TB Notes Newsletter
No. 1, 2006
Update on Surveillance Data:
Release of 2004 Annual Report and Slide Set
Beginning in 1953, through the cooperation of state and local health
departments, CDC has been collecting information on the numbers
of newly reported cases of TB disease in the United States. Since
its initial publication in 1963 (then entitled Reported Tuberculosis
Data, and now Reported Tuberculosis in the United States), the annual
summary of TB surveillance has been revised periodically to improve
the interpretation and dissemination of TB surveillance data. Reported
Tuberculosis in the United States, 2004 features the following methodological
- In contrast to previous annual summaries in which TB case counts
of preceding years were not updated, the current summary reports
the number of cases of confirmed TB for each year from 1993 to
2003 based on updated information. Therefore, case counts for
these years may differ from those reported in the annual summaries
- Tables 1–5, 20, 28, and 46, in addition to case count
(numerator) updates, apply population updates (denominator) to
calculate TB case rates for 1993–2004.
- The method for calculating the annual percentage change in
the TB case rate was modified. In contrast to methods used in
previous summaries, “unrounded” figures are now applied
to calculate the percentage change in the case rate, lending a
degree of precision and accuracy greater than those reported in
Other notable changes and enhancements are as follows:
Statistical highlights of Reported Tuberculosis in the United
States, 2004, include the following:
- 14,517 TB cases were reported to CDC from the 50 states and
the District of Columbia, representing a 2.3% decrease from 2003
- Foreign-born persons constituted 54% of the total number of
cases in the United States in 2004
- The TB case rate declined to 4.9 per 100,000
- 19 states reported increases in case counts
- For the first time, Hispanics exceeded blacks as the racial/ethnic
group with the largest percentage of all cases: 29% vs. 28%
- U.S.-born blacks represented 45% of TB cases in U.S.-born persons
and more than one fifth of all cases
- The TB case rate was 2.6 per 100,000 for U.S.-born persons
and 22.8 for foreign-born persons
- Asians continue to have the highest case rate among all racial
and ethnic groups
- The proportion of all cases with primary multidrug-resistant
TB remained approximately 1.0%, and the proportion of these cases
occurring in foreign-born persons increased to 73%
Reported Tuberculosis in the United States, 2004, released October
2005, is available in hard copy and is posted on the Internet at
Following are suggested citations for hard copy and online versions:
Hard copy: CDC. Reported Tuberculosis in the United States, 2004.
Atlanta, GA: U.S. Department of Health and Human Services, CDC,
Online: Centers for Disease Control and Prevention. Reported Tuberculosis
in the United States, 2004 [online]. Atlanta, GA: U.S. Department
of Health and Human Services, CDC; 2005. Available at http://www.cdc.gov/nchstp/tb/surv/surv2004/default.htm.
—Reported by Valerie Robison, DDS, MPH,
Div of TB Elimination
Updating the TB Biotechnology Engagement
Project in the Republics of Armenia and Georgia, 2005
Background. The Biotechnology Engagement Program (BTEP) is a congressionally
mandated program residing in the U.S. Department of Health and Human
Services (DHHS), Office of Global Health Affairs.1 The
BTEP enables former biologic weapons scientists from Russia and
Northern Eurasia to work collaboratively with U.S. experts in conducting
operational research that addresses critical in-county public health
concerns using evidence-based science. BTEP projects are funded
for 12–36 months. Priority diseases funded through BTEP include
TB, HIV/AIDS, hepatitis, influenza, other infectious diseases, and
food and waterborne diseases.
CDC staff, in collaboration with the Ministries of Health in the
Republics of Armenia and Georgia, developed a TB BTEP project described
in TB Notes No.1, 2003, called the “Development of
Multiple-drug Resistant Tuberculosis Surveillance and National TB
Program Evaluations, Republics of Armenia and Georgia.” This
project, which was awarded 3 years of funding effective October
2004, consists of the nine tasks further described in TB Notes No.
2, 2005. Tasks 1 (description of TB surveillance system in Armenia)
and 2 (evaluation of current TB surveillance system in Armenia)
have been completed. Task 3 is to assess the prevalence of M.
tuberculosis in the Republic of Armenia because of uncertainty
around current estimates.
TB in Armenia. Armenia has a 3.2 million population2
and is located between Turkey, Georgia, Iran, and Azerbaijan. It
is divided into 11 administrative regions (or marzes), with over
a third (36%) of the country’s population residing in the
capital of Yerevan. The collapse of the former Soviet Union in 1991
and subsequent social, political, and economic transitions have
had a negative impact on health and healthcare in the newly independent
states (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan,
Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan,
Ukraine, and Uzbekistan). Population migration, decreases in life
conditions, lack of essential health care services, and lack of
access to essential drugs3 have created conditions favorable
for the rise and spread of infectious diseases, including TB.
Before the collapse of the Soviet Union, TB surveillance and treatment
systems in Armenia and each of the former Republics of the FSU followed
the Soviet model and were centrally planned. After the collapse
of the Soviet Union, there was officially still a TB system in place
in Armenia. However, in-country experts state that for several years
after 1991, there was in reality no functioning TB system in the
country. There was a subsequent two-fold increase in TB morbidity.
The incidence (number of new cases per year) of TB in Armenia more
than doubled from 932 in 1990 to 2146 in 2003.4 The number
of TB cases notified or reported (WHO definition of a TB case notification
which includes new and relapse cases) tripled during 1990–2003
from 590 to 1538.
With the assistance of foreign partners such as the International
Committee of the Red Cross (ICRC), GTZ (the German equivalent of
the US Agency for International Development), and WHO, the TB program
in Armenia has started to rebuild. In December 2003, the Armenian
National TB Program (NTP) was approved by the Armenian government.
TB continues to be a major public health problem in Armenia; however,
there have been no recent TB prevalence surveys done, nor is there
accurate information about the magnitude of multidrug-resistant
TB (MDR TB). In the absence of knowledge about the magnitude of
TB, it is imperative to conduct a TB prevalence survey to estimate
the prevalence of TB in the country.
According to WHO, conducting population-based surveys as epidemiological
measurements for TB control can provide an accurate measure of bacteriologically
confirmed disease. National TB prevalence surveys have been conducted
in developing countries and used to measure decreases in TB prevalence
due to successful implementation of short-course chemotherapy following
WHO guidelines,5 set targets for NTP and gain political
will and financial support for TB control,6-7 and show
TB trends over time.8
Task 3. The purpose of Task 3 is to conduct a cross-sectional
population-based survey using multi-stage stratified cluster sampling
in Yerevan, the capital of Armenia. This survey will provide much-needed
insight on how to combine public health surveillance and public
health action to not only support, but also enhance, Armenia’s
NTP and further the country’s TB reform goals.
—Reported by Nita Patel, MPH, Kashef Ijaz,
and Scott J.N. McNabb, PhD, MS
Div of TB Elimination
Nita Patel and Kashef Ijaz with the Armenian TB BTEP Team Members,
Yerevan, Armenia, June 2005.
- U.S. DHHS, Office of Global Health Affairs, DHHS Biotechnology
Engagement Program. Found at http://www.hhs.gov/ogha/europeaffairsdhhs.shtml
- 2003 population, calculated on the basis of RA 2001 Population
Census. Statistical Yearbook of Armenia, 2004.
Found at http://www.armstat.am/
- The Patient in Focus: A strategy for pharmaceutical sector
reform in newly independent states. Action Program on Essential
Drugs, February 1998. Geneva, World Health Organization (EUR/ICP/QCPH
06 22 02 WHO/DAP/98.8)
- Global tuberculosis control: surveillance, planning, financing.
WHO report 2005. Geneva, World Health Organization (WHO/HTM/TB/2005.349).
- China Tuberculosis Control Collaboration. The effect of tuberculosis
control in China. Lancet 2004; 364:417-422.
- Tupasi TE, Radhakrishna S, Rivera AB, Pascual ML, Quelapio
MI, Co VM, Villa ML, Beltran G, Legaspi JD, Mangubat NV, Sarol
JN Jr, Reyes AC, Sarmiento A, Solon M, Solon FS, Mantala MJ. The
1997 Nationwide Tuberculosis Prevalence Survey in the Philippines.
Int J Tuberc Lung Dis 1999; 3(6):471-7.
- Tupasi TE. The power of knowledge to effect change: the 1997
Philippines nationwide tuberculosis prevalence survey. Int J Tuberc
Lung Dis 2000; 4(10): 990-992.
- Hong YP, Kim SJ, Lew WJ, Lee EK, Han YC. The seventh nationwide
tuberculosis prevalence survey in Korea, 1995. Int J Tuberc Lung
Dis 1998; 2:27-36.
Conference on the Economics of TB Prevention
The second annual conference on the economics of TB prevention
and control was held at the University of North Texas Health Science
Center at Fort Worth on October 11 and 12, 2005 (c.f., photo below
of attendees). The conference built on the previous gathering in
Fort Worth in 2004. The purpose of the conference was to bring together
national, state, and local TB officials and academics to explore
techniques and tools for monitoring and evaluating TB programs,
leading to enhanced efficiency and effectiveness.
Organized by Dr. Peter Hilsenrath of the School of Public Health
at the University of North Texas Health Science Center, this conference
was supported by Task Order #10 of the TB Epidemiologic Studies
Consortium. Task Order #10 began in 2003 at two locations: Hillsborough
County (Tampa), Florida, and Tarrant County (Fort Worth), Texas.
A primary objective of Task Order #10 is to develop techniques and
tools to monitor and evaluate TB programs.
Epidemiologists in Florida and Texas have compiled cost data and
performance measures of national TB goals to help evaluate the efficiency
and effectiveness of TB programs. Preliminary work has resulted
in a number of presentations and publications, including two papers
in the Annals of Epidemiology. The latest, authored by
Thaddeus Miller, Steve Weis, and others, is titled “Using
Cost and Health Impacts to Prioritize the Targeted Testing of Tuberculosis
in the United States.” The paper compared TB programs for
homeless and jail populations. It found that resources generate
relatively better results among the homeless than among jail inmates.
This suggests that for a given level of TB funds, efficiency would
be improved by shifting resources to the homeless. The Florida and
Texas teams presented some of these and other findings at a recent
conference of the American and Canadian Evaluation Associations
in Toronto on October 29, 2005.
The Fort Worth conference emphasized both practical and theoretical
issues on the first day. Following an update on Task Order #10,
there was a presentation of the Florida experience and tool by Betial
Teweldemedhin. Participants then heard a talk about the principles
of cost accounting by Joseph Coyne of Washington State University,
two presentations by Victoria Phillips, an economist with Emory
University, about cost-effectiveness analysis, and a presentation
by Travis Porco of the State of California Department of Health
on epidemiology and the measurement of health outcomes. The second
day focused more on implementation issues and the differing perspectives
of local, state, and federal organizations. The day began with a
presentation by Gerry Burgess Drewyer with the Tarrant County TB
program about the primary concerns of local health departments such
as hers. This was followed by two talks by state officials familiar
with the allocation of resources to TB surveillance, control, and
treatment. First, Keith Hughes discussed the evolution of budgeting
for TB in Florida and what really matters most in determining these
allocations. Second, Charles Wallace with the State of Texas provided
valuable insights about how resources have been allocated in Texas
for TB. This was followed by a presentation from Heather Duncan
of CDC who offered a view from the federal perspective.
In the afternoon of October 12, there was a return to theoretical
issues with an overview of discounting by Todd Jewell of the University
of North Texas at Denton. This helped participants understand the
sometimes-arcane logic of economists and finance departments who
do not typically view the value of money as static and commonly
discount future revenues and costs for the purposes of decision
making. The conference wrapped up with a roundtable discussion about
accomplishments and directions for future work.
The concept of compiling basic accounting data to measure costs
and linking these with health outcome data is not a breakthrough
in management thinking. However, there is growing realization throughout
the United States and within international and federal circles (especially
at CDC) that greater attention must be paid to efficiency and to
monitoring and measuring health impacts. This extends well beyond
simply producing at low cost. It also means being better at making
difficult decisions about where to allocate scarce resources.
One just has to look at the World Health Organization (WHO) as
it transforms itself by results-based budgeting and management.
Now in its fourth budgeting cycle based on program performance and
health impacts, the Director General of the WHO, Dr. Jong-wook Lee,
believes that the transition to results-based budgeting and management
has been a “considerable success” in building a WHO-wide
focus on results, improving the targeting of resources, and achieving
greater accountability (WHO Budget 2006–2007).
So, why not CDC and the state and local TB programs?
As stated by CDC Director Julie Gerberding, MD, MPH, in a letter
to partners, “We are refocusing our efforts to address goals
that truly have an impact on people’s health and safety across
their lifespan…Our new structure better aligns CDC to achieve
these goals. Our new coordinating centers will help CDC's scientists
collaborate and innovate across organizational boundaries, improve
efficiency so that more money can be redirected to science and programs
in our divisions, and improve the internal services that support
and develop CDC staff.”
As we work in an era of accelerating change, CDC can flourish
by enhancing results-based decision-making. Results-based management
is all about aligning TB goals and CDC agencywide health goals to
the program planning process—i.e., to program performance
and the budget. Once done, it makes sense to fund programs (and
projects within those programs) that support agreed-upon health
goals and perform well, so as to achieve the results that ultimately
lead to positive health impacts.
The participants in Task Order #10 believe that our work has the
potential to contribute to more efficient TB control and hope that
future work will develop user-friendly products that can be tested
in a variety of demonstration sites around the country.
—Submitted by Peter Hilsenrath, Ph.D.,
Dept of Health Management and Policy
School of Public Health
University of North Texas Health Science Center
and Scott J.N. McNabb, Ph.D., M.S.
Div of TB Elimination
Participants of the Economics of TB Prevention and Control Conference,
Ft. Worth, TX, October, 2005.
Preliminary Findings of the NTCA/CDC
At the request of attendees of last year's National TB Controllers
Association (NTCA) meeting, a small NTCA/CDC workgroup formed to
increase our understanding of the current needs of the national
genotyping program. The workgroup’s focus has been to determine
what resources are available or required to assist states in managing
genotyping data. An initial study conducted in 2004 determined that
many state and local TB control programs were at the planning and
development stages for implementation of universal genotyping programs.
A second NTCA/CDC web-based study in August 2005 reassessed states’
use of genotyping data. Specifically, the study was designed to
obtain feedback on improving the current universal genotyping program:
how programs were using genotyping data, what programs would like
to do differently, better, or more easily with genotyping surveillance,
and how NTCA and CDC might be able to facilitate these improvements.
A total of 49 (94%) of 52 TB programs completed the survey. Forty-six
(94%) reported that they were conducting universal genotyping (submitting
one isolate per culture-positive case). Of the three that do not
conduct universal genotyping now, two plan to transition to universal
genotyping by the end of 2006. Twenty-six (53%) programs mandated
submission of isolates to a county or state public health laboratory.
Isolate tracking. Forty-four (88%) programs reported
having some system for tracking isolates, but only 15 (31%) had
the capability of tracking isolates during the genotyping submission
process that could provide an alert when results were delayed.
Genotyping Data Management. Thirty-one (63%) of the programs
received genotyping results directly at the TB program, while 14
(29%) received results via the state public health laboratory only.
A majority of the programs reviewed genotyping results as soon as
they were reported; 34 (69%) and 38 (78%) reviewed genotyping results
to decide whether to request RFLP or conduct a cluster investigation,
respectively. Three programs review data only two to three times
per year, suggesting they were not using genotyping data to direct
the implementation of real-time interventions. To manage the reports
received from the reference laboratories, 24 (49%) programs merged
new genotype reports with prior reports in a single cumulative Microsoft
Excel spreadsheet, while 18 (37%) used another database program
such as Microsoft Access.
Linking Data to Epidemiologic Information. Twelve (25%)
programs routinely linked epidemiologic information to genotyping
results on all of their isolates; 15 (31%) linked epidemiologic
information only on clustered isolates. Under certain circumstances,
such as assessing suspected outbreaks or unusual clusters, eight
(16%) programs linked epidemiological information. Of the programs
that linked epidemiologic and genotyping data to characterize clusters,
more than half were able to do so by geographic distribution (72%),
drug susceptibility (62%), country of origin (64%), race or ethnicity
(56%), and other TB risk factors such as alcoholism or homelessness
(74%). Only 10 programs (20%) made no attempt to link genotype data
with epidemiologic data. The following reasons emerged as potential
barriers to making such linkages: lack of resources, few reported
cases, and difficulty in determining which unique identifiers to
use to link the data.
Communication. Six (12%) of the programs routinely held
cluster conferences to discuss the status of ongoing genotype cluster
investigations, 18 (37%) held meetings as needed, and 23 (47%) held
no conferences or meetings. Eighteen (37%) programs reported occasionally
communicating with other programs. However, 30 (61%) rarely or never
communicated with neighboring jurisdictions or states to compare
or discuss genotyping results.
Satisfaction. Only four (8%) of the programs were very
satisfied with their state’s current use of genotyping data.
Many responders felt that their current program depended too much
on one or two key personnel to review data (31%), they could not
easily link epidemiologic information (31%), they needed more education
on how to interpret results (33%), or they could not easily compare
state results to national results (53%).
This survey provided much-needed insight into the programmatic
use of genotyping across the United States. Several important issues
have emerged as challenges for continued success of the national
genotyping program. Improving local access to useful data management
tools that help facilitate linking epidemiologic variables and sharing
interstate genotyping information is needed. Even though 61% of
the programs reported rarely or never communicating with neighboring
jurisdictions, about 80% of responders were willing to share genotyping
results with other TB controllers, and another seven were willing
to do so if certain criteria were met, such as approval from leadership
and assurance of confidentiality. DTBE continues to collaborate
with the NTCA Genotyping Workgroup to develop new tools to manage
and query genotyping data. Specifically, we are currently developing
an online system to help local TB programs share genotyping information
related to interstate clusters. CDC is committed to improving the
programmatic use of genotyping data for local interventions and
will provide consultation and education to local programs. If programs
have questions about genotyping laboratory procedures, they should
call Lauren Cowen at (404) 639-1481 (firstname.lastname@example.org);
for questions concerning the interpretation of genotyping results,
call Patrick Moonan at (404) 639-5310 (email@example.com).
—Submitted by Patrick Moonan, Epidemiologist
and Michele Hlavsa, EIS Officer
Div of TB Elimination
and Phil Griffin, co-Chair
NTCA Genotyping Workgroup
Kansas Department of Health and Environment