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TB Notes 2, 2000
Earlier this year I shared the following preliminary news: a total
of 17,528 TB cases were reported from the 50 states and the District
of Columbia in 1999, a decrease of 5% from 1998 and 34% from 1992,
the height of the TB resurgence in the United States. The 1999 rate
was 6.4 per 100,000 population, the lowest recorded since national
surveillance for TB began in 1953. Keep up the great work!
The Advisory Council for the Elimination of Tuberculosis (ACET)
met on February 9 and 10 in Atlanta. Paul Poppe discussed TB Controllers'
concerns about the FY2000 TB cooperative agreement process. Dr.
Eugene McCray discussed the Leadership and Investment to Fight an
Epidemic (LIFE) initiative, which is providing $35 million to combat
HIV/AIDS in Africa and other areas of the world hard-hit by AIDS.
A new CDC office has been created, the Global AIDS Activity (GAA),
through which CDC will carry out its LIFE initiative activities.
Dr. McCray has accepted a full-time position as Director of the
GAA. Dr. Renee Ridzon summarized a TB infection control meeting
held in Arlington, Virginia, in December 1999. The group concluded
that the risk of occupationally-acquired TB and TB infection is
decreasing in the United States, but that continued vigilance is
needed to keep the problem under control. I then gave an update
on division-wide issues. DTBE will continue to directly support
some states on outbreak investigations, but CDC and the states need
to develop a long-term response plan. DTBE continues to focus on
trials of treatment for latent infection, since this activity is
the most relevant research component for the United States. DTBE
has approved a recommendation to develop a consortium with state
and local health departments in an effort to build capacity for
these institutions to conduct epidemiologic studies. The group then
discussed the epidemiology of TB in low-incidence areas and the
possible need for an ACET statement on TB control in such areas.
Dr. Philip Spradling reported on a TB outbreak in a dormitory for
HIV-infected inmates in a South Carolina prison. ACET also discussed
a suggested review and update of the 1994 occupational health policies,
which do not emphasize the significance of skin testing, the fit
testing issue, or the administration and completion of preventive
therapy among workers who convert.
On June 7 and 8, 2000, ACET met again in Atlanta with the following
agenda items and proceedings: Dr. Helene Gayle and I provided the
Directors' reports and updates. These included a briefing on the
important Ministerial Conference on Tuberculosis and Sustainable
Development that was held March 22-24 in Amsterdam, and an update
on the IOM report on TB elimination in the United States. Dr. Bess
Miller spoke about LIFE initiative country assessments and the role
of tuberculosis. After the lunch break, we focused on the topic
of TB control in low-incidence states. Dr. Kathleen Gensheimer gave
a state epidemiologist's perspective on TB control in a low-incidence
state; Dr. John Tillinghast discussed the role of the private medical
sector in TB control for such areas; and Ms. Carol Pozsik described
the impact of an outbreak on a state TB control program. Dr. John
Jereb talked of the internal assessment of TB control in low-incidence
areas. Dr. Nolan then lead a discussion of the draft outline of
a proposed ACET document on the subject. When the meeting resumed
next day, Dr. Nolan and I reviewed and lead a discussion about the
recommendation to review and update the 1994 occupational health
guidelines. Dr. Andy Vernon described findings from the TB Trials
Consortium (TBTC) Study 22. Dr. Charles Nolan discussed the next
steps in working with Immigration and Naturalization Services (INS)
staff regarding the problem of detaining immigrants with TB. The
next meeting will be held October 18-19, 2000.
The 5th Regional Conference of the North America Region (NAR) of
the International Union Against TB and Lung Disease (IUATLD) was
held in Vancouver, BC, Canada, on February 24-26. The calibre of
the presentations was outstanding; undoubtedly the NAR/IUATLD meeting
has become an important forum for the exchange of scientific and
World TB Day was March 24th. This annual event commemorates the
date on which Robert Koch announced his discovery of the TB bacillus.
Events for this year's World TB Day included a significant world
TB conference entitled "Tuberculosis and Sustainable Development,"
held in Amsterdam, The Netherlands, beginning on March 22 and ending
on World TB Day, March 24. In addition, the new WHO report on drug-resistant
TB was released at that time. High-level representatives of governments
from 20 high-prevalence countries attended the ministerial conference
in order to better understand the social and economic impacts of
TB, to assess how effective TB programs can contain the epidemic
and contribute to overall development, and to identify priority
actions for the new millennium. Dr. Donna Shalala, the Secretary
of DHHS, Dr. Margaret Hamburg, the Assistanty Secretary of DHHS,
Dr. Helene Gayle, Director of NCHSTP, and other CDC staff attended
this important conference.
In early May the Institute of Medicine (IOM) released its report
on the status of TB elimination in the United States. It is available
on the Internet on the IOM website at http://www.nationalacademies.org/includes/tb.html.
This report, entitled Ending Neglect: The Elimination of Tuberculosis
in the United States, addresses the questions, Is TB elimination
in this country a feasible goal? And if so, how do we proceed? The
experts who prepared the report concluded that TB can be eliminated,
but it will not be possible with the current tools we have. Such
an effort will require additional financial resources and a strong
commitment by policymakers. This, of course, is what CDC and the
ALA have been promoting since the resurgence of TB in the 1980s
and 1990s. Very importantly, the report identified areas for accelerated
progress and made several recommendations for specific activities
to be undertaken by CDC. On July 26 and 27, DTBE staff met to discuss
these recommendations and develop strategies for their implementation.
This process reinforced and validated our existing priorities for
TB control and elimination, while presenting new challenges for
our Division. DTBE senior staff have identified cross-branch workgroups
that will be responsible for follow-up activities toward implementing
The "ATS 2000 Toronto" conference and the "ALA/CLA
2000" conference were held in Toronto, Ontario, Canada, on
May 5-10, 2000. The sessions offered the latest information in clinical
science, basic science, and behavioral aspects of respiratory disease
and public health education. As part of the ATS 2000 Conference,
there was a program of special interest to TB control workers entitled
"Tuberculosis Control Strategies." This year's TB poster
session was cosponsored by the DTBE and the Division of Tuberculosis
Prevention and Control (DTBPC), Bureau of HIV/AIDS, STD and TB (BHST),
Laboratory Centre for Disease Control (LCDC), Health Canada.
The American Thoracic Society and CDC have published two new statements,
the first being "Diagnostic standards and classification of
tuberculosis in adults and children," Am J Respir Crit Care
Med 2000;161:1376-95. The second, "Targeted tuberculin testing
and treatment of latent tuberculosis infection," was published
as a journal article, Am J Respir Crit Care Med 2000;161(Part 2):S221-S247,
and was also published in the Morbidity and Mortality Weekly Report
(MMWR) Recommendations and Reports series. If you wish to access
the statements on your computer or obtain copies, please visit the
DTBE Web site at www.cdc.gov/nchstp/tb.
A reminder that the National TB Controller's Workshop is scheduled
for August 30 through September 1, 2000, in Atlanta at the Omni
Hotel, located at the CNN Center. The workshops will concentrate
on the very important theme of orchestrating better contact investigations.
I hope to see you there!
Kenneth G. Castro, MD