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TB Notes 2, 2003

UPDATES FROM THE SURVEILLANCE AND EPIDEMIOLOGY BRANCH

CDC Investigates TB Cases at a Community Hospital in Guatemala City

In November and December 2002, CDC collaborated with officials at a Guatemala City hospital in an investigation of an outbreak of M. tuberculosis largely among HIV-coinfected patients, which had the potential risk of nosocomial transmission to hospital staff and patients. Concern about the perceived increase in the number of patients being diagnosed with active TB among patients attending the HIV clinic and inpatient medicine wards prompted the Chief of Infectious Diseases at the hospital and the Ministry of Health to request CDC assistance in the investigation.

In November 2002, a team from CDC visited Guatemala. The team consisted of Drs. Kenneth G. Castro, Thomas R. Navin, Idalia M. González, and Abraham Miranda of DTBE and Mr. Edwin Rodriguez of the State of New York Department of Health. The team principally met with officials from the hospital and Ministry of Health National TB Control Program and assessed the situation at the hospital, a tertiary-care referral center with approximately 42,000 annual discharges. In addition, the team met with officials from another HIV clinic run by a nongovernment organization in Guatemala City, as well as with senior members of the U.S. Agency for International Development (USAID) mission in Guatemala and the Pan American Health Organization (PAHO).

Based on preliminary findings and discussions, the team felt that CDC could offer immediate assistance in an epidemiologic investigation of the possible nosocomial transmission of TB at the hospital, as well as with an environmental assessment of the factors that could be contributing to such transmission.

A week after returning from the initial assessment visit, Drs. González and Miranda and Mr. Rodriguez departed to Guatemala to conduct the epidemiologic investigation. They were later joined by Dr. Paul A. Jensen, a DTBE occupational safety engineer for the environmental assessment, and by Dr. Soju Chang from CDC’s Division of Healthcare Quality and Promotion to assist with the ongoing investigation.

The microbiologic diagnosis of TB at this hospital is done mostly by acid-fast bacilli smear of sputum or other tissues, or by biopsy of a tissue specimen. The laboratory did not have the capacity to do microbiologic identification or susceptibility testing. Therefore, several TB isolates that were stored at the hospital microbiology laboratory from the last several years were sent to CDC for identification and microbiologic susceptibility testing. The specimens have been evaluated; all isolates were susceptible to first-line antituberculosis medications, except two isolates that were resistant to streptomycin.

The hospital does not have a computerized medical records system, which made it difficult to ascertain the number of patients who were hospitalized or treated as outpatients with a diagnosis of TB. Eight separate lists from different sources (e.g., pharmacy, laboratory, medical wards, outpatient HIV clinics, pathology) were generated to try to arrive at an incidence figure of TB cases. Review of medical records revealed that 71 patients were either hospitalized or treated as outpatients with a diagnosis of active TB during the previous 12 months.

Preliminary results showed that 59 (83%) of these patients had pulmonary involvement, 35 (49%) were HIV coinfected, and 14 (20%) died. Deficiencies in engineering and administrative controls essential to the prevention of TB transmission were found. Some of these included the absence of a written TB infection control plan, the lack of surveillance for TB, multiple patients with different isolation needs occupying the same room, the lack of respirators for staff use, and the lack of negative air-pressure rooms.

In addition, a survey on the knowledge, attitudes, and practices of a convenience sample of health care workers was conducted. As a consequence of this investigation, we expect to be able to recommend several relatively inexpensive interventions to decrease the risk of nosocomial transmission of TB in the hospital. An in-depth analysis of the findings of this investigation is under way.

—Submitted by Idalia M. González, MD, MPH
Div of TB Elimination

Summary of the BTEP Project

The Biotechnology Engagement Program (BTEP) seeks to establish collaborations between US government scientists and former Soviet bioweapons scientists to address urgent public health concerns in Russia and the northern Eurasia region. Additional background information on BTEP was provided in the last TB Notes. Here we describe a BTEP project that is being developed by CDC staff from DTBE and the Division of HIV, STD, and TB Laboratory Research (DASTLR) in collaboration with scientists from the Moscow Research Institute of Phthisiopulmonology (RIPP) and the State Research Center for Applied Microbiology (SRCAM) in Obolensk.

In November 2002, the CDC collaborators (Rachel Albalak, Rick O’Brien, Jack Crawford, and Peter Cegielski) met with their Russian scientist counterparts in Moscow and Obolensk to develop ideas for a TB clinical trial to be proposed under BTEP, and assess the infrastructure requirements of RIPP and SRCAM for carrying out a TB clinical trial.

Based on discussions held during the site visit, the collaborators agreed that there would be two phases to the project. Phase I would include infrastructure enhancements of the laboratory and computer facilities at SRCAM and infrastructure enhancements of the laboratory, computer, and clinical facilities at RIPP. It would also include training in laboratory processes and in data management and statistics for clinical trials. This phase would also be used for development of the clinical trial protocol. Phase II would be the conduct of the clinical trial.

The proposed clinical trial for Phase II is an evaluation of the safety and microbiological activity of a moxifloxacin-containing regimen administered during the first 2 months of treatment of patients with sputum smear-positive pulmonary TB. The primary outcomes would be the culture-conversion rate at 2 months of therapy and discontinuation of therapy due to drug toxicity or intolerance.

This year, the CDC Tuberculosis Trials Consortium will begin a study to evaluate moxifloxacin in place of ethambutol in the initial phase of TB therapy. Results of this study would be expected to inform the design of the proposed BTEP study. Moreover, studies of moxifloxacin in an experimental (mouse) model of TB, which include moxifloxacin replacement of pyrazinimide and isoniazid, are underway at Johns Hopkins University. Results of these studies, which will be available this year, would likewise inform the design of this study.

These proposal ideas are pending final approval from the Russian collaborators. An additional site visit was conducted in February 2003 to write the proposal, which will be submitted to the BTEP Secretariat.

—Reported by Rachel Albalak, PhD
Div of TB Elimination

Tuberculosis Epidemiologic Studies Consortium Update

The Tuberculosis Epidemiologic Studies Consortium (TBESC) was established in September 2001. The purpose of TBESC is to conduct programmatically relevant TB research and to strengthen TB public health infrastructure in the United States and Canada, ultimately contributing to the goal of TB elimination. TBESC is composed of 22 sites across the United States and Canada (Figure 1). Each site has a formal partnership between an academic institution and a TB control program. TBESC conducts epidemiologic, behavioral, economic, laboratory, and operational research. This research entails the identification, diagnosis, prevention, and control of active TB disease and latent TB infection (LTBI). Over the past year TBESC has completed several activities that support its mission, goals and purpose.


Research Sites of the TBESC

Thirteen research projects (task orders) have been approved for further development by DTBE, each at different stages of progress (Table 1). Since the last TBESC update (TB Notes No. 1, 2002), TBESC convened for a second time in Denver, Colorado, August 7-9, 2002, and a third time April 9-11, 2003, in Chicago, Illinois. The second meeting was convened to prioritize and further develop research proposals in the areas of latent TB infection, contact investigation, and TB among foreign-born persons. The proposal to examine TB among foreign-born persons will be the first consortium-wide study. The purposes of the study are to a) conduct enhanced surveillance to describe the epidemiology of TB among persons who were born outside of the US or Canada; b) identify missed opportunities to diagnose active TB in foreign-born persons before their arrival in either the US or Canada; and c) identify approaches that quickly diagnose active and latent TB in foreign-born persons in the United States and Canada in order to reduce the risk of disease transmission and the risk of progression from LTBI to active TB.

TBESC is in the process of completing its bylaws. Currently, five committees are operating:

  • The Steering Committee, which includes all 22 sites and one CDC representative (the TBESC project officer, who serves as one of the co-chairs), oversees all TBESC activities, both scientific and administrative
  • The Research Committee, consisting of nine members, is responsible for developing the research agenda and overseeing the development and conduct of research protocols for the TBESC
  • The Bylaws Committee, consisting of eight members, is responsible for drafting and updating the bylaws and facilitating voting (motions, nominations, and elections)
  • The Meetings Committee, consisting of four members, is responsible for coordinating future TBESC general meetings, i.e., developing agendas, identifying and scheduling presenters, collecting relevant materials, specifying meeting dates and times, and identifying locations for meetings
  • The Executive Committee, consisting of the chairs of all TBESC committees, serves as the executive arm of the steering committee, managing the day-to-day activities of the steering committee

At the third meeting, the Bylaws Committee proposed and the Steering Committee accepted three additional committees to build on the Consortium’s infrastructure. They include the following:

  • The External Relations Committee will be responsible for disseminating results of research conducted by TBESC for the purpose of advocating for additional TB research and to promote the goals of TB elimination=
  • The Publications and Presentations Committee will be responsible for coordinating the development and progress of presentations, publications, and special issues or supplements highlighting TBESC research
  • The Process Evaluation Committee will be responsible for overseeing the conduct and quality of ongoing studies

The composition, activities, and purpose of each committee will be finalized at a later date. In addition to the bylaws, TBESC discussed funded and future research projects and long-term objectives of the Consortium. Look for further details about the meeting in Chicago in TB Notes No. 3, 2003.

—Reported by Viva Combs, MPH
Div of TB Elimination

Table 1. Current TBESC Research Activities

Task Order No.

Title

Principal Investigator(s)

No. Participating Sites

Stage/Phase

2

Prospective evaluation of immunogenetic and immunologic markers for susceptibility to TB infection and progression from M. tuberculosis infection to active TB

Mary Reichler, MD

8

Data collection

3

Zero tolerance for pediatric TB

Mark Lobato, MD

3

Finalizing protocol

4

Models for incorporating HIV counseling, testing, and referral into TB contact investigations

Suzanne Marks, MPH, MA

1

Data collection

5

Prevalence of LTBI among high –risk populations in the US

Rachel Albalak, PhD

5

Protocol development

6

Regional capacity-building in low-incidence areas

Paul Tribble, MPH

1

Site selection

7

Use of network analysis methods to characterize M. tuberculosis transmission patterns among women and other high-risk populations

Peter McElroy, PhD & Maureen Wilce, MPH

Sites have not been selected yet

Site selection

8

A national genotyping registry for a molecular epidemiologic analysis of multi-drug resistant M. tuberculosis

Kashef Ijaz MD

Sites have not been selected yet

Task Order has been announced

9

Enhanced surveillance to identify missed opportunities for TB prevention in foreign-born populations in US and Canada

Amy Davidow, PhD Dolly Katz, PhD, and Randall Reves, MD

22

Protocol development

10

Applying a New Conceptual Framework to Evaluate Tuberculosis Surveillance and Action Performance and Measure Costs

Scott McNabb, PhD, MS

TBD

Task Order Development

11

Addressing TB Among African Americans in the Southeast:  Identifying and Overcoming Barriers to Treatment Adherence for LTBI and TB Disease

Nickolas DeLuca, MA

TBD

Task Order Development

12

Assessing the Tuberculosis (TB) Knowledge, Attitudes, Beliefs, and Practices Among Private Providers Serving Foreign-born Populations at Risk for TB

Nickolas DeLuca, MA

TBD

Task Order Development

13

Prospective cohort study of risk factors for acceptance of, adherence to, and toxicity from treatment for LTBI

C. Robert Horsburgh, MD, MUS

TBD

Task Order Development

 

 


Released October 2008
Centers for Disease Control and Prevention
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