TB Notes Newsletter
After the challenges of this past fall, I hope the holidays left
you rested and with renewed energy to tackle the new year. Please
accept my best wishes for 2006 and for the new opportunities we
will have to continue our progress in eliminating tuberculosis.
The 2005 Program Managers Course was held October 24–28,
2005, at the Sheraton Colony Square Hotel in Atlanta, Georgia. About
40 persons attended the course this year. Next year the Division
of Tuberculosis Elimination (DTBE) will add a section on laboratory
issues, which will be an important enhancement to this training
course with excellent reviews. I would like to take this opportunity
to thank the course instructors and organizers for their outstanding
efforts in making this training course such a successful event.
Much planning and hard work goes into the development and presentation
of these training sessions. Those involved are deserving of our
thanks and appreciation for taking on this important task each year.
The Advisory Council for the Elimination of Tuberculosis (ACET)
met on November 16 and 17, 2005, in Atlanta, Georgia. After the
welcome by Drs. Masae Kawamura and Ron Valdiserri, ACET heard updates
on recent activities of DTBE and of the National Center for HIV,
STD, and TB Prevention (NCHSTP). Dr. Valdiserri reported that Dr.
Janet Collins, who had served as Acting Director of NCHSTP since
June 2004, was named Director of the National Center for Chronic
Disease Prevention and Health Promotion (NCCDPHP) in August 2005,
and that a permanent NCHSTP director would be named in November.
We have since learned that Kevin Fenton, M.D., Ph.D., has been selected
as Director of NCHSTP. Dr. Fenton has been serving in the Division
of STD Prevention as Chief of CDC’s Syphilis Elimination Effort
since January 2005, and has worked in research, epidemiology, and
the prevention of HIV and other STDs since 1995. Dr. Fenton was
previously the Director of the HIV and STI Department at the United
Kingdom’s Health Protection Agency. We welcome Dr. Fenton
to this new position and look forward to working with him in the
important work of our center.
Dr. Michael Iademarco gave the DTBE Director’s Report in
my absence. He reported that DTBE had completed eight Epi-aids in
2005, three of which involved Hmong refugees in Thailand and in
California. He reported that in preliminary evaluation findings
for the U.S.-Mexico Binational Card project, political will remains
strong in support of the project. The evaluation has led to improvements,
and the project is expanding to new sites; but insufficient funding
is a critical constraint. He reported that a number of DTBE guidelines
were at or near completion (they have since been published): the
latest statement on controlling tuberculosis in the United States
came out in November 2005 in the Morbidity and Mortality Weekly
Report (MMWR); guidelines on the use of QuantiFERON-Gold, on
conducting contact investigations, and on preventing the transmission
of M. tuberculosis in health care settings were published in December
in the MMWR. Please see the “New CDC Publications”
section of this issue for the citations of these publications. Recommendations
on managing TB in correctional settings are expected in 2006. We
heard a report from Mr. Joe Posid of the Bioterrorism Preparedness
and Response Program within the Coordinating Center for Infectious
Diseases (of which NCHSTP is now a part) on CDC activities related
to assessing biological agents of public health importance. With
CDC working in concert with the Department of Homeland Security
and DHHS, these activities will result in an updated list of potential
biological terrorism agents, which should be finalized in 2006.
Dr. Valerie Robison, DTBE’s surveillance team leader, gave
an update on CDC’s TB surveillance systems, and Dr. Tom Navin,
chief of the Surveillance, Epidemiology, and Outbreak Investigations
Branch, provided information on new TB surveillance initiatives.
These include the development and release of the Online TB Information
System (OTIS), a Web-based national TB surveillance dataset that
allows individual researchers to generate TB surveillance reports;
a system for reporting adverse events caused by any LTBI treatment;
the availability of genotyping for outbreak detection; the revision
of the Report of Verified Case of Tuberculosis (RVCT); and the data
ACET heard reviews of three articles. First, Dr. Dick Menzies
of the Montreal Chest Institute in Canada gave a summary of the
article, “Domestic returns from investment in the control
of tuberculosis in other countries”; Drs. Kayla Laserson of
DTBE and Susan Malone of the Division of Global Migration and Quarantine
(DGMQ) were co-authors. The analysis showed that U.S.-funded expansion
of national TB program DOTS programs in high-incidence countries
such as Mexico would reduce TB-related illness and deaths among
migrants, with net savings to the United States. This is based on
the concept that U.S. financial assistance provided to the national
TB programs of TB-prevalent countries will help decrease the burden
of TB in those nations; this will reduce the number of TB-infected
persons from that country migrating to the United States, and this
will ultimately reduce TB and TB control costs in the United States.
Next Dr. Henry Blumberg, Hospital Epidemiologist of Grady Hospital
in Atlanta, discussed “How many sputum specimens are necessary
to diagnose pulmonary tuberculosis?” Dr. Blumberg presented
data showing that in the high-risk, inner-city patient population
at Grady, the number of specimens needed to diagnose pulmonary TB
disease may be reduced from three to two; a third smear did not
appear to add much information in a robust TB-oriented health-care
setting with excellent quality infection control systems in place.
This was followed by a related discussion by Dr. Sundari Mase, a
physician from California, on the yield of two vs. three AFB sputum
smears for evaluating pulmonary TB suspects. Her review suggested
that the mean incremental yield of a third smear is 3%–5%;
if the yield of the first and second smears is improved, the yield
of the third would be even lower. She pointed out that requiring
only two smears would involve less work for the laboratory, fewer
costs, and more time to perform the two smears. The “cons”
would be decreased case detection and increased transmission, resulting
in TB infection. Proposed next steps were to study the policy implications
of two vs. three sputum smears and to review the WHO case definition
of smear-positive pulmonary TB.
Dr. Bill Burman of Denver Public Health and a member of the TB
Trials Consortium presented an exciting talk on opportunities and
challenges in TB clinical trials for the next decade. He suggested
that promising new anti-TB agents may permit reduction in the length
of TB treatment from 6 months to 2 if clinical trials could be adequately
funded. After an exchange of comments and questions, ACET members
decided to draft a letter to the Secretary of DHHS advocating for
additional funding for multiple TB control components, including
clinical trials. We then heard from Ms. Kimberly Lane, senior advisor
to the Chief Management Official of CCID, who reviewed CDC’s
reorganization and discussed the proposed new design of CCID.
Dr. Charles Wells gave an overview of USAID’s Tuberculosis
Country Assistance Program (TB CAP), which is a follow-up project
to the TB Coalition for Technical Assistance. TBCAP is a 5-year
project based on a partnership between USAID and several international
organizations, including the KNCV, ALA, ATS, WHO, CDC, and IUATLD.
Its main components consist of advocacy and social mobilization,
DOTS expansion, laboratory capacity building, TB/HIV services, and
training and human resource development; its strengths are that
it is an effective mechanism for coordination among TB organizations,
it reduces duplication of efforts, and it allows close management
of activities and high accountability for partners. Dr. Iademarco
then discussed a USAID-funded and -sponsored project that has the
goal of developing a set of international standards for TB care.
The focus or intent is to ensure high-quality treatment for all
patients in all settings. These standards will call for a level
of care above the current WHO standards. A number of follow-up items
were addressed, after which the meeting was adjourned. The group
will reconvene in February 2006.
From October 17 to 23, 2005, DTBE staff attended and participated
in the 36th World Conference on Lung Health, the annual meeting
of the International Union Against Tuberculosis and Lung Disease
(IUATLD), in Paris, France. The theme was “Scaling up and
sustaining effective tuberculosis, HIV, and asthma prevention and
control.” CDC was well represented in the planning and organization
of the meeting and in the outstanding presentations that were given.
This meeting provided DTBE staff with the opportunity to contribute
to global TB prevention and control efforts through ongoing collaboration
with the Union, Stop TB, and other national TB prevention programs.
As discussed during the last ACET meeting, recent publications have
highlighted the importance of global TB control to the fulfillment
of our domestic goals (Schwartzman K, Oxlade O, Graham Barr R, et
al. Domestic returns from investment in the control of tuberculosis
in other countries. N Engl J Med 2005; 353: 1008-1020;
and Bloom BR, Salomon JA. Enlightened self-interest and the control
of tuberculosis. N Engl J Med 2005; 353: 1057-1059).
Please note that the 2006 National TB Controllers Workshop will
be held June 13 to 15, 2006, in Atlanta at the Sheraton Buckhead
Hotel. Details will be forwarded as they become available. Hope
to see you there!
Kenneth G. Castro, MD