TB Notes Newsletter
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No. 1, 2006
Beginning in 1953, through the cooperation of state and local health departments, CDC has been collecting information on the numbers of newly reported cases of TB disease in the United States. Since its initial publication in 1963 (then entitled Reported Tuberculosis Data, and now Reported Tuberculosis in the United States), the annual summary of TB surveillance has been revised periodically to improve the interpretation and dissemination of TB surveillance data. Reported Tuberculosis in the United States, 2004 features the following methodological changes:
- In contrast to previous annual summaries in which TB case counts
of preceding years were not updated, the current summary reports
the number of cases of confirmed TB for each year from 1993 to
2003 based on updated information. Therefore, case counts for
these years may differ from those reported in the annual summaries
- Tables 1–5, 20, 28, and 46, in addition to case count
(numerator) updates, apply population updates (denominator) to
calculate TB case rates for 1993–2004.
- The method for calculating the annual percentage change in the TB case rate was modified. In contrast to methods used in previous summaries, “unrounded” figures are now applied to calculate the percentage change in the case rate, lending a degree of precision and accuracy greater than those reported in the past.
Other notable changes and enhancements are as follows:
- The slide set for Reported Tuberculosis in the United States,
2004, can be directly downloaded into PowerPoint format at http://www.cdc.gov/tb/pubs/slidesets/surv/
- Slide sets for 1997–2003 can also be directly downloaded
into PowerPoint format at http://www.cdc.gov/tb/pubs/slidesets/surv/default.htm.
- Addition of a technical note to clarify a point of confusion generated by a note from the 2003 report, in which two new species were added to the M. tuberculosis complex.
Statistical highlights of Reported Tuberculosis in the United States, 2004, include the following:
- 14,517 TB cases were reported to CDC from the 50 states and
the District of Columbia, representing a 2.3% decrease from 2003
- Foreign-born persons constituted 54% of the total number of
cases in the United States in 2004
- The TB case rate declined to 4.9 per 100,000
- 19 states reported increases in case counts
- For the first time, Hispanics exceeded blacks as the racial/ethnic
group with the largest percentage of all cases: 29% vs. 28%
- U.S.-born blacks represented 45% of TB cases in U.S.-born persons
and more than one fifth of all cases
- The TB case rate was 2.6 per 100,000 for U.S.-born persons
and 22.8 for foreign-born persons
- Asians continue to have the highest case rate among all racial
and ethnic groups
- The proportion of all cases with primary multidrug-resistant TB remained approximately 1.0%, and the proportion of these cases occurring in foreign-born persons increased to 73%
Reported Tuberculosis in the United States, 2004, released October 2005, is available in hard copy and is posted on the Internet at http://www.cdc.gov/tb/surv/default.htm).
Following are suggested citations for hard copy and online versions:
Hard copy: CDC. Reported Tuberculosis in the United States, 2004. Atlanta, GA: U.S. Department of Health and Human Services, CDC, September 2005.
Online: Centers for Disease Control and Prevention. Reported Tuberculosis in the United States, 2004 [online]. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2005. Available at http://www.cdc.gov/tb/surv/surv2004/default.htm.
—Reported by Valerie Robison, DDS, MPH,
Div of TB Elimination
Background. The Biotechnology Engagement Program (BTEP) is a congressionally mandated program residing in the U.S. Department of Health and Human Services (DHHS), Office of Global Health Affairs.1 The BTEP enables former biologic weapons scientists from Russia and Northern Eurasia to work collaboratively with U.S. experts in conducting operational research that addresses critical in-county public health concerns using evidence-based science. BTEP projects are funded for 12–36 months. Priority diseases funded through BTEP include TB, HIV/AIDS, hepatitis, influenza, other infectious diseases, and food and waterborne diseases.
CDC staff, in collaboration with the Ministries of Health in the Republics of Armenia and Georgia, developed a TB BTEP project described in TB Notes No.1, 2003, called the “Development of Multiple-drug Resistant Tuberculosis Surveillance and National TB Program Evaluations, Republics of Armenia and Georgia.” This project, which was awarded 3 years of funding effective October 2004, consists of the nine tasks further described in TB Notes No. 2, 2005. Tasks 1 (description of TB surveillance system in Armenia) and 2 (evaluation of current TB surveillance system in Armenia) have been completed. Task 3 is to assess the prevalence of M. tuberculosis in the Republic of Armenia because of uncertainty around current estimates.
TB in Armenia. Armenia has a 3.2 million population2 and is located between Turkey, Georgia, Iran, and Azerbaijan. It is divided into 11 administrative regions (or marzes), with over a third (36%) of the country’s population residing in the capital of Yerevan. The collapse of the former Soviet Union in 1991 and subsequent social, political, and economic transitions have had a negative impact on health and healthcare in the newly independent states (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan). Population migration, decreases in life conditions, lack of essential health care services, and lack of access to essential drugs3 have created conditions favorable for the rise and spread of infectious diseases, including TB.
Before the collapse of the Soviet Union, TB surveillance and treatment systems in Armenia and each of the former Republics of the FSU followed the Soviet model and were centrally planned. After the collapse of the Soviet Union, there was officially still a TB system in place in Armenia. However, in-country experts state that for several years after 1991, there was in reality no functioning TB system in the country. There was a subsequent two-fold increase in TB morbidity. The incidence (number of new cases per year) of TB in Armenia more than doubled from 932 in 1990 to 2146 in 2003.4 The number of TB cases notified or reported (WHO definition of a TB case notification which includes new and relapse cases) tripled during 1990–2003 from 590 to 1538.
With the assistance of foreign partners such as the International Committee of the Red Cross (ICRC), GTZ (the German equivalent of the US Agency for International Development), and WHO, the TB program in Armenia has started to rebuild. In December 2003, the Armenian National TB Program (NTP) was approved by the Armenian government. TB continues to be a major public health problem in Armenia; however, there have been no recent TB prevalence surveys done, nor is there accurate information about the magnitude of multidrug-resistant TB (MDR TB). In the absence of knowledge about the magnitude of TB, it is imperative to conduct a TB prevalence survey to estimate the prevalence of TB in the country.
According to WHO, conducting population-based surveys as epidemiological measurements for TB control can provide an accurate measure of bacteriologically confirmed disease. National TB prevalence surveys have been conducted in developing countries and used to measure decreases in TB prevalence due to successful implementation of short-course chemotherapy following WHO guidelines,5 set targets for NTP and gain political will and financial support for TB control,6-7 and show TB trends over time.8
Task 3. The purpose of Task 3 is to conduct a cross-sectional population-based survey using multi-stage stratified cluster sampling in Yerevan, the capital of Armenia. This survey will provide much-needed insight on how to combine public health surveillance and public health action to not only support, but also enhance, Armenia’s NTP and further the country’s TB reform goals.
—Reported by Nita Patel, MPH, Kashef Ijaz,
and Scott J.N. McNabb, PhD, MS
Div of TB Elimination
Nita Patel and Kashef Ijaz with the Armenian TB BTEP Team Members, Yerevan, Armenia, June 2005.
- U.S. DHHS, Office of Global Health Affairs, DHHS Biotechnology Engagement Program. Found at http://www.hhs.gov/ogha/europeaffairsdhhs.shtml
- 2003 population, calculated on the basis of RA 2001 Population
Census. Statistical Yearbook of Armenia, 2004.
Found at http://www.armstat.am/
- The Patient in Focus: A strategy for pharmaceutical sector reform in newly independent states. Action Program on Essential Drugs, February 1998. Geneva, World Health Organization (EUR/ICP/QCPH 06 22 02 WHO/DAP/98.8)
- Global tuberculosis control: surveillance, planning, financing. WHO report 2005. Geneva, World Health Organization (WHO/HTM/TB/2005.349).
- China Tuberculosis Control Collaboration. The effect of tuberculosis control in China. Lancet 2004; 364:417-422.
- Tupasi TE, Radhakrishna S, Rivera AB, Pascual ML, Quelapio MI, Co VM, Villa ML, Beltran G, Legaspi JD, Mangubat NV, Sarol JN Jr, Reyes AC, Sarmiento A, Solon M, Solon FS, Mantala MJ. The 1997 Nationwide Tuberculosis Prevalence Survey in the Philippines. Int J Tuberc Lung Dis 1999; 3(6):471-7.
- Tupasi TE. The power of knowledge to effect change: the 1997 Philippines nationwide tuberculosis prevalence survey. Int J Tuberc Lung Dis 2000; 4(10): 990-992.
- Hong YP, Kim SJ, Lew WJ, Lee EK, Han YC. The seventh nationwide tuberculosis prevalence survey in Korea, 1995. Int J Tuberc Lung Dis 1998; 2:27-36.
The second annual conference on the economics of TB prevention and control was held at the University of North Texas Health Science Center at Fort Worth on October 11 and 12, 2005 (c.f., photo below of attendees). The conference built on the previous gathering in Fort Worth in 2004. The purpose of the conference was to bring together national, state, and local TB officials and academics to explore techniques and tools for monitoring and evaluating TB programs, leading to enhanced efficiency and effectiveness.
Organized by Dr. Peter Hilsenrath of the School of Public Health at the University of North Texas Health Science Center, this conference was supported by Task Order #10 of the TB Epidemiologic Studies Consortium. Task Order #10 began in 2003 at two locations: Hillsborough County (Tampa), Florida, and Tarrant County (Fort Worth), Texas. A primary objective of Task Order #10 is to develop techniques and tools to monitor and evaluate TB programs.
Epidemiologists in Florida and Texas have compiled cost data and performance measures of national TB goals to help evaluate the efficiency and effectiveness of TB programs. Preliminary work has resulted in a number of presentations and publications, including two papers in the Annals of Epidemiology. The latest, authored by Thaddeus Miller, Steve Weis, and others, is titled “Using Cost and Health Impacts to Prioritize the Targeted Testing of Tuberculosis in the United States.” The paper compared TB programs for homeless and jail populations. It found that resources generate relatively better results among the homeless than among jail inmates. This suggests that for a given level of TB funds, efficiency would be improved by shifting resources to the homeless. The Florida and Texas teams presented some of these and other findings at a recent conference of the American and Canadian Evaluation Associations in Toronto on October 29, 2005.
The Fort Worth conference emphasized both practical and theoretical issues on the first day. Following an update on Task Order #10, there was a presentation of the Florida experience and tool by Betial Teweldemedhin. Participants then heard a talk about the principles of cost accounting by Joseph Coyne of Washington State University, two presentations by Victoria Phillips, an economist with Emory University, about cost-effectiveness analysis, and a presentation by Travis Porco of the State of California Department of Health on epidemiology and the measurement of health outcomes. The second day focused more on implementation issues and the differing perspectives of local, state, and federal organizations. The day began with a presentation by Gerry Burgess Drewyer with the Tarrant County TB program about the primary concerns of local health departments such as hers. This was followed by two talks by state officials familiar with the allocation of resources to TB surveillance, control, and treatment. First, Keith Hughes discussed the evolution of budgeting for TB in Florida and what really matters most in determining these allocations. Second, Charles Wallace with the State of Texas provided valuable insights about how resources have been allocated in Texas for TB. This was followed by a presentation from Heather Duncan of CDC who offered a view from the federal perspective.
In the afternoon of October 12, there was a return to theoretical issues with an overview of discounting by Todd Jewell of the University of North Texas at Denton. This helped participants understand the sometimes-arcane logic of economists and finance departments who do not typically view the value of money as static and commonly discount future revenues and costs for the purposes of decision making. The conference wrapped up with a roundtable discussion about accomplishments and directions for future work.
The concept of compiling basic accounting data to measure costs and linking these with health outcome data is not a breakthrough in management thinking. However, there is growing realization throughout the United States and within international and federal circles (especially at CDC) that greater attention must be paid to efficiency and to monitoring and measuring health impacts. This extends well beyond simply producing at low cost. It also means being better at making difficult decisions about where to allocate scarce resources.
One just has to look at the World Health Organization (WHO) as it transforms itself by results-based budgeting and management. Now in its fourth budgeting cycle based on program performance and health impacts, the Director General of the WHO, Dr. Jong-wook Lee, believes that the transition to results-based budgeting and management has been a “considerable success” in building a WHO-wide focus on results, improving the targeting of resources, and achieving greater accountability (WHO Budget 2006–2007).
So, why not CDC and the state and local TB programs?
As stated by CDC Director Julie Gerberding, MD, MPH, in a letter to partners, “We are refocusing our efforts to address goals that truly have an impact on people’s health and safety across their lifespan…Our new structure better aligns CDC to achieve these goals. Our new coordinating centers will help CDC's scientists collaborate and innovate across organizational boundaries, improve efficiency so that more money can be redirected to science and programs in our divisions, and improve the internal services that support and develop CDC staff.”
As we work in an era of accelerating change, CDC can flourish by enhancing results-based decision-making. Results-based management is all about aligning TB goals and CDC agencywide health goals to the program planning process—i.e., to program performance and the budget. Once done, it makes sense to fund programs (and projects within those programs) that support agreed-upon health goals and perform well, so as to achieve the results that ultimately lead to positive health impacts.
The participants in Task Order #10 believe that our work has the potential to contribute to more efficient TB control and hope that future work will develop user-friendly products that can be tested in a variety of demonstration sites around the country.
—Submitted by Peter Hilsenrath, Ph.D.,
Dept of Health Management and Policy
School of Public Health
University of North Texas Health Science Center
and Scott J.N. McNabb, Ph.D., M.S.
Div of TB Elimination
Participants of the Economics of TB Prevention and Control Conference, Ft. Worth, TX, October, 2005.
At the request of attendees of last year's National TB Controllers Association (NTCA) meeting, a small NTCA/CDC workgroup formed to increase our understanding of the current needs of the national genotyping program. The workgroup’s focus has been to determine what resources are available or required to assist states in managing genotyping data. An initial study conducted in 2004 determined that many state and local TB control programs were at the planning and development stages for implementation of universal genotyping programs.
A second NTCA/CDC web-based study in August 2005 reassessed states’ use of genotyping data. Specifically, the study was designed to obtain feedback on improving the current universal genotyping program: how programs were using genotyping data, what programs would like to do differently, better, or more easily with genotyping surveillance, and how NTCA and CDC might be able to facilitate these improvements.
A total of 49 (94%) of 52 TB programs completed the survey. Forty-six (94%) reported that they were conducting universal genotyping (submitting one isolate per culture-positive case). Of the three that do not conduct universal genotyping now, two plan to transition to universal genotyping by the end of 2006. Twenty-six (53%) programs mandated submission of isolates to a county or state public health laboratory.
Isolate tracking. Forty-four (88%) programs reported having some system for tracking isolates, but only 15 (31%) had the capability of tracking isolates during the genotyping submission process that could provide an alert when results were delayed.
Genotyping Data Management. Thirty-one (63%) of the programs received genotyping results directly at the TB program, while 14 (29%) received results via the state public health laboratory only. A majority of the programs reviewed genotyping results as soon as they were reported; 34 (69%) and 38 (78%) reviewed genotyping results to decide whether to request RFLP or conduct a cluster investigation, respectively. Three programs review data only two to three times per year, suggesting they were not using genotyping data to direct the implementation of real-time interventions. To manage the reports received from the reference laboratories, 24 (49%) programs merged new genotype reports with prior reports in a single cumulative Microsoft Excel spreadsheet, while 18 (37%) used another database program such as Microsoft Access.
Linking Data to Epidemiologic Information. Twelve (25%) programs routinely linked epidemiologic information to genotyping results on all of their isolates; 15 (31%) linked epidemiologic information only on clustered isolates. Under certain circumstances, such as assessing suspected outbreaks or unusual clusters, eight (16%) programs linked epidemiological information. Of the programs that linked epidemiologic and genotyping data to characterize clusters, more than half were able to do so by geographic distribution (72%), drug susceptibility (62%), country of origin (64%), race or ethnicity (56%), and other TB risk factors such as alcoholism or homelessness (74%). Only 10 programs (20%) made no attempt to link genotype data with epidemiologic data. The following reasons emerged as potential barriers to making such linkages: lack of resources, few reported cases, and difficulty in determining which unique identifiers to use to link the data.
Communication. Six (12%) of the programs routinely held cluster conferences to discuss the status of ongoing genotype cluster investigations, 18 (37%) held meetings as needed, and 23 (47%) held no conferences or meetings. Eighteen (37%) programs reported occasionally communicating with other programs. However, 30 (61%) rarely or never communicated with neighboring jurisdictions or states to compare or discuss genotyping results.
Satisfaction. Only four (8%) of the programs were very satisfied with their state’s current use of genotyping data. Many responders felt that their current program depended too much on one or two key personnel to review data (31%), they could not easily link epidemiologic information (31%), they needed more education on how to interpret results (33%), or they could not easily compare state results to national results (53%).
This survey provided much-needed insight into the programmatic use of genotyping across the United States. Several important issues have emerged as challenges for continued success of the national genotyping program. Improving local access to useful data management tools that help facilitate linking epidemiologic variables and sharing interstate genotyping information is needed. Even though 61% of the programs reported rarely or never communicating with neighboring jurisdictions, about 80% of responders were willing to share genotyping results with other TB controllers, and another seven were willing to do so if certain criteria were met, such as approval from leadership and assurance of confidentiality. DTBE continues to collaborate with the NTCA Genotyping Workgroup to develop new tools to manage and query genotyping data. Specifically, we are currently developing an online system to help local TB programs share genotyping information related to interstate clusters. CDC is committed to improving the programmatic use of genotyping data for local interventions and will provide consultation and education to local programs. If programs have questions about genotyping laboratory procedures, they should call Lauren Cowen at (404) 639-1481 (firstname.lastname@example.org); for questions concerning the interpretation of genotyping results, call Patrick Moonan at (404) 639-5310 (email@example.com).
—Submitted by Patrick Moonan, Epidemiologist
and Michele Hlavsa, EIS Officer
Div of TB Elimination
and Phil Griffin, co-Chair
NTCA Genotyping Workgroup
Kansas Department of Health and Environment