Surveillance of Tuberculosis and AIDS Co-Morbidity -- Florida, 1981-1993

Because immunosuppression induced by human immunodeficiency virus (HIV) infection increases the likelihood that latent tuberculosis (TB) infection will become active in HIV-infected persons (1,2), in 1987, extrapulmonary or disseminated TB was added to the acquired immunodeficiency syndrome (AIDS) surveillance case definition (3), and in 1993, pulmonary TB in HIV-infected persons was added to the case definition (4). In Florida and other areas (5), AIDS surveillance activities include assessment of the completeness and validity of reported cases based on confidential record linkages with the TB registry and other disease registries. In December 1993, the Florida Department of Health and Rehabilitative Services (HRS) matched cases from the AIDS and TB registries to verify documented TB data, include more complete TB data on the AIDS registry, and identify cases from the AIDS registry with unreported TB. This report summarizes an analysis of this match, which underscored the need for collaboration and crosstraining of surveillance staff in AIDS and TB reporting.

HRS matched the records of all 16,559 cases of TB reported in Florida from 1984 (the earliest year for which computerized TB data were available) through December 22, 1993, with records of all 36,002 cases of AIDS reported in Florida from 1981 through December 22, 1993. Persons with atypical mycobacterioses and persons who did not reside in Florida at the time of TB diagnosis were excluded. Computer matching was based on combinations of the variables of name, date of birth, race, and sex and identified 5135 possible matches. Manual record reviews by HRS staff confirmed that 2567 (7.1%) patients reported with AIDS on the AIDS registry also were reported with TB on the TB registry.

Of the 2567 identified registry matches, 2137 (83.2%) were previously reported with TB on the AIDS registry; the remaining 430 cases had been reported to the AIDS registry without documentation of TB (Figure_1). AIDS cases matched with the TB registry were updated with more complete TB data, including date of diagnosis and whether the TB was pulmonary, extrapulmonary, or both.

Of the 36,002 cumulative AIDS cases, reports for 2816 (7.8%) cases indicated that the patient also had TB. For 679 AIDS cases with TB that were listed on the AIDS registry but that had not been reported to the TB registry as having TB, medical records were reviewed by HRS AIDS and TB surveillance staff, and cases were classified into mutually exclusive categories (Table_1). Reviews confirmed 78 (11.5%) as newly identified TB cases for the TB registry. Of the 516 AIDS cases that lacked validated TB diagnoses, for 298 (43.9%) investigators could not identify data to substantiate the CDC TB case definition, and for 90 (13.3%), cultures indicated infection with other species of mycobacteria (most frequently Mycobacterium avium). In addition, some cases originally diagnosed by physicians as TB were later revised, based on subsequent documentation, to a diagnosis of pneumonia from other causes. Because most (99%) of the 516 records without validated TB had other documented AIDS case criteria, they remained in the AIDS registry after correction of their TB status. Following the addition of updated TB data to some AIDS cases and the removal from the AIDS registry of some initially TB-defined AIDS cases with nonvalidated TB information, the number of reported AIDS cases with TB decreased 4.5% (from 2816 to 2690).

Reported by: L Conti, DVM, S Lieb, MPH, T Liberti, R White, MBA, L Crockett, MD, R Hopkins, MD, State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs. Surveillance Br, Div of HIV/AIDS Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The AIDS and TB registry match conducted by Florida HRS evaluated the quality of AIDS and TB surveillance data, and enhanced completeness of reporting for both surveillance systems. For example, 11.5% of the TB cases in persons reported with AIDS had not been reported previously to the TB registry. However, 13.3% of the reported cases of AIDS with TB that had not been reported previously to the TB registry were identified as mycobacterial infections other than M. tuberculosis, underscoring the need for collaboration between TB and AIDS surveillance personnel to verify the TB data. Medical record reviews of most (76.0%) of the 679 unmatched cases of AIDS with TB could not validate a TB diagnosis, reflecting, in part, insufficient documentation of TB case-criteria by health-care providers when specific positive-culture results were absent.

The increased incidence of TB as a result of the HIV epidemic (6-8) requires that health departments assist health-care providers in increasing their familiarity with the CDC TB case definition (9) to improve diagnostic accuracy and patient follow-up. In addition, state and local health departments should facilitate access by persons with TB to HIV testing and counseling services and provide tuberculin skin testing to persons with HIV infection (10). TB and AIDS registries should be matched at least annually to assist in characterizing the extent of co-morbidity and planning for necessary services. In Florida, AIDS and TB surveillance personnel have received additional training to improve their knowledge about both conditions. These training efforts have improved collaborative activities to ensure the accuracy and completeness of TB and AIDS surveillance data.

References

1. Selwyn PA, Hartel DH, Lewis VA, et al. A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection. N Engl J Med 1989;320:545-50.

2. Buehler JW, Ward JW. A new definition for AIDS surveillance. Ann Intern Med 1995;118:390-2.

3. CDC. Revision of the CDC surveillance case definition for AIDS. MMWR 1987;36(no. 1-S):3S-15S.

4. CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41(no. RR-17):6-7.

5. CDC. Co-incidence of HIV/AIDS and tuberculosis -- Chicago, 1982-1993. MMWR 1994;44:227-31.

6. Braun MM, Cote TR, Rabkin CS. Trends in death with tuberculosis during the AIDS era. JAMA 1993;269:2865-8.

7. Reider HL, Cauthen GM, Bloch AB, et al. Tuberculosis and acquired immunodeficiency syndrome -- Florida. Arch Intern Med 1989;149:1268-73.

8. Burwen DR, Bloch AB, Griffin LD, Ciesielski CA, Stern HA, Onorato IM. National trends in the concurrence of tuberculosis and acquired immunodeficiency syndrome. Arch Intern Med 1995;155:1281-6.

9. CDC. Case definitions for public health surveillance. MMWR 1990:39(no. RR-13):39-40.

10. CDC. USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus: a summary. MMWR 1995;44(no. RR-8).

TABLE 1. Mycobacterium tuberculosis (TB) validation results of AIDS cases not
matched to the TB registry -- Florida, 1981-1993
===============================================================================
Finding                        No.      (%)
----------------------------------------------
TB validated
  New TB cases                   78    ( 11.5)
  TB previously reported         35    (  5.2)
  TB reported out-of-state       10    (  1.5)
  Totaldated                    123    ( 18.2)


TB not validated
  TB case criteria not met      298    ( 43.9)
  No mention of TB              128    ( 18.8)
  Mycobacterium avium
    complex (MAC)                70    ( 10.3)
  Mycobacterial species
    other than TB or MAC         20    (  2.9)
  Total                         516    ( 76.0)


Other
  Deleted duplicate AIDS case    35    (  5.2)
  Data entry error                5    (  0.7)
  Total                          40    (  5.9)

Total                           679    (100.0)
----------------------------------------------
===============================================================================

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