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TB Notes 2, 2002

International Notes

International Activity Organizational Restructuring

The International Activity (IA) in DTBE was established in 1993 and currently consists of a staff of 17 professionals, including six epidemiologists or medical epidemiologists, two public health advisors, three Epidemic Intelligence Service Officers, two Fellows, and an administrative support staff member based in Atlanta. DTBE/IA field staff include a medical epidemiologist assigned to a field site in Botswana, a medical epidemiologist detailed to the International Union Against Tuberculosis and Lung Diseases (IUATLD) in France, and until recently a medical epidemiologist detailed to the World Health Organization (WHO) in India.

In addition, multiple members of DTBE as well as others at CDC work closely with a wide range of international collaborating partners including WHO, the U.S. Agency for International Development (USAID), the Royal Netherlands Tuberculosis Association (KNCV), and numerous national tuberculosis control programs (NTPs) around the world to provide technical assistance and expert consultation.

The mission of IA is to improve the quality of TB control internationally and among foreign-born persons in the United States, and to provide leadership and coordination of CDC activities in countries with a high burden of TB or of strategic interest for TB control in the United States. IA was restructured in July 2001, and its staff were grouped into four teams. Each team is focused on a specific objective or theme:

Team 1- Epidemiology and Evaluation (team leader Kayla Laserson, ScD): Evaluates TB control programs by providing operations research on TB programmatic activities. Also provides technical assistance for surveillance of TB and MDRTB in countries with high TB burden or those of strategic interest to the United States.

Team 2 - TB in Foreign-born Populations (team leader Kayla Laserson, ScD): Assists in the improvement and evaluation of overseas screening for TB disease among immigrants and refugees, undertakes epidemiologic investigations leading to improved targeted testing and treatment of latent TB infection (LTBI), and improves binational communication regarding individual TB.

Team 3 - TB/HIV (team leader Elizabeth Talbot, MD): Improves diagnosis and treatment of active TB in HIV-infected persons, improves the diagnosis and treatment of LTBI in HIV, and promotes and evaluates integration of TB and HIV programs, including the appropriate use of antiretrovirals.

Team 4 - MDR TB (team leader Peter Cegielski, MD, MPH): Prevents further emergence of multidrug-resistant TB (MDR TB) by enhancing basic TB control and improving institutional infection control, promotes effective anti-TB drug resistance diagnosis and surveillance, assists in implementing programs to treat MDR TB, and evaluates program performance.

óReported by Erika Vitek, MD
Division of TB Elimination

Tuberculosis Control in India, 2001

As reported in a recent MMWR, nearly 2 million people develop TB annually in India, accounting for one fourth of the worldís new TB cases. Following a comprehensive review of national TB control activities in 1992, the Government of India established a Revised National Tuberculosis Control Programme (RNTCP) using the World Health Organizationís (WHO) recommended strategy of directly observed treatment, short-course (DOTS). The DOTS strategy consists of sustained government commitment, effective laboratory-based diagnosis, standard treatment given under direct observation, a secure drug supply, and systematic monitoring and evaluation. The program was implemented in pilot areas beginning in 1993, and large-scale implementation of the RNTCP began in late 1998. As of November 2001, the RNTCP offered TB control services to regions that represent >40% of the countryís population (>440 million persons), up from less than 2% in mid-1998. Currently, over 5,000 patients are examined for TB under the RNTCP, and more than 1,300 patients are started on treatment daily. Under the DOTS strategy, more than 80% of patients have been successfully treated, and 81% of initially sputum smear-positive patients have laboratory evidence of sputum conversion to negative. The 4% death rate in RNTCP areas is remarkably lower than the observed mortality in non-RNTCP areas, where 29% mortality has been documented among treated smear-positive TB patients.

Efforts to expand effective and comprehensive TB care in India have been remarkably successful despite considerable challenges, several of which were enumerated in a recent WHO program review. A large private sector continues to be the first provider for many patients, often resulting in uncoordinated and inconsistent diagnosis and treatment of TB. Many areas lack regular electric supply, limiting the effectiveness of microscopy. Drought and economic hardships cause large-scale migration, reducing treatment completion and cure rates. Drug resistance is also an impending threat, and surveillance in several areas in India has found that 1% to 3.3% of new patients have multidrug-resistant TB. This is higher than in many countries, but much lower than in ďhot spotsĒ described by the WHO, such as areas of the Former Soviet Republics (10% to 15%) and New York City in the early 1990s (7%). The HIV pandemic is considered to be the most serious threat to TB control in India. Current estimates suggest that there are nearly 4 million HIV-infected people (less than 1% of the population) in India, and that approximately half of these individuals are also infected with M. tuberculosis. Continued spread of HIV will likely contribute to increases in TB cases, potentially threatening recent advances in TB control in some areas.

At its current size, the TB control program in India is now one of the largest public health programs in the world. Continued expansion to the entire country is under way, with plans to cover 80% of the country by 2004 and 100% by 2005. Sustaining and expanding this program will require continued high-level commitment from the central and state governments of India, supplemented by coordinated assistance from international and bilateral organizations.

óReported by Lorna Thorpe, PhD
Division of TB Elimination

Bidding Adieu to Susan Cookson, A Valuable DGMQ Asset

Susan Temporado Cookson, MD, Chief of the Medical Health Assessment Section (MHAS) within the Division of Global Migration and Quarantine (DGMQ), will leave the Division in September 2002 to obtain a masters degree in public health through the International Health Leadership Program at Emory University's Rollins School of Public Health. Part of her work at Emory University will include a project with Anne Haddix, formerly of CDC, in cost-effectiveness analysis. From March through August 2002, Susan will work in the Office of the Director, DGMQ, preparing manuscripts reflecting the health assessment work that has taken place during her tenure.

One of the main foci of migration health assessment is TB. Susanís interest in TB extends back to the late 1980s, when she operated a TB clinic in Nicaragua for 3 years. Following completion of an infectious disease fellowship, she came to CDC in 1995 as an EIS Officer, and was assigned to the then-named Hospital Infections Program, now the Division of Healthcare Quality Promotion (DHQP), subsequently publishing 11 articles. Susan joined the Division of Quarantine (now the Division of Global Migration and Quarantine) in January 1997. In October 1998, she became Chief of the Medical Screening and Health Assessment Section (now the Migration Health Assessment Section) within the division. Through Susanís leadership, many substantial improvements have been made within the section. These are highlighted below:

Standardization of Quality Assessment

The evaluation of overseas panel physician sites that assess potential immigrants and refugees changed from visits by two public health advisors stationed overseas to a structured assessment by a bidisciplinary team. This team, composed of a physician and a microbiologist, uses formal tools for evaluating the sitesí medical, laboratory, radiology, and vaccination activities. Currently, the tools are being revised to allow an even more objective assessment. Terry Comans, the microbiologist, is now the team leader of this quality assessment effort.

Creation of New U.S. Department of State Health Evaluation Form and Worksheets

In conjunction with the U.S. Department of State, DQ staff created a new health evaluation summary form, with three accompanying worksheets. A more detailed explanation of the overseas applicant evaluation was also formulated. The chest x-ray and classification worksheet provides an algorithm for the panel physician to use to determine whether an applicant has a Class A TB condition requiring treatment before entry into the United States, or a suspected Class B TB condition, resulting in notification of a state health department that follow-up is needed after entry into the United States. The form and worksheets were introduced to the U.S. consulates in spring 2001.

Introduction of Electronic Notification System

The TB and Refugee Notification System (TBRN), a pilot study to determine the feasibility of electronically notifying states of the arrival of all refugees and of all immigrants and refugees with suspected TB, was conceived in 1998 and proved to be quite successful. The pilot study, which is being conducted in California, Georgia, Florida, Illinois, Massachusetts, New York, Texas, and Virginia, with participation from New York City and Chicago, is now fully operational. Plans for continuing and expanding the electronic notification system are already underway and will be spearheaded by James (Bo) Barrow of DGMQ and Stuart McMullen of DTBE after Susanís departure.

Personnel Expansion

Recent additions to the MHAS staff include Maria Cano, MD, MPH, an infectious disease specialist responsible for the refugee and vaccination activities of the section, and Mary Naughton, MD, MPH, a radiologist who is responsible for day-to-day TB activities within the section. Pam Copelan, formerly employed by the Immigration and Naturalization Service (INS), continues to contribute her extensive expertise in INS and regulation issues, and Terry Comansí role has expanded to include oversight of other microbiologists in addition to supervision of revision of the quality assessment tools.

MHAS has changed dramatically during Susanís tenure. We thank her for her many contributions and her tireless dedication to the section and wish her the best as she continues to expand her knowledge of and work within the field of international public health.

óReported by Mary Naughton, MD, MPH
TB Medical Officer
Division of Global Migration and Quarantine


Released October 2008
Centers for Disease Control and Prevention
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