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TB Notes 2, 2004


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 analyzed.

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 and
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 were to

  1. Establish a trained cohort of Ethiopian public health scientists and faculty in oral communications and scientific writing;
  2. Develop the capacity so that the trained cohort could both deliver and teach others to give high-quality oral communications and scientific writing;
  3. Establish a coordinator position at the EPHA; and
  4. 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 writing.

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

Picture of Effective Oral Communications and Scientific Writing Class


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.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:

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

chart displaying Liver Injury Associated with Rifampin and Pyrazinamide by Treatment Start Date. United States, 1999-2003.

*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 2003;167:603-62.

6. American Thoracic Society, CDC. Targeted tuberculin testing and treatment of latent tuberculosis infection. Am J Respir Crit Care Med 2000;161:S221-S247).


TBESC Update

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 topics:

  • 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:

  • TB Diagnostics
  • Fiscal issues
  • Research related to current and future task orders
    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. 

April Meeting

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


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

Please send comments/suggestions/requests to:, or to
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Communications, Education, and Behavioral Studies Branch
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