Multidrug-Resistant Tuberculosis in a Hospital -- Jersey City, New Jersey, 1990-1992

Since 1986 (the first full year following implementation of the revised tuberculosis {TB} surveillance case definition), the reported rate of TB per 100,000 persons in New Jersey increased from 9.5 cases to 12.6 cases in 1992 (1). Of the 984 cases reported to CDC from New Jersey in 1992, 108 (11.0%) were reported from Jersey City (1990 population: 230,300) -- the city ranked second in number of TB cases reported (1) and fourth in rate of TB (46.9 per 100,000) in the state. In addition, in 1992, the rate of multidrug-resistant TB (MDR-TB) (i.e., Mycobacterium tuberculosis isolates resistant to at least isoniazid {INH} and rifampin {RIF}) among TB patients in New Jersey was 5%; the rate in Jersey City was 13% (1,2). To characterize the epidemiologic features of persons with drug-resistant TB, the New Jersey Department of Health and the Infectious Diseases Division of the Jersey City Medical Center conducted a study among patients treated at that hospital during 1990-1992. This report presents the findings of the study and compares the hospital's rates of drug-resistant TB with previously reported rates, rates for other cities in New Jersey, and rates for the state.

The hospital serves a predominantly inner-city population and treats more than 40% of TB patients in Jersey City. Information about hospital inpatients with TB was abstracted from mycobacteriology log books and TB reporting forms. Mycobacterial species identification and drug-susceptibility testing were performed at the New Jersey Public Health Laboratory (NJPHL) or a commercial laboratory. The DNA probe method was used for species identification (3). Drug susceptibility was determined by the radiometric method for NJPHL and the conventional plate method for the commercial laboratory (4).

Data were analyzed for all 146 patients with culture-positive M. tuberculosis during 1990-1992. Of the 142 patients for whom TB reporting forms were available, 131 (92%) had had drug-susceptibility tests performed for anti-TB drugs. Patients ranged in age from 11 to 79 years (mean: 40 years); 95 (73%) patients were male. A total of 36 (28%) patients had extrapulmonary TB. Although no serologic survey for human immunodeficiency virus (HIV) infection was performed, matching of state TB records with state HIV/acquired immunodeficiency syndrome records indicated that at least 58 (44%) TB patients had concurrent HIV infection.

Of the 131 patients for whom drug-susceptibility testing had been performed, 32 (24%) had M. tuberculosis isolates resistant to at least one drug, and 21 (16%) had MDR-TB (Table_1). Of the six patients with a prior history of TB, four (67%) had MDR-TB, compared with 17 (14%) of the 125 patients with no prior history of TB (relative risk {RR}=4.9). Of the 97 patients known to have been born in the United States, 23 (24%) had TB resistant to at least one anti-TB drug, and 12 (12%) had MDR-TB; in comparison, of the 22 known foreign-born patients, four (18%) had MDR-TB (RR=0.7). Of the 18 foreign-born patients for whom information was available, seven had resided in the United States for 5 or fewer years before diagnosis of TB. Of those seven, two (29%) had MDR-TB, compared with two (18%) of the 11 persons who had resided in the United States more than 5 years (RR=1.6). Among these 131 patients, drug resistance was not associated with sex, age, race, or known HIV infection; because these cases were not associated with clustering in time or location in the hospital, nosocomial transmission of M. tuberculosis was unlikely.

Reported by: A Lin-Greenberg, MD, Jersey City Medical Center, Jersey City; A Cortes, Tuberculosis Control Program, New Jersey Dept of Health. Div of Tuberculosis Elimination, National Center for Prevention Svcs; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that the rate of MDR-TB in New Jersey varied widely: the rate among patients treated at the hospital described in this report during 1990-1992 was similar to that for Jersey City in 1992 but substantially higher than that reported for the state and for other New Jersey cities (2). For example, in Newark in 1992, the rate of MDR-TB was nearly one third (5%) of that reported for the Jersey City hospital, and although the number of isolates tested was small, no cases of MDR-TB were reported from Trenton or Camden -- urban areas with demographic and socioeconomic compositions similar to Jersey City's (2). In addition, the rate of primary INH resistance among patients at the hospital in Jersey City was higher during 1990-1992 (21%) than during 1984-1986 (15%), while the rates of presumptive primary MDR-TB during 1990-1992 and 1984-1986 were similar (14% and 13%, respectively) (5).

The higher rate of MDR-TB among patients in the hospital in Jersey City than in Newark and for the state of New Jersey may reflect a greater prevalence of non- adherence to treatment and/or exposure to persons with drug-resistant TB -- known risk factors for drug resistance (6). Jersey City is located near New York City, in which 19% of patients with TB in 1991 had MDR-TB (7) and outbreaks of MDR-TB have occurred recently (8). In addition, the five counties in New Jersey that reported more than one case of MDR-TB in 1992 are located closest to New York City (2). The findings in this report also are consistent with previous reports indicating an association between MDR-TB and prior history of TB (6).

The pattern of anti-TB drug resistance in Jersey City and other communities in New Jersey illustrates the substantial geographic variations in this problem, even within a small state. Knowledge of local resistance patterns is critical for determining optimal treatment regimens before drug-susceptibility test results are available. As a result of this study, use of directly observed therapy was instituted in hospitals throughout Jersey City. In areas with rates of INH resistance of 4% or more, anti-TB treatment should be initiated with four drugs (INH, RIF, pyrazinamide, plus either ethambutol or streptomycin), and directly observed therapy should be used (9). Institutions experiencing outbreaks or high rates of MDR-TB may need to begin five- or six-drug regimens as initial therapy. These regimens should include the four-drug regimen and at least three drugs to which the suspected MDR strain may be susceptible (9).

References

1. Bureau of Tuberculosis Control, New Jersey Department of Health. Annual report, 1992. Trenton, New Jersey: New Jersey Department of Health, Bureau of Tuberculosis Control, 1993.

2. Bureau of Tuberculosis Control, New Jersey Department of Health. Multiple drug-resistant tuberculosis in New Jersey. Trenton, New Jersey: New Jersey Department of Health, Bureau of Tuberculosis Control, 1992.

3. Body BA, Warren NG, Spicer A, Henderson D, Chery M. Use of Gen-Probe and Bactec for rapid isolation and identification of mycobacteria: correlation of probe results with growth index. Am J Clin Pathol 1990;93:415-20.

4. Heiferts L. Qualitative and quantitative drug susceptibility tests in mycobacteriology. Am Rev Respir Dis 1988;137:1217-21.

5. Lin-Greenberg A, Deltieure M. Primary resistance to anti-tuberculosis drugs in a New Jersey hospital. New Jersey Medicine 1987;84:427-8.

6. Barnes PF. The influence of epidemiologic factors on drug resistance rates in tuberculosis. Am Rev Respir Dis 1987;136:325-8.

7. Frieden TR, Sterling T, Pablos-Mendez A, Kilburn JO, Cauthen GM, Dooley SW. The emergence of drug-resistant tuberculosis in New York City. N Engl J Med 1993;328:521-6.

8. CDC. Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infected persons -- Florida and New York, 1988-1991. MMWR 1991;40:585-91.

9. CDC. Initial therapy for tuberculosis in the era of multidrug resistance: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1993;42(no. RR-7).

TABLE 1. Number of persons with reported cases of drug-resistant tuberculosis (TB),
by anti-TB drug -- Jersey City, New Jersey, 1990-1992 *
=====================================================================================
                            All cases         New cases
                             (n=131)           (n=125)
                            ----------        ---------
Drug resistance             No.    (%)        No.   (%)
-------------------------------------------------------
Isoniazid                    30   (23)         26  (21)
Rifampin                     22   (17)         18  (14)
Streptomycin                  7   ( 5)          6  ( 5)
Ethionamide                   6   ( 5)          5  ( 4)
Ethambutol                    0    --           0   --
>=1 Drug                     32   (24)         28  (22)
Multidrug-resistant TB +     21   (16)         17  (14)
-------------------------------------------------------
* n=142. Excludes 11 persons with no-drug susceptibility tests.
+ Resistance to at least isoniazid and rifampin.
=====================================================================================

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