11, 1993, a total of 1,236 residents of Contra Costa County have been
diagnosed with AIDS. This number represents 77 new cases reported since our last report to
this committee on August 4, 1993. The increase (5%) is primarily due to cases diagnosed under
the new and expanded AIDS surveillance case definition.
HIV/AIDS EPIDEMIOLOGY REPORT
During recent months more than 2,500 copies of a report on the epidemiology of the
HIV/AIDS epidemic in Contra Costa County have been distributed to health care providers,
community organizations, city officials and others throughout the county. Data pertinent to
Contra Costa County was gathered from different sources and made available to the community
for information, education, planning and grant applications. In addition to HIV/AIDS incidence
and prevalence data, information was included describing aspects of the local response funded
by the Ryan White CARE Act in terms of services provided to people with HIV/AIDS, the
financial status of the recipients of assistance and reports of unmet needs. , Copies of the
HIV/AIDS Epidemiology Report are included here.
Rnums OF THE 1992 HIV SURVEY OF CHMDBEARNG WOMEN
The California Department of Health Services has provided Contra Costa County with
the results of the 1992 HIV Survey of Childbearing Women. Every year since 1988, the blood
of all babies born during the third quarter of the year is tested for HIV to assess the prevalence
of HIV among the mothers of these babies. The babies born to infected mothers have a 30%
chance of being infected.
Merrithew Memorial Hospital&Clinics Public Health - Mental Health - Substance Abuse - Environmental Health
Contra Costa Health Plan Emergency Medical Services - Home Health Agency - Geriatrics
A-14r) (2/511)
I I
Report to the Internal Operations Committee Page 2
On Communicable Disease in Contra Costa County
Contra Costa County has had higher rates of HIV than the State as a whole, a trend
observed in other San Francisco Bay Area counties as well. During 1992, four women out of
3,258 delivering babies during the third quarter were found to be HIV infected. This is the
same number of infected mothers found in 1990 and 1991. The rate for 1992 was 0.123%,
which is equivalent to one women infected in every 815. In 1992, two (50%) of the infected
women delivering babies were teenagers (19 years of age or younger). All four of the women
were African American.
HIV Seroprevalence Survey of Childbearing Women
Contra Costa County
1988 1989 1990 1991 1992.: 1988-92
Number 3029 3261 3245 3406 16,199
Tested
Positive 2 9 4 4 4 23
Rate per 6.60 27.60 12.33 11.74 .12:2814.19
10,000
AMERICAN JOURNAL OF PUBLIC HEALTH ARTICLE ON HIV TESTING AMONG CONTRA COSTA
COUNTY INJECTION DRUG USERS
In the October 1993 issue of the American Journal of Public Health an article by
members of the Public Health Division, Communicable Disease Control Programs reported
findings on the success of voluntary, confidential HIV counseling and testing performed "in-
house" by methadone clinic staff members, as measured by the acceptance of such tests and by
the level of HIV infection awareness among HIV infected injection drug users. The information
and experience gathered in Contra Costa County has been distributed through this publication
to its more than 50,000 subscribers. Copies of this article are attached.
HIV counseling and testing is not enough to prevent all new infections and the article
makes reference to the evidence of new HIV infections among Contra Costa injection drug users,
which has previously been reported to the Board of Supervisors. Nevertheless, HIV testing was
largely accepted by injection drug users entering treatment, it facilitated access to early treatment
for HIV complications and is potentially helpful in limiting the spread of HIV to non-infected
partners.
Report to the Internal Operations Committee Page 3
On Communicable Disease in Contra Costa County
COMMUNICABLE DISEASE
TuBERcmosis
Tuberculosis continues, as it has for the past five years, to be reported at high rates. In
1985 our rate of tuberculosis cases was 8.5/100,000, in 1992 our case rate was 12.6/100,000.
Contra Costa County has reported 97 confirmed cases as of November 1, 1993, with four
additional cases pending confirmation. We continue to see cases in younger people, 25-44 years
of age, and in the minority populations. Additionally, the bulk of the cases, 80%, are occurring
in West and East County.
To control tuberculosis by rapidly finding new cases and preventing new infection the
Health Services Department has been working in several areas:
• TB/HIV Jail Project - The Public Health staff in cooperation with medical staff
of the jail continue to test each entering inmate for tuberculosis infection. Those
persons testing positive are examined by a physician after receiving a chest x ray.
The additional service that has been added is that each inmate started on treatment
is met by a Public Health worker who will follow the person after he/she is
released in the Directly Observed Therapy program (DOT). This delivering of
medication to the person at home two times a week until the six month therapy
is completed will prevent infection from progressing to disease.
STD/HIV/TB Mobile Clinic - Each Friday our mobile.clinic parks in the North
Richmond area or in Pittsburg/Bay Point to provide STD diagnosis and treatment
services. The original mission of this van was to see women at risk for STD and
their partners. However, we have also added HIV testing and counseling and TB
skin testing and referral. In cooperation with Neighborhood House of North
Richmond (Northstar Drug Treatment) in the Richmond area and Pittsburg Pre
School Coordinating Council in East County we do outreach before the clinic
arrives to encourage the persons at highest risk for any of these diseases to be
seen when the clinic is held. This has been very successful, with 15-30 people
being seen at each four hour clinic. We plan to substantially increase the number
by January 1994 and add immunization and family planning services.
0 Cross Training of Personnel - We have instituted.a policy of cross training all
of our field workers in the Communicable Disease Programs (STD, AIDS, TB,
Immunizations) to be able to provide information and service to the public, in all
areas of communicable disease control. They are able to give educational
information, referral and assistance to people who have questions or need any
Communicable Disease services. The program workers are now less program
specific in their training and orientation to the patient. This has been an
important change since many of these workers in the various programs were
serving the same people. Change has been made in the utilization of funding.
Although outside funding continues to be categorical, merging programs at the
local level enables us to use TB, immunization, AIDS and STD funds in a unified
service delivery unit. Workers are often funded under more than one program.
Report to the Internal Operations Committee Page 4
On Communicable Disease in Contra Costa County
• TB/HIV Screening in the IDU Population - We have worked in cooperation
with UCSF and Dr. John Watters to test people for HIV and TB, in West
County, over the past two years. We have referred those people to services
within the county who are HIV positive. For people who were TB skin test
positive we have held several special clinics to obtain chest x rays and examine
for signs of tuberculosis disease. Those infected, without disease, who agreed
were places on preventive therapy. This out-of-treatment, drug using population
is at very high risk for both HIV and tuberculosis. For the past five years the
number of patients diagnosed with tuberculosis who use inject drugs or cocaine
has increased substantially. This is a population that does not seek medical care.
We experienced a major outbreak of tuberculosis in the cocaine using population
of West County in 1989-90 due to poor medical care, close quarters and many
other factors. The HIV rates in the drug injecting population continue to be very
high, with 26.5% infection rate for those surveyed in Richmond in 1992. This
year we hope to be working with this same project offering HIV and TB testing.
In addition, follow up Directly Observed Therapy (DOT) for those study
participants who are placed on preventive Tb therapy will be provided.
IMMUNIZATION
Although we have increased our immunization clinics in the past four years by more
100% per month with the cost remaining very low or free, the youngest children in the county
continue to be inadequately immunized. Last year more than 48% of the children under two
years of age were under-immunized. We have again expanded services and have added Immuni-
zation Services to other services where young children are seen in order to encourage
appropriate immunization of this highest risk population.
• Immunization Coupons - Even if the$5.00 fee is waived, on request, people do
not want to ask. We have begun handing out coupons for Free Immunizations
through our Immunization Outreach worker, WIC clinics and in any area where
immunization levels are very poor. This has been very successful in the past
when the coupons were handed out for Immunization Awareness Month. We
hope it will continue with the high rate of return.
• Immunization Outreach Worker - Through new State funding we have been
able to place an outreach worker in the field to work with communities, families
and organizations on immunization issues. He has been arranging clinics in high
need areas such as housing developments, churches which serve mainly non
English speaking populations and community centers. He will also be visiting
medical care providers giving information on immunizations and clinic resources.
The merging of service provision and cross training of workers has been a very
rewarding experience. As we continue to serve greater numbers of high risk persons, the need
to maximize each contact will grow. We will continue to expand the cross training of other
outreach workers within the Health Services Department, such as prenatal and Child Health &
Disability Prevention (CHDP) outreach workers to provide communicable disease information
and referral at each contact.
American.'coma' Are HIV-Infected Injection Drug
Of Public trealrh Users Taking HIV Tests?
rcpt
Ilium
Juan Reardon, MD, MPH, Nancy Warner, PHN, Rusty Kedch, MA, Dale
Jensen, RN, Francie Wise, PHN, MPH, and Wendel Bntnner, MD, MPH
Obiex im. Knowledge of infer-
tion is essential for human immuno- Introdudion •What is the 1991 HIV-1 seroprev-
deficiencyvirus-type 1(MV-1)treat- :..:. alence for all injection drug users
Tnent initiation and epidemic control. Regardless of sexual orientation,in- entering treatment in Contra Costa
this study infection"owl- jection drug users constitute 14.8% of County and for those accepting a
edge among infected njection drug us- adult acquired immunodeficiency syn- voluntary test?
as and acceptance of confidential test- .. drone (AIDS) cases in California' and •Are injection drug users entering
ing among injection drug users,: treatment accepting a confidential
19.3% of such cases in Contra Costa
infectedwithHIV-1: County, California (San Francisco Bay
HIV-1 antibody to
Mediods.A total of 810 injectiott likely o
dru � • e those who are infected e t
Area),2 where human immunodeficiency
8 �entering t �' be aware of their infection?
tra Costa �,�cam were ..-., virus-type 1(HIV-1)seroprevalence rates •Are those who are infected and un-
among Qieattswent testedwithumfinked among these drug users appear to be par- likely to accept a test.
boded tests and simultaneously
ticularly high for African Americans.3•4
aware
oourzLseled and offered writ P con Voluntary HN-1 anti
testing of in-
ftidential HIV-1 antibody testing.Data: jection drug users has been recommended Methods
as an effective approach to limit' the
- � � +1>� � � Unlinked HN-1 serosurveys were
vim.t use, and demo spread of HIV-1 5 For example,early in-
testing, �11g conducted at two methadone clinics op-
information y� ..., in-
tervention with zidovudine has been
" gmP�� erating in Contra Costa County,Califor-
Results. Of the 810 tested; 105. :. proven beneficial in postponing the occur-
ria,from January 1 to December 31,1991.
%
13.0were infected. The current rence of illness in infected with
{ ) . n pStandardized research protocols devel-
oonfidenfral test was 307 .. HIV-1 6 Some people believe drug
that d
.b5' oped by the Centers for Disease Control
(62.6%). HIV seroprevalence in the abuse treatment personnel can develop di- (C were utsed.12 The study population
unlarkedstrrveywasfauirtimesgreater ..:. agnostic and therapeutic relationships consisted of drug users entering metha-
[hatt in the voluntary survey(13%and with injection drug users more effectively done detoxification programs and of those
.3S%, respectively). HIVl infection than can practitioners in more traditional entering or continuing methadone mainte-
was associated with.rdusal of a confi-. settings? The reluctance or inability of nance.A total of 810 consecutive injection
bential test largely because most in- these drug users to become involved with drug users who entered methadone treat-
fected injection drug users (n=:58; traditional medical clinics may postpone ment and had their blood drawn for hep-
552%)already knew of their khction. HIV-1 diagnosis until very late,deferring atitis screening were included. Excluded
Ofthe47it>jectiottdtuguserswhoA'=:;`: appropriate interventions. were clients retesting during the study pe-
not aware of their infection,12(2539111) In previous work we reported that, riod(n = 294).
accepted the test..Although African-.. of all injection drug users admitted to All clients received individualized
.American injection drug risers pre treatment in 1990, 60.0% (614/10p) ac- FHV/AIDS counseling and were offered a
sented with a.higher.infection rate. cepted a confidential antibody test but confidential HIV-1 antnbody test. Demo-
(373%,they three thnes less only 33.6%(36/107)of the infected users graphic data,drug use history,and infor-
lticely to know of their infection.. (in unlinked surveys) accepted testings mation regarding acceptance of confiden-
C.anchaimu "logic" HIV-1. Finding lower HIV seroprevalence rates
vesting is highly accepted,and wast in with voluntary testing surveys, com-
fected clients in treatment will learn pared to unlinked surveys,was reported The authors are with the Contra Costa County
their status:Nevertheless,voluntary previously in other poputlations,941 and Health Services Department,Public Health Di-
testutg data are lnlcely to yield.eonsid- '. the 1990 data did not include whether re- vision,Martinez,Calif.
. . erable la derestanat.es of the.t [ue rate... fusal of a test was owing to prior knowl- Requests for reprints should be sent to
of infection among injection drug us edge of positive status. Therefore, our Juan Reardon, MD, MPH, Contra Costa
County Health Services Department,597 Cen-
em. (Am J Public Weakk 1993;83:.. analysis of 1991 data intends to clarify the ter Ave,Suite 200,Martinez,CA 945534669.
1414-1417) :.: following: This paper was accepted January 12,1993.
:1414.Atnericati ioumal of Public Health October 1993,Vol.83,No.10
E11V ami8 Drug Uses
tial HIV-1 testing were collected for each
client tested with the unlinked method. TABLE 1--itY-1 Seroprovatence among I*ctlon Drug Uses EnWing Tmatmerit
This information allowed grouping the 810 in Contra Costa County,Cantomia,1991,and lJri OVIOle.C.ompariSCns
injection drug users by HIV-1 status, of
; ' ..
knowledge of that status,and acceptance
enigswc
of testing.Repetitive reactive enzyme im-
HIV
munoassay tests(at least two positive tests) ...;
AN {is>iirdced survetr} ..810 .:.. : ::::.105 13A.... ...:.. ..4.0.: . .2.4,72 ....
were confirmed by Western blot.The As-
Gs tested
sociation of State and Territorial Public
507 .. .. 18
Health Labotato Directols/CDC criteria 't70 65.. 132 2 . . .:.t)8,:1.9
�' Pemaie
t
for a positive Western blot were used.13 ..:: ..
.
.AMM Arnerkn� ..: 217 81. : .:'37.3 18.0:. 9.7,33.7
Clients testing positive for HIV-1 no
80 6. .. 7.5 24
O.S.6.9
with the voluntary 'test were given clinical
! OlNer 4p .50.8
and support services referrals and prefer- Wh to. .. . :.`
ential admission to methadone mainte-
18.. ' .; 5 ;'.. .. 26.3.,
nance treatment. The statistical signifi- Meteroewwal
784 :::: ., 99, `.;.....12,B . :.:.::1
canoe of associations was evaluated using West cou* 417 71 22. 1;4,3.4
chi-square and Fisher's Exact tests. 8.7HIV1:.: ..:.
-1 seroprevalence group differences Abe 30 and over.:... 730.: 101 13 8 3 0:':`. ..::fA4,.115
and the likelihood of infected drug users Age under 30 .: :.
79 4 5.0.: .: f
knowin their status at admission were Malnter
g :.290 57. 19.7 2.4
evaluated with crude odd ratios(ORs). mon 474`
%n on.un gerKW acrd race was erg horn lour.NXIbAeded derrts aw:one kResults
Jectad cierit
ti�rrrrsgon on seoalei orierrtebon was rrriasin *om sk nwhiected cse b.wd one irdected cierrt..
.:
krfixtr an oo.ape was misshrg(torn one narntded dwt Treatment madalty httoiawbw was
Seroprevalence levels are reported in nri�krp for.t3 norbrdected cGerrts and 1pa trAecxed cierds.and reported as"otliei".tor28 rronntected
Table 1.African-American drug users rep-
resented 27.0% of the clinic population
and 77.9% of the clients infected with
HIV-1.The seroprevalence among clients
in methadone maintenance was higher TABLE 2-Acceptance among lnoction thug users of a Confidential.HN Test
upon Admission to Trastmerit,
a
than that for those entering methadone Contra Costs may'
detoxification.Injection drug users under
30 years of age were less likely to be in- n HtY Testfected than
were older clients,and cents .: .. . .:. . . ,.
at the West County clinic had higher rates kw**&Ad Users 705.. .., "::.. .4 -10.9
of infection.Overall,a confidential HIV-1 X05 . 18
17.1 kifect
test was largely accepted(62.6%),but in-
fected clients were more likely to decline of -1 sus
a confidential test(Table 2).
Of the 105 infected drug users, 58 jection drug users infected with HIV-1 other hand, the West County clinic had
(55.2%)already knew of their HIV infec- knew of their infection. most of the infected clients(67.6%) and
tion and only 6 of those chose to test again. Only 12(25.5%)of the 47 who were most of the African-American clients
There were 47 drug users (44.8%) who unaware of their infection accepted a con- (73.7%). African Americans constituted
were infected and unaware of the infection fidential test upon admission to treatment 38.6%of the West County clinic popula-
(Table 3).Infected users entering detoxd- in 1991(Table 3).Of the 35 infected drug tion and only 14.60/c of the East County
fication programs were less likely to know users who were unaware of their infection clinic population.We found no significant
of their infection than those entering or and declined a confidential test,27(77.1%) difference by clinic in the acceptance of an
continuing in maintenance programs reported having had at least one such test HIV test among infected African-American
(P<0.001).The group less likely to take in the past,and 16(45.7%)had had a neg- clients who were unaware of their infection
a confidential test were methadone main- ative test within the past 12 months;mark- (East County clinic = 28.6% vs West
tenance clients from the West County ing recent seroconversions or infections. County clinic=20.6%).Also of some in-
clinic(P= .054).Infected African Amer- Regarding clinic differences, with terest is the observation that injection drug
icans were less likely overall to know of similar client population sizes, the East users who were aware of their infection re-
their infection than White (OR =0.15; County clinic, had clients more likely to ported using crack cocaine more often(IV
95% confidence interval [CI] = 0.02, know of their infection(Table 4),was sig- 58,or 20.7%)than those who were unaware
0.74), but some clinic variation existed. nificantly more successful (P< .001) in (4147,or 8.7%)(P= .07).
Among infected African-American drug recruiting clients for an HIV test than the
users, those entering treatment in East West County clinic(76.3%vs 49.6%),and DiW SSIOn
County, although fewer in number, also appeared more successful in recruit-
seemed more likely than those entering ing among the infected who were not Contra Costa seroprevalence rates
treatment in West County to know of their aware of their infection(40.0%vs 21.6%). for injection drug users are among the
HIV infection.All five gay or bisexual in- This difference was not significant.On the highest reported in California.The policy
October 1993,Vol.83,No.10 American Journal of Public Health 1415
Rearddo et aL
'TABLE3-,Acceptance da C Rental . TABLE of Serosfetus w
County Drug U- A .
}$V-1 Teel9
SlllOrlg Trsat n t in.Contra Costa 1991: ::, ... ...:.:: ;
Drtrg Users Entering
Treatment kYCorttra Coetae
may,tallornle,1991,
n .
`No
Who were Not Awae o4.: of ir�tec OR
7h*mon
East County drtic ,...... $4 24. 70 i:.::B.T l-4,10.1.::
NIO
West
Yom. '71::,. ':: •.. 34.:. ::.. . :.47.8 ...:1..; .. .. .
l+lcoeptrtg .'.:. Otler 6111nic group. :.:. .: :..:. ..:'.: 23 :.:. .'.:..:.18%.% 78.3. ..:.3.7 12,:138....::
n .:HfV Test. 96: : Airkm Arneric ari` : $i 40: 49.4
African Amerloen/Esst
County clinic .:22 : ::....: :.7. :.`::".::
31.$ 2.9 .. 0.94,9.6 .
Toth 47 ::-12.....::.25.5 African AmericarMest
.. .: ....... .. County clinic .:59. ... 25 42.4 i� .. ..
Male:. 91.. 8. 19.4 :
Ferirele:.:.:...:. .: .:.16 :::::: :6 37.5..
.A*icani4rnerican: ..... 41 5,..`.:22.5 meAll Infection DUsers
ter.shic omw '::, 5 :2 40.0rug. ,:...
I ! I
YVestCDunlydittc. 37 8 21.6 Male s...•
East Catty cfetic . 10-: . :.4: 40.0 Female •,...
MethadoneAfrican American .o•
14 1. 7.1 . Latino •..,.
Other p�.,•
deb ftaddin.,;: ..3D $... . 26.7 White
NagetFMetestintast Under ape 30 •,...
Ape 30 and over •....
East County clinic I ,a
91.... .$ ::.;': 258 ' West County clinic .•.•.
NlestCour�+cioniC.: Infected �.,.
11 ::......;0. AA Not Infected •...•
Ar other diems 33 : 9
:27.3 .
Infected and aware +o.,•I
Nae lift. on race was rnWwgframone at. Infected and unaware :,.•.
these dents,who sooeQBed the}4v teat Treed 0% 20% 40% 80% 80% 100%
not modatty infotrtteiki was m sing for three
of these tiacted.dism the tree aoneped the FIGURE 1--Acceptance of an HN-1 antibody test by Injection drug users entering .
bestrnent in Contra Costa
County,CalFfomia 1991.
of actively and preferentially admitting in- ents admitted to drug therapy(62.6%),and clinic.The East County clinic appears to
fected clients to maintenance programs the availability of these programs has cer- have established a more accepting atmo-
will likely result in a rising seroprevalence tainly contributed to infection awareness. sphere,which brings into testing more ch-
among maintenance clients, which, it is Clearly,not all detoxification clients may ents of all groups, including the infected
hoped,will be accompanied by a declining be ready for a confidential HIV-1 test at and unaware. Race distributions in each
seroprevalence rate among detoxification the time of admission,and it may be better clinic may also be a factor in the difference
clients. This will represent a successful for some to postpone the news of infection between clinics because African-Ameri-
combination of the protective measures to facilitate the first steps of recovery.14 can clients entering treatment in both din-
implemented by those who are continuing Nevertheless,among infected clients un- ics were less hkely than other clients to
to inject drugs and the reduced probability aware of their status, the test was ac- accept a test,and the East County clinic
of such drug users encountering a needle- cepted more often by those enrolling in had a smaller African-American clientele.
sharing partner infected with HIV-1.But methadone detoxification than by those These observations suggest that the par-
this public health goal has not been enrolling in or continuing methadone ticular environment created at the East
reached yet.The 1991 seroprevalence for maintenance,who are likely further into County clinic made acceptance of the test
detoxification clients was 9.30/&—lower, recovery.In airy event,the test mast con- the norm(76.3%)and contributed to the
but not significantly so,than the 9.8%rate tinue to be available to injection drug users test's acceptance by infected and unaware
of 1990.It is hoped that continued efforts and their sexual partners at any time after clients,but it was not enough to eliminate
to reach,counsel,educate,and test injec- admission and upon request.Certain drug the general reluctance of African Ameri-
tion drug users in Contra Costa County users who are infected and unaware of the can clients to test.Further research is also
and to offer facilitated and preferential ad- infection may not feel at risk because they needed on drug abuse patterns(e.g.,abuse
mission to methadone maintenance pro- have been in maintenance treatment for of crack cocaine)of injection drug users
grams will be reflected in declining sero- some time,or they may have specific con- who learned of their HIV-1 infection.
prevalence rates among drug users cern about the test or its consequences. Additionally, our data confirmed that
entering detoxification programs in future This group needs to be studied further. one-to-one education and testing alone is
years. The acceptance of a confidential test not guaranteed to prevent all infection
The programs for in-house HIV-1 by clients who are infected and unaware of among these users.'s Complementary ap-
confidential testing at these clinics were their infection parallels the general level of proaches to counseling and treatment,in-
successful in recruiting the majority of cli- acceptance of the test by all clients at each cluding programs to make clean needles
1416 American Journal of Public Health October 1993,Vol.93,No.10
MV among I41ectkm Drug Users . .
available to those continuing to inject The authors acknowledge the profes- 8. Reardon J,Warren N,Keilch R,Jenssen
drugs,are needed to reduce the incidence sional participation and assistance of Mary less D,Wise F,Brunner W.HIV serostatus and
of HIV-1 in this population. Wilson, MD, MPH (California State Depart- confidential HIV antibody testing in meth-
Ourment of Health Services, Office of AIDS); adone clinics in Contra Costa County,Cal- i
study shows the potential for bi- Charles Deutschman,MFCC,and Steve Love- ifornia,USA, 1990.Seventh International
ased underestimation of HIV-1 preva- Seth(Contra Costa County Substance Abuse Conference on AIDS;June 16-21, 1991;
lence in voluntary testing surveys. The Division); Rodney Smith,PhD(Contra Costa Florence,Italy.Abstract WC 3367.
knv rate of acceptance of voluntary con- County Public Health Laboratory); Emmett 9. Hull MF, Bettinger CJ, Gallaher MM,
Velten, PhD (Bay Area Addiction Research Keller MM,Wilson J,Mertz GJ.Compar-
fidential HN-1 testing among those in- Treatment;and the San Francisco Ba Area
fected resulted in a voluntarytesting Prev- ) y lie n of consenting
HIV-antibody prevalence in pa-
SBP HIV Seroprevalence Regional Coordinating tients consenting to and declining HIV-
alence estimate(3.5%)four times smaller Committee. antibody testing in an STD clinic.JAMA.
than the estimate obtained by the unlinked 1988;260(7):935-938. I
survey(13.0%),which included all clients References 10. Cabral-Evins DN, Stone S,Anderson L,
admitted into treatment.In the study pop- 1• California Department of Health Services, Gaudino JA.Association of human immu-
ulation, the main reason for the lack of Office of AIDS.Calif HIY44IDS Update. nodeficiency virus serostatus with confi-
1993;6(1):7. dential and unlinked antibody testing in an
acceptance of voluntary testing by the in- 2. Contra Costa County Health Services De- STD clinic.Sixth International Conference
fected clients seems to have been previous partment, Public Health Division. Quar- on AIDS;June 20-24,1990;San Francisco,
knowledge of their infection. Hence the reriy Rep HIVIAIDS Star. April-June Calif.Abstract FC-684,vol.2.
more successful the past voluntary testing 19922• 11. Hart G.Factors associated with requesting
programs have been, the fewer infected 3. Yano E,Longshore D,Gorman M,Hughes and refusing human immunodeficiency vi-
M,Anglin MD.HIV Infection among In- rus antibody testing. Med J Australia.
clients will accept the voluntary test in travenous Drug Users. California Depart- 1991;155(9):586-589.
subsequent survey periods,and the lower ment of Health Services, UCLA Drug 12. Jones TS,Allen DM,Onorato IM,Peter-
and more biased the estimates will be.In Abuse Research Group for the Office of sen LR,Dondero TJ,Pappaioanou M.HIV
addition, lack of knowledge, misunder- AIDS;.1991:68. seroprevalence surveys in drug treatment
standings, and fears may hinder specific 4. Watters JK, Cheng YT, Bluthenthal R. centers.Public Health Rep. 1990;105(2):
Carlson J, Lorvick J. Drug injectors and 125-130.
racial or ethnic groups'acceptance of con- HIV-1 infection in the San Francisco Bay 13. Centers for Disease Control.Interpretation
fidential testing. These areas of concern Area.Eighth International Conference on and use of the Western blot assay for se-
must be adequately addressed by volun- AIDS;July 19-24,1992;Amsterdam,The rodiagnosis of human immunodeficiency
tary testing programs. ❑ Netherlands.Abstract PoC 4700. virus type 1 infections.MMWR. 1989;38
5. Brickner PW,Tortes RA,Barves M,et al. (No S-7):1-7.
Recommendations for control and preven- 14. Magura S, Grossman JI, Lipton DS,
tion of human immunodeficiency virus Amann KR,Koger J,Gehan K.Correlates
Acknowledgments (HIV)infection in intravenous drug users. of participation in AIDS education and
Blinded seroprevalence surveys were funded Ann Intern Med 1989;110:833-837. HIV antibody testing by methadone pa-
by the CDC National HIV Seroprevalence Sur- 6. Volberding PA,Lagakos S,Koch MA,et tients.Public Health Rep. 104(3):231-240.
veys through the California Department of al.Zidovudine in asymptomatic human im- 15. Calsyn DA, Saxon AJ, Freeman G Jr,
Health Services,Office of AIDS.Confidential munodeficiency virus infection.N Engl J Whittaker S.Ineffectiveness of AIDS ed- i
testing for HIV-1 antibodies was funded by the Med 199022:941-949. ucation and HIV antibody testing in reduc-
CDC through the California State Department 7. Haverkos HW. Infectious diseases and ing high-risk behaviors among injection
of Alcohol and Drug Program, Division of drug abuse.JSubsrAbuse Treat. 1991;(8): drug users.Am J Public Health. 1992;
Drugs,AIDS Intervention Section. 269-275. 82(4):573-575.
October 1993,Vol.83,No.10 American Journal of Public Health 1417
1048 Concise Communications JID 1993;168(October)
Discrepancies in Tuberculin Skin Test Results with Two Commercial Products
in a Population of Intravenous Drug Users
Alan R. Lifson,John K. Watters, Stvsnne Thompson, Departments of Epidemiology and Biostatistics and of Family and
Charles M.Crane,and Francie Wise Community Medicine.School of Medicine,and Urban Health Study.
Institute for Health Policy Studies. University of California.San
Francisco;Communicable Disease Control, Public Health Division.
Contra Costa County Health Services Department.Martinez.California
Screening for tuberculosis(using the Mantoux test)and human immunodeficiency virus(HIV)
was conducted among intravenous drug users(IVDUs)recruited from a San Francisco Bay Area
neighborhood.Of 178 IVDUs skin-tested with one commercial purified protein derivative(PPD)
preparation,a reaction of a5 mm of induration occurred in 62(47%)of 133 HIV-negative and 13
(29%)of 45 HIV-positive IVDUs(P=.037).Forty-two IVDUs with an initial PPD reaction a5
mm were retested with a second commercial preparation; 11 (26%)had no reaction(0 mm)on
retesting.These 11 were 5(56%)of 9 HIV-positive and 6(18%)of 33 HIV-negative persons(P=
.038).These discrepancies may be unique to specific lots of product or may reflect more general
differences. A degree of caution in evaluating unexpected tuberculin skin test results may be
indicated.Response to different tuberculin products by HIV status should be further evaluated.
Screening of high-risk populations for infection with MKo- tant component of the national plan to combat tuberculosis
bacterium tuberculosis has been recommended as an impor- (TB)[1,2].Such screening is commonly done with the Man-
Received 23 March 1993;revised 7 June 1993. toux tuberculin skin test.with intracutaneous injection of 5
Presented: IX International Conference on AIDS/IV STD world Con- tuberculin units (TU) of purified protein derivative (PPD)
gress.Berlin.6-11 June 1993. [3].For certain persons who have a positive skin test without
Informed consent was obtained from study subjects.using guidelines of evidence of active TB, therapy with isoniazid is recom-
the University of California Committee on Human Research.Participants in
this study received a small monetary reimbursement. mended (2]to prevent latent TB infection from progressing
Grant support: National Institutes of Health (DA-06908);Centers for to active disease.
Disease Control and Prevention(U62-CCU902017).Office of AIDS.San TB represents a significant cause of morbidity and mortal-
Francisco Department of Public Health(83-07069).
Reprints or correspondence(present address):Dr.Alan R.Lifson.Divi- ity among intravenous drug users(IVDUs)[4,51.IVDUs are
sion of Epidemiology.School of Public Health. University of Minnesota. also at risk for infection with human immunodeficiency virus
1300 S.Second St..Suite 300.Minneapolis.MN 55454-1015. (HIV), which may increase the likelihood of developing ac-
The Journal of Infectious Diseases 1993068:1048-51 tive TB; in one stud the incidence of active TB amort
®1993 by The University of Chicago.All rights reserved. y' g
0022-1899/93/6804-D039S01.00 HIV-positive PPD-positive IVDUs was 7.9 cases/100 per-
JID 1993.168(October) Concise Communications 1049
son-years[4]. IVDUs are therefore an important population interpretation.Trained staff measured the size of induration for
for whom TB screening is recommended[I].Preventive ther- skin test antigens by both palpation and the ballpoint pen
apy with isoniazid is recommended for all IVDUs with a method [7]: results were recorded on standard forms. For this
PPD skin test of>_10 mm of induration and for certain per- analysis, we defined anergy as a reaction to PPD of 0 mm of
sons with induration >5 mm, including those infected with induration and a reaction to both controls c 1 mm.
HIV [1]. Retesting. Seventy-five IVDUs had a reaction>5 mm on the
As part of a study of IVDUs recruited from community- initial screening with product A.Attempts were made to contact
based settings, we conducted screening for TB and HIV y- these subjects by letters, phone calls, or outreach workers to
offer a repeat skin test. Forty-three persons (57%)agreed to a
one San_Francisco Bay Area neighborhood. Our initial TB second skin test with product B (Tubersol, lot 233422), of
screening was done with one commercial tuberculin prepara- whom 42 returned 2 days later for skin test reading. Retesting
tion (PPD product A. Aplisol. Parke-Davis. Morris Plains, was done 2 months after the initial screening.
NJ). After this testing, we became aware of a number of Statistics. Discrete variables were compared by using the xi
employees of the University of California, San Francisco or Fisher's exact test: continuous variables were compared by
(UCSF)who had a positive skin test reaction with product A using Student's t test.Confidence intervals(Cl)were calculated
and who were retested with a different commercial prepara- about proportions. Statistical analyses comparing initial PPD
tion(PPD product B.Tubersol:Connaught.Swiftwater.PA). measurements with retest measurements on the same persons
On retesting, most of these employees were skin test—nega- are not presented because,by definition,retesting was done only
tive(R. Harrison,personal communication).Preliminary in- on persons who had an initial induration Z5 mm.This selection
formation indicated that employees with discrepant results for retesting based on exceeding a certain threshold of a mea-
sured characteristic may result in a "regression toward the
had been tested with the same lot of product A used in our mean"effect at the time of the next measurement.
initial screening of IVDUs.
Because we were concerned about these discrepancies and
possible inappropriate referral of subjects for isoniazid ther- Results
apy,we attempted to contact all subjects who had a reaction Initial skin testing. During the initial screening. 192
,>5 mm with product A to offer retesting with product B. IVDUs had PPD skin tests with product A. 178 (93%) re-
This report summarizes our findings. turned 48-72 h later for evaluation. Of the 178 who re-
turned, 75 (42%) had a reaction ;-5 mm. Induration of>5
Method:ubjecis.
mm was present in 62 (47%) of 133 HIV-negative and 13
(29%)of 45 HIV-positive IVDUs(P= .037).a reaction>10
Study The Urban Health Study evaluates IVDUs mm was present in 48 (36%) of 133 HIV-negative and 12
recruited from San Francisco Bay Area neighborhoods with a (27%)of 45 HIV-positive IVDUs(P> .10). Of 166 IVDUs
high prevalence of drug use. In these communities, a targeted who received both control skin tests as well as PPD and who
sample of IVDUs are recruited by experienced outreach workers returned for evaluation, 6% of HIV-negative and 20% of
[6]. All participants must be current IVDUs and have visible HIV-positive persons were classified as anergic (P= .012).
signs of recent venipuncture.The study described here was con- After those who were anergic were excluded,a reaction a5
ducted in Richmond.California. mm was present in 48%of HIV-negative and 39% of HIV-
1VDUs who agree to participate undergo an interview and positive IVDUs(P> A0). IVDUs with induration ;_o5 mm
HIV antibody testing. Screening for HIV antibody is done by were referred to the county health department for further
EIA with confirmation by Western blot.Minimum criteria for a
positive Western blot are the presence of bands at at least two of evaluation and possible isoniazid therapy.
the following:p24,p41.and gp120/160. Repeat PPD tests. Of 42 IVDUs who were skin-tested
Skin rests. IVDUs who had already agreed to HIV testing with both products A and B, 29 (69%) were male and 13
were asked if they would also be willing to receive a TB skin test. (31%)were female. Thirty-eight(90%)were African-Ameri-
Exclusion criteria for TB testing included a history of active TB, can and 4(10`i;)of other race/ethnicity,reflecting the study
a positive TB skin test resulting in further workup or institution population evaluated at this site. The mean age was 42.7
of preventive therapy,and a severe or allergic reaction to the TB years. 9 persons(21%)were HIV-antibody positive. Among
skin test. the 75 persons who initially had a reaction >5 mm, those
Screening for M. tuberculosis was done using an intradermal who returned for a second skin test reading did not differ
injection of 0.1 mL of 5 TU of PPD stabilized with Tween 80
(Mantoux test),administered through asingle-dose syringe by a significantly from those who did not by sex, age, race/
trained staff member.The initial skin tests were done with prod- ethnicity,or HIV antibody status(P> .10).
uct A (Aplisol, lot 00952P). Subjects were also evaluated for Of those tested with both products A and B. the median
anergy by using two controls: 1:100 dermatophytin "O." Can- skin test reactions were 16.0 and 12.5 mm,respectively.Ta-
dida antigen (Hollister-Steir, Spokane, WA) and mumps skin ble 1 categorizes subjects by their initial and repeat skin test
test antigen (Connaught). The location of skin test placement results.Of IVDUs retested. 11 (2617<)had no reaction(0 mm)
on the arms was recorded on a standard form.Participants were with product B.No reaction on retesting occurred in 5(56r�)
asked to return 48-72 h after the initial placement for skin test of 9 HIV-positive and 6(18%)of 33 HIV-negative persons(P
1050 Concise Communications !ID 1993.168(October)
Table 1. Categorization of 42 intravenous drug users by indura- 9]. For example,one report described 16 school district em-
tion response on initial and repeat tuberculin skin tests. ployees who had a positive skin test with product A; 13
Initial results(product A) persons were retested with product B and were PPD-
negative[8].
5-9 mm 10-14 mm >15 mm Between any two tuberculin tests there may be some vari-
Repeat results ability in skin test response or interpretation,even if subjects
(product s) HIV- HIV* HIV- HIV* HIv- HIV* Total are tested with the same product[101.To improve accuracy
0 mm a I 0 3 2 I 11 and reduce variability, skin tests were administered and in-
1-4 mm 2 0 1 0 0 0 3 terpreted using standard criteria by trained staff, many of
5-9 mm 1 0 1 0 0 0 2 whom participated in both screenings. Although we cannot
10-14 mm 1 0 3 0 1 1 6 exclude variability as a partial explanation for our findings.if
>IS mm o 0 I 0 16 3 20 the discrepancies we identified were entirely due to variabil-
_ NOTE. HIV- or Hlv*, negative or positive for human immunodefi- ity in skin test response, this raises significant questions '
ciency virus. about the reliability of tuberculin skin test results.
If the discrepancies we identified were not entirely due to
variability,then some IVDUs may have had either false-po-
_ .038). Of the I 1 IVDUs with no reaction to product B, 8 sitive skin test with product A or a false-negative test with
reacted to at least one of the two skin test controls,2 had no product B. False-positive tuberculin tests may be due to hy-
reaction to either control,and I did not receive mumps but persensitivity to other mycobacteria[I 11,including Mvcobac-
had no reaction to the Candida control. The two persons Cerium avium complex, an important cause of disease in
who did not react to either control or to product B were both HIV-infected persons. Among those retested,discrepant re-
HIV-infected. Of 31 IVDUs who had some reaction (>0 sults were more common in HIV-infected IVDUs. Dissemi-
mm)with product B, 30 reacted to at least one of the con- nated infection and disease due to M. avium complex tends
trols.and 1 had no reaction to either control. to occur in HIV-infected persons with severe immunosup-
By design,all 42 persons had induration>5 mm with prod- pression [12]. However, it is possible that HIV-infected per-
uct A.in contrast,28(67%;95%CI,50%-806)had a skin test sons in this study(even in the absence of disease)were more
. reaction to product B >5 mm. Thirty-three (79%; 95% Cl, likely than HIV-negative persons to be infected with atypical
63%-89%)of those tested with product A and 26(62%;95% mycobacteria or to be colonized with greater numbers of or-
CI,46%-76%)of those tested with product B had a reaction ganisms.Another theoretical explanation for a false-positive
?--10 mm. Isoniazid preventive therapy is recommended for result with product A is a reaction to a different, nonmyco-
all IVDUs with a reaction to PPD 310 mm and for HIV-posi- bacterial antigen.
tive IVDUs with induration >5 mm[1].Of those who were False-negative skin test reactions may be due to a number
retested,on the basis of only PPD result and HIV status, 34 of factors related to the tuberculin used,method of adminis-
IVDUs would have been referred for isoniazid therapy ac- tration, test interpretation, or person being tested [3, 11].
cording to product A results and 26 according to product B Although HIV-induced immunodeficiency may lead to fail-
results. ure to respond to diagnostic skin tests[131,it seems unlikely
Thirty-six IVDUs indicated that they had received a pre- that more than half the HIV-infected IVDUs with a positive
vious TB skin test (prior to our studies), of whom 4 (11%) initial skin test would become anergic at the time of repeat
reported that the most recent skin test preceding our initial testing only 2 months later. Furthermore,even among HIV-
screening was positive;this lower rate reflects our exclusion negative IVDUs, 18%had no reaction on retesting.
criteria. The previous skin test was not positive in 8 IVDUs There may be more than one explanation for our results.
with induration of 0 mm on retesting(product B), I IVDU However, several factors suggest that at least some propor-
with a reaction 1-4 mm on retest,and 23 of 27 IVDUs with a tion oUthe initial PPD results represent false-positive re-
retest reaction >5 mm. sponses.Our retesting was initiated because of anecdotal re-
ports of discordant PPD results in some health care workers;
in this setting,the single positive result(with the same lot of
Discussion product A as in our initial screening) was believed most
likely to represent a false-positive skin test. In addition. the
Of 42 IVDUs who had a PPD skin test reaction >5 mm rates of PPD positivity identified in our initial screening were
with one commercial product, 26% had no reaction when somewhat higher than we expected on the basis of studies in
retested 2 months later with a different product. Whether other cities[4. 141.and our own studies of IVDUs.For exam-
these differences were unique to a particular lot of PPD prod- ple.in another San Francisco neighborhood characterized by
uct or represent a more general problem is unknown. How- high rates of drug use and TB.25%of HIV-negative IVDUs
ever, discordant results with use of products A and B have had induration >10 mm and 20% of HIV-positive IVDUs
been previously described in health department bulletins 18, had induration >5 mm [15].
JiD 1993;168(October) Concise Communications 1051
Whether the discrepancies we observed are due to differ- Hams, Jennifer L.orvick, Charles Richardson, Bernadine San-
ent concentrations of tuberculin in the two commercial skin tana, and Tia Wagner for help with the study; James Carlson
test preparations or to some other factor, both false-positive and the UCSF AIDS Tissue Bank for assistance with HIV anti-
and false-negative responses are of concern. False negatives body testing or specimen storage;and Denise Koo,Sarah Royce,
could result in failure to initiate preventive therapy in a per- George Rutherford,and Mark Segal for helpful suggestions.
son infected with M. tuberculosis. False positives may result
in inappropriate initiation of isoniazid(with the potential for
hepatotoxicity or other adverse effects)as well as diversion of References
health care resources toward following such patients. Incor- 1. Centers for Disease Control.Screening for tuberculosis and tuberculous
rectly identifying an individual as having a positive PPD skin infection in high-risk populations,and the use of preventive therapy
test will also make it more difficult to detect a true skin test for tuberculous infection in the United States:recommendations of
conversion if it subsequently develops. the Advisory Committee for Elimination of Tuberculosis. MMWR
Quantitating the sensitivity and specificity of specific PPD 1990:39(RR-8):1-12.
skin test products is difficult for several reasons. Because 2. American Thoracic Society. Control of tuberculosis in the United
States.Am Rev Respir Dis 1992;146:1623-33.
there was no conclusive reference standard for latent M. tu- 3. American Thoracic Society.Diagnostic standards and classification of
berculosis infection, a definitive interpretation of discordant tuberculosis.Am Rev Respir Dis 1990:142:725-35.
skin test results was not possible. In our retesting,we evalu- 4. Selwyn PA,Hartel D.Lewis VA,et al.A prospective study of the risk of
ated only IVDUs who had a reaction>,5 mm with product A, tuberculosis among intravenous drug users with human immunodefi-
with the previously noted potential for a "regression to the ciency virus infection.N Engl J Med 1989;320:545-50.
5. Stoneburner RL.Des Jarlais DC.Benezra D,et al.A larger spectrum of
mean" effect. We did not detect persons who theoretically severe HIV-I-related disease in intravenous drug users in New York
could have had a negative skin test with product A and posi- City.Science 1988;242:916-9.
five results with product B.To identify the specificity of one 6. Watters JK, Biernacki P.Targeted sampling:options for the study of
skin test product, it would also be necessary to know the hidden populations.Soc Probl 1989;36:416-30.
7. Longfield JN,Margileth AM.Golden SM.Lazoritz S.Bohan JS,Cruess
number of subjects who were free of M.tuberculosis infection DF.Interobserver and method variability in tuberculin skin testing.
with negative skin test results. For these reasons,our discus- Pediatr infect Dis 1984;3:323-6.
sion focuses on certain discrepancies in results between the 8. Infectious Disease Branch,California Department of Health Services.
two PPD products. False positive tuberculin skin test reactions and product variability.
The existence of such discrepancies, for whatever reason, California Morbidity 1989.28(July 21):1.
raises questions that warrant additional investigation. A de-
9. Section of Epidemiology,Alaska Department of Health and Social Ser-
vices.False-positive Aplisol PPD reactions.State Alaska Epidemiol
gree of caution in the interpretation of specific skin test re- Bull 1992;9(May 12):1.
sults may be indicated in certain situations, particularly if 10. Chaparas SD.Vandiviere HM.Melvin I,Koch G,Becker C.Tuberculin
such results are inconsistent with epidemiologic data or ex- test: variability with the Mantoux procedure. Am Rev Respir Dis
pectation of M. tuberculosis infection. Additional studies si- 1985;132:175-7.
11. American Thoracic Society.The tuberculin skin test.Am Rev Respir
multaneously evaluating different PPD produce in the same Dis 1981.124:356-63.
persons, including those who are HIV-infected,may help to 12. Horsburgh CR. M'Pcobacterium avium complex infection in the ac-
further evaluate issues raised here. If significant discrepan- quired immunodeficiency syndrome.N Engl J Med 1991:324:1332-
cies between skin test products are noted, particularly in g.
high-risk subjects such as IVDUs,this raises important issues 13. Centers for Disease Control.Purified protein derivative(PPD)-tubercu-
for TB control programs and lends support to refinement of Lin anergy and HIV infection:guidelines for anergy testing and man-
agement of anergic persons at risk of tuberculosis. MMWR
current assays and development of additional diagnostic 1991;40(RR-5):27-33.
measures to identify M. tuberculosis infection in those with- 14. Graham NMH.Nelson KE.Solomon L,et al.Prevalence of tuberculin
out active disease. positivity and skin test anergy in HIV-1-seropositive and-seronega-
tive intravenous drug users.JAMA 1992.267:369-73.
Acknowledgments 15. Lifson AR, Watters JK, Thompson SM, Crane CM, Schecter GF.
Screening for tuberculosis(TB)among injection drug users(IDUs)
We thank Rickv Bluthenthal, Jose Carrasco, Myrto COnto- recruited from street-based settings.Presented:IX international Con-
gouris, Michelle Estilo, Daryl Gault, Sauda Garrett, Charles ference on AIDS/IV STD World Congress,Berlin,June 1993.
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