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TB Notes 1, 2000
Introduction
Where We've Been and Where We're Going: Perspectives from CDC's Partners in TB Control
Changes I've Seen
TB Control in New York City: A Recent History
Not by DOT Alone
Baltimore at the New Millennium
From Crickets to Condoms and Beyond
The Denver TB Program: Opportunity, Creativity, Persistence, and Luck
National Jewish: The 100-Year War Against TB
Earthquakes, Population Growth, and TB in Los Angeles County
TB in Alaska
CDC and the American Lung Association/ American Thoracic Society: an Enduring Public/Private Partnership
The Unusual Suspects
The Model TB Prevention and Control Centers: History and Purpose
My Perspective on TB Control over the Past Two to Three Decades
History of the IUATLD
Thoughts about the Future of TB Control in the United States
Where We've Been and Where We're Going: Perspectives from CDC
Early History of the CDC TB Division, 1944-1985
CDC Funding for TB Prevention and Control
Managed Care and TB Control - A New Era
Early Research Activities of the TB Control Division
The First TB Drug Clinical Trials
Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC)
TB Communications and Education
TB Control in the Information Age
Field Services Activities
TB's Public Health Heroes
Infection Control Issues
A Decade of Notable TB Outbreaks: A Selected Review
International Activities
The Role of CDC's Division of Quarantine in the Fight Against TB in the U.S.
The STOP TB Initiative, A Global Partnership
Seize the Moment - Personal Reflections
 
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This is an archived document. The links are no longer being updated.

TB Notes 1, 2000

Where We've Been and Where We're Going: Perspectives from CDC

Early History of the CDC TB Division, 1944 - 1985
by John Seggerson
Associate Dir. for External Relations, DTBE

In 1944, Congress passed the Public Health Service Act, which authorized grants to the states for TB control and established the "Division of Tuberculosis Control," then located in Washington, DC. At the time of the creation of the TB Division, TB drugs were not available, and the primary method of TB control was the isolation of persons with active disease in TB sanatoria where they were "treated" with healthful living, bed rest, calorie-laden meals, fresh air, sunshine, and sometimes with surgery and/or collapsed lung therapy. From the beginning of the 20th century, the National Tuberculosis Association (later the American Lung Association), and its state and local affiliates, played a major role in establishing and supporting the TB sanatorium movement in the US. During the post-WW II period and into the 1950s, TB associations and health departments employed small-film x-ray units to conduct TB screening in general populations, with one x-ray unit often screening as many as 500 persons per day. The screening did not effectively cover large city populations and by 1947, the PHS Division of TB Control was operating mobile x-ray unit teams in some 20 cities of more than 100,000 population which participated in this PHS big city program. By 1953, after some 20 million people had been x-rayed for TB, the program was discontinued owing to declining yield and high cost. Many health department and TB association community x-ray screening programs were also discontinued, although some continued until the late 1960s.

Image 1: Picture of a Public Health Service mobile x-ray unit

In 1959, a group of nationally recognized TB experts was convened in Harriman, New York, to review the status of US TB control, and they issued the "Arden House Report," which recommended the eradication of TB with effective treatment programs to cure disease and prevent spread. The Arden House group also recommended isoniazid treatment of latent TB infection based on extensive PHS chemoprophylaxis trials.

In late 1960, the PHS TB program, by then renamed the "Tuberculosis Branch," was transferred from Washington, DC, to Atlanta, to what was then called the Communicable Disease Center. The TB research activity remained in Washington for the time being, then was also transferred to Atlanta in the early 1970s.

In the 1960s it became increasingly obvious that long-term hospitalization of patients with active TB was no longer necessary because of the availability of effective chemotherapy, and the TB Branch began to advocate that patients receive most or all of their care on an out-patient basis. The sanatoria began to close, with most of them being closed by the end of the 1970s. It has been estimated that the closing of the sanatoria represented a savings of more than $400 million to state and local governments.

In 1963, in response to a special Surgeon General's Task Force report on TB, categorical TB grant programs were established and funds were utilized to address the two newly emerging major challenges in TB control: establishing outpatient TB control services and designing ways to effectively identify and treat TB and asymptomatic latent TB infection. Long before the hospitals all closed, sanatorium clinicians began lowering the hospitalization period from the entire treatment period of 18-24 months gradually down to only the first 6 months or less. This meant that patients with uncomplicated TB were treated on an outpatient basis for up to 18 months. There literally were no outpatient clinic programs in most of the country; and in many places, when patients were discharged to outpatient care, they had to return frequently to the sanatorium for outpatient exams and medication refills. Public health nurses had for years been doing routine contact investigations in the field, but most health departments did not have the outreach staff needed for all these TB patients suddenly being treated on an out- patient basis. Acquired drug resistance due to outpatient treatment lapse became an important problem. So as TB sanatoria began to increasingly discharge patients early, health departments had to provide both the TB clinics and the follow-up staff needed to ensure completion of treatment and preventive therapy. The TB branch consulted with health departments in this undertaking which included establishing or improving TB registers needed to effectively monitor and track TB treatment and follow-up for TB patients.

INH had been introduced in 1952, but its prevention possibilities were not realized until Edith Lincoln in New York noted that children with primary TB treated with INH had a much lower incidence of serious TB complications. She suggested controlled trials to look at the possibility of using INH as preventive therapy for TB. Soon, the controlled trials conducted by TB Research Section staff (Shirley Ferebee, Carol Palmer, George Comstock, Lydia Edwards, and others) and other institutions began demonstrating that INH could be effectively and inexpensively used to prevent TB infection from progressing to disease. In the mid-1960s, the TB Branch began to promote and fund the implementation of the "Child-Centered Program," which prioritized the screening of school children to identify TB infection and ensure that identified children completed a preventive course of INH. Part of the "Child-Centered Program" was a concerted effort to conduct "cluster testing" or follow-up of contacts to children with TB infection to identify the infecting "source case" and also to identify other infected children who may have been exposed to and infected by the same source case. In addition to providing health department categorical funding to help address these challenges, the TB Control Branch and the ALA's American Thoracic Society regularly updated and widely disseminated guidelines for the diagnosis, treatment, prevention, and control of TB.

Almost since its inception, the TB Branch had collected, analyzed, and reported national morbidity, hospitalization, and screening data, and has also provided consultative staff to support and review TB prevention and control efforts at the state and local levels. During the early 1960s, the TB Branch also began working with health departments to establish the TB program management reports to evaluate the effectiveness of TB prevention and control efforts. Program management reports continue to be an important component for evaluation of national, state, and local TB prevention and control efforts. Don Brown managed this activity from the early 1960s until the mid-1990s. A new concept in the type of assistance provided by the TB Branch was initiated in the mid-1960s with the assignment of CDC TB Public Health Advisors to assist health departments in the operation and evaluation of TB prevention and control programs. The TB Branch also began recruiting and assigning TB Medical Officers to health departments for 2-year periods. These Medical Officers, along with CDC Public Health Advisors, began working as a team with state and local TB Controllers and their staff. These assignees were in effect "on loan" to the health departments and operated as state or local employees, although they were subject to frequent transfer by CDC among the health departments. By the mid-1960s, almost every state plus Guam and Puerto Rico had a TB project grant (Wyoming did not).

The number of TB Medical Officers began to decline after 1967 as recruitment became more difficult and the categorical grants were phased out. However, Public Health Advisors continued to be requested and effectively work in health department TB programs where they were supported by Partnership for Health and later prevention block grants. The Advisors and TB Medical Officers had a major impact on TB control in the areas where they were assigned and afterwards. After serving in the field, many of the TB Medical Officers continued on in public health and national TB leadership. Larry Farer and Dixie Snider started as TB Medical Officers in Utah and Oklahoma, respectively, and both later went on to become directors of the TB Division. There is a long list of other former TB Medical Officers who continued in leadership roles in TB including current ATS president Jeff Glassroth, John Sbarbaro, Phil Hopewell, Tony Catanzaro, and others. The last of the original TB Medical Officer field group was Eric Brenner. (The concept of field Medical Officers was revived on a smaller scale in the early 1990s and continues today.) The TB Branch in the late 1960s and early 1970s also supported a number of "Clinical Associates" who were not PHS medical officers but worked like "TB fellows" in pulmonary training and were assigned to key institutions. For example, Mike Iseman was assigned to Harlem Hospital under Julia Jones. These clinical associates were basically pulmonary fellows working in pulmonary clinics who concentrated on TB and worked in the TB clinics. Lee Reichman was also a TB Branch Clinical Associate, as was Ray McDonald, who works in New Jersey with Dr. Reichman.

No early history of the TB Division would be complete without a mention of the "TB Today!" course, which was conducted by the TB Division from the late 1960s until the early 1990s. The course evolved from courses taught at National Jewish Hospital in Denver and Battey Hospital in Rome, Georgia. Seth Leibler directed the development of this course, working closely with the Director, Al Holguin, and Don Kopanoff, who later served as the TB Division's Associate Director for External Affairs. Later the course was implemented by Ginny Bales, now CDC Deputy Director for Program Management, and Kathy Rufo, now Deputy Director of the Diabetes Translation Division; they were all essential to the design and early conduct of this course. Later, Barbara Holloway (currently Deputy Director of the CDC Epidemiology Program Office) directed the course. It was designed for key TB program managers including physicians, TB Controllers, TB nurses who had management responsibilities, and other TB program managers. The course was presented in a workshop format with heavy emphasis on program evaluation and management by objectives. The attendees worked through the course using their own program's TB morbidity and program evaluation data. They developed objectives for their program based on their unique problems, and developed strategies for achieving the objectives. They went back to their programs and began to implement the plans and achieve the objectives. Many of the TB Controllers from that era will testify the course changed their whole approach to TB from a perspective of clinical management of TB patients to one of managing programs and effectively supervising people. Since the late 1960s, nearly every state and major city TB Controller and head TB nurse has attended the course, which has been revised over time.

The 1970s were belt-tightening times for TB control staff at CDC and across the nation. The last of the special TB project grants were phased out by 1973. The TB Research Section was transferred from Washington to Atlanta with Jerry Weismeuller as Chief, but many of the TB Research Section staff retired or moved on to other positions rather than move to Atlanta. In 1974 the TB Branch again became the TB Division. In 1976, Larry Farer became Director of the TB Division and Dixie Snider became Chief of the Research Branch. John Seggerson came to CDC as the Chief of Field Services in late 1977, replacing Larry Sparks who had served there before going to the CDC Washington office and later serving as Executive Director for NIOSH and then as Deputy Director of NCIPC. Jerry Brimberry worked as a TB consultant with Larry Sparks and later moved on to Executive Officer of the Diabetes Field Services Branch. The last of the original TB Medical Officer field assignees, Eric Brenner, left the field for Atlanta and the TB Division in 1978. In the late 1970s and early 1980s, the role of the TB Division program consultants was enhanced and they became the lead contacts with health department TB control programs for the Division, establishing ongoing contact and close working relationships between the Division and the field. A long parade of very effective and motivated TB program consultants moved through the Division and on to higher level positions: Charlie Watkins transferred to the regional offices and then to CDC Chief of Regional Affairs; Wilmon Rushing became one of the first CDC AIDS officials and moved up to the NCID Associate Director for Management; Willis Forrester became Chief of Field Services for the AIDS program; Chris Hayden became Chief of the TB Communications and Education Branch; Mack Anders headed the TB Division field staff; George Rogers is the PHS Deputy Regional Health Administrator Director (Chicago), and Carl Schieffelbein is the current DTBE Associate Director for Special Projects. (The current DTBE Field Services Section Chiefs, Joe Scavotto and Greg Andrews, were also DTBE program consultants.)

1980 was an especially difficult time for TB programs when the block grants were completely phased out for a short time, there were no categorical TB grants, and TB program managers had to scramble to cover lost resources. This was a tough time also for TB Division Public Health Advisor field assignees, some of whom had to accept assignments in other programs, while many stayed on in TB field assignments where local health departments were able to cover their salary costs with state or local funds under the Intergovernmental Personnel Assignment Act. Things began to look up again in 1981 and 1982 when categorical TB project grants were again funded, although initially on a very small scale. Since the TB Medical Officer field assignee activity had been phased out by 1978, the Division began recruiting physicians and other scientists from the EIS officer group for TB Division medical posts beginning with Rick O'Brien, George Cauthen, Ken Powell, Bess Miller, Hans Reider, and Alan Bloch, who were the first of this respected group.

The TB individual case report was introduced in the mid-1980s, enhancing the national TB surveillance system. Nonetheless, through the late 1970s and early 1980s, many TB programs increasingly felt the impact of cutting resources that began in the early 1970s. The first documented outbreak of drug-resistant TB occurred in 1976 and 1977 in rural Alcorn County, Mississippi. TB-related resources and infrastructure continued to deteriorate in most areas, and in the early 1980s, HIV/AIDS began to affect TB, at first in Florida and then in the New York City metropolitan area and elsewhere. Because of the decline of the infrastructure, many health departments were simply unable to cope with the emerging TB-related problems associated with AIDS, along with increasing numbers of foreign-born TB patients and other problems having an impact on TB. By the mid-1980s the long-time decline in the Nation's TB morbidity trend ended and outbreaks of MDR TB in hospitals, prisons, and other institutions were underway.

The following articles by the lead staff of DTBE's branches and programs will provide a more current perspective on division activities.

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

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