title: A tuberculosis outbreak fueled by cross-border travel and illicit substances: Nevada and Arizona.
abstract: OBJECTIVE
  From May 2006 to August 2008, the Southern Nevada Health District identified eight tuberculosis (TB) cases in six adults and two children in a Hispanic community. We conducted an outbreak investigation to determine the extent of TB transmission and prevent additional cases.
  
  
  METHODS
  We investigated TB cases in Nevada and Arizona with the outbreak genotype or cases with suspected epidemiologic links to this cluster but without genotyping data. We reviewed medical records and interviewed patients and contacts. Subsequently, genotype surveillance was conducted for approximately four years to monitor additional outbreak-related cases.
  
  
  RESULTS
  Eight outbreak cases were identified among six adults and two children. All patients were Hispanic and five were U.S.-born. The index patient was diagnosed while detained in Immigration and Customs Enforcement custody but deported before treatment completion. He was lost to follow-up for two years, during which time he served as the source for six secondary TB cases, including his own child. Along with the index patient, five patients reportedly engaged in the sale or use of methamphetamine. Follow-up surveillance in the two states identified eight additional cases with the outbreak genotype; three had epidemiologic links to the index case.
  
  
  CONCLUSIONS
  We found that incomplete TB treatment led to extensive TB transmission. We recommend thorough discharge planning and active measures to ensure continuity of care and TB treatment completion for people in custody at higher risk for loss to follow-up, which likely includes those engaged in the sale or use of illicit substances.
authors.affiliation: Centers for Disease Control and Prevention, Division of Tuberculosis Elimination, Atlanta, GA.
authors.forename: Kiren
authors.initials: K
authors.lastname: Mitruka
authors.affiliation: Southern Nevada Health District, Tuberculosis Treatment and Control Clinic, Las Vegas, NV.
authors.forename: Haley
authors.initials: H
authors.lastname: Blake
authors.affiliation: Centers for Disease Control and Prevention, Division of Tuberculosis Elimination, Atlanta, GA.
authors.forename: Philip
authors.initials: P
authors.lastname: Ricks
authors.affiliation: Centers for Disease Control and Prevention, Division of Tuberculosis Elimination, Atlanta, GA.
authors.forename: Roque
authors.initials: R
authors.lastname: Miramontes
authors.affiliation: Centers for Disease Control and Prevention, Division of Tuberculosis Elimination, Atlanta, GA.
authors.forename: Sapna
authors.initials: S
authors.lastname: Bamrah
authors.affiliation: Arizona Department of Health Services, Phoenix, AZ.
authors.forename: Carla
authors.initials: C
authors.lastname: Chee
authors.affiliation: Southern Nevada Health District, Tuberculosis Treatment and Control Clinic, Las Vegas, NV.
authors.forename: Laurie
authors.initials: L
authors.lastname: Hickstein
mesh_terms: D000293:Adolescent; D000328:Adult; D001130:Arizona / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D016358:Contact Tracing; D004196:Disease Outbreaks; D004641:Emigration and Immigration; D005838:Genotype; D006801:Humans; D013287:Illicit Drugs; D007223:Infant; D008297:Male; D009169:Mycobacterium tuberculosis / Q000235:genetics; D009505:Nevada / Q000453:epidemiology; D011159:Population Surveillance; D019966:Substance-Related Disorders / Q000150:complications*; D014376:Tuberculosis / Q000453:epidemiology* / Q000635:transmission*
chemical_list: D013287:Illicit Drugs