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TB Notes 3, 2001

International Updates

International Activities in Peru

In August 2000, the Bill & Melinda Gates Foundation awarded a 5-year grant of $44.7 million to the collaborating group PARTNERS (Partnership Against Resistant Tuberculosis: A Network for Equity and Resource Strengthening). This collaboration is made up of the National Tuberculosis Program of Peru, the Program in Infectious Disease and Social Change and Partners in Health at Harvard Medical School, the World Health Organization, the Task Force for Child Survival and Development, and CDC. The goals of this collaboration are to 1) demonstrate in one country (Peru) the success of an integrated TB control program that can contain drug-resistant TB; 2) develop the infrastructure necessary to support this program model and make it exportable to other settings where drug-resistant TB is a problem; 3) export this program model and evaluate its effectiveness in at least one other hot spot of drug-resistant TB; and 4) help develop an integrated TB control model that can support a WHO/CDC–led strategy for global TB elimination. 

CDC activities in this partnership to date have included members of International Activities (IA), the Research and Evaluation Branch (REB), and the Communications and Education Branch (CEB). Together, we have contributed to the development of studies to 1) examine and compare individualized and standardized regimens; 2) examine contacts of MDRTB cases; 3) evaluate prognostic factors for death of MDRTB patients, including the role of HIV infection; and 4) evaluate the cost-effectiveness of different MDRTB regimens and treatment strategies. Through this partnership, CDC is also participating in the development of a core data set with consistent definitions for the collection of MDRTB data globally. We are also planning to participate in the organization of a workshop or meeting to discuss operational research needs for this project and for MDRTB control and management in general. Finally, CDC has participated in the assessment of infection control needs in hospitals in Lima, Peru.



—Reported by Kayla Laserson, ScD
Division of TB Elimination


CDC Technical Assistance in Three Russian Oblasts

1. Ivanovo Oblast

CDC, the World Health Organization (WHO), and the US Agency for International Development (USAID) officially assumed responsibility for support of the basic directly observed therapy, short-course (DOTS) program in Ivanovo Oblast as of January 1, 2000. (An oblast is comparable to a US state.) CDC staff provided training during the first two quarters, and also developed and implemented an incentive program for patients and employees. As a result of the implementation of the incentive program, significant improvements are being seen in patient outcomes (increased cure and completion rates) and decreased default rates.

One of the most significant forms of technical assistance provided by CDC staff is training. In February 2001, a CDC laboratory consultant taught a course in basic mycobacteriology, assembled and demonstrated the use of new equipment delivered by WHO, trained staff, and provided laboratory evaluations at the oblast dispensary. The topics covered in the course were specimen collection, acid-fast microscopy, isolation by culture, drug-susceptibility testing, laboratory safety, and quality assurance. CDC staff also made arrangements for a laboratory consultant from the State of Florida to stay in Ivanovo during the months of February and March and work onsite with Ivanovo staff to improve their skills and assist with laboratory methods. The outcome has been excellent in terms of improved validity of drug susceptibility testing results. CDC coordinated the work of the consultant there with ongoing project activities, and is working to implement her recommendations. CDC has also been actively planning an infection control course. Masks were procured and will be provided to the oblast lab and medical staff in preparation for the course.

CDC, WHO, and USAID began evaluating cohort performance as of July 1, 2000. New patients are now enrolled in the DOTS program under the new CDC / WHO / USAID DOTS protocol. DOTS performance outcomes have begun to improve in the Ivanovo Oblast due to intensive supervision.

Summary for patients enrolled in the second quarter of 2000: out of 170 patients, 125 completed and were cured (73.5%), 15 died (8.9%), 15 failed treatment (8.8%), 10 defaulted (5.9%), and 5 transferred out (2.9%). The newly implemented incentive program has significantly increased the percentage of patients completing treatment. Preliminary data indicate an 81.3% success rate for patients registered in the third quarter of 2000 in Ivanovo city. The region began working with the prison sector during the second quarter of 2001.

2. Orel Oblast

The project was initiated on October 1, 1999, with plans to gradually phase in all patients over the course of a year. New and retreatment patients from both the civilian sector and the prison sector are being registered and managed in accordance with the DOTS program. Also, a DOTS-Plus project is to be launched in Orel in January 2002.

CDC again provided the basic mycobacteriology course that was taught in Ivanovo, assembled and demonstrated new equipment delivered by WHO, trained staff, and provided laboratory evaluations at the oblast dispensary from February 24 to March 9, 2001. Data continue to indicate that the Orel site is implementing the WHO TB control strategy very well. CDC, WHO, and USAID are giving strong consideration to establishing the Orel site as a training center for other regions in Russia that are or will be implementing the WHO TB control strategy.

Summary data from the Orel Oblast provide the following for the first and second quarter of 2000 for all smear-positive patients, including Category II patients in the civilian and prison sectors: out of 172 patients, 121 completed and were cured (70%), 10 died (5.8%), 16 failed treatment (9.3%), 8 defaulted (5.6%), 4 transferred out (2.3%), and 13 are continuing treatment with the outcome pending at this time (7.5%). It is expected that the patients with a pending outcome will have a successful one, which will increase the total success rate to 78% (134 patients). These outcome results are exceeding expectations, considering that new treatment regimens for Category II patients have not been implemented during this cohort period. Orel Oblast continues to document the viability of a successful DOTS project in Russia with few additional resources. Success rates among new pulmonary cases range between 75% to 78% for smear-positive patients and 85% to 86% for all patients. A drug-resistance survey was initiated in August and is now completed. The results have been shared with WHO and the region. The combined level of MDRTB among civilian and prison TB cases without prior history of treatment is 3.7%; however, among retreatment cases the combined MDRTB level is 30%.

3. Vladimir Oblast

The DOTS project was initiated on October 2, 2000, with plans to gradually phase in patients over the course of a year, including new and retreatment patients. Over 300 patients were registered into the program in the civilian sector during the first two cohorts and 114 patients were registered in the prison sector in the first cohort. Overall, physicians in the civilian sector are following the treatment protocol correctly; however, in the prison sector there were some systematic deviations. After the last monitoring mission there were still many unresolved issues that had been raised previously in this oblast. CDC recommended making concrete short-term and long-term plans for addressing the most pressing issues (connecting laboratory equipment, improving drug management practices, identifying a mechanism to implement patient incentives and enablers) by the end of June 2000. Other issues that need special attention in this oblast include improving smear microscopy performance, timeliness in reporting from the raion to the oblast level (a raion is a district or municipality, comparable to a US county), improving case management, and providing additional training of prison physicians.

A patient incentive plan was drafted and is currently being evaluated by the oblast administration. In February 2001, laboratory technicians from the Vladimir Oblast attended the 5-day training course in basic mycobacteriology that was taught in Ivanovo. The CDC laboratory consultant also supervised the presentation of a 3-day course on acid-fast microscopy held by the Vladimir Oblast Dispensary Laboratory staff for raion laboratory staff.



—Reported by Gustavo Aquino, MPH
Division of TB Elimination


The New LIFE Act and Impact on US Health Departments

Background
The Legal Immigration Family Equity (LIFE) Act was introduced by Hal Rogers (R-KY), Chair, House Appropriations Subcommittee on Commerce, Justice, State, and the Judiciary in 2000. It was passed as H.R. 5548 on December 21, 2000. The purpose of the LIFE Act is to encourage immigrant family reunification. There are several elements of this new law, but the facet of the LIFE Act that relates to public health is the addition of a new nonimmigrant visa (NIV) or temporary status category (V visa) for spouses and dependent children of permanent residents (green card holders) who have been waiting 3 years or longer for their permanent residence. A number of other NIV applicant categories already exist, including visitors (B visa), students (F visa), temporary workers (H, J, and L visas), and fiancées (K visa). 

The underlying intent of the LIFE Act is to reunite families that have been or could be subject to long periods of separation during the process of immigration to the United States. It also addresses the current INS backlog for approving family-based petitions. For any family member to be eligible for the new V status, he or she must satisfy the following three criteria:

  • Be the spouse or unmarried child (younger than 21 years of age) of a permanent resident.

  • Have the family-based petition filed with INS on or before December 21, 2000.

  • Have the family-based petition awaiting INS approval for at least 3 years, or have the petition approved by INS but 3 years have passed since the filing date of the petition and no green card has been issued.

Therefore, the total number of people eligible for V status will not be determined until December 21, 2003.



Impact on US Health Departments
Most NIV applicants, such as visitors (B visa), students (F visa), and temporary workers (H, J, and L visas) are not required to have a medical examination before coming to the United States. However, the fiancée (K visa) applicant, whose visa implies that he or she is coming to the United States to live permanently, is required to have an overseas medical examination. Using this precedent, the law requires that those people outside of the United States and eligible for the new V status have an overseas medical examination by a panel physician. Panel physicians are those local physicians who have been designated by a US embassy or consulate to perform the medical examination for immigration purposes. The examination will include all elements of the medical examination required for immigrants (for example, screening for TB, human immunodeficiency virus, syphilis, and certain mental disorders). However, because these people are applying for V status, immunizations will not be required until they apply for adjustment of status within the United States. The INS has also indicated that regulations for those already in the United States and eligible to change to V status will require that a medical examination be performed by an INS-designated physician (civil surgeon). However, the INS is still in the process of developing the regulatory guidance addressing this issue.

Many of the V visa applicants will be coming from countries with TB incidences that are higher than the United States incidence (see table). As it does with other foreign-born people receiving an overseas TB classification (Class A: acid-fast bacilli smear positive, suggestive of active TB; Class B1: acid-fast bacilli smear negative, suggestive of active TB; or Class B2: suggestive of inactive TB), the Division of Global Migration and Quarantine (DQ) will notify receiving health departments of the TB classifications of these people as they arrive. DQ is currently in communication with US consulates and embassies and with the INS to find the best method of identifying V visa applicants with Class A and Class B TB conditions when they enter the United States. Furthermore, DQ is communicating with the Department of State and INS about the lack of an alien number for these V visa applicants and what can be used as a replacement.

Table. Posts Expecting to Process >1,000 V Visas:

Region
           Post
Min. Expected Numbers
1999 WHO TB Rate* for All Types
Africa
Accra, Ghana 1873 281
Addis Ababa, Ethiopia 1305 373
Lagos, Nigeria 1753 301
Asia
Guangzhou, China 3933 103
Ho Chi Minh City, Vietnam 2264 189
Manila, Philippines 6958 314
Latin America/Caribbean
Bogota, Colombia 1954 51
Ciudad Juarez, Mexico 206,667 39
Georgetown, Guyana 1722 101
Guatemala City, Guatemala 2391 85
Guayaquil, Ecuador 2231 172
Havana, Cuba 1967 15
Kingston, Jamaica 3664 8
Lima, Peru 1367 228
Port au Prince, Haiti 6267 361
San Salvador, El Salvador 4758 67
Santo Domingo, Dominican Republic  14,596 135
Tegucigalpa, Honduras 2415 92
Indian Sub-continent
Dhaka, Bangladesh 3435 241
Islamabad, Pakistan 2162 177
Mumbai, India 1387 185
New Delhi, India 1375 185
Eastern Europe
Warsaw, Poland 3791 39
Other Posts 16,622
Total 296,857

*Rate: Reported incidence of all types of TB per 100,000 population. Source: World Health Organization. Global Tuberculosis Control. WHO Report 2001.WHO, Geneva, Switzerland.

These new V visa applicants will need to have immunizations at the time they adjust their statuses to permanent residency. Because more than a year will probably pass from the time the V visa is issued and permanent residence is applied for, these V visa holders will be required to undergo another medical examination by an INS-designated civil surgeon in the United States.

To date, almost 7,000 V visas have been issued in Ciudad Juarez, Mexico; 2,000 in Santo Domingo, Dominican Republic; and almost 700 in Manila, the Philippines.



—Submitted by Mary Naughton, MD, MPH, Pam Copelan, and Susan Cookson, MD
Division of Global Migration and Quarantine

 


Released October 2008
Centers for Disease Control and Prevention
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