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TB Notes 1, 2002

Dear Colleague:

The Advisory Council for the Elimination of Tuberculosis (ACET) met in Atlanta on February 6 and 7, 2002. Following are a few highlights: After the NCHSTP Director's report, I provided updates on DTBE activities that would not be covered in the ACET agenda, such as the first meeting of the TB Epidemiologic Studies Consortium in December 2001, the TIMS summit with NTCA in November 2001, and progress in the areas of education and training, outbreak investigations, and international technical assistance. Drs. Masae Kawamura, TB Controller for San Francisco, and Mark Lobato of the Field Services Branch then discussed the report being prepared on detention of foreign-born TB patients by the Immigration and Naturalization Service (INS); ACET approved the report's recommendations to improve treatment outcomes among INS detainees. The recommendations are as follows: "To reduce the risk of exporting or re-importing persons with active TB identified while in INS custody, ACET recommends to the Departments of Health and Human Services and Justice that they form an interagency policy group involving other key organizations and entities to work toward a consensus on the following measures: 1) Explore the feasibility of treating INS detainees in the United States until TB is cured in the least restrictive setting. Consideration should be given to changing or amending current policies or federal laws for detainees... 2) Work with professional correctional associations to improve adherence to local public health laws and CDC guidelines... 3) Enact policies requiring report of cases and suspects in INS custody prior to the transfer or deportation of an INS detainee with TB... 4) Expand the medical hold authority of the Division of Immigration Health Services..." The report will be revised for submission to the CDC Morbidity and Mortality Weekly Report (MMWR). Dr. Elsa Villarino of the Research and Evaluation Branch reported that DTBE plans to summarize the initial recommendations for using the QuantiferonŽ test, which was approved last November by the Food and Drug Administration as an aid in the diagnosis of latent TB infection. Dr. Renee Ridzon of the Surveillance and Epidemiology Branch (SEB) discussed the meeting that was held on January 23 and 24 in Atlanta to obtain comments from outside consultants on the proposed revisions to CDC's "Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities, 1994" (MMWR 1994;43[No. RR-13]). The meeting was productive; we currently have no firm publication date for the revised guidelines. Related to this, OSHA has reopened the docket for public comments on the section of their Standard which deals with TB infection control. In a session on TB elimination in the Southeastern states and on racial and ethnic disparities, Dr. George Counts of the CDC's Division of Sexually Transmitted Diseases reported on that division's goal of eliminating racial health disparities as part of its Syphilis Elimination Plan. Mr. Lex Gibson discussed the Southeast TB Strategic Plan and disparity issues for African Americans. This is an important area of concern for many TB controllers as well as for CDC, and may warrant a separate meeting in the future to address the disparity in TB risk in African Americans and other racial and ethnic minorities. An update on TB laboratory capacity was followed by an update from Dr. Peter McElroy of SEB on the reported adverse events associated with taking 2 months of rifampin and pyrazinamide (2RZ) to treat latent TB infection (LTBI). To date, CDC has received reports of adverse events related to any LTBI treatment in 132 persons. Of these, 35 persons met the case definition for having adverse events associated with 2RZ (liver injury from 2RZ resulting in admission to a hospital, or death). Of these 35 persons, 7 died. To date, CDC staff members have investigated 28 cases, including 6 of the fatalities. No risk factors for death have been identified thus far. CDC's revised recommendations for the use of 2RZ for the treatment of LTBI are as follows: 1) The 2-month RIF-PZA treatment regimen for LTBI should be used with caution, especially in patients also taking other medications associated with liver injury and those with alcoholism. 2) For persons not infected with HIV, 9 months of daily INH is still the preferred treatment for LTBI; 4 months of daily RIF is an acceptable alternative. Two months of RIF-PZA may be useful when the completion of longer treatment courses is unlikely and when the patient can be monitored closely. 3) Available data do not suggest excessive risk for severe hepatitis associated with RIF-PZA treatment among HIV-infected persons. However, experience from trials may not translate to all clinical practice settings, and it may be prudent to use 9 months of daily INH for treatment of HIV-infected persons with LTBI when completion of treatment can be assured. 4) No more than a 2-week supply of RIF-PZA should be dispensed at a time (with a PZA dose not exceeding 20 mg/kg per day and a maximum of 2 gm/d) to facilitate periodic clinical assessments. Patients should be reassessed in person by a health care provider at 2, 4, and 6 weeks of treatment for adherence, tolerance, and adverse effects, and at 8 weeks to document treatment completion. 5) Serum aminotransferase and bilirubin levels should be measured at baseline and at 2, 4, and 6 weeks of treatment in patients taking RIF-PZA.

CDC has several new publications available or in progress. On Friday, February 8, the summary of U.S. TB cases reported in 2000 was published in the MMWR. The article was initially scheduled for publication in November 2001, but was rescheduled after MMWR required publication of updates on anthrax and bioterrorism investigations. The summary is based on data from the national TB surveillance system and provides data for 2000 with comparisons to previous years, through 1992. Much of this information has been published in tabular format in the DTBE national surveillance report, Reported Tuberculosis in the United States, 2000, and is also available on DTBE's Web site at Also, Dr. Mary Reichler has an article entitled "An evaluation of investigations conducted to detect and prevent transmission of tuberculosis" in the February 27, 2002, issue of the Journal of the American Medical Association. Thirdly, the most recent statement on the treatment of TB is now in its final draft and is scheduled for publication later this year in the American Journal of Respiratory and Critical Care Medicine. This document, which is a joint statement of the CDC and the American Thoracic Society (ATS) and is also cosponsored by the Infectious Diseases Society of America, will update the 1994 ATS/CDC guidelines.

As previously announced, the 4th World Congress on Tuberculosis will be held in Washington, DC, June 3-5. Cosponsored by CDC, the National Institutes of Health, and the World Health Organization/Special Programme for Research and Training in Tropical Diseases, the Congress will evaluate the state of the global TB epidemic since the last TB World Congress, which was held in 1992; review the status of TB research; and identify research gaps. The meeting, which will cover fundamental, translational, and operational research topics, should be of interest to global TB control officials, TB researchers, health systems services researchers, policymakers and funders, as well as infectious disease and pulmonary physicians. The Program Committee invited researchers to submit abstracts, which were due by March 1, and notification of acceptance will be sent out on or about April 1. For international travelers only, a limited amount of travel support may be available for those presenting posters or "late-breaker" talks. Detailed information regarding the meeting program can be found at the Web site

World TB Day is observed every year on March 24. This annual event commemorates the date when Robert Koch announced his discovery of the microbe that causes TB. Around the world, nongovernmental organizations and others take advantage of the increased interest that World TB day generates to describe their own TB-related problems and solutions, and to support worldwide TB control efforts. I hope that each year you are taking the opportunity afforded by this globally recognized event to garner press coverage of your local TB problems and concerns and to involve others in the fight to eliminate TB - a fight that we can and must win, and that we will win, through all of our continued dedicated efforts! Now is the time to grasp a vision; a vision of coming together on World TB Day in the near future to celebrate the elimination of TB in this country.

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.


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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