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TB Notes NewsletterReturn to Main Menu - TB Notes 2, 2007No. 2, 2007Director's LetterDear 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 |
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