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TB Notes 2, 2002

Updates from the Surveillance and Epidemiology Branch

The RVCT Revision Process – Update

As many of you know, an e-mail was sent out to U.S. TB controllers in summer 2001 announcing DTBE's plan to revise the Report of Verified Case of Tuberculosis (RVCT). It was anticipated that this would be a multiyear process; to start the process, we asked for your comments, as well as volunteers for an ad hoc RVCT working group. 

Since the initial announcement, a summary of your comments has been compiled and a working group established. The working group (about 25 members) has been in contact routinely (every 1 or 2 weeks) by conference call since mid-September and has been systematically reviewing the submitted comments, the RVCT variables, and the RVCT instructions. By mid-February 2002, the working group had reviewed the comments and variables, and is currently assembling a first draft of the revised RVCT variables and instructions. Additional conference calls are planned to further discuss pending issues and it is anticipated that by the summer of 2002, a draft of the revised RVCT will be available for comment. In addition, we have met with the Tuberculosis Information Management System (TIMS) team and presented our preliminary timeline and general comments. The working group will continue to work with the TIMS team on revised RVCT and National Electronic Disease Surveillance System (NEDSS) issues.

An update and brief summary of the RVCT revision process to date is planned for the National TB Controllers Workshop in 2002.  As always, the revision process continues to accept comments, so if you have any questions or concerns, please do not hesitate to contact Dr. Eileen Schneider by telephone at (404) 639-5345 or by e-mail at

—Submitted by Eileen Schneider, MD
Division of TB Elimination

Revising the 1994 TB Infection Control Guidelines

In 1999, on the recommendation of the Advisory Council for the Elimination of Tuberculosis (ACET), CDC began revising the 1994  “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Facilities.”  As part of this process, CDC held a consultation with TB experts in Atlanta January 24-25, 2002.

The meeting was attended by 38 outside TB experts and 15 CDC employees. Outside experts included TB controllers, TB control program staff, infection control (IC) physicians and nurses, hospital epidemiologists, industrial hygienists and engineers, labor union representatives, and staff from the Occupational Safety and Health Administration (OSHA). CDC staff included members from DTBE, the National Center for Infectious Diseases, the Public Health Practice Program Office (PHPPO), the Division of Healthcare Quality Promotion, the National Institute for Occupational Safety and Health, the Occupational Health Services, and the Division of Oral Health. The members of the TB IC workgroup are Dr. Paul Arguin, Dr. Diane Bennett, Dr. Denise Cardo, Dr. Jennifer Cleveland, Dr. Michael Iademarco, Dr. Paul Jensen, Ms. Lauren Lambert, Dr. Adelisa Panlilio, Ms. Teri Palermo, Dr. John Ridderhoff, Dr. Renee Ridzon, and Dr. Pattie Simone. 

On the first morning of the meeting, members of the TB IC workgroup made presentations and generated discussion about the proposed changes to the guidelines.  In the afternoon, the participants met in small breakout groups for further discussion. On the second day, the entire group reconvened and recorders from the small breakout sessions presented their group’s recommendations.

The primary differences between the 1994 guidelines and the 2002 draft are as follows: the guidelines have been expanded to include other health care settings in addition to hospitals; new terminology has been adopted (e.g., tuberculin skin test or TST rather than PPD, treatment for latent TB infection or LTBI rather than preventive therapy); recommendations for  skin testing frequency have been revised; and the discussion of environmental controls has been expanded.  The new IC guidelines will also include an appendix with frequently asked questions (FAQs), which will provide examples and clarify misconceptions. 

A follow-up meeting to discuss the proposed revisions and recommendations was held in Atlanta on March 20, and the next meeting will be held in Atlanta on May 8, 2002. The final guidelines will be submitted for approval to ACET, and will then be published in the Federal Register before being published in final form in the MMWR.

—Reported by Lauren A. Lambert
Division of TB Elimination

Tuberculosis Morbidity Among U.S.-born and Foreign-born Populations — United States, 2000

(The following is a summary of the TB morbidity article published Feb. 8, 2002, in the MMWR. The article can be accessed at the Web site

This report summarizes data from the national TB surveillance system for 2000 and compares them with data for 1992 to 1999. During 2000, a total of 16,377 cases (5.8 cases per 100,000 population) of TB were reported to CDC from the 50 states and the District of Columbia (DC), representing a 7% decrease from 1999 and a 39% decrease from 1992 when the number of cases and case rate most recently peaked in the United States. However, the case rate among foreign-born persons remains at least seven times higher than among U.S.-born persons. To address the high rate, CDC is collaborating with public health partners to implement TB control initiatives among recent international arrivals and residents along the border between the United States and Mexico and to strengthen TB programs in countries with a high incidence of TB disease.

In 2000, 53% of reported cases were among U.S.-born persons while 46% were among foreign-born persons. In 1992, in contrast, 72% of reported cases were among U.S.-born persons while 27% were in foreign-born persons. The number of states with >50% of their annual total of reported TB cases among foreign-born persons increased from four in 1992 to 21 in 2000. Of these 21 states, California, Hawaii, Massachusetts, Minnesota, and New Hampshire had >70% of their annual total of cases among foreign-born persons.

In 2000, of the 7,554 cases of TB in foreign-born persons, 41% occurred among persons from Central and South America or the Caribbean, and 33% were from the Western Pacific (designated by the World Health Organization). These regions also had the largest number of cases in 1992 (44% and 40%, respectively). From 1992 to 2000, the number of cases approximately doubled among persons from the Mediterranean (2% in 1992 and 5% in 2000) and among persons from Southeast Asia (6% in 1992 and 10% in 2000), while the number of cases among persons from Africa tripled (2% in 1992 and 6% in 2000).

The proportion of patients with MDR TB decreased from 3% in 1993 to 1% in 2000. However, of the total number of reported MDR TB cases, the proportion occurring in foreign-born persons increased from 31% (150 of 486) in 1993 to 72% (101 of 141) in 2000. The proportion of TB patients placed on a recommended initial treatment regimen (i.e., isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol), increased from 1993 to 1998. The proportions of patients who completed treatment within 1 year and who were treated with directly observed therapy (at least for a portion of treatment) increased also during this period.

From 1992 to 2000, TB case rates in the United States decreased for U.S.-born and foreign-born persons; however, the decrease among foreign-born persons was less substantial. Decreases in the number and proportion of MDR TB cases also occurred. The overall improvement is consistent with the finding of an increasing proportion of patients receiving initial four drug regimens, completing treatment within 1 year, and being treated with directly observed therapy.

Despite the decrease in case rate among foreign-born persons, nearly half of TB cases in the United States in 2000 occurred in this population, and the case rate was seven times greater in this population than among U.S.-born persons. To address the high rate, CDC is collaborating with other national and international public health organizations to 1) improve overseas screening of immigrants and refugees by developing systematic tools for monitoring and evaluating the screening process; 2) improve the current notification system that alerts local health departments about the arrival of immigrants or refugees with suspected TB to assist patients in obtaining a medical evaluation and, if necessary, in completing a course of recommended drugs; 3) improve coordination of and communication about TB control activities between the United States and Mexico to ensure completion of treatment among TB patients who cross the border; and 4) test recent arrivals from high-incidence countries for latent TB infection and ensure completion of treatment. In addition, CDC continues to strengthen collaborations with international partners, including the World Health Organization, to improve TB control in high-incidence countries.

Accelerating progress in national TB elimination activities, however, will require broader prevention efforts to evaluate and address unmet needs in other population risk groups such as persons living with HIV, and persons living in poverty with limited access to medical care and adequate housing and nutrition. In addition, low-incidence areas in the United States need continued support to ensure they maintain the capacity and expertise to respond to cases when they occur. CDC is currently updating its comprehensive national action plan to ensure that priority prevention activities are undertaken with optimal collaboration and coordination among national and international public health partners. Commitment and participation by CDC in efforts towards curtailing the global TB epidemic will remain a critical component of the national plan.

—Reported by Lilia Manangan, RN, MPH
Division of TB Elimination


Released October 2008
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