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TB Notes 1, 2000
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This is an archived document. The links are no longer being updated.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

International Activities

by Nancy Binkin, MD, MPH,
Chief, International Activity and
Michael Iademarco, MD, MPH
International Activity

As the rate of tuberculosis (TB) cases falls in the United States (US), an increasing percentage of TB cases occur among US residents born in countries with a higher burden of TB. The US rate of TB cases is relatively low compared with the rate in 22 high-burden countries where 80% of global TB cases occur and where 62% of the world's population resides. Given the latency period between TB infection and disease, continued immigration into the US, and increasing international travel, efforts to eliminate TB in the US must extend beyond our geographical borders. Recognition of the public health impact of the global TB epidemic led CDC to officially organize an International Activity within the Division of TB Elimination (DTBE) in 1994 as international efforts are part of the overall strategic plan of DTBE.

The mission of the International Activity is, first, to provide leadership and coordination for CDC activities related to improving TB prevention and control efforts among foreign-born persons in the US. Its mission is, second, to contribute to global TB prevention and control efforts by conducting operations research and providing technical support to high-priority countries, i.e., those that have a major TB burden or that are of strategic interest for TB control efforts in the US. Coordination and collaboration with other international public health partners are critical to accomplish our mission.

Immigrants from Mexico, the Philippines, and Viet Nam are the leading contributors to the US foreign-born TB case burden and therefore constitute a high priority for TB control efforts in the US. The aim of International Activity efforts in these countries is to reduce the burden of TB by improving the TB control capacity of the respective national programs, by providing technical assistance and contributing to human resource development. Historically efforts in Mexico and the Philippines have been hampered by ongoing political and social changes. More recently, however, progress has been made.

Image 1: Illustration/map of Mexico.


Because of their proximity and our shared border, persons born in Mexico represent the single largest group of foreign-born persons in the US with TB. Previously CDC worked with the Mexican government to conduct surveillance of drug-resistant isolates of TB in Mexico as part of a WHO collaborative study. More recently, DTBE has been working with the United States Agency for International Development (USAID) and the National TB program of Mexico to identify areas of potential collaboration as part of a proposed 5-year project to improve TB control. Proposed activities include expanding the number of directly observed treatment, short-course (DOTS) pilot projects, improving operations research capacities, and developing activities to foster public-private health sector collaboration.

Additionally, DTBE has been a participating member of Ten Against TB, a binational initiative developed initially by the Texas Department of Health beginning in 1995. The ten US and Mexican border states have collaborated to reach a consensus on addressing joint issues of TB control through community-based public and private sector partnerships. Along with other partners in the Division and in the health departments of the border states, CDC has also been developing a series of recommendations to improve the diagnosis and management of cases along the US-Mexico border.


In collaboration with the Department of Health of the Republic of the Philippines (DOH) and the Epidemiology Program Office of CDC, DTBE is providing technical assistance to a USAID-funded project. The objective of this 5-year project is to reduce the threat of HIV/AIDS and other selected infectious diseases in the Philippines. Of those diseases in the Philippines, TB has the most significant public health impact and therefore figures prominently in the project. The broad, cross-cutting nature of the project design addresses the decentralized health care organization in the Philippines. DTBE is working with the DOH to organize and conduct operations research training, expansion of directly observed treatment, short-course (DOTS) pilot projects, and public-private collaborative projects.

Image 2: Illustration/map of the Philippine Islands.

Viet Nam

Collaboration with the National TB Control Program of the Socialist Republic of Viet Nam (NTP) has been more longstanding. Since 1996, DTBE has worked with the NTP to improve TB control. Several laboratory quality control projects have been conducted and others are ongoing with the national reference laboratory responsible for southern Viet Nam. In 1997, DTBE conducted a 2-week operations research course for supervisory staff of the NTP and provincial TB managers held in Hanoi. As a result of the course, six protocols were developed on operational topics such as risk factors for treatment failure and for default, reasons for patient delay in seeking initial TB treatment, and knowledge, attitudes, and beliefs about HIV and HIV testing and counseling among TB patients. Each group has been provided with a CDC mentor and funding to conduct the research. The work for one protocol is complete and has been presented by the Viet Namese principal investigator at the International Union Against Tuberculosis and Lung Disease World Congress in Madrid this past September. Other projects are near completion. Based on the success of the operations research course and with support from USAID, DTBE has initiated a 3-year public health practice training program with the NTP.


Other DTBE international efforts have aimed to contribute to the global control of TB and HIV/AIDS co-epidemics. In February 1995, at the request of the Ministry of Health in Botswana, the BOTUSA Project was established as a TB epidemiologic research collaboration located in Botswana. Approximately 25% of the adult population and 75% of TB patients are HIV-infected. The BOTUSA Project activities have focused on improving TB surveillance and electronic reporting, improving Botswana National TB Programme (BNTP) activities through operational research, improving diagnostics through laboratory and clinical research studies, and studying the epidemiology of the disease. At least 17 different formal studies have been completed to date and highlight the tremendous impact of the HIV epidemic on the TB epidemic in the country. Image 3: Logo of the BOTUSA Project

The site is collaborating with WHO and other countries on several projects, including involvement of the community in the care of patients with TB and advanced AIDS, provision of TB preventive therapy to persons living with HIV, and improvement of TB surveillance through the use of a software tool initially developed by BOTUSA and recently adopted by the World Health Organization (WHO) for global application. Through collaboration with the US Food and Drug Administration, the site and DTBE have raised global awareness of the potential for substandard TB drugs in the market through the pilot-testing of appropriate technology for the rapid screening of drugs. Specific research projects completed in 1998 included a spectrum of lung disease study in adults hospitalized with AIDS, an autopsy study to determine causes of death in adults and children dying of AIDS, a validation study of the TB surveillance system, a study of risk factors for TB transmission in the household, and a study of transmission at the population level through the use of RFLP techniques. Another study underway is assessing the malabsorption of TB drugs in patients with TB and HIV, as well as conducting long-term follow-up of these treated patients to determine risk factors for relapse, reinfection, and death.

Strengthening the capacity of laboratory facilities to cope with the ever-increasing demands brought on by the TB and HIV epidemics has been a component of the BOTUSA project. Substantial support in terms of equipment, training, and supplies has been provided to the national TB Reference Laboratory. BOTUSA also serves as an important training site for EIS officers, US medical students, and public health students fromUC-Berkeley.

Russia and countries of the former Soviet Union

As a result of a joint Department of Health and Human Services and White House conference, the Russian Federation and the countries of the former Soviet Union have been targeted for CDC TB control technical assistance efforts. The number of TB patients and the levels of drug resistance are increasing at alarming rates. Contributory factors include an inability to financially support the previous infrastructure for TB diagnosis and treatment, the lack of availability of quality drugs, high levels of TB transmission in prison settings, and reluctance to adopt the DOTS strategy as employed in the US and elsewhere and recommended by the WHO. The DTBE, USAID, and WHO are collaborating to institute basic DOTS programs in two oblasts (territorial administrative divisions) that have indicated a willingness to begin the DOTS strategy, and to strengthen DOTS in Ivanovo oblast, where a WHO-supported program was implemented in 1995 but where cure rates remain unacceptably low. A recent study in this second oblast has documented further increases in the levels of multidrug-resistant (MDR) TB. DTBE will also implement DOTS-plus, the WHO strategy for the management of MDR TB treatment in low-resource settings, in this oblast. In addition, DTBE has been involved in the establishment of a center of excellence for MDR TB in Latvia, which was formerly part of the Soviet Union and which has a successful DOTS program, but nonetheless has one of the highest levels of MDR TB in the world. Finally, an MDR TB training course run by DTBE in collaboration with National Jewish Medical Center was conducted overseas this past year in Estonia for participants from Russia and the Baltics.


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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