TB Notes Newsletter

No. 4, 2010

Dear Colleague:

Every year around this time, I pause and reflect on the exciting work that has been accomplished by the staff of the Division of Tuberculosis Elimination (DTBE) and our partners. We have a full complement of news and reports in this issue of TB Notes reflecting the multitude of projects in which we are involved. I hope you will have time to read it before taking your well-deserved holiday annual leave.

On December 8, the World Health Organization announced a policy update providing a “roadmap” for the use of the Xpert MDR/RIF rapid diagnostic test as a way to improve global case detection and rapid detection of rifampin resistance as a proxy for multidrug-resistant (MDR) TB. This new tool could revolutionize our ability to significantly reduce diagnostic delays.

 We were saddened to learn of the unexpected death of Susan Bacheller, who was TB Team Leader in the Bureau of Global Health of the U.S. Agency for International Development (USAID). Her colleagues at USAID posted an eloquent tribute to her, which we have included in this issue.

The earthquake that struck Haiti in January 2010 occurred in what was already the most precarious public health system in our hemisphere. CDC was among the groups ready to assist, and DTBE staff members were among these CDC responders. We have an article that reports on a typical assignment to Haiti.

Heather Duncan, who had served as Associate Director for Management and Operations for the Division of Tuberculosis Elimination (DTBE), accepted a promotion to serve as the CDC Deputy Chief of Staff. She had been on detail as acting Deputy Chief of Staff since September 12, 2010. Heather helps manage the day-to-day operations of the CDC Director's office. We are sorry to lose Heather, but we are proud of the continued tradition of TB control staff moving into leadership positions.

DTBE’s Surveillance team and state and local TB control colleagues worked diligently on the larger-than-expected “decrease in reported TB cases” anomaly that was noted earlier in the year. The group members studied and analyzed this unprecedented drop in TB cases, and finalized the official number of 2009 reported TB cases. On October 26, the Surveillance team released these data. The number of reported TB cases for 2009 was 11,545, and the case rate was 3.8 cases per 100,000; these figures represent declines of 10.5% and 11.3%, respectively, compared to 2008. Please access the full report at http://www.cdc.gov/tb/statistics/reports/2009/default.htm

The 2010 Program Managers’ Course was held October 18–22, 2010, at the Westin Atlanta Perimeter North.  As many of you know, this is a course for TB Program Managers, Nurse Consultants, Public Health Advisors, and TB Controllers who have programmatic responsibilities at the state, city, or regional level. I extend my thanks to the dedicated DTBE staff who took time from their schedules to serve as organizers and faculty for the course. Please see the summary provided in this issue.

The Advisory Council for the Elimination of Tuberculosis (ACET) met in Atlanta November 2–3; I include here highlights from that meeting. Dr. Hazel Dean, Deputy Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), gave the NCHHSTP Director’s Update. She reported on the leadership of CDC’s new Center for Global Health: Kevin De Cock, MD, takes the helm as Director and Pattie Simone, MD, serves as the Principle Deputy Director. Dr. Simone started out in TB and was a DTBE medical officer for a number of years; she later served as branch chief of the Field Services and Evaluation Branch (FSEB) in her last DTBE position. We are very happy to see another TB alumna rise to further prominence. Dr. Dean also announced that Terry Chorba, MD, previously the Associate Director for Science for the Center, is now the chief, FSEB, for our division. We are most pleased that Dr. Chorba, who has had a long-time interest in TB, has now formally joined the TB family. 

In my DTBE Director’s Update, I noted that DTBE staff participated in investigating six outbreaks in 2010. I reported that, owing to HHS-CDC changes in contract funds management, DTBE will make strategic, one-time investments to address priority areas of need in three areas: strengthening and protecting programs; increasing access to new diagnostics; and improving knowledge of the U.S. burden of infection. I also reported that on October 7, DTBE held a special consultation with 30 national TB representatives concerning the Affordable Care Act. The group recommended strengthening the partnership between CDC and HRSA; developing model partnerships between community health centers and TB control programs; developing a model infectious disease “screening package” for primary care providers; developing solutions for undocumented persons who need TB services; and investigating “meaningful use” of TB surveillance and evaluation data. In an update on the TB Genotyping Information Management System (TB GIMS), I shared NTCA user survey results that 71% are satisfied with the system, and 77% do use the system to evaluate genotype clusters.

In updates on global migration, Dr. Drew Posey of the Division of Global Migration and Quarantine (DGMQ) reported that 30 countries are now implementing the 2007 TB Technical Instructions (TIs), with several more expecting to begin implementing them in 2011. Dr. Jenny Flood reported on Vietnam’s good progress in implementing the 2007 TIs. Mr. Yecai Liu of DGMQ presented data showing that, in addition to immigrants and refugees, long-term visitors (such as students and some workers) from high-prevalence countries contribute substantially to the burden of TB in foreign-born persons in the U.S.

An update on NCHHSTP health equity activities by Dr. Kathleen McDavid Harrison was well received. In June, an article by NCHHSTP staff on social determinants of health (SDH) was published online in Public Health Reports. On October 19, NCHHSTP held a health equity symposium, during which a SDH white paper was released. NCHHSTP is already incorporating the SDH approach into current and planned activities. In a report on TB and homelessness, we learned that since 1993, 4%-6% of U.S. TB cases have been in homeless persons. Also, during 2002–2010, of the 32 domestic TB outbreaks investigated by CDC, 28 (72%) involved homeless persons.  Members of DTBE’s Homeless Initiative team have developed an agenda aimed at eliminating TB in the homeless and are exploring initial projects. We look forward to hearing about innovative interventions from the group.

We heard several workgroup reports. Dr. Elsa Villarino gave us an update on the recommendations for preventing MDR TB and extensively drug-resistant (XDR) TB in health care workers who engage in humanitarian work in areas where MDR TB is endemic. She reported that comments on the recommendations are quite diverse, and she was encouraged by ACET to complete the harmonization of comments and begin the clearance process for this important document.

Dr. Dolly Katz gave an update on the revised guidelines for preventing TB in foreign-born persons. A new and major recommendation of this document is that every U.S. resident born in a TB-endemic country should be screened for TB and tested for LTBI at least once as part of routine health maintenance. Drs. Katz, Masae Kawamura, and Michael Fleenor have collaborated on refining and distilling the workgroup’s draft. ACET membership suggested modifications, to be incorporated by Dr. Katz, and the group will review and hopefully approve a final document at the next ACET meeting.

Lisa Thombley, JD, reported that the Menu of Suggested Provisions for State TB Prevention and Control Laws has been finalized and made widely available. She asked ACET for suggestions for further distribution and dissemination. The menu features a set of provisions for consideration by public health officials and their legal counsel in developing or amending laws to prevent and control TB. This document is available at http://www.cdc.gov/tb/programs/laws/menu/default.htm and http://www2.cdc.gov/phlp/tbcontrol.asp.

Stop TB USA convened a retreat on September 1–2, 2010, to review its mission, by-laws, and ongoing activities. It also hoped to develop a plan of action for its report, Tuberculosis Elimination Plan for the United States. The retreat participants concluded that the group must be adequately resourced; the benefits for and expectations of members must be clarified and made transparent; and a patient/family membership category should be added. By adding a forum for the patient’s voice, Stop TB USA can gain a valuable ally and advocate.

In light of the serious challenge of TB in the U.S./Mexico border area, a U.S./Mexico TB Summit was held on June 24, 2010, where an ambitious collaborative agenda was established. I reported on this summit, and several others spoke about plans for addressing TB along the border, and the many barriers to implementing the activities. There is much to do, but we have many dedicated partners on both sides of the border.

Dr. Bev Metchock gave an update on the first year of the DTBE Laboratory Branch’s molecular detection of drug resistance (MDDR) service. This new service appears to be working well and providing useful information for treatment guidance, significantly sooner than conventional methods. The branch anticipates being able to offer rapid detection of drug resistance soon, as well. Finally, Dr. Jenny Flood described the challenges some areas are facing in obtaining second-line drugs for treatment of MDR TB. Owing to the increase in MDR TB in some regions of the world, more such cases are being diagnosed in the United States and must be treated; yet many patients, and even some TB control programs, cannot afford these second-line drugs. CDC will be working urgently with partners to find a solution to this problem. After a number of business items were discussed, the meeting was adjourned. The next meeting will be held in early March 2011.

I extend to all of you my thanks for the challenging and important work you do every day and the amazing accomplishments you have achieved, this year and every year. I am proud of the work we do together and fortunate to count all of you as colleagues. Best wishes to you and your families for a safe and peaceful winter season!

Kenneth G. Castro, MD
Assistant Surgeon General,
USPHS & Commanding Flag Officer
CDC/ATSDR Commissioned Corps
Director, Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis,
STD, and TB Prevention