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CDC's Response to Ending Neglect

The Plan

GOAL IV: Increase involvement in global efforts
Increase U.S. involvement in international TB control activities to reduce the global burden of TB.

TB cannot be eliminated in the United States without a considerable reduction in the global burden of TB.9 In 2001, approximately 50% of newly diagnosed U.S. TB patients were born outside the United States.7 Most of these patients acquired their TB infections in countries such as Mexico, the Philippines, Vietnam, India, China, and Korea but did not have clinical disease when they entered the United States. Subsequently, for reasons not sufficiently understood, their immune systems were unable to keep the infections in check and they developed active TB. Within the next several years, it is expected that more than half of the new TB patients diagnosed each year in the United States will be foreign-born persons.

The global community is fighting TB on several fronts. Based on the pioneering work of the IUATLD, WHO has developed a specific strategy for TB control in low-income countries. Thestrategy, called "directly observed treatment, short-course" (DOTS), combines five elements: 1) the political commitment of the government to support TB control programs, 2) bacteriologically-based diagnosis, with AFB-smear microscopy of sputum specimens of patients with symptoms of TB, 3) standardized treatment with rifampin-based (short-course) regimens given under direct supervision, 4) a reliable supply of quality drugs and diagnostic supplies, and 5) individualized reporting of treatment outcome coupled with program monitoring and supervision. DOTS coverage has expanded greatly during the past decade, but inadequacies in diagnostic and treatment tools limited its easy applicability. A global partnership, Stop TB was created to help coordinate the efforts of governments, nongovernmental agencies, and donor agencies in global TB control. Working through the Stop TB Partnership, CDC has contributed to DOTS expansion and also addressed the recalcitrant problems of MDR TB and HIV-associated TB.

Although MDR TB has come under control in the United States, it appears to be a much more serious problem internationally. In 1999, the estimated proportion of multidrug resistance in new TB patients was 1.6% in the United States but reached as high as 10% in Latvia and Russia (see graph). Rates of TB and drug-resistant TB have been increasing at an alarming rate in Russia, fueled by 1) lack of continuous access to quality drugs, 2) the country's inability to support the TB diagnosis and treatment infrastructure, 3) high levels of TB transmission in prisons, 4) limited TB control policies and reluctance to adopt the WHO-recommended DOTS strategy, and 5) increasing levels of HIV infection.

At the request of the USAID mission in Moscow, WHO, CDC, and USAID are implementing DOTS programs in the Orel and Vladimir oblasts (territorial administrative divisions) and strengthening the DOTS program started by WHO in Ivanovo oblast in 1995. As part of the implementation of DOTS-Plus (WHO's strategy for managing MDR TB in low-resource settings) in the Ivanovo oblast, CDC 1) developed a diagnostic and treatment protocol that has become the basis for the Russian DOTS programs, 2) posted CDC public health advisors to 3-month temporary assignments to help implement DOTS and DOTS-Plus strategies, 3) helped establish a national TB surveillance system, and 4) conducted epidemiologic studies of risk factors for development of MDR TB. CDC has also provided laboratory training, quality assurance for drug sensitivity testing, and consultation. As a result of these actions, cure rates in Ivanovo oblast have risen from 61% to 75%; in the initial cohort in Orel, the cure rate was 83%.

CDC has also been involved in activities to strengthen TB laboratory services in low-income countries. Throughout much of the world AFB microscopy is the basis for diagnosis and control of TB, but there is currently no practical guidance for national programs in monitoring and promoting quality testing at the clinic level. CDC and its Stop TB partners are developing international guidelines on national external quality assessment programs for microscopy. CDC has also developed several products that are focused on providing training to the laboratory technician performing AFB microscopy at the local level in middle- and low-income countries.

CDC is also engaged in WHO-sponsored international efforts to evaluate the effectiveness of treatment strategies for MDR TB in low-resource settings and to conduct large-scale purchases of MDR TB drugs that will lower prices to a fraction of current levels. CDC is a charter member of an MDR TB working group and serves as one of five international agencies that review MDR TB treatment protocols submitted by national TB programs for potential participation in WHO's MDR TB treatment network.

Efforts to address TB-HIV coinfection include the implementation of the BOTUSA Project in Botswana. In 1995, at the invitation of the Ministry of Health, CDC established a TB-HIV field site in Botswana, a country with high HIV prevalence and high TB case rates. The field site is collaborating with the Botswana Ministry of Health, WHO, and other countries on the provision of TB preventive therapy to persons with HIV infection and the development of methods to improve TB diagnosis in low-resource settings. The BOTUSA site serves as a base for regional USAID-funded TB activities throughout southern Africa, including an assessment of drug quality and the implementation of a computer-based TB surveillance system. Research projects have addressed 1) causes of illness in patients with suspected TB whose initial diagnostic evaluation was negative, 2) use of molecular epidemiology techniques to identify risk factors for TB transmission, 3) absorption of TB drugs in patients coinfected with TB and HIV, 4) TB drug resistance, 5) patients' knowledge and attitudes about HIV and TB testing, 6) acceptability of preventive therapy, and 7) TB patients' risk behaviors for HIV transmission. BOTUSA is working with the national AIDS and TB programs to explore the use of preventive therapy postnatally in HIV-positive women and to identify other populations for TB preventive therapy.

Objective IV-A

In collaboration with WHO and other international partners, provide leadership in public health advocacy for TB prevention and control.


  1. Increase collaboration with the Stop TB Partnership at both the global and regional levels.
  2. Working with the USAID-funded TB Technical Advisors Consortium, increase the pool of skilled persons who can provide technical assistance to TB control programs.
  3. Support the educational programs of IUATLD.
  4. Contribute to the development of technical guidelines and recommendations through participation on international working groups (e.g., Green Light Committee, WHO Scientific and Technical Group for TB, Regional WHO Advisory Committees).
  5. Provide technical assistance to USAID for activities related to TB control.
  6. Coordinate with NIH in international TB control and research.

Objective IV-B

Provide technical support and build capacity for implementation of DOTS, especially in those countries that contribute significantly to the U.S. TB burden.

  1. Contribute technical support and capacity-building assistance to strengthen epidemiologically-based DOTS implementation in 3 to 5 countries from which a high volume of U.S. TB cases originate and in several of the other 22 high-TB burden countries identified by WHO.
    • Conduct operational studies to enhance the implementation of DOTS.
    • Improve TB surveillance.
    • Provide training in program management, epidemiologic methods, and operations research.
    • Assist in program reviews (WHO, IUATLD, USAID).
  2. In collaboration with the Stop TB Partnership, develop technical guidelines and training products that strengthen laboratory services in high-burden countries.

Objective IV-C

In collaboration with WHO and other partners, develop models for the diagnosis and treatment of MDR TB in countries with high rates of drug resistance.

  1. Expand and enhance the Latvian model center (see page 50).
  2. Provide assistance to the MDR TB project in Peru funded by the Bill and Melinda Gates Foundation.
  3. Implement DOTS-Plus in Ivanovo, Russia.

Objective IV-D

Provide technical, programmatic, and research support aimed at reducing the incidence of TB as an opportunistic disease in high HIV-burden countries.

  1. Through collaboration with CDC's Global AIDS Program (GAP), provide technical assistance for TB surveillance in countries with high rates of HIV-associated TB.
  2. Through collaboration with GAP, provide technical assistance for enhanced TB laboratory capability in countries with high rates of HIV-associated TB.
  3. Through BOTUSA and other GAP-supported programs, conduct operational research to improve the diagnosis and treatment of HIV-associated TB.
  4. Conduct large-scale feasibility studies of various regimens for the treatment of latent TB infection in HIV-infected persons.

Center of Excellence for the Management of MDR TB in the Baltics

Latvia has one of the highest rates of drug resistance in the world. In 1999, 10% of new TB patients had MDR TB; this compares with 1.6% in the United States and <1% in most African countries. The high rates of MDR TB are attributed to poor treatment programs and drug shortages that occurred in the early 1990s after the fall of the Soviet Union.

In 1999, with fiscal support from the U.S. Department of State, CDC and USAID signed a Memorandum of Agreement to 1) develop a Center of Excellence for the diagnosis and management of MDR TB in Latvia, and 2) disseminate lessons learned to Estonia, Lithuania, and other republics of the former Soviet Union where TB control efforts have been compromised by drug resistance. The Center was designed to develop local expertise and facilities that can provide world-class diagnosis and treatment of MDR TB and to use locally trained experts and facilities to train persons from other countries in the region. The project builds on a foundation of basic TB and MDR TB treatment programs that are being supported by the Latvian government with financial and technical support from the World Bank and the Nordic countries.

Since the signing of the agreement, the Center has made substantial progress in three focus areas:

1) building expertise among Latvian physicians by strengthening clinical practice and management,

2) designing and implementing infection-control measures, and

3) organizing MDR TB training for physicians from elsewhere in the region.

In September 1999, the Center initiated a study of risk factors for primary and acquired MDR TB; findings will facilitate early targeting of patients with likely MDR TB for more rapid diagnosis and possible presumptive treatment. The training component began in March 2000 with a course for Latvian physicians who manage MDR TB patients. By use of videoconferencing, the Center also conducts regular meetings in which Latvian physicians present and discuss difficult management issues with U.S.-based experts. Finally, the Center has started development of an MDR TB data management system that will facilitate case management and treatment outcome studies, the results of which can be used to improve clinical practice. The data system can also serve as a model for a WHO consortium of countries conducting pilot projects in MDR TB management.

Infection-control efforts are designed to respond to evidence of ongoing transmission of MDR TB to staff and patients. The Center is developing an infection-control plan that includes the installation of air-cleaning equipment. A plan to ensure more rapid laboratory diagnosis of drug resistance is also being developed so that MDR TB patients can be segregated from other patients and treated more quickly.

Regional training, the final component of the project, began in January 2001 with the training of the first group of physicians from Russia. The 3-week course, which was taught by CDC's Latvian collaborators in Russian, was an expanded version of the initial MDR TB course staged for Latvian physicians in March 2000 and included extensive opportunities for discussion of case management.


Initiative/Global AIDS Program

In 2000, the U.S. government launched the Leadership and Investment in Fighting an Epidemic (LIFE) initiative with a $100 million increase in U.S. support to 14 countries in Africa and India. CDC received $35 million of the initial funds and through its newly formed Global AIDS Program is working closely with USAID to implement this initiative. CDC's objectives are to 1) reduce HIV transmission through primary prevention of sexual, mother-to-child, and bloodborne transmission, 2) develop programs to improve community and home-based care and treatment of HIV infection, other sexually transmitted infections, and opportunistic infections, and 3) strengthen the capacity of countries to collect and use surveillance data and to manage national HIV/AIDS programs. Improving TB prevention and control efforts is an important component of the project, and CDC staff have been involved in 1) developing project blueprints consisting of "best practices," 2) participating in site visits, and 3) convening experts to provide input into the selection of countries for initial efforts and the proposed content for country-specific projects; initial TB efforts have focused on six countries.


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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