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TB Notes 3, 2001
Highlights from State and Local Programs
Farewell Note from Dr. Davidson
of LA County
Dr. Davidson presented the following information and comments at
a meeting of the California Public Health Commission prior to his
retirement. He gave permission for his remarks to be reprinted in
I will be retiring from County service October 1, 2001, after completing
18 years as Director of Tuberculosis Control for Los Angeles County,
California. These have been eventful years, full of twists and turns
in the circumstances related to the control of TB as well as in
the many changes in the California Department of Health Services
and Public Health. I believe I can honestly say that I will leave
the control of tuberculosis in a more favorable condition for the
County then when I arrived. I regret to say that there is still
a long way to go before this disease can be eliminated in Los Angeles.
However, at the current level of disease, the possibility of elimination
is at least in sight.
I would like to summarize some of the important trends in the incidence
of TB in Los Angeles County and some of the outcome accomplishments
related to program objectives. I will conclude by making a few general
reflections as I begin to fade out of the picture.
During the year 2000 the number of cases of reported TB declined
for the eighth year in a row at 1065. This is a 9% decline from
the number in 1999 and outpaced both the State of California and
the United States, which have also had 8 years of declining incidence.
The incidence of TB is at a historical low for all these jurisdictions.
There has also been a decline in the number of cases in all races
and ethnic groups during the past 8 years. Persons of Asian and
of black race continue to be overrepresented and whites underrepresented
as compared to the overall population. Hispanics are equally represented.
The number of cases by age group has declined most dramatically
in the 15 to 34 age group during the past 8 years. However, there
has been a leveling in the number of cases in this age group during
the past 4 years. The 65-and-older age group has remained level
for many years and contributes the second largest number of cases.
As TB is controlled and gradually eliminated, the 65-and-older age
group will become the predominant group in terms of cases and incidence.
The corollary to this is that the 0 to 14 age group should be the
first age group to approach zero if TB is fully under control and
moving toward elimination.
The number of cases of TB in both foreign-born and US-born persons
has declined during the past 8 years. However, the percentage of
cases in foreign-born persons has been steadily increasing from
62.6% in 1990 to 72.7% in 2000. Since TB continues to be out of
control in many parts of the world, the foreign-born population
may be the Achilles heel that will make elimination of TB in Los
Angeles County very difficult.
The cases in persons infected with HIV and in the homeless have
reached an all-time low in 2000 with 77 and 76 cases, respectively.
A decline in the control of the spread of HIV or a serious downturn
in the economy could adversely affect TB in these populations. The
same would hold true with persons who have multiple risk factors
such as being foreign-born, homeless, and HIV infected.
Considerable effort is being placed on setting objectives and measuring
outcomes for all public health programs. Los Angeles Tuberculosis
Control, in collaboration with the State of California and CDC,
has been evaluating program effectiveness and documenting outcomes
related to TB for many years. Our ability to participate in this
process has been dramatically increasing with the availability of
computerized data systems and the strengthening of the data management
and epidemiology staff at Tuberculosis Control and in the Health
Centers. Directly observed therapy (DOT) is a highly effective
program activity that ensures that patients receive their medications.
The number of TB patients receiving DOT has steadily increased since
1995. Our objective is to reach 100% of all cases being managed
The CDC national objective regarding the percentage of TB patients
who should complete a prescribed course of therapy within 12 months
is 85%. In 2000, Los Angeles County performed at the 65% level.
There are a number of factors that inhibit our reaching this objective
such as patients dying, moving, or taking longer to complete therapy.
We have very little ability to control some of these factors. Overall
a very high percentage of patients who are started on treatment
in Los Angeles County eventually complete treatment if they do not
die within the first 12 months. A very small percentage of patients
(1.9%) are lost to follow-up.
Los Angeles County has exceeded the national objective of 92% in
drug susceptibility testing for a number of years with 98.5% in
2000. This is a reflection on the excellent Public Health Laboratory
support we have in Los Angeles County.
New guidelines concerning preventive therapy were published by CDC/ATS
this past year. The Tuberculosis Control Program for Los Angeles
County recently approved and circulated the standards expected for
Los Angeles County. These standards are based on the CDC/ATS and
the State of California guidelines. Among the changes has been the
terminology. “Treatment of latent tuberculosis infection” (LTBI)
is now preferred to that of “preventive therapy.” One of the highest
priorities for treatment of LTBI is for contacts of contagious cases
of TB. The national objective for treating contacts is that 85%
should complete treatment of LTBI. The 1999 cohort of contacts in
Los Angeles County only completed therapy in 47.3%. The national
objective for completing treatment of LTBI in other groups that
are targeted because of increased risk is 75%. The results of completing
treatment by the community-based organizations that had contracts
with the County were 52.8%, significantly below the set objective.
Testing those at high risk for tuberculosis infection and successfully
treating those with LTBI will need to be a higher priority for the
Tuberculosis Control Program in coming years as we move toward elimination
of this disease.
In conclusion, a great deal of work must be done before we can declare
victory over TB. I believe the following are some of the more important
aspects for Los Angeles Public Health to address in coming years
to ensure the decline and eventual elimination of this disease:
- Every effort must be made to maintain the necessary infrastructure
to get the job of eliminating TB done. This includes maintaining
level and in some cases increased funding despite decreasing numbers
- The treatment of TB is a specialty. It will be necessary to
maintain specialty clinics staffed by appropriately trained and
experienced physicians, nurses, and support personnel.
- The availability of DOT is essential to the eventual elimination
of TB. This includes availability to patients cared for by both
the private and public sectors.
- There should be continued efforts to establish TB specialty
clinics in strategically located full-service outpatient facilities.
- As TB declines it will be increasingly found in members of limited
subsegments of the population, many of whom will be difficult
to reach and serve. New programs will be necessary to successfully
eliminate TB in these populations. Examples of such populations
include the elderly, the homeless and the poor, the undocumented
foreign-born, and the mentally ill.
- Maintenance of incentives and enablers will remain an essential
part of eliminating TB. New and innovative approaches will be
necessary. Flexibility will be essential.
- A highly skilled field services staff will be necessary to find
cases as early as possible and test and find those at risk for
developing disease. Supervision of treatment with DOT and other
enablers is critical. Innovation is also necessary here. The roll
of community workers and other nonlicensed persons should be expanded
into testing, case finding, and providing treatment services for
cases and those on treatment of LTBI.
Above all, the first priority is to prevent the
transmission of TB. Only then will there be an emerging succession
of generations free of infection, without risk of developing
disease, vigorously marching toward the elimination of this
amazingly persistent disease.
—Paul T. Davidson, M.D.
Director, Los Angeles TB Control
Childhood Screening for
TB in Texas
As TB continues to decrease in Texas, the strategies
to control and prevent its spread must change to target those populations
most at risk. On January 18, 2001, the Texas Department of Health
(TDH) convened a group of pediatric TB experts, which was designated
the Blue Ribbon Committee on Childhood TB, to consider the best
strategies for controlling TB disease and infection in children.
In May and June, the Committee’s recommendations and a questionnaire
developed by the committee to help in screening for risk of TB exposure
were presented for review and comment to groups with an interest
in child health. These included representatives from TDH programs
that provide services to children and representatives from school
districts and other state agencies.
In July, TDH sent a copy of the recommendations and the questionnaire
to local and regional health departments and asked them to work
with school districts to use the risk assessment questionnaire in
place of universal TB skin testing, which some school districts
were continuing to require for all children entering their schools.
The questionnaire asks about exposure of children to adults with
symptoms or risk factors for TB. Children for whom positive responses
are given to the questions about risk factors should be evaluated
for TB infection with a tuberculin skin test and followed appropriately.
Use of the questionnaire is recommended for school entry in seven
counties in Texas where the 3-year average rate of TB is double
the state rate. In six counties that have a 3-year average rate
of TB that is 50% to 99% higher than the average rate for Texas,
the decision to require TB screening with the questionnaire for
school entry should be a joint decision of the local health department
and the school district, as resources allow.
The “Health Steps” program in Texas, which provides screening and
health services for Medicaid-eligible children, plans to adopt the
questionnaire for TB screening as the program revises its service
delivery guide manual in 2002.
—Submitted by Phyllis Cruise
CDC Senior Public Health Advisor
and Ann Tyree
TB Elimination Division, Texas Dept of Health
Meeting of New TB Controllers
The Northern Rocky Mountain TB Controllers Association
held its inaugural meeting on July 27, 2001. Mr. Alex Bowler, TB
Control Officer for the State of Wyoming, invited participants to
Jackson Hole, Wyoming, for the first annual meeting of this new
Those accepting Alex's invitation were Dr. Christine Hahn (Idaho),
Dr. Randall Reves (Denver), Ms. Denise Ingman (Montana), Ms. Kristin
Rounds (South Dakota), Ms. Pat Infield (Nebraska), and Mr. Walt
Page, Executive Director of the National TB Controllers Association
(NTCA). Two DTBE Program Consultants, Andy Heetderks and Scott Jones,
were in attendance as well; they presented a brief update on CDC
activities and discussed the FY 2002 Cooperative Agreement. The
TB Control Officers from Utah and North Dakota had been invited
but were unable to attend.
The agenda for this meeting is similar in format to the Midwestern
and Southeastern TB Controller Conferences. Each TB Controller presented
a program overview with emphasis on a particular aspect. For example,
the Nebraska and South Dakota TB controllers emphasized the impact
of refugee resettlement on programs with limited resources, which
prompted a helpful discussion of approaches and strategies from
the other participants.
All attendees voiced their appreciation for the opportunity to meet
as a region. Some stated that a regional focus was very helpful,
in that suggestions and solutions were immediately transferable
between states with similar challenges. A tentative agreement was
reached to meet again next year; Ms. Ingman of Montana volunteered
to act as host for the second annual Northern Rocky Mountain TB
—Reported by Scott Jones
Division of TB Elimination