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No. 1, 2011

SURVEILLANCE, EPIDEMIOLOGY, AND OUTBREAK INVESTIGATIONS BRANCH UPDATE

DTBE Homeless Initiative

Did you know that in the United States, 1% of persons experience homelessness each year, while 6% of persons diagnosed with TB have been homeless in the previous year?

TB was recognized as a disease disproportionately affecting persons in unhealthy living conditions as early as 1815.  In 1914, an editorial in the Journal of the American Medical Association noted that TB was a “disease of malnutrition, bad housing, and low wage” and that cheap lodgings frequented by homeless persons were “veritable breeding places” for TB. Over three quarters of TB outbreaks recently investigated by DTBE have involved homeless persons.  In one outbreak, all 31 persons with TB were linked to a single homeless shelter. CDC recently instituted a new surveillance system for detecting aberrations in TB genotype clusters; this system continuously scans TB patient reports for statistical anomalies that indicate possible outbreaks. Analyses of genotyping data have shown that homelessness is a powerful predictor of TB genotype cluster growth. These findings are not surprising, given that persons who are homeless have a high prevalence of conditions that increase the risk of TB, including substance use, HIV infection and other medical conditions, and residence in crowded shelters—a combination conducive to Mycobacterium tuberculosis transmission in a population that often lacks ready access to medical care.

DTBE has established a multibranch committee to better understand the burden of TB among persons experiencing homelessness and the work being done by state and local TB programs and other federal agencies to improve screening, diagnosis, and treatment of TB among homeless persons. The committee has proposed a number of projects to describe the problem more thoroughly, solicit feedback from TB controllers, and provide venues to discuss this issue—for example, a symposium at the 2011 National TB Conference.  

To begin this process of improved partnership with providers caring for the homeless, Sapna Bamrah and Krista Powell attended the 2010 National Health Care for the Homeless Council Annual Meeting in June 2010. There, they met with providers interested in TB care, learned about the Health Care for the Homeless Clinician’s Network and Research Council, and discussed potential future collaborations.

In August 2010, members of DTBE’s committee on homelessness were part of CDC’s first Homeless Symposium, coordinated by Samantha Williams (NCHHSTP, DSTDP). Dr. Castro moderated a session at the symposium dedicated to TB.  Krista Powell and Adam Langer from SEOIB’s Outbreak Investigation Team shared data from a recent outbreak investigation and analyses of the effect of homelessness on TB cluster growth using data from the National TB Genotyping Service.  Steve Martin, an industrial engineer from NIOSH, shared his experiences in providing guidance on improved environmental controls after a TB outbreak in a homeless shelter. As a result of the symposium, NCHHSTP is in the process of establishing a formal Public Health and Homeless Workgroup. The symposium planning committee was recently awarded the NCHHSTP Director’s Recognition Award for their efforts in coordinating this CDC-wide event focused on homelessness.

On a more local level, some of the DTBE committee members volunteer with local homeless-person service providers in Atlanta to provide medical care and other services to individuals and families experiencing homelessness. In the first weeks of February 2011, these DTBE staff also served as interviewers with Pathways and St. Joseph’s Mercy Care on the biennial Atlanta homeless census. TB controllers and providers have historically been at the forefront of innovative care for challenging populations, particularly in persons experiencing homelessness, and we hope to continue that trend with this new initiative.

Reported by Sapna Bamrah, MD
Div of TB Elimination

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18th Semiannual Meeting of the Tuberculosis Epidemiologic Studies Consortium (TBESC)

Charging the Tuberculosis Epidemiologic Studies Consortium (TBESC) members to “finish what you started; reap what you harvest,” Dr. Ken Castro, Director, Division of Tuberculosis Elimination, welcomed participants to the 18th Semiannual TBESC Meeting in Atlanta, GA. Approximately 150 principal investigators, project coordinators, and other TBESC personnel attended the meeting January 19–20, 2011, at the Crowne Plaza Ravinia Hotel in Atlanta, GA, to discuss recent TB research and to plan next steps needed for current research in breakout sessions. The 18th Semiannual Meeting was of particular importance to attendees, as the current TBESC contract will end in September 2011. At this time, research activities must be completed. Unlike previous meetings in which projects were in various stages of development, every participant at this meeting was focused on completion of research and bringing the projects to fruition.

New analysis of data from Task Order 9, Preventing Tuberculosis in the Foreign-born, suggests that counting of prevalent TB cases may partially explain the high rates of TB among foreign-born persons in the first year after arrival in the United States. These cases, which likely had onset in the patient’s home country, are counted as incident cases. Because control strategies differ for prevalent and incident cases, it is important to separate the two. The Task Order 9 analysis of questionnaire and surveillance data from 1,454 foreign-born adults noted that nearly half of TB patients diagnosed in the first year of arrival were diagnosed within the first 3 months.  Of those reporting symptom onset on or before the date of arrival, almost three quarters were diagnosed within the first 3 months.  The results suggest that prevalent cases could be distinguished from incident cases by two criteria: 1) diagnosis within the first 3 months of arrival, and/or 2) symptom onset before arrival. 

Dan Blumenthal from the Atlanta Clinical and Translation Science Institute discussed “Translating Research into Practice.” The translation of TBESC research into findings that can be used by the TB community was particularly germane as the group focuses on the completion of current research projects. Dr. Blumenthal told the group to design interventions in collaboration with those who will be intervened upon, e.g., health care providers. He instructed the group to retain the core elements of the studied intervention, and stated that the best way to implement an intervention is through multimedia presentations. Live interventions such as meetings are also effective; printed articles are generally ineffective in changing health care provider behavior.

Denise Garrett, MD, project officer for TBESC, also gave an update on the TBESC recompetition. Her presentation included a timeline for the recompetition and an estimate that the Request for Proposal will be released soon.

Highlights of the second day of the meeting included preliminary data from the study, “National study of determinants of early diagnosis, prevention, and treatment of TB in the African-American community.” Rachel Royce, PhD, reported that analysis of current data indicates that the median number of healthcare visits prior to TB diagnosis is two in African Americans and three in whites. Further, more whites than African Americans had over 12 months elapse between symptom onset and TB diagnosis. African Americans diagnosed with TB were younger than whites, more likely to be male, and more likely to have an income less than $20,000 per year.

Other highlights from the second day of the conference included updates from the Publications and Presentations Committee, the Translating Research into Practice Workgroup, and the External Relations Committee.

The 19th Semiannual TBESC meeting, and final meeting for the current consortium, will be held in Chicago, IL, July 20–21, 2011.

—Reported by Suzanne Beavers, MD
Div of TB Elimination

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