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Notes 1, 2000 > Where We've Been & Where We're Going
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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. |
