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TB Notes 3, 2004
The United States lost one of its most productive and influential
figures in TB control this summer: Dr. William Stead, former TB
controller of Arkansas, died in July. Dr. Stead was a very creative
and thoughtful contributor to the science of TB. Over a 30-year
period, he helped pioneer the use of intermittent short-course regimens,
made notable contributions to our understanding of TB epidemiology
(such as the role of progression to TB disease vs. reinfection in
late life, transmission from prison to community, transmission within
nursing homes, and the protective effect of prior infection following
re-exposure), guided one of the premier U.S. TB control programs
for many years, and advocated effectively for the role of medical
informatics in medical and public health research and practice.
An inquisitive but polite colleague, he encouraged young investigators
and contributed to many successful careers. His personal influence,
creativity, and thoughtfulness will be missed. His obituary is included
in the Personnel Notes section of this issue; I hope you will take
a moment to read about his inspiring life and career.
The Advisory Council for the Elimination of Tuberculosis (ACET)
convened in Atlanta June 23-24 in Corporate Square. Among those
giving updates was Dr. Janet Collins, the Acting Director of the
National Center for HIV, STD, and TB Prevention (NCHSTP). Dr. Collins,
a behavioral scientist, comes to NCHSTP from the position of Deputy
Director of CDC’s National Center for Chronic Disease Prevention
and Health Promotion. She gave an update on NCHSTP activities and
news, including Dr. Andy Vernon’s returning to DTBE to take
the position of Chief of the Clinical and Health Systems Research
Branch and Ann Cronin’s joining DTBE as Associate Director
for Management and Operations. She spoke as well on CDC’s
Futures Initiative, reminding us that to achieve the greatest health
impact and reduce health disparities for our customers, CDC needs
to focus on four key elements: alignment of our strategies with
our goals and actions; performance measurement and improvement;
integration across organizational units; and marketing. Under the
Futures Initiative, NCHSTP is being combined with two other CDC
centers, the National Center for Infectious Diseases (NCID) and
the National Immunization Program (NIP), under a proposed new Coordinating
Center for Infectious Diseases. Following Dr. Collins’ remarks,
Dr. Michael Tapper and I discussed the revised infection control
guidelines; Dr. Tapper explained that the new guidelines give much
attention to the choice of respirators. After OSHA withdrew its
proposed TB standard in December 2003, it set July 1, 2004, as the
deadline for implementing the General Industry Respiratory Protection
standard. After the meeting, ACET drafted and sent a letter to OSHA
indicating its concerns.
We then heard from Ms. Eva Moya of the Border Health Commission,
who discussed the binational card and the fact that health officials
are seeing evidence of its success: patients are adhering to therapy.
Dr. Sue Maloney talked about the continuing and serious challenges
of overseas TB screening and stateside notification of immigrating
TB patients. Dr. Michael Kurilla of the National Institutes of Health
(NIH) gave an overview of the extensive portfolio of TB research
projects his agency supports and conducts to find new TB drugs,
vaccines, and diagnostics. From DTBE, Dr. Jerry Mazurek gave an
update on the next generation of the QuantiFERON® test; Dr.
Elsa Villarino provided updates on the TB Trials Consortium; and
Dr. John Jereb discussed tumor necrosis factor blockers (TNF) and
TB. These TNF blockers are given to patients with rheumatoid arthritis
and other autoimmune conditions. They block the body’s natural
macrophage-mediated immune response, thus preventing the inflammation
caused by the immune response but also leaving the body vulnerable
to infectious agents such as M. tuberculosis. DTBE and
partners recently published guidance on TNF blockers: Tuberculosis
associated with blocking agents against tumor necrosis factor-alpha---California,
2002--2003. MMWR 2004; 53(30): 683-686.
The next morning was taken up with a discussion of budget and funding
issues. Dr. Geralyn Johnson of the Division of Immigration Health
Services (DIHS), Health Resources and Services Administration (HRSA)
followed, announcing that in May 2004, Immigration and Customs Enforcement
(ICE) had approved the institution of a medical hold procedure for
TB patients being deported from the country. The medical hold allows
DIHS to notify local public health departments, enroll patients
in treatment programs, and coordinate their removal with the public
health authorities in the receiving country. Diana Schneider of
DIHS and Mark Lobato of DTBE were acknowledged as having been instrumental
in getting this change made, and Dr. Johnson requested formal ACET
recognition of their contributions. Dr. Bess Miller of the Global
AIDS Program provided updates on the President’s Emergency
Plan for AIDS Relief (PEPFAR). This initiative was announced in
January 2003, and has expanded to 15 countries now. Eight of those
15 are among the 22 countries with the highest TB burden, and 13
of the 15 have had large annual increases in TB since 1997. Dr.
Miller suggested that TB DOTS programs can contribute to meeting
the goals of PEPFAR, and that possibly PEPFAR funds could be used
to support TB control. Dr. Michael Fleenor then gave an update on
the activities of the ACET Workgroup on TB in the Foreign-born.
The workgroup had been charged with determining if the 1998 guidelines
on TB control in foreign-born populations are still adequate; their
well-researched finding was no, they are not. The next step will
be to obtain ACET input into how the guidelines need to be revised.
Finally, Dr. Marisa Moore provided an update on Healthy People (HP)
2010 objective 14-11, Reduce tuberculosis. DTBE has proposed a revision
of the HP 2010 target, from 1.0 new case per 100,000 population
to 3.0 new cases per 100,000 population. This change will bring
our HP 2010 target into alignment with the DTBE goal described in
the Government Performance Results Act document.
On July 19, we were officially joined by our new coworkers from
the former Division of AIDS, STD, and Tuberculosis Laboratory Research
(DASTLR), now the DTBE Tuberculosis / Mycobacteriology Branch; Dr.
Tom Shinnick is the branch chief. Staff of this important unit conduct
laboratory studies on the microbiology, molecular biology, and biochemistry
of mycobacteria, as well as on the pathogenesis and immunology of
mycobacterial infections. Program areas focus on understanding M. tuberculosis
and the pathogenesis of tuberculosis, but also incorporate studies
with several other important pathogenic mycobacteria such as M.
avium and M. leprae. The branch consists of two teams
or sections: the Diagnostic Mycobacteriology Team, which is lead
by Dr. Beverly Metchock, and the Immunology and Molecular Pathogenesis
Team, which is lead by Dr. Jack Crawford.
Please mark your calendars: the 2005 TB Controllers Workshop has
been scheduled for June 28-30, 2005, at the J.W. Marriott - Lenox
in Atlanta. Pre-conference meetings will be scheduled for Monday,
Our work is becoming more interesting and challenging as CDC experiences
a major reorganization and U.S. TB cases are increasingly found
among complex social networks and foreign-born populations. Thanks
to all of you for your willingness to weather these changes and
your steady devotion to our common goal of TB prevention, control,
Kenneth G. Castro, MD
NOTE: The use of trade names in this issue is for identification
only and does not imply endorsement by the Public Health Service
or the U.S. Department of Health and Human Services.