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No.1, 2006

Dear Colleague:

After the challenges of this past fall, I hope the holidays left you rested and with renewed energy to tackle the new year. Please accept my best wishes for 2006 and for the new opportunities we will have to continue our progress in eliminating tuberculosis.

The 2005 Program Managers Course was held October 24–28, 2005, at the Sheraton Colony Square Hotel in Atlanta, Georgia. About 40 persons attended the course this year. Next year the Division of Tuberculosis Elimination (DTBE) will add a section on laboratory issues, which will be an important enhancement to this training course with excellent reviews. I would like to take this opportunity to thank the course instructors and organizers for their outstanding efforts in making this training course such a successful event. Much planning and hard work goes into the development and presentation of these training sessions. Those involved are deserving of our thanks and appreciation for taking on this important task each year.

The Advisory Council for the Elimination of Tuberculosis (ACET) met on November 16 and 17, 2005, in Atlanta, Georgia. After the welcome by Drs. Masae Kawamura and Ron Valdiserri, ACET heard updates on recent activities of DTBE and of the National Center for HIV, STD, and TB Prevention (NCHHSTP). Dr. Valdiserri reported that Dr. Janet Collins, who had served as Acting Director of NCHHSTP since June 2004, was named Director of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) in August 2005, and that a permanent NCHHSTP director would be named in November. We have since learned that Kevin Fenton, M.D., Ph.D., has been selected as Director of NCHHSTP. Dr. Fenton has been serving in the Division of STD Prevention as Chief of CDC’s Syphilis Elimination Effort since January 2005, and has worked in research, epidemiology, and the prevention of HIV and other STDs since 1995. Dr. Fenton was previously the Director of the HIV and STI Department at the United Kingdom’s Health Protection Agency. We welcome Dr. Fenton to this new position and look forward to working with him in the important work of our center.

Dr. Michael Iademarco gave the DTBE Director’s Report in my absence. He reported that DTBE had completed eight Epi-aids in 2005, three of which involved Hmong refugees in Thailand and in California. He reported that in preliminary evaluation findings for the U.S.-Mexico Binational Card project, political will remains strong in support of the project. The evaluation has led to improvements, and the project is expanding to new sites; but insufficient funding is a critical constraint. He reported that a number of DTBE guidelines were at or near completion (they have since been published): the latest statement on controlling tuberculosis in the United States came out in November 2005 in the Morbidity and Mortality Weekly Report (MMWR); guidelines on the use of QuantiFERON-Gold, on conducting contact investigations, and on preventing the transmission of M. tuberculosis in health care settings were published in December in the MMWR. Please see the “New CDC Publications” section of this issue for the citations of these publications. Recommendations on managing TB in correctional settings are expected in 2006. We heard a report from Mr. Joe Posid of the Bioterrorism Preparedness and Response Program within the Coordinating Center for Infectious Diseases (of which NCHHSTP is now a part) on CDC activities related to assessing biological agents of public health importance. With CDC working in concert with the Department of Homeland Security and DHHS, these activities will result in an updated list of potential biological terrorism agents, which should be finalized in 2006.

Dr. Valerie Robison, DTBE’s surveillance team leader, gave an update on CDC’s TB surveillance systems, and Dr. Tom Navin, chief of the Surveillance, Epidemiology, and Outbreak Investigations Branch, provided information on new TB surveillance initiatives. These include the development and release of the Online TB Information System (OTIS), a Web-based national TB surveillance dataset that allows individual researchers to generate TB surveillance reports; a system for reporting adverse events caused by any LTBI treatment; the availability of genotyping for outbreak detection; the revision of the Report of Verified Case of Tuberculosis (RVCT); and the data accuracy project.

ACET heard reviews of three articles. First, Dr. Dick Menzies of the Montreal Chest Institute in Canada gave a summary of the article, “Domestic returns from investment in the control of tuberculosis in other countries”; Drs. Kayla Laserson of DTBE and Susan Malone of the Division of Global Migration and Quarantine (DGMQ) were co-authors. The analysis showed that U.S.-funded expansion of national TB program DOTS programs in high-incidence countries such as Mexico would reduce TB-related illness and deaths among migrants, with net savings to the United States. This is based on the concept that U.S. financial assistance provided to the national TB programs of TB-prevalent countries will help decrease the burden of TB in those nations; this will reduce the number of TB-infected persons from that country migrating to the United States, and this will ultimately reduce TB and TB control costs in the United States. Next Dr. Henry Blumberg, Hospital Epidemiologist of Grady Hospital in Atlanta, discussed “How many sputum specimens are necessary to diagnose pulmonary tuberculosis?” Dr. Blumberg presented data showing that in the high-risk, inner-city patient population at Grady, the number of specimens needed to diagnose pulmonary TB disease may be reduced from three to two; a third smear did not appear to add much information in a robust TB-oriented health-care setting with excellent quality infection control systems in place. This was followed by a related discussion by Dr. Sundari Mase, a physician from California, on the yield of two vs. three AFB sputum smears for evaluating pulmonary TB suspects. Her review suggested that the mean incremental yield of a third smear is 3%–5%; if the yield of the first and second smears is improved, the yield of the third would be even lower. She pointed out that requiring only two smears would involve less work for the laboratory, fewer costs, and more time to perform the two smears. The “cons” would be decreased case detection and increased transmission, resulting in TB infection. Proposed next steps were to study the policy implications of two vs. three sputum smears and to review the WHO case definition of smear-positive pulmonary TB.

Dr. Bill Burman of Denver Public Health and a member of the TB Trials Consortium presented an exciting talk on opportunities and challenges in TB clinical trials for the next decade. He suggested that promising new anti-TB agents may permit reduction in the length of TB treatment from 6 months to 2 if clinical trials could be adequately funded. After an exchange of comments and questions, ACET members decided to draft a letter to the Secretary of DHHS advocating for additional funding for multiple TB control components, including clinical trials. We then heard from Ms. Kimberly Lane, senior advisor to the Chief Management Official of CCID, who reviewed CDC’s reorganization and discussed the proposed new design of CCID.

Dr. Charles Wells gave an overview of USAID’s Tuberculosis Country Assistance Program (TB CAP), which is a follow-up project to the TB Coalition for Technical Assistance. TBCAP is a 5-year project based on a partnership between USAID and several international organizations, including the KNCV, ALA, ATS, WHO, CDC, and IUATLD. Its main components consist of advocacy and social mobilization, DOTS expansion, laboratory capacity building, TB/HIV services, and training and human resource development; its strengths are that it is an effective mechanism for coordination among TB organizations, it reduces duplication of efforts, and it allows close management of activities and high accountability for partners. Dr. Iademarco then discussed a USAID-funded and -sponsored project that has the goal of developing a set of international standards for TB care. The focus or intent is to ensure high-quality treatment for all patients in all settings. These standards will call for a level of care above the current WHO standards. A number of follow-up items were addressed, after which the meeting was adjourned. The group will reconvene in February 2006.

From October 17 to 23, 2005, DTBE staff attended and participated in the 36th World Conference on Lung Health, the annual meeting of the International Union Against Tuberculosis and Lung Disease (IUATLD), in Paris, France. The theme was “Scaling up and sustaining effective tuberculosis, HIV, and asthma prevention and control.” CDC was well represented in the planning and organization of the meeting and in the outstanding presentations that were given. This meeting provided DTBE staff with the opportunity to contribute to global TB prevention and control efforts through ongoing collaboration with the Union, Stop TB, and other national TB prevention programs. As discussed during the last ACET meeting, recent publications have highlighted the importance of global TB control to the fulfillment of our domestic goals (Schwartzman K, Oxlade O, Graham Barr R, et al. Domestic returns from investment in the control of tuberculosis in other countries. N Engl J Med 2005; 353: 1008-1020; and Bloom BR, Salomon JA. Enlightened self-interest and the control of tuberculosis. N Engl J Med 2005; 353: 1057-1059).

Please note that the 2006 National TB Controllers Workshop will be held June 13 to 15, 2006, in Atlanta at the Sheraton Buckhead Hotel. Details will be forwarded as they become available. Hope to see you there!

Kenneth G. Castro, MD

 

 

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