TB Notes Newsletter
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Surveillance, Epidemiology, and Outbreak Investigations Branch Updates
Texas reported the second highest number of U.S. TB cases in 2006. While the proportion of multidrug-resistant (MDR) TB cases (i.e., those resistant to at least isoniazid [INH] and rifampin [RIF]) in the United States has remained stable at approximately 1%, the rising specter of extensively drug-resistant (XDR) TB threatens the recent gains in TB control. The objective of this project was to validate the drug-susceptibility test (DST) data for MDR cases reported to the NTSS (National TB Surveillance System) by the state of Texas.
We selected cases reported by Texas during 2000–2006 that were both INH and RIF resistant on initial or follow-up DST results submitted to the NTSS. DST results were abstracted from the medical records of MDR cases at the Texas Center for Infectious Diseases and the Texas Department of State Health Services (TDSHS) by matching the actual sputum collection date (as reported on the RVCT), and compared to the reported data from the NTSS. DST categories were “resistant,” “susceptible,” “not done,” or “unknown” (not found), using the same definitions as on the RVCT forms. Data quality was assessed for completeness and accuracy. Completeness was calculated by dividing the number of reported results of individual drug testing by the total number of actual results that could be abstracted from one of the medical records. For the initial DST panel (INH, RIF, and ethambutol [EMB]), completeness was 99%, while for the extended panel (pyrazinamide [PZA] + 6 second-line drugs), 91% of the results were reported. For the four drugs not tested by Texas labs (cycloserine, p-aminosalicylic acid, amikacin, and ciprofloxacin), which required testing at an outside reference lab, the completion rate was 67%. For data accuracy, only the DST results reported as resistant or susceptible were compared to the abstracted results. For the four first-line drugs (INH, RIF, PZA, and EMB), there was 95% concordance between NTSS and the medical records, while for the remaining 10 second-line drugs from the RVCT, there was 99% concordance.
From the analyses above, it appears that incompleteness of DST data is mainly due to PZA not being included in the initial DST panel, and certain drugs requiring testing at a reference lab. Overall, these results represent excellence in TB reporting. One limitation of this evaluation is its lack of generalizability to the entire NTSS dataset. Different reporting jurisdictions are expected to have unique challenges and constraints to the complete, accurate, and timely reporting of TB cases. Nonetheless, we believe that this exercise was a fruitful attempt at evaluating the state of MDR TB surveillance in the United States by validating the DST variables in the NTSS dataset.
Many thanks to Dr, Barbara Seaworth (Heartland RTMCC) and Maria Rodriguez (TDSHS) for making this possible.
—Submitted by Mitesh Desai, MD, MPH, and
John Oeltmann, PhD
Div of TB Elimination
Tuberculosis Epidemiologic Studies Consortium’s
“Translating Research into Practice” (TRiP) Workgroup
“What we want to get at is not how many reports have been done, but how many people’s lives have been bettered by what has been accomplished. In other words, is it being used, is it being followed, is it actually being given to patients?”
—John Porter, House Appropriations Subcommittee on Labor, HHS and Education, 1998
In today’s world of public health, with insufficient resources and dwindling numbers of TB cases, we cannot afford to do research that merely answers questions at a theoretical level and does not impact management and care of TB patients. This was the impetus for a group of researchers of the Tuberculosis Epidemiologic Studies Consortium (TBESC) to form the Translating Research into Practice (TRiP) workgroup in 2005. TRiP can play an advocacy role in emphasizing the importance and applicability of completed TBESC research. TBESC recognizes the importance of disseminating research findings and making practical use of the findings for "front line" TB control practice. Since one of the goals of TBESC research is to improve TB control and work towards TB elimination, TRiP works to make TBESC research accessible to public health workers.
The mission of the TRiP workgroup is to help translate promising research from TBESC studies into best practices for U.S. TB control programs. The team works with study PIs, CDC staff, TB controllers, and others such as the National TB Controllers Association (NTCA), the National TB Nurse Coalition (NTNC), and the Regional Training and Medical Consultation Centers (RTMCCs) to facilitate translation of TBESC research findings into best practices that can be easily implemented by state and local TB control programs.
Highlight the key research findings from completed TBESC studies and their relevance to core TB program activities
Suggest how specific TBESC research findings can be translated into practical measures to enhance TB elimination and improve patient care
Influence communications/disseminations, priorities, future research, and guidelines by making recommendations to TBESC, DTBE, NTCA, NTNC, and the RTMCCs
First project translated
The first project undertaken by TRiP was Task Order 4, “Models for Incorporating HIV Counseling, Testing, and Referral into TB Contact Investigations.” The main objectives of this study were to increase HIV counseling, testing, and referral (CTR) among close contacts to TB patients in New York City (screen all HIV-infected contacts for TB), and to provide LTBI treatment to HIV-infected contacts and prevent additional AIDS opportunistic infections through referral to and accessing of care for HIV.
This study was published as an article titled “Human
immunodeficiency virus counseling, testing, and referral of close
contacts to patients with pulmonary TB: feasibility and costs”
(Journal of Public Health Management and Practice 2007; 13:
Main study findings for dissemination
Contacts of patients with TB and HIV were more likely to also be HIV-infected and thus should be prioritized for testing if resources are limited.
The most common reason for refusing an HIV test (50% of refusals) was patient’s perception of low HIV risk.
Personnel costs for providing HIV information (averaging 2 minutes per patient) were $1 per patient; it cost $5–$8 per patient to offer HIV counseling, testing, and referral to all close contacts and $24 per patient for HIV testing. Total variable costs for all HIV CTR efforts averaged $18 per contact.
TRiP was able to provide input and disseminate the results from Task Order 4 in a “Dear Colleague letter” that was sent to the TB controllers along with existing HIV CTR resources for training or conducting rapid testing.
A CDC fact sheet regarding HIV CTR of TB patients, contacts, and LTBI patients was developed with the help of TRiP. In 2007, a TRiP representative was invited to present the group’s work at the annual meetings of NTCA in June and the TB Education and Training Network in August.
The membership of TRiP has evolved over time to include not only interested TBESC members, but also many members of our partner groups, including other staff from CDC, the NTCA, the NTNC, the RTMCCs, and others. The broad membership of TRiP has proven valuable to the workgroup’s functioning.
Translation into best practices recommendations requires multiple partners and collaborations to develop practical applications of epidemiologic research and dedicated staff time to communicate with partners and identify methods/tools to share TBESC study results with end users. The translation of TBESC Task Order 4 results would not have been possible without the dedicated work of five TRiP members and the enthusiastic participation of the two principal investigators of the study. The next study scheduled for translation is Task Order 3 titled “Zero Tolerance for Pediatric TB.”
Come and join TRiP if you want to make a difference, and help us eliminate TB! Please contact Smita Chatterjee at firstname.lastname@example.org or Lisa Pascopella at email@example.com if you would like to join TRiP.
—Submitted by Smita G. Chatterjee, MS
Texas Department of State Health Services, TRiP Chair, and
Lisa Pascopella, PhD, MPH
The goal of the TB Epidemiologic Studies Consortium Task Order 6
(TO6) is to identify approaches for regionalizing TB control in a
low-incidence area (encompassing the states of Idaho, Montana, Utah,
and Wyoming). It was determined early in the project, as a result of
a comprehensive needs assessment and review of legal authority and
state infrastructures, that TB control activities were essentially a
local function and could not be implemented through a single
regional laboratory, clinic, and a few regional TB control staff.
The objective evolved to create and evaluate tools for regional
activities that would add value to state-oriented TB control
activities across the four-state region. Each of these states has
differing TB epidemiology and TB control program structure, but they
share the common challenge associated with maintaining TB control
program and clinical expertise in the context of low TB incidence
and few resources.
Regional interventions were developed and prioritized through a
consensus process that involved the TB program managers and public
health laboratory directors in four low-incidence states, as well as
local and national partners. Advisory groups were formed around
priority areas identified through program review and needs
assessment: laboratory, policy and planning, surveillance, quality
assessment, training and education, advocacy and collaboration, and
clinical consultation. Evaluation plans were designed and
implemented for each intervention area.
A TB manual template was created for low-incidence areas and piloted in Montana. The purpose of the manual is to provide guidance to a generalist local public health workforce for TB control activities (e.g., case management). It is expected that use of the manual will improve the use of recommended procedures, and will standardize TB control practices across a low-incidence region. As part of the evaluation plan, a baseline survey of information-seeking practices and confidence in using information to perform TB control activities was performed in Montana and Idaho. A follow-up survey will be implemented and analyzed to determine whether and how having access to the TB manual changes information-seeking and confidence in performing TB control activities.
An outbreak response plan template was created for low-incidence areas and assessed and finalized during an outbreak investigation in Idaho. It provides a definition of “TB outbreak” and guidance to low-incidence areas for response coordination.
A laboratory advisory group was formed to serve as a network for sharing mycobacteriology challenges and solutions, and to identify areas for improvement in TB laboratory services across the four-state region. Surveys of laboratory practice across the region identified areas for training and improvement: turnaround times, laboratory safety, and reporting to local health jurisdictions. Regional trainings were held in collaboration with state public health laboratory directors and the National Laboratory Training Network.
An evaluation of the Idaho case management teleconference series was completed, revealing the success of a local-state collaboration with invited external TB experts. This collaboration is a model for quality assurance and education and will be submitted as a best practice model to NACCHO (National Association of County and City Health Officials).
Surveillance of cross-jurisdictional transmission across a low-incidence region was implemented in the form of a regional genotyping surveillance system. A Regional Coordinator position was created, new tools were developed to securely share data and identify growth and location of genotyping clusters, a quarterly report was developed to share data across the region, and procedures for responding to clusters were created and implemented. An evaluation plan to assess the added value of genotyping surveillance across this region is being developed.
Clinical consultation was provided through an expanded Warmline function at the FJ Curry National Tuberculosis Center. The four-state region was assigned three specific expert clinicians to respond to requests for clinical consultation throughout the course of case management of complex cases. Three of the four states do not have access to in-state TB clinical consultants. Each state’s TB controller has explicitly expressed the need for this type of service.
Our short-term evaluations have demonstrated that regional tools
have provided additional capacity to control TB in this
low-incidence area. An important study finding was the evolution of
the definition of “regionalization.” The original view of
regionalization, as outlined in the IOM report Ending Neglect (1)
and the ACET recommendations (2) was to share TB-specific staff,
e.g., a TB epidemiologist and a TB nurse consultant, among several
low-incidence states. What we learned is that local and state TB
control services must be maintained within their legally mandated
infrastructure, and that these may be enhanced by technical support
provided through a regional structure. The operational research
performed as part of TO6 resulted in the development and evaluation
of regional tools that would require maintenance and updating if
they are to remain functional. We believe that one full-time staff
equivalent will provide the regional structure needed to maintain
enhanced TB control in this low-incidence area.
An important question arises as we reach the end of this project: What is required to maintain a regional approach to continue to build upon the successes of TO6? TB controllers in each of the participating states have strongly endorsed this approach. All partners in TO6 believe it will be important to build upon what has been learned. We believe that further investment would be needed to evaluate the feasibility and impact of implementing best practice models in low-incidence regions within the United States. We expect that the findings and products of TO6 may be useful for other low-incidence areas.
Institute of Medicine. Ending Neglect: The Elimination of Tuberculosis in the United States. Washington, DC: National Academy Press; 2000.
CDC. Progressing toward tuberculosis elimination in low-incidence areas of the United States: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 2002 May 3; 51 (No. RR-5).
—Submitted by Lisa Pascopella, Randall Reves,
Charlie Nolan, and Charles Daley
The Biotechnology Engagement Program (BTEP) is a Congressionally
mandated program residing in the U.S. Department of Health and Human
Services (HHS), 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
CDC and WHO/EURO staff (Drs. McNabb, Ijaz, McElroy, Reves, Flood, and de Columbani) in collaboration with the Ministries of Health in the Republics of Armenia and Georgia developed a nine-task 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 was awarded 3 years of funding beginning October 2004 and consisted of the nine tasks described in TB Notes No. 2, 2005 .
The nine tasks were designed to empower and enable local public health officials and to build capacity within the two countries:
Tasks 1 (description of TB surveillance system in Armenia) and 2 (evaluation of current TB surveillance system in Armenia) have been completed. A concise report describing all aspects of TB surveillance in Armenia and Georgia has been finalized for submission to the Ministries of Health and National Tuberculosis Programme (NTP) decision makers.
Task 3 was to assess the prevalence of M. tuberculosis in the Republic of Armenia because of uncertainty around current estimates. This task was stopped due to political and administrative complications including the reorganization of the Ministry of Health in Armenia. This task will not be completed within the BTEP timeline.
Task 4 was to improve the understanding of the burden of undetected TB cases in Armenia and Georgia. All interviews have been conducted and the databases completed. This task is currently in the analysis and reporting phase.
Task 5 was to determine private-sector use of TB medications by developing a line list of TB medication as well as the quantity imported and a description of retails sales of TB medication in both Armenia and Georgia. This task has been completed in Armenia and Georgia and the reports finalized.
Task 6 was to evaluate the data management systems at peripheral and national levels and to design a TB surveillance information system (TBSIS) in Armenia. A TBSIS is in the process of being finalized.
Task 7 was to measure the magnitude of MDR TB in Armenia and Georgia. Task 7 was linked to Task 3 in Armenia and was also stopped owing to political and administrative complications. Task 7 will not be completed within the BTEP timeline in Armenia. Task 7 is ongoing in Georgia with only data analysis and report generation left to be completed by the end of October.
Task 8 was to evaluate a TB patient population group called “chronics.” This task is in the data analysis and report finalization phase. Data from the evaluation will be used to address public health policy.
Task 9 was to provide training to Armenian and Georgian national TB control staff, both in country as well as in the United States, in epidemiology, biostatistics, TB prevention and control, TB medical management, scientific writing, and advocacy. All planned trainings have been completed with the exception of the “TB Surveillance Software & TB Monitoring and Evaluation,” which will be done in conjunction with the implementation of TBSIS and the U.S.-based training which was only conducted for the Georgian specialists in Denver, CO. Education and Training with the Division of Mycobacterial and Respiratory Infections.
Because of political changes, the Armenian BTEP team was unable to complete tasks 3 and 7. Task 3 — a cross-sectional population-based survey which was to use a multi-stage stratified cluster sampling technique in Yerevan, the capital of Armenia — was meant to give a clearer picture of the incidence and prevalence of TB in Armenia. In-country experts currently estimate that the true magnitude of disease in Armenia has been underestimated. This task could provide much-needed support for a public health surveillance agenda in Armenia that could then be linked to public health action by Armenia’s NTP and could have furthered the country’s TB reform goals. Our recommendation to the Ministry of Health is to complete this task if they can secure funding.
Task 3 protocol be used to conduct prevalence study in Armenia and Georgia
Creation, implementation, and dissemination of national guidelines for diagnosis and treatment of TB in Armenia
Surveillance and pharmacy practice integrated into national guidelines (Armenia and Georgia)
DOTS (directly observed therapy, short-course), standard, integrated into national guidelines
Cooperation between NTP and Republic TB dispensary
Appointment of liaisons to coordinate communication between NTP and Republic TB dispensary
Refresher TB training courses for general practitioners (case detection)
Use of liquid media for culture (to decrease diagnosis time)
Procurement and use of tuberculin skin tests (TST)
Educational outreach to address stigma and increase TB awareness in both countries
Improve case management
Improve lab capacity, outside of Yerevan, Armenia
Georgian and U.S. BTEP collaborators, 2007
Currently various members of the team are in the process of writing up the outcomes of various tasks for publication. Daniel Ehlman, MPH, will be writing up Task 1 and 2 for both Armenia and Georgia, Dana Schneider will writing up Task 4 for Armenia and Georgia, and Ngozi Ogbuawa, MSc., MPH, will be writing up Task 8 for Armenia.
Armenian and U.S. BTEP Collaborators, 2007
The ultimate plan for the Armenia and Georgia Biotechnology Engagement Project (BTEP) is to lay the foundation for a national notifiable diseases surveillance program.
McNabb, Scott. The Biotechnology Engagement Program. In: TB Notes No. 1, 2003. CDC: Atlanta; 2003: 28-29.
Demas S, McNabb S. Update on the Biotechnology Engagement Program in the Republics of Armenia and Georgia, Spring 2005. In: TB Notes No. 2, 2005. CDC: Atlanta; 2005: 22-23.
Patel N, Ijaz K, McNabb S. Updating the TB Biotechnology Engagement Project in the Republics of Armenia and Georgia, 2005. In: TB Notes. No. 1, 2006. CDC: Atlanta; 21-23.
—Submitted by Ngozi Ogbuawa, MSc., MPH
Public Health Prevention Service Fellow, CDD, OWCD
and Scott McNabb, PhD, MS
Director, Division of Integrated Surveillance Systems and Services (DISSS)
National Center for Public Health Informatics