Tuberculosis disparity between US-born blacks and whites, Houston, Texas, USA.
After the unprecedented resurgence in tuberculosis (TB) in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. during 1985-1992, the annual incidence rate of TB steadily decreased from 1993 to 2007. However, this decline recently decelerated, raising concerns that progress toward eliminating TB is slowing. In 2007, a total of 13,293 TB cases (4.4 cases per 100,000 population) were reported in the United States, representing a 4.2% decline in incidence from 2006 (1). Despite this decline, TB incidence remains higher among certain racial/ethnic minorities, i.e., blacks, Hispanics, and Asians, than for non-Hispanic whites. For instance, US-born young blacks probably account for the largest number of secondary TB cases in the country (2). In addition, TB rates for non-Hispanic blacks continue to be 8 times greater than for non-Hispanic whites (3). Hispanics and non-Hispanic blacks also accounted for nearly three quarters (73.9%) of 11,480 TB cases in children reported during 1993-2001, of which more than half occurred in children <5 years of age (4).
These findings clearly suggest recent ongoing transmission of Mycobacterium tuberculosis Mycobacterium tuberculosis
Mycobacterium tuberculosis in these ethnic groups rather than reactivation reactivation
to become active after a period of quiescence or, as in bacterial and viral infections, latency.
cross reactivation of latent infection. Recently, molecular epidemiologic studies epidemiologic study A study that compares 2 groups of people who are alike except for one factor, such as exposure to a chemical or the presence of a health effect; the investigators try to determine if any factor is associated with the health effect , which estimate the proportion of clustered TB cases, have been used to support this hypothesis (5). For instance, a molecular epidemiologic study of TB in San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden during 1991-1992 found M. tuberculosis M. tuberculosis,
n the bacterium responsible for tuberculosis, generally a respiratory infection in man; nonrespiratory tuberculosis is considered an indicator disease for AIDS. See also tuberculosis. clustering in 191 (41%) of 471 patients studied that were distributed in 44 clusters. Hispanic ethnicity or black race, birth in the United States, and an AIDS diagnosis independently predicted clustering (6). Similarly, other population-based studies in New York City New York City: see New York, city.
New York City
City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S. and in Tarrant and Harris counties in Texas found clustering of 36%-52% (7-9).
Molecular studies of clustering and identification of risk factors that contribute to these racial/ethnic disparities are crucial for efforts to eliminate TB in the United States. Although differences in socioeconomic status socioeconomic status,
n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion. and access to the healthcare system among non-Hispanic blacks have been postulated pos·tu·late
tr.v. pos·tu·lat·ed, pos·tu·lat·ing, pos·tu·lates
1. To make claim for; demand.
2. To assume or assert the truth, reality, or necessity of, especially as a basis of an argument.
3. as the main barriers to TB diagnosis and treatment in this group, further information is needed (3,10). We studied the traditional and molecular epidemiology molecular epidemiology Molecular medicine An evolving field that combines the tools of standard epidemiology–case studies, questionnaires and monitoring of exposure to external factors with the tools of molecular biology–eg, restriction endonucleases, of TB in US-born blacks enrolled in the Houston Tuberculosis Initiative (HTI HTI Haiti (ISO Country code)
HTI High Tech Institute
HTI Hand Tools Institute
HTI Hamilton Island, Queensland, Australia (Airport Code)
HTI Horizontal Technology Integration ) during 1995-2004.
Materials and Methods
The study population comprised patients recruited through HTI, a population-based active surveillance and molecular epidemiologic study that enrolls persons with TB reported to the City of Houston Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS and Harris County Public Health and Environmental Services The various combinations of scientific, technical, and advisory activities (including modification processes, i.e., the influence of manmade and natural factors) required to acquire, produce, and supply information on the past, present, and future states of space, atmospheric, . In this study, we examined data from TB patients enrolled by HTI who had been reported during October 1995-September 2004.
Study participants were interviewed by trained interviewers using a standardized questionnaire designed to gather details of participant demographics, living situation, transportation, travel and social contacts, tobacco and alcohol use, illicit drug illicit drug Street drug, see there use, sexual behavior sexual behavior A person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life. , history of incarceration Confinement in a jail or prison; imprisonment.
Police officers and other law enforcement officers are authorized by federal, state, and local lawmakers to arrest and confine persons suspected of crimes. The judicial system is authorized to confine persons convicted of crimes. , and personal medical history. Clinical information was supplemented through record review of all available inpatient, outpatient, and public health medical records.
Molecular Characterization of M. tuberculosis
We analyzed M. tuberculosis isolates with 3 molecular typing methods. First, isolates were characterized by an internationally standardized protocol of insertion sequence insertion sequence
Any of several discrete DNA sequences that repeat at various sites on a bacterial chromosome, on certain plasmids, and on bacteriophages and that can move from one site to another on the chromosome, to another plasmid in the same [IS] 6110 restriction fragment length polymorphism restriction fragment length polymorphism
n. Abbr. RFLP
Intraspecies variations in the length of DNA fragments generated by the action of restriction enzymes and caused by mutations that alter the sites at which these enzymes act, changing (RFLP RFLP
restriction fragment length polymorphism
restriction fragment length polymorphism.
RFLP ) profiling (11) and analyzed with BioImage Whole Band Analysis version 3.2 software (BioImage, Ann Arbor Ann Arbor, city (1990 pop. 109,592), seat of Washtenaw co., S Mich., on the Huron River; inc. 1851. It is a research and educational center, with a large number of government and industrial research and development firms, many in high-technology fields such as , MI, USA). Second, for isolates with <5 IS6110 copies, the spacer oligonucleotide Oligonucleotide
A deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) sequence composed of two or more covalently linked nucleotides. Oligonucleotides are classified as deoxyribooligonucleotides or ribooligonucleotides. type (spoligotype) was determined by using a commercially available kit (Isogen Bioscience BV, Maarsen, the Netherlands) according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. the manufacturer's instructions. A member of the Beijing family was defined as having an octal A numbering system that uses eight digits. It is used as a shorthand method for representing binary characters that use six-bits. Each three bits (half a character) is converted into a single octal digit. Okta is Greek for 8. spoligotype pattern of 000000000003771 (previously designated as S1) (12). Third, isolates were assigned to a principal genetic group on the basis of polymorphisms at codon codon: see nucleic acid. 463 of the katG gene, which encodes catalase catalase /cat·a·lase/ (kat´ah-las) a hemoprotein enzyme that catalyzes the decomposition of hydrogen peroxide to water and oxygen, protecting cells. peroxidase peroxidase /per·ox·i·dase/ (per-ok´si-das) any of a group of iron-porphyrin enzymes that catalyze the oxidation of some organic substrates in the presence of hydrogen peroxide.
n. , and at codon 95 of the gyrA gene, which encodes the A subunit sub·u·nit
A subdivision of a larger unit.
Noun 1. subunit - a monetary unit that is valued at a fraction (usually one hundredth) of the basic monetary unit
fractional monetary unit of DNA gyrase DNA gyrase (ji´ras) a type II DNA topoisomerase. (13). Susceptibility testing was performed by using BACTEC 460 radiometric culture system (Becton Dickinson BD (NYSE: BDX), is a medical technology company that manufactures and sells medical devices, instrument systems and reagents. Founded in 1897 and headquartered in Franklin Lakes, New Jersey, BD employs 27,000 people in nearly 50 countries. , Sparks, MD, USA), at the hospital or reference laboratories supplying isolates to the HTI (14).
We assigned race/ethnicity on the basis of self-report. M. tuberculosis isolates were defined as clustering if they satisfied 1 of the following criteria: 1) [greater than or equal to]2 isolates from the same principal genetic group with identical IS6110 banding profiles containing [greater than or equal to]5 copies of IS6110 or 2) isolates with identical IS6110 banding profiles containing [less than or equal to]4 copies of IS6110 and sharing the same spoligotype and principal genetic group. We evaluated clusters H03 and H33 as a single cluster because they differ in only 1 band by IS6110 RFLP.
We defined drug-resistant TB as an isolate resistant to at least 1 drug, including isoniazid isoniazid (ī'sōnī`əzĭd), drug used to treat tuberculosis. Also known as isonicotinic acid hydrazide, isoniazid is the most effective antituberculosis drug currently available. , rifampin rifampin (rĭfăm`pĭn), antibiotic used in the treatment of tuberculosis. It is also used to eliminate the meningococcus microorganism from carriers and to treat leprosy, or Hansen's disease. , ethambutol ethambutol /etham·bu·tol/ (e-tham´bu-tol) an antibacterial, specifically effective against Mycobacterium; used with one or more other antituberculous drugs in the treatment of pulmonary tuberculosis, administered as the , pyrazinamide, or streptomycin streptomycin (strĕp'tōmī`sĭn), antibiotic produced by soil bacteria of the genus Streptomyces and active against both gram-positive and gram-negative bacteria (see Gram's stain), including species resistant to other . Multidrug-resistant TB was defined by resistance to isoniazid and rifampin, with or without resistance to other agents.
Questionnaire data were entered into a longitudinal database (initially Epi Info Epi Info is a public domain statistical software for epidemiology developed by Centers for Disease Control and Prevention.
Developed by the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (USA), Epi Info has been in existence for over 20 years and is version 6.02b, Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. , Atlanta, GA, USA; and subsequently Microsoft Access A database program for Windows, available separately or included in the Microsoft Office suite. Access is programmable using Visual Basic for Applications (VBA). Access can read Paradox, dBASE and Btrieve files, and using ODBC, Microsoft SQL Server, SYBASE SQL Server and Oracle data. , Microsoft, Redmond, WA, USA) for storage and analysis. Statistical analyses were conducted with STATA version 8.0 SE (StataCorp., College Station, TX, USA). Descriptive analysis was initially conducted, and selected demographic, social, and clinical factors were studied by univariate logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. to test for differences between US-born blacks and US-born whites. We used US-born whites, as opposed to all others, as the comparison group because of the heterogeneity in the latter group, particularly in non-US-born Hispanics and Asians. Variables with p<0.2 in the univariate analysis were considered in the elaboration of a multivariate The use of multiple variables in a forecasting model. logistic regression model to identify with factors independently associated with black race in TB patients. Covariates were not included in the model if they substantially decreased the sample size because of missing data. In our final model, we used the variable injection drug use instead of drug use because of colinearity and a strong association with the former variable. Covariates that were no longer significant after adjustment for other significant variables in the full model were dropped from the final parsimonious par·si·mo·ni·ous
Excessively sparing or frugal.
Individual participants gave written informed consent before enrollment in the study. We obtained parental consent Parental consent laws (also known as parental involvement or parental notification laws) in some countries require that one or more parents consent to or be notified before their minor child can legally engage in certain activities. and patient assent for participants 13 to <18 years of age, and a parent served as a proxy for the interview of participants <13 years of age. Proxy permission and interview also were used for participants who had died or were not mentally capable of giving informed consent. The study was approved by the Institutional Review Board of Baylor College of Medicine Baylor College of Medicine is a private medical school located in Houston, Texas, USA on the grounds of the Texas Medical Center. It has been consistently rated the top medical school in Texas and among the best in the United States. , Houston, Texas “Houston” redirects here. For other uses, see Houston (disambiguation).
Houston (pronounced /'hjuːstən/) is the largest city in the state of Texas and the , and affiliated hospitals, and the University of Texas Health Science Center-Houston, Committee for the Protection of Human Subjects.
A total of 4,312 persons with TB were reported in Harris County during October 1995-September 2004. Of those, 3,662 (85%) agreed to participate in the study and were interviewed by trained HTI personnel. The study population comprised 1,318 (36.0%) US-born blacks, 1,220 (33.3%) Hispanics, 545 (14.9%) US-born non-Hispanic whites, 463 (12.6%) Asians, 85 (2.3%) foreign-born blacks, 20 (0.5%) foreign-born non-Hispanic whites and 11 (0.3%) others. Of participants interviewed, 3,064 (84%) had a positive culture for M. tuberculosis; 2,806 (92%) of those isolates underwent molecular characterization. Interviewed participants were more likely to be younger, black, HIV-seropositive, and M. tuberculosis culture-positive than were persons who refused to participate or could not be located (p<0.01 for first 3 comparisons and p = 0.03 for the last comparison).
Rates of TB during the Study Period
Although the overall US incidence of TB decreased from 8.0 to 4.9 cases per 100,000 persons during 1996-2004, TB incidence in Harris County has remained fairly stable since 2000 after an initial decrease in 1996-1999 (Figure 1). Blacks consistently had the highest TB incidence in Harris County. In 2004, blacks accounted for approximately 56% of all TB cases among US-born participants despite representing only 18% of the Harris County population (Texas State Data Center and Office of the State Demographer de·mog·ra·phy
The study of the characteristics of human populations, such as size, growth, density, distribution, and vital statistics.
[French démographie : Greek , http://txsdc.utsa.edu/tpepp/txpopest.php).
US-born Blacks versus US-born Whites
US-born blacks were more likely than US-born whites to be younger, unmarried, and unemployed; have less education; reside in the inner city, earn less income; use public transportation; have renal and extrapulmonary disease; be HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. seropositive seropositive /se·ro·pos·i·tive/ (-poz´i-tiv) showing positive results on serological examination; showing a high level of antibody.
adj. , M. tuberculosis culture-positive, and part of a cluster; and have drug-resistant M. tuberculosis (Table 1).
The 614 HIV-infected TB patients in our study reflected a 28% rate of co-infection for US-born blacks and 20% for US-born whites (p<0.001). Rates of HIV co-infection were markedly lower for Hispanics and Asians (9.1% and 1.7%, respectively). Pulmonary disease was the predominant clinical presentation in the study population; however, extrapulmonary disease was reported more frequently for US-born blacks than for US-born whites (p<0.01).
Resistance to at least 1 anti-TB agent was recorded for 80 (7.3%) isolates from US-born blacks, compared with 22 (4.5%) isolates from US-born whites (p = 0.04). Multidrug-resistant TB represented only 1% of all cases. Mortality rate (i.e., death within 180 days after TB diagnosis) was [approximately equal to]10% and was similar for US-born blacks and US-born whites.
Clustering of Cases within Groups
Among all 4,312 cases reported during the study period, 3,578 (including enrolled and nonenrolled participants) had at least 1 positive M. tuberculosis culture. Isolates from 3,227 (90%) were genotyped, including 1,984 (61.5%) that matched at least 1 other isolate. A total of 242 clusters were identified, and cluster size varied from 2 to 172 patients (mean 57.2, median 27).
Isolates of 1,765 (63%) of the 2,807 enrolled persons were clustered, including 822 (82%) of 1,007 isolates from US-born blacks and 349 (77%) of 448 isolates from US-born whites (p = 0.05). Rates of clustering were significantly lower for Hispanics and Asians (52% and 28%, respectively; p<0.01), probably underscoring a higher proportion of reactivation of latent infection in these patients. Cluster size for US-born blacks was larger (mean 69.3, median 45) than for US-born whites (mean 46.7, median 14; p<0.001). TB strains belonging to the Beijing family represented 26% and 29% of isolates from US-born blacks and US-born whites, respectively (p = 0.25). Two (H03/ H33 and L16) of the 9 largest clusters containing at least 30 patients had more US-born blacks than US-born whites (Table 2, Figure 2).
Multivariate Logistic Regression Analysis
In our final model (Table 3), factors independently associated with black race among TB patients included younger age, fewer years of education, inner city residence, use of public transportation, prison history, renal disease Renal disease
Mentioned in: Glycogen Storage Diseases
hypertension High blood pressure Cardiovascular disease An abnormal ↑ systemic arterial pressure, corresponding to a systolic BP of > 160 mm Hg , and HIV seropositivity Seropositivity is the presence of a certain antibody in a blood sample. A patient with seropositivity for a particular antigen or agent is termed seropositive. . US-born blacks were significantly less likely than U.S.-born whites to report current homelessness, smoking, alcohol abuse, injection drug use, and same-sex behavior. Although male sex, not being married, M. tuberculosis culture positivity, employment, and extrapulmonary disease were significant in the univariate analysis, they were no longer significant in the full model and therefore were dropped from the final parsimonious model. Because including certain covariates significantly decreased the sample size (and the representativeness of the dataset), we developed a second model (data not shown) by adding drug resistance and clustering to the final model. In this model, drug resistance remained significantly higher for US-born blacks than for US-born whites (odds ratio [OR] 1.76; 95% confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. [CI] 1.02-3.04, p = 0.04); however, clustering did not remain significant (OR 1.13, 95% CI 0.82-1.54, p = 0.46).
[FIGURE 1 OMITTED]
Although the incidence rate of TB in the United States during 2007 was the lowest recorded since national reporting began in 1953, the decline has slowed from an average of 7.1% per year (1993-2000) to an average of 3.8% per year (2001-2007) (1). Our population-based study of TB in a large US metropolitan city emphasized the epidemiologic, molecular, and clinical characteristics of US-born blacks. During the 9-year study period, the overall incidence of TB in Harris County, Texas Harris County is a county located in the U.S. state of Texas within the Houston–Sugar Land–Baytown metropolitan area. As of 2000 U.S. Census, the county had a population of 3.4 million (though a 2006 estimate placed the population at nearly 3. , decreased dramatically; however, the incidence among blacks remained fairly stable (22.6-25.2 cases per 100,000) over the past 5 years of the study. This incidence is 4-5x the US national TB incidence rate (1). Numerous factors have been postulated to explain the disproportionately high TB rate for blacks, including socioeconomic characteristics, biasing presence of comorbidities, and genetics (15,16).
Our evaluation of socioeconomic characteristics demonstrated that younger age, fewer years of education, use of public transportation, and inner city residence were independently associated with black race among TB patients. These associations support the concept that TB remains predominantly a disease of disadvantaged and marginalized persons (17,18). Contrary to findings recently reported (18), our population-based study showed that US-born whites with TB were more likely than US-born blacks with TB to be homeless. In addition, certain clinical conditions such as renal disease and HIV seropositivity were more likely in US-born blacks with TB.
M. tuberculosis isolates from US-born blacks were more likely to be resistant than were those from US-born whites, which was in accordance with previously reported findings (19). However, foreign-born persons, particularly Hispanics and Asians, still have the most drug-resistant TB in Houston (20). Among our study population, death from any cause within 6 months after TB diagnosis reported was [approximately equal to]10%. We found no difference in TB-associated mortality rates between US-born blacks and whites.
TB strains clustered in a high proportion of both US-born blacks and US-born whites (81.6% and 77.2%, respectively; p = 0.46). We previously demonstrated that ethnicity was not a significant covariate for strain clustering after adjustments for factors related to socioeconomic status (21). Isolates belonging to the Beijing genotype genotype (jēn`ətīp'): see genetics.
Genetic makeup of an organism. The genotype determines the hereditary potentials and limitations of an individual. family clustered in 26% and 29% of US-born blacks and US-born whites, respectively (p = 0.25). This genetically highly conserved family, reported worldwide but particularly prevalent in Asia and the territories of the former Soviet Union (22,23), is frequently associated with large TB outbreaks, increased virulence Virulence
The ability of a microorganism to cause disease. Virulence and pathogenicity are often used interchangeably, but virulence may also be used to indicate the degree of pathogenicity. , and multidrug resistance multidrug resistance,
n the adaptation of tumor cells or infectious agents to resist chemotherapeutic agents. (24,25).
[FIGURE 2 OMITTED]
One of the most striking findings of our study is the markedly large size of clusters. Previous US-based studies had reported cluster sizes not exceeding 30-78 patients each (6,8,9). We reported 9 clusters with >30 patients each and 3 clusters with >100 patients each, including 1 with a predominance of blacks. This may be due to the longer surveillance period used here, as well as to endemic spread of highly transmissible transmissible /trans·mis·si·ble/ (trans-mis´i-b'l) capable of being transmitted.
Capable of being conveyed from one person to another. strains, including several of the Beijing family. We estimated that at least 54% (1,984-242 [of 3,227]) of TB cases in Houston resulted from recent infection that had progressed to active disease during the 9-year study period (6). We believe this estimate is conservative because a strict definition of identical IS6110 RFLP bands was used for clustering, and several RFLP patterns in our study were similar but with [+ or -]1 band (Figure 2).
Several TB genotypes remain endemic to Houston, particularly in minorities such as US-born blacks. A high proportion of endemic strains of M. tuberculosis remain actively transmitted within this population. Further research on the dynamics of the disease, including possible delays in care-seeking behavior or diagnosis in this racial group, is of paramount importance to achieve the national goal for TB elimination.
This project was funded in part by the National Institute of Allergy and Infectious Diseases infectious diseases: see communicable diseases. and the National Institute of Drug Abuse, National Institutes of Health, under contracts N01-A0-02738 and DA09238.
Dr Serpa is an assistant professor of medicine in the section of Infectious Diseases at Baylor College of Medicine. His current research interests are epidemiology of tuberculosis and immunology of pneumococcal vaccine pneu·mo·coc·cal vaccine
A vaccine containing purified capsular polysaccharide antigen from the most common infectious types of Streptococcus pneumoniae, used to immunize against pneumonococcal disease. .
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members of the genus Mycobacterium.
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The nonrandom association between two or more alleles such that certain combinations of alleles are more likely to occur together on a chromosome than other combinations of alleles. of novel SNPs in the human NLI-IF gene: evidence of human origin and lack of association with tuberculosis susceptibility. J Hum Genet genet: see civet. . 2002;47:140-5. DOI: 10.1007/s100380200016
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adj. rud·di·er, rud·di·est
a. Having a healthy, reddish color.
b. Reddish; rosy.
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(1) Preliminary analysis of data contained in this paper was presented at the 45th Annual Meeting of the Infectious Diseases Society of America The Infectious Diseases Society of America (IDSA) is a medical association representing physicians, scientists and other health care professionals who specialize in infectious diseases. , October 4-7, 2007, San Diego, California “San Diego” redirects here. For other uses, see San Diego (disambiguation).
San Diego is a coastal Southern California city located in the southwestern corner of the continental United States. As of 2006, the city has a population of 1,256,951. , USA (abstract no. 346).
Jose A. Serpa, Larry D. Teeter, James M. Musser, and Edward A. Graviss
Address for correspondence: Edward A. Graviss, Department of Pathology, The Methodist Hospital Methodist Hospital is the name of numerous medical institutions.
Author affiliations: Baylor College of Medicine, Houston, Texas, USA (J.A. Serpa, E.A. Graviss); and The Methodist Hospital Research Institute, Houston (L.D. Teeter, J.M. Musser, E.A. Graviss)
Table 1. Univariate analysis of selected epidemiologic and clinical characteristics of participants in the Houston Tuberculosis Initiative, Texas, 1995-2004 * Variable US-born black US-born white Demographics Age, y, mean (median) 42.5 (43.0) 48.2 (47.0) Male sex 938 (71.2) 429 (78.7) Not married 1,091 (82.8) 412 (75.6) Years of education, mean (median) 10.6 12.0 11.7 12.0 Employed 453 (34.4) 214 (39.3) Inner city residence ([dagger]) 538 (40.9) 198 (36.7) Household size, mean (median) 5.2 (3.0) 4.5 (2.0) Social history Income <$10K/year 554 (51.7) 161 (36.0) Use of public transportation 664 (50.4) 177 (32.5) Current homelessness 129 (9.8) 77 (14.2) Stay in a shelter ([double dagger]) 132 (10.0) 65 (11.9) Current smoking 745 (56.7) 388 (71.5) Alcohol abuse ([section]) 601 (45.8) 311 (57.4) Drug use ([double dagger]) 351 (26.7) 129 (23.7) Injection drug use ([double dagger]) 25 (1.91) 25 (4.6) Same-sex sexual behavior 129 (9.9) 91 (17.0) Commercial sex 168 (13.1) 67 (12.6) Prison history 281 (21.4) 92 (16.9) Medical history Known TB exposure 502 (38.1) 222 (40.7) Previous TB 112 (8.5) 55 (10.1) Asthma 85 (6.4) 28 (5.1) Diabetes 168 (12.7) 61 (11.2) Renal disease 76 (5.8) 15 (2.8) HIV seropositivity 364 (27.6) 109 (20.0) Diagnosis and prognosis Pulmonary TB 1,067 (81.0) 496 (91) Extrapulmonary TB 400 (30.3) 97 (17.8) Cavitation 458 (45.1) 213 (46.1) Smear-positive pulmonary TB 577 (54.2) 257 (51.9) M. tuberculosis culture positivity 1,102 (83.7) 486 (89.2) TB clustering 822 (81.6) 349 (77.2) Drug resistance 80 (7.3) 22 (4.5) Multidrug resistance 3 (0.3) 1 (0.2) Death ([paragraph]) 143 (10.8) 62 (11.4) Variable Hispanic Asian Demographics Age, y, mean (median) 36.9 (36.0) 45.1 (43.0) Male sex 783 (64.2) 257 (55.5) Not married 742 (60.8) 202 (43.6) Years of education, mean (median) 254 (20.8) 260 (56.3) Employed 501 (41.1) 209 (45.1) Inner city residence ([dagger]) 384 (31.5) 40 (8.6) Household size, mean (median) 4.7 (4.0) 5.1 (4.0) Social history Income <$10K/year 466 (46.0) 78 (18.1) Use of public transportation 363 (29.8) 40 (8.6) Current homelessness 32 (2.6) 4 (0.9) Stay in a shelter ([double dagger]) 17 (1.4) 5 (1.1) Current smoking 279 (22.9) 80 (17.3) Alcohol abuse ([section]) 251 (20.6) 50 (10.8) Drug use ([double dagger]) 110 (9.0) 4 (0.9) Injection drug use ([double dagger]) 9 (0.74) 1 (0.22) Same-sex sexual behavior 69 (5.7) 2 (0.4) Commercial sex 52 (4.3) 2 (0.4) Prison history 49 (4.0) 5 (1.1) Medical history Known TB exposure 375 (30.7) 86 (18.6) Previous TB 56 (4.6) 41 (8.9) Asthma 40 (3.3) 12 (2.6) Diabetes 224 (18.4) 62 (13.4) Renal disease 34 (2.79) 21 (4.54) HIV seropositivity 111 (9.1) 8 (1.7) Diagnosis and prognosis Pulmonary TB 966 (79.2) 341 (73.7) Extrapulmonary TB 354 (29.0) 153 (33.0) Cavitation 405 (45.0) 111 (37.1) Smear-positive pulmonary TB 473 (49.2) 132 (38.7) M. tuberculosis culture positivity 979 (80.2) 402 (86.8) TB clustering 466 (51.8) 100 (27.9) Drug resistance 105 (10.7) 79 (19.7) Multidrug resistance 15 (1.5) 9 (0.9) Death ([paragraph]) 80 (6.6) 28 (6.0) US-born black vs. Variable white, OR (p value) Demographics Age, y, mean (median) 0.98 (<0.001) Male sex 0.67 (0.001) Not married 1.56 (<0.001) Years of education, mean (median) 0.90 (<0.001) Employed 0.81 (0.045) Inner city residence ([dagger]) 1.19 (0.094) Household size, mean (median) 1.00 (0.454) Social history Income <$10K/year 1.90 (<0.001) Use of public transportation 2.11 (<0.001) Current homelessness 0.66 (0.007) Stay in a shelter ([double dagger]) 0.82 (0.222) Current smoking 0.52 (<0.001) Alcohol abuse ([section]) 0.63 (<0.001) Drug use ([double dagger]) 1.17 0.179) Injection drug use ([double dagger]) 0.40 (0.002) Same-sex sexual behavior 0.54 (<0.001) Commercial sex 1.05 (0.758) Prison history 1.34 (0.026) Medical history Known TB exposure 0.88 (0.222) Previous TB 0.83 (0.274) Asthma 1.27 (0.282) Diabetes 1.16 (0.353) Renal disease 2.16 (0.007) HIV seropositivity 1.52 (0.001) Diagnosis and prognosis Pulmonary TB 0.42 (<0.001) Extrapulmonary TB 2.01 (<0.001) Cavitation 0.96 (0.714) Smear-positive pulmonary TB 1.10 (0.405) M. tuberculosis culture positivity 0.62 (0.002) TB clustering 1.31 (0.050) Drug resistance 1.65 (0.043) Multidrug resistance 1.32 (0.808) Death ([paragraph]) 0.95 (0.741) * Stratification based on race does not include information about foreign-born blacks. Data presented as no. (%) participants except as indicated. OR, odds ratio; TB, tuberculosis; M. tuberculosis, Mycobacterium tuberculosis. ([dagger]) Defined according to specific zip codes. ([double dagger]) Within 6 months before TB diagnosis. ([section]) Drinks alcohol daily or nearly daily. ([paragraph]) Within 180 days after TB diagnosis. Table 2. Characteristics of the 9 largest Mycobacterium tuberculosis clusters, Houston Tuberculosis Initiative, Texas, 1995-2004 * IS6110 CDC spoligotype Genetic Cluster copy no. designation group H01 12 7760 3777 7760 771 3 H03/H33 20/21 0000 0000 0003 771 1 H02 13 0000 0000 0003 771 1 H15 9 0000 0000 0003 771 1 H07 10 0000 0000 0003 771 1 H16 9 7777 0375 7760 771 2 H04 6 7777 7677 7760 771 2 L08 2 7777 7677 7760 601 2 L16 3 7777 7677 7760 601 2 Participant data US-born black, US-born white, Hispanic, Cluster no. (%) no. (%) no. (%) H01 96 (9.5) 29 (6.4) 22 (2.44) H03/H33 109 (10.8) 31 (6.9) 8 (0.89) H02 77 (7.75) 28 (6.2) 20 (2.22) H15 25 (2.48) 7 (1.5) 6 (0.67) H07 46 (4.6) 22 (4.9) 11 (1.22) H16 28 (2.8) 8 (1.8) 5 (0.56) H04 12,(1.2) 50 (11.1) 10 (1.11) L08 55 (5.5) 23 (5.1) 28 (3.11) L16 26 (2.6) 2 (0.4) 4 (0.44) Participant data Asian, US-born black vs. Cluster no. (%) white, OR (p value) H01 4 (1.11) 1.54 (0.051) H03/H33 2 (0.56) 1.65 (0.018) H02 1 (0.28) 1.25 (0.322) H15 0 1.62 (0.264) H07 0 0.94 (0.802) H16 0 1.59 (0.254) H04 1 (0.28) 0.10 (<0.001) L08 2 (0.56) 1.08 (0.770) L16 0 (0.00) 5.96 (0.015) * IS, insertion sequence; OR, odds ratio. Table 3. Factors associated with black race in multivariate analysis in US-born TB patients, Houston Tuberculosis Initiative, Texas, 1995-2004 * Risk factor OR 95% CI p value Age 0.98 ([dagger]) 0.97-0.99 <0.001 Years of education 0.93 ([dagger]) 0.89-0.96 <0.001 Inner city residence 1.44 1.13-1.85 0.003 ([double dagger]) Use of public transportation 2.44 1.91-3.11 <0.001 Current homelessnes 0.48 0.33-0.68 <0.001 Current smoking 0.54 0.42-0.70 <0.001 Alcohol abuse ([section]) 0.63 0.50-0.80 0.001 Injection drug 0.3 0.16-0.57 <0.001 use ([paragraph]) Same-sex sexual behavior 0.28 0.19-0.41 <0.001 Prison history 1.42 1.06-1.91 0.020 Renal disease 2.61 1.38-4.92 0.003 HIV seropositivity 1.89 1.37-2.61 <0.001 * TB, tuberculosis; OR, odds ratio; CI, confidence interval. ([dagger]) ORs per additional year at risk. ([double dagger]) Defined according to specific zip codes. ([section]) Drinks alcohol daily or nearly daily. ([paragraph]) Within 6 months before TB diagnosis.