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Directors Letter

Dear Colleague:

The 2008 National TB Controllers’ Workshop was held in Atlanta, Georgia, June 9–12, 2008, at the Crowne Plaza Ravinia Hotel in Atlanta. As always, this was a well-planned event with outstanding presentations by experts in TB control, updates on important research topics, timely and useful break-out sessions, and opportunities to network with colleagues. Our theme this year, “Many Cultures – One Cause,” allowed us to focus on some of the challenges and solutions of preventing and controlling tuberculosis among the diverse cultural populations residing in the United States. Please mark your calendars for the 2009 National TB Controllers Workshop, which will be held June 15–19, 2009.

The Division of Tuberculosis Elimination (DTBE) commemorated World TB Day 2008 through three major events: a CDC-wide program on March 20, the second annual TB Awareness Walk on March 22, and the World TB Day luncheon on March 24. These events were the culmination of the work of many people in the division. None of the above activities, or those that go on throughout the year, would be possible without the contributions of our many partners: the National TB Controllers Association, the National Coalition for the Elimination of TB/Stop TB USA, the American Lung Association (including state/local chapters), RESULTS International, the Georgia Division of Public Health, the Fulton County Health Department, the Watsonian Society, and state and local TB control programs across the country. I hope World TB Day provided you with opportunities to educate the public about TB, celebrate your successes, and renew your dedication to our common goal, the elimination of TB.

The 2008 North American Region Stop TB Partnership met in San Diego on February 28 for a special session. At this session, Stop TB USA (formerly the National Coalition for the Elimination of Tuberculosis, or NCET) was officially launched. The new name “Stop TB USA” better aligns and identifies the coalition with other global Stop TB Partners such as Stop TB Canada and Stop TB Mexico, and thus clarifies its role as a partner in a larger group rather than a stand-alone U.S. entity. Coalition building and advocacy continue to be the core functions of Stop TB USA. The original coalition, NCET, is credited with playing a major role in bringing about a significant increase in federal support for TB control in the 1990s. Stop TB USA has formed a work group to develop an updated TB elimination plan for the United States. The updated Plan will include a revised endpoint for TB elimination, possibly 2025, and will include cost estimates for carrying out the recommendations. The group’s current goal is to complete the new plan in 2008.

Immediately following the Stop TB Partnership meeting, the 2008 conference of the International Union Against Tuberculosis and Lung Disease–North American Region (IUATLD-NAR) was held Feb. 28–March 1. With the theme, “Tuberculosis: A Disease Without Borders,” the conference focused on building partnerships and collaborations beyond the North American region. The message conveyed was that by linking with Latin American partners, North American TB controllers will likely find their efforts enhanced in preventing and controlling tuberculosis. This year the IUATLD-NAR partnered with the California Tuberculosis Controllers Association, affording a focus that was at the same time international and community based.

The Advisory Council for the Elimination of Tuberculosis (ACET) met in Atlanta March 26–27 and again June 17–18. At the March meeting, Kevin Fenton, MD, PhD, Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), reported on Dr. Julie Gerberding’s testimony before Congress in February regarding CDC’s response to drug-resistant TB. The hearing went very well, and served as an essential step in raising awareness about our ongoing work. Dr. Fenton also mentioned the availability of the summary report from the August 2007 Program Collaboration and Service Integration (PCSI) consultation. PCSI activities remain among Dr. Fenton’s top priorities.

I reported on DTBE’s 2007 provisional surveillance data. These data reveal the worrisome trend of a slowing in the annual percentage rate change, from an average decrease of 7.3% during 1993–2000, to an average decrease of only 3.8% during 2000–2007. Dr. Tom Navin outlined a process for refining the focus of the TB Epidemiologic Studies Consortium (TBESC). DTBE will decide on the new focus by the end of 2009 and select new TBESC partners in 2010, if feasible. Dr. Rick Goodman and Heather Duncan gave an update on CDC’s Public Health Law Program: TB laws will be organized, reviewed, and described; using that information, a Model TB Act will be developed; and a handbook on TB control laws will be developed.

Suzanne Marks and Dr. Jennifer Flood reviewed data on TB as a cause of death, which suggest that access to health care may be a problem for HIV-infected persons. Dr. Max Salfinger, representing the Association of Public Health Laboratories (APHL), urged more widespread use of nucleic acid amplification testing for TB diagnosis and detection of drug resistance. Dr. Diana Schneider outlined problems relating to U.S.-Mexico border TB control, and proposed the establishment of a model binational TB control program to provide case management and DOT, and to build laboratory capacity. Dr. Barbara Seaworth reported that the BCG Workgroup had developed recommendations about the use of BCG in persons traveling to high-risk areas (i.e., areas with increased MDR and XDR TB). In general, they recommend consideration of BCG vaccination when MDR or XDR TB transmission is likely, and there is no evidence the individual has LTBI or active TB.

ACET reconvened on June 17–18, 2008. Dr. Fenton related that the fiscal year 2007 NCHHSTP Annual Report (PDF) is available in print, and online. I reported on ACET’s draft recommendations for the use of BCG vaccine to prevent TB in health care workers traveling to high-risk areas. Members of the Advisory Committee on Immunization Practices (ACIP), who are working with ACET on these guidelines, will meet with ACET June 26 in Atlanta to discuss them. I also gave an update on the expert consultation on nucleic acid amplification tests (NAATs) held in Atlanta on June 13. The experts agreed that all persons suspected of having pulmonary TB should have a respiratory specimen tested by NAAT, and a negative NAAT with two negative AFB smear results should suffice to gain release of TB patients from isolation. Also, on August 4–5, CDC will host an expert consultation on interferon gamma release assays (IGRAs) in Atlanta. More information on all these guidelines will be forthcoming.

Dr. Drew Posey reported that as of June 13, 2008, persons from 14 countries are being screened using the new 2007 TB technical instructions for panel physicians. He also reminded us that, by the end of fiscal year 2008, the Electronic Disease Notification (EDN) system will replace the paper-based system for reporting the arrival of immigrants and refugees with TB. Ms. Laura Leidel gave an update on the use of Do Not Board lists to prevent the spread of TB during air travel. An MMWR with updated procedures and protocols for using this tool has been drafted; expedited clearance will be requested.

Dr. Kashef Ijaz and Mr. Phil Griffin reviewed the formula for TB funding redistribution; funding for laboratories and big cities are still under discussion, but in general the process is on track. Amera Khan and Dan Ruggiero outlined the recent activities and accomplishments of the four Regional Training and Medical Consultation Centers (RTMCCs). Meetings will be held with DTBE and partners to determine how to best use RTMCC resources in the future. Ms. Tonya Martin, Senior Advisor for Informatics with the Coordinating Center for Infectious Diseases, reported on the TIMS-to-NEDSS transition: as of January 2009, states will begin using the new RVCT for reporting cases. The reporting mechanism for the new RVCT will be the NEDSS HL7 TB Case Notification Message; TIMS will not be updated to work with the new RVCT.

Dr. Tom Navin provided an overview of DTBE surveillance activities, including an enhanced surveillance project for MDR and XDR TB; information on this project will be analyzed this summer. Dr. Andy Vernon discussed a recent review of the TB Trials Consortium (TBTC) by its Scientific Advisory Group of Experts (SAGE). The SAGE review highlighted TBTC’s progress and its continuing challenges. He voiced concern about the contrast between promising new drugs and regimens and the continuing gradual erosion of TBTC's funding base—particularly significant now with the TBTC scheduled for recompetition in FY 2009, and an increasing emphasis upon engaging sites in high-burden countries.

Dr. Rick Goodman and Heather Duncan provided the latest update on activities related to reviewing and characterizing TB control laws and developing new legal resources for TB control. A model act on TB control is scheduled to be completed by the end of this year. Mr. Shannon Jones and Ms. Gail Grant summarized the impressive work that has been done by the ACET workgroup on TB in African Americans, and Dr. Dolly Katz gave a progress report on the updated guidelines for controlling TB in foreign-born persons. She asked ACET if CDC should recommend testing with IGRAs as preferable to testing with the tuberculin skin test. Key issues are that the IGRA seems to be more sensitive, but it is also more expensive. More on this will be forthcoming.

Dr. Tom Navin discussed challenges encountered related to requirements under the Paperwork Reduction Act; Drs. Terry Chorba and Vishnu Sneller of NCHHSTP gave further guidance on this topic, informing us that CDC has been somewhat lenient in observing the Paperwork Reduction Act and will need to be more compliant in the future. Dr. Tom Shinnick gave an overview of the genetic basis of drug resistance and the methods available for detecting resistance. He reported that line-probe assays for drug-susceptibility testing for MDR TB are fast and sensitive; these tests still require FDA approval. After further discussion of business matters, the meeting was adjourned.

Late summer and fall will be a busy time for DTBE staff, owing to the many meetings and conferences scheduled. Some of these include the TB Education and Training Network 8th Annual Conference (August 5–7), the 5th National Conference on Laboratory Aspects of Tuberculosis (August 11–13), and the 2008 TB Program Managers Course (October 27–31), all in Atlanta. There are a number of other scientific and regional program meetings as well. Before all these activities begin, I hope you will find time to relax this summer and recharge your batteries!

Kenneth G. Castro, MD

 
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