ARTICLE
A Tuberculosis Outbreak in a Private-Home Family
Child Care Center in San Francisco, 2002 to 2004
Puneet K. Dewan, MDa, Houmpheng Banouvongb, Neil Abernethy, PhDc, Thomas Hoynes, BAb, Liliana Diaz, MSWb, Melaku Woldemariamb, Theresa Ampieb, Jennifer Grinsdale, MPHb, L. Masae Kawamura, MDb
aDivision of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia;bTuberculosis Control Section, San Francisco Department of Public
Health, San Francisco, California;cMedical Informatics, Stanford University School of Medicine, Palo Alto, California
The authors have indicated they have no financial relationships relevant to this article to disclose.
ABSTRACT
BACKGROUND.Child care facilities are well known as sites of infectious disease trans-mission, and California child care facility licensure requirements include annual tuberculosis (TB) screening for on-site adults. In April 2004, we detected an adult with TB living in a private-home family child care center (child care center A).
METHODS.We reviewed patient medical records and conducted a contact investiga-tion. The investigation included all persons at the child care center, the workplace and leisure contacts of the adult patient with TB, and the household contacts of secondary case patients. Contact names were obtained through patient interviews.
A positive tuberculin skin test result was defined as induration ofⱖ5 mm. DNA
fingerprints of Mycobacterium tuberculosis isolates were analyzed. Outbreak cases
were those that had matching DNA fingerprint patterns or were linked epidemi-ologically, if DNA fingerprint results were not available.
RESULTS.Between August 2002 and July 2004, we detected 11 outbreak cases,
including 9 (82%) among children (⬍18 years of age). All 11 outbreak patients
lived or were cared for at child care center A. The 9 pediatric TB patients were
young (⬍7 years of age), United States-born children of foreign-born parents, and
4 (44%) had positive cultures forM tuberculosis.Including isolates recovered from
the 2 adult patients, all 6 M tuberculosis isolates shared identical, 7-band, DNA
fingerprint patterns. The contact investigation identified 3 (33%) of the 9 pediatric cases; 2 (22%) presented with illness and 4 (44%) were detected by primary care providers during routine TB screening. Excluding case subjects, 36 (54%) of 67 named contacts had latent TB infection.
CONCLUSIONS.Provider adherence to locally adapted pediatric TB screening recom-mendations proved critical to outbreak control. TB screening compliance by the child care center and more aggressive source-case investigation by the TB program might have prevented or abated this large pediatric TB outbreak.
www.pediatrics.org/cgi/doi/10.1542/ peds.2005-1380
doi:10.1542/peds.2005-1380
Key Words
child care, tuberculosis, outbreak, pediatric, day care
Abbreviations TB—tuberculosis
SFDPH—San Francisco Department of Public Health
AFB—acid-fact bacilli TST—tuberculin skin test LTBI—latent tuberculosis infection
Accepted for publication Aug 16, 2005 Address correspondence to Puneet K. Dewan, MD, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333. E-mail: phd8@cdc.gov
C
HILD CARE FACILITIES are well recognized as com-mon sites of disease transmission. Large outbreaks of diarrheal illness and upper respiratory tract infectionsare common.1 However, instances of Mycobacterium
tu-berculosis transmission within child care facilities have been reported rarely. In San Francisco, California, al-though the rate of tuberculosis (TB) is among the highest of any major US city, pediatric TB is uncommon. In 2003, the San Francisco rate of TB (20.4 cases per 100 000 population) was nearly 4 times the national TB case rate of 5.2 cases per 100 000 population but only 7 (4.3%) of 162 reported TB cases occurred among
chil-dren ⬍18 years of age, including just 2 (1.2%) among
children⬍5 years of age.2
In April 2004, an adult residing at a private-home family child care center (child care center A) was diag-nosed as having TB by the San Francisco Department of Public Health (SFDPH). A community provider who sus-pected TB first detected and referred this patient to SFDPH. The patient was foreign-born, had been in the United States since July 2003, and had never previously had a tuberculin skin test (TST). At the time of diagnosis,
the patient was symptomatic, with a ⬎1.5-year history
of cough. The patient tested negative for HIV, had spu-tum smears with positive results for acid-fast bacilli (AFB), and demonstrated multiple pulmonary cavities in chest radiographs. Furthermore, the patient reported a history of intermittent self-medication with unknown TB drugs obtained abroad. We report a large TB outbreak among children centered at child care center A, and we review the public health interventions implemented to improve contact investigations and to minimize the like-lihood of similar events in the future.
METHODS
Public Health Response and Contact Investigation
The adult index case was removed from child care center A and treated with standard anti-TB medications (isoni-azid, rifampin, pyrazinamide, and ethambutol) through
directly observed therapy. M tuberculosis was recovered
from sputum culture, and the isolate was found to be susceptible to all standard anti-TB drugs. Disease control investigators interviewed both the adult index patient and the child care center A operator and requested
iden-tification of all adults and children who spent⬎1 day at
the center in the past 2 years. Workplace and leisure contacts of the index patient were also contacted. We called named contacts (or their parents), informed them of TB exposure, and offered medical evaluation for TB.
Medical evaluation of contacts consisted of an initial symptom review and a Mantoux TST with intradermal administration of 5 tuberculin units of purified protein derivative (Tubersol; Connaught Laboratories, Toronto, Canada). A positive TST result was defined as measured
induration of ⱖ5 mm 48 to 72 hours after
administra-tion, regardless of BCG vaccination status. TST conver-sion was defined as a documented change within 2 years
from negative to positive TST results, with a ⱖ10-mm
increase in TST induration. For each contact, the TST was conducted as soon as possible and, if negative results were obtained, the TST was repeated 3 months after the last documented exposure to the presumed site of trans-mission (ie, child care center A). Contacts were evalu-ated with chest radiographs and medical examinations if
they had positive TST results, were ⬍5 years of age, or
had symptoms indicating TB.3 Diagnostic specimens
were obtained through inpatient collection of
early-morning gastric aspirates (if ⬍5 years of age) or
outpa-tient sputum induction (ifⱖ5 years of age).
All TB suspects were the subjects of complete contact
investigations. For children⬍5 years of age with positive
TST results, all household members (adults and chil-dren) were also evaluated through TST and symptom review, in an attempt to identify and to evaluate all possible sources of the child’s TB infection. The SFDPH notified community pediatricians about the outbreak by fax, by using a registry of providers, and disseminated current SFDPH and American Academy of Pediatrics TB screening guidelines.
Treatment of TB and Latent TB Infection
TB suspects were treated with standard anti-TB medica-tions through directly observed treatment. Their TB
di-agnoses were verified ifM tuberculosiswas isolated from
a clinical specimen or if they had radiographic and clin-ical evidence of TB disease with improvement after 3 months of treatment with anti-TB medications.
Contacts with latent TB infection (LTBI) who were
ⱕ15 years of age or immunocompromised were offered
9 months of treatment with isoniazid (10 mg/kg per day, up to 300 mg); all other contacts with LTBI were offered 6 months of isoniazid treatment, according to SFDPH
guidelines. Contactsⱕ15 years of age with initial
nega-tive TST results were also offered window prophylaxis4
(isoniazid) if ⬍3 months had elapsed since their most
recent exposure at child care center A or to the pre-sumed source case; if the follow-up TST yielded negative results, then isoniazid treatment was discontinued and the patient was classified as uninfected. Contacts with a documented history of completed prior treatment for
LTBI and ⬍8 hours of exposure at child care center A
were not offered treatment.
Laboratory Investigation
Isolates were tested for drug susceptibility to standard anti-TB medications with radiometric respirometry with the BACTEC 460 system (Becton Dickinson, Franklin Lakes, NJ). We performed DNA fingerprint analysis with restriction fragment length polymorphism assays with
Epidemiologic Investigation
We reviewed medical and public health records of all pediatric patients with TB reported from April 2002 through November 2004. Records were reviewed for epidemiologic links to child care center A or any persons living at this private home. Exposure at child care center
A was defined as ⬎24 hours of cumulative time in the
center between August 2002 and April 2004. An out-break case was defined as TB in a person sharing a DNA fingerprint with the index patient. If DNA fingerprint results were not available, then an outbreak case was defined as TB in a person named as a contact by the index patient or exposed to child care center A. Case subjects and contacts were mapped into a diagram show-ing the relationships between individuals (social
net-work). Contacts named byⱖ2 case subjects were
rein-terviewed and asked to provide names of any persons at child care center A.
RESULTS
Case Subject Characteristics
Of the 78 persons identified during this outbreak inves-tigation, 11 had outbreak-associated TB, including 2 adults (the index patient and 1 other adult) and 9
chil-dren ⬍7 years of age (Table 1 and Fig 1). Besides the
index patient, the other adult with outbreak-associated TB (patient A2 in Table 1) had sputum smears with
AFB-positive results and cultures positive forM
tubercu-losis but reported just 3 months of symptoms, far less than the index patient. Both adults tested negative for HIV.
For the 9 pediatric patients, the median age was 3.4 years (range: 0.5– 6 years). All pediatric patients were United States-born Hispanic children of foreign-born parents, and none had been vaccinated with BCG vac-cine. At the time of diagnosis, all 9 demonstrated positive
TST results (median measured induration: 19 mm; range: 10 –30 mm). Six children had prior documented TST results within 2 years, all of which were negative (0-mm induration); therefore, these 6 children were classified as having experienced TST conversion. Four (44%) of the 9 cases were symptomatic. Radiographic abnormalities included pulmonary infiltrates in 6 (67%) of the 9 cases and lymphadenopathy alone in 3 (33%). Either induced sputum or gastric aspirate specimens were submitted in all 9 cases; specimens from 4 patients
(44%) were culture-positive forM tuberculosis. No
par-ents were known to be HIV positive, and all denied HIV risk factors; HIV testing was offered to pediatric patients and parents but was declined by all. Isolates from the 4 culture-positive pediatric patients and the 2 adult pa-tients had identical, 7-band, DNA fingerprint patterns and were sensitive to all standard anti-TB drugs.
Contact Investigation and Treatment of Infected Contacts Excluding the 11 active TB cases, 67 unique persons were named during the contact investigations of out-break-associated cases; medical evaluation of contacts was completed for 61 (91%), including all 19 (28%)
pediatric contacts ⬍18 years of age (Table 2). Four
(21%) of 19 pediatric contacts were foreign-born, and 15 (79%) were United States-born children of foreign-born parents. In contrast, 47 (98%) of 48 adult contacts were foreign-born, all from either Mexico or Central America. A large proportion of contacts (36 of 67 tacts, 54%) had LTBI, including 8 (12%) with TST con-version. Of those 8 contacts, 4 (50%) were adults; they were not parents of pediatric case subjects. Treatment for LTBI was initiated for 27 (93%) of 29 eligible patients and was completed for 18 (62%), including all 5 children and 13 (54%) of 24 eligible adults.
TABLE 1 Outbreak-Associated TB Case Characteristics in the Child Care Center A TB Outbreak in San Francisco, 2002 to 2004 Type No. Diagnosis
Date
Age, y
Clinical Symptoms TST, mm
TST Status
Major Chest Radiographic Findings
Mycobacterium tuberculosis
Culture (Specimen)
M tuberculosis
Isolate RFLP Match
Adult A1a April 2004 27 1.5-y cough, night sweats PP PP Multiple cavities Positive (sputum) Yes
A2 April 2004 36 3-mo cough 19 No prior Multilobar infiltrates Positive (sputum) Yes Pediatric P1b August 2002 4 None 10 Converter Perihilar infiltrates Negative (sputum) NA
P2b,c September 2002 3 None 17 No prior Lobar infiltrate Positive (gastric asp) Yes
P3b December 2003 0.5 Cough, SOB 25 No prior Right hilar LAD Positive (gastric asp) Yes
P4b January 2004 2 Cough, SOB 22 Converter Lobar infiltrate Positive (gastric asp) Yes
P5 April 2004 2 SOB, night sweats 10 No prior Lobar infiltrate Negative (gastric asp) NA
P6 April 2004 6 None 30 Converter Right hilar LAD Negative (sputum) NA
P7 April 2004 6 None 32 No prior Lobar infiltrate Negative (sputum) NA
P8 June 2004 4 None 21 Converter Lobar infiltrate Negative (gastric asp) NA
P9 July 2004 3 Night sweats 20 Converter Right hilar LAD Positive (gastric asp) Yes
Converter indicates a documented increase in TST induration ofⱖ10 mm within 2 years; PP, prior positive TST result; RFLP, restriction fragment length polymorphism; gastric asp, early morning gastric aspirate; SOB, shortness of breath; LAD, lymphadenopathy; NA, not applicable.
aOutbreak source case.
Epidemiologic Investigation
Child care center A was a private apartment in a pre-dominantly Hispanic neighborhood. It had been operat-ing as a child care center for several years but was not licensed for child care. Residents and employees of this private-home child care center had not been screened for TB before the first pediatric TB case (August 2002). The index patient had lived intermittently at child care center A since June 2002 but was not named in a contact investigation until December 2003. Child care center A
was the only common exposure setting among all 11 case patients (Fig 2). The operator was also a common contact for all 11 but was found to have only LTBI and not active TB. Although few patients (or their parents) named the index patient specifically, all had child care center A exposure during the period of time that the index patient was presumed to be infectious and residing at child care center A. Of the 77 persons identified dur-ing this outbreak investigation (excluddur-ing the index pa-tient), 24 (31%) reported exposure to child care center A and 53 (69%) were exposed at sites other than child care center A. Among the 24 persons with reported exposure to child care center A, 10 (42%) had TB and 10 (42%) had LTBI, for an overall attack rate for TB infection of 84% (Table 3). TST conversion was documented for 9 (38%) of 24 child care center A contacts, including 5 TST conversions that occurred among TB patients. At the workplace of the index patient, 7 (78%) of 9 contacts had LTBI, including 4 (44%) with prior positive TST results and 1 with documented TST conversion. A smaller proportion of household contacts of the
second-FIGURE 1
Outbreak of TB among children and adults in child care center A in San Francisco, 2002 to 2004. All boxes indicate children⬍7 years of age who were diagnosed as having TB, except those marked A for adult.
TABLE 2 Outbreak-Associated Contact Evaluation and Treatment Outcomes in the Child Care Center A TB Outbreak in San Francisco, 2002 to 2004
Contact Characteristics No. (%)
Children⬍18 y of Age (n⫽28)
Adults (n⫽49)
Total (n⫽77) Hispanic ethnicity 27 (96) 49 (100) 76 (99)
Foreign-born 4 (14) 48 (98) 52 (68)
Positive TST resultsa
United States-born 11 (39) 0 (0) 11 (14)
Foreign-born 3 (11) 32 (65) 35 (45)
Diagnostic evaluation results
Not evaluated 0 (0) 6 (12) 6 (8)
Uninfected 14 (50) 11 (22) 31 (40)
TB cases 9 (32) 1 (2) 10 (13)
TST converters 5 (18) 0 (0) 5 (18)
TST positive, no past TST 4 (14) 1 (2) 5 (18)
LTBI 5 (18) 31 (63) 36 (47)
TST converters 4 (14) 4 (8) 8 (10)
TST positive, no past TST 1 (4) 19 (39) 20 (26)
Past TST positive 0 (0) 8 (16) 8 (10)
Treatment of LTBI
Eligibleb 5 (100) 24 (100) 29 (100)
Started 5 (100) 22 (92) 27 (93)
Completed 5 (100) 13 (54) 18 (62)
The adult index case was excluded. TLTBI indicates treatment of LTBI.
aIncludes patients with prior history of positive TST results and case patients other than the
adult index case.
bDefined as a patient with no prior history of treatment for active TB or LTBI.
FIGURE 2
ary case patients had LTBI (19 of 44 contacts, 43%), including 3 (6.8%) with TST conversion and 5 (11%) with prior positive TST results. Reinterviews of adult
contacts named byⱖ2 patients failed to generate
addi-tional contacts or potential sites of transmission. We reviewed case histories to determine missed op-portunities for outbreak detection before April 2004. Of the 9 pediatric outbreak-associated cases, 4 (44%) had been diagnosed before identification of the index patient (Fig 1). Identification of the first patient (patient P1) in August 2002 sparked a large contact investigation that included screening of all adults identified at child care center A. No other source patient was identified despite home visits to the household of patient P1 and child care center A, with screening of all identified adults. The index patient, although living at child care center A and symptomatic at the time, was not named or detected in that 2002 contact investigation. The second patient (pa-tient P2) was diagnosed in a neighboring county in September 2002; although child care center A was re-ported to SFDPH by the neighboring jurisdiction as a site of possible exposure, no connection was made at the time, and the TB program did not revisit the site.
Fur-thermore, theM tuberculosis isolate recovered from
pa-tient P2 was evaluated with restriction fragment length polymorphism assays at a different laboratory than sub-sequent isolates. No data were shared between labora-tories; therefore, no DNA fingerprint comparison with results for subsequent patients was made before the outbreak investigation. The third patient (patient P3), whose infection was diagnosed in December 2003, was a 6-month-old infant who had no exposures except family members and child care center A. At that time, the individual identified subsequently as the index patient (patient A1) was reported as a contact (for the first time) but could not be located despite multiple health worker visits to child care center A. The source of the TB infec-tion of patient P3 was thought initially to be an elderly family member who was reported to have pulmonary symptoms but who had left the country and could not be evaluated. Also, although gastric aspirate cultures were
positive forM tuberculosis, DNA fingerprint results were
not available for 2 months (because of transport time between laboratories and a batch-processing method), by which time the outbreak had been detected. The fourth patient (patient P4) was not known initially to have been exposed at child care center A; complete exposure history was obtained only in reinterviews dur-ing the outbreak investigation.
Routine primary care TB screening with TSTs led to detection of 4 children (44%) with TB. In each of these 4 cases, the child was asymptomatic and the primary care physicians had no knowledge of the TB outbreak. TB screening with TSTs was performed on the basis of epidemiologic risk factors, in accordance with American Academy of Pediatrics and SFDPH guidelines (Table 4), and subsequent investigation of TST-positive results led to case diagnosis.
DISCUSSION
Extensive prolonged transmission of TB from an adult resident of a private-home child care center led to one of
TABLE 3 TB Infection Status Among All Contacts, According to Exposure Setting, in the Child Care Center A TB Outbreak in San Francisco, 2002 to 2004
Evaluation Outcome Exposure Setting, No. (%)
Index Case Household (Child Care Center A)
(n⫽24)
Index Case Workplace (n⫽9)
Households of Secondary Cases
(n⫽44)
Uninfected (n⫽31) 4 (16) 2 (22) 25 (57)
TB cases (n⫽10) 10 (42) 0 (0) 0 (0)
LTBI (n⫽36) 10 (42) 7 (78) 19 (43)
Converters 4 (17) 1 (11) 3 (7)
Positive TST, no prior 1 (4) 2 (22) 5 (9)
Prior positive TST 5 (21) 4 (44) 11 (25)
TABLE 4 Recommendations for Primary Care Providers for Screening for Risk Factors for LTBI Among Children and Adolescents3
Be familiar with local epidemiologic factors for TB disease
Screen children and adolescents with a risk assessment questionnaire, assessing ⱖ4 major risk factors
Include assessment of Foreign birth
Foreign travel to TB-endemic countries Contact with TB disease
Household contact with LTBI
Can include, depending on local epidemiologic factors and priorities History of drinking raw milk or eating unpasteurized cheese
Contact with anyone with known HIV infection or history of illegal drug use, incarceration, or homeless shelter exposure
Household member born in TB-endemic country Household with foreign travel to TB-endemic countries
Perform risk assessment once each year, to assess acquisition of any new risk factors since last assessment
Educate children and adolescents and/or their families about risk factors for TB and LTBI, including the need for reassessment if a new risk factor occurs For children or adolescents at low risk for LTBI, remember that a TST should not
the largest reported pediatric TB outbreaks in the United
States in the past 30 years.6 Although TB outbreaks
among school-aged children and adolescents have been reported frequently, this outbreak is unusual because of its occurrence in a child care center and the involvement of multiple young children with active TB.
A second adult with TB living at the site might have contributed to transmission, although the duration of symptoms and the extent of disease were substantially less than those of the presumed index case. We cannot exclude the possibility of child-to-child TB transmission; 4 (44%) of 9 pediatric TB patients had cultures positive forM tuberculosis, including 2 with a history of cough and pulmonary infiltrates. TST conversion was noted for 3 (6.8%) of 44 household contacts of secondary cases. However, TB transmission from young children has been reported very rarely. Generally, the burden of disease among young children is much lower than that among adults; in particular, cavitary disease is very uncommon. Also, young children may not have a cough strength
adequate to generate droplet nuclei.7Patients with
low-burden disease, defined by sputum smears with negative results for AFB, demonstrate markedly less TB
transmis-sion than patients with AFB smear-positive results.8
Fur-thermore, in several smaller pediatric outbreaks in school and nursery settings that were reported recently, the sources of disease were usually either adolescents or
adults.9–14 In this outbreak involving very young
chil-dren, child-to-child or child-to-adult transmission of TB was thus unlikely.
M tuberculosis transmission in child care centers has
been reported rarely,6,15but this outbreak demonstrated
that child care centers should be considered and inves-tigated as potential sites of exposure when children are identified as having TB infection. In California, licensure requirements for child care facilities include annual TB
screening of adults who work or live at the facility.16In
this outbreak, child care center A was unlicensed, and residents and employees of this private home were not screened for TB until the contact investigation occurred. Although in this instance we were able to implement routine TB screening at child care center A, unlicensed private-home child care centers by their very nature are unlikely to meet health and safety code requirements routinely.
Each contact investigation conducted for the 4 pedi-atric outbreak-associated cases that occurred before April 2004 was a missed opportunity for earlier detection of the infectious adult source patient. Factors such as poor communication between the child care center A operator and SFDPH disease control investigators, in-complete contact investigations, and poor data manage-ment all contributed to ongoing TB transmission and instances of preventable disease. Although we did not collect information about immigration status, it is possi-ble that some individuals were undocumented. Fear of
deportation might have been a barrier to cooperation with the contact investigation and might have contrib-uted to delayed diagnosis of infectious cases. Subsequent cooperation with contact investigations might have been improved in 2004 when disease control investigators began to incorporate early discussions of confidentiality protections with case subjects, contacts, and parents. Other program interventions to improve contact inves-tigations have included improved data management through a new TB patient management relational
data-base,17designed to notify staff members when contacts
or sites were named in previous contact investigations and to facilitate network analysis. Most importantly, however, finding children with active TB should prompt aggressive investigation of adult exposures, including those outside the child’s home, with particular attention to exposure at current or previous child care facilities. These instances represent important opportunities to find the source patient and halt ongoing TB transmis-sion. Unfortunately, pediatric contact investigations fre-quently are unsuccessful in identifying source cases. An evaluation of 111 contact investigations around pediatric TB cases in 8 California jurisdictions (not including San Francisco) reported that additional patients with undi-agnosed TB disease were found in just 10 (9%) investi-gations, which demonstrates substantial room for
con-tact investigation improvement.18
Primary care providers played a critical role in case diagnosis and outbreak abatement. By performing rou-tine, risk factor-based, TB screening in accordance with SFDPH guidelines, primary care providers detected 4 of 9 outbreak-associated pediatric TB cases. Early detection of TB might have prevented significant morbidity among these very young children, because they are generally considered to have greater susceptibility to severe forms of disease. Recommendations for LTBI screening by
pri-mary care providers are summarized in Table 4.3
Prospective application of social network or genotyp-ing analysis might have allowed detection of the out-break and the site of transmission earlier. When it be-came clear that not all contacts had been reported, we ensured the completeness of the contact investigation by reinterviewing contacts named more than twice. Al-though this effort failed to yield any previously un-named contacts, it reduced uncertainty about the full scope of the outbreak. DNA fingerprint results for all San Francisco TB cases are now centralized in 1 database, and all isolates are submitted to the National
Tubercu-losis Genotyping and Surveillance Network.19With the
CONCLUSIONS
A large outbreak of pediatric TB resulted from prolonged TB transmission in a private-home family child care center, from an infectious adult. Primary care providers played a key role in case detection, through adherence to existing pediatric TB screening guidelines. Intensifica-tion of contact investigaIntensifica-tions surrounding children and systematic improvements in data management by TB programs may improve future outbreak control efforts.
ACKNOWLEDGMENTS
We acknowledge Charles Crane for the cooperation of Costra Conta County with the investigation, Roxanne Aga and Midori Kato of the Stanford Center for Tuber-culosis Research for DNA fingerprinting assistance, Andi Shane (University of California, San Francisco) for her review of this manuscript, and Ann Lanner (Centers for Disease Control and Prevention) for editorial assistance.
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DOI: 10.1542/peds.2005-1380
2006;117;863
Pediatrics
Kawamura
Diaz, Melaku Woldemariam, Theresa Ampie, Jennifer Grinsdale and L. Masae
Puneet K. Dewan, Houmpheng Banouvong, Neil Abernethy, Thomas Hoynes, Liliana
Francisco, 2002 to 2004
A Tuberculosis Outbreak in a Private-Home Family Child Care Center in San
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