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CDC Telebriefing Transcript
World TB Day 2002: New Data on TB Epidemics Worldwide

March 21, 2002

CDC MODERATOR: Good afternoon, all. On the eve of World TB Today our topic for today's call is going to be the impact of TB.

Joining us is Kenneth Castro, M.D., and his last name is spelled C-a-s-t-r-o. He is the director of CDC's TB Elimination Program. He will make a few brief remarks, and then he will it over to Dr. Lorna Thorpe who is a Ph.D. Her name is spelled L-o-r-n-a, for the first name, and her last name is T-h-o-r-p-e. She is the lead author on this week's MMWR article.

After their presentations, both the speakers will be available to answer your questions.

I am now going to turn it over to Dr. Castro. Ken.

DR. CASTRO: Thank you very much, Cynthia, and good afternoon to all of you who've joined us today, and thank you for calling in.

In commemoration of this year's World Tuberculosis Day, we have dedicated a notice to readers, and two articles in this week's issue of the "Morbidity and Mortality Weekly Report." For the ninth straight year in a row, the number of people suffering with tuberculosis in the United States has decreased to an all-time low.

According to provisional tuberculosis surveillance data received by CDC from all 50 states and the District of Columbia, a total of 15,991 persons were reported with tuberculosis in 2001. This is a decrease of 2 percent since the year 2000.

While this single yearly change does not constitute a trend, it provides an early warning of the possible stagnation of recent progress towards the elimination of tuberculosis in the United States.

This latest decrease highlights the progress we've made in reducing tuberculosis in the United States.

Over an 8-year period, from 1992 to 2000, the number of new tuberculosis cases decreased an average of 7 percent per year. But from 2000 to 2001, this rate of decrease slowed to 2 percent.

This slowing of the decline is concerning, especially when coupled with a few troubling trends which have emerged in recent years, and underscore the continued challenges to eliminating tuberculosis in the United States.

First, we have seen an increasing concentration of tuberculosis among foreign-born individuals living in the United States.

This reflects the global nature of tuberculosis as a serious health problem and points to the fact that we have to address tuberculosis across the world in areas where the incidence is highest.

In the year 2000, the World Health Organization identified 23 high-burdened countries which account for 80 percent of all tuberculosis cases in the world.

The second observation is we have also seen the need to promptly respond to multiple tuberculosis outbreaks in low-incidence communities in the United States, many of which [inaudible] not seeking treatment expertise because of the relative of tuberculosis in these communities. This points to the importance of maintaining expertise in every community in order to ensure that tuberculosis is quickly and correctly addressed when an outbreak does occur.

The two articles in today's issue of the "Morbidity and Mortality Weekly Report" touch on each of these two issues that I have mentioned, and I'd like, now, to turn the call over to Dr. Thorpe who will describe, in more detail, the substance of these articles. Over to you, Dr. Thorpe.

DR. THORPE: Thank you, Ken.

In the United States half of all TB cases are among foreign-born people, which underscores the fact that we need to address TB globally in order to reduce TB here at home.

India has one of the greatest TB burdens in the world and its progress towards TB control has direct implications for TB elimination efforts in the U.S.

Here, in the year 2000, nearly 10 percent of foreign-born TB cases were from India. Only people from Mexico, the Philippines, and Vietnam are more frequently diagnosed with TB in the U.S.

In India, 2 million people are diagnosed with TB annually, accounting for almost one-fourth of the world's new TB cases. In today's MMWR, the government of India and CDC review progress made towards controlling one of the world's largest TB epidemics.

This review comes four years after a large-scale implementation of a revised national TB control program. The impact of India's expanded TB control program has been remarkable.

As of November 2001, the TB control program has reached more than 40 percent of India's population, and that means over 440 million people.

This is up from less than 2 percent in mid 1998, and treatment results under the TB program have been very good.

Over 80 percent of the patients are being successfully treated and the death rate among TB patients in areas served by the program has dropped to 4 percent compared to previous estimates of 29 percent.

We attribute India's success to their expanded use of the following principles: observed therapy; secure supply of TB drugs; improved diagnostic tools; and the use of a disease surveillance system that can easily track the number of TB cases and treatment outcomes.

However, India still faces many challenges, most notably the level of poverty.

Economic hardships often force large-scale migration, reducing people's ability to complete TB treatment. And without a regular supply of electricity, laboratory diagnostic services are often limited.

HIV is also seriously impacting India. As the virus spreads, the TB epidemic will increase and may become uncontrollable in some areas.

Another major threat is drug resistance and the difficult-to-treat multi-drug resistant TB is present and possibly increasing in several areas of the country.

Overall, the CDC strongly supports the continued expansion of India's revised TB control program, which confirms that high quality diagnosis and patient management is feasible, even in countries with the highest burden of TB.

But now let's move back to the United States. Although the incidence of TB in the U.S. is low on a global scale, we are facing important challenges that threaten our efforts to eliminate TB domestically.

Let me turn to another example in today's MMWR. Recently, the CDC assisted with a TB outbreak investigation on the Fort Belknap Indian reservation in Montana. In the initial investigation conducted, after a patient with infectious TB was diagnosed, local health care providers identified only one secondary TB case among screened contacts. A secondary TB case is a person who catches TB from the infectious index patient.

Subsequently, three additional cases of TB occurred, and these are among individuals missed by the initial investigation, when it was focused primarily on family members.

Further analysis revealed that all of the secondary TB cases were regular drinking partners of the index-patients, and the contact investigation focus was then quickly shifted.

The investigation team also reviewed the clinical management of the five TB patients, and revised their treatment so that it would meet current recommendations.

The reservation has not diagnosed any further cases of TB since then. In Fort Belknap, where only one case of TB had been reported in the prior eight years, health care providers were very quick to recognize that their knowledge was limited and they requested assistance early in the investigation from federal and state public health officials in order to bolster their TB control skills.

As a result, the local providers rapidly improved their clinical management in TB control practices and they were able to effectively manage the outbreak on their reservation.

This collaboration described in the MMWR demonstrates how rapid expansion of local capacity can be achieved in low-incidence settings where expertise may have waned due to lack of familiarity with the disease.

This rapid search capacity is a critical component of the strategy to eliminate TB in the United States.

And I would like to turn the call back over to you, Ken.

DR. CASTRO: Thank you, Lorna, for providing us with the summary of the article that appeared in the "Morbidity and Mortality Weekly Report." I'd like to ask John to move over to the question-and-answer session, and ask John, our moderator, to let us know who's on the line and we'll take them from here. Thank you.

AT&T MODERATOR: And ladies and gentlemen, once again, if you do have a question at this time please press one. You'll hear a tone indicating you've been placed in queue. You may remove yourself from queue at any time by depressing the pound key.

Once again, if you have a question please press the one. And we have a question from the line of Ted Vigodsky from Public Broadcasting. Please go ahead.

MR. VIGODSKY: Thank you, Dr. Castro and Dr. Thorpe. I'd like to ask this question, two parts.

Could you update us on the CDC efforts to enhance directly-observed therapy programs through the grant that you did, for instance, the big grant you provided New York City some years ago when the epidemic was going full bore, and then if you could say anything about any new generation of antibiotics to address the ongoing concerns about multi-drug resistance in tuberculosis. Thank you.

DR. CASTRO: Thank you, Ted.

CDC has continued throughout the last several years to provide resources that are appropriated by Congress to state and local health departments tuberculosis programs. These programs have been using a lot of these resources to hire outreach workers and provide directly-observed therapy for persons with active tuberculosis.

The reasons for relying on the direct observation of treatment is because we know that adherence to a long-term regimen is very poor and it's not predictable.

In other words, any person, whether a physician, or a worker in any place, is not likely to completely a long term of treatment, in this case requiring at least six months, we have seen that these directly-observed treatment programs tend to work best when they are coupled with the ability to provide referrals, and what we call incentives and enablers.

In other words, making clinic hours more friendly to the individuals, and also making sure that there's access to transportation for those who may not have access to transportation.

The resources received by CDC in year 2002 were around $132 million. A majority of that, about 90 percent, goes directly out to state and local health departments' TB programs.

You were asking also about the new generation of antibiotics for the treatment of tuberculosis.

I should start by saying that the currently available antibiotics are, by far, the best in curing people with drug-susceptible TB, that is tuberculosis strains that are not resistant to any antibiotics. Using the four drug regimens that rely on isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin, achieve cure rates that exceed the 95 percent rate.

In other words, you expect to have fewer than 3 percent relapses or failures if people take these drugs the way they're supposed to be taken.

So that's what, the best available. The second-line drugs are called second line because they're less effective and more toxic, and we only want to rely on them when the other drugs are not very useful, and that's usually in the case of drug-resistant strains.

In some studies, we've seen a new generation of long-acting rifamycin, rifapentine, appears to be useful, and also the family of fluoroquinalone antibiotics seems to provide quite a bit of promise in the treatment of persons with drug-resistant TB, and within the fluoroquinalones we have ciprofloxacin, gatifloxacin, sparfloxcin. So there's a whole number and host of new antibiotics that are being tried for these persons.

We are hopeful that the new efforts of the Global Alliance for Research into the development of new drugs [clarification: referring to The Global Alliance for TB Drug Development] will identify even better antibiotics, but nothing has panned out yet, and what we would be hopeful, that could be accomplished, is a reduction in the time to cure persons with TB and achieving at least the same cure rate that I was able to mention for the existing drugs.

I hope that addresses those questions and I apologize for the relative length of the answer, but I thought it was necessary go to into some of the background for both of these questions.

CDC MODERATOR: Can we have the next question, please?

AT&T MODERATOR: Certainly, and that's from Asafi Kadree [ph] with the Atlanta Samachar [?] Press. Please go ahead.

MR.Kadree : Hi, this is actually Matthew from the Atlanta Samachar. Our question, we had about--we had two questions. First, is the CDC going to be communicating with the INS on possibly changing standards, entry standards for people from countries like India and Mexico on pre-testing requirements, and the other question is has the Indian government shown any interest in working with the CDC on educating people about the TB results from your recent testing?

DR. CASTRO: Okay. Thanks for the question. Let me start, and I might ask Dr. Thorpe to touch on the second question.

We are working with INS and the Division of Immigrant Health Services, housed out of the Human Resources and Services Administration, also known by their acronym, HRSA, to not change the entry standards but make sure that the medical evaluation that is supposed to take place for those who apply to enter the United States as immigrants or refugees is done well, and that the follow-up is done as recommended, and promptly.

The other aspect that we've been discussing with our advisory council is making sure that we find ways to improve the completion of treatment for INS detainees who, you know, may be in the process of being deported but are being treated for tuberculosis, and we feel that it's crucial to make sure that they complete therapy since there's a public benefit to that effort.

The second question, Is the Indian government interested in working with CDC to improve educational efforts?

The report that appears in this week's "Morbidity and Mortality Weekly Report" is, indeed, the result of a collaboration between the national Indian tuberculosis program and CDC as well as the World Health Organization, joining forces to help implement the strategies to control tuberculosis, and as part of that we believe that an important contribution would be building local capacity to achieve tuberculosis control using the available drugs and monitoring the results.

I visited India recently and I know that Dr. Thorpe was there as part of the work that's being reported in this week's MMWR and I can tell you that sometimes it's quite awesome to see the type of educational campaigns using public media, using poster boards, et cetera, to get the message to the public that if you have a chronic cough, it could be TB and you need to be medically evaluated.

Let me ask if Dr. Thorpe has any other comments based on her own experience, having visited India last year.

DR. THORPE: I'd just like to second Dr. Castro's comments. The Indian Ministry of Health and Family Welfare has really done a remarkable job, especially in the last four years, making education a primary component of its revised national TB control program, and they're working very closely with the World Health Organization, and the CDC often works together with the WHO and the Ministry of Health, to make sure that education remains a priority, and you do see a lot of information about tuberculosis in the areas where the RNTC [Revised National Tuberculosis Control Programme] has been expanded to. You see it in the streets and you see it in high-quality literature and pamphlets, and in the clinics, as well as a very educated staff is addressing TB to the patients.

This is a very, very important component of TB, especially where a lot of TB in India is being diagnosed in the private sector, and the larger awareness that is put out around TB also sort of permeates the private sector. It permeates quality into the privates sector treatment.

CDC MODERATOR: Next question.

AT&T MODERATOR: And that's from the line of Karen Jacobs with Reuters. Please go ahead.

MS. JACOBS: Hi. I just had a general question, and I was just wondering if you see the resources for tuberculosis control being curtailed in the U.S. or elsewhere in the world?

DR. CASTRO: The resources for tuberculosis control in many parts of the world have been grossly inadequate, and if you look at the writings of the World Health Organization and reports, they have identified the single most important need is to achieve the political commitment by the decision makers to consider tuberculosis a priority in countries where this public health problem is highly endemic and to make the commitment to implement programs that would make sure that people who have TB get identified and offered the drugs till they get cured, and, in fact, there's a global effort called the Stop TB Initiative, housed out of the World Health Organization and one of their recent efforts was to bring together the ministers of Health of these 23 high-burdened countries. And in that process they made a commitment to indeed consider tuberculosis a high priority and as part of this, WHO is trying to leverage donor support to make sure that high-quality drugs are purchased, are made available, and avoid stockouts which have been known to happen when people get started on TB drugs.

In the United States, we had resources for tuberculosis increased back in 1992 and they remain more or less level over the last several years. With those resources, we've prioritized the recommendations for the elimination of tuberculosis and have implemented what we can with those resources provided to us.

CDC MODERATOR: Can we take the next question, please?

AT&T MODERATOR: And just a quick reminder, ladies and gentlemen, if you do have a question please press the one at this time.

And Ms. Glocker, there are no further questions in queue.

CDC MODERATOR: Okay. Thank you, everybody, for joining us today. If by any chance you were unable to ask a question, please give us a call at [404] 639-8895, and we'll be able to have one of the scientists talk to you immediately. Thank you for joining us today, again.

AT&T MODERATOR: And ladies and gentlemen, that does conclude your conference for today. Thank you for your participation and you may now disconnect.


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