TB NOTES

Provisional TB Surveillance Data for 2022

On March 23, 2023, DTBE published provisional 2022 U.S. TB data in Morbidity and Mortality Weekly Report.

Compared with 2020 and 2021, U.S. TB incidence increased during 2022 but remained lower than during prepandemic years. After a substantial decline in 2020 and partial rebound in 2021, incidence appears to be returning to the pre-pandemic trajectory among U.S.-born and non–U.S.-born populations.

TB epidemiology in 2022 was characterized by more cases among persons newly arrived in the United States, higher TB incidence among American Indian or Alaska Native and Native Hawaiian/other Pacific Islander persons and persons aged less than 4 and 15–24 years, and slightly lower incidence among persons over 65 years old. TB disparities persist and addressing these disparities requires timely TB diagnosis and treatment to interrupt transmission, as well as prevention of TB through treatment of latent TB infection.

Submitted by Kimberly Schildknecht, RN, MPH and Julie Self, PhD

2021 State and City Tuberculosis Report

The State and City Tuberculosis Report provides key process and outcomes measures that are used to monitor progress towards TB elimination in the United States. Data for calculating these performance measures are derived from the National Tuberculosis Surveillance System (NTSS) and the Aggregate Reports for Program Evaluation (ARPE). The 2021 report contains a new section on Sputum Culture Conversion (a patient had a positive sputum culture before being treated for TB disease but after starting treatment their sputum culture became negative). This conversion from positive to negative is the best way to measure how well a patient is responding to treatment and can help to:

• Detect failure to respond to therapy or early warning signs of relapse of TB disease
• Monitor patients with multidrug-resistant TB disease to ensure they continue to respond to therapy
• Determine length of treatment (the longer it takes to convert, the longer the length of treatment)
• Document that the patient no longer has TB disease at the end of therapy

For more information, visit the 2021 State and City TB Report.

Submitted by Rachel Woodruff, MPH, and Ashley Rodriguez

Diagnosis, Treatment, and Prevention of TB Among Persons Experiencing Homelessness in the United States

On January 27, 2023, Public Health Reports released “Diagnosis, Treatment, and Prevention of Tuberculosis Among People Experiencing Homelessness in the United States.”

TB is a public health problem, especially among people experiencing homelessness (PEH). The Advisory Council for the Elimination of Tuberculosis issued recommendations in 1992 for TB prevention and control among PEH. The goal of the recent publication is to provide current guidelines and information in one place to inform medical and public health providers and TB programs on TB incidence, diagnosis, and treatment among PEH.

The current U.S. guidelines and recommendations relevant to TB diagnosis, treatment, and prevention call for health care providers serving PEH to:

1. Assess the magnitude of homelessness in their jurisdictions
2. Test PEH and shelter staff for TB disease and latent TB infection and treat those diagnosed with TB using short-course treatment regimens
3. Identify TB among PEH by using TB diagnostics that can detect TB within 24 to 48 hours
4. Immediately report possible TB among PEH to the local public health department
5. Screen routinely for HIV among all PEH who begin treatment for TB
6. Provide temporary housing and link PEH to permanent housing opportunities
7. Perform location-based contact investigations with PEH who are infected with TB

This publication found that direct observation resulted in increased adherence to treatment among PEH, as did involvement of social workers in the provision of housing, food, safety, and comorbidity treatment, especially for HIV and substance abuse disorders. Testing and treating latent TB infection helps prevent the progression of latent TB infection to TB disease and shorter latent TB infection regimens improve adherence. By following existing recommendations and using client-centered approaches, providers serving PEH can improve TB diagnosis, treatment, and prevention among PEH.

To eliminate TB in the United States, we must diagnose, treat, and prevent TB, especially among groups at increased risk of TB. Timely diagnoses of TB save lives and prevent spread in our communities.

Submitted by Suzanne Marks, MPH, MA

Service Enhancements for CDC’s TB Molecular Detection of Drug Resistance (MDDR) Service

The Division of Tuberculosis Elimination Laboratory Branch has implemented a new targeted next generation sequencing (tNGS) assay as the primary method for CDC’s Molecular Detection of Drug Resistance (MDDR) service. The new assay enhances early detection of mutations associated with drug resistance and allows for examination of genetic loci associated with resistance to rifampin, isoniazid, ethambutol, pyrazinamide, fluoroquinolones, second-line injectables, clofazimine, linezolid, and bedaquiline. Growth-based drug susceptibility testing will also be performed concurrently but will not yet include testing for clofazimine, linezolid, and bedaquiline. Turnaround time for molecular results is 7-to-10-days; turnaround time for growth-based susceptibility test results is 35 days.

Additionally, as part of the service enhancements, reporting of tNGS results will be sent through CDC’s laboratory information management system (LIMS) with reports going primarily to state public health laboratories. This is a change in that MDDR reports will no longer be provided via secure fax. The report format has been simplified to aid review of results. Public health laboratory submitters are encouraged to explore use of CDC’s Specimen Test Order and Reporting (CSTOR) web portal.

The MDDR User’s Guide provides additional details regarding the tNGS assay and MDDR service with instructions for sample submission including the use of the MDDR Request Form.

An informational webinar was hosted to discuss these changes to the MDDR Service: Service Enhancements for CDCs TB Molecular Detection of Drug Resistance Service. The webinar included an overview of the MDDR Service, described the new tNGS assay, provided a description of the bioinformatic pipeline and outputs, reviewed the new laboratory report format and reporting through CDC’s LIMS, reviewed specimen acceptance criteria and sample submission information, and provided information about the CSTOR portal.

For any questions regarding this new tNGS assay, please contact tblab@cdc.gov.

Submitted by Angela Starks, PhD and Monica Youngblood, MPH, M(ASCP)

27th Annual Conference of the Union-North America Region (NAR)

The annual NAR Conference was held from February 22 – 25, 2023, at the Sheraton Wall Centre Hotel in Vancouver, BC, Canada. DTBE staff members presented and participated in a variety of forums during the conference, including:

• Glenn Morlock: Determination of Minimal Inhibitory Concentrations (MICs) of drug-resistant and susceptible Mycobacterium tuberculosis isolates to the novel antibiotic Teixobactin
• Kimberly Schildknecht, Molly Deutsch-Feldman, Divia Forbes MPH2, Maryam Haddad PhD, Jonathan Wortham: Tuberculosis and End-Stage Renal Disease, United States, 2010–2019
• 

  Wenming Zhu, Morlock, G.P, Burns, S., Cowan L., Posey, J. E.: Determination of MICs for Rifampin (RIF), Rifabutin (RFB) and Rifapentine (RFP) in Mycobacterium tuberculosis strains possessing various missense mutations in rpoΒ

• Mari Galvis: Challenges to Program Implementation of the Four-Month Rifapentine-Moxifloxacin Regimen for the treatment of Drug-Susceptible Tuberculosis in New York City
• Elise Caruso: Evaluation of the Think. Test. Treat TB National Latent Tuberculosis Infection Communications Campaign
• Joan Mangan: Community Engagement to Build Trust and Transform Health Systems and presented the Lifetime Achievement Award to Dr. Max Salfinger
• Carla Winston: Updates on CDC Recommendations for Tuberculosis Treatment
• Thomas (Dan) Filardo: Epidemiology and Clinical Characteristics of People with Ocular Tuberculosis in the United States, 1993‒2019

Oeltmann J, Vohra D, Matulewicz HH, DeLuca N, Smith JP, Couzens C, Lash RR, Harvey B, Boyette M, Edwards A, Talboy PM, Dubose O, Regan P, Loosier P, Caruso E, Katz DJ, Taylor MM, Moonan PK. Isolation and quarantine for COVID-19 in the United States, 2020–2022, Clin Infect Dis 2023.

DeLuca N, Caruso E, Gupta R, Kemmerer C, Coughlin R, Chan O, Vohra D, Oeltmann J, Taylor M, Moonan P, Thorpe P, Loosier P, Haile G, CDC COVID-19 Case Investigation and Contact Tracing Task Force. Experiences with COVID-19 case investigation and contact tracing: A qualitative analysis, June 2023. SSM – Qualitative Research in Health.

Li R, Deutsch-Feldman M, Adams T, Law M, Biak C, Pitcher E, Drees M, Hernandez-Romieu AC, Filardo TD, Cropper T, Martinez A, Wilson WW, Althomsons SP, Morris SB, Wortham JM, Benowitz I, Schwartz NG, White K, Haddad MB, Glowicz JB; Bone Allograft Tuberculosis Investigators. Transmission of Mycobacterium tuberculosis to healthcare personnel resulting from contaminated bone graft material, United States, June 2021–August 2022. Clin Infect Dis 2023. Epub ahead of print.

Marks SM, Self JL, Venkatappa T, Wolff MB, Hopkins PB, Augustine RJ, Khan A, Schwartz NG, Schmit KM, Morris SB. Diagnosis, treatment, and prevention of tuberculosis among people experiencing homelessness in the United States: current recommendations. Public Health Rep 2023. Epub ahead of print.

Woodruff RC, Garg S, George MG, Patel K, Jackson SL, Loustalot F, Wortham JM, Taylor CA, Whitaker M, Reingold A, Alden NB, Meek J, Anderson EJ, Weigel A, Henderson J, Bye E, Davis SS, Barney G, Bennett NM, Shiltz E, Sutton M, Talbot HK, Price A, Sperling LS, Havers FP; COVID-19-Associated Hospitalization Surveillance Network. Acute cardiac events during COVID-19–associated hospitalizations. J Am Coll Cardiol 2023;81(6):557–69.

Tsang CA, Patel NN, Stout JE, Fernando R, Pratt R, Goswami ND. Factors associated with receiving longer than recommended therapy among culture-negative pulmonary tuberculosis patients. Open Forum Infect Dis 2022;9(12):ofac630.

Chuey MR, Stewart RJ, Walters M, Curren EJ, Hills SL; COVID-19 Miramar Response Team Working Group, Moser KS, Staples JE, Braden CR, McDonald E. COVID-19 case investigations among federally quarantined evacuees from Wuhan, China and exposed personnel at a US military base, United States, February 5–21, 2020. Public Health Rep 2022;137(2):203–7.

Thomas EV, Jennings MA, Kidder DP, Fechter-Leggett ED, Bautista GJ, Johns MM; Ally Training Committee. Development and evaluation of the Ally Sexual and Gender Minority Diversity and Inclusion Training at the Centers for Disease Control and Prevention. J Public Health Manag Pract 2023;29(1):56–63.

Walker WL, Schmit KM, Welch EC, Vonnahme LA, Talwar A, Nguyen M, Stojanovic D, Langer AJ, Cocoros NM. Using the Food and Drug Administration´s Sentinel System for surveillance of TB infection. Int J Tuberc Lung Dis 2022;26(12):1170–6.