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No. 4, 2008

Directors Letter

The last quarter of 2008 kept us busy with a variety of activities. Division of Tuberculosis Elimination (DTBE) staff organized and attended several meetings this summer and fall. These included an expert consultation on the use of interferon gamma release assays (IGRAs), held August 4–5 in Atlanta. The Tuberculosis Education and Training Network (TB ETN) 8th Annual Conference was held in Atlanta August 5–7; please see the related article by Holly Wilson in this issue. The 5th National Conference on Laboratory Aspects of Tuberculosis was held in Atlanta August 11–13; we will provide a summary of that meeting in a later issue of TB Notes.  Two meetings were held on November 13–14, 2008: The TB Trials Consortium (TBTC) held an important meeting in Atlanta to discuss and plan for the 2009 recompetition of the TBTC sites. Also, the Evaluation Work Group (EWG) convened in Atlanta to review the implementation of the 2004–2008 EWG Strategic Plan, identify implementation challenges, and seek input from members as well as from the Advisory Council for the Elimination of Tuberculosis (ACET), the National TB Controllers Association (NTCA), state and local programs, and DTBE staff.  As a result of this meeting, the EWG will establish a strategic plan for program evaluation for the next 5 years. On November 18–19, the TB Epidemiologic Studies Consortium (TBESC) met to conduct its Semiannual Tuberculosis Advisory Review (STAR) process. The Coordinating Center for Infectious Diseases Board of Scientific Counselors (BSC) meeting was held December 4–5, 2008. The BSC topic was antimicrobial resistance; DTBE presenters at that meeting included Drs. LoBue, Moonan, Navin, Robison, and Vernon. And on December 9–10, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) held a consultation in Atlanta on social determinants of health and infectious diseases; participants discussed how social determinants affect health and health outcomes and generated suggestions to guide policy, program, and research efforts. Suzanne Marks presented on TB disparities in African Americans at that consultation. 

ACET met in Atlanta October 7–8, 2008. Dr. Hazel Dean, NCHHSTP Deputy Director, gave the NCHHSTP Director’s Update in Dr. Fenton’s absence. She discussed CDC’s Healthiest Nation Initiative. The intent of this initiative is to develop a broad-based U.S. movement that supports and promotes health. It will mainly draw on broad-based partnerships to energize Americans to not only take personal responsibility for their health, but also encourage others to do so as well. In other updates, Dr. Dean related that a continuing resolution was signed; it extends federal government operations through March 6, 2009. Also, on September 16, Dr. Gerberding testified before Congress on HIV/AIDS in the United States. In her testimony, she spoke of the new HIV incidence figures that were released in August. The first analyses, published in the August 6 issue of the Journal of the American Medical Association (JAMA), showed that in 2006, an estimated 56,300 new HIV infections occurred; this is substantially higher than the previous estimate of 40,000 annual new infections. However, the new estimate does not represent an actual increase in HIV, but more accurate tracking as a result of using more advanced technology.

In my remarks to ACET, I reported on the 15 investigations of TB clusters or outbreaks in which DTBE staff were involved from January 2007 through August 2008. I also reported on the National TB Genotyping Service; as of September 2008, there had been 40,000 isolates genotyped. I shared two items of good news: starting in October 2008, CDC will cover shipping costs for isolates to be genotyped, and CDC has successfully renewed contracts for genotyping services with laboratories in California and in Michigan. Also, we now have an aberration detection unit (Molecular Epidemiology Activity) as part of DTBE’s surveillance team. Members of the team will provide on-site consultation to TB controllers in prioritizing their genotyping clusters.

I reported that this year, TB control workers in the Gulf region were prepared for the return of hurricane season, having applied the lessons gained from Hurricanes Katrina and Rita. When hurricanes Gustav and Ike bore down on Louisiana and Texas, TB patients had been given 2- or 4-week supplies of medications and the telephone numbers of TB staff. Members of NTCA and DTBE communicated with each other and TB controllers to find and keep track of evacuated TB patients. As a result of the advance preparations, almost all TB patients have been found and returned to treatment. DTBE staff have collaborated with respective health departments to report on these activities for subsequent publication in CDC’s Morbidity and Mortality Weekly Report (MMWR).

Dr. Denise Garrett gave an update on the TB Epidemiologic Studies Consortium (TBESC) recompetition. In essence, the next round of TBESC task orders will focus on a single overarching goal. A Strategic Planning working group developed a list of broad research concepts, and determined that the focus should be on latent TB infection. Next steps will include developing concepts into proposals, developing a detailed research plan, selecting the new TBESC research, and selecting the new sites.

Drs. Drew Posey and Francisco Averhoff of DGMQ reported on immigrant health and on travel restrictions. Dr. Posey reported that as of October 1, 2008, persons from 14 countries are being screened according to the 2007 Technical Instructions for Tuberculosis Screening and Treatment; this includes 28% of the immigrants and 40% to 50% of the refugees. He also reported on the Electronic Disease Notification (EDN) system; DTBE and DGMQ planned to jointly hold a summit in November to discuss EDN and come to a consensus on moving forward. Dr. Averhoff reported on air travel restrictions for public health purposes, specifically the Do Not Board (DNB) list. The DNB list is a new tool that helps public health officials prevent travel on commercial aircraft by persons posing a serious risk for infection to other travelers; please see the related report, Federal air travel restrictions for public health purposes—United States, June 2007–May 2008. MMWR 2008; 57(37): 1009–1012.

We heard a number of laboratory-related presentations. Dr. Tom Shinnick reported on an expert consultation that was convened on June 13, 2008, in Atlanta to consider revisions to the current recommendations for the use of nucleic acid amplification (NAA) tests for the diagnosis of TB. The working group suggested several revisions to the current guidelines for using NAA: all diagnosticians should have access to molecular tests; NAA testing should become standard practice; and the test should be done on at least one specimen from each suspected TB patient. He encouraged ACET and CDC to discuss and consider adopting the recommendations of the expert panel. (Editor’s note: On the basis of the group’s report and consultations with ACET, CDC issued Updated Guidelines for the Use of Nucleic Acid Amplification Tests in the Diagnosis of Tuberculosis (MMWR Jan 16, 2009; 58[1]: 7-10). Dr. Shinnick also discussed issues around molecular drug susceptibility testing. A working group will develop recommendations for this testing in early 2009. Dr. Beverly Metchock discussed the pros and cons of direct specimen microscopy, and raised the issue of whether procedural restrictions on direct microscopy improves the quality of the procedure or slows down the diagnosis. We also heard an update regarding the expert consultation on IGRAs that was held August 4–5, 2008. Guidelines on the use of this assay are being developed and will be published in the MMWR after ACET review.

Dr. Kashef Ijaz gave an update on proposed changes to the TB cooperative agreement funding formula. The NTCA formula workgroup members— representing ACET; DTBE; big cities; laboratories; and high-, medium-, and low-incidence states—have recommended a revised formula (55% base / 45% redistribution) using data reported to CDC for 2004–2008. We also heard about the investigation into several cases of multidrug-resistant (MDR) TB in Chuuk, Micronesia. The Epi-Aid and the follow-up work succeeded, owing in part to the program collaboration and service integration (PCSI) efforts of several public health entities. Dr. Rick Goodman gave an update on current activities regarding TB laws, including the review and characterization of selected states’ express laws for TB control, a practitioner's handbook, and the development of a “Model TB Act” to be used as a tool by state and local TB controllers.  The primary authors for these products are with the Centers for Law and the Public's Health, a collaborative team at Johns Hopkins and Georgetown Universities. CDC and a number of collaborating partners (including ACET, NTCA, and others) have been reviewing and providing feedback on the Model TB Act since the initial draft was received in early November 2008.  We look forward to having the Center’s report on express TB laws, the accompanying handbook and slides, and the Model TB Act possibly in early 2009.

Mr. John Seggerson discussed the activities of Stop TB USA, which has been updating the plan for elimination of TB in the United States. The group recommends increases in advocacy, mobilization, and partnerships. Because responsibility for planning and implementing TB control cannot stay exclusively within the public health sector, its members have been deliberating over the draft TB Elimination Plan. Earlier this fall, the draft was distributed and commented upon. A community consultation was held in October, and the Plan is now being finalized. We look forward to the publication of this important document scheduled for World TB Day 2009.

We heard from Drs. Elsa Villarino and Andy Vernon that the TB Trials Consortium (TBTC) sites will be recompeted in 2009. Owing to fiscal restraints, fewer sites will be funded. The new TBTC configuration will be determined by public health and scientific needs, availability of patients, and funding. In addition, Dr. Villarino provided recommendations from the BCG Workgroup on the use of BCG vaccine to prevent TB in persons working in high-risk areas of the world. The Workgroup has drafted recommendations for the use of BCG in these situations, with all needed and appropriate caveats and instructions for its use.

Dr. Sundari Mase gave an update from another workgroup that had been asked to develop evidence-based guidelines for discontinuation of isolation for MDR TB. The workgroup conducted a literature review and found that most transmission occurred in facilities that did not initiate recommended isolation precautions. The group’s recommendations will likely include the criteria of having a regimen tailored to susceptibility results, clinical improvement (no cough), a negative smear, and three negative cultures. Dr. Mase anticipated that guidelines would be published in 2009. Ann Cronin discussed after-action reports resulting from high-visibility incidents involving TB and air travel. CDC’s recommendations include a call for increased laboratory capacity and additional investment in rapid diagnostics. After a few additional items of business, the meeting was adjourned. The next ACET meeting is scheduled for March 3–4, 2009, in Atlanta.

The 39th International Union Against TB and Lung Disease (IUATLD) World Conference on Lung Health was held in Paris October 16–20. The conference theme was “Global threats to lung health: The importance of health system responses.” Conference sessions explored the challenges of building up and strengthening the readiness and preparedness of health systems in preventing global threats to lung heath and mitigating their impact.  DTBE was represented by a contingent of staff who organized, coordinated, led, or presented data at one or more of the many sessions.

The 2008 TB Program Managers Course was held this year during the week of October 27–31. This is an important annual training course that offers new TB managers an overview of the basic principles and practices of current TB control, with didactic lectures given by subject-matter experts, and hands-on exercises that help attendees practice what they have learned. We would like to thank those who took time out of their busy schedules to serve as faculty for the course. Please see the summary article by Regina Bess and Allison Maiuri about this year’s course.

We and many others observed World TB Day on March 24. This annual event commemorates the date in 1882 when Dr. Robert Koch announced his discovery that the organism M. tuberculosis is the cause of TB. Every year, TB control workers around the world take advantage of this day to celebrate hard-won victories and acknowledge persisting challenges. The next issue of TB Notes will include information on the events and activities that were enjoyed by DTBE staff in Atlanta.

Kenneth G. Castro, MD

Last Updated: 03/25/2009

 

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