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TB Notes 2, 2004
UPDATES FROM THE SURVEILLANCE, EPIDEMIOLOGY,
AND OUTBREAK INVESTIGATIONS BRANCH
Year in Review: TB Outbreak Investigations 2003
Like the previous year, 2003 was a busy year for the Outbreak Investigations
Team (OIT) in DTBE’s Surveillance, Epidemiology, and Outbreak Investigations
Branch (SEOIB). During 2003, DTBE’s Outbreak Evaluation Unit received
34 reports of TB outbreak activity. In response to these, at the
local jurisdictions’ request, the OIT conducted six on-site Epi-Aid
investigations (five national and one international) and provided
technical assistance in response to three other reports. The Field
Services and Evaluation Branch (FSEB), the Communications, Education,
and Behavioral Studies Branch (CEBSB), and the Clinical and Health
Systems Research Branch (CHSRB) collaborated with OIT on these investigations.
The highlights of the year’s outbreak investigations were the predominant
outbreak investigations among homeless persons and the use of the
Quantiferon®-TB test (QFT) as part of a research protocol
for detection of latent TB infection (LTBI) during large contact
investigations and outbreaks.1 The results of QFT use
will be described later once the study is completed and data are
During 2003, the OIT conducted three Epi-Aid investigations among
homeless persons (in Seattle, Washington; Portland, Maine; and Wichita,
Kansas). Although the three situations were similar in involving
homeless persons, there were differences in the demographic characteristics
and risk factors among these groups that warranted the use of a
variety of innovative strategies by the epi-investigation teams
to conduct detailed and thorough contact investigations.
The first of these investigations was conducted during May 2002
– September 2003 in Seattle, Washington, where Public Health – Seattle-King
County (PH-SKC) found 44 persons with outbreak-associated TB. All
but three of the outbreak-associated patients were homeless at the
time of diagnosis; 43 (98%) were born in the United States, 34 (77%)
were male, 21 (48%) were American Indian or Alaska Native, and 17
(39%) were black. Of the 38 (86%) persons with pulmonary disease,
23 (61%) had acid-fast bacilli detected on sputum smear at diagnosis.
Seven (16%) outbreak-associated patients were also infected with
human immunodeficiency virus (HIV). In January 2003, a CDC Epi-Aid
team, along with PH-SKC, assisted in finding contacts at highest
risk for exposure. Investigators reinterviewed outbreak patients
and health care providers serving homeless facilities to find additional
patient contacts. Sites of transmission were determined by review
of homeless facility intake registries for the presence of persons
with infectious TB disease and the rates of positive tuberculin
skin test (TST) results among staff and clients. Exposed cohorts
were found at three sites of transmission. The cohort prioritized
for intensive testing included 385 contacts from three homeless
facilities and 86 other contacts named by patients or health care
providers. In February 2003, PH-SKC began an intensive effort to
test the high-priority cohort for TB disease and LTBI in the TB
clinic and at homeless facilities; this included symptom review,
chest radiograph, sputum examination and culture, TST, and voluntary
HIV counseling and testing. During February–September 2003, approximately
380 contacts were screened with chest radiograph or sputum culture
or both. Of the 44 outbreak-associated patients, 20 were reported
during this time, and 11 (55%) were found through these intensive
and focused screening efforts, limiting the amount of time these
persons were exposing others in the community.2
The second investigation was conducted in Portland, Maine, which
is a low-incidence state. During June 2002 – July 2003, seven men
with pulmonary TB disease in Portland, Maine, were reported to the
Maine Bureau of Health (MBH). Six were linked through residence
at homeless shelters; four had matching genotypes. As of November
20, 2003, the investigation had found 1,069 contacts, 36 (3%) of
whom reported having a positive TST result previously. Among the
1,033 persons eligible for a TST, 648 (63%) received at least one
test, and 56 (9%) of these had a positive result; 15 (27%) of the
56 are receiving, and one completed, therapy for LTBI. A total of
163 (15%) contacts had chest radiographs; no additional active cases
were detected. Delayed diagnosis and missed opportunities for TB
prevention were determined to be major contributors for TB transmission.
Prompt investigation and identification of contacts likely prevented
further spread of TB.3
The third investigation was conducted in Sedgwick County, Kansas,
where in 2003, TB genotyping detected a potential five-case cluster.
Traditional name-based TB contact investigations had not revealed
epidemiologic links. An Epi-Aid team conducted a targeted investigation
in collaboration with the Sedgwick County health department to determine
location-based links and the extent of transmission, and recommend
TB control measures. Medical records were reviewed to determine
TB patients’ infectious periods, followed by reinterviews about
their activities and locations while contagious. Homeless facilities’
logs were reviewed to find common stays between contagious TB patients
and other facility clients. Clients were divided into exposure categories
according to number of common stays. Location-based contacts received
TB screening, including a TST. TB genotyping provided the impetus
to investigate locations linking the patients in this cluster. The
investigation determined plausible transmission sites and directed
the county’s TB control strategies, which now include mandatory
TB screening at all homeless facilities.
As the TB control community collectively moves towards TB elimination
in the United States, it is important to remember that TB is receding
back into the traditional “pockets” of infection as evidenced by
the TB outbreaks among homeless persons described above. These and
other high-risk, hard-to-reach populations will provide challenges
to all of us. We should remain vigilant and closely monitor TB control
efforts, especially in population groups at high risk for TB. Moreover,
we all face the additional challenge of reduced public health resources.
It is now more important than ever for public health organizations
at the local, state, and national levels to continue to work closely
together against TB. Health departments may request DTBE assistance
with outbreaks, cluster investigations, or other instances of TB
transmission by contacting their DTBE Program Consultant. Such
assistance may take the form of programmatic consultation, technical
assistance, or on-site assistance (for example, an Epi-Aid). Your
partners in DTBE are eager to work with you to achieve our common
goal of TB elimination.
—Reported by Kashef Ijaz, MD, MPH
Div of TB Elimination
1. CDC. Guidelines for using the QuantiFERON®-TB test
for diagnosing latent Mycobacterium tuberculosis
infection. MMWR 2003; 52 (No. RR-2: [15-18]).
2. CDC. Public health dispatch: Tuberculosis outbreak among homeless
persons-King County, Washington, 2002-2003. MMWR 2003; 52(49);1209-1210.
3. CDC. Public health dispatch: Tuberculosis outbreak in a homeless
population-Portland, Maine, 2002-2003. MMWR 2003; 52(48);1184-1185.
Effective Oral Communications
Successful Scientific Writing:
Training for Public Health Scientists, Faculty,
and Students in Ethiopia
Do you think it is important
to communicate effectively? Well, so does Dr. Tadesse Wuhib (EIS
’96), CDC/Global AIDS Program (GAP) assignee and country director
for CDC/GAP’s activities in Ethiopia. As a part of his mission,
Dr. Wuhib recognized that little capacity existed among public
health scientists, faculty, and students in Ethiopia to communicate
important public health messages orally and to publish their work
in the peer-reviewed literature – even among those who speak English
well. Further, he recognized that the current journal for communicating
public health information — the Ethiopian Journal of Health
Development, published by the Ethiopian Public Health Association
(EPHA) — required a new look, including a new publication plan,
vision, and format.
Public health advocacy can be an effective tool for mobilizing
public health action and setting priorities, including budgetary
decisions. It has an impact on policy and facilitates appropriate
decision-making. Further, it should be incorporated into public
health academic training programs from the outset. Students need
training in public health advocacy, especially as it relates to
issues involved in effective oral presentation and successful
scientific writing and the publication of scientific findings.
To this end, Dr. Wuhib invited me to “institutionalize” in Ethiopia
the course that Ms. R. Elliott Churchill and I teach at the Emory
University Rollins School of Public Health, titled Applied
Public Health Advocacy: Effective Oral Communications. His
vision was to establish capacity within the EPHA to provide this
training in the future to enable public health scientists, faculty,
and students to improve the quality of their oral scientific communications
and their manuscripts.
The goals of the two short-term consultancies in 2003 to Ethiopia
- Establish a trained cohort of Ethiopian public health scientists
and faculty in oral communications and scientific writing;
Develop the capacity so that the trained
cohort could both deliver and teach others to give high-quality
oral communications and scientific writing;
Establish a coordinator position at the
Complete the revisions of the monthly journal.
The core element of this capacity development effort included
a 2-week training module (80 contact hours) that was designed
to convey the principles and practice of dynamic and persuasive
techniques for oral communication and successful scientific writing.
Dr. Paul Siegel, Ms. R. Elliott Churchill, and I served as faculty.
All of us currently teach in the areas of public health communications.
We used a train-the-trainers approach that enhanced the
ability of the student-faculty participants to participate in
critiques of good and bad presentations provided by us. This also
allowed for exercises to be conducted by small working groups
of participants that facilitated participation by all trainees
and provided a sense of reality in the discussion and preparation
of sample presentations on assigned topics. During the first week
(40 contact hours), instruction in specific areas of oral communication
included hands-on workshops (e.g., class presentations and videos).
The second week (40 contact hours) focused on successful scientific
We hope and believe the capacity was developed. We have planted
the seed, and we will know if it grows to fruition if the trainees
begin to conduct the training themselves in the six medical schools
and schools of public health. Stay tuned …
—Submitted by Scott JN McNabb, Ph.D., M.S.
Div of TB Elimination
Effective Oral Communications and Scientific Writing
Class, Nazareth, Ethiopia, July 2003
National Surveillance for Severe
Adverse Events (Hospitalization or Death) Associated with Treatment
of Latent Tuberculosis Infection
Between October 2000 and December 2003, DTBE received reports of
49 patients with severe adverse events associated with the use of
the 2-month regimen of rifampin and pyrazinamide (RZ) for the treatment
of latent tuberculosis infection (LTBI); 12 (24%) of the 49 patients
died. In addition, since January 1, 2004, DTBE has received two
reports of serious adverse events for patients started on therapy
(RZ=1 and isoniazid=1).
A severe adverse event is defined as hospitalization or death of
a person receiving treatment for LTBI.1-4 On the basis
of these data, the American Thoracic Society and CDC recommended
that RZ should generally not be offered for treatment of persons
with LTBI, regardless of HIV status.4 Rifampin
and pyrazinamide should continue to be administered in multidrug
regimens for the treatment of persons with active TB disease.5
To better estimate the incidence of severe adverse events (hospitalization
or death) associated with any treatment for LTBI in the United States,
DTBE is developing a national surveillance system. Surveillance
of such events will provide data to support further revisions of
guidelines, if deemed necessary, for treatment of persons with LTBI.
To facilitate this surveillance system, DTBE requests that health
care providers and health departments report any hospitalization
or death related to any treatment for LTBI to Lilia Manangan in
the Surveillance Team; Surveillance, Epidemiology, and Outbreak
Investigations Branch; DTBE, CDC; telephone number: 404-639-8401
or email: email@example.com.
—Reported by Lilia Manangan, RN, MPH
Div of TB Elimination
*For latent tuberculosis infection (LTBI).
LTBI guidelines: see reference 6 below.
1. CDC. Fatal and severe hepatitis associated with rifampin and
pyrazinamide for the treatment of latent tuberculosis infection
— New York and Georgia, 2000. MMWR 2001;50(15):289-91.
2. Update: Fatal and severe liver injuries associated with rifampin
and pyrazinamide for latent tuberculosis infection, and revisions
in American Thoracic Society/CDC recommendations — United States,
2001. MMWR 2001;50(34).
3. CDC. Update: Fatal and severe liver injuries associated with
rifampin and pyrazinamide treatment for latent tuberculosis infection.
MMWR 2002; 51(44):998-9.
4. American Thoracic Society/CDC. Update: Adverse event data and
revised American Thoracic Society/CDC recommendations against the
use of rifampin and pyrazinamide for treatment of latent tuberculosis
infection — United States, 2003. MMWR 2003;52(31):735-9.
5. American Thoracic Society, CDC, Infectious Diseases Society
of America. Treatment of tuberculosis. Am J Respir Crit Care Med
6. American Thoracic Society, CDC. Targeted tuberculin testing
and treatment of latent tuberculosis infection. Am J Respir Crit
Care Med 2000;161:S221-S247).
The 4th semiannual meeting of the TB Epidemiologic
Studies Consortium (TBESC) was convened November 20-22, 2003,
in San Francisco, California. The goals were to inform participants
of progress in TBESC research activities, discuss implications
of the Health Insurance Portability and Accountability Act of
1996 (HIPAA) and a centralized institutional review board (IRB)
process, elect members for the three newly established TBESC
committees, establish the Diagnostics and TBESC Performance
Standards Workgroups, and enhance participants’ budgetary, fiscal,
and research skills.
There were over 90 attendees. CDC staff, TBESC members, and
guest speakers gave presentations about proposed or ongoing
task orders, administrative issues, and other activities related
to TB research. Presentations were given on the following
- Updates on Task Orders 1-14
- TBESC Data Management System
- Sampling Methods for Population-Based Epidemiologic Studies
- Westat Update
- TBESC Proposed Performance Standards
- HIPAA Issues: Programmatic and Research
- Effective Task Order Planning
- Outcome of TB Leads
- Bylaws Update
- Communications: eRoom and TBESC Web site
- Research Committee Update
- TBTC Update
- New Committee Reports
Attendees also provided input during small group or breakout
sessions addressing the following topics:
Research related to current and future
New committees (External Relations, Publications
and Presentations, and Process Evaluation)
The meeting was very productive. Our next steps include continuing
with the research involved in the current task orders, developing
a Data Management and Communications System (DMACS) for TBESC, moving
forward with Phases II and III of Task Order #13, establishing the
Diagnostics Workgroup, developing research concepts for TB Leads,
and facilitating the coordination of IRB activities.
The 5th semiannual meeting was held April 28-29, 2004,
in Atlanta at the Westin Peachtree Plaza. Details regarding the
meeting will be forthcoming.
— Reported by Viva Combs, MPH
Division of TB Elimination