TB NOTES

Preliminary TB Surveillance Data for 2018

In recognition of World TB Day, DTBE published preliminary TB surveillance data for 2019. Data from CDC’s national tuberculosis (TB) surveillance system show the lowest number of TB cases in the United States on record, but the pace of decline has slowed in recent years. TB cases declined 1.1% between 2018 and 2019 (from 9,021 to 8,920 cases), while TB rates declined 1.6% (from 2.8 to 2.7 cases/100,000 persons). TB elimination requires maintaining and strengthening current TB control priorities while expanding targeted testing and treatment for high-risk persons with longstanding, untreated latent TB infection. CDC is working with public health partners and primary care providers to encourage testing and treatment for latent TB infection as a routine and integral part of healthcare for patients at-risk for latent TB infection.

Good news from the Surveillance Team! 

The deadline for the implementation of the 2020 Report of Verified Case of Tuberculosis (RVCT) has been extended from December 31, 2020 to December 31, 2021. This means reporting areas do not need to make the transition to the new case notification message format until December 31, 2021. Please do continue to implement the new 2020 items to the extent possible. DTBE is prepared to facilitate the onboarding of any reporting area between now and the end of 2021.

In a collaborative effort, DTBE is developing online 2020 RVCT training resources, including:

• 2020 RVCT Instruction Manual
  • RVCT 2009 to RVCT 2020 form comparison guide
  • Item-by-item review
• 2020 RVCT training PowerPoint slide set with script
• List of Frequently Asked Questions with responses
• Case Studies Manual (with examples)
• Recorded webinars for each RVCT item

For technical assistance related to the 2020 RVCT or any other surveillance data issues, please contact the DTBE Helpdesk at DTBEsupport@cdc.gov.

Submitted by Lauren Lambert, MPH, Epidemiologist, Surveillance Team, Acting Team Lead

Coronavirus (COVID-19): Information for TB Programs

A public health emergency can make efforts to help TB patients continue their treatment difficult. TB programs’ work ensures that people who are receiving treatment for TB disease can continue their treatment, even if routine health care services are affected.

In the event of a public health emergency, TB programs can help to mitigate potential shifts in staff assignments and resources.

• Make sure contact information for patients is current, and staff can reach patients with updates and information.
• Provide contact numbers of TB program personnel to patients.
• Communicate any changes or updates in service to community partners.
• Consider providing additional medications to patients if health department operations are likely to be affected.
• If policies and procedures are in place, consider alternative treatment delivery methods, such as electronic directly observed therapy (eDOT).

Persons with COVID-19 infection may seek care at TB clinics given the primary symptoms are similar to manifestations of TB, e.g., fever, cough, and shortness of breath. Patients with TB can become infected with COVID-19, which could result in an unexpected deterioration of a patient’s condition (e.g., was responding well to treatment and develops new acute cough, fever, or shortness of breath). TB patients who are at least 65 years old; have respiratory compromise from their TB; or other medical conditions, including HIV and other immunocompromising conditions, are at greater risk for severe COVID-19 infection. Therefore, respiratory infection control precautions, with which TB programs are familiar, are of even greater importance now as are general precautions, such as frequent hand washing, disinfecting surfaces, and avoiding touching one’s face.

COVID-19 guidance for healthcare facilities, including outpatient facilities, is available at the CDC COVID-19 website.

Community Partnership to Expand Latent TB Infection Services in Houston, TX

Initiating Partnership

Pictured from left to right: Hanan Noori, MA, Hope Clinic; Maria Galvis, CDC, Public Health Advisor assigned to Houston Health Department; Tonia Ellison, LVN, Houston Health Department; Barbarah Martinez RN, BSN, Hope Clinic; Kara Green MSN, APRN, FNP-BC, Hope Clinic; Nguyen Tran, MA, Hope Clinic

The Houston Health Department Bureau of Tuberculosis Control works to ensure the health of Houstonians by identifying and treating TB cases and their contacts. In addition to the program’s TB core activities, the program launched a new project of partnering with community clinics to expand their latent TB infection services and offering once-weekly isoniazid-rifapentine for 12 weeks (3HP) to high-risk populations. This new initiative is the component needed to steer the program towards TB elimination.

The Hope Clinic was selected for this project since there was already an existing relationship. Also known as the Asian American Health Coalition (AAHC), the Hope Clinic is a federally qualified community clinic serving the uninsured, underinsured multicultural residents in Houston. The Hope Clinic’s Director of Clinical Services has collaborated with the Houston Health Department for several years by reporting, referring, and ensuring optimal TB patient care. This existing relationship facilitated initial conversations regarding implementing latent TB infection treatment in the community.

Overview of the Partnership

The Houston Health Department provided Hope Clinic with a training focused on latent TB infection, specifically the short-course 3HP regimen. The medical assistants at the clinic were observed during the administration of 3HP to ensure the process and documentation was being done according to CDC guidelines. The outlined roles for the Hope Clinic include screening qualified patients for 3HP, providing medical evaluation and performing directly observed therapy (DOT) to the patients on 3HP. The Houston Health Department supports the project by providing medication and patient incentives, in addition to providing training and educational materials as needed. Both parties signed a scope of services agreement, beginning the formal partnership in Fall 2017. The project started as a pilot in early 2018 with a maximum enrollment of 20-25 patients per quarter.

Successes and Challenges

At the beginning of the project, the program experienced very low enrollment in 3HP. Some of the providers were a bit reluctant to prescribe the 3HP regimen. The Houston Health Department conducted a refresher meeting with the medical director to re-emphasize the benefits of offering 3HP to the patients. Incentives were given to Hope Clinic to give to patients who agreed to come for their weekly DOT, and the number of enrollees increased. Clearly, the use of incentives has been instrumental to both increase 3HP enrollment as well as encourage completion of treatment. Since the project started, 22 patients have enrolled, and the treatment completion rate is about 88%.

Conclusion

Although new projects are usually confronted by resistance, the beginning of new projects provide the opportunity for programs to grow and expand their preventive services. In all, the various in-person meetings, education and provider training, incentives, and most importantly the strong communication between both partners have led to a successful latent TB infection project. Future plans for the project include expanding latent TB infection treatment services through the use of video DOT (VDOT).

Submitted by Maria E. Galvis, PHA assigned to Houston Health Department

Acknowledgments:

Hope Clinic Staff: Andrea Caracostis MD, MPH Chief Executive Officer; Kara Green MSN, APRN, FNP-BC; Nguyen Tran, MA; Hanan Noori, MA

Houston Health Department: Richard Stancil, Bureau Chief; Tonia Ellison, LVN

2018 State and City Tuberculosis Report

The 2018 State and City Tuberculosis Report is now available online. This report provides key process and outcomes measures for TB control programs in the United States used to monitor progress towards TB elimination at the state and local level. These indicators were selected by CDC in cooperation with partners in state and local health departments. Data for calculating these indicators are derived from the National Tuberculosis Surveillance System (NTSS) and the Aggregate Reports for Program Evaluation (ARPE). CDC publishes indicator data to assist TB programs in:

• Evaluating progress toward achievement of national objectives through monitoring of TB program performance.
• Assessing the need for education and technical assistance.
• Identifying areas that need improvement.

Learn more about the National TB Program Objectives and Performance Targets for 2025.

Updates from the Division of Tuberculosis Elimination Health Equity Work Group

The goal of the CDC Division of TB Elimination Health Equity Work Group (DTBE-HEWG) is to inform and shape DTBE’s agenda for programs, research, education, and policies towards reducing TB health disparities. The HEWG is made up of representatives from each DTBE branch and the Office of the Director. DTBE strategic priorities include reducing health disparities, congruent with the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB (NCHHSTP) and CDC commitments.

HEWG meets monthly to review and discuss progress made toward reducing TB health disparities, to explore new data sources, to identify gaps in activities based on evidence, and to champion improvements in health equity and efforts to reduce health disparities overall. Activities undertaken by the HEWG include:

• Consistently review social determinants of health data on reported TB cases (e.g., race/ethnicity, country of birth, employment, gender, homelessness, and incarceration) and reviewed data on medical determinants that contribute to TB disparities (e.g., HIV, diabetes, other immunosuppression).
• Explores new cross-cutting data and evidence-based practices to address TB health disparities.
• Contributed to writing the DTBE 2020 notice of funding opportunity (NOFO) that included TB health disparities language and content for applicants to address, including TB prevention activities target populations experiencing persistent TB disparities.
• Represented DTBE on the NCHHSTP Health Equity Work Group and maintained communication between NCHHSTP and other CDC entities and partners on health disparities and health equity issues.
• Developed and maintained a list of contributions by DTBE staff to the literature on TB health disparities and equity issues (presentation, publications, and reports). Published a major article in the American Journal of Public Health (Khan et al., 2018;108: S321-S326) that highlighted persistent disparities and, in some populations, increases in disparities.
• Invited presentations from two DTBE branches (health equity issues in clinical trials, presented by the Clinical Research Branch; health equity related activities by the Communications, Education, and Behavioral Science Branch) and from the NCHHSTP HEWG at DTBE HEWG monthly meetings.
• Developed and shared a DTBE framework to address TB disparities and equity that will serve as guide to identify underlying factors affecting TB disparities and to develop innovative approaches to moving toward health equity.
• Developed a list of potential data sources on latent TB infection diagnosis and treatment to facilitate monitoring of population-specific indicators in the latent TB infection care cascade.

Even though reported TB cases and rates have been decreasing since their height in 1992, TB control and prevention efforts must address the persistent disparities that exist among populations affected by TB.

Submitted by Awal Khan, PhD, and Suzanne Marks, MPH, MA

TB ETN-PEN Conference Scheduled for September 2020 is Postponed until 2021

The TB ETN-PEN Conference currently scheduled for September 22-24, 2020 will be postponed until 2021.  Many of our TB colleagues across the country and around the world are now engaged in the response to COVID-19. We will share information on the rescheduled TB ETN-PEN conference in 2021 as soon as we determine new dates. 

Coronavirus (COVID-19): Information for TB Laboratories

CDC is providing updates on the current status of national tuberculosis (TB) laboratory services during the ongoing COVID-19 response efforts.

• CDC’s Molecular Detection of Drug Resistance (MDDR) Service is operational, and we are working diligently to ensure sufficient staffing and resources to provide both molecular and growth-based drug-susceptibility testing (DST). Turnaround times for issuance of reports back to submitters could be delayed. If you need additional information or have questions, please feel free to contact TBLab@cdc.gov or 404-639-2455.
• The National DST Reference Center for Mycobacterium tuberculosis at the California Microbial Diseases Laboratory is operational. For enrolled laboratories, please continue to refer specimens and isolates for pyrosequencing or MGIT DST as per your usual procedure. For additional information, please contact CDPHTBDST@cdph.ca.gov or 510-412-3949.
• The National TB Molecular Surveillance Center at the Michigan Department of Health and Human Services Bureau of Laboratories is operational and referral of M. tuberculosis isolates should continue. CDC is continuing to provide conventional genotyping results and conducting analysis of whole genome sequencing data, as applicable. For additional information, please contact Angie Schooley at schooleya@michigan.gov or 517-335-9637.

The response to COVID-19 is an unprecedented event and could impact public health laboratory testing for TB. CDC has received reports of shifting or rotating mycobacteriology staff to support COVID-19 testing and have received notification that some public health laboratories are implementing continuity of operations plans. As always, CDC encourages regular communication between TB programs and public health laboratories to understand any impacts to TB testing capacity.

False Positive Investigation Toolkit: A Resource for Mycobacteriology Laboratories

CDC’s Division of Tuberculosis Elimination, Laboratory Branch recently released the False Positive Investigation Toolkit: A Resource for Mycobacteriology Laboratories False-positive Mycobacterium tuberculosis complex (MTBC) results can be difficult to identify, investigate, and resolve. These results often have serious implications for patient isolation, patient therapy, contact investigations, and unnecessary laboratory testing. The toolkit was developed to provide updated resources to aid recognition of potential false-positive results and to assist staff in conducting false-positive investigations. The false-positive investigation toolkit features a narrative document and job-aids, posters, and templates that can be modified for specific local use.

An accompanying online interactive case study training module, Mycobacteriology False-Positive Case Studies, can be accessed on the Association of Public Health Laboratories (APHL) website. The training module has five different case studies that walks the participant through different scenarios of a potential false-positive investigation, using knowledge checks to guide the participant.

Submitted by Monica Youngblood

TBTC 45^th Semi-Annual Meeting is Canceled

Due to issues related to the COVID-19 pandemic, DTBE’s Clinical Research Branch (CRB) has decided to cancel the in-person TBTC 45^th Semi-Annual Meeting scheduled for May 6 – 8, 2020. CRB is planning a remote participation alternative to the May meeting that will cover the excellent work done by the consortium over the past six months. CRB looks forward to seeing the consortium group in-person in Atlanta in November 2020 for the 46^th Semi-Annual Meeting.

This February, DTBE staff attended the 24^th Annual Conference of The Union North America Region in Chicago, IL. This three-day scientific conference brings together national and international experts of national and international to focus on topics of importance to public and respiratory health, with emphasis on TB and lung disease.

Highlights from the conference include:

• Nick Deluca, PhD, gave a talk titled, “Engaging Communities in TB Elimination through Effective Communication”
• Richard Brostrom, MD, MSPH, gave a talk titled, “Active Case Finding in Majuro”
• Sapna B. Morris, MD, served as plenary chair for a session titled, “Taking the Leap – Active Case Finding and TB Elimination Project”
• Joan Mangan, PhD, MST, served as primary chair of the nursing sponsored session, “Compassionate Conversations”
• Neela Goswami, MD, MPH, moderated a session titled, “2020 and Beyond: New Tools in the TB Toolbox for Diagnosis, Infection Control, and Treatment”
• DTBE staff gave several poster presentations with topics related to updated recommendations for TB screening, testing, and treatment of health care personnel, training for the new RVCT form, health message testing findings, using electronic health data to describe the TB care cascade and improve TB infection surveillance, and more
• DTBE staff facilitated poster sessions including Molecular Epi and Outbreaks, Latent TB Infection, Program Evaluation, Training and Education, and Special Populations
• DTBE hosted a booth at the conference to share key resources and connect with participants

Agizew T, Chihota V, Nyirenda S, Tedla Z, Auld AF, Mathebula U, Mathoma A, Boyd R, Date A, Pals SL, Lekone P, Finlay A. Tuberculosis treatment outcomes among people living with HIV diagnosed using Xpert MTB/RIF versus sputum-smear microscopy in Botswana: a stepped-wedge cluster randomised trial. BMC Infect Dis 2019;19:1058.

Ahmed A, Feng PI, Gaensbauer JT, Reves RR, Khurana R, Salcedo K, Punnoose R, Katz DJ; Tuberculosis Epidemiologic Studies Consortium. Interferon-γ release assays in children <15 years of age. Pediatrics 2019:pii:e20191930. Epub ahead of print.

Armstrong GL, MacCannell DR, Taylor J, Carleton HA, Neuhaus EB, Bradbury RS, Posey JE, Gwinn M. Pathogen genomics in public health. N Engl J Med 2019;381:2569–80.

Auld AF, Agizew T, Mathoma A, Boyd R, Date A, Pals SL, Serumola C, Mathebula U, Alexander H, Ellerbrock TV, Rankgoane-Pono G, Pono P, Shepherd JC, Fielding K, Grant AD, Finlay A. Effect of tuberculosis screening and retention interventions on early antiretroviral therapy mortality in Botswana: a stepped-wedge cluster randomized trial. BMC Med 2020;18:19. (Shepherd, also with Yale University School of Medicine).

Chen MP, Miramontes R, Kammerer JS. Multidrug-resistant tuberculosis in the United States, 2011–2016: patient characteristics and risk factors. Int J Tuberc Lung Dis 2020;24:92–9.

Click ES, Kurbatova E, Alexander H, Dalton TL, Chen MP, Posey JE, Ershova JJ, Cegielski P. Isoniazid- and rifampin-resistance mutations associated with resistance to second-line drugs and with sputum culture conversion. J Infect Dis 2020;pii:jiaa042. Epub ahead of print.

Dorman SE, Nahid P, Kurbatova EV, Goldberg SV, Bozeman L, Burman WJ, Chang KC, Chen M, Cotton M, Dooley KE, Engle M, Feng PJ, Fletcher CV, Ha P, Heilig CM, Johnson JL, Lessem E, Metchock B, Miro JM, Nhung NV, Pettit AC, Phillips PPJ, Podany AT, Purfield AE, Robergeau K, Samaneka W, Scott NA, Sizemore E, Vernon A, Weiner M, Swindells S, Chaisson RE; AIDS Clinical Trials Group and the Tuberculosis Trials Consortium. High-dose rifapentine with or without moxifloxacin for shortening treatment of pulmonary tuberculosis: study protocol for TBTC study 31/ACTG A5349 phase 3 clinical trial. Contemp Clin Trials 2020:105938. Epub ahead of print.

Haddad MB, Lash TL, Hill AN, Navin TR, Castro KG, Gandhi NR, Winston CA. Robustness of NHANES estimates of the U.S. prevalence of a positive tuberculin skin test. Epidemiology 2019. Epub ahead of print. (Haddad, Hill, and Winston, also with Emory University).

Klopper M, Heupink TH, Hill-Cawthorne G, Streicher EM, Dippenaar A, de Vos M, Abdallah AM, Limberis J, Merker M, Burns S, Niemann S, Dheda K, Posey J, Pain A, Warren RM. A landscape of genomic alterations at the root of a near-untreatable tuberculosis epidemic. BMC Med 2020;18:24.

Pratt RH, Manangan LP, Cummings CN, Langer AJ. Noncountable tuberculosis case reporting, National Tuberculosis Surveillance System, United States, 2010–2014. Public Health Rep 2019:33354919884302. Epub ahead of print.

Reichler MR, Bruden D, Thomas H, Erickson BR, Knust B, Duffy N, Klena J, Hennessy T; Household Transmission Investigative Team. Ebola patient virus cycle threshold and risk of household transmission of Ebola virus. J Infect Dis 2019;pii:jiz511. Epub ahead of print.

Vernon A, Bishai W. Modelling treatment of latent TB: shortening the leap of faith? Am J Respir Crit Care Med 2019. Epub ahead of print.

Vernon A, Fielding K, Savic R, Dodd L, Nahid P. The importance of adherence in tuberculosis treatment clinical trials and its relevance in explanatory and pragmatic trials. PLoS Med. 2019;16):e1002884.