TB Notes Newsletter
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No. 4, 2006
Director's Letter -
December 2006
Dear Colleagues:
For 2005 we reported the good news of
another decrease in the overall number of new tuberculosis (TB)
cases, with 14,097 confirmed cases and a case rate of
4.8/100,000. This compares with 14,515 cases and a 4.9/100,000
case rate for 2004. Our hard-working state and big city TB
control staff accomplished this despite the many fiscal and
programmatic challenges facing them. The state of Wyoming
reported zero TB cases for 2005 (and in fact did this in 1989 as
well!). Please accept my congratulations for the outstanding
work all of you are doing. However, we cannot be complacent.
National figures mask some worrisome underlying trends: there
has been a slowing in the rate of decline for the past 3 years,
and 20 states reported an increase in the incidence of TB.
The Advisory Council for the Elimination
of Tuberculosis (ACET) met July 26–27 and December 5–6 in
Atlanta. In the July meeting, Dr. Ron Valdiserri announced he
would be leaving CDC to join the Veterans Health Administration
in Washington, DC, and Dr. Masae Kawamura finished her 2-year
commitment as Chair of ACET; Dr. Michael Fleenor of Alabama will
serve as ACET’s new Chair. I announced the release of DTBE’s
newest TB control guidelines, “Prevention and control of
tuberculosis in correctional and detention facilities:
recommendations from CDC,” (MMWR 2006; 55 [No. RR-9]). I also
reported that on May 16 and 17 in Atlanta, CDC and RTI
International hosted a successful summit, “Stop TB in the
African-American Community.” DTBE staff were planning the annual
TB Education and Training Network conference (please see Scott
McCoy’s summary of that conference in this issue) as well as the
TB Managers’ Course. I reported that US Public Health Service/TB
Trials Consortium (TBTC) Study 26 underwent review in May 2006
by the Data Safety Monitoring Board, which recommended
continuation of the study. This trial of short-course treatment
of latent TB infection uses a 3-month once-weekly regimen of
isoniazid and rifapentine, compared to standard 9-month therapy
with isoniazid. Enrollment continues for Study 28, a trial
substituting moxifloxacin for isoniazid in standard
intensive-phase TB treatment and assessing the effect on 2-month
sputum conversion rates. This could be a defining study for
fluoroquinolones in TB treatment regimens. I mentioned that as
of June 30, 2006, states had submitted 18,386 isolates to the
contract laboratories for genotyping. I also related news of the
upcoming departures of several valued DTBE staff: Dr. Lisa
Nelson was leaving to head up CDC’s TB/HIV office in Mozambique,
Subroto Banerji was taking a position as a public health advisor
assigned to South Africa for CDC’s Global AIDS Program, and Dr.
Michael Iademarco had accepted the position of Health and Human
Services (HHS) Health Attache for Vietnam.
Dr. Mary Naughton of the Division of
Global Migration and Quarantine (DGMQ) and I discussed issues
around civil surgeons, who examine patients here in the United
States applying for a change of their immigration status. The US
Citizenship and Immigration Services (USCIS) will be revising
the civil surgeon rule to strengthen civil surgeon
qualifications and will transfer funds to CDC for its continued
technical assistance with the program. Dr. Drew Posey of DGMQ
discussed the revised Technical Instructions for overseas TB
screening of immigrants: diagnostic testing will be more
comprehensive, children will be required to be medically
evaluated, the medical exam will be valid for only 3 months, and
treatment for TB must be given overseas as directly observed
therapy. Dr. Posey and Kai Young of DTBE gave updates on TB in
the Hmong refugees being resettled in the United States. After
the treatment algorithm was revised in early 2005, case rates of
TB, including MDR TB, declined from 508/100,000 in refugees who
were resettled June 2004–January 2005 to 69/100,000 in those
resettled February 2005–July 2006. Also, Dr. Tom Navin reported
on the TB Evaluation Workgroup’s process to readdress and better
define high-priority national TB program objectives.
ACET met again on December 5 and 6. Dr.
Michael Fleenor and CDC committee management staff gave new
members an orientation in which ACET’s role as a public health
advisory council was described. Dr. Fleenor provided an overview
of some of ACET’s major initiatives between 2003 and 2006. These
have included meetings and communications focused on improving
U.S. TB control efforts in African Americans and foreign-born
populations and increasing the funding for TB drug research. I
reported that in 2006, CDC/DTBE was invited by local/state
health departments to assist with five outbreak investigations;
the affected populations included two foreign-born communities,
two groups of drug users, and a large group consisting of
sailors and civilians traveling together aboard a U.S. Navy
ship. I also provided an update on the ongoing process and
timetable for revising the TB case report form (Report of
Verified Case of TB). The revision team is currently requesting
comments from TB partners and will ask ACET to review the
proposed revision in early 2007; CDC and OMB clearances are
expected in another year, and availability of the new RVCT is
estimated for 2009. I cited the achievements of the Regional
Training and Medical Consultation Centers: combined, they have
completed over 200 hours of training and have trained over 500
participants annually. They have developed a number of new
education and training products and have established medical
consultation services. I also provided an update on the
“Projects to Intensify Efforts for Reducing TB Rates in
African-American Communities.” In 2002, ACET called for CDC to
address high rates of TB in African-American communities; as a
result, DTBE competitively awarded supplemental funds to
Georgia, South Carolina, and Chicago for the development,
implementation, and evaluation of TB-reduction interventions in
these communities. We learned a number of lessons from these
projects: partnerships with community organizations serving
African Americans are crucial; care providers must be culturally
acceptable and physically accessible to patients; and patient
mistrust, misconceptions, and fear of stigma must be overcome. I
reported on the TB Epidemiologic Studies Consortium’s Task Order
18, which will evaluate new Interferon-gamma release assays for
the diagnosis of LTBI in health care workers, and compare these
assays to the tuberculin skin test (TST). This will be a
longitudinal study of about 2500 health care workers who will be
retested every 6 months until they have been retested at least
three times. Participating sites include the health departments
of Texas, Maryland, and Denver, and Columbia University.
I then shared DTBE’s budget plans. We
anticipate that for fiscal year (FY) 2007, the division will
experience an overall 5% budget cut. DTBE branches are currently
reviewing areas where reductions can occur. Hiring actions will
be postponed, and funding will be reduced for cooperative
agreements and research projects. Funding for travel, printing,
and information technology infrastructure will be reduced. Our
budget planning will include consultations with our national TB
control partners and with ACET.
Dr. Charles Wells gave an overview of
extensively drug-resistant (XDR) TB and its implications for TB
control. Some of the countries of origin of U.S. foreign-born TB
patients also have a high burden of multidrug-resistant (MDR) TB
and a high risk of XDR TB, such as Mexico, the Philippines, and
Vietnam. Increases in MDR TB and XDR TB would create increasing
demands on the capacity of U.S. laboratories. In addition, XDR
TB would likely have a negative impact on U.S. initiatives for
HIV treatment and care, as well as U.S. capacity to respond to
outbreaks and provide treatment. He cited a need for updated
policies and guidelines as well as a comprehensive U.S.
government response. In updates on the resettlement of Hmong and
Burmese refugees, we learned that the prevalence of TB is
similar among the two groups, but that the prevalence of MDR TB
is much lower among the Burmese. Dr. Drew Posey, DGMQ, gave an
update on the Technical Instructions for Overseas Screening and
Treatment of Tuberculosis. DGMQ is developing a manual that will
provide information on implementing the new Technical
Instructions; it will be used by DGMQ and panel physicians. A
draft is expected in June 2007 and will be provided to NTCA and
ACET. Members of NTCA and ACET are reviewing the current draft
of the Technical Instructions. We learned from Dr. Bill Mac
Kenzie that in 2005, persons from Mexico made up 14% of the
total U.S. cases. Drug-susceptibility testing is limited in
Mexico; to address this, a national survey for TB drug
resistance is planned for that country. Ms. Molly Lindner of
USAID Mexico provided an update on TB projects in Mexico
supported by USAID. Joe Scavotto gave a progress report on DTBE
efforts to develop a redistribution formula for the TB
cooperative agreement funding; discussions on this topic will
continue. Dr. Phil LoBue indicated that the Federal TB Task
Force will be refocusing on the global threat of XDR TB; members
are discussing potential areas of coordinated U.S. government
response. Mr. Scott Danos reported that the current electronic
TB surveillance system, TIMS, will definitely still be in place
for calendar years 2007 and 2008. After that, it will be
replaced by the National Electronic Disease Surveillance System
(NEDSS) TB program area module, a web-based system with instant
messaging of RVCT data to CDC.
Two new slide sets are available on the
DTBE Internet, the
2005
Surveillance slide set and the slide set that accompanies
the MMWR publication “Guidelines
for preventing the transmission of M. tuberculosis in
health-care settings, 2005.”
My heartfelt thanks to all for your
outstanding work and accomplishments this year, and best wishes
for a safe and peaceful holiday season!
Kenneth G. Castro, MD |
