TB NOTES

Provisional TB Surveillance Data for 2021

On March 24, 2022, DTBE published provisional 2021 U.S. TB data in Morbidity and Mortality Weekly Report.

The COVID-19 pandemic has had a substantial effect on TB disease trends in the United States. Before COVID-19, TB disease diagnoses typically declined between 1% and 2% each year.  However, data show that during COVID-19, reported TB disease diagnoses fell 20% in 2020 and remained 13% lower in 2021 than pre-pandemic levels. While these changes represent true reduction in TB disease, concerns remain about missed or delayed TB disease diagnoses.

CDC provides information and resources to help providers prevent, diagnose, and treat TB and is committed TB elimination. Healthcare and public health systems must be restored and strengthened to address TB disease in the wake of COVID-19, and prevent TB through expanded partnerships with providers and community-based organizations.

Submitted by Julie Self, PhD

Decrease in Tuberculosis Cases during COVID-19 Pandemic also Reflected by Outpatient Pharmacy Data

The COVID-19 pandemic has affected many areas of public health, including TB prevention and response. TB cases reported to the U.S. National TB Surveillance System in 2020 decreased 20% compared with the average number of cases reported during 2016–2019. Investigators at CDC analyzed outpatient pharmacy data, namely anti-TB medication dispensing, to determine the extent to which the reported decrease in TB cases  was actual decline, a result of underreporting cases to public health (but persons with TB were still treated), or an indicator of missed or delayed TB diagnoses.

The outpatient pharmacy data also showed large declines in 2020, which strongly correlated with national TB surveillance case counts, helping to rule out underreporting as a cause. However, the strong possibility of underdiagnosis means that public health programs should be prepared for a possible rebound in TB cases after the pandemic, given that delayed and missed diagnoses could result in increased transmission because people with TB disease remain infectious for longer periods of time.

Read the full article in Emerging Infectious Diseases and hear more in a corresponding podcast.

Submitted by Kathryn Winglee, PhD

Surveillance definitions for extensively drug resistant (XDR) and pre-XDR tuberculosis

Effective with national TB products published starting this year (using data on TB cases counted in 2021), CDC is adopting new hybrid definitions of extensively drug-resistant (XDR) and pre-XDR TB for U.S. TB surveillance purposes. The hybrid definitions allow for either the existing U.S. definitions or the new 2021 WHO definitions (announced January 2021) to be used, with the exception that documented resistance to isoniazid in addition to rifampin (WHO definitions are inclusive of rifampin resistance only) would be a requirement for all U.S. resistance classifications. This approach keeps the current U.S. pre-XDR and XDR TB definitions intact but recognizes the revised WHO definitions within the United States and adds bedaquiline and linezolid to the list of drug classes that are considered when classifying cases into resistance groups. The new U.S. surveillance definitions are shown below:

• Multidrug-resistant (MDR) TB: caused by an organism that is resistant to at least isoniazid and rifampin
• Pre-XDR TB: caused by an organism that is resistant to isoniazid, rifampin, and a fluoroquinolone OR by an organism that is resistant to isoniazid, rifampin, and a second-line injectable (i.e., amikacin, capreomycin, and kanamycin)
• XDR TB: caused by an organism that is resistant to isoniazid, rifampin, a fluoroquinolone, and a second-line injectable (amikacin, capreomycin, and kanamycin) OR by an organism that is resistant to isoniazid, rifampin, a fluoroquinolone, and bedaquiline or linezolid

Read the Dear Colleague Letter for more information.

Submitted by Julie Self, PhD

Disease Surveillance Among U.S.-Bound Immigrants and Refugees — Electronic Disease Notification System, United States, 2014–2019

Each year, approximately 500,000 immigrants and tens of thousands of refugees (range: 12,000–85,000 during 2001–2020) move to the United States. While still abroad, immigrants, refugees, and others who apply for admission to live permanently in the United States must undergo a medical examination.

A new report published in MMWR summarizes health information that was reported to CDC’s Electronic Disease Notification (EDN) system for refugees, immigrants, and eligible others who arrived in the United States during 2014–2019.

The EDN system has both surveillance and programmatic components. The surveillance component is a centralized database that collects 1) health-related data from the overseas medical examination for immigrants with class A or B TB conditions and for all refugees and eligible others and 2) TB-related data from the post-arrival TB examination.

During 2014–2019, the overseas medical examination system prevented importation of 6,586 cases of infectious TB, 815 cases of syphilis, and 131 cases of gonorrhea. When the examination is used to offer public health interventions, most refugees (up to 96%) accept the intervention. Post-arrival follow-up examinations, which were completed for 88,190 persons and identified 475 cases of culture-positive TB, represent an important opportunity to further limit spread of TB disease in the United States by identifying and providing, if needed, preventive care for those with latent TB infection or treatment for those with TB disease.

Additional public health interventions that could be offered during the overseas medical examination should be considered (e.g., treatment for latent TB infection). Finally, for persons with class B TB, measures should be taken to identify and remove barriers to completing post-arrival examinations to reduce risk for TB disease and community transmission, along with measures to encourage reporting of completed examinations for better data-driven decision-making.

Read the full report in MMWR published on January 21, 2022. For additional background information, visit the EDN webpage.

Submitted by Julie Self, PhD

Provision Guidance for the Use of BPaL

In February, CDC released “Provisional CDC Guidance for the Use of Pretomanid as part of a Regimen [Bedaquiline, Pretomanid, and Linezolid (BPaL)] to Treat Drug-Resistant Tuberculosis Disease.” The provisional guidance includes considerations for clinicians, dosing and administration, precautions and adverse event monitoring, microbiologic monitoring, and more.

CDC encourages clinicians, pharmacists, and public health professionals to review the provisional guidance. Clinicians can contact state and local TB control offices and the TB Centers of Excellence for Training, Education, and Medical Consultation for additional information on diagnosing and treating drug-resistant TB disease.

Submitted by Terence Chorba, MD, MPH, DSc and John Parmer, PhD

2020 State and City Tuberculosis Report

In January, CDC published the 2020 State and City Tuberculosis Report . This report provides key process and outcomes measures for TB control programs in the United States. These measures are used to monitor progress towards TB elimination at the state and local level. The 2020 report contains a new section on health equity goals for populations of people who experience health disparities related to TB disease. Data for calculating these measurement 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.

Submitted by Rachel Yelk Woodruff, MPH and Bria Marlowe, MPH, CHES

Laboratory Branch Welcomes New Laboratory Scientists

Wan Moon joins DTBE’s Laboratory Branch as a Quality Manager supporting the branch laboratory quality management system and accreditation efforts. Before working at CDC, Wan worked in the Molecular/Emergency Preparedness Branch at the Georgia Public Health Laboratory and as a Senior Microbiologist at the Texas Department of State Health Services in the Serological Analysis/HIV/STD laboratory. Wan obtained his BS in Biology from Texas A&M University.

Ashlie Blinn is the newest biologist on the Reference Laboratory Team where she performs CLIA-compliant growth-based drug susceptibility testing to provide critical results to help guide treatment decisions for patient care. Prior to joining CDC, Ashlie served as an Environmental Health Technician/Science Officer in the United States Army and as a Biology Instructor and Science Laboratory Coordinator at West Georgia Technical College. Ashlie holds an MS and BS in Biology from University of West Georgia.

Sean Buono is the newest Laboratory Consultant on the Laboratory Capacity Team providing oversight and technical consultation to the laboratory component of the TB Cooperative Agreement. Sean began his CDC career in the Meningitis and Vaccine Preventable Disease Branch, Bacterial Meningitis Laboratory as a CDC Laboratory Leadership Service fellow. Sean also worked in the Public Health Microbiologist Research and Training Unit at the Los Angeles County Public Health Laboratory and at the San Francisco Public Health Laboratory as an Emerging Infectious Disease Training fellow. Sean obtained his PhD in Environmental Health Sciences at UCLA Fielding School of Public Health and his BS in Science from University of California Irvine.

Wenming (Ming) Zhu joins the Laboratory Branch as a microbiologist on the Applied Research Team performing research improving understanding and detection of drug-resistance in Mycobacterium tuberculosis. Prior to joining the Laboratory Branch, Ming was a member of the CDC Clinical and Environmental Microbiology Branch in the Division of Healthcare Quality Promotion. Ming completed his postdoctoral training at Emory University, received his PhD in Molecular Microbiology from University of Mississippi Medical Center and his MS and BS in Laboratory Medicine and Microbiology from Third Medical College in Chongqing, China.

Newly Released Tuberculosis Laboratory Aggregate Report

DTBE’s Laboratory Branch recently published the TB Laboratory Aggregate Report—Sixth Editionpdf icon. This report includes a comparison of cooperative agreement awardee aggregate workload volume data, nucleic acid amplification test (NAAT) trends, and workload performance turnaround time (TAT) data for calendar years 2017, 2018, and 2019. Also included in this report is the most recent information (2020) regarding TB testing methods in awardee public health laboratories (PHLs). This report is compiled for PHLs to assess progress towards meeting national TB testing benchmarks and for peer comparison with other PHLs with similar specimen or testing volume, using similar methods, or in a similar geographical location.

Submitted by Stephanie Johnston, MS and Monica Youngblood, MPH

TB Elimination Alliances Releases Strategic Plan

The TB Elimination Allianceexternal icon has released their 2021 and 2022 Strategic Planpdf iconexternal icon that includes information on community engagement, access to testing and treatment, provider education, as well as research and data.

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Lambrou AS, Shirk P, Steele MK, Paul P, Paden CR, Cadwell B, Reese HE, Auki Y, Hassell N, Zheng X, Talarico S, Chen JC, Oberste MS, Batra D, McMullan LK, Laufer Halpin A, Galloway SE, MacCannell DR, Kndor R, Barnes J, MacNeil A, Silk BJ, Dugan VG, Scobie HM, Wentworth DE; Strain Surveillance and Emerging Variants Bioinformatic Working Group; Strain Surveillance and Emerging Variants NS3 Working Group. Genomic surveillance for SARS-CoV-2 variants: predominance of the Delta (B.1.617.2) and Omicron (B.1.1.529) variants—United States, June 2021–January 2022. MMWR Morb Mortal Wkly Rep 2022;71:206–11.

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Phares CR, Liu Y, Wang Z, Posey DL, Lee D, Jentes ES, Weinberg M, Mitchell T, Stauffer W, Self JL, Marano N. Disease surveillance among U.S.-bound immigrants and refugees—Electronic Disease Notification system, United States, 2014–2019. MMWR Surveill Summ 2022;71(No. SS-2):1–21.

Shrestha S, Winglee K, Hill A, Shaw T, Smith J, Kammerer JS, Silk BJ, Marks S, Dowdy D. Model-based analysis of tuberculosis genotype clusters in the United States reveals high degree of heterogeneity in transmission, and state-level differences across California, Florida, New York, and Texas. Clin Infect Dis 2022. Epub ahead of print.

Wang Z, Posey DL, Brostrom RJ, Morris SB, Marano N, Phares CR. Post-arrival evaluation of immigrant and refugee children in the USA with latent tuberculosis infection diagnosed overseas, 2007‒2019. J Pediatr 2022:S0022-3476(22)00080-4. Epub ahead of print.

Liu Y, Posey DL, Yang Q, Weinberg MS, Maloney SA, Lambert LA, Ortega LS, Marano N, Cetron MS, Phares CR. Multidrug-resistant tuberculosis in U.S.-bound immigrants and refugees. Ann Am Thorac Soc 2021. Epub ahead of print.

Podany AT, Pham M, Sizemore E, Martinson N, Samaneka W, Mohapi L, Badal-Faesen S, Dawson R, Johnson JL, Mayanja H, Lalloo U, Whitworth WC, Pettit A, Campbell K, Phillips P, Bryant K, Scott N, Vernon A, Kurbatova E, Chaisson RE, Dorman S, Nahid P, Swindells S, Dooley KE, Fletcher CV; AIDS Clinical Trials Group & Tuberculosis Trials Consortium. Efavirenz pharmacokinetics and HIV-1 viral suppression among patients receiving TB treatment containing daily high-dose rifapentine. Clin Infect Dis 2021. Epub ahead of print.

Smith JP, Gandhi NR, Silk BJ, Cohen T, Lopman B, Raz K, Winglee K, Kammerer S, Benkeser D, Kramer M, Hill AN. A cluster-based method to quantify individual heterogeneity in tuberculosis transmission. Epidemiology 2021. Epub ahead of print.

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Belay ED, Godfred Cato S, Rao AK, Abrams J, Wilson WW, Lim S, Newton-Cheh C, Melgar M, DeCuir J, Webb B, Marquez P, Su JR, Meng L, Grome HN, Schlaudecker E, Talaat K, Edwards K, Barnett E, Campbell AP, Broder KR, Bamrah Morris S. Multisystem inflammatory syndrome in adults after SARS-CoV-2 infection and COVID-19 vaccination. Clin Infect Dis 2021. Epub ahead of print.

Fast HE, Zell E, Patel Murthy B, Murthy N, Meng L, Gibbs Scharf L, Black CL, Shaw L, Chorba T, Harris LQ. Booster and additional primary dose COVID-19 vaccinations among adults aged ≥65 years—United States, August 13, 2021–November 19, 2021. MMWR Morb Mortal Wkly Rep 2021;70(50):1735–9.

Ghosh S, Felix D, Kammerer JS, Talarico S, Brostrom R, Starks A, Silk B. Evaluation of sputum-culture results for tuberculosis patients in the United States-Affiliated Pacific Islands. Asia Pac J Public Health 2021. Epub ahead of print.

Kaniga K, Hasan R, Jou R, Vasiliauskienė E, Chuchottaworn C, Ismail N, Metchock B, Miliauskas S, Viet Nhung N, Rodrigues C, Shin S, Simsek H, Smithtikarn S, Ngoc ALT, Boonyasopun J, Kazi M, Kim S, Kamolwat P, Musteikiene G, Sacopon CA, Tahseen S, Vasiliauskaitė L, Wu MH, Vally Omar S. Bedaquiline Drug Resistance Emergence Assessment in MDR-TB (DREAM): a 5-year prospective in-vitro surveillance study of bedaquiline and other second-line drug-susceptibility testing in MDR-TB isolates. J Clin Microbiol 2021. Epub ahead of print.

Nabity SA, Han E, Lowenthal P, Henry H, Okoye N, Chakrabarty M, Chitnis AS, Kadakia A, Villarino E, Low J, Higashi J, Barry PM, Jain S, Flood J. Sociodemographic characteristics, comorbidities, and mortality among persons diagnosed with tuberculosis and COVID-19 in close succession in California, 2020. JAMA Netw Open 2021;4(12):e2136853. (Nabity, also with California Department of Public Health).

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Punetha A, Green KD, Garzan A, Thamban Chandrika N, Willby MJ, Pang AH, Hou C, Holbrook SYL, Krieger K, Posey JE, Parish T, Tsodikov OV, Garneau-Tsodikova S. Structure-based design of haloperidol analogues as inhibitors of acetyltransferase Eis from Mycobacterium tuberculosis to overcome kanamycin resistance. RSC Med Chem 2021;12(11):1894–909.