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TB Notes Newsletter
No. 2, 2007
Director's Letter
Dear Colleague:
On March 23, 2007, CDC’s Morbidity and Mortality
Weekly Report (MMWR) included a World TB Day “box”
statement on the cover, as well as two articles,
“Extensively Drug-Resistant Tuberculosis” and “Trends in
Tuberculosis Incidence” (MMWR 2007; 56[11]: 245–253). In
the trends article, DTBE provisionally reported a total
of 13,767 tuberculosis (TB) cases (4.6 per 100,000
population) for 2006, representing a 3.2% decline from
2005. I congratulate all who helped achieve this
accomplishment, but our optimism must be tempered by
caution: the TB rate in 2006 was the lowest since
national reporting began in 1953, but the rate of
decline is slowing. The average annual percentage
decline in the TB incidence rate decreased from 7.3% per
year during 1993–2000 to 3.8% during 2000–2006. Our
challenge, which I know we can meet, is to maintain our
progress in the face of the realignment of public health
resources.
World TB Day is observed around the world on March
24. This year, staff of the Division of Tuberculosis
Elimination (DTBE) contributed to the global observance
of this event in several ways. In addition to producing
the MMWR statement and reports mentioned above, DTBE
staff in Atlanta gathered for a World TB Day luncheon on
March 23. We were entertained and enlightened by a
number of outstanding performances and presentations. On
March 24, World TB Day, DTBE staff and their friends,
families, and coworkers, including CDC Director Dr.
Julie L. Gerberding and National Center for HIV/AIDS,
Viral Hepatitis, STD, and TB Prevention (NCHHSTP)
Director Dr. Kevin Fenton, gathered in Grant Park in
Atlanta for the first TB Awareness Walk. DTBE staff also
produced two articles that appeared on the CDC employee
Intranet website, “CDC Connects.” Please see the related
items in this issue.
The Advisory Council for the Elimination of
Tuberculosis (ACET) met on March 20–21, 2007, in
Atlanta, Georgia. Highlights from the meeting are as
follows: In his update, Dr. Kevin Fenton reported that
Dr. Gerberding had participated in a Congressional
briefing on March 7, at which she had the opportunity to
inform Congress about TB and extensively drug-resistant
(XDR) TB. She also testified on March 21 in a hearing
before the Subcommittee on Africa and Global Health of
the House Foreign Affairs Committee. The hope is that
these briefings will result in increased resources to
address unmet needs in the fight against TB. In an
update on the NCHHSTP budget, Dr. Fenton announced that
the joint FY2007 budget resolution provides flat funding
for TB; for FY2008, the President’s budget request for
TB is $136.8 million. Describing changes in NCHHSTP’s
leadership, he announced that Dr. Nick DeLuca of DTBE is
serving a 120-day detail as the Acting Associate
Director for Health Disparities, subsequent to Dr. Hazel
Dean taking the position of Acting Deputy Director,
NCHHSTP. Susan DeLisle is the Acting Associate Director
for Program Integration.
Dr. Fenton
also discussed program integration, the
concept of organizing and blending interrelated
activities and services in order to maximize public
health impact, through linkages that facilitate the
delivery of services. He stated that integration should
be focused at the field level or client level, where the
interface between the system and the consumer takes
place. Dr. Fenton’s short-term goals for program
integration include supporting implementation of new
adult hepatitis B vaccination guidelines in STD and HIV
evaluation and care settings; developing strategies to
strengthen partnerships among governmental and community
organizations; and building collaborations across NCHHSTP’s HIV, STD, and viral hepatitis prevention and
surveillance programs.
He then indicated several
priority integration activities
:
conducting integrated
Program Consultant meetings; establishing reverse site
visits, in which state or field staff come to Atlanta
for program review meetings, and an integrated approach
for program review; improving communication to grantees
on PGO issues; developing a web-based NCHHSTP Intranet
and Internet presence for Program Consultant sharing and
communication of best practices; developing templates
and standards for joint trip reports; and maximizing
Program Consultant and field staff deployment during
public health emergencies. Dr. Fenton then described a
successful site visit to California during the week of
February 5–9, 2007. During the visit, the NCHHSTP team
examined integrated, client-centered programs. Finally,
Dr. Fenton reminded the group about the TB Awareness
Walk, the first of what is hoped to be an annual event.
It was being held on Saturday, March 24, in Atlanta’s
Grant Park.
Dr. Fleenor provided information on a March 15–16
meeting of the Board of Scientific Counselors (BSC). He
indicated that the BSC meeting had been quite positive
and energizing. The group had discussed the need for new
technology for surveillance of drug-resistant TB and for
new diagnostic technologies.
He
summarized the
meeting by saying that he was pleased with the direction
of the new BSC so far.
Ms. Carol Pozsik, Executive Director of the National
TB Controllers Association (NTCA), described issues and
challenges that TB control programs face in attempting
to obtain reimbursement from Medicaid for TB services.
In a 2006 survey, NTCA found that only 5 of the 50
states use the Medicaid TB option; the others do not use
it for a variety of reasons such as the complexity of
the process, the limitations of the coverage, and the
administrative burden it puts on TB programs. We also
learned that some states require copayments from
clients; several ACET members commented that patient
copayments are a barrier to patient completion of
therapy and a real deterrent to TB control efforts. I
mentioned that studies have been done on the costs of
treatment and hospitalization for TB patients, and
commented that ACET might want to recommend
discontinuation of the requirement of TB patient
copayments, in order to remove all barriers to patient
treatment and care to interrupt the chain of TB
transmission.
In my DTBE Director’s report, I
described recent CDC
TB-related activities. On March 6–7, CDC staff met with
staff of the Office of the Global AIDS Coordinator (OGAC);
that office is providing funds for fighting TB/HIV in
the amount of $120 million. Also, in the upcoming weeks
CDC staff would be meeting with a White House
interagency team on XDR TB.
I presented the data mentioned earlier, i.e., that
there has been a statistically significant slowing in
the rate of TB decline since 2000. In both 2004 and
2005, 1.2% of TB cases were multidrug resistant.
However, the proportions of MDR and of XDR TB cases
occurring in foreign-born persons are increasing. I also
communicated that we recently learned the National
Electronic Disease Surveillance System (NEDSS) TB
Program Area Module (PAM) is no longer being supported
by CDC. However, the NEDSS standards and the NEDSS Base
System will still be supported by CDC. In the short
term, TIMS will continue to be used. In the long term,
DTBE will collaborate with NTCA, TB program directors,
and TB surveillance coordinators to agree on an action
plan.
Dr. Phil LoBue gave an update on the Federal TB Task
Force (FTBTF) response to XDR TB. The charge to the
FTBTF was to develop an action plan by February 28,
2007. Most sections of the plan were submitted by the
deadline. The document will be shared with partners such
as ACET, NTCA, APHL, and ATS. The document will be
revised based on comments and then cleared by CDC, OGAC,
and USAID. Dr. LoBue had learned recently that the White
House was convening an interagency team to address XDR
TB. The FTBTF plan will be shared with the White House
team; further action will be determined by direction
from the White House.
Claire Wingfield of the Treatment Action Group (TAG)
discussed funding needs and gaps in global TB research
and development efforts; according to TAG, about $20
billion will need to be spent over the next decade in
order to eliminate TB by the year 2050. Dr. Rachel
Albalak gave an update on the TB Epidemiologic Studies
Consortium (TBESC). While a number of new research
studies have been approved for FY2007, TBESC’s budget
has been reduced; these reductions may require
fundamental changes to its approaches or operating
model. Dr. Andy Vernon gave an update on the
Tuberculosis Trials Consortium (TBTC), in which he
discussed current studies and reported on recent
external TBTC reviews. The TBTC received excellent
assessments from the external reviewers; however,
funding for this activity has also declined.
We also heard summaries of the recently completed
projects, “Intensification of TB Prevention, Control,
and Elimination Activities in African-American
Communities.” Highlights from the Chicago site, the
South Carolina site, and the Georgia site were provided
by Ms. Gail Burns-Grant of DTBE, Mr. Joseph Kinney, and
Mr. Ken Johnson, respectively. Dr. Ana Lopez-DeFede
presented findings from the project evaluation that
identified potential barriers to TB control in this
population, including poor knowledge of TB, which was
much lower than among other racial groups, and patient
beliefs and fears about TB, which may also present
barriers to accessing care. For example, many associate
TB with HIV, which may create stigma, or may consider TB
itself stigmatizing. Suggestions for overcoming these
barriers included providing education to patients about
preventing TB and to health care providers about making
and maintaining client contact; developing new treatment
strategies; and providing a comprehensive community
health care approach.
Drs. Nick Deluca and Rachel Royce
presented reports on two additional projects concerning
disparities in African Americans. Nick discussed the
evaluation results of the “Stop TB in the
African-American Community” summit, describing the many
specific action items that had been completed by the
summit’s breakout groups. Rachel provided formative
research results from TBESC task order 11, “Addressing
TB Among African Americans in the Southeast,” describing
challenges similar to those outlined by Dr. Ana Lopez-DeFede:
socioeconomic and other health problems, lack of
knowledge about TB, and stigma.
We received several updates on international topics.
Dr. Diana Schneider and Mr. Dan Reyna gave reports on
US-Mexico border issues, and Dr. Kathleen Moser and Ms.
Del Garcia gave updates on San Diego County’s CureTB and
the Migrant Clinicians Network’s TBNet. These persons
and their organizations are helping ensure that
migrating TB patients complete their therapy. Challenges
include discontinued funding for printing of the TB
binational card and problems in Mexico with directly
observed therapy. With the global concerns about
extensively drug-resistant (XDR) TB, it is vital to
ensure treatment completion for patients.
Dr. Dolly Katz
gave a progress report on the revised guidelines for
preventing and controlling TB in foreign-born persons;
important data supporting the revision will be provided
by the nearly completed TBESC task order, “Missed
Opportunities for TB Prevention in Foreign-born
Populations in the United States and Canada.” Dr. Drew
Posey discussed the Technical Instructions for Overseas
Screening and Treatment of Tuberculosis. The revised
instructions have been formally distributed to the
Department of State and the International Organization
for Migration to allow for budget planning and to begin
implementation; several countries are expected to
implement the new instructions in 2007. As others had
indicated, ensuring patient completion of therapy is a
challenge in many countries.
Members discussed several policy issues, the first
being whether DTBE should promote the recent HIV testing
recommendations in health care settings. These
guidelines recommend that HIV testing be offered to all
TB patients, with written consent not required; patients
have the option to refuse the testing. ACET supported
the recommendations but were concerned about the
financial implications of performing HIV testing in
large contact investigations. The group will develop a
statement of support for the new HIV testing policy, and
will continue its discussions on addressing barriers to
implementation.
We next discussed the revised Report of
Verified Case of Tuberculosis (RVCT). The RVCT workgroup
has finalized the revision and cleared it through DTBE.
By June 26, 2007, ACET and NTCA must provide their
comments on the revision; July 2, 2007, is the deadline
for submitting the final version to the Office of
Management and Budget for approval. In addition, we
considered the establishment of a workgroup to address
TB in African Americans. After discussing the merits of
the issue, the group decided by vote to approve the
establishment of a “TB in African Americans” workgroup;
I noted that this represents a reestablishment of ACET’s
previous such American workgroup that was chaired by Dr.
Stephanie Bailey. Mr. Shannon Jones was designated
acting chair of the new ACET workgroup.
The group also
revisited the issue of Medicare/Medicaid reimbursement
for TB services. After a discussion of the evidence that
a requirement for patient copayments has a negative
effect on patient treatment, the group agreed to issue a
formal statement recommending removal of all patient
copayments for Medicaid TB services. Finally, several
members of DTBE presented a special World TB Day
observance. Drs. Bill MacKenzie and Eric Pevzner
presented data from their recently published MMWR
reports, and Mr. Vic Tomlinson wrapped up the
presentations with a reminder about the TB Awareness
Walk. The next ACET meeting is scheduled for July 10–11,
2007, in Atlanta.
Please note that
the DTBE Web team recently updated the DTBE website URLs
(webpage addresses). Specifically, "NCHSTP" was removed,
and long, cumbersome URLs were shortened. Redirects to
the new URLs are being temporarily posted on the old
webpages. The Web team will monitor usage of the old
URLs and, as usage decreases, will replace the specific
redirects with a general redirect to the DTBE homepage.
Once usage drops to zero, the general redirect will be
removed. Remember to update your bookmarks.
Forging Partnerships to Eliminate Tuberculosis: A
Guide and Toolkit has been posted on the DTBE website
and is available at www.cdc.gov/tb. The print version
should be available within the next few months. In
addition, several new fact sheets on XDR TB are also
available on the website.
The 2007 National TB Controllers
Workshop is being held in Atlanta, Georgia, June 12–14,
2007, at the Crowne Plaza Ravinia Hotel. I hope that
many of you will be attending the workshop and taking
advantage of all the opportunities this meeting presents
for TB control professionals. See you there!
Kenneth G.
Castro, MD
Last Reviewed: 05/18/2008 Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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