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TB Notes 2, 2001

Dear Colleague:

This spring and summer brought a number of important meetings that were attended by staff of the Division of TB Elimination (DTBE). The American Thoracic Society (ATS) held its 97th International Conference from May 18 to 23, 2001, in San Francisco, California. I am pleased to report that the CDC-sponsored poster session was well attended. Following the ATS meeting I had an opportunity to review ongoing activities of the San Francisco TB Control Section, with visits to two outreach centers, the TB laboratory, and the Francis J. Curry National TB Center. I also visited the California TB Control Branch in Berkeley. I came away with a most favorable impression of the operations at these sites and of the effective manner in which federal resources are being used to complement the efforts of state and local TB control programs.

The TB Trials Consortium (TBTC) convened in San Francisco May 18-19, since many members were in town for the ATS meeting. Highlights of the TBTC meeting included discussion about, and agreement regarding, developing a research collaboration with the TB Research Unit (TBRU), sponsored by the National Institute of Allergy and Infectious Diseases, National Institutes of Health. Attendees also agreed on the need to ensure close coordination between the TBTC and the newly-formed TB Epidemiologic Studies (TBES) Consortium.

The National TB Controllers Association (NTCA) and DTBE conducted the 2001 National TB Controllers Workshop from June 19 to 21, 2001, in Baltimore, Maryland. The theme of this year's Workshop was "TB Elimination -- Accelerating the Decline." The workshop was a tremendous success, owing to the planning and hard work of the NTCA members and DTBE staff involved. DTBE will publish the workshop proceedings in the next few months. The NTCA subcommittee on Information Technology (IT) also met in Baltimore on June 20. The members of the subcommittee agreed to convene an IT workgroup in September to further develop a core set of standards for patient management data.

The Advisory Council for the Elimination of Tuberculosis (ACET) met July 12 and 13, 2001, in Atlanta. Dr. Helene Gayle and I provided Director’s Reports, giving updates on the activities and plans of the National Center for HIV, STD, and TB Prevention (NCHSTP) and of DTBE, respectively. It appears that DTBE's proposed reorganization will be delayed because of new staffing standards set by the Department of Health and Human Services. We are considering a modified proposal that would convert the International Activity to a branch, and would change the names of four other branches. The current proposal for reorganization brings more clarity and visibility to existing DTBE functions in a manner consistent with the recommendations in the Institute of Medicine (IOM) report, Ending Neglect: The Elimination of Tuberculosis in the United States. Mr. Gary Ewart, Associate Director, ATS Government Relations, gave an update on the status of the TB Elimination Act. He reported that legislative proposals HR1167 (the Comprehensive TB Elimination Act) currently has 75 cosponsors, and HR1168 (the Stop TB Now Act) has >80 cosponsors; the Senate versions of these bills, S1115 and S1116 respectively, have six cosponsors. The ALA plans to conduct a related Congressional briefing in September. Dr. Rick O’Brien talked about two treatment issues: the status of the ATS/CDC statement on treating TB, and the activities being conducted in connection with investigations of hepatitis associated with the use of rifampin and pyrazinamide for the treatment of latent TB Infection (LTBI) (see additional details below). Mr. John Seggerson gave a report on the draft Federal TB Task Force Plan. The plan is being developed by representatives of over 40 federal agencies in response to the IOM report Ending Neglect; members of the Task Force are now collaborating with other partners to develop specific strategies and detailed action plans. Drs. Charles Wallace and Sarah Royce, NTCA representatives, are collaborating with Federal TB Task Force members and providing input into this plan. Dr. Charles Nolan led a review of the draft ACET statement on plans for managing and eliminating TB in low-incidence states, and I talked about CDC's report, "CDC's Plan for Ending Neglect: the Elimination of Tuberculosis from the United States." Comments from the meeting will allow ACET and DTBE to finalize these documents.

As you know, in April 2000, the ATS and CDC published recommendations entitled "Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection." These guidelines include a new option, based on the results of recent clinical trials, to use 2 months of rifampin and pyrazinamide for LTBI in HIV-positive (and HIV-negative) persons. In April 2001, CDC published a report entitled "Fatal and Severe Hepatitis Associated with Rifampin and Pyrazinamide for the Treatment of Latent Tuberculosis Infection — New York and Georgia, 2000." (MMWR 2001;50:4-5). The report describes adverse events in two individuals who had been treated with 2RZ for LTBI. The first patient was a 53-year-old incarcerated man with a history of alcohol abuse and hypertensive heart disease who died after being treated with 2RZ for one and a half months; the second was a 59-year-old woman with suspected exposure to drug-resistant TB who was hospitalized with severe hepatitis associated with 2RZ.

In response to these events, I formed a DTBE ad hoc working group that has met regularly to review available data on LTBI-related adverse events. Each report of adverse events has been investigated or scheduled for investigation. Dr. John Jereb and Mr. Dan Ruggiero in the Field Services Branch are the primary focal points for the working group and for receiving reports. DTBE is asking to be notified of severe hepatitis in patients being treated with any LTBI treatment regimen (“severe” means death or admission to a hospital). To report such events, please call (404) 639-8125. In June the ATS, the NTCA, the Infectious Diseases Society of America (IDSA), and CDC convened in Baltimore to review information on additional reported cases; review prospective studies of LTBI treatment, with a focus on 2RZ; consider the need for revising the recent guidelines; and determine additional data needs. To summarize what we know so far about the epidemiology of hepatitis associated with treatment with 2RZ: it appears to occur in older persons, in persons with other underlying diseases, in those taking other medications, and in persons who have experienced INH-related hepatitis. It is believed to be associated with a provider’s inability to routinely or consistently monitor patients, and with continued treatment after onset of signs and symptoms of adverse events. CDC is currently revising the guidelines for the use of 2RZ for treatment of LTBI; this revision will likely be published soon.

The DTBE surveillance data slide set for the year 2000 is now available, accessible via Internet at Other news from the Surveillance and Epidemiology Branch (SEB) is that the Surveillance Section of SEB is initiating the process of revising the Report of Verified Case of Tuberculosis (RVCT). Based on expressions of interest from a number of areas, DTBE has begun preparing a list of people interested in participating in the ad hoc workgroup, as well as preparing a summary of the comments that have been submitted to date. We would like to thank those who have already submitted their suggestions on improving the RVCT; these suggestions were to be provided to Dr. Eileen Schneider by telephone or e-mail by July 30, 2001. We expect that the workgroup's first conference call, discussing initial suggestions, will occur in late August. Once proposed changes have been summarized, we plan to distribute this document to TB controllers and other interested persons for general comments.

One final note: DTBE has recently instituted an Awards Committee, whose purpose is to find ways to promote awareness about incentive awards in the Division. We hope this will lead supervisors to learn about and use the awards system to recognize the important work of their staff. I hope we all recognize that the most important asset of any organization is the people working there. A good way for managers to motivate (and thus retain) these precious resources is to let them know that we are aware of their hard work and that we value their contributions. Sometimes a supervisor may be reluctant to recognize an employee for fear of causing other employees to feel resentful or unappreciated. The solution, of course, is to give more awards to others deserving of recognition, not fewer! The process of becoming knowledgeable about the types of awards available and of writing nominations may feel awkward at first because they are unfamiliar activities. However, once a culture of appreciation and recognition has been established in an office, it becomes natural and routine to recognize those outstanding staff contributions, leading directly to improved employee morale and productivity, leading to more awards ... and a powerful cycle of mutual appreciation, support, and loyalty is set in motion. This is the classic "win/win" situation, and I truly believe our plans and strategies for the elimination of tuberculosis depend on our forging such bonds with our staff.

Thank you for your continued dedication to the cause of TB prevention, control, and eventual elimination.

Kenneth G. Castro, MD


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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