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TB Notes 2000

Christmas Seal Campaign, 1945. Recognize possible signs and symptoms of tuberculosis. Early diagnosis and treatment reduces spread.

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Tent colony for TB patients, TB sanitorium,Colorado Springs, Colorado.

Community x-ray screening campaign. Dr. Robert Koch, discoverer of the tubercle bacillus, the cause of TB.

TB cases reported annually in the U.S. from 1953, the first year of national TB surveillance.

Drugs used to treat TB disease. From left to right: isoniazid, rifampin, pyrazinamide, and ethambutol.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and Prevention

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DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

________________________________________________________________________________________________ Centers for Disease Control

and Prevention (CDC)Atlanta GA 30333

TB NotesNo. 1, 2000

Dear Colleague:

This has been planned as a special issue to commemorate “TB Control at the Millennium.” Wewanted to take the occasion to note what has been accomplished in TB control over the years,and to look forward to the challenges of the future. Our focus is mainly on progress made inthis country, since that is our charge and our responsibility, but one cannot talk about TB controlwithout talking about the important work of researchers and workers in other countries, andtherefore we have included articles about international efforts as well.

In this issue you will find information about the history of the interaction between mankind andMycobacterium tuberculosis; the many accomplishments of our partners in TB contol; the past andpresent activities of the Division of TB Elimination (DTBE); a timeline of some of the highlightsof TB control over the past century; educational materials available from DTBE; and photos ofhistorical people, places, events, and memorabilia that we believe you will find interesting.

I also take this opportunity to thank all who answered our invitation to contribute articles to thisvery special issue. I have both learned immensely from and thoroughly enjoyed these variouscontributions.

Please feel free to share this with individuals and organizations with an interest in TB control.We have printed extra copies to be able to accommodate requests for additional copies.

Kenneth G. Castro, MD

A Century of Notable Events in TB Control

Introduction: A Glimpse at the Colorful History of TB: Its Toll and Its Effect on the U.S. and the World,Dan Ruggiero................................................................................................................................................1

Where We’ve Been and Where We’re Going:Perspectives from CDC’s Partners in TB Control.......................................................................................7

Changes I’ve Seen in TB, 1949 - 1999, William Stead.............................................................................7TB Control in New York City: A Recent History, Paula Fujiwara and Thomas Frieden..................9Not by DOT Alone, Mike Holcombe......................................................................................................12Baltimore at the New Millennium, Kristina Moore and Richard Chaisson..........................................13From Crickets to Condoms and Beyond, Carol Pozsik........................................................................15The Denver TB Program: Opportunity, Creativity, Persistence, and Luck, John Sbarbaro............16National Jewish: The 100-Year War Against TB, Jeff Bradley and Michael Iseman............................18Earthquakes, Population Growth, and TB in Los Angeles County, Paul Davidson.........................20TB in Alaska, Robert Fraser......................................................................................................................22CDC and the Americal Lung Association/American Thoracic Society: an Enduring Public/ Private Partnership, Fran DuMelle and Philip Hopewell...............................................................23The Unusual Suspects, Lee Reichman.....................................................................................................27The Model TB Prevention and Control Centers: History and Purpose, Elizabeth Stoller and Russ Havlak.............................................................................................................................................29My Perspective on TB Control over the Past Two to Three Decades, Jeffrey Glassroth..................32History of the IUATLD, Donald Enarson and Annik Rouillon..........................................................33Thoughts about the Future of TB Control in the United States, Charles Nolan..............................37

A Century of Advances in TB Control, United States (2-page chart)........................................................40

Where We’ve Been and Where We’re Going:Perspectives from CDC.............................................................................................................................42

Early History of the CDC TB Division, 1944 - 1985, John Seggerson................................................42CDC Funding for TB Prevention and Control, Patricia Simone and Paul Poppe.............................46Managed Care and TB Control - A New Era, Bess Miller....................................................................47Early Research Activities of the TB Control Division, George Comstock..........................................49The First TB Drug Clinical Trials, Rick O’Brien and George Comstock.............................................51Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC), Andrew Vernon.............52TB Communications and Education, Wanda Walton..........................................................................54TB Control in the Information Age, Jose Becerra.................................................................................56Field Services Activities, Patricia Simone...............................................................................................57TB’s Public Health Heroes, Dan Ruggiero, Olga Joglar, and Rita Varga........................................58Infection Control Issues, Renee Ridzon.................................................................................................60A Decade of Notable TB Outbreaks: A Selected Review, Scott McCombs........................................62International Activities, Nancy Binkin and Michael Iademarco...........................................................65The Role of CDC’s Division of Quarantine in the Fight Against TB in the U.S., Paul Tribble....68The STOP TB Initiative, A Global Partnership, Bess Miller...............................................................70Seize the Moment - Personal Reflections, Carl Schieffelbein...............................................................72

Description of DTBE Training and Education Resources........................................................................75

Notable Events in TB Control

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A Glimpse at the Colorful History of TB:Its Toll and Its Effect on the

U.S. and the Worldby Dan Ruggiero

Division of TB Elimination

In their 1969 book Tuberculosis, Lowell et al.tell us that “Tuberculosis is an ancient diseasewith a lineage that can be traced to the earliesthistory of mankind . . . In the last millenniumit has been universally distributed among allbranches of the human race.”

Phthisis (from the Greek word to waste away),scrofula (swellings of the lymph nodes of theneck), the white plague (the TB epidemic inEurope during the 18th century), consumption(progressive wasting away of the body), TB(the presence or products of the tuberclebacillus) are all words for tuberculosis markinga specific point in history. Each has a signifi-cant connotation and meaning to millions ofpeople about a disease that has afflicted hu-mans from the dawn of history and continuesto ravage mankind in large numbers. DuringWorld TB Day 1999 it was reported that anestimated one billion persons died of thedisease worldwide during the 19th and early20th centuries alone. This invisible enemycontinues to challenge man’s knowledge andmock his efforts; the “Captain of the men ofdeath” continues to march forth leavingbehind a trail of human misery, economicchaos, and death. What is the origin of thisinvisible predator that even today has beenable to adapt and survive by fending off themany remedies and cures that the best mindsin science have placed before it?

The tubercle bacillus, the organism that causesTB disease, can be traced as far back as 5000BC when archeologists found evidence inhuman bones of the existence of TB. Evidencewas found in ancient Egyptian mummieswhich showed deformities consistent with TBdisease. Paleontologists have concluded thatthe disease must have been prevalent in thatpart of the civilized world.

Evidence of TB appears in Biblical scripture,in Chinese literature dating back to around4000 BC, and in religious books in Indiaaround 2000 BC. In ancient GreeceHippocrates mentions TB around 400 BC, asdoes Aristotle, who talked about “phthisis andits cure” (ca. 350 BC).

It was widely believed that European explor-ers, sailors, and the settlers who followedColumbus to the new world brought withthem many infectious diseases, among themTB. However, paleopathologists suspected thatTB existed in the New World before 1492,based on ancient skeletons and bones thatcontained lesions resembling those caused byTB. Evidence to that effect was found in 1994,when scientists reported that they had identi-fied TB bacterium DNA in the mummifiedremains of a woman who had died in theAmericas 500 years before Columbus set sailfor the New World.

The TB epidemic in Europe that came to becalled the “Great White Plague” probablystarted in the early 1600s and continued forthe next 200 years. The epidemic reached itspeak in western Europe and in the UnitedStates in the late 1700s and early 1800s. Inearly 19th century England, TB was so perva-sive a killer that it dwarfed other dreadeddiseases like cholera and typhus. So commonand so little understood was TB that deathfrom the disease was accepted as inevitable. TBin the early 19th century may have accountedfor one third of all deaths. Death from TB

Evidence of TB in ancient human bone

TB Control at the Millennium

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was clearly evident in the literature of the timein the writings of John Keats (1795-1821) inthe Ode to a Nightingale, of John Bunyan(1628-1688) in The Life and Death of Mr.Badman, of Charles Dickens (1812-1870) inNicholas Nickleby, and of other famous writersof the time.

In 1720, in his publication, A New Theory ofConsumption, the English physician BenjaminMarten was the first to conjecture that TBcould be caused by “wonderfully minute livingcreatures,” which, once they had gained afoothold in the body, could generate thelesions and symptoms of the disease. Hecontinued that “It may be therefore very likelythat by an habitual lying in the same bed witha consumptive patient, constantly eating anddrinking with him, or by very frequentlyconversing so nearly as to draw in part of thebreath he emits from the Lungs, a consump-tion may be caught by a sound person . . . Iimagine that slightly conversing with con-sumptive patients is seldom or never sufficientto catch the disease.” For a physician living insuch an early era, Dr. Marten showed muchmedical insight.

In 1882, at a time whenTB was raging throughEurope and the Ameri-cas, killing one in sevenpeople, a German biolo-gist by the name ofRobert Koch presentedto the scientific commu-nity his discovery of theorganism that causedTB. It was called a

tubercle bacillus because small rounded bodies(tubercles) occurred in the diseased tissue andwere characteristic of the disease. Through hismany experiments with the organism, Dr.Koch worked on developing a cure for TB.Koch was able to isolate a protein from thetubercle bacillus that he tried as an immuniz-ing agent and later as a treatment for TB; inboth cases it failed. However, the substance,

now called “old tuberculin,” was to be laterused as the screening tool (tuberculin skintests) for identifying people and animalsinfected with tubercle bacilli.

A further significant advance came in 1895when Wilhelm Konrad von Roentgen discov-ered the radiation that bears his name. Thisallowed the progress and severity of a patient’sdisease to be accurately followed andreviewed.

Another important development was providedby the French bacteriologist Calmette. To-gether with Guerin, he used specific culturemedia to lower the virulence of the bovine TBbacterium, thus creating the basis for the BCGvaccine still in widespread use today.

TB in America during the colonial period wasaccepted as a scourge of humanity that wascommon to the poor and rich alike. The firstavailable mortality figures from Massachusettsin 1786 indicated 300 deaths per 100,000population. The peak mortality figure reachedin New England was 1,600 per 100,000 in1800. With the industrial development, theepidemic traveled to the Midwest in 1840 andto the West in 1880. Though the diseaseoccurred in blacks at a lower rate than inwhites before the Civil War, the increase wasmassive among blacks after the war, whenemancipation and urbanization created anideal atmosphere for transmission of TB. TheAmerican Indians and Alaskans were the lastAmerican populations to become affected bythe TB epidemic.

At the turn of the century it was estimatedthat 10% of all deaths in the United Stateswere due to TB. By 1904 the TB death ratefor the United States was 188, by 1920 the ratewas 100 per 100,000, and by 1955 the rate haddecreased to less than 10 per 100,000 peopleper year.

The TB sanatorium movement, which wasstarted in Germany by Dr. Hermann

Robert Koch


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Brehmeris in the 1850s, did not take hold inthe United States until after 1884. EdwardLivingston Trudeau, a physician who recov-ered from TB disease, started a sanatorium inSaranac Lake, New York, based on the Euro-pean model of strict supervision in providingfresh air and sunshine, bed rest, and nutritiousfoods.

As infection control measures took hold inlarge urban centers of the country, TB patientswho could not be treated in local dispensarieswere removed from the general populationand placed into sanatoriums. Soon a greatmovement was underway to build TB sanato-riums. By 1938 there were more than 700sanatoriums throughout the United States, yetthe number of patients outnumbered the bedsavailable.

For those households in which the adultscould not be placed in a sanatorium, childrenwere removed from infected parents andplaced in preventoriums that were created forchildren.

A milestone in the history of TB control inthe United States occurred in the autumn of1893, when the New York City Board ofHealth called on Dr. Hermann Michael Biggs,the Chief Inspector of the Division of Pathol-ogy, Bacteriology, and Disinfection, for areport on TB. In the report, Biggs stated thatTB, which was responsible for more than6,000 deaths in New York City in 1892, was

both communicable and preventable. Some ofthe recommendations made to the Board in hisreport were the need to1) educate the public of the dangers that thedisease posed to the person and his/her con-tacts,2) properly dispose of and immediately de-stroy sputum or the “discharges from thelungs” of individuals with disease,3) have all physicians of pulmonary casesreport such cases to the health department,4) have health inspectors visit the familieswhere TB exists and deliver proper literatureand take specific measures to disinfect theareas as may be required,5) obtain and submit sputum specimens to thelaboratory for analysis, and6) create a consumptive hospital to care forindigent patients.

The Board adopted most of the recommenda-tions made by Biggs, including the creation of“The Consumptive Hospital.” These recom-mendations created a storm of controversyamong the medical community. Many privatedoctors objected to the mandatory reporting,believing that it violated physician-patientconfidentiality. Because of the resistance fromthe medical community, reporting practiceswere not fully implemented for several years.In the end, Biggs’ recommendations to theBoard and their implementation in New YorkCity created the model for TB control pro-

“Little Red,” first cottage for tuberculous patients atTrudeau Sanatorium.

With no drug therapies, past TB suffers likethese in 1953 were isolated in sanatoriums.


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grams that was emulated by other healthdepartments across the country and laid thegroundwork for a campaign called the “Waron Consumption.”

During the first part of the 20th century, greatemphasis was placed on improving socialconditions and educating the general publicabout good hygiene and health habits. If youwent to public school anytime between 1900and 1930, you got the TB message, which saidessentially that spit is death. In hospitals itwas common to see signs that read “Spit IsPoison.” Notices were plainly printed inpublic places and government buildings thatstated “Do Not Spit on the Floor; To Do SoMay Spread Disease.”

In the 1920s, when freshair and bed rest did notsecure improvement inthe patient’s condition,physicians sometimesperformed surgery orcollapsed one of thelungs (pneumothorax).During this time therewere many other “sure-

cure” remedies being advertised by many firmsand physicians.

In 1902 at the first International Conferenceon Tuberculosis held in Paris, Dr. GilbertSersiron suggested the adoption of the Crossof Lorraine, used by the Knights of the FirstCrusade, as the symbol of a new movement, acrusade for good health against sickness anddeath, and against TB. The double-barred crosswas adopted as the international symbol forthe fight against TB. This symbol was lateradopted in 1904 in the United States by theforerunner of the American Lung Association.

It was not until the turn of the century thatprivate voluntary groups in the United Statesjoined the fight against TB. In April 1892, Dr.Lawrence F. Flick organized the first Ameri-can voluntary anti-TB organization, the

Pennsylvania Society for Prevention of Tuber-culosis. The organization was instrumental inhelping organize free hospitals for poor con-sumptive patients in Philadelphia. In 1902,Dr. S. Adolphus Knopf of New York was oneof the men responsible for the movement thatlaunched the Committee on the Prevention ofTuberculosis of the Charity OrganizationSociety of New York City. The aim of thecommittee was to disseminate informationthat TB was a communicable, preventable, andcurable disease. The Committee advanced themovement for hospitals, sanatoriums, anddispensaries for consumptive adults and chil-dren. As a result of his focus on the need for anational TB association, in 1904 a voluntaryhealth agency was organized under the Na-tional Association for the Study and Preven-tion of Tuberculosis, later renamed the Na-tional Tuberculosis Association (NTA) andnow known as the American Lung Associa-tion.

To fund the activities of the many local affili-ates, the Association adopted a method thatwas originated in Denmark in 1904 by EinorHolboll, a Danish postal clerk, who soldChristmas Seals. In 1907, many TB sanatori-

ums had sprung up allaround the country; moswere small and make-shift. One in Delawarewas in such urgent needof funds that it was goingto have to close unless$300 could be raised.Dr. Joseph Wales, one ofthe doctors working atthat sanatorium, con-tacted his cousin, Emily

t

Bissell, to help raise themoney. Emily was a welfare worker inWilmington, Delaware; she was also active inthe American Red Cross and had fund-raisingexperience. After reading an article about theChristmas seals in Denmark, she created adesign, borrowed money from friends, andhad 50,000 Christmas seals printed. The seals

Emily Bissell


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were sold for a penny each at the post office.She worked hard to make the campaign asuccess, personally presenting the idea to allsorts of groups and officials, including thePhiladelphia North American newspaper,emphasizing how buying Christmas sealswould help children and adults with TB. Theidea took hold, and by the end of the holidayseason, $3,000 had been raised — 10 times theamount she had set out to raise. By 1946 atleast 10 million people were purchasing sealsor giving to the Christmas seal fund. TheChristmas seal campaign was so widely adver-tised on buttons, milk caps, postcards, schoolbooklets, billboards, book marks, rail and buspasses, etc., that it permeated many aspects ofsocial life. The National TB Association said

at that time that “Nonationwide programhas rested for so manyyears on so broad abase made up of mil-lions of small gifts.”

Then, in the middle ofWorld War II, camethe final breakthrough,the greatest challengeto the bacterium thathad threatened human-

ity for thousands of years: chemotherapy.

In fact, the chemotherapy of infectious dis-eases, using sulfonamide and penicillins, hadbeen underway for several years, but thesecompounds were ineffective against Mycobac-terium tuberculosis. Since 1914, Selman A.Waksman had been systematically screeningsoil bacteria and fungi, and at the Universityof California in 1939 had discovered themarked inhibitory effect of certain fungi,especially actinomycetes, on bacterial growth.In 1940, he and his team were able to isolatean effective anti-TB antibiotic, actinomycin;however, this proved to be too toxic for use inhumans or animals.

Success came in 1943. In test animals, strepto-mycin, purified from Streptomyces griseus,combined maximal inhibition of M. tuberculo-sis with relatively low toxicity. On November20, 1944, the antibiotic was administered forthe first time to a critically ill TB patient. Theeffect was almost immediate and impressive.His advanced disease was visibly arrested, thebacteria disappeared from his sputum, and hemade a rapid recovery. The new drug had sideeffects — especially on the inner ear — but thefact remained, M. tuberculosis was no longer abacteriological exception; it could be assailedand beaten into retreat within the humanbody.

A rapid succession of anti-TB drugs appearedin the following years. These were importantbecause with streptomycin monotherapy,resistant mutants began to appear within a fewmonths, endangering the success of antibiotictherapy. However, it was soon demonstratedthat this problem could be overcome with thecombination of two or three drugs.

Although there were some attempts at provid-ing guidance on TB control measures throughpublication and conferences, the federal con-trol of TB did not occur until the mid-1940s,when the 1944 Public Health Service Act(Public Law 78-410) authorized the establish-ment of a TB control program. On July 6,1944, the Surgeon General established a Tuber-culosis Control Division in the Bureau of StateServices of the Public Health Service (PHS).Doctor Herman E. Hilleboe was appointedmedical director of the new division. ThePublic Health Service provided supplementalfiscal support to state and local health depart-ments for TB control activities through for-mula grants and special grants-in-aid. Thesegrants were to assist states in establishing andmaintaining adequate measures for prevention,treatment, and control of TB and focusedgreater attention on the need for case finding.


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In 1947, the PHS organized and supportedmass x-ray screening in communities withpopulations greater than 100,000. Over aperiod of 6 years more than 20 million peoplewere examined; the program ended in 1953.

The mobile x-rayvans continued to beused in the commu-nities into the mid-1960s. It was com-mon use to showwell-known figuressuch as Santa Clausposing for x-raypictures, stimulatingthe population’scompliance withbeing tested.

A new era was advancing with the introduc-tion of TB drugs, resulting in a decliningmorbidity. The mainstreaming of TB treat-ment to general hospitals and local communityclinics reduced the need for and dependencyon sanatoriums. In 1959 at the Arden HouseConference, sponsored by the National Tuber-culosis Association and the U.S. Public HealthService, recommendations were made formobilizing community resources and applyingthe widespread use of chemotherapy as apublic health measure along with other case-finding activities under the control of publichealth authorities. With the natural decline indisease and the introduction of chemotherapyin the 1940s and 1950s, TB disease started totake on a dramatic decline in the UnitedStates. Morbidity declined at a rate of about5% per year until 1985, when 22,201 caseswere reported in the U.S. for a case rate of 9.3per 100,000 population. By 1970, only ahandful of sanatoriums still remained in theUnited States and by 1992 there were onlyfour TB hospitals with 420 beds providingcare.

Between 1953 and 1979, along with the declin-ing morbidity came declining funding fromstate, local, and federal agencies responsible for

TB control. The cutback in TB control pro-grams across the country left a dismantled andfrail public health infrastructure, too weak toward off the emergence of a new epidemicwave that was brewing. Little did the expertsknow that a new illness that was first observedamong gay men in New York City and SanFrancisco (HIV/AIDS) would have a dramaticimpact on TB morbidity.

The mid-1980s and early 1990s saw an increasein TB morbidity. It was not long before thecountry started to see TB and HIVcoinfections as well as cases with multidrugresistance. Facilities with poor or no infectioncontrol measures experienced numerousnosocomial outbreaks, and there were highdeath rates in hospital wards and correctionalfacilities throughout the country.

The unprecedentedmedia coverage of TB,a disease barely no-ticed for more than 20years, gave rise toincreased funding bystate, local, and fed-eral agencies for TBcontrol activities.With the infusion offunds came the task ofrebuilding a national

infrastructure to control TB and the introduc-tion to TB control programs of a concept thatwas old, yet new: that of directly observedtherapy (DOT), in which the TB patientsingest or take their therapy in the presence ofa health care worker.

As the numbers of TB cases continue todecline in the United States, nearly half of thenew cases reported are occurring in peoplewho have immigrated to the United States. In1998, of the 18,361 cases reported in theUnited States, 7,591 or 41.3% occurred inforeign-born persons. Most of these personscame to the United States from countrieswhere TB is still endemic (e.g., Mexico, the


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Philippines, Viet Nam, China, and India). Where We’ve Been and Where We’reWhile the United States continues to bring its Going: Perspectives from CDC’sTB problem under control, it must be realized Partners in TB Controlthat the United States is not an island untoitself, isolated from the rest of the global Changes I’ve Seen in TB,community. 1949 - 1999

by William W. Stead, MD, MACPIn 1993, the World Health Organization Former Director, TB Program

declared TB a global emergency. Approxi- Arkansas Department of Health

mately 8 million new cases and 2-3 million Professor of Medicine Emeritus, UAMS

deaths occur each year around the world fromTB. In an effort to reduce TB morbidity and When I took a junior staff position with the

TB Service at the Minneapolis Veterans Hospi-mortality worldwide, we must share ourtal in July 1949, under Drs. J.A. Myers andexpertise, successes, and failures, if we are toW.B. Tucker, I had no interest in TB. In mymove toward national and global TB elimina-spare time I worked with Drs. Richard Eberttion.and Don Fry in the physiology of emphysema.The TB dogma at the time was that primaryWe have the power to relegate this ancientTB occurred in childhood and almost neverenemy to the confinement of laboratory vials became serious except in infants. TB in adultsand store it in a deep freeze. As we journey was the challenge and was said to be caused byinto a new century and a new millennium, we catching a new infection on “previouslywill face new opportunities and challenges and sensitized tissues.”

write new chapters in the history of TB. Willwe learn from the past? Will we develop and I lived with this paradigm until 1953 when Iuse new technology to the utmost efficiency? was recalled by the army as the AssistantWill we utilize our resources prudently, and Chief of the TB Service at the Fitzsimonsshare information with our neighbors? Will Army Hospital in Denver. We had an 80-bedwe devote our energies and talents to the ward full of young men returning from Koreaelimination of our common enemy? How with what was then called “idiopathic pleurallong will it take us to accomplish our goals? effusion.” Because of the occasional need toHow many more lives will be sacrificed to explore one of these, we learned that suchTB? The answer to those questions rests in effusions were due to soiling of the pleura by aeach of us who works in TB control. small subpleural lesion of primary TB in the

lower half of one lung (Am Rev Tuberc PulmIn 1956, the Minnesota Tuberculosis and Dis, 1955).Health Association encouraged school chil-dren to be Knights of the Double-Barred Cross My real immersion in TB came in 1960 atand to pledge “. . . to do everything . . . to Marquette University as Chief of the Pulmo-overthrow the enemy, TB.” Are we willing to nary Disease Section of the Milwaukeetake the same pledge today? County Hospital/Muirdale TB Sanatorium.

This was 3 years after the death of my 83-year-old father, whose autopsy showed cavitary TBin the right upper lobe and active renal in-volvement. I felt pretty sure he had not beenreinfected, because there were old scars on thescreening chest x-ray (CXR) done on admis-sion to the extended care facility 3 years earlier


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and all patients were x-rayed annually to At about the same time we showed thatscreen for TB. It seemed pretty evident that primary TB in adults can produce the fullhis TB was due to reactivation of some of spectrum of pulmonary lesions seen in cases ofthose old scars. reactivated TB (Ann Intern Med, 1968).

So, I sought the help of my four older siblings It was not until the 1970s as TB Controller for(including Eugene, who is 10 years my senior Arkansas that I really began to understand TB.and at the time was Chairman of Medicine at In 1976 we encountered an outbreak of TB inDuke). We were able to piece together a likely our state prison with evidence that it had beenscenario. Dad’s father had died of “consump- going on for at least 5 years. Ten active casestion” in 1890 when Dad was a healthy 15-year- among 1,500 inmates gave an incidence of 667/old. In 1902 he had some illness of which we 100,000 vs 21 in the state at large that year.had no details except that a doctor had sug- We found about 100 TST converters, evenlygested that Dad sleep out-of-doors as much as split between black inmates and white inmatespossible. Later, as a traveling salesman over (JAMA, 1978). At the time I did not realizefour southern states, he would sleep in a tent that there were about 1,000 white and onlyat the edge of whatever town he happened to 500 black inmates. So, I missed the differencebe in at dusk. Eugene traveled with him some in their infectibility. I held a monthly Chestsummers and attests to this story. Clinic at the prison for 8 years to screen new

inmates for TB and to see that TST reactorsI can recall that Dad commonly “hawked and got INH therapy.spit” a greenish-yellow sputum. Gene recalledthat he required frequent massage of a “boggy” My next shock came in 1978 when we foundprostate gland and that he had a number of an outbreak at a nursing home. I was notepisodes of painless hematuria, all of which surprised at finding a case of TB in a nursingsuggested chronic renal TB. Finally, in 1941 a home, because most of the population wouldsister returned home with a pre-school son be TST positive from living through the 1920swho at age 6 developed an illness with a and 1930s when TB was so common.cough, positive tuberculin skin test (TST), and Hermione Swindol, PHN, argued that itabnormal CXR. He was confined to bed for 6 would spread and she proved to be right.months. At the time Dad was not suspected as What I did not know then was that healthythe source. Two of my siblings and I had elderly people often outlive their TB germspositive tuberculin tests. Mother remained and the TST reverts to negative. Only 15%-well but I have no information on her TST. 20% of new admissions were TST positive,

leaving 80%-85% susceptible to a new infec-With this scenario suggesting a long and tion. We found 60 converters, 10 of whomlargely healthy life with TB, I began to ques- had active TB (Ann Intern Med, 1981).tion the dogma of adult TB being due to anexogenous reinfection. Fortunately, the Because of these findings we got the 225Sanatorium had vast numbers of old CXRs, nursing homes in Arkansas to do two-stepsome back to glass plates. With these I was TSTs on all new admissions not known al-able to find old scars in a fairly large percent- ready to be positive. Twice a year they reportage of our active cases of TB and published TSTs of their new admissions and update thetwo papers on the natural history of TB in data on other residents. At first I kept theman (Am Rev Respir Dis, 1967, and New Engl J records in a Radio Shack TRS80 Model 1Med, 1967). computer. I now have demographic, skin test,

and TB data on 115,000 nursing home resi-dents from 1984 through 1998 (Int J Tuberc


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Lung Dis, 1998). Only 5%-10% of admissionsto our nursing homes are TST positive now.

Perhaps the principal discovery that has comefrom these data is that there is a significantdifference in innate resistance to TB infectionbetween whites and blacks. In addition, studyof our TB case data base from 1976-1997shows that blacks with active TB are 50%more likely than whites to be sputum-smearpositive and thus highly infectious.

I am now preparing a paper to show theimportant public health implications of such adifference in TB risk. While health depart-ments routinely try to identify all close con-tacts with infectious cases of TB, a particularlygreat effort should be made among the AfricanAmerican and Native American contactsbecause of their greater risk both of infectionand of becoming infectious. It is importantfor such reactors to take the full course ofchemoprophylaxis to prevent development ofTB and further spread. This applies especiallyto exposures in close living quarters, i.e.,dormitories, nursing homes, shelters, andprisons.

It has been an interesting half century. Thebest part was the quarter century in publichealth in Arkansas from 1973-1998.

TB Control in New York City:A Recent History

by Paula I. Fujiwara, MD, andThomas R. Frieden, MD, MPH

Current and former Directors of theNYC TB Control Program

Many of the tenets of modern TB controlwere developed more than a century ago inNew York City by Dr. Hermann Biggs, aphysician working for the Department ofHealth. These included the policies of free,high-quality sputum examination, the manda-tory reporting of cases, health departmentsupervision of isolation and treatment, educa-tion of the public regarding TB, and thefostering of a social movement for control ofthe disease. The City’s TB control programwaxed and waned over the next 100 years,with the lowest number of reported TB casesin the city occurring in 1978.

During the 1980s, the rapid rise in TB wasfueled by the human immunodeficiency virus(HIV) epidemic; growing poverty,homelessness, and incarceration rates; andimmigration from countries with high TBprevalence. In this context, the infrastructureof TB control had been dismantled, the victimof a one-two knockout punch of a fiscal crisisin the City and a change to a system of blockgrants for federal funding. One long-timeemployee, when asked how it felt to see theincrease in cases year after year, said, “Wethought that’s just the way it was.” Staff weretrapped in a cycle of reporting cases, startingtreatment on those they could locate, butlosing many of them. Staff knew they shouldbe searching for the lost patients but weredistracted by the overwhelming number ofnew infectious cases. Citywide, less than halfof the patients completed treatment. Repeatedwarnings from experts and panels did not leadto increased concern or funding.


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It was not until 1991 that TB got the attentionit warranted. The first alarm was a series ofnosocomial outbreaks of multidrug-resistantTB (MDR TB) in various hospitals in NewYork City. The second alarm was the an-nouncement of the results of a month-longcitywide drug resistance survey, which re-vealed that 19% of all M. tuberculosis culturesin New York City were resistant to isoniazidand rifampin. Remarkably, half of all patientswith positive cultures had been treated before,many of them for months. These patientsrepresented a failure of the system to ensurethat patients were reliably treated, and fullyone third of these patients had MDR TB. Bycomparison, a nationwide survey during thefirst quarter of 1991 showed that only 3% ofall cultures were multidrug-resistant (withNew York City accounting for two thirds ofthe cases), a proportion similar to that in NewYork City just 7 years earlier, in a 1984survey.

Phase I: the battleDr. Karen Brudney, an astute clinician withinternational experience in TB control whohad worked with Dr. Karel Styblo in Nicara-gua, called the City Health Department toreport that she suspected that drug resistancewas increasing. Dr. Brudney had writtenhighly publicized (and accurate) articles high-lighting the dismantling of the TB controlinfrastructure in New York City and docu-menting that in Central Harlem, only 11% ofpatients started on treatment completed the

treatment. In 1991, one of the authors (TF),then working at the New York City Depart-ment of Health as an Epidemic IntelligenceService Officer, conducted the citywide surveyof drug resistance mentioned above in re-sponse to Dr. Brudney’s concern. Working inone of the Department’s chest clinics since1990, he had seen the TB problem first-hand.Margaret A. Hamburg, who was the Commis-sioner of Health at that time, appointed Dr.Frieden the Director of the Bureau of TBControl (changed in September 1999 to theNYC TB Control Program). At the height ofthe epidemic in early 1992, in a meeting withthe entire staff of the Program, Dr. Friedensurprised staff by stating that he was “proud tobe part of the organization that would controlTB in New York City.” The basic tenets ofthe program were developed: the patient is theVIP, directly observed therapy (DOT) is thestandard of care for TB treatment, laboratoriesneed to be supported and monitored, comple-tion of treatment is the report card of howwell the program is performing, and everystaff member is accountable for his or herperformance. Against considerable barriers,doctors, nurses, outreach workers, and otherstaff were hired, chest clinics were opened onSaturdays and evenings, and the TB Programbecame a significant source of income for theDepartment of Health through improvedbilling practices. TB control doctors andnurses even performed new employee physi-cals so staff could be hired without the typicalmonths-long delays. The TB program had thecrucial and unwavering support of Commis-sioner Hamburg.

At every opportunity, it was emphasized thatoutreach workers were “modern public healthheroes.” The TB Program worked on multiplefronts, simultaneously striving to improve themedical care of TB patients, promote standard-ized treatment guidelines, expand surveillance,improve laboratories, expand social servicesfor TB patients, control outbreaks in hospitalsand correctional facilities, encourage andconduct epidemiologic studies, educate and


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train doctors and other staff, and delineate theproper use of increasingly restrictive measuresagainst TB patients, including detention.After a visit by Dr. Karel Styblo to New YorkCity, the TB Program implemented a cohortreview process, in which the Director person-ally reviewed every one of the thousands ofcases for treatment details and completion.The outcome was a steep increase in comple-tion rates and, beginning in 1993, a steepdecline in the number of reported TB cases.More impressive was the even sharper declinein the number of reported cases of MDR TB,from 441 cases in 1992 to just 38 cases in 1998.Cases of TB in US-born persons decreasedfrom 2,939 in 1992 to 700 in 1998.

Phase II: new frontiersAfter completion rates increased, cohortreview meetings began to include informationon contact evaluation and preventive treat-ment. The efficacy of this process was recog-nized when, in 1998, the NYC TB ControlProgram was honored as one of 25 finalists,out of a field of more than 1,300 nominees, forthe prestigious Innovations in AmericanGovernment Award, given by the Ford Foun-dation and the Harvard School of Govern-ment.

After TB case completion rates improved,program staff began to concentrate on treat-ment of patients with latent TB infection(LTBI), especially those at high risk of devel-oping TB disease, such as the HIV-infected,close contacts, recent immigrants from TB-endemic countries, and persons with evidenceof “old” TB. A unit to monitor treatment ofimmigrants and refugees was created, and anexpanded contact investigation unit evaluatedcases of TB in workplace as well as congregateand school settings. Treating those who “only”have TB infection rather than disease has beenin many ways even more difficult than treat-ing those with TB disease. It has been difficultto convince people to take medications whenthey do not feel sick. The City’s health codedoes not allow (nor should it) the TB program

the same powers to use increasingly restrictivemeasures against the patients who do not taketreatment for LTBI. Some physicians in NewYork City, including many trained outside ofthe country, do not believe that treatment forLTBI is important, and pass this belief on totheir patients.

Facing the next century, one of the program’sbiggest challenges is to improve completion oftreatment for LTBI while at the same timeeffectively treating the more than 100 newcases of TB that arise every month.

Phase III: New York City in the context ofglobal TB controlDuring the late 1980s and early 1990s, HIVfueled New York City’s TB epidemic. Thismasked the slower rise in the number of casesin persons born outside of the United States.In 1997, the percentage of cases in foreign-bornpersons in New York City exceeded thenumber of cases in United States-born personsfor the first time in recent history. The rise incases in the foreign-born has created newchallenges. Bicultural and bilingual staff havebeen hired. People’s fears that the TB controlprogram is connected to the Immigration andNaturalization Service must be quelled. Peoplefrom Ecuador, the Dominican Republic,Puerto Rico, and Mexico may share a commonlanguage, but have disparate beliefs about TBtransmission and risk. It is not possible to havea one-size-fits-all approach to identifyingpatients, encouraging them to present forevaluation and treatment of TB disease orinfection, and helping them adhere to treat-ment. TB control activities must be specifi-cally tailored not only to the patients, but alsoto those who provide their care. When pa-tients move back to their country of origin,New York City’s program staff communicatewith patients’ health care providers to ensurethat adequate treatment continues. It is notunusual for staff to call Costa Rica, Pakistan,Mexico, or the Ivory Coast to glean informa-tion on treatment completion in order to“close the loop” for cohort reporting!


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What is the role of New York City in theglobal fight against TB? Many people migrateto places such as New York City to bettertheir economic lot, and many of these peoplecome from areas of the world where TB isendemic. New York City’s TB cases representa microcosm of TB around the world; in 1998,these cases came from 91 countries, led byChina, the Dominican Republic, Haiti, Ecua-dor, India, and Mexico. In some instances,people (including those with MDR TB) cometo New York City specifically to be treated,having heard of the program’s success.

One of New York City’s contributions to theglobal battle against TB is to support interna-tional colleagues’ TB control efforts, to advo-cate for more funding for these programs, andto be gracious hosts and teachers when offi-cials from different countries visit to learnabout New York City’s success. In 1900, theTB control program of the New York CityDepartment of Health, under the leadership ofHerman Biggs, was an international model.Today, New York City’s experience providesglobal hope and evidence that even in thecontext of an HIV epidemic and a high rate ofmultidrug resistance, the battle against TB canbe won and the disease can be controlled.

Not by DOT Aloneby J. Michael Holcombe, MPPA, CPM

Mississippi TB Controller

Mississippi proved directly observed therapy(DOT) to be a great tool toward TB elimina-

tion. However, DOT is not a programmaticcure-all, a stand-alone solution, or the prover-bial yellow-brick road. Not what you expectedto hear from Mississippi, is it?

We know that DOT is the best way to treatTB. It might not always be the most conve-nient or the easiest, but with the correct drugs,dosing, monitoring, and delivery, it is unsur-passed at present. When it comes to DOT andits impact, we must remember the Chineseproverb, “Hear and forget; see and remember;do and understand.”

With full implementation of universal DOTon a statewide basis in the mid-1980s, TBprogram performance indicators began toimprove. Patients’ sputum converted faster,reducing the potential period of infectiousness;a greater percentage of patients completedtherapy; a greater percentage completedtherapy in a timely manner; the number ofpatients acquiring drug resistance decreasedrapidly; the number of program admissionsfor inpatient care dropped dramatically; theaverage length of an inpatient stay dropped;and the number of new TB cases began to fall.The reduction in morbidity allowed moretime for contact follow-up, the expansion oftargeted testing, and the implementation ofdirectly observed preventive therapy in selecthigh-risk populations. This increased thenumber of patients on preventive therapy andthe percentage of patients completing preven-tive therapy.

To further support the strengthened efforts,laws were modified to improve our ability toprotect the public from patients who fail tocooperate with treatment or isolation, andrules were changed to improve reporting. Weplaced emphasis on outpatient care and priva-tized elements of the program best and mostefficiently provided by private providers —radiology services, for example — to expandavailability, improve quality, and amelioratecost.


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Many told us universal DOT could not bedone; a few said it should not be done. But wecontinue to truly believe DOT is the bestservice we can offer our patients and thepublic. We believe DOT offers the surest andbest chance for a timely cure. Why should wetreat anyone with less than what we believe isthe best we can offer? Their future is ourfuture.

True, Mississippi has made great strides in TBcontrol. But we’ve made those strides not byDOT alone.

Each and every one of those great strides wasmade by everyday people: nurses, aides, clerks,outreach workers, doctors, disease interven-tion specialists, and volunteers — hard work-ing, dedicated, and passionately devotedindividuals who were, and are, determined tomake a difference one patient, one facility, onecommunity at a time.

From the establishment of our sanatoriumearly in the century through its demise and therise and continuing refinement of our outpa-tient treatment delivery system, public healthnurses have made most of those great stridespossible. Usually, the nurse comforts, edu-cates, and gives hope to the distressed patientwho has been notified of exposure or disease.The nurse confronts and calms the angry,hostile, and all-too-often dangerous patientwho has given up and no longer cares abouthimself or others. The public health nursepersists through heat or snow, wind or rain,dogs, gangs, or alligators and finds the patientsand persistently guides, cajoles, or bribes themthrough treatment. If, along the way, thatmeans baking a few extra cookies, making anextra trip after work to deliver a home-cookedmeal to a homeless or lonely patient, buyingan extra can of soup or a chicken for an im-poverished patient while grocery shopping, ortaking the time to put a grubby little 4-year-old on the lap and reading a story in hope ofmaking the treatment seem a little morepalatable . . . that’s nothing special. That’s just

the way DOT happens: good people doinggood things. No bells, whistles, or wreaths oflaurel — just another great stride taken insilence and out of public view.

Public health nurses, of course, don’t work inisolation or independently. Without a doubt,each stride is made easier by the clerk whogreets the patient kindly and patiently, thenhelps expedite the visit. Each stride is madeeasier by the outreach worker who helpsensure each dose of medication is ingested andeach appointment is kept. Physicians who taketime from their busy practice to conductregular clinics at the health department alsomake each stride easier, more sure, and morepurposeful. And the advances in science, theeffective anti-TB drugs available, and theemerging technology for more rapid andaccurate diagnosis have been and are unques-tionably essential to the progress we havemade.

Yes, DOT has been a vital tool for ensuringprogress and managing cost. We used it as thefulcrum to move Mississippi from a deepeningrut and to change the direction of TB control.But, DOT was only part of the plan. Progresscannot be achieved by DOT alone. DOTrequires achievement goals; community sup-port; good legislation; adequate infrastructureand funding; a dedicated, determined publichealth field staff; and the strong support ofadministration.

Baltimore at the New Millenniumby Kristina Moore, RN, andRichard E. Chaisson, MD,

Professor of Medicine, Epidemiology,and International Health

Johns Hopkins University

Mr. C, a Baltimore City resident, knows hewas diagnosed with active pulmonary andlymphatic TB in May 1999. He receives hisTB treatment through the Baltimore CityHealth Department (BCHD)/Eastern Chest


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Clinic (ECC) by directly observed therapy(DOT) in his home on Mondays and Thurs-days. Provided he does not miss either of histwice-weekly intermittent supervised doses(TWIS) of TB medications, he receives two $5food coupons on Thursdays to fortify hisnutritional intake. If Mr. C needs to comeinto the ECC for a clinician evaluation, histransportation is provided by BCHD. A nurseoutreach team manages Mr. C’s case. His casemanager is a registered nurse and his DOTmanager is a licensed practical nurse. Mr. C’scase is reviewed by the nurse team weekly andby a BCHD clinician monthly. As a result ofcontact with Mr. C, his family and friendshave all been offered TB screening evaluationsand follow-up, free of charge. Mr. C is alsoparticipating in a national TB research proto-col, one that is evaluating the efficacy andsafety of a rifabutin-based treatment regimenfor HIV-related TB. His BCHD/ECC clini-cian is also his HIV care provider at the JohnsHopkins Hospital HIV Clinic.

What Mr. C may not know is that the com-prehensive care he is receiving through theBCHD took years to develop, research, andrefine. He also may not know that as a resultof the once innovative, now national standardof care he is receiving, the Baltimore TB caserate is at the lowest level ever recorded, andthat the resurgence of TB that occurred else-where in the US between 1985 - 1992 did notaffect Baltimore (see graph).

In Baltimore, DOT was the brainchild of thelate Dr. David Glasser, Baltimore City’sDirector of Disease Control/Assistant Com-missioner of Health. Implemented in 1978 forhigh-risk clinic TB patients, DOT was ex-panded in 1981 to a community-based,citywide program. As a result, between 1978and 1992, TB case rates in Baltimore declinedby 81%, and the city’s national rank for TBdropped from second in 1978 to 28th in 1992,despite the emergence of an HIV/AIDS epi-demic. Cases and case rates have continued todecline to a record low of 84 cases (13 per100,000) in 1998.

Baltimore’s declining TB case rates are alsoattributable, in part, to another ofDr. Glasser’s novel approaches to TB control.In the mid 1970s he convinced Baltimore’sCity Council to pass an ordinance mandatingpharmacies to report any issuance of anti-mycobacterial drugs to the BCHD. Pharmacyreporting led to improved TB case reporting,improved treatment regimens, and an increasein DOT through BCHD managed cases. Thesetreatment and management improvements alsoexplain, in part, Baltimore’s low incidence ofdrug resistance (5.9% in 1998), and high inci-dence of treatment completion (96.5% in1997).

Yet another of Dr. Glasser’s foresights was todevelop an outreach and liaison program withthe City’s methadone maintenance clinics.Recognizing injecting drug use as an importantrisk factor for TB, Dr. Glasser implemented aTB screening and preventive treatment pro-gram at the city’s methadone clinics. By themid-1990s, BCHD had bridged TB effortswith nearly all of the city’s drug treatmentprograms.

Dr. Glasser’s ideas laid the foundation for thehard-working members of Baltimore’s TBprogram, who have continued to build uponhis TB control legacy through the years.Baltimore has implemented additional innova-tive TB control strategies in the last two


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decades. The development of liaisons withMaryland Department of Health and MentalHygiene, Maryland Division of Corrections,and private providers has improved casereporting, case management, case follow-up,and case prevention efforts. Forging a treat-ment, prevention, and research collaborationwith nearby Johns Hopkins University’s(JHU) Center for TB Research has also con-tributed to improved BCHD TB controlmeasures. BCHD/ECC’s Medical Director,clinician staffing, and radiology support are allprovided through a contractual agreementwith JHU. In addition, this cooperative rela-tionship has resulted in several exciting TBresearch projects, including neighborhood-based TB screening, TB prevention studies ininjection drug users, and DNA fingerprintingstudies. BCHD and JHU have also collabo-rated to form a contract site for the TBTC(Tuberculosis Trials Consortium).

The challenges for Baltimore City TB Controlin the new millennium will involve continu-ing the successful case reduction efforts of thepast century through new initiatives. A mainpriority will be focusing efforts on the treat-ment of latent TB infection (LTBI). Efforts toevaluate the possibilities of even shorter coursetherapy and additional treatment options forboth active cases and LTBI will also be para-mount. Another key interest will be partici-pating in the efforts to develop a more effica-cious TB vaccine. All of these new initiativeswill depend upon the development of nationaland international collaborative networks inTB research. For TB elimination to finallytake its place in history, a global approach isan absolute necessity.

As the new millennium begins, Baltimore CityTB Control is ready to join the world inmeeting its challenges. Patients like Mr. C willcontinue to benefit from the dedication of aCity Health Department committed to theultimate goal: treating the last case of TB.

From Crickets to Condoms and Beyondby Carol Pozsik, RN, MPH

South Carolina TB Controller

It’s history now but people still chuckle aboutthe story of the man who was given cricketsfor fishing as an incentive when he couldn’t belocated to take his TB medications. Clearly,fishing was more important that his TB treat-ment. His public health nurse recognized thatit was going to take an unusual motivator toget him to meet her for directly observedtherapy, and thus was born the story of thecrickets given to the fisherman. It wasn’t thefirst time that nurses or other health careworkers had given incentives to encouragepatients to comply and it certainly wasn’tgoing to be the last. For TB nurses in SouthCarolina, incentives and enablers becamesomething that they could not do without.The concept has spread nationwide, and isnow an accepted intervention in the treatmentof TB infection and disease.

For many years the American Lung Associa-tion of South Carolina (ALASC) had givenmoney for patient needs to the State Tubercu-losis Sanatorium. As the sanatorium popula-tion dwindled in 1981, the Executive Directorof the Lung Association began to wonder howthe Patient Needs Funds could be used to helpTB patients who were not in the hospital. Itwas at that time that the fisherman’s TB nurseapproached the ALASC and appealed forfunds to provide incentives to more patientswho needed them. That was the beginning ofthe use of incentives and enablers in the SouthCarolina TB Program.

Enablers and Incentives

TBTuber culos is

Cont r ol


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At first some of the nursing staff resisted theidea of using incentives. Change was difficultto accept; about that same time, the programwas also starting what was then called SIT(supervised intermittent therapy), and is nowcalled DOT (directly observed therapy). Somenurses could be heard griping about “spoon-feeding” the patients. (Translated, this meantthat they felt that the patients should taketotal responsibility for their treatment, andthat the nurses shouldn’t have to give themanything to get them to be responsible.) Forsome staff, it was all too much: asking them tonot only watch patients take their medicines,but then, asking them to give the patientssmall gifts as well — it was just more than theycould bear! However, as time wore on, thesesame nurses became zealous about doing DOTand giving incentives. (In fact, one nurse felland broke her leg during the course of givingDOT and, in spite of a compound fracture,she demanded that the ambulance drivers takeher on to her next two visits so she couldcomplete her DOT rounds.) Those big heartsin the TB nurses were hooked and the con-cepts of DOT and incentives really took hold.Soon everyone in South Carolina was usingDOT and the stories of the incentives thatwere used were told and the success rate ofcompletion of therapy got better and better.

In those early days the incentives were simple:juice, hamburgers, chicken snacks, fruit,candy, even condoms. Today, the staff havemoved to more sophisticated incentives suchas smoke alarms for fire protection in substan-dard housing and swimming lessons for under-privileged children. TB nurses and DOTworkers have big hearts and they dig deep topersonalize the incentives and enablers fortheir patients.

Dr. Dixie Snider, former Director of CDC’sDivision of TB Elimination, knew about thesuccess of the incentives and enablers programin South Carolina and gave us encouragementto publicize the stories about incentives andDOT in order to educate other TB programs,

so that they might begin to use incentives.With the help of the ALA of South Carolina,the booklet Using Incentives and Enablers in aTuberculosis Control Program was published.The book gives the history of incentives andhelpful advice about their use. Still popularafter many printings, the book continues tohelp TB workers in their use of incentivesboth in the United States and in other coun-tries. TB workers and others love to hear thestories and see the pictures of real patientswith their caregivers. The pictures give a realface to TB and give encouragement to newstaff in the program that they too can besuccessful with incentives. Whenever I amasked to speak about improving compliance,naturally I also talk about the importance ofusing incentives and enablers to make ourwork easier, but more importantly to bondthe caregiver with the patient in a trustingrelationship.

The successful use of DOT and DOPT inSouth Carolina could not have ever happenedwithout the use of incentives. Who wouldhave thought that something as unscientific asa red bridle for a mule, a cold drink on a hotday, a pair of warm socks, or an oldoverstuffed chair would contribute signifi-cantly to the successful treatment and preven-tion of TB in the United States?

The Denver TB Program:Opportunity, Creativity, Persistence,

and Luckby John A. Sbarbaro, MD, MPH, FCCP

Professor of Medicine and Preventive MedicineUniversity of Colorado Health Sciences Center

Four words — opportunity, creativity, persis-tence, and luck — summarize the successes ofDenver’s TB program.

For decades, Colorado had been a mecca forthe victims of TB. However, along with thedemise of the sanatorium era, Denver’s TBcontrol program had progressively deterio-rated. As in other large cities, the insured


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disappeared into the private sector, while thepoor and those from the street continued to behoused for months upon months on a forgot-ten floor of the public hospital.

In 1965, Denver was awarded a CDC TBBranch grant, which included the assignmentof one of the CDC’s first six TB medicalofficers. The project award was designed toenhance the city’s decimated TB clinic. How-ever, the standard of treatment, 24 months ofdaily INH and PAS, presented a dauntingobstacle to the ambulatory treatment of a largepopulation of chronic alcoholics and disadvan-taged, socially isolated inpatients. How totreat effectively yet compassionately was thequestion.

A little-noticed report in a foreign journalprovided an answer. In Madras, India, theBritish Medical Research Council (BMRC)appeared to have successfully treated patientswith high doses of INH and streptomycingiven intermittently over one year. Theregimen made sense scientifically and pro-grammatically. If directly administeredthroughout treatment, the opportunity forcure would be maximized and a concernedpublic assured that these ambulatory patientsdid not place the community at risk becausethey were receiving adequate treatment(“chemical isolation”). Fortunately, at thatmoment there was no local health departmentauthority to say “no” and the regimen wasimplemented, although modified to include athree-drug intensive phase and an 18-monthtwo-drug continuation phase.

The uniqueness of this treatment approachspawned widespread changes in Denver’sambulatory TB program. The resultant emer-gence of one-to-one relationships betweennurses and patients led to a major role expan-sion, with nurses encouraged to function moreindependently, including reading x-rays anddetermining which standing treatment orders

to implement. By early 1966, both DOT andthe nurse-directed TB clinic had indeed arrivedin the US. And what nurses do, they docu-ment — every action and every outcome —and with that documentation, Denver’s ongo-ing research program was established. Innova-tion, when measured, becomes meaningfulclinical research. A long list of skilled TBnurse specialists such as B.J. Catlin, Jan Tapy,and Maribeth O’Neill not only provided careto thousands of patients but served as thecornerstone for Denver’s contributions to thescientific and social understanding of TBcontrol.

However, organizations either continue togrow or they die, and growth requires change.As new knowledge emerged and new drugsbecame available, so did new opportunities.Fortunately, the arrival of Mike Iseman earlyin the program and subsequently of DaveCohn ensured that no opportunity would passunnoticed. Program components were evalu-ated for cost-effectiveness and communityimpact. Denver was amongst the first toeliminate the mobile chest x-ray in favor ofselected population skin testing; to focus onthe effect of inducements and enforcement onpatient compliance; and to create a meaningfulrole for community outreach workers. Newshort-course DOT regimens were developedand tested; screening programs were evaluated;the effect of TB drugs in infected humanmacrophages documented; and “molecularepidemiology” was applied to a long-standingdatabase and a freezer stored with isolates ofmycobacteria.

The emergence of HIV stimulated new ques-tions, new initiatives, and an opportunity tofurther build upon 30 years of close workingrelationships with, and support from, theCDC. Denver’s long history of integratingfederal, state, and private grants into a singlelocal program encouraged its early inclusion inmulticenter national studies sponsored byCDC and the National Institutes of Health


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Denver’s TB program was, and is, based uponthe principle that it is responsible for curingthe patient. In the long run, the persistence ofthat belief is the true foundation of Denver’ssuccess.

National Jewish:The 100-Year War Against TB

by Jeff Bradley andMichael Iseman, MD

Director, National Jewish Medicaland Research Center

Denver, Colorado

National Jewish Medical and Research Center,which celebrated its centennial in 1999, isknown today for its expertise in a wide arrayof respiratory, immunologic, allergic, andinfectious diseases. At the time of its founding,however, it had a single purpose: the care ofimpoverished victims of TB.

The need for a TB hospital became acute inDenver in the 1880s. In those days, peoplebelieved that the dry climate of the high plainson which Denver is located would curetuberculars (i.e., persons with TB disease).Consequently, many TB sufferers spent theirlast dollars coming to Colorado. By the 1890s,it was estimated that one out of every threeresidents of the state was there for respiratoryreasons.

In Denver, TB patients were literally dying onthe streets. Boarding houses often banned“lungers,” as they were called, and many ofthem were too sick to support themselves. Awoman named Frances Wisebart Jacobs recog-nized the need for a TB hospital and, after

Old National Jewish Hospital

(NIH). Strong academic ties with the Univer-sity of Colorado’s Health Sciences Center,collaborative teaching at the National JewishMedical and Research Center, consultationwith the IUATLD and WHO, and member-ship on ACET provided expanded opportuni-ties to share the “Denver experience” and tolearn from colleagues throughout the world.

During these years, the recruitment ofDenver’s retired TB “greats” such as Gen. CarlTemple and Drs. Roger Mitchell and JackDurrance to work regular hours each week inthe clinic ensured that the knowledge of thepast would not be forgotten in the excitementof the future. Unhappily, their days of contri-bution have passed, but the camaraderieestablished between physicians, nurses, andclinic staff produced an environment in whichprofessional creativity continues to flourish.Challenging existing beliefs and methods hasbecome standard operating behavior. Theentrance of Randall Reeves and later of BillBurman ensures that it will continue, high-lighted by their scientific leadership in the TBTrials Consortium.

The underlying philosophy driving the Den-ver TB Clinic is perhaps best summarized intwo quotes from a 1970 publication, “ThePublic Health Tuberculosis Clinic, Its Place inComprehensive Health Care” (Am Rev RespirDis 1970;101:463-465):

In the private sector, “even with thebest intentions of the physicians andstaff, the actual responsibility for carerests with the patient. In TB control,the responsibility for care rests withthe clinic.”

“...the clinic is the best way to husbandthe meager resources of personnel andmoney and the only way to fix respon-sibility on the providers of servicerather than on the recipients... ”


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joining forces with a young rabbi, the tworaised enough money to buy some land anderect a building, which was ready for patientsin 1893. Unfortunately, however, Denver washit with the Silver Crisis that year, and therewas not enough money to open and run thehospital.

This setback convinced the organizers thatthey should expand their fundraising effortsbeyond Colorado. The thinking in Denverwas that, since patients came there from allover the nation, people all over the UnitedStates should help support the hospital. Theyturned to B’nai B’rith, a national Jewishservice organization, and contributions camein from across the country. The buildingfinally opened in 1899 as the “National JewishHospital for Consumptives.”

National Jewish was the first hospital in thenation to focus exclusively on indigent TBpatients. As expressed in a singular motto, thisphilosophy was “None may enter who canpay, none can pay who enter.” From day one,National Jewish was non-profit and non-sectarian.

The hospital opened with a capacity of 60patients; the goal was to treat 150 patients peryear. This was made possible by putting a 6-month limit on patient stays. Furthermore,National Jewish only accepted patients in theearly stages of TB. At least that was the plan.In reality, however, several chronic suffererswere admitted, and after a few months, the 6-month limit was lifted.

The treatment at National Jewish was in linewith the protocols at other turn-of-the-centuryTB sanatoria: plenty of fresh air, lots of food,moderate exercise, and close scrutiny of everyaspect of patients’ lives. The inhabitants ofNational Jewish, thus, could expect to sleepoutside — or with their heads outside — everynight, and were all but stuffed with food. In1911, for instance, the annual report recordsthat National Jewish spent $3,631 on eggs —

roughly equivalent to $62,000 today — for just120 patients.

In 1914, National Jewish erected a building forthe study of TB; this was the first place inwhich research on the disease was done out-side of a medical school setting. Other ad-vances included the nation’s first self-con-tained facility for treating children with activecases of TB and work on anti-TB drugs such asisoniazid (INH) in the early 1950s. Later inthat same decade, doctors at National Jewishcame up with a new protocol for TB thatincluded abandonment of bed rest and asubstitution of physical activity; use of micro-biological assay measurements to determinethe proper dosage of INH; and combined drugtherapy using streptomycin, INH, and para-aminosalicylic acid.

As TB gradually came under control in theUnited States, National Jewish expanded itsmission to include asthma and other respira-tory diseases, but maintained a strong presencein TB. Research continued on better drugs,and the institution expanded its educationefforts. In 1963, the 1- to 2-week TB controlcourse was offered for specialists from all overthe world, a course that is still offered today.Indeed, over the past 20 years, nearly 5,000physicians and nurses have visited Denver forthe course.

Rifampin, the most widely used drug for TBtoday, was tested at National Jewish in 1970.Two years later, federal funds established astate-of-the-art laboratory to study difficult TBcases. This helped establish National Jewish asa highly specialized center for drug-resistantTB and atypical mycobacterial infections.

Today, National Jewish continues to be asteady contributor in the fight against TB.The hospital offers compassionate care tovictims of MDR TB, often providing treat-ment for the poor at no charge. Leadingpharmaceutical companies collaborate withNational Jewish to test new drugs. Perhaps


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the greatest contribution of National Jewish isin education. In addition to the TB course,the hospital maintains a Mycobacterial Con-sult Line, a free service whereby physiciansanywhere in the world can call up and receiveadvice from our specialists. Over the past 5years this service has responded to over 2,000calls annually.

At the opening of National Jewish back in1899, the president of the institution, speakingof TB in the exalted rhetoric of that day,declared that it was his dream for the hospital“that its doors may never close again until theterrible scourge is driven from the earth.”Now, at the time when the World HealthOrganization estimates that one out of everythree people in the world is infected with TB,those doors are still open.

Earthquakes, Population Growth, and TBin Los Angeles County

by Paul T. Davidson, MDLos Angeles TB Controller

In the late 1960s, Los Angeles County built astate-of-the-art TB hospital. Most of the 1,300or more persons being diagnosed with newcases of this disease each year were spendingmany months in the hospital before receivingtreatment as outpatients. The Sylmar earth-quake of 1971 essentially destroyed the hospi-tal and propelled the County into consideringother approaches to managing this disease.Some patients were transferred to Rancho LosAmigos Hospital, a long-term rehabilitationfacility. The majority were referred to theover 40 Public Health Centers then in exist-ence throughout the county. This began whathas since become a largely outpatient systemfor the follow-up and care of TB patients. Sixcounty hospitals have continued to diagnoseand treat many TB patients. Liaison nursesassigned by the TB Control Program facilitatethe transfer of these patients to the PublicHealth Clinics. Approximately 25% of TBpatients are diagnosed and followed by theprivate health sector.

During the past 30 years there have beennumerous changes in Los Angeles County thathave impacted upon the TB problem. Adramatic increase in the population has oc-curred. Many of the new residents are immi-grants from countries where TB is prevalentand in many cases increasing in incidence. Bythe end of the 20th century nearly 75% of allthe new cases in Los Angeles occurred in theforeign born. Poverty and homelessness havebeen a persistent social and cultural factorsupporting continued spread of TB. By thelate 1980s, the emergence of HIV infection anddisease contributed to the number of TB cases,reaching a peak of 15% of all the cases beingHIV positive in 1991.

In the 1980s efforts were increased to fight theTB problem among the homeless. A satelliteclinic in the Skid Row area of downtown LosAngeles was established. This clinic dependedon outreach workers to find and transportpatients to the clinic for directly observedmedication and medical management. Becausemany of the homeless still defaulted on treat-ment and spent repeated episodes in the hospi-tals, a pilot project funded by the State ofCalifornia was instituted. It provided housingand food incentives to the homeless in SkidRow in exchange for taking medication andcompleting TB treatment. The results weredramatic, with better than 95% of the partici-pants completing therapy and the number ofhospital days being much reduced. The pro-gram was eventually funded by the Countyand extended to other areas wherehomelessness is also a problem. This programcontinues, and the number of TB cases amongthe homeless is declining more rapidly thanthe overall number of cases.

In the late 1980s an HIV/TB program wasestablished to provide liaison with HIV pro-viders. Screening guidelines for TB wereestablished regarding admission of HIV pa-tients to hospitals, hospices, and other congre-gate living facilities. The liaison nurse essen-


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tially case-managed all known HIV/TB casesand helped to facilitate their care throughoutthe healthcare system. To date, there havebeen no known outbreaks of TB in any of thehealth care facilities within the County.Today the HIV/TB liaison program continuesto work closely with the many early interven-tion clinics where TB testing is a standard ofcare for all patients.

The 1990s have been a time of rapid influx ofboth federal and state funding for the elimina-tion of TB. This allowed the implementationof a number of new programs. Directly ob-served therapy (DOT) is now the standard ofcare and in 1998 more than 75% of publichealth clinic patients were on DOT. The TBControl Program has contracted with a num-ber of community-based organizations (CBOs)to screen high-risk persons for TB and providepreventive therapy. This has resulted in thou-sands of persons being screened and givenpreventive therapy who otherwise would nothave been reached by the health department.A project to screen homeless persons for TBby using a mobile radiology unit detecteddozens of cases of TB that were treated earlierthan otherwise, preventing further transmis-sion of infection to this vulnerable population.This helped to accelerate the decline of TBdisease in the homeless. An MDR unit wasestablished to monitor and consult on everyMDR patient in the county whether underprivate or public care. The percentage of suchcases has been kept below 2% of the total casesfor many years. Most of the cases that dooccur come into the county from other loca-tions already with MDR. Most of them aresuccessfully treated while remaining in Los

Angeles County. The Public Health Labora-tory for the county was given personnelresources and the latest technical equipment tobetter serve the needs of the TB control pro-grams.

The State of California has been very active inaddressing many of the problems that havehindered TB control. For example, a law isnow in place that requires health care facilitiesto obtain permission from the local healthofficer or TB controller before any personsuspected or diagnosed with TB is discharged.The health officer can refuse discharge if thefollow-up plan is inadequate or the patientcontinues to be a threat to the public health ofthe community. Another law establishes aprocess for the legal detention of patients withTB who represent a threat to the publichealth. The State has also appropriated moneyto pay for the detention of TB patients andalso to pay for housing of the homeless. LosAngeles County has taken full benefit of theseactions. The Surveillance Unit at the TBControl Program and the Liaison nurses at thecounty hospitals have been given the responsi-bility for approving hospital discharges underthe Director’s supervision. The County, withthe help of State funding, has recently openeda Southern California regional center for thedetention of TB patients at one of our countyfacilities. This facility can also provide long-term skilled nursing care for any TB patientneeding it and the services of a drug andalcohol treatment center.

An earthquake of another nature occurred in1995. The Los Angeles County Departmentof Health Services faced the possibility ofbankruptcy. A huge, complicated reorganiza-tion of the department resulted. TB services aswell as all public health services were con-densed into 11 locations throughout thecounty where previously there had been morethan 30. This created trying times, but fortu-nately TB cases were not lost. On the otherhand there was a significant drop-off in thenumber of patients being screened and placed


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on preventive therapy. In addition, the PublicHealth Programs and Services Division of theDepartment of Health Services has continuedto undergo extensive reorganization, redirec-tion of priorities, and change of leadership.

The 20th century has clearly ended with aperiod of constant change. One can onlypredict that the new century will continue inthe same mode, possibly as the norm. In themeantime, the number of TB cases continuesto decline, to an all-time low by the turn ofthe century. Hope, tempered by the reality ofa huge problem with TB in the world as awhole, suggests that the goal of elimination ofTB can be reached in Los Angeles Countyduring the early decades of the 2000s.

TB in Alaskaby Robert Fraser, MD

Former Alaska TB Controller

TB is probably a relatively new disease in theAlaska population that was introduced byearly explorers and other newcomers to theterritory of Alaska. One of Captain Cook’smates died of TB at the time of his voyage in1786 to Alaska. By the early part of the 20thcentury, TB was widespread in the villages ofAlaska, and treatment options were verylimited. Attempts at isolating individualfamily members in the home was the majortreatment available. In the late 1940s a smallTB hospital was opened in Skagway. In theearly 1950s coordinated efforts by the Bureauof Indian Affairs and the territory of Alaskawere directed to this major public healthproblem.

In a large land area like Alaska with poortransportation, case finding was a majorchallenge. In the early 1950s the territory ofAlaska operated three health boats that visitedcoastal communities and communities alongthe Yukon River. These ships carried x-rayfacilities, a physician, a dentist, and publichealth nurses. By the mid-1950s most commu-nities had “bush” air service, which enabledportable x-ray facilities to be taken into com-munities and chest x-rays taken. Hospitalfacilities also improved with the availability ofthe facilities at the old naval base in Sitka,which was turned over to the Bureau of IndianAffairs, and the construction of a new hospitalfacility for the Bureau of Indian Affairs, whichopened in Anchorage in 1953. At the sametime, medication effective against M. tuberculo-sis became available, with streptomycin avail-able in 1946, PAS in 1947, and INH in 1953.These treatment modalities permitted theeffective treatment of TB.

In the mid-1950s the TB reactor rate amongchildren in rural Alaska was about 50% inschool enterers and approached 90% in thethird grade. Deaths from TB in some yearsapproached 500, and thousands of residents ofAlaska awaited hospitalization for treatmentof their disease. The initial studies using INHto prevent TB were effectively carried out in anumber of villages in the Bethel area ofAlaska, demonstrating better than 80% effec-tiveness in preventing the development of TBin infected individuals. The results also raisedthe possibility of treating people with activedisease outside of the hospital. Subsequentlymost patients with TB had been treated inAlaska with either no hospitalization or shorthospitalization followed by outpatient treat-ment.

As the incidence of TB fell, supervision of theinfected individuals in smaller communitieswas possible using traveling x-ray techniciansand the identification of problem communitieswas done on the basis of tuberculin testing.Tuberculin testing programs were imple-


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mented in selected age groups in the schools.Review of immigrants coming to Alaska fromSoutheast Asia and South America allowedpublic health personnel to identify and treatactive disease, thus minimizing the spread ofTB into Alaska.

Effective treatment of TB has increasinglyrequired directly observed therapy, or DOT,for successful management of the disease.Many communities in Alaska have few tuber-culin reactors among school age children, butthere still remains a significant reservoir ofindividuals who have had TB infection in thepast and who may potentially develop disease,posing a challenge for public health. How toidentify new cases of TB at a time whenconcern for the disease has diminished andhow to provide direct administration ofmedication to infected individuals in remoteareas are continuing challenges.

As Alaska enters a new century, there is apotential to eliminate TB from the populationand there is also the potential that the diseasewill remain a chronic problem. The newcentury will pose new challenges with dimin-ished public awareness of TB, and with HIVinfections in rural communities complicatingthe problem.

CDC and the American Lung Association/American Thoracic Society: an Enduring

Public/Private Partnershipby Fran DuMelle, MS

Deputy Managing Director, ALAand Philip Hopewell, MD

Associate Dean, Univ of California, San Francisco

The origins of the American Lung Association(ALA) and the American Thoracic Society(ATS) and of their collaborations with theCDC lie within the anti-TB movement of thelate 1800s and early 1900s. The potential valueof an organized voluntary society constitutedof both physician and lay members was recog-nized in the late 1800s and marked by thefounding of the Pennsylvania Society for the

Prevention of Tuberculosis in Philadelphia in1892. Twelve years later, in 1904, under theguidance of many of the luminaries of Ameri-can medicine at that time — Osler, Trudeau,Welch, Janeway, Knopf — the National Asso-ciation for the Study and Prevention of Tuber-culosis (NASPT) was founded. Although theNASPT was largely composed of physiciansand other health professionals (only twolaymen were included on its first 29-memberboard of directors), its mission was publiceducation and public policy, not clinical careor research.

In 1918 the NASPT changed its name to theNational Tuberculosis Association (NTA), aname it retained for the next 50 years. Becausethe organization was progressively involvingitself in a broader range of activities, in 1968,after considerable discussion and debate, thename was changed to the National Tuberculo-sis and Respiratory Disease Association(NTRDA). After being burdened with thisunwieldy name for 5 years, the NTRDAbecame simply the American Lung Associa-tion in 1973.

In 1905, a year after NASPT was chartered, asubgroup — the American Sanatorium Asso-ciation (ASA) — was formed by physicianmembers of NASPT who, for the most part,were directors of TB sanatoria. This group wasfocused on the science of TB and on theclinical care of patients with the disease.Although comprising initially only sanato-rium-based physicians, the ASA subsequentlybecame more inclusive, with membershipopen to all physicians and researchers in thefield. In 1939 the name of the ASA was


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changed to the American Trudeau Society,honoring Edward Livingston Trudeau andrecognizing the broader interests of the mem-bers. Finally in 1960 the name was againchanged to the American Thoracic Society(ATS) in keeping with the evolution of themedical specialty area from pthisiology topulmonology, including TB and the wholerange of respiratory disorders.

The involvement of the ancestral ALA andATS with organized TB control efforts in theUnited States began well before there was evena United States Public Health Service(USPHS), let alone a CDC. In fact, a majoractivity of the NASPT was promoting theestablishment of public health departmentswith TB control programs in every commu-nity in the country. Lawmakers were urged tosupport such programs and to use taxes tomake care for TB free to all patients. Thus,from its inception, the progenitor of the ALAhad as its core mission advocacy for effectiveTB control and accessibility of clinical servicesfor patients with the disease.

Among the factors recognized as limiting theability to mount a countrywide TB controlprogram were the lack of data describing themagnitude of the disease and the absence ofany assessment of the availability of facilitiesfor the care of patients with TB. The first ofthese voids was filled by an analysis conductedon behalf of the Charity Organization Society(COS) of the City of New York by MissLillian Brandt in 1903. This report, “TheSocial Aspects of Tuberculosis, Based on aStudy of Statistics,” compiled the data avail-able for the US and presented in a systematicfashion both the scale and complexities of TBin the United States in the early 1900s.

Miss Brandt also provided the initial collectionof data describing existing facilities and pro-grams for patients with TB, “A Directory ofInstitutions and Societies Dealing with Tuber-culosis in the United States and Canada.” Thissurvey, which served to highlight the dearth of

facilities for TB, was jointly funded by COSand NASPT, and was the first project of thenew society. Subsequent editions of the “Di-rectory” were funded and published entirelyby NASPT and provided the focus for thesociety’s major advocacy program: to increasepublic funding for TB and to have TB controlprograms in all departments of public health.In 1916 the NASPT adopted a resolutionstating that participation of the federal govern-ment in TB control is “desirable and neces-sary” and that the “proper federal agency forthe purpose is the US Public Health Service.”A bill providing that a division of TB shouldbe set up in the US Public Health Service wasintroduced in the House of Representatives in1916. This plan was not realized, however,until nearly 30 years later, in 1944.

In 1961 the federal government instituted thefunding of state programs that were designedto support community-based outpatient careefforts, to shift TB control away frominhospital treatment. Funding increasedprogressively through the 1960s but declinedprecipitously in 1970 as federal support wasshifted to block grants. By 1973 there were nocategorical funds for TB control at the CDC.After several years’ experience with blockgrants, it was clear that the states were spend-ing few or none of these funds for TB control.

It was logical, therefore, that when the ALAopened its first full-time government relationsoffice in Washington in 1980, among its firstpriorities was funding for TB control. In fact,the first victory logged by the fledgling office,under the leadership of long-time ALA andATS employee Robert Weymuller and itslegislative counsel Harley Dirks, was theCongressional authorization of the “ProjectGrants for Tuberculosis for Preventive HealthProjects” (replacing block grants). This billrestored categorical funds for TB control tothe CDC in 1980 after an 8-year hiatus. Fol-lowing this success, the ALA/ATS proceededwith an intensive advocacy campaign to securefunding — $1 million in FY1982, a significant


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amount in 1982 dollars. Throughout the 1980sthe ALA/ATS continued to advocate forincreased funding for the CDC, but it was notuntil 1993, after the resurgence of TB in theUS had peaked, that funding increased dra-matically.

The success in gaining increased funding forTB was facilitated by having in place theAdvisory Council for the Elimination ofTuberculosis (ACET), an advisory group tothe CDC that was specifically authorized byCongress as a result of ALA/ATS lobbyingefforts. Among the first tasks of the ACETwas the development of the Strategic Plan forthe Elimination of Tuberculosis. This plan,plus the newly-created National Coalition forthe Elimination of Tuberculosis (NCET),provided new energy and focus for the advo-cacy efforts, and funding levels grew to theircurrent level of approximately $120 million by1995.

The creation of NCET harkens back to theearly days of the ALA and its activities incommunity organization. NCET was formedat a time when TB cases were increasing andthere was rising concern about drug resistance,yet public apathy and Congressional inactioncontinued. The goals of ALA in fostering thecreation of NCET were nearly identical to thegoals of the NASPT almost 90 years earlier:increasing public awareness of TB and advocat-ing for adequate public funding of controlprograms. As noted above, NCET played animportant role in the intensified response tothe resurgence of TB in the 1990s. In 1998NCET reevaluated its role and structure and isfocusing on advocacy at the state level forfunding and for ensuring an appropriate legalframework for TB control, while not aban-doning it national activities.

Both the ALA and the ATS have concernswith international, as well as domestic, TBcontrol — concerns that are consistent withthe traditions of the organizations, withcurrent epidemiologic realities, and with the

increasing interna-tional focus of theCDC. Soon afterits founding, theNASPT becameinvolved in inter-national activities,hosting the sixthInternationalCongress onTuberculosis in

1908. True to its origins, the ALA currentlyis an important constituent of the Interna-tional Union Against Tuberculosis and LungDisease (IUATLD). Additionally, the ALAand the ATS are founding partners of the StopTB Initiative, together with the CDC, theWorld Health Organization, the World Bank,the IUATLD, and the Royal NetherlandsAntituberculosis Association. The Initiative isa global partnership to accelerate TB controlworldwide and in part is a product of thesuccessful efforts of the ALA/ATS in advocat-ing for funding of international TB controlthrough the US Agency for InternationalDevelopment.

At the first annual meeting of NASPT in 1905,two committee reports were read, “EarlyDiagnosis” and “Clinical Nomenclature.”These reports, which served to define the stateof the art on one hand and standard terminol-ogy on the other, set the pattern for futureactivities of both the NASPT and ASA. TheSociety’s journal, the American Review ofTuberculosis (subsequently the AmericanReview of Tuberculosis and Pulmonary Disease,then the American Review of RespiratoryDisease, and now the American Journal ofRespiratory and Critical Care Medicine) wasfirst published in 1917. The first issue carriedan article, “The Classification of PulmonaryTuberculosis,” which was the first of anongoing series of statements entitled “Diagnos-

An illustration from Huber the Tuber, a book about tuberculosiswritten and illustrated by H. A. Wilmer, MD, and published bythe National Tuberculosis Association in 1942.


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tic Standards and Classification of Tuberculo-sis” (first so-named in 1920). The “DiagnosticStandards” document continues to provideimportant guidance to TB control efforts inthe US. The most recent revision has just beencompleted.

In addition to the “Diagnostic Standards,” theearly ATS developed expert opinions, pre-sented in the form of committee reports, onvarious clinical, research, and public healthaspects of TB. Obviously, because there wasno TB control agency within the federalgovernment until 1944, when the Division ofTB Control was established, these reportswere not collaborative ventures but were,nevertheless, intended to guide the publichealth aspects of TB. Although persons em-ployed in various federal agencies were mem-bers of some of the committees, there was noofficial USPHS representation (at least noneidentified in published committee reports)until 1943 when, in the “Report of the Com-mittee on Tuberculosis Sanatorium Stan-dards,” it was noted that a Dr. Sharp wasrepresenting the USPHS. Additional involve-ment of the ATS with the Division of Tuber-culosis Control was noted in the “Report ofthe Committee on Postgraduate MedicalEducation” in 1946. Dr. Herman Hilleboe, thefirst director of the Division, requested sugges-tions for the training of medical officers in TBcontrol and asked for the committee to reviewcourses that he had outlined.

In the same year the Committee on Rehabilita-tion (of patients with TB) reported that theUSPHS, the NTA (and ATS), and the FederalOffice of Vocational Rehabilitation wouldjointly provide a team to study rehabilitationprograms in the US. Also in 1946, the NTAand ATS, together with the USPHS and theAmerican Hospital Association, developed aninformational package describing how hospi-tals should conduct mass radiography screen-ing (“Report of Committee on TuberculosisAmong Hospital Personnel”). These sorts ofcollaborations continued on a more or less

informal basis through the 1950s and early1960s. In the 1960s there were several instancesin which the ATS specifically endorsedUSPHS reports (the US Public Health ServiceTask Force Report on Tuberculosis Control;the USPHS Recommendations on the Use ofBCG Vaccine in the United States.)

It was not until 1971 that the first formallyacknowledged joint ATS/CDC statement waspublished (Preventive Treatment of Tubercu-losis: A Joint Statement of the AmericanThoracic Society, National Tuberculosis andRespiratory Disease Association and theCenters for Disease Control). Since that timejoint statements have also been published onBCG vaccines (1975), eradication strategies(1978), short-course chemotherapy (1980), TBcontrol (1983), treatment and prevention(1986, 1994) and diagnostic standards andclassification of TB (1990). Currently, thereare three joint statements: “Diagnostic Stan-dards and Classification,” and “TargetedTesting and Treatment of Latent TuberculousInfection,” both of which have been revisedrecently, and the “Treatment of Tuberculosis”that is now undergoing revision.

Although the historical and ongoing collabora-tions between the ATS and the CDC areexemplified most clearly by the formal jointstatements, the interactions go well beyondthese activities. Staff of the Division of Tuber-culosis Elimination are active and valuedmembers of the ATS, participating especiallyin the programs of the Assembly on Microbi-ology, Tuberculosis, and Pulmonary Infec-tions, and assuming leadership roles in manyof the Assembly’s undertakings. Likewise ATSmembers, both as Society representatives andas individuals, are regular participants in avariety of CDC activities, including serving inadvisory roles, contributing to trainingcourses, and conducting program evaluations(often organized by state ALAs).

It is striking to note the degree to which thecurrent collaborations of the ALA and the


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ATS with the CDC Division of TuberculosisElimination are consistent with the goals andactivities of their forebears and adhere totraditions established early in the lifetimes ofthe organizations — to support and advocatefor scientifically sound, publicly funded,government-based TB control.

The Unusual Suspectsby Lee B. Reichman, MD, MPH

Professor of Medicine,Preventive Medicine and Community Health

Executive Director,New Jersey Medical School National TB Center

A Founding Component of the International Centerfor Public Health

TB people have always been an “in” group.They always tend to talk to each other, andmeet at their own meetings such as the Inter-national Union Against Tuberculosis andLung Disease, the American Thoracic Society,and the National Tuberculosis ControllersAssociation. Before 1992, if you went tomeetings of other groups (the InfectiousDiseases Society of America, the AmericanPublic Health Association, the AmericanCollege of Physicians, the European Respira-tory Society to name a few), there was pre-cious little TB, if any, on the program.

But TB docs aren’t the only ones who treatTB, and since TB remains a serious globalproblem, they shouldn’t be the only onesconcerned about TB.

TB in the United States is now in a downwardspiral. Even though TB in the world remainsrampant, in the United States TB rates aredown 7 years in a row including 1999. But,paradoxically, during this period of decline,interest in TB seems to have markedly in-creased, and such interest apparently hasincreased outside the parochial TB commu-nity. This to my mind is the factor that isreinvigorating TB and TB control worldwide.It leads me, on the basis of present evidence, tohumbly suggest that the salvation of TB

control in the world as well as in the UnitedStates will only occur when the players are nolonger exclusively from that “in” group. Thenew outside players could be characterized asunusual suspects.

In the past I’ve been very publicly critical ofthe WHO’s ex-Global TuberculosisProgramme staff for all too often going italone, but I’d like to now commend them andtheir successes, tentatively at least, for adopt-ing and leading more of a team approach todeal with worldwide TB. And their leadershipin the “Stop TB” Initiative, which necessarilyrequires partnerships, will hopefully be onemore important (if seriously overdue) ex-ample. There is now increasing evidence thatthey have reached out to many other “unusualsuspects.” In March 1998 WHO called to-gether an Ad Hoc Committee on the GlobalTB Epidemic (the London conference). Thiscertainly isn’t big news. However, the Ad HocCommittee of 19 consisted not only of physi-cians; more importantly, it included severalunusual suspects: the Commissioner of theSecurities Commission of Jordan, an econo-mist from Zambia, a civil service administra-tor from India, a nonphysician universityprofessor from Indonesia, and others. Whenthis group called on heads of state, parliamen-tary leaders, finance, planning, and healthminsters, as well as the Director General ofWHO, each to exercise his or her own pivotalrole, it certainly carried more weight than theopinions of a cadre of self-serving TB doctorsand nurses, TB controllers, or TB researchers.And when the committee called upon govern-mental leaders to address TB as an issue out-side the health sector which, if not dealt withproperly, must increase costs for the laborforce and reflect negatively on tourism andforeign investment, it also carried importantinfluence. When they suggested that TBshould be handled as a defense program ratherthan a social program, such a theme stood abetter chance of success than if broached bythe usual interested parties.


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For several years many in the TB communityhave pleaded with USAID to get involved ininternational aspects of TB control, if onlybecause of the realization that this is the bestway to control TB in the United States, whereincreasing numbers of cases (now 42% in 1998)are in the foreign-born. But it wasn’t untilRalph Nader’s Princeton Project 55 (unusualsuspects, to say the least) got involved, thatUSAID made a commitment to worldwidecontrol of TB and properly made the UnitedStates a significant donor nation in the globalfight against TB.

In a similar vein, the Public Health ResearchInstitute of New York and the Open SocietyInstitute (the George Soros Foundation) —again, at least for TB, unusual suspects — wereable to get Russia to mount significant TBinvolvement in Russian prisons, which willnecessarily require prison as well as civilianDOT, something that WHO and CDC hadbeen unable to do for years.

The recognition that DOTS works in drug-sensitive cases but may amplify already exist-ing drug resistance and that MDR TB can beeffectively treated by tailored second-lineregimens was made not by TB physicians, butby Partners in Health, a group from HarvardUniversity specializing in anthropology andhuman rights, and which has led to acceptanceby WHO of the so-called DOTS Plus move-ment (tailored treatment of MDR TB).

We stand at a crossroads. Some of the playershave now acknowledged that teamwork andpartnerships are needed to realistically dealwith TB. A fresh look at a thorny problem byunusual suspects can have lively and usefulresults.

In 1992 at the National Commission on AIDS,Joseph A. Califano, Jr., who had been Presi-dent Jimmy Carter’s Secretary of Health,Education and Welfare, warned that theconjoined epidemics of AIDS, TB, and drugaddiction form the most frightening threat to

public health America had ever faced. Helikened the link of the three epidemics toCerberus, the mythological three-headed dogguarding the gates of Hell!

Mr. Califano, another unusual suspect as far asTB is concerned, would likely be pleased toknow about the progress made in TB domesti-cally since introducing his metaphor, butglobal TB still remains a major problem.

I’d like to suggest that the proper approach todealing with the global TB epidemic is alsothree-headed; however, not a Cerberus, but athree-headed or three-pronged thrust into the21st century, reflecting a new collaborationbetween usual and unusual suspects.

I think we all must agree that government,whether it be WHO, CDC, or individualministries of health, cannot do the job alone,and it is hoped that they will continue to reachout meaningfully both for advice as well asassistance. Nongovernmental organizationssuch as IUATLD, ALA/ATS, or KNVC(Royal Netherlands TB Association) cannot dothis job alone either, and need to includeacademe and foundations, which are unusualsuspects. But the third prong, previouslytotally neglected except as a source of dona-tions and therefore a very unusual suspect asfar as TB goes, is commercial industry!

Industry is the one potential player that hasusually demonstrated the ability to create andmaintain an infrastructure, motivation, exper-tise, and perhaps most importantly, an abilityto get things done. They get things done, tomy mind at least, because they are in it forprofit, and profit still seems to be a strongermotivation than “doing good.”

In 1996 at the Lancet conference and then in1997 at the IUATLD annual conference inParis, I castigated industry. I asked why,currently, the most widely used diagnostic testfor TB infection was introduced in 1880. I alsoasked why there was essentially only one drug


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company trying at that time to license a newdrug with admitted TB indications.

At that time I stated that drug companiesdon’t sit with us at the TB table because aspublic corporations they must ask, “What’s init for us?” To a great extent, if we want themwith us, there must be something in it forthem beyond “doing good,” a virtue thatshareholders and financial analysts probablyunderstand less well than even politicians.

I’m not the only one suggesting this. In Busi-ness Week, April 6, 1998, the cover storystated: “Still, TB, like malaria, attracts fewerresources than other infectious diseases. Andit’s not hard to figure out why. . . There’sbeen the least effort to develop new anti-infectives (against these diseases) because of theinability of the population in the most affectedareas to pay. That’s just one reason the warwith microbes may never be fully won. Com-panies and nations need to launch — andmaintain — effective campaigns not onlyagainst strep and flu but also against thescourges that ravage far too many of theworld’s people. Only then would we have achance of relegating these killers to the pagesof our history books.”

So in response, we need to define strategies toallow drug and technology companies to befull prospective players, along with govern-ment and nongovernment organizations,academe and foundations. Let’s find out whatthey need and want, and then let’s providethem with incentives and enablers; let thempromote their wares as well as promote ourneeds. And let’s let them earn a fair andproper profit for what they do.

Many years ago, the IUATLD Council (Ithink it was 1979 in Brussels) held an exten-sively prolonged discussion over whether theBulletin of IUATLD, the predecessor to theInternational Journal of Tuberculosis and LungDisease, would be irreparably corrupted if itaccepted paid advertising. But TB control is

too fragile and important to attack with onlythe usual suspects. Adding unusual suspects asfull participants, such as nongovernmentalorganizations, academe, foundations andindustry, is the only way we can ever imple-ment and carry out the global plan, rectifyingthe continuing worldwide embarrassment anddanger of TB.

In 1955, soon after the introduction of wide-spread use of TB drug therapy, ProfessorJames Waring at Colorado pointed out inJAMA that TB was unique in that, essentially,it stayed around and spread until it was prop-erly treated. In other words, it doesn’t goaway.

The global situation with TB reminds me ofthe man who advertised FRAM Oil Filters ontelevision several years ago. In that commer-cial, a scruffy garage-mechanic type ap-proached the camera holding an oil filter inone hand and a burned out car engine in theother. He stated: “Last week the owner of thiscar could have had a new FRAM Oil Filter for$4.95. He decided not to buy it. Today he hasto buy a new car engine for $1,275.00.

“You can pay me now. . . or you can pay melater.”

The Model TB Prevention and ControlCenters: History and Purpose

by Elizabeth J. Stoller, MPHFormer Director, Francis J. Curry National TB Center

and Russ HavlakFormer Assoc. Dir. for Special Projects, DTBE

On January 22-23, 1992, a conference onmultidrug-resistant TB (MDR TB) was held atCDC in Atlanta. Part of the strategy outlinedin the resulting National Action Plan to Com-bat Multidrug-Resistant Tuberculosis was toestablish centers of excellence for treatingdifficult-to-manage TB cases, especially MDRTB cases. The Plan also called for developing acadre of health-care professionals with exper-tise in the management of TB and MDR TB


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through training. In 1993, the CDC Divisionof TB Elimination released a request forproposals for Model TB Prevention andControl Centers as a competitive supplementto the Surveillance, Prevention, and Control/Elimination cooperative agreements. Thefederal funds appropriated to support emer-gency TB grants were targeted to the 13 statesand cities that had reported the largest num-bers of TB cases in 1992.

Model TB Centers were to be located in high-incidence urban areas. The recipient healthdepartment was required to utilize a current,or establish a new, relationship with a schoolof medicine or public health for Center opera-tion. The Centers were to provide1. Comprehensive, coordinated state-of-

the-art diagnostic, treatment,prevention, and patient educationservices for TB cases, suspects, contacts,and recipients of preventive therapy(treatment for latent TB infection);

2. Innovative approaches for ensuringadherence with drug therapy and forcarrying out other prevention andcontrol activities; and

3. Training for all levels of health careworkers providing TB screening,prevention, and control services withinthe targeted area.

Three sites were selected for Model Centerawards: Newark, NJ, New York City, NY,and San Francisco, CA.

The New Jersey National Tuberculosis Centeris located at the University of Medicine andDentistry of New Jersey, serving Newark andEssex County. The New York City operationis located at the Harlem Hospital Center, andserves Central and East Harlem. The SanFrancisco Center is operated by the TBcontrol program of the San FranciscoDepartment of Public Health, and includes thesurrounding Bay Area counties as the targetarea.

The programmatic emphasis of each Centerwas designed to address the needs of eachrespective target area. New Jersey developedan integrated approach to managing high-riskurban populations through interdisciplinaryteams and a nurse case management model,telephone information services for health careprofessionals and the general public, and acomprehensive training program. TheHarlem Center featured enhanced clinicalservices, a clinic-based DOT model, andtraining of house-staff and communityphysicians. The San Francisco program wasdesigned to replicate local successful programcomponents in surrounding jurisdictions inthe target area, as well as offer enhancedregional surveillance, laboratory andinstitutional “hazard evaluation” services,clinical and epidemiologic consultationservices, and a comprehensive trainingprogram.

In 1997, Kenneth Castro, MD, Director,Division of TB Elimination, CDC, called ameeting of the Model Center principals todiscuss a change in programmatic emphasis forthe Centers. While the expectation was thatactivities would continue, efforts should bemade to “capture” the outcome of each majoreffort in some sort of enduring product. Thiswould allow other TB Control programs inthe nation to make use of the strategies andtools developed, tested and/or perfected byeach of the Centers. The Centers were askedto redesign their programs in accordance withthe new directive and submit proposals withexhibits organized under three headings: State-of-the-Art Care, Training, and InnovativeActivities. Effective January 1998, the Centersshifted into “product” mode. In less than 2years, the Centers have developed anddisseminated the following innovativeprogram products:


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Harlem:• Six case studies to be used for training

physicians in clinical management ofTB infection and disease

• Improving Treatment Completion forLatent Tuberculosis Infection amongHealth Care Workers, a guide foremployee health services and chestclinics

• Tuberculosis Training for InternationalMedical Graduates, a guide forresidency program directors, healthadministrators and TB controlprograms

• Social Support Services forTuberculosis Clients, a guide to helpproviders establish and enhance socialsupport services

New Jersey:• A TB School Nurse Handbook• Guidelines for a School-Based Directly-

Observed Therapy Program• Tuberculosis Preventive Therapy

Database for patient tracking andoutcome evaluation

• TB drug treatment pocket card forclinicians

• Standardized patient scenarios

San Francisco:• A series of guidelines on institutional

infection control measures• A videotape on engineering methods

for institutional M. tuberculosisprevention

• A CD-ROM on patient management• A searchable database of TB training

and education resources fromthroughout the US and internationalprograms

• A software program (TB Info) for real-time program data analysis

The three Centers have undertaken severalcollaborative efforts, including thedevelopment of a national strategic plan ontuberculosis training and education; a nationalsatellite broadcast series for health careproviders; and print-based educationalmaterials for civil surgeons and panelphysicians. Collectively, the Centers haveprovided training to tens of thousands ofhealth care providers and the public healthworkforce, and consultation to providers froma broad range of practice settings.

The Centers continue to operate in responseto the needs of the programs in theirrespective target areas and, with guidance fromthe CDC, the National TB ControllersAssociation (NTCA), and the National TBNurse Consultant Coalition (NTNCC),increasingly in response to the needs of thenation. These Centers are designed to meetyour program needs: be sure to contact themfor assistance or for resources.

Francis J. Curry National Tuberculosis Center(San Francisco)Web address: www.nationaltbcenter.eduTelephone: 415/502-4600

Charles P. Felton National TuberculosisCenter at Harlem Hospital (New York)Web address: www.harlemtbcenter.orgTelephone: 212/939-8254


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New Jersey Medical School NationalTuberculosis Center (Newark):Web address: www.umdnj.edu/ntbcTelephone: 973/972-3270

My Perspective on TB Control over thePast Two to Three Decades

by Jeffrey Glassroth, MDProf of Medicine, Univ of Wisconsin Medical School

President, American Thoracic Society

In 1975 case rates for tuberculosis (TB) in theUnited States were in double digits per100,000. Increasingly, those patients wereindividuals with serious social problems. Amajor concern at CDC that year was thescreening for TB of newly arriving Vietnameserefugees; the treatment of active cases wasprovided, and notification to local healthdepartments of latently infected individualswas undertaken. There was also concern aboutthe quality of immigrant screening doneoverseas, but the major focus of “imported”TB was along the border with Mexico.Monitoring of TB drug resistance, particularlyprimary resistance (i.e., among persons notpreviously treated), was pursued and,reassuringly, indications were found that theserates were generally stable and low,particularly with respect to rifampin. A majortreatment study was beginning and it wouldhelp to define the role of rifampin in so-called“short-course chemotherapy,” meaning 9months of daily treatment as opposed to thestandard of 18-24 months that existed at thetime. “TB Today!,” an intensive educationalprogram that provided essential knowledge toTB control staff from around the country,presented material on TB microbiology anddiagnosis that emphasized the (then) state-of-the-art methods; a description of classicalmicrobiologic techniques that had changedlittle in the near-century since Koch describedthe tubercle bacillus. Also taught in the coursewas a segment on optimizing the use andinterpretation of the tuberculin skin test foridentifying TB infection. A study was aboutto begin to assess the importance of skin test

boosting when sequential tuberculin tests wereapplied. Much of what was underlying thoseefforts with tuberculin skin testing actuallyreflected concerns and frustrations with theuse of isoniazid (INH) for treating latent TBinfections, so-called TB prophylaxis. On theone hand prophylaxis was effective but, on theother hand, it came with a risk of side effects,most notably hepatitis. The challenge was toidentify, via skin testing, the persons mostlikely to derive benefit from INH and leastlikely to be harmed by it; a classic benefit/risk“equation.” BCG vaccination, though widelyused outside the US, was rarely used here,because of perceived limited effectiveness andproblems with skin test interpretation.

The intervening quarter century has seenremarkable changes with respect to TB but, insome ways, little has changed. A number ofyears ago, then–CDC Director Dr. JamesMason urged that CDC’s TB unit not think interms of TB “control” but of “elimination.”The name of the unit changed to reflect thisnew, more ambitious mission. Indeed, in theUS, after some years of rising rates, TB ratesare again falling and are a fraction of whatthey were 25 years ago. However, in manyways the challenges to TB elimination in theUS are greater today than a quarter centuryago. Worldwide, TB prevalence is increasing,and today over 40% of cases reported in theUS are “imported” in the person ofimmigrants from high-prevalence countries.The worldwide TB burden is fueled by HIVinfection, an entity unknown in 1975, whichfacilitates every aspect of the natural history ofTB from transmission to disease. Inrecognition of this, and to more efficientlycombat these interrelated public healthproblems, the TB division at CDC is nowadministratively “housed” with the HIVdivision. Moreover, CDC has dramaticallyincreased its worldwide collaborations to assistin efforts at containing TB abroad.

Rifampin is now well entrenched as acornerstone of treatment, and several related


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rifamycins have come into use. Short-coursetherapy has been further abbreviated to astandard of 6 months’ duration by addingpyrazinamide during the first 2 months oftreatment. Moreover, the proven efficacy ofintermittent treatment has facilitated thewidespread use of directly observed orsupervised therapy (“DOT”) as a means ofimproving adherence to treatment and is amajor factor in treatment success.Unfortunately, drug resistance has become anadditional issue contributing to treatmentproblems. Moreover, resistance is increasinglya problem with the rifamycins (almostunheard of 25 years ago), and outbreaks andsporadic cases of multidrug-resistant TB (MDRTB) represent a major concern for cliniciansand public health officials alike.

Perhaps nowhere has change been moredramatic than in the area of diagnostics.Although skin testing is fundamentallyunchanged, the microbiologic approach to TBdiagnosis has been revolutionized by theapplication of molecular biologic techniques.Thus, laboratories are now capable ofobtaining genetic material from small numbers

of tubercle bacilli inspecimens, amplifying ormultiplying thatmaterial, and thentesting the resulting“soup” for specificsegments of DNA orRNA that are unique toTB. Refinements ofthese techniques alsopermit the identificationof resistant strains insome cases and thetracking of outbreaks ormini-epidemics, and helpus better understand the

epidemiology of the disease as it currentlyexists. Such techniques hold the very realpromise of rapid, highly sensitive, andspecific diagnostic tests for TB disease.Powerful tools indeed!

Preventive treatment of latent TB infectionstill emphasizes the use of INH. However,because of occasional concerns about resistanceto INH, and also in an effort to reduce thetime required to complete a course ofpreventive therapy, other regimens —particularly those using rifampin — have beenincreasingly used and shown to be effective(though more costly) alternatives to INH.Although additional studies have documentedthe limitations of BCG vaccination, there isincreasing interest, in the US and abroad, thatthrough the technical developments of recentyears, more effective vaccines are feasible.Given the worldwide problems I have noted,application of a truly effective vaccine wouldbe a logical strategy for dealing with thisdisease.

So what has happened in TB in the last 25years? Lots of change and technologicdevelopment but fundamental challengesremain. Worldwide the number of cases isrising and treatment is becoming moredifficult in some regions. In the US, numbershave declined but current cases often requiremore resources and sophistication to treat thanthey did even just a few years ago.

History of the IUATLDby Donald A Enarson, MDand Annik Rouillon, MD

International Union Against TB and Lung Disease68 boulevard Saint-Michel, 75006 Paris FRANCE

The International Union Against Tuberculosisand Lung Disease (known to its members as“the Union”) is the only internationalvoluntary organization dealing specificallywith TB. It is very special in terms of itsstructure, membership, and diversity ofactivities.

Roots of the Union, 1867-1914TB was presented as a communicable diseasein the first international conference ofmedicine specialists convened in Paris in 1867.


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Conferences specifically addressing TBfollowed in Paris in 1888, 1891, 1892, and1898. The 1899 conference took place in Berlinand, for the first time, official representativesfrom both governments and nongovernmentalagencies were present. The independentdevelopments of sanatoria (1854), thediscovery of the bacillus (1882), the opening ofTB dispensaries (1887), the development of thevoluntary movement (1890), and theorganization of periodic conferences called fora centralized agency for coordination andcommunication. The Central Bureau forPrevention of Tuberculosis was formalized inBerlin in 1902, and the double-barred crosswas adopted then as its symbol. Periodicinternational conferences systematicallyaddressing clinical, research, and sociologicalaspects of TB were held until the outbreak ofthe First World War in 1914.

Establishment of the Union, 1920-1939In 1920, a conference on TB was convened inParis in which 31 countries participated,including Australia, Bolivia, Brazil, Chile,China, Colombia, Cuba, Guatemala, Japan,Panama, Paraguay, Iran, and Thailand, inaddition to those of Europe and NorthAmerica. In an impressive procession,delegates one by one pledged “to agree on themeans to fight TB, to make a consensus on thestrategy, to jointly apply the most effectiveweapons to combat this common enemy,”thus establishing the International UnionAgainst Tuberculosis (IUAT) in its presentform. It was conceived as a federation ofnational associations (130 by 1999). Teninternational conferences followed until 1939.

In order to supplement the routine reports ofthe conferences, a regular publication wascommenced in 1923. In this prewar period, theBulletin included administrative reports andstatistics (subsequently compiled by WHO) aswell as information on the strategy andpolicies for the fight against TB and results ofnumerous surveys on specific aspects of thedisease and the campaign. The Bulletin

continued publication until mid-1940, the finaleditions containing the main reports to havebeen given at the 11th conference planned forBerlin in September 1939, the very monthwhen the Second World War commenced.

Relaunching of the Union, 1946-1961At the first reunion of the ExecutiveCommittee after the war in 1946, the IUATrecommended to the planners of the futureWorld Health Organization “establishment ofa strong Division of Tuberculosis.” Officialrelations with the WHO were then establishedwhich continue to the present time.

The first postwar conference in 1950 inCopenhagen, with participation of 43 nations,was followed by a series of conferences, withthe 29th world conference in Bangkok in 1998,when 105 countries participated. Conferencesoutside North America and Europe were heldin Brazil in 1952, India in 1957, and Turkey in1959. During this period a series ofinternational symposia were also organized,generally in Paris, addressing a variety oftopical issues such as TB in Africa, strainvariation in BCG, radiography for TB, newdrugs, and the role of voluntary agencies,among others.

In order to strengthen the administration ofthe growing agency, a post of full-timeExecutive Director was established in 1952. Asystem of quotas was devised for membershipcontributions. Over many years, theAmerican Association has continuallymaintained a high quota share. Fees were alsolevied from individual members. In 1951,scientific committees were commenced andmet annually for intensive discussion of theemerging strategy for the fight against TB. In1953, regions were established in order toremain close to where the needs are. In 1958,the first international collaborative clinicaltrial for treatment of any disease wasundertaken, with a total of 17,391 patientsfrom 17 countries evaluated for drugresistance. This was followed by a


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collaborative controlled clinical trial startingin 1960, to evaluate the efficacy ofchemotherapy in previously untreatedpatients. In this period, the IUAT contributedto annual international courses on TB controlsponsored by WHO in Istanbul, Prague,Rome, and Caracas.

A global view 1961-1978In 1961, at the suggestion of the ExecutiveDirector, Dr. Johannes Holm, the Mutual

Assistance Program was launched toencourage transfer of technology, resources,and information from industrialized to newlyindependent countries, through the agency ofnational associations in the developingcountries. This was followed by travellingseminars in Africa and in Eastern and MiddleEast regions, and by field projects in Mali, SriLanka, Peru, and India, among many others.

In this period, the scientific committeescontinued to focus on the strategy for TBcontrol. Some examples of the activitiesfollow. In 1961, two internationalcollaborative studies evaluated the testcharacteristics of 1,099 films read by 90 readersfrom 7 countries and WHO. A subsequentstudy evaluated sputum smear microscopy.Starting in 1965, an international collaborativestudy on tuberculin skin testing evaluated75,000 children in 21 countries. Furthercontrolled clinical trials addressed the issue ofpreviously treated patients and daily self-administered versus intermittent supervisedregimens. In 1968, a survey evaluated adversereactions to BCG vaccination, with over

10,000 events analyzed. Also in 1968, ATechnical Guide for Sputum Smear Microscopywas published; the 5th edition of this guide waspublished in 1999.

In 1965, the Tuberculosis SurveillanceResearch Unit was established under Dr. KarelStyblo. It developed an index to evaluateinfection and its trends, clarified the naturalhistory of the disease (including transmissionprobabilities and risk factors), and estimatedthe impact of control measures. In 1969, incollaboration with the then–CommunicableDisease Center of the United States and sevenmember countries in Eastern Europe, aninternational trial of preventive chemotherapyfor fibrotic lesions of the lung in 25,000individuals was commenced and was evaluatedover 5 years of follow-up. In 1973, it wasproposed that the mandate of the IUAT beextended to include other lung diseases.However, the name of the organization wasnot changed to reflect this extension until 13years later.

In 1975, Dr. Halfdan Mahler, DirectorGeneral of WHO, publicly acknowledged thecrucial role played by the IUAT in the fightagainst TB. In early 1976, 18 NGOs(nongovernmental organizations) responded toIUAT’s invitation to consider jointly the rolewhich NGOs may and should play in primaryhealth care (PHC) programs. The resultingposition paper was presented at the jointUNICEF / WHO International Conferenceon PHC in Alma Ata in 1978.


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Modeling the global fight against TB, 1978-1991In 1978, in response to a request from theMinister of Health of Tanzania, the IUATproposed the establishment of a National TBProgram under the direction of thegovernment and with support andcoordination of the IUAT. This proposal wasthe basis of a new program of TechnicalAssistance of the IUAT and became the basisin 1979 for the first edition of the TB Guide.Such assistance eventually extended to ninelow-income countries and became the basis ofthe current DOTS Strategy of the WHO.

In 1981, the IUAT became the firstorganization to adopt a policy that itsmeetings be designated “non-smoking”conferences. In 1982, the Koch centenary wascelebrated at the 25th conference in BuenosAires, where the Koch Medal of the IUATwas awarded to Drs. Johannes Holm andWallace Fox. That same year saw theestablishment of World TB Day on March 24each year, following a proposal by the MaliAssociation. In 1984 the IUAT was officiallyregistered with USAID, a very rare privilegefor a non-US agency. The IUAT officiallychanged its name in 1986 to the IUATLD toreflect the inclusion of other lung diseases inits mandate. In 1987, a delegation from theIUATLD visited WHO to encourage it toconsider the problem posed for TB by theemergence and spread of HIV infection thathad been noted in the collaborative projects.

In 1989, the Burden of Health Study carriedout by Harvard University was pivotal indemonstrating the cost-effectiveness of theIUATLD model, which was instrumental inconvincing planners and policymakers toadopt the strategy as a part of the generalhealth services.

A global fight, 1991-presentThe principles of the model National TBProgram, outlined on the occasion of theretirement of Dr. Styblo in 1991, weresubsequently enumerated as the “DOTS”Strategy, promoted as the official policy of theWHO. In that year, the international TBtraining course of the IUATLD was first heldin Arusha, Tanzania, to illustrate theprinciples of the model program. From 1993to 1996, the training and technical supportactivities of the IUATLD were extended froma largely African base to represent everyregion of the world. In 1996, the IUATLDentered into a formal agreement to providetraining fellowships with support from theInternational Fogarty Foundation.

By 1998, field activities involved 10 countriesin the Eastern Region, 5 in the Middle East, 10in Africa, 15 in Europe, 8 in Latin America,and 2 in North America. The network ofcourses in management included Tanzania,Benin, Nicaragua, and Viet Nam, and thecourses on research methods included Turkey,Kenya, South Africa, Mexico, Chile,Argentina, Brazil, Peru, Malaysia, and China.During this period, more than 1 millionpatients with TB were cared for in the contextof the collaborative programs of the IUATLD.In 1998, the IUATLD joined with the WHOand other international partners to form the“Stop TB” Initiative in the hopes of extendingthe model to all countries of the world.

These activities were made possible thanks tofunds entrusted to the Union from richerassociations and by governments of a numberof affluent countries.


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Characteristics of the IUATLDThe distinguishing qualities of the IUATLD,besides its universality, its spirit of solidarity,and its tolerance, are its continual striving forquality and its independence. Thanks to these,it provides the international community withan invaluable asset, namely, its pioneering rolein devising and encouraging or testinginnovations. It provides a neutral platform forinternational collaboration, exchange ofinformation, friendship, mutual esteem andeducation, and a reduction of prejudice. Itmaintains not only a program of scientificconferences and publications but also aprogram of action for health in thecommunity, comprising technical assistance,education, and research. Dr. Gro HarlemBrundtland outlined the future in thefollowing statement to the 51st session of theWorld Health Assembly in Geneva in 1998:“We must reach out to the NGO community.Their reach often goes beyond that of anyofficial body. Where would the battle againstleprosy, TB, or blindness have been withoutthe NGOs?”

Thoughts about the Future of TB Controlin the United Statesby Charles M. Nolan, MD

Director, TB Control ProgramSeattle-King County Dept of Public Health

It is gratifying, isn’t it, to be back on thepathway toward TB elimination. I guess it’strue that we who work in TB control hadmore prominence and visibility in the recentera during which TB was resurgent; adeclining public health problem is never verynewsworthy. Still, speaking personally, thesatisfaction of watching the regular declines inUS TB morbidity each year since 1992 exceedsthe cheap thrill of being interviewed by localTV news personalities about the loomingthreat to our community of resurgent TB.

But what does the future hold for TBcontrollers? Will we continue to see ourefforts rewarded by predictable declines in TB

case numbers and rates into the indefinitefuture, until we finally arrive at our goal, theelimination of TB from the US? Even thoughwe are good people, working toward a noblecause that we deserve to achieve, I submit thatthis optimistic view of an inevitable futuredecline of TB in the US is not necessarily ourdestiny. I fear that as we continue to workagainst TB in its current epidemiologicalexpression in the US, we may be destined toreach a point at which the force of TB controlis balanced by the force of the disease in ourpopulation. In that scenario, with neitheropposing force having the upper hand, TBmorbidity in the US will not continue todecline but will become level.

I am emboldened to hypothesize, in theabsence of new factors in the equation, aforthcoming equilibrium between TB and TBcontrol in the US, and a stabilization in theTB incidence rate in the US, because that isprecisely what has happened in recent years inmy community. The accompanying figureportrays the numbers of TB cases reported in

Seattle-King County, Washington, and in theUS from 1990 through 1998. Even though thenumbers of cases represented in the twojurisdictions differ dramatically, the trend isunmistakable; during a period in which the TBmorbidity in the US declined by 35%, that inSeattle-King County remained basically stable.


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(If annual incidence rates rather than casenumbers had been presented, the trends wouldhave been the same).

Here is my explanation for the trends shownin the figure. At the national level, we are nowreaping the harvest of reinvesting in good TBcontrol. We have secured the necessaryfunding and have applied those fundsstrategically throughout the country tostrengthen surveillance and case finding, toexpand directly observed therapy for TB casesin order to increase completion rates andreduce acquired drug resistance, and to stopnosocomial transmission and other pockets ofcurrent transmission of TB.

Speaking in terms of a theory of TB control,our investment has allowed us to regain theground that was lost during the resurgence byapplying to their best advantage our currenttools (this fact was noted in a JAMA editorialwritten in 1997 by Drs. Bess Miller and KenCastro of the Division of TB Elimination). Inthat sense, the drop in cases and case ratesnationally represent a reduction in “excessmorbidity” that arose during the time whenthe national infrastructure was weakened inrelation to the strength of the dual epidemicsof TB and HIV, increased immigration fromhigh-prevalence areas, and person-to-persontransmission of TB, including nosocomialtransmission.

Some places such as Seattle, however, did notexperience the full power of the TBresurgence. For example, we were onlymodestly impacted by the HIV/TBphenomenon, with rapid person-to-personspread of disease, and MDR TB. Ourinfrastructure had not been dismantled, andwe experienced less excess morbidity in thosebad days. In the decade of the 1990s, however,even though we believe we have a goodprogram structure, a talented staff, andfunding sufficient to allow us to do good TBcontrol work, we have failed to effect ameaningful reduction in TB morbidity in our

community. In other words, we appear tohave reached an equilibrium with our targetdisease, given its current epidemiologicalpattern in our community. This experience isthe basis for my suggestion that it is possiblethat the nation as a whole will also reach suchan equilibrium point, once its excess TBmorbidity has been “mopped up.” When thatpoint may be reached, and at what level ofmorbidity, I of course cannot say.

I don’t want to leave the impression that wehave passively accepted the current status quoin Seattle. We are aggressively attempting todisrupt the equilibrium between TB and TBcontrol by learning more about theepidemiology of TB in our community and byincreasing the effectiveness of our community-based TB control plan. For example, in ourcommunity, persons born outside the USaccount for 70%-75% of cases, and RFLPsurvey data suggest that nearly all of our casesin foreign-born persons arise throughreactivation of latent infection, includingpersons who have received preventive therapy.This information suggests that we need toexpand treatment of latent TB infection inhigh-risk foreign-born persons; to accomplishthat, we have established a Preventive TherapyPartnership Program with a number of healthcare facilities that provide primary health careto high-risk foreign-born persons. Also, giventhat we regularly see TB occur in foreign-bornpersons who have received preventive therapyin the past, we are reevaluating the traditionalapproach to preventive therapy, and havesecured funding to develop new approaches toincrease the uptake and completion ofpreventive therapy by newly-arrivedimmigrants and refugees.

Should the nation encounter such a “mudhole” in the road to TB elimination, similarstrategies will be required to move beyond it.ACET, in its recent publication, TBElimination Revisited: Obstacles, Opportunities,and a Renewed Commitment, has made severalpractical suggestions, including the need for


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every locale and/or state to understand theunique nature of its own TB problem, in orderto apply current tools for TB control to theirbest advantage. The establishment of newpartnerships to reach locally-identified high-risk groups is another important new concept.

Another way that an equilibrium between TBand TB control may become tipped in favor ofTB control is by the introduction of new toolsfor the diagnosis, treatment, or prevention ofTB. This point was also made by Dr. Millerand Dr. Castro in their JAMA editorial.Consider, for example, the advantage of beingable to identify, among a population of 100persons screened and found to have positivetuberculin skin tests, the handful that aredestined to develop TB in the future, and tooffer treatment only to those who are truly atrisk, rather than to the entire cohort.Likewise, based on forthcoming ATS/CDCrecommendations, we now have a range ofoptions for treatment for latent TB infection,which should result in more effective use ofthat preventive intervention. Finally, given theevents of the past year, with burgeoninginterest in a TB vaccine on the part of the USgovernment, private philanthropicorganizations, and the pharmaceuticalindustry, the notion of a TB vaccine at last (inthe immortal words of Ken Castro) “passes thelaugh test.”

Even as Seattle’s current impasse with TB hasserved to motivate us to redouble our efforts,to think creatively, and to engage newpartners in our struggle, I am confident that,should our trend become a national one, thenation will be equal to that challenge. “Theman (or woman) who is tenacious of purposeis not shaken from his firm resolve by thetyrant’s threatening countenance.”Horace, 23 BC.

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Where We’ve Been andWhere We’re Going:

Perspectives from CDC

Early History of the CDC TB Division,1944 - 1985

by John SeggersonAssociate Dir. for External Relations, DTBE

In 1944, Congress passed the Public HealthService Act, which authorized grants to thestates for TB control and established the“Division of Tuberculosis Control,” thenlocated in Washington, DC. At the time of thecreation of the TB Division, TB drugs werenot available, and the primary method of TBcontrol was the isolation of persons withactive disease in TB sanatoria where they were“treated” with healthful living, bed rest,calorie-laden meals, fresh air, sunshine, andsometimes with surgery and/or collapsed lungtherapy.

From the beginning of the 20th century, theNational Tuberculosis Association (later theAmerican Lung Association), and its state andlocal affiliates, played a major role in establish-ing and supporting the TB sanatorium move-ment in the US. During the post-WW IIperiod and into the 1950s, TB associations andhealth departments employed small-film x-rayunits to conduct TB screening in generalpopulations, with one x-ray unit often screen-ing as many as 500 persons per day. The

screening did not effectively cover large citypopulations and by 1947, the PHS Division ofTB Control was operating mobile x-ray unitteams in some 20 cities of more than 100,000population which participated in this PHS bigcity program. By 1953, after some 20 millionpeople had been x-rayed for TB, the programwas discontinued owing to declining yield andhigh cost. Many health department and TBassociation community x-ray screening pro-grams were also discontinued, although somecontinued until the late 1960s.

In 1959, a group of nationally recognized TBexperts was convened in Harriman, NewYork, to review the status of US TB control,and they issued the “Arden House Report,”which recommended the eradication of TBwith effective treatment programs to curedisease and prevent spread. The Arden Housegroup also recommended isoniazid treatmentof latent TB infection based on extensive PHSchemoprophylaxis trials.

In late 1960, the PHS TB program, by thenrenamed the “Tuberculosis Branch,” wastransferred from Washington, DC, to Atlanta,to what was then called the CommunicableDisease Center. The TB research activityremained in Washington for the time being,then was also transferred to Atlanta in theearly 1970s.

In the 1960s it became increasingly obviousthat long-term hospitalization of patients withactive TB was no longer necessary because ofthe availability of effective chemotherapy, andthe TB Branch began to advocate that patientsreceive most or all of their care on an out-patient basis. The sanatoria began to close,with most of them being closed by the end ofthe 1970s. It has been estimated that theclosing of the sanatoria represented a savingsof more than $400 million to state and localgovernments.

In 1963, in response to a special SurgeonGeneral’s Task Force report on TB, categori-

PHS mobile x-ray unit


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cal TB grant programs were established andfunds were utilized to address the two newlyemerging major challenges in TB control:establishing outpatient TB control services anddesigning ways to effectively identify and treatTB and asymptomatic latent TB infection.Long before the hospitals all closed, sanato-rium clinicians began lowering the hospitaliza-tion period from the entire treatment periodof 18-24 months gradually down to only thefirst 6 months or less. This meant that patientswith uncomplicated TB were treated on anoutpatient basis for up to 18 months. Thereliterally were no outpatient clinic programs inmost of the country; and in many places,when patients were discharged to outpatientcare, they had to return frequently to thesanatorium for outpatient exams and medica-tion refills. Public health nurses had for yearsbeen doing routine contact investigations inthe field, but most health departments did nothave the outreach staff needed for all these TBpatients suddenly being treated on an out-patient basis. Acquired drug resistance due tooutpatient treatment lapse became an impor-tant problem. So as TB sanatoria began toincreasingly discharge patients early, healthdepartments had to provide both the TBclinics and the follow-up staff needed to ensurecompletion of treatment and preventivetherapy. The TB branch consulted with healthdepartments in this undertaking which in-cluded establishing or improving TB registersneeded to effectively monitor and track TBtreatment and follow-up for TB patients.

INH had been introduced in 1952, but itsprevention possibilities were not realized untilEdith Lincoln in New York noted that chil-dren with primary TB treated with INH had amuch lower incidence of serious TB complica-tions. She suggested controlled trials to look atthe possibility of using INH as preventivetherapy for TB. Soon, the controlled trialsconducted by TB Research Section staff(Shirley Ferebee, Carol Palmer, GeorgeComstock, Lydia Edwards, and others) andother institutions began demonstrating that

INH could be effectively and inexpensivelyused to prevent TB infection from progressingto disease. In the mid-1960s, the TB Branchbegan to promote and fund the implementa-tion of the “Child-Centered Program,” whichprioritized the screening of school children toidentify TB infection and ensure that identi-fied children completed a preventive course ofINH. Part of the “Child-Centered Program”was a concerted effort to conduct “clustertesting” or follow-up of contacts to childrenwith TB infection to identify the infecting“source case” and also to identify other in-fected children who may have been exposed toand infected by the same source case.In addition to providing health departmentcategorical funding to help address thesechallenges, the TB Control Branch and theALA’s American Thoracic Society regularlyupdated and widely disseminated guidelinesfor the diagnosis, treatment, prevention, andcontrol of TB.

Almost since its inception, the TB Branch hadcollected, analyzed, and reported nationalmorbidity, hospitalization, and screening data,and has also provided consultative staff tosupport and review TB prevention and controlefforts at the state and local levels. During theearly 1960s, the TB Branch also began work-ing with health departments to establish theTB program management reports to evaluatethe effectiveness of TB prevention and controlefforts. Program management reports continueto be an important component for evaluationof national, state, and local TB prevention andcontrol efforts. Don Brown managed thisactivity from the early 1960s until the mid-1990s. A new concept in the type of assistanceprovided by the TB Branch was initiated inthe mid-1960s with the assignment of CDCTB Public Health Advisors to assist healthdepartments in the operation and evaluation ofTB prevention and control programs. The TBBranch also began recruiting and assigning TBMedical Officers to health departments for 2-year periods. These Medical Officers, alongwith CDC Public Health Advisors, began


44

working as a team with state and local TBControllers and their staff. These assigneeswere in effect “on loan” to the health depart-ments and operated as state or local employ-ees, although they were subject to frequenttransfer by CDC among the health depart-ments. By the mid-1960s, almost every stateplus Guam and Puerto Rico had a TB projectgrant (Wyoming did not).

The number of TB Medical Officers began todecline after 1967 as recruitment became moredifficult and the categorical grants were phasedout. However, Public Health Advisors contin-ued to be requested and effectively work inhealth department TB programs where theywere supported by Partnership for Health andlater prevention block grants. The Advisorsand TB Medical Officers had a major impacton TB control in the areas where they wereassigned and afterwards. After serving in thefield, many of the TB Medical Officers contin-ued on in public health and national TBleadership. Larry Farer and Dixie Sniderstarted as TB Medical Officers in Utah andOklahoma, respectively, and both later wenton to become directors of the TB Division.There is a long list of other former TB MedicalOfficers who continued in leadership roles inTB including current ATS president JeffGlassroth, John Sbarbaro, Phil Hopewell,Tony Catanzaro, and others. The last of theoriginal TB Medical Officer field group wasEric Brenner. (The concept of field MedicalOfficers was revived on a smaller scale in theearly 1990s and continues today.) The TBBranch in the late 1960s and early 1970s alsosupported a number of “Clinical Associates”who were not PHS medical officers butworked like “TB fellows” in pulmonarytraining and were assigned to key institutions.For example, Mike Iseman was assigned toHarlem Hospital under Julia Jones. Theseclinical associates were basically pulmonaryfellows working in pulmonary clinics whoconcentrated on TB and worked in the TBclinics. Lee Reichman was also a TB BranchClinical Associate, as was Ray McDonald,

who works in New Jersey with Dr.Reichman.

No early history of the TB Division would becomplete without a mention of the “TBToday!” course, which was conducted by theTB Division from the late 1960s until the early1990s. The course evolved from courses taughtat National Jewish Hospital in Denver andBattey Hospital in Rome, Georgia. SethLeibler directed the development of thiscourse, working closely with the Director, AlHolguin, and Don Kopanoff, who later servedas the TB Division’s Associate Director forExternal Affairs. Later the course was imple-mented by Ginny Bales, now CDC DeputyDirector for Program Management, and KathyRufo, now Deputy Director of the DiabetesTranslation Division; they were all essential tothe design and early conduct of this course.Later, Barbara Holloway (currently DeputyDirector of the CDC Epidemiology ProgramOffice) directed the course. It was designed forkey TB program managers including physi-cians, TB Controllers, TB nurses who hadmanagement responsibilities, and other TBprogram managers. The course was presentedin a workshop format with heavy emphasis onprogram evaluation and management byobjectives. The attendees worked through thecourse using their own program’s TB morbid-ity and program evaluation data. They devel-oped objectives for their program based ontheir unique problems, and developed strate-gies for achieving the objectives. They wentback to their programs and began to imple-ment the plans and achieve the objectives.Many of the TB Controllers from that era willtestify the course changed their whole ap-proach to TB from a perspective of clinicalmanagement of TB patients to one of manag-ing programs and effectively supervisingpeople. Since the late 1960s, nearly every stateand major city TB Controller and head TBnurse has attended the course, which has beenrevised over time.

The 1970s were belt-tightening times for TB


45

control staff at CDC and across the nation.The last of the special TB project grants werephased out by 1973. The TB Research Sectionwas transferred from Washington to Atlantawith Jerry Weismeuller as Chief, but many ofthe TB Research Section staff retired or movedon to other positions rather than move toAtlanta. In 1974 the TB Branch again becamethe TB Division. In 1976, Larry Farer becameDirector of the TB Division and Dixie Sniderbecame Chief of the Research Branch. JohnSeggerson came to CDC as the Chief of FieldServices in late 1977, replacing Larry Sparkswho had served there before going to theCDC Washington office and later serving asExecutive Director for NIOSH and then asDeputy Director of NCIPC. Jerry Brimberryworked as a TB consultant with Larry Sparksand later moved on to Executive Officer of theDiabetes Field Services Branch. The last of theoriginal TB Medical Officer field assignees,Eric Brenner, left the field for Atlanta and theTB Division in 1978. In the late 1970s andearly 1980s, the role of the TB Division pro-gram consultants was enhanced and theybecame the lead contacts with health depart-ment TB control programs for the Division,establishing ongoing contact and close work-ing relationships between the Division and thefield. A long parade of very effective andmotivated TB program consultants movedthrough the Division and on to higher levelpositions: Charlie Watkins transferred to theregional offices and then to CDC Chief ofRegional Affairs; Wilmon Rushing becameone of the first CDC AIDS officials andmoved up to the NCID Associate Director forManagement; Willis Forrester became Chief ofField Services for the AIDS program; ChrisHayden became Chief of the TB Communica-tions and Education Branch; Mack Andersheaded the TB Division field staff; GeorgeRogers is the PHS Deputy Regional HealthAdministrator Director (Chicago), and CarlSchieffelbein is the current DTBE AssociateDirector for Special Projects. (The currentDTBE Field Services Section Chiefs, JoeScavotto and Greg Andrews, were also DTBE

program consultants.)

1980 was an especially difficult time for TBprograms when the block grants were com-pletely phased out for a short time, there wereno categorical TB grants, and TB programmanagers had to scramble to cover lost re-sources. This was a tough time also for TBDivision Public Health Advisor field assignees,some of whom had to accept assignments inother programs, while many stayed on in TBfield assignments where local health depart-ments were able to cover their salary costswith state or local funds under the Intergov-ernmental Personnel Assignment Act. Thingsbegan to look up again in 1981 and 1982 whencategorical TB project grants were againfunded, although initially on a very smallscale. Since the TB Medical Officer fieldassignee activity had been phased out by 1978,the Division began recruiting physicians andother scientists from the EIS officer group forTB Division medical posts beginning withRick O’Brien, George Cauthen, Ken Powell,Bess Miller, Hans Reider, and Alan Bloch,who were the first of this respected group.

The TB individual case report was introducedin the mid-1980s, enhancing the national TBsurveillance system. Nonetheless, through thelate 1970s and early 1980s, many TB programsincreasingly felt the impact of cutting re-sources that began in the early 1970s. The firstdocumented outbreak of drug-resistant TBoccurred in 1976 and 1977 in rural AlcornCounty, Mississippi. TB-related resources andinfrastructure continued to deteriorate in mostareas, and in the early 1980s, HIV/AIDSbegan to affect TB, at first in Florida and thenin the New York City metropolitan area andelsewhere. Because of the decline of theinfrastructure, many health departments weresimply unable to cope with the emerging TB-related problems associated with AIDS, alongwith increasing numbers of foreign-born TBpatients and other problems having an impacton TB. By the mid-1980s the long-time de-cline in the Nation’s TB morbidity trend


46

ended and outbreaks of MDR TB in hospitals,prisons, and other institutions were underway.

The following articles by the lead staff ofDTBE’s branches and programs will provide amore current perspective on division activities.

CDC Funding for TB Prevention andControl

by Patricia Simone, MDChief, Field Services Branch, DTBE

and Paul PoppeDeputy Director, DTBE

Federal fiscal support for TB control beganwith the passage of the Public Health ServiceAct, which was created to assist states inestablishing and maintaining adequate mea-sures for the prevention and control of TB.To enhance case-finding activities, the 1955Appropriation Act (Public Law 83-472) di-rected federal grants with local matching fundsto be used only for prevention and case-finding activities. In 1961, Congress providedfor project grants that were to be used forimproving services to known TB patientsoutside of hospitals, examination of contacts,and diagnosis of suspects. In December 1963,the Surgeon General’s task force issued areport recommending a 10-year plan to en-hance the federal role in national TB controlthrough increased grants for services forunhospitalized cases and inactive cases, contactinvestigations, school skin test screening, andhospital radiograph screening programs. By1967, there were 82 TB control programs inthe United States, with federal appropriationsof $3 million in formula grants and $14.95million in TB project grants.

However, in 1966 the Public Health ServicesAct was amended, changing project grants toblock grants. These new grants did not requirethat any funds be used for TB control, andmany health departments eventually redistrib-uted the funds to other programs. Whilecategorical TB appropriations were restored in1982, there were very modest amounts of

federal funding (approximately $1 million to$9 million per year) available for TB controluntil fiscal year 1992.

Despite an overall decline in funds being spentfor TB control, the number of reported TBcases continued to decline nationally through1984. However, from 1985, the number ofcases began increasing and continued to risethrough 1992. Recognition of the outbreaksof multidrug-resistant TB, the high mortalityassociated with TB in HIV-infected persons,and transmission to health-care workersresulted in strong recommendations for en-hanced funding for TB prevention and controlprograms and more stringent infection controlpractices. In fiscal year 1992 the appropriationwas increased to $15 million from the previousyear’s funding of $9 million. It increased againin 1993 to $73 million, when Congress appro-priated $34 million for the continuation andexpansion of the TB cooperative agreementsand $39.2 million in emergency funds for usein the areas of the country most heavilyaffected by the increased cases. Congressappropriated yet another increase for categori-cal TB grants in 1994, and the appropriationfor TB project grants was increased to over$117 million. In addition, approximately $25million in redirected HIV funds have beenavailable for TB control activities each yearsince 1992, for a total of over $142 million infunding for CDC for TB-related activities. Asa result of this infusion of funding, TB pro-gram infrastructures have been rebuilt and theresults are evident with six consecutive annualdecreases in the number of reported TB casesin the United States.

1977 - 1998In millions

160

140

120

100

80

60

40

77

Year

$144

98959289868380

TB Funding History vs. Reported Tuberculosis Cases

TB CasesTB Funding


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Since 1994, however, CDC has receivedapproximately level funding for TB-relatedactivities. The Tuberculosis Elimination andLaboratory Cooperative Agreement wasrevised for FY2000 to ensure prioritization ofthe core TB activities (completion of therapy,contact investigation, surveillance, and labora-tory) for all TB programs, with separatefunding provided on a competitive basis fortargeted testing and treatment of latent TBinfection for high-risk groups in programsdemonstrating good performance on the coreactivities.

Federal funds are intended to supplement thestate and local activities for TB control andprevention, and in many states, federal fundsrepresent only a small fraction of the totalfunds available to the TB program. However,in many other states, federal funds representthe majority of TB funding available. Further-more, some areas are actually reporting areduction in their state or local TB funding.Yet the level of federal funding is expected toagain remain the same in fiscal year 2000 and2001, which will result in a decreased amountof available funds when inflation factors areapplied. Although cases have declined since1993, the case rate of 6.8 per 100,000 in 1998 isstill far short of the target of 3.5 per 100,000by the year 2000 set by CDC, and aggressiveTB prevention and control efforts must besustained to continue on a successful course toelimination. This will require the continua-tion of our current efforts and the develop-ment of new or increased funding initiatives atevery level, including federal, state, and local.

The Advisory Council for the Elimination ofTuberculosis (ACET) published “Tuberculosiselimination revisited: obstacles, opportunities,and a renewed commitment” in the MMWR,August 13, 1999/Vol. 48/No. RR-9, and alsostated the need for additional resources to fullyimplement effective elimination strategies. Inaddition to fiscal resources, ACET recom-mended building a stronger advocacy at everylevel of government as well as engaging new

partners at the local level, and strengtheningcoalitions by revitalizing the National Coali-tion for the Elimination of Tuberculosis(NCET) to garner more private support, andstrategically utilizing the media to inform thegeneral public and legislators regarding TB.

Managed Care and TB Control –A New Era

by Bess Miller, MD, MScAssociate Director for Science, DTBE

After the TB sanatoria were closed during the1960s and 1970s, typically both clinical careand public health functions for TB controlwere carried out in the health departmentsetting. However, during the past three de-cades, there has been an increasing trendtoward the provision of clinical care forpatients with TB by the private sector. By1998, about 50% of the care for patients withTB was provided either partially or totally bythe private medical sector. More recently, themanaged care transformation has increasedthis movement of patients with TB away fromclinical care in health department settings.Patients with TB may be enrolled in managedcare organizations as a result of coverage underemployee benefit plans, privately purchasedinsurance policies, or as a result of enrollmentin Medicaid or Medicare programs. TheOmnibus Budget Reconciliation Act of 1993(OBRA) permitted states to extend Medicaidcoverage to persons with TB, and some stateshave used this legislation to enroll such pa-tients in their Medicaid programs. In addition,as part of overall Medicaid managed carerestructuring, a few states have expandedcoverage to include previously uninsuredpersons. The vulnerable populations amongthe newly insured are likely to include personsat high risk for TB. The shifting of care ofpatients with TB into managed care plans,with the emphasis on management of costs,has raised new concerns in the public healthcommunity with regard to the ability tomaintain adequate community TB control aswell as to provide optimal management of


48

patient care in light of these changes.

A survey of state and big city TB controllersconducted in collaboration with the NationalTB Controllers Association in late 1997revealed the following: 1) health departmentsare still acting as the traditional provider ofTB clinical services in most areas of the coun-try; 2) in some areas, however, managed carehas changed the way TB clinical services arebeing delivered (examples of these new ar-rangements included managed care organiza-tions as providers of clinical services to theirenrollees with TB, health departments actingas members of managed care organizationsprovider networks, and health departmentsacting as non-network, fee-for-service provid-ers to managed care organizations); 3) healthdepartments are providing the majority ofpublic health services for TB patients who areenrolled in managed care organizations (con-tact tracing, providing directly observedtherapy, and returning lost patients to care);4) many managed care organizations are usingtheir own or other private laboratories toprocess TB specimens, rather than state labora-tories; and 5) in many areas, health depart-ments are not being consistently reimbursedfor providing TB services to patients withprivate insurance coverage or Medicaidcoverage.

During the past several years, there have beena number of symposia addressing the impact ofmanaged care on TB control, which wereconducted at national meetings of the Ameri-can Public Health Association, the NationalTB Controllers Association, and the Centersfor Disease Control and Prevention. In thesesymposia, a number of themes have emerged,including the urgency of ensuring quality carefor TB patients by health care providers withexpertise in treating TB; continuous treatmentand completion of therapy with the use ofDOT; use of laboratories with expertise inmycobacteriology; timely reporting of cases tothe health department and initation of contactinvestigations; development and use of perfor-mance measures to monitor patient care and“public health performance”; and systems toensure ongoing dialogue between healthdepartment staff and managed care organiza-tion providers.

At the same time, there is recognition that thedelivery of health services through managedcare organizations presents opportunities topublic health leaders, including improvedaccess to high-risk populations for preventiveservices and to health care providers fortraining and education on best practices. Inaddition, the administrative data systems ofmanaged care organizations may provideopportunities for improved surveillance andevaluation of quality of care. The Division ofTuberculosis Elimination has collaboratedwith Harvard Pilgrim Health Care, a largemixed model health maintenance organizationin New England, to review the use of adminis-trative data systems to augment tuberculosissurveillance and the use of pharmacy recordsto assess the management of tuberculosis.(Please see “Supplementing tuberculosis sur-veillance with automated data from healthmaintenance organizations.” Yokoe DS,Subramanyan GS, Nardell E, Sharnprapai S,McCray E, and Platt R. Emerging InfectiousDiseases 1999; 5:779-787, and “Using auto-mated pharmacy records to assess the manage-ment of tuberculosis.” Subramanyan GS,

The pioneering industrial social worker LeeFrankel envisioned insurance as a powerfulmeans toward improving the lot of theunderprivileged. When he was hired by theMetropolitan Life Insurance Company, heestablished MetLife’s Welfare Division.Frankel’s early work centered on theprevention of TB, the “white plague” thataccounted for 20 percent of all death claims.He realized that public education was thekey. In 1909, 10,000 MetLife agents deliv-ered Frankel’s pamphlet A War UponConsumption to millions of urban poor, whoare most at risk for TB (source: Metropoli-tan Life Insurance Co. Web site).


49

Yokoe DS, Sharnprapai S, Nardell E, McCrayE, and Platt R. Emerging Infectious Diseases1999; 5:788-791). Administrative data setsprovided useful information in both studies.

To assist health departments, State MedicaidAgencies, and managed care organizations inthe development of written agreements toensure the provision of quality patient careand public health TB prevention and controlpractice, DTBE has collaborated with theOffice of Health Care Partnerships of theEpidemiology Program Office, CDC, andwith the George Washington UniversityMedical Center’s Center for Health PolicyResearch to develop model contract specifica-tions. (Refer to the article “Tuberculosiscontrol in a changing health care system:Model contract specifications for managedcare organizations.” Miller B, Rosenbaum S,Stange PV, Solomon SL, and Castro KG.Clin Infect Dis 1998;27:677-686.) Thesespecifications can be accessed on the internetat the following website: http://www.gwu.edu/~chsrp.

Early Research Activities of the TBControl Division

By George W. Comstock, MD, DrPH, FACEAlumni Centennial Professor of Epidemiology

Johns Hopkins UniversitySchool of Hygiene and Public Health

Herman E. Hilleboe was the first Chief of theTuberculosis Control Division of the UnitedStates Public Health Service, with Carroll E.Palmer as director of the Field Studies Sec-tion, the unit responsible for most of theDivision’s research. This review is basedlargely on perusal of the 70 TuberculosisControl Issues, published during the first weekof every month as special issues of PublicHealth Reports. This arrangement continuedfrom March 1, 1946, to December 7, 1951,when Public Health Reports changed to amonthly schedule.

The Student Nurse Study was initiated byPalmer, and was supported by the NationalTuberculosis Association until the foundationof the Tuberculosis Control Division. Duringthe period from 1943 to 1949, some 22,000student nurses in 76 schools were given tuber-culin tests every six months by a speciallytrained team. On one of these occasions,approximately 10,000 nurses were also givenchest radiographs. Comparison of skin test andradiographic findings showed that manypulmonary calcifications were due to histoplas-mosis, that histoplasmosis was concentrated incertain areas of this country, and that manypositive tuberculin reactions were due tonontuberculous mycobacteria.

Confirmation of these results came from aresearch unit established in 1945 in KansasCity, Missouri, to study the epidemiology ofhistoplasmosis. Two little-known findingsdeserve emphasis. In two midwestern counties,there was remarkable local variability in thefrequency of histoplasmin reactions amongcattle. Farms with histoplasmin-positive cattlewere interspersed irregularly among those withno reactors. (This marked small-area variabilitywas later found in Maryland among highschool students, suggesting that risk factors forendemic and outbreak histoplasmosis aredifferent.)

Studies of tuberculin, histoplasmin, and variousnontuberculous mycobacterial antigens reachedtheir peak with the testing of more than amillion US Navy recruits from 1958 to 1969. Adetailed report of the results of the first half-million tests delineated the extent of theseinfections in cities, counties, and states. Otherimportant findings were as follows: a) in anyarea with nontuberculous mycobacterialinfections, the larger the tuberculin reaction,the greater the probability that its cause wastubercle bacilli; b) the risk of developing TBafter infection was high among underweightpersons and low among the obese; c) there wasa suggestion that nontuberculous mycobacte-rial infections conferred some resistance against


50

TB; and d) there was also a suggestion thatsocial stress increased the risk ofdeveloping TB.

A major purpose of the Muscogee County(GA) Tuberculosis Study, started in 1946, wasto evaluate the role of mass chest x-ray surveysin TB control. The prospectus and a descrip-tion of the coverage of the survey and preva-lence of TB were included in the first twopapers published on this study. Calculation ofparticipation rates was made possible by thepopulation denominator provided by a privatecensus. Basic factors associated with participa-tion and the prevalence among participantswere described, as well as reasons for nottaking part in the survey. Subsequent papers,building on this foundation, were able toprovide information on the incidence of TBamong tuberculin reactors and the risks ofreactivation among persons with inactive TB,information that has been used to the presenttime.

The first report of the BCG trials in MuscogeeCounty and Russell County (AL) appeared in1951. The school children vaccinated in 1947were retested 6 months later, and many con-trols and vaccinees were tested with tuberculinagain in 1950. Both groups had had less than 5-mm induration to the 100-TU dose of PPDtuberculin in 1947. Although 46% of thevaccinees had 5 or more mm of induration to5 TU of PPD-tuberculin 6 months later, only24% of them had reactions this large in 1950;at that time, only 3% of controls had similarreactions. Subsequent follow-up of persons inthese trials produced findings that were com-pletely unexpected at the time of their initia-tion. In contrast to the belief that most TBoccurred very shortly after infection and thatthose who survived this short-term risk wererelatively safe thereafter, approximately 80%of TB developed among the initially positivereactors who continued to be at risk. Thisfinding dashed an early hope, namely that thesource of a new case of TB ought to be readilyfound among recent contacts. An unpublished

finding involved the first 56 cases amongsurvey participants who did not have a knowncase in the household. Some 13,000 possiblecontacts were identified (relatives, friends,workers in the same factory, school mates,etc.). Approximately 11,000 were examined,with the identification of only one possiblebut unlikely source case. The facts that solittle TB developed among nonreactors (thoseeligible for vaccination) and that BCG ap-peared to cause harm among school childrenand to afford very little protection to olderpersons were major considerations in thehesitancy to advise BCG vaccination in theUnited States. Over a 23-year period, therewere slightly but significantly more cancercases among vaccinees than controls, mostmarkedly for tumors of the lymphoid tissues.

Many other studies were carried out by theField Studies Section during this period.There were numerous reports relevant to masschest x-ray surveys, then in their heyday,dealing with topics such as x-ray generators,fluorescent screens, films, protection of per-sonnel, and the feasibility of taking photofluo-rograms without having participants disrobe.The development of standardized fungalantigens, notably histoplasmin, was also animportant endeavor. Finally, and far fromleast important, was the publication of CarrollPalmer’s ideas for research that could be donein conjunction with the mass tuberculintesting and BCG vaccination then underwayin the International Tuberculosis Campaign.

(Editor’s note: Dr. George Comstock con-ducted the trials in Georgia from 1946 to 1955.He continued to make major contributions tothe knowledge of TB and measures to preventthe development of TB. After retirement fromthe PHS he became the Alumni CentennialProfessor of Epidemiology at Johns HopkinsUniversity. Dr. David Sencer, a medicalofficer, was then assigned to Georgia to con-tinue Dr. Comstock’s work. He subsequentlyrose through the CDC ranks to become theDirector of CDC, serving from 1966 to 1977.)


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The First TB Drug Clinical Trialsby Rick O’Brien, MD

Chief, Research and Evaluation Branch, DTBEand George Comstock, MD, DrPH, FACE

Alumni Centennial Professor of EpidemiologyJohns Hopkins University

School of Hygiene and Public Health

The United States Public Health Service(USPHS), together with the British MedicalResearch Council (MRC) and the US ArmedForces–Veterans Administration CooperativeTrials, played a key role in the development ofthe chemotherapy of TB.

The first USPHS trial, a placebo-controlledstudy of streptomycin, was initiated by theField Studies Section and the TuberculosisStudy Section of the National Institutes ofHealth (NIH) in 1947, the same year as themuch smaller but better known MRC study ofstreptomycin. In the PHS study, a total of 541patients with moderate to far-advanced pulmo-nary TB were enrolled at 14 hospitals andsanatoria throughout the US and Alaska. Thepublished account gives no hint of how thiscontrolled evaluation of streptomycin wassaved from being only the series of uncon-trolled observationsthat was initiallyproposed. Funds fora study of streptomy-cin in the treatmentof TB had beenallocated, probablyin 1946, to a numberof prominent hospi-tals. When CarrollPalmer heard thatthere were to be nocontrols, he wasupset and expressedhis concerns to Dr. Van Slyke, director of theNIH. Van Slyke agreed with Palmer, anddirected that a controlled trial be planned andconducted under the general supervision of thenewly convened Tuberculosis Study Section.Dr. Esmond Long, from Phipps Clinic in

Philadelphia, was the chairman of the StudySection’s Steering Committee. Ms. Ferebee,Chief of the Therapy Evaluation Branch, FieldStudies Section, became the study administra-tor. With some grumbling from those whohad lost their streptomycin allocation, acontrolled trial was conducted, althoughwithout the placebo controls Palmer andFerebee had wished. All investigators tookpart in various reviews of clinical and radio-graphic findings and in committees set up toconsider appeals from the protocol, proce-dures continued in future PHS therapy trialsas a way to bring investigators together andgive them a real part in major decisions.

The study demonstrated the remarkableability of streptomycin to reduce mortalityand improve clinical status. However,monotherapy with streptomycin led to thedevelopment of drug resistance in a significantnumber of patients. In 1951, the one-yearstatus was reported for the patients givenstreptomycin: 40% had negative cultures, 5%had died, 17% still had tubercle bacilli sensi-tive to streptomycin, and 39% had resistantorganisms. In another 1951 report, PAS wasfound to be highly effective in preventingresistance to dihydrostreptomycin (similar inaction to streptomycin but with a higher riskof ototoxicity.)

The second USPHS study, begun in 1949 at 11institutions, randomized a total of 315 patientsto either streptomycin or streptomycin-PAS.After 6 months of treatment, over 40% ofpatients receiving monotherapy developedstreptomycin resistance, compared to only12% of patients on combination therapy.

A major advance in TB treatment occurred in1952 with the initial report of an MRC studyof isoniazid. During the next 2 years, a total of5,324 patients were enrolled in three USPHStrials (which became known as Studies 1, 2,and 3), examining a variety of combinations ofthe three drugs. The conclusion of thesestudies was that the triple combination did not


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appear to be more efficacious than the combi-nations of any two of the drugs. However,the combination of isoniazid and PAS wasmuch better tolerated. Evidence from anMRC study indicated that initial streptomycindid contribute to treatment efficacy in patientswith advanced disease. Another MRC studydetermined that the optimal duration oftherapy with these drugs was 2 years.

With the scientific basis for TB chemotherapyfirmly established, the PHS turned its atten-tion to the next drugs that became availablefor clinical study, pyrazinamide and cyclos-erine. However, initial evaluation of pyrazina-mide at much higher dosages than are cur-rently used suggested that the drug was tootoxic for use in initial treatment, although itappeared to have a role in the treatment ofdrug-resistant disease. Subsequently, througha series of elegant studies in Africa and Asia,the MRC defined the critial role of that agentin modern short-course therapy.

While continuing to conduct treatment effi-cacy studies, the USPHS also embarked onpioneering studies of isoniazid for the preven-tion of TB in persons with latent TB infection(LTBI). Between 1955 and 1959, nearly 65,000persons including children with primary TB,contacts of infectious TB patients, patients inmental institutions, and Alaskan villagers,were entered into placebo-controlled trials thatdemonstrated the efficacy of isoniazid fortreatment for LTBI.

In 1960, CDC was given responsibility for TBcontrol and research. However, the researchdivision resisted pressure to move to Atlantaand continued its work from Washington. InUSPHS studies 12 to 16, the role of ethambu-tol as a first-line drug replacing PAS wasdefined. In 1969, the USPHS began the first ofa series of studies of rifampin, ushering in themodern era of short-course therapy. Study 18found that the combination of isoniazid andrifampin was superior to the best regimen thathad been evaluated up to that time. USPHS

Study 19 evaluated various dosages of rifampinand found that the optimal daily dosage was 10mg/kg or 600 mg for most adults.

As rifampin-based short-course therapy be-came firmly established, support for therapytrials in the US began to wane. Study 20, thefirst USPHS study initiated after the researchdivision moved to CDC, attempted to dupli-cate a smaller MRC study of a 6-month regi-men of isoniazid and rifampin and found thatthe relapse rate of 10% was unacceptably high.Study 21, which began enrollment in 1981,was plagued by continuing shortages in finan-cial support such that the study was nearlyterminated several times before it successfullycompleted enrollment. That study confirmedthe results found by the MRC and led to theadoption of 6-month therapy in the US. Itwas not until the resurgence of TB in the US,with the concomitant increased support forTB research, that the capacity of the USPHSto conduct high-quality TB treatment trialswas restored.

Current TB Drug Trials:The Tuberculosis Trials Consortium

(TBTC)by Andrew Vernon, MD, MHS

Research and Evaluation Branch, DTBE

The USPHS and the Veterans Administration(VA) have a distinguished history of conduct-ing clinical trials to evaluate new drug regi-mens for both the treatment and prevention ofTB. In 1960, CDC assumed a major role inthese studies when the USPHS TuberculosisDivision was transferred to CDC. Subse-quently, CDC coordinated a series of


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multicenter clinical trials that helped to estab-lish rifampin-based, short-course therapy asthe standard for TB treatment. It also con-ducted studies to provide the scientific basisfor preventive chemotherapy, which remains amajor component of our TB eliminationstrategy.

Support for the infrastructure required forthese studies gradually diminished, so that thelast completed trial, USPHS Study 21, wasnearly terminated several times during itscourse for lack of adequate funding. With theinfusion of federal support for TB control andelimination in the early 1990s, CDC estab-lished a consortium of clinical investigators forthe specific purpose of conducting USPHSStudy 22, a trial of once-weekly isoniazid andrifapentine in the continuation phase oftherapy for pulmonary TB. This consortium,whose sites include public health departments,academic medical centers, and VA medicalcenters (VAMC), required both time andsubstantial financial resources to establish andsupport, but is now functioning efficiently.

Did you know that... Aspirin was developed as a cure for tuberculosis? Researchers in Switzerland looking for a cure for TB were excited to discover that one particular compound was able to relieve the fever and pain of TB patients. They subsequently found that it only provided temporary relief, not a cure, and they put the drug aside. The compound was later rediscovered and named aspirin (from A. Karlen, Man and Microbes, Putnam & Sons, NY, 1995).

Currently new drugs and regimens for bothTB treatment and prevention, new diagnostictests, and new vaccine candidates are becomingavailable for clinical investigation. Concur-rently, the challenges posed by the goal of TBelimination are increasing, as global rates ofdrug resistance increase and as the costs associ-ated with assuring high rates of adherence rise.

The consortium now provides a unique andimportant resource for further clinical studies,and has demonstrated its ability to play animportant role in TB treatment andprevention.

The original group of clinical sites included 12academic centers and health departments (7contracts issued in 1993, and 5 more in 1994),and 15 VAMCs (funded through a Memoran-dum of Agreement with the Washington, DC,VAMC). Enrollment into USPHS Study 22began in April 1995, and continued to comple-tion in November 1998. In 1997 CDC beganworking with the USPHS Study 22 investiga-tors to develop a structure that would engagemore fully the capacities of the study investiga-tors in the work of the group. The TBTC wasthus organized, with formal by-laws adoptedin 1998. Several working committees wereestablished; these are composed of selectedConsortium investigators and coordinators, incollaboration with CDC staff. One committee(Core Science) oversees the scientific programof research, a second (Implementation andQuality) supervises the conduct and quality ofongoing studies, and a third (Executive Af-fairs) serves as the executive arm of the steer-ing committee. This structure is modeled onthe Community Programs for Clinical Re-search on AIDS (CPCRA), which is supportedby the National Institute of Allergy andInfectious Diseases (NIAID).

In 1999 the TBTC underwent a formal exter-nal re-competition. New 10-year contractswere awarded to 13 offerors (7 prior TBTCmembers and 6 new sites). The VA side of theconsortium underwent a similar process, andfunded 10 VA Medical Centers to continue asmembers of the TBTC.

The current studies of the TBTC are as fol-lows:

Study 22: Randomized open-label trial toevaluate the efficacy of once-weekly isoniazidand rifapentine in the continuation phase of


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therapy for pulmonary TB. Enrollment closedin November 1998 with 1,004 HIV-negativeparticipants. Follow-up will continue throughmid-2001.

Study 22 PK Substudy: Substudy to evaluateisoniazid, rifampin, and rifapentine pharmaco-kinetics in 150 patients enrolled in Study 22.Currently in analysis.

Serum Bank Study: Collection of docu-mented serum specimens from patients withsuspected or proven TB, from baselinethrough the course of therapy. Nearingcompletion.

Study 23: Single-arm clinical trial to evaluatethe safety and efficacy of rifabutin-containingshort-course therapy for HIV-infected TBpatients receiving HIV protease inhibitors.Aims to enroll 200 patients over 2 years, with2-year follow-up. Enrollment began in March1999.

Study 23a: Substudy to evaluate isoniazid andrifabutin pharmacokinetics in Study 23 TBpatients with HIV receiving antiretroviraltherapy. Enrollment began July 1999.

Study 23b: Substudy to evaluate rifabutin andnelfinavir pharmacokinetics in TB patientswith HIV receiving nelfinavir as part ofantiretroviral therapy. CDC IRB approvalgranted in November 1999.

Study 23c: Substudy to evaluate rifabutin andefavirenz pharmacokinetics in TB patientswith HIV receiving efavirenz as part ofantiretroviral therapy. Enrollment beganDecember 1999.

Study 24: Single-arm study of largelyintermittent, short-course therapy for patientswith INH-resistant TB or INH intolerance.Aims to enroll 200 patients over 2 years with 2years of follow-up. Enrollment beganSeptember 1999.

NAA Substudy: Study of the performance ofseveral nucleic acid amplificationmethodologies in the diagnosis andmanagement of active TB. CDC IRB approvalgranted in October 1999.

Study 25: Phase I-II dose escalation study ofrifapentine using same design as Study 22, withpatients completing 2-month standardinduction randomized to 600, 900, and 1200mg of once-weekly rifapentine/isoniazid.Expected to demonstrate safety andtolerability of higher doses of rifapentine,which may improve efficacy, prevent acquiredrifampin resistance in HIV-infected patients,and permit use of once-weekly treatment ininitial phase. Enrollment began July 1999.

Study 26: Trial of short-course treatment oflatent TB infection among contacts of activecases, using a 3-month once-weekly regimen ofisoniazid and rifapentine, compared to therecently recommended 2-month daily regimenof rifampin and pyrazinamide. Protocol indesign.

For further information about theConsortium, please visit the TBTC web site athttp://www.cdc.gov/nchstp/tb/tbtc

TB Communications and Educationby Wanda Walton, M. Ed.

Chief, Communications and Education Branch

Training and education in TB have changeddramatically over the years. In the not-too-distant past, these efforts were primarilylimited to face-to-face classroom instruction


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and the distribution of print-based materials.Educational films, then later videotapes, weredeveloped and distributed, but often thesematerials had a very limited distributionbecause of the costs of the films and tapes andthe limited availability of audiovisualequipment for viewing.

Today, through the availability of technologyand reduced production costs, we have a vastarray of materials and courses that aredistributed through a wide variety of media.Some of the media include print-basedcurricula with slides (e.g., the CoreCurriculum on Tuberculosis); CD ROM (e.g.,Tuberculosis: An Interactive CD ROM for

Clinicians); satellite-based courses (e.g., theSatellite Primer on Tuberculosis); videotapes(e.g., the Skin Testing Video); audiotapes (e.g.,the TB voice information system); andInternet-based courses (e.g., the Web-BasedSelf-Study Modules). With the use of satellite-based courses, instructors can simultaneouslyreach thousands of health care providers inevery US state and territory with accurate, up-to-date information. Reduced costs for thereproduction of videotapes and CD ROMsallow for wide-spread distribution ofmaterials. In addition, the Internet allows fordistribution of materials and courses toaudiences we may have never reached before,both professionally and geographically, at noadditional cost after initial production.

Print-based materials are also accessible in a

variety of ways. Hard copies can be orderedby mail, by telephone, by fax, or through theInternet online ordering system. Materials canalso be downloaded and printed from theInternet. The electronic files of the materialsavailable through the Internet can also beutilized as the basis for adaptation anddevelopment of site-specific or population-specific materials.

Another big change in TB training andeducation is in the methodologies used toinfluence health care providers’implementation of TB recommendations. Inthe past, the primary method utilized wasinformation dissemination to increase thehealth care providers’ knowledge of therecommendations. However, we know thatinformation alone is not sufficient to changethe practice of many health care providers. Inaddition to knowledge or information, healthcare providers must be persuaded to try thenew recommendations. This persuasion canoccur if the health care provider thinks thatthe recommendations provide an advantage(is it better than what it’s replacing?); iscompatible with the current system (no majorconflicts created in the current system toimplement); is not too complex (how hard is itto do or use?); can be tried beforehand (can Itry it before I decide to really use it withpatients?); can be observed (can I actually seethe result of using this innovation?); and isflexible to being adapted to the current system.After being persuaded that there is anadvantage to the new recommendation, healthcare providers must progress through adecision process (adopt or reject), then toimplementation, then to continued, ongoinguse of the recommendations. Behavioraltheories and models can be utilized to guidethe development of educational and traininginterventions to aid in this progress.Interventions such as academic detailing andthe use of opinion leaders can be utilized tofacilitate the progress.

For current and future efforts, utilization of


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behavioral science and implementation ofoperational research are essential fordeveloping effective interventions in TBcommunications, training, and education.With decreasing TB cases in the United States,it becomes even more important to be vigilant,efficient, and effective in our efforts to keephealth care providers aware of recommend-ations, and utilizing them appropriately.

Note: Please feel free to use the DTBEEducational and Training Materials orderform included in this issue. Materials can alsobe ordered from the DTBE web site at http://www.cdc.gov/nchstp/tb

TB Control in the Information Ageby Jose Becerra, MD, MPH

Chief, Computer and Statistics Branch

“TRS is a computer-basedsystem devised to furnishcurrent information on clinicalmanagement of patients and up-to-date statistical summaryreports for public healthadministrative purposes.” -Tuberculosis Branch, State andCommunity Services Division,National CommunicableDisease Center, Sept. 1969.

Thus was recorded one of the first iterations ofan electronic information management systemfor the purpose of tracking the epidemiologyand clinical management of TB in the UnitedStates. The Tuberculosis Record Service(TRS), a mainframe system using punch cardsand computer tapes for data processing, was apredecessor of the DOS-based SURVS-TB(Software for Expanded TuberculosisSurveillance). SURVS-TB, a microcomputersystem depending on mailed diskettes for datatransfer, and the Tuberculosis DatabaseSystem (TBDS), a patient managementrecordkeeping system, were used until 1998when the Tuberculosis InformationManagement System (TIMS) was

implemented. Regardless of names andversions, TB information management systemspursue the same general objective: the use ofmeaningful data, that is, intelligence-addeddata, to perform organizational work andmonitor outcomes.

TIMS is an integrated client-server applicationin Windows, meaning that many users(“clients”) may simultaneously access a fullyrelational database residing in a secure serverwithin a computer network, using theMicrosoft Windows graphics user interface.TIMS has replaced the mailing of disketteswith dedicated modem communications fordata transfer purposes. Furthermore, TIMSallows the generation of surveillance data fromthe patient management module integratedwithin TIMS. Soon, TIMS will also be able toimport surveillance data from other systems tocompletely eliminate the need for double dataentry.

However, when TIMS was originallydesigned, the Internet revolution thatnowadays dominates the informatics worldwas just beginning. The World-Wide Webmodel, wherein interactive and secure datatransactions are conducted using a commonviewer or “browser,” regardless of the originalplatform in which an application is developed,poses new opportunities and challenges to thefuture of TIMS. Among these challenges are1) the speed with which informationtechnology is being adopted (and abandoned);and 2) the call for fully “integrated”information systems.

The transition of TIMS into a Web-enabled


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application will eventually occur. We canenvision a local department of health, with alow-end (“thin”) computer and a browser,logging in to a state or regional server tosecurely send in interactively validated TBdata or to browse the results of somedescriptive trend analyses. We can alsoenvision a health maintenance organizationuploading data on a batch of TB suspects andcontacts to be worked up by local healthdepartment staff. These data would besubsequently sent to CDC without personalidentifiers, using a commonly agreed-uponformat. However, the speed with whichinformation technology is changing manytimes hinders the wise selection of platforms,software development tools, and practices thatpermit the design of durable and reliable Web-based surveillance systems.

The word integration is trendy nowadays.However, integration is a value-laden termthat may mean consolidation to some, as inblock grants, while it may mean coordinationof efforts to others. TIMS might be consideredan integrated system: it integrates patientmanagement with surveillance data. AndTIMS will become fully integrated with otherinformation management systems once its dataimport utilities are completed and a newversion is released complying with publichealth, clinical, and laboratory informaticsstandards now in development as part of theCDC-wide surveillance integration efforts.The future of TIMS hinges on the assumptionthat TB will remain a categorically fundedprogram, possibly integrated with other

disease-prevention efforts in a patient-centeredhealth care delivery model, but ultimatelyaccountable for its funding. Therefore, TIMSwill reflect this funding accountability byprotecting TB data integrity and its proper usefor program evaluation purposes.

Our organizational mission is to promotehealth and quality of life by preventing,controlling, and eventually eliminating TBfrom the United States. Our NationalStrategic Plan calls for a reduction of the TBcase rate to less than one per millionpopulation by the year 2010. Therefore, weneed to leverage information technology tomanage, analyze, and synthesize practicalknowledge at the local, state, national, andinternational level to facilitate theorganizational work that will move us closerto that organizational objective.

Data are processed; information is managed;knowledge empowers. Information becomesknowledge, and thus power, whensystematically structured and functionallyorganized for a specific purpose. But there isone crucial premise in this line of reasoning:the existence of an organizational will. Anorganizational will requires commitment toaccomplish a mission, and that commitmentbegins with a will to know. Once thatorganizational will is present, and it certainlyis present in the TB prevention community,TIMS is and will be ready to facilitate theorganizational work that will move us closerto achieve our organizational objectives for theyear 2000 and beyond.

Field Services Activitiesby Patricia M. Simone, MDChief, Field Services Branch

In the early 1960s, with the initiation ofcategorical project grants, the TuberculosisBranch moved to Atlanta to join CDC, calledthen the Communicable Disease Center. In1974, the Tuberculosis Branch became the

Old TB recordkeeping system.


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Division ofTuberculosis Controlwith two branches: theProgram ServicesBranch (which alsocontained training andsurveillance) and theResearch Branch. In1986, surveillancebecame a separatebranch. The ProgramServices Branch was reorganized into twosections: the Program Operations Section andthe Program Support Section. The ProgramOperations Section was responsible forproviding technical assistance andadministering cooperative agreement fundingto the state and local TB programs. A team ofprogram consultants served as project officersfor the project sites, and field staff wereassigned to various state and local TBprograms to assist with programimplementation. The Program SupportSection was responsible for training andeducational activities as well as programevaluation through information collected inthe Program Management Reports.

In 1991, the name of the division changed tothe Division of Tuberculosis Elimination. In1996, the Division of TuberculosisElimination was reorganized. The ProgramServices Branch became the Field ServicesBranch (FSB). The Program Support Sectionof the Program Services Branch became theCommunications and Education Branch,although the program evaluation activitiesremained in FSB. The Program OperationsSection became two sections, Field OperationsSections I and II, with approximately one halfof the project sites covered by each. A medicalofficer was assigned to each of the newsections to work closely with the programconsultants to enhance technical assistance andprogram evaluation capacity. A third medicalofficer conducts studies and other activitiescentered around program evaluation andprogram operations.

The number of field staff positions grew froma low of 25 in 1980 to over 60 by 1996. Inaddition to assigning more Public HealthAdvisors to the project sites for enhancedcapacity building, FSB has hired several fieldmedical officers serving as medicalepidemiologists and medical directors invarious TB project sites. These positions alsoserve as key training positions to develop TBclinical and programmatic expertise as olderTB experts retire. In order to better meet theneeds of the larger field staff, the Field StaffWorking Group was established to enhancecommunication between headquarters and thefield, and a field staff training and careerdevelopment coordinator was added to theheadquarters staff of FSB.

The last group of persons hired in the PublicHealth Advisor (PHA) series were recruited in1993. Through attrition and promotion, thepool of PHAs has continued to diminishwithout being replenished with new recruits,yet the demand for Public Health Advisors tobe assigned to the TB project areas continues.FSB is in the process of completing work on arecruitment and training program for junior-level field staff to be assigned to state and localTB programs.

FSB is looking to the future by continuing toemphasize core TB prevention and controlactivities, enhancing program evaluationactivities to help ensure that programs are asefficient and productive as possible, andworking toward TB elimination.

TB’s Public Health Heroesby Dan Ruggiero, Olga Joglar, and Rita Varga

Division of TB Elimination

Tuberculosis is frequently called a “socialdisease with medical implications.” The popu-lations most affected by TB today are urbanand poor; they are the medically underservedlow-income populations such as high-riskminorities, foreign-born persons, alcoholics,

✴✢

✣❏■▼ ❒❏●

M

AKING A DIFFERENCE

CD

C DTBE FIELD STAFF


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intravenous drug users, residents in long-termcare facilities such as correctional facilities, andthe homeless. Active tuberculosis with subse-quent spread of infection to contacts poses asignificant threat to the community. Practicingphysicians, for the most part, focus on theindividual patient, and to some extent on thefamily; public health officials focus on patientsas a group, on families, and on the commu-nity. So, in controlling TB, who are the realheroes? Who, on a daily basis, deals with thepatients, their families, and the health careproviders? Who does the leg work required toensure patients are monitored throughcompletion of treatment, and that contacts are

identified and evaluated? Public health fieldworkers are the real heroes in the fight againsttuberculosis.

Historically, in the United States, communityoutreach workers have played an importantrole in waging a successful battle in the waragainst tuberculosis. Hermann Biggs, in 1896,called for health inspectors to visit homes ofTB patients and educate their families on howto deal with those suffering with the diseaseand how to prevent future cases. In the 1920sand 1930s visiting nurses were climbing andjumping over New York City tenement rooftops to visit TB patients who were being given

the “fresh air treatment.”

In the 1950s, federal public health advisorswere assigned to local health departments toprovide technical assistance and treatmentguidelines and to assist local health depart-ments with TB surveillance and control activi-ties. In the 1960s New York City hired “laytuberculosis investigators” to track downnoncompliant patients. The workers wouldvisit patients’ homes, and as needed, trackthem to unsavory locations, such as local bars,clubs, and hangouts. Since then, most stateand local health departments have hired andtrained lay persons and nurses to carry outsimilar functions and activities. Who are thesepeople that have played an important role inthe fight against tuberculosis and why is it thatwe hear so little about them? They are thebackbone of the TB control program, the footsoldiers who are willing to place their lives onthe frontline each day in order to do battleagainst the common enemy - tuberculosis.

TB control programs have used public healthfield workers with different backgrounds andexpertise to monitor patients and assist themin adhering to and completing the recom-mended course of treatment. Responsibilitiesassigned to these workers vary by area anddegree of complexity. Some workers conductsurveillance activities by visiting hospitals,laboratories, and infection control officials;others provide services out in the field such asconducting home visits or providing DOT,which can put them in risky situations. Andeven under difficult circumstances, fieldworkers continue doing their work. Fieldreports document clients and patients directingviolent threats and hostile incidents to publichealth workers. Field workers survive bylearning conflict resolution and field safetyand by using precautionary measures whenconducting their activities. The threat ofviolence that field public health workersexperience while in the line of duty cannot becontrolled by detection devices used in office

Nurse crossing roofs to visit patients


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facilities to provide protection to workers.Although these workers know of the risksinvolved, they continue to carry out theirefforts to control TB in their areas.

Many names have been used to describe thejob of these dedicated individuals. Outreachworkers, public health advisors, case manag-ers, DOT workers, and epidemiology techni-cians are some of the titles given to the publichealth field workers. The heroes of TB comefrom all backgrounds, education, and ethnicgroups. Hiring requirements vary from stateto state, and while many have advanced col-lege degrees, others may be from the samepopulation group as the patients they serveand have little or no schooling.

Public health workers have the responsibilityof establishing effective communication withpatients. The outreach workers are usually thefirst contact the patients have with the healthdepartment and TB programs. The ability ofoutreach workers to use their interpersonaland communication skills in dealing withpatients will set the stage for a positive ornegative attitude toward the healing process,and consequently whether the patients willcomply with the recommended regimen. Fieldworkers must be culturally sensitive and mustunderstand patients’ beliefs, cultures, andenvironment; in many instances they developrelationships with patients that extend beyondthe duration of treatment. Just like the TBheroes at the turn of the century, they bringwith them a spirit, zeal, vision, and determina-tion to assist those individuals afflicted withTB disease and infection and to bring about anend to this disease.

The dramatic decrease in the number of TBcases in the US since 1993 could not have beenaccomplished without the persistent hardwork of theses individuals. The success weenjoy today came about, and continues,through the efforts of thousands of outreachworkers. Whether it is a public health advisor

purchasing pizza out of his or her own pocketto ensure DOT compliance, or a nurse drivinglong distances to make sure that patients livingin rural areas receive their medication or aretransported to a clinic or hospital for tests,public health field workers do whatever isnecessary to achieve their objective: tuberculo-sis control.

What do we call these individuals who havebeen central figures in the tuberculosis controlmovement for the past 40 years? Public healthheroes!

Infection Control Issuesby Renee Ridzon, MD

Surveillance and Epidemiology Branch

In recent years, transmission of TB within theworkplace has received much attention in thescientific and popular press. However, thenotion of TB as an occupational hazard is notnew, and since the beginning of this centuryTB has been recognized as an occupationalhazard for doctors and nurses. In fact, therehave been several studies published in the firstpart of the 1900s documenting low rates ofM. tuberculosis infection among medical andnursing students prior to the start of training.After completion of clerkships caring for TBpatients, high rates of tuberculin skin testconversions and even cases of TB were seen.Concern about this occupational risk waned,however, with the dramatic fall in the numberof TB cases in the US.

With the re-emergence of TB in the mid-1980s,the emergence of multidrug-resistant TB(MDR TB), and recognition of the increasedmorbidity caused by MDR TB and HIV-related TB, concern regarding TB wasreawakened in this country. Media reportsabout the danger of TB were fueled by anumber of published reports regardingexplosive outbreaks of MDR TB in hospitals,mostly in New York City, among personswith HIV infection. Concern was furtherheightened by episodes of transmission of


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disease to health care workers caring for thepatients involved in these outbreaks.

With recognition of the increased risk for TBamong persons with HIV infection, in 1990CDC issued Guidelines for Preventing theTransmission of Tuberculosis in Health-CareSettings with Special Focus on HIV-RelatedIssues. Despite these guidelines,implementation of appropriate infectioncontrol measures was incomplete in manyhospitals, and some of the published reports ofnosocomial transmission documented lapses inor absence of infection control measures in thehealth care facilities. Because of its legalmandate to ensure that no worker is harmedas a result of his or her work experience, aswell as the outbreaks of MDR TB, in 1992 theNational Institute for Occupational Safety andHealth (NIOSH) recommended the use ofpowered-air purifying respirators (PAPRs) byhealth care workers potentially exposed toM. tuberculosis.

As a result of the ongoing outbreaks of TB andthe NIOSH recommendation for the use ofPAPRs, the adequacy of the 1990 guidelineswas discussed at a large national meetingconvened in 1993. In attendance at thismeeting were representatives from multiplegroups concerned with nosocomialtransmission of M. tuberculosis, includinginfection control practitioners, laborrepresentatives, and occupational medicinepractitioners. The meeting concluded that inmost of the outbreak settings, the 1990guidelines had not been adequatelyimplemented, and there was a need for revisedand expanded guidelines. In 1993 a draft of therevised guidelines was published in the FederalRegister for public comment. After a period ofcomment and public meetings, the reportGuidelines for Preventing the Transmission ofMycobacterium tuberculosis in Health-CareFacilities, 1994 was published in the Morbidityand Mortality Weekly Report. This documentcontained detailed, comprehensiverecommendations for prevention of

nosocomial transmission of M. tuberculosis.Included in the recommendations was ahierarchy of controls composed of, mostimportantly, administrative controls(including assignment of responsibility, riskassessment, development of a TB infectioncontrol plan with periodic reassessment, andtuberculin skin testing of health care workers),followed by engineering controls, and then bypersonal respiratory protection. Personalrespiratory protection devices that wererecommended for use in the health care settingneeded to meet the following criteria:1) ability to filter particles of 1 micron with afilter efficiency of 95%, 2) ability to be fittested to obtain a face seal leak of 10% or less,3) ability to fit different face sizes, and4) ability to be checked for face-piece fit byhealth care workers each time the respiratorwas used. At the time the 1994 guidelines werewritten, the only respiratory protection devicethat was NIOSH-approved and met the abovecriteria was the high efficiency particulate air(HEPA) filter respirators. In July 1995NIOSH updated its respirator testing andcertification requirements to permit theapproval of other respirators. Under theupdated testing, respirators that contain aNIOSH-certified N-series filter with 95%efficiency (N-95) rating meet therecommendations of the CDC guidelines.

Like NIOSH, the Occupational Safety andHealth Administration (OSHA) has a legalmandate for the protection of workers;however, unlike NIOSH, which can only

I. Source Control(most effective, efficient)

II. EnvironmentalControl

III. Protective devicesfor workers (leasteffective, efficient)

Hierarchy of TB Control Measures


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issuerecommendations,OSHA has thecapacity to enforce itsstandards. In 1997,OSHA published adraft TB standard inthe Federal Register.Following thepublication of thedraft standard, therewas a period forpublic commentfollowed by a series of hearings for testimony.Detailed comments were submitted from aCDC committee including staff members ofNIOSH, the Hospital Infections Program, andthe Division of Tuberculosis Elimination, aswell as many other professional organizations.In July 1999, OSHA reopened the docket forfurther public comment. The OSHA TBstandard is currently undergoing revision, andits final content and release date are not yetknown.

In order to better understand the risk oftransmission of M. tuberculosis to health careworkers, CDC undertook several studiesdesigned to examine rates of skin testconversions in health care workers. The mostcomprehensive of these was a study initiatedin 1995 called StaffTRAK-TB. This studyincluded over 13,000 health care workers.Data from this study demonstrate a rate ofskin test conversions among health careworkers of 4.4 conversions per 1,000 person-years of follow-up. For US-born persons, therate was even lower at 3.2 conversions per1,000 person-years. From data currentlyavailable from studies such as StaffTRAK-TB,the risk of nosocomial transmission of TBappears to be quite low. As a result CDC isconsidering revision of the 1994 guidelines,especially in the areas of frequency oftuberculin skin testing of health care workers.

The risk of transmission of M. tuberculosis inhealth care settings is a real one. However, the

magnitude of this risk depends on manyfactors such as implementation ofadministrative and engineering controls,prevalence of patients with infectious TBwithin the facility, and risk for infectionoutside of the healthcare facility. All of thesefactors need to be weighed in decisionsregarding recommendations or mandates forTB control measures within health carefacilities. As the rates of TB in the UScontinue to decline, these recommendationswill need to be tailored to offer protection topatients and workers within the health caresetting, without an unnecessary burden oftesting and expense.

A Decade of Notable TB Outbreaks:A Selected Review

by Scott B. McCombs, MPHDeputy Chief, Surveillance and Epidemiology Branch

The Surveillance and Epidemiology Branch ischarged with monitoring TB morbidity andmortality in cooperation with state and localhealth departments. One of the mostfascinating and important parts of our role isto assist our partners in responding tooutbreaks of TB when they occur. This articlesummarizes a cross-section of some of themore notable outbreaks from the 1990s.

Extensive transmission of Mycobacteriumtuberculosis from a child (Curtis, Ridzon,Vogel, et al. N Engl J Med 1999;341:1491-1495).Although young children rarely transmit TB,infectious TB was diagnosed in a 9-year-oldboy in North Dakota in July 1998. The childwas screened because extrapulmonary TB wasdiagnosed in his female guardian. The child,who had come from the Republic of theMarshall Islands in 1996, had bilateral cavitaryTB. Because he was the only known possiblesource of his guardian’s TB, an investigation ofthe child’s contacts was undertaken. Family,school, day-care, and other social contactswere notified of their exposure and giventuberculin skin tests (TST). Of the 276


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contacts tested, 56 had a positive TST (10 mminduration), including 3 of 4 householdmembers, 16 of his 24 classroom contacts, 10of 32 school-bus riders, and 9 of 61 day-carecontacts. A total of 118 persons receivedpreventive therapy. The 9-year-old patient’stwin brother had TB, but was deemed notinfectious on the basis of a negative sputumsmear. This investigation showed that childrenwith TB, especially cavitary or laryngeal TB,should be considered infectious, and thatscreening of their contacts may be required.

Spread of Strain W, a highly drug-resistantstrain of Mycobacterium tuberculosis, acrossthe United States (Agerton, Valway,Blinkhorn, et al. Clin Infect Dis 1999;29:85-92).Strain W, a highly drug-resistant strain ofMycobacterium tuberculosis, was responsible forlarge nosocomial outbreaks in New York inthe early 1990s. This article is a review of datafrom epidemiologic investigations, nationalTB surveillance, regional DNA fingerprintinglaboratories, and the CDC MycobacteriologyLaboratory to identify potential cases of TBdue to Strain W. From January 1992through February 1997, 23 cases wereidentified in nine states and Puerto Rico; 4of the 23 cases transmitted disease to 10other people. Eighty-six contacts of the 23cases were presumed to be infected withStrain W. The authors conclude that StrainW TB cases will occur throughout theUnited States as persons infected in NewYork move elsewhere. CDC asked healthdepartments to notify CDC of cases of TBthat were resistant to isoniazid, rifampin,streptomycin, and kanamycin. The referencesfor this article include citations for earlierinvestigation results that have been published,including this next one.

Transmission of a highly drug-resistantstrain (Strain W1) of Mycobacteriumtuberculosis: Community outbreak andnosocomial transmission via a contaminatedbronchoscope (Agerton, Valway, Gore, et

al. JAMA 1997;278:1073-1077).In 1995, eight patients with MDR TB wereidentified in South Carolina; all were resistantto seven drugs and had matching DNAfingerprints (Strain W1). Community linkswere identified for five patients (patients 1-5),but no links were identified for the other threepatients (patients 6-8) except being hospitalizedat the same hospital as one communitypatient. Patients 5 and 8 both died of MDRTB less than one month after diagnosis.Patients 6 and 7 each had one positive culturefor MDR TB; specimens were collected duringbronchoscopy. Patient 6 had a skin testconversion after bronchoscopy. Neitherpatient 6 nor patient 7 had a clinical courseconsistent with MDR TB, neither was treatedfor MDR TB, and both are alive and well.There was no evidence of laboratorycontamination of specimens, transmission onwards, or contact among patients. All fourreceived bronchoscopy in the same month.Observations revealed that bronchoscopecleaning and disinfection was inadequate andled to subsequent false-positive cultures inpatients 6 and 7, transmission of infection to

patient 6 and activeMDR TB to patient 8.

An outbreak involvingextensive transmissionof a virulent strain ofMycobacteriumtuberculosis (Valway,Sanchez, Shinnick, etal. N Engl J Med1998;338:633-639).

From 1994 to 1996 there was a large outbreakof TB in a small, rural community with apopulation at low risk for TB. Twenty-onepatients with TB were identified; the DNAfingerprints of the 13 isolates available fortesting were identical. To determine the extentof transmission, we investigated both the closeand casual contacts of the patients. Using amouse model, we also studied the virulence ofthe strain of Mycobacterium tuberculosis thatcaused the outbreak. The index patient, the


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source patient, and one other patient infectedthe other 18 persons. In five, active diseasedeveloped after only brief, casual exposure.There was extensive transmission from thethree patients to both close and casualcontacts. Of 429 contacts, 311 (72%) hadpositive skin tests, including 86 documentedskin test conversions. The growthcharacteristics of the strain involved in theoutbreak greatly exceeded those of otherclinical isolates of M. tuberculosis. Theextensive transmission of TB in this outbreakmay have been due to the increased virulenceof the strain rather than to environmentalfactors or patient characteristics.

A nosocomial outbreak of multidrug-resistant tuberculosis (Kenyon, Ridzon,Luskin-Hawk, et al. Ann Intern Med1997;127:32-36).This article details an outbreak of seven casesof MDR TB (in six patients and one healthcare worker, all of whom had AIDS) thatoccurred in a hospital in Chicago. Thehospital had a respirator fit-testing programbut no acid-fast bacilli isolation rooms. Allseven M. tuberculosis isolates had matchingDNA fingerprints. Of patients exposed to M.tuberculosis, those who developed TB hadlower CD4+ T-lymphocyte counts and weremore likely to be ambulatory than those whodid not. Of 74 exposed health care workers,the 11 who converted their skin tests were nomore likely than those who did not convert toreport that they always wore a respirator witha HEPA filter. Transmission of M. tuberculosisoccurred in a hospital that did not haverecommended isolation rooms. A respiratorfit-testing program did not protect health careworkers in this setting.

Outbreak of drug-resistant tuberculosiswith second-generation transmission in ahigh school in California (Ridzon, Kent,Valway, et al. J Pediatr 1997;131:863-868).In the spring of 1993 four students in a highschool were diagnosed with TB resistant toisoniazid, streptomycin, and ethionamide. A

retrospective cohort study with caseinvestigation and skin test screening wasconducted in the school of approximately1,400 students. DNA fingerprinting ofavailable isolates was performed. Eighteenstudents with active TB were identified.Through epidemiologic and laboratoryinvestigation, 13 cases were linked. Nine of the13 had positive cultures for M. tuberculosiswith isoniazid, streptomycin, and ethionamideresistance, and all eight available isolates hadidentical DNA fingerprints. No staff memberat the school had TB. One student remainedinfectious for 29 months and was the sourcecase of the outbreak. Another student wasinfectious for 5 months before diagnosis andwas a treatment failure. This studentsubsequently developed additional resistanceto rifampin and ethambutol. The initial skintest screening found 292 of 1263 (23%)students tested had a positive TST. Risk ofinfection was highest among twelfth gradersand classroom contacts of the two studentswith prolonged infectiousness. An additional94 of 928 (10%) students tested later had apositive TST; 22 were classroom contacts ofthe student with treatment failure and 21 ofthese were documented TST conversions.This article documents extensive transmissionof drug-resistant TB along with missedopportunities for prevention and control ofthe outbreak. Prompt identification of TBcases and timely interventions should helpreduce these problems.

Transmission of multi-drug resistantMycobacterium tuberculosis during a longairplane flight (Kenyon, Valway, Ihle, et al.N Engl J Med 1996;334:933-938).In April 1994 a passenger with infectiousMDR TB traveled on commercial-airlineflights from Honolulu to Chicago and fromChicago to Baltimore and returned one monthlater. We sought to determine if this passengerinfected any of her contacts on this extensivetrip. Of 925 people on the airplanes, 802responded to a request to complete aquestionnaire and be screened by tuberculin


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skin test. All 11 contacts with positive TSTwho were on the April flights and 2 of 3contacts with positive TST on the Baltimore-to-Chicago flight in May had other risk factorsfor tuberculosis. More contacts on the 8.75hour flight from Chicago to Honolulu had apositive TST than on the other three flights.Of 15 contacts with a positive TST on theChicago-to-Honolulu flight, six (four withskin-test conversions) had no other riskfactors; all six sat in the same section as theindex patient. Passengers seated within tworows of the index patient were more likely tohave a positive TST than those in the rest ofthe section. Transmission of M. tuberculosis inthis setting involved a highly infectiouspassenger, a long flight, and close proximity ofcontacts to the index patient.

The Division of TB Elimination and ourpartners in state and local health departmentshave benefitted tremendously from what hasbeen learned from these and other outbreaks.Our continued cooperation, diligence, andtimely systematic response to future outbreaksare critical to our eventual success ineliminating TB from the United States.

International Activitiesby Nancy Binkin, MD, MPH,

Chief, International Activity andMichael Iademarco, MD, MPH

International Activity

As the rate of tuberculosis (TB) cases falls inthe United States (US), an increasingpercentage of TB cases occur among USresidents born in countries with a higherburden of TB. The US rate of TB cases isrelatively low compared with the rate in 22high-burden countries where 80% of global TBcases occur and where 62% of the world’spopulation resides. Given the latency periodbetween TB infection and disease, continuedimmigration into the US, and increasinginternational travel, efforts to eliminate TB inthe US must extend beyond our geographicalborders. Recognition of the public health

impact of the global TB epidemic led CDC toofficially organize an International Activitywithin the Division of TB Elimination(DTBE) in 1994 as international efforts arepart of the overall strategic plan of DTBE.

The mission of the International Activity is,first, to provide leadership and coordinationfor CDC activities related to improving TBprevention and control efforts among foreign-born persons in the US. Its mission is, second,to contribute to global TB prevention andcontrol efforts by conducting operationsresearch and providing technical support tohigh-priority countries, i.e., those that have amajor TB burden or that are of strategicinterest for TB control efforts in the US.Coordination and collaboration with otherinternational public health partners are criticalto accomplish our mission.

Immigrants from Mexico, the Philippines, andViet Nam are the leading contributors to theUS foreign-born TB case burden and thereforeconstitute a high priority for TB controlefforts in the US. The aim of InternationalActivity efforts in these countries is to reducethe burden of TB by improving the TBcontrol capacity of the respective nationalprograms, by providing technical assistanceand contributing to human resourcedevelopment.Historicallyefforts inMexico andthePhilippineshave beenhampered byongoingpolitical andsocial changes. More recently, however,progress has been made.

MexicoBecause of their proximity and our sharedborder, persons born in Mexico represent thesingle largest group of foreign-born persons in


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the US with TB. Previously CDC workedwith the Mexican government to conductsurveillance of drug-resistant isolates of TB inMexico as part of a WHO collaborative study.More recently, DTBE has been working withthe United States Agency for InternationalDevelopment (USAID) and the National TBprogram of Mexico to identify areas ofpotential collaboration as part of a proposed 5-year project to improve TB control. Proposedactivities include expanding the number ofdirectly observed treatment, short-course(DOTS) pilot projects, improving operationsresearch capacities, and developing activities tofoster public-private health sectorcollaboration.

Additionally, DTBE has been a participatingmember of Ten Against TB, a binationalinitiative developed initially by the TexasDepartment of Health beginning in 1995. Theten US and Mexican border states havecollaborated to reach a consensus onaddressing joint issues of TB control throughcommunity-based public and private sectorpartnerships. Along with other partners in theDivision and in the health departments of theborder states, CDC has also been developing aseries of recommendations to improve thediagnosis andmanagement ofcases along the US-Mexico border.

PhilippinesIn collaborationwith theDepartment ofHealth of theRepublic of thePhilippines (DOH)and theEpidemiologyProgram Office ofCDC, DTBE is providing technical assistanceto a USAID-funded project. The objective ofthis 5-year project is to reduce the threat ofHIV/AIDS and other selected infectious

diseases in the Philippines. Of those diseases inthe Philippines, TB has the most significantpublic health impact and therefore figuresprominently in the project. The broad, cross-cutting nature of the project design addressesthe decentralized health care organization inthe Philippines. DTBE is working with theDOH to organize and conduct operationsresearch training, expansion of directlyobserved treatment, short-course (DOTS)pilot projects, and public-private collaborativeprojects.

Viet NamCollaboration with the National TB ControlProgram of the Socialist Republic of Viet Nam(NTP) has been more longstanding. Since1996, DTBE has worked with the NTP toimprove TB control. Several laboratoryquality control projects have been conductedand others are ongoing with the nationalreference laboratory responsible for southernViet Nam. In 1997, DTBE conducted a 2-weekoperations research course for supervisorystaff of the NTP and provincial TB managersheld in Hanoi. As a result of the course, sixprotocols were developed on operationaltopics such as risk factors for treatment failureand for default, reasons for patient delay inseeking initial TB treatment, and knowledge,attitudes, and beliefs about HIV and HIVtesting and counseling among TB patients.Each group has been provided with a CDCmentor and funding to conduct the research.The work for one protocol is complete andhas been presented by the Viet Nameseprincipal investigator at the InternationalUnion Against Tuberculosis and Lung DiseaseWorld Congress in Madrid this pastSeptember. Other projects are nearcompletion. Based on the success of theoperations research course and with supportfrom USAID, DTBE has initiated a 3-yearpublic health practice training program withthe NTP.

BotswanaOther DTBE international efforts have aimed


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to contribute to the globalcontrol of TB and HIV/AIDS co-epidemics. InFebruary 1995, at therequest of the Ministry ofHealth in Botswana, theBOTUSA Project wasestablished as a TBepidemiologic research

collaboration located in Botswana.Approximately 25% of the adult populationand 75% of TB patients are HIV-infected. TheBOTUSA Project activities have focused onimproving TB surveillance and electronicreporting, improving Botswana National TBProgramme (BNTP) activities throughoperational research, improving diagnosticsthrough laboratory and clinical researchstudies, and studying the epidemiology of thedisease. At least 17 different formal studieshave been completed to date and highlight thetremendous impact of the HIV epidemic onthe TB epidemic in the country.

The site is collaborating with WHO and othercountries on several projects, includinginvolvement of the community in the care ofpatients with TB and advanced AIDS,provision of TB preventive therapy to personsliving with HIV, and improvement of TBsurveillance through the use of a software toolinitially developed by BOTUSA and recentlyadopted by the World Health Organization(WHO) for global application. Throughcollaboration with the US Food and DrugAdministration, the site and DTBE haveraised global awareness of the potential forsubstandard TB drugs in the market throughthe pilot-testing of appropriate technology forthe rapid screening of drugs. Specific researchprojects completed in 1998 included aspectrum of lung disease study in adultshospitalized with AIDS, an autopsy study todetermine causes of death in adults andchildren dying of AIDS, a validation study ofthe TB surveillance system, a study of riskfactors for TB transmission in the household,and a study of transmission at the population

level through the use of RFLP techniques.Another study underway is assessing themalabsorption of TB drugs in patients withTB and HIV, as well as conducting long-termfollow-up of these treated patients todetermine risk factors for relapse, reinfection,and death.

Strengthening the capacity of laboratoryfacilities to cope with the ever-increasingdemands brought on by the TB and HIVepidemics has been a component of theBOTUSA project. Substantial support interms of equipment, training, and supplies hasbeen provided to the national TB ReferenceLaboratory. BOTUSA also serves as animportant training site for EIS officers, USmedical students, and public health studentsfrom UC-Berkeley.

Russia and countries of the former SovietUnionAs a result of a joint Department of Healthand Human Services and White Houseconference, the Russian Federation and thecountries of the former Soviet Union havebeen targeted for CDC TB control technicalassistance efforts. The number of TB patientsand the levels of drug resistance are increasingat alarming rates. Contributory factors includean inability to financially support the previousinfrastructure for TB diagnosis and treatment,the lack of availability of quality drugs, highlevels of TB transmission in prison settings,and reluctance to adopt the DOTS strategy asemployed in the US and elsewhere andrecommended by the WHO. The DTBE,USAID, and WHO are collaborating toinstitute basic DOTS programs in two oblasts(territorial administrative divisions) that haveindicated a willingness to begin the DOTSstrategy, and to strengthen DOTS in Ivanovooblast, where a WHO-supported program wasimplemented in 1995 but where cure ratesremain unacceptably low. A recent study inthis second oblast has documented furtherincreases in the levels of multidrug-resistant(MDR) TB. DTBE will also implement

BOT

Project


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DOTS-plus, the WHO strategy for themanagement of MDR TB treatment in low-resource settings, in this oblast. In addition,DTBE has been involved in the establishmentof a center of excellence for MDR TB inLatvia, which was formerly part of the SovietUnion and which has a successful DOTSprogram, but nonetheless has one of thehighest levels of MDR TB in the world.Finally, an MDR TB training course run byDTBE in collaboration with National JewishMedical Center was conducted overseas thispast year in Estonia for participants fromRussia and the Baltics.

The Role of CDC’s Division of Quarantinein the Fight Against TB in the US

by Paul TribblePublic Health Advisor, DQ

The Division of Quarantine (DQ), the oldestorganization in the United States PublicHealth Service, has had a rich and colorfulhistory and plays an important role in thenation’s fight against tuberculosis (TB),especially with respect to immigrants andrefugees. DQ, which was established by theNational Quarantine Act of 1878, wastransferred to the Centers for Disease Control

(CDC) in 1967. DQ has had several previoustitles, including the Division of ForeignQuarantine and Quarantine Division, and iscontinuing to evolve with another proposedname: the Division of Global Migration andQuarantine.

United States (US) immigration law mandatesan overseas health assessment for immigrantsand refugees, with the intent of denyingadmission to persons with certain diseases ofpublic health significance, physical or mentaldisorders associated with harmful behavior,drug abuse or addiction, or likelihood ofbecoming a ward of the state. The conditions,the requirements as to who must be screened,and the examination and tests to be performedare prescribed by the Secretary of theDepartment of Health and Human Services,with oversight by DQ.

The current list of communicable diseases ofpublic health significance that are considered“inadmissible” are infectious TB, syphilis,lepromatous Hansen’s disease, HIV infection,and certain sexually transmitted diseases(STDs). The overseas health assessment,which is valid for 12 months, is carried out bylocal physicians known as “panel physicians,”who are appointed by the US embassy orconsulate. In some cases, clinics or hospitalsare designated as panel physicians in countrieswhere large numbers of immigrants originate(e.g., Mexico, the Philippines, and Viet Nam).Panel physicians are provided with a bookletof technical instructions concerning theassessment process which, in addition to theTB evaluation, consists of a medical history,physical examination, and screening forphysical and mental disorders, substanceabuse, STDs, Hansen’s disease, and HIVinfection.

Panel physicians make their ownarrangements for the required radiologic andlaboratory tests. Currently, no countries haveon-site supervision beyond the local consularofficer, except Viet Nam, which has a CDCmicrobiologist consultant. Panel physiciansdo, however, receive periodic visits by CDCphysicians and microbiologists based inAtlanta. Panel physicians are paid for theirservices by immigrant applicants on the basisof a fee scale set locally. In the case of refugees,the US Department of State reimburses the

Immigrants of the past awaiting medical clearance


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panel physicians for providing the healthassessment. Presently, there are approximately650 panel physicians worldwide.

The TB component of the health assessmentconsists of a chest x-ray for all persons 15 yearsof age or older. (Children less than 15 years ofage who are suspected of having TB or whohave a history of contact with a known TBcase are given a tuberculin skin test. Thosewith a positive skin test must undergo a chestx-ray.) If the x-ray is consistent with active TBdisease, three consecutive early-morningsputum specimens are collected for acid-faststaining and microscopic examination. Personswhose sputum smears are positive for acid-fastbacilli (AFB) are classified as having Class A,infectious TB, which is an inadmissiblecondition for purpose of entry into the UnitedStates. Such persons may enter the UnitedStates by meeting either of the following twoconditions. First, sputum smear–positiveimmigrants and refugees who successfullycomplete a recommended course of TBtreatment overseas can be medically clearedfor US travel; they will have been reclassifiedas having Class B2 or old, healed TB (seedescription of TB classifications below).Secondly, they may enter the United Stateswith a medical waiver, once they are no longerinfectious, by providing three consecutivenegative sputum smears. To obtain a medicalwaiver, the US relative of the Class Aimmigrant must complete an application. Thisis signed by a US health-care provider and iscountersigned by the local health department(or signed only by the local health departmentacting as the health-care provider) at theimmigrant’s intended US destination, thusguaranteeing that the provider will assumeresponsibility for the completion of TBtreatment. Class A refugees with TB are notrequired to have a relative residing in theUnited States, as the waiver is completed bythe resettlement agency at the intended site ofdestination. Immigrants are responsible forpaying for their own TB treatment overseas;in the case of refugees, the costs are assumed

by the US Department of State.

Applicants whose chest x-ray is consistentwith active TB disease but whose three sputumsmears are negative for AFB are designated ashaving Class B1 (clinically active, notinfectious) TB. If the initial chest x-ray is readby the panel physician as consistent with old,healed TB, no specimens of sputum need beobtained, and the applicant is designated as

having Class B2 (not clinically active, notinfectious) TB. Both Class B1 and B2designations are considered significant healthconditions, but neither is inadmissible forimmigration purposes.

Class A and Class B designations forimmigrants are placed on the officialimmigration documents collected byinspectors of the Immigration andNaturalization Service at one of 295international airports, land crossings, or portsin the United States; refugees must enter thecountry through one of eight internationalairports that are staffed by DQ inspectors.This information is sent to or collected at oneof the quarantine stations, where a notificationform is mailed to the state or local healthdepartment at the intended destination of thearriving immigrant or refugee. Healthdepartments are expected to complete andreturn the forms to DQ, thus reporting on theoutcome of the evaluation. The immigrant or

Current immigration clearance process


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refugee is informed of the need to be furtherevaluated for their TB and to report to thelocal health department as soon as possibleafter arrival. Persons with Class A TB arerequired to report to the local healthdepartment, present all medical records andchest x-rays from overseas, and submit to thenecessary testing, isolation, and treatmentuntil discharged. They risk deportationshould they fail to do so. For persons havingClass B1 or B2 TB, the health department visitis considered voluntary.

Many health departments in the United Statesperform active follow-up of arrivals designatedas having Class B1 or B2 TB, on the basis ofthe DQ notification. Studies conducted in themid-1990s by the Division of TB Elimination,DQ, and health departments in various partsof the country have shown from 3% to 14% ofClass B1 immigrants and refugees werediagnosed with TB disease within one year oftheir arrival; between 0.4% to 4.0% of thosewith Class B2 TB were diagnosed with TBdisease within one year of arrival. Of theremaining persons, many are high-prioritycandidates for preventive therapy regardless oftheir age because they are tuberculin skin testpositive with an abnormal chest x-raysuggestive of TB disease.

The current overseas TB evaluationprocedures described above are based upon thefollowing three principles: 1) the requirementsapply specifically to immigrants and refugees,as they are most likely to become permanentUS residents; 2) the procedures reduce theimportation of active infectious TB that posesan immediate public health risk by denyingadmission to persons who have positivesputum smears; and 3) they allow thosepersons with evidence of TB disease but whosesmears are negative to enter the United States,where a more complete medical evaluation canbe performed and appropriate treatment canbe provided under supervision. Forcingimmigrants and refugees with noninfectiousTB to undergo treatment overseas could prove

to be counter-productive, as it may be difficultto ensure that the drug regimens are adequate,and that applicants are regularly ingesting therequired medications. In such a scenario,incomplete treatment as well as developmentof drug resistance may be the result.

The overseas screening process for identifyingand treating TB in immigrants and refugees isresponsible for the identification of substantialnumbers of persons arriving in the UnitedStates who have active TB. However, not allcases in newly arrived immigrants or refugeeswere identified overseas as having suspect TB,which is in part due to several limitations ofthe screening process. Although panelphysicians do function under a contractualagreement with their respective US consulates,they receive no formal training or certificationper se. In 1997, a training needs assessment wasperformed on a sample of panel physicians in astudy undertaken by the Division of TBElimination and DQ. The assessmentindicated that, although 98% of panelphysicians in the sample understood whichimmigrants and refugees should receive a chestx-ray, over 60% indicated a need for training.

Presently, efforts are underway to develop self-study training materials for panel physicians toenhance their ability to diagnose and treat TB,and to improve their ability to monitor theperformance of contracted laboratory andradiologic services. A training plan will bedeveloped, and self-study materials will bepilot-tested later this year in countries withlarge numbers of persons who immigrate tothe United States and have a high TBprevalence.

The STOP TB Initiative,A Global Partnershipby Bess Miller, MD, MSc

Associate Director for Science, DTBE

Over the past few decades, when we havelooked at the agendas of international health


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agencies, major donors to the health sector,government health ministries, academia, andcivil society, we have wondered, Where is TB?Why is TB on the back burner? The STOPTB Initiative is a global campaign to move TBto the FRONT BURNER.

Why now?

With the arrival last year of the new DirectorGeneral of the World Health Organization(WHO), Dr. Gro Brundtland, there has beenan interest in intensifying the relationshipbetween WHO and its global partners. For anumber of diseases, but especially for malariaand TB, WHO has initiated campaigns to joinforces with other agencies and donors in thepublic and private sectors to achieve globalhealth objectives.

Additional factors have added fuel to thesparks of this new campaign. Over the pastseveral years the World Bank has given anunprecedented number of loans to developingcountries to strengthen TB control efforts andhas established TB as one of its top prioritydiseases. There has been renewed interest inTB research in the areas of vaccinedevelopment, new drug development, and newdiagnostics. Large donors such as the Sorosand Gates Foundations have shown an interestand commitment to TB control and TBresearch. The stars are aligned.

In November 1998, at the annual meeting ofthe International Union Against Tuberculosisand Lung Disease held in Bangkok, Thailand,Dr. Brundtland launched the STOP TBInitiative, a WHO-led global partnershipwhose mission is to put TB higher on the

international public health agenda and tosubstantially increase the investment in TBworldwide. It aims to increase involvement ofinternational players at all levels, includinginternational health agencies, donor agencies,governments, nongovernmental organizations,professional societies, and communityorganizations involved in TB at the countrylevel. The focus of the initiative is on the 22so-called “high-burden” countries whichWHO has identified as responsible forapproximately 80% of all reported cases of TBin the world. These include India, China,Indonesia, Bangladesh, Pakistan, Nigeria,Philippines, South Africa, Ethiopia (Fed.Democratic Republic of), Viet Nam, RussianFederation, Congo (Democratic Republic),.Brazil, Tanzania (United Republic of), Kenya,Thailand, Myanmar, Afghanistan, Uganda,Peru, Zimbabwe, and Cambodia. In addition,countries with extremely high rates of TB,especially those impacted by the HIVepidemic, will be targeted.

The STOP TB Initiative will focus attentionon addressing the specific constraints to actionon TB identified at the London Ad HocCommittee Meeting on the Global TBEpidemic held in March 1998. The needsidentified at this meeting include political willand commitment, human resourcedevelopment, a secure supply of quality anti-TB drugs, research, financing, organizationand management, information systems, andhealth sector reform.

The founding partners of the STOP TBInitiative are the WHO, the RoyalNetherlands TB Association (KNCV), theInternational Union Against TB and LungDisease, the World Bank, the American LungAssociation, the American Thoracic Society,and the Centers for Disease Control andPrevention. New partners include UNICEF,UNAIDS, the National Institutes of Health,the Japan Anti-TB Association, theNorwegian Heart and Lung Association, theCanadian International Development Agency,


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the Soros Foundation, and the RockefellerFoundation. Many, many others are joining.The tremendous energy and inspiration thesenew partners bring to the Initiative cannot beoverstated.

Current efforts of the STOP TB Initiative aredirected at the following four areas: 1) thecreation of a global drug supply facility toprovide universal availability of quality TBdrugs; 2) the development of a globalpartnership agreement to catalyze and securepublic agreements among donor agencies andhigh-burden countries on specific steps to betaken to control TB; 3) the co-sponsorship ofan initiative to develop new drugs for TB; and4) the co-sponsorship with the Government ofthe Netherlands of a Ministerial Conference inMarch 2000. This conference broughttogether the ministers of health as well as offinance, development, and planning from thehighest burden countries to set the stage forexpanded country action against TB acrosssectors of government and society.

While many efforts are underway at the“global” level, TB control efforts take place atthe local level, and it is at this level that wewill concentrate future efforts. This pastsummer, the Initiative sponsored a series ofregional workshops with the highest burdencountries to identify constraints to TB controlat the country level. Suggestions for the STOPTB Initiative made at these workshopsincluded the following activities: 1) expandbeyond traditional partners for TB control;2) strengthen advocacy; 3) develop a socialmobilization campaign; and 4) increaseoperations research in affected countries.

CDC is actively participating in the STOP TBInitiative and is represented on the SteeringCommittee (Bess Miller, Associate Directorfor Science and Carl Schieffelbein, DeputyDirector for Special Projects, DTBE), as wellas the Secretariat in Geneva (Mark Fussell,Public Health Advisor, DTBE).

Yes, TB is on the front burner at last, and weplan to keep it there!

Seize the Moment - Personal Reflectionsby Carl Schieffelbein

Deputy Director for Special Projects, DTBE

We all have opportunities during our careersto stand at critical decision points. Sometimesit is clear that these are major events; at othertimes they appear routine, but subsequently itis seen that they had (or could have had) majorimpact. During the past 33 years I’ve had theopportunity to stand at many decision pointsand now can look back to see where morecould have been done, if the opportunities hadreally been fully utilized. I will outline a fewdecision points in which I participated and tryto share what went well and what I believecould have been done better. I will also outlinesome of the decisions we will all face in 2000.

Decision point: late 1960s. Closing of the TBsanatoria. Due to advances in treatment, long-term sanatorium care was no longer needed.CDC supported efforts to close TBsanatoriums and move toward an outpatientsystem. We succeeded in reducing the need forlong-term sanatorium care and more rapidlygot patients back to their families andcommunities. The costs of maintainingsanatoria were reduced. However, we did notdo well in diverting the funds available as aresult of the closings to the support of strongTB outpatient care systems. As cases wentdown, political will to support TB programsalso diminished in the early 1970s. We foundthat many existing TB control systems wereunable to effectively survive when federalcategorical appropriations for TB wereeliminated in 1972.

Decision point: 1989. The Strategic Plan for theElimination of Tuberculosis in the United States.The plan articulated the goal of definedelimination of TB by 2010. It caught theattention of some advocates and spelled out inbroad strokes (still relevant today) the three


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critical steps needed. However, we laterrealized that we talked about the plan onlywithin the “TB family” and with our peers.We were not successful enough in gettinginfluential leaders and policy and opinionmakers to commit their organizations to fullshared ownership and thus, the necessaryadvocacy to fully implement the Strategic Planat federal, state, and local levels.

Decision point: November 1991. The rise inTB cases, and the emergence of multidrug-resistant TB (MDR TB). A small group of usmet with Dr. Roper (then CDC Director) todiscuss a plan of action. It was decided afederal TB Task Force would be created tobring together all HHS/PHS agencies (and afew others) to develop a coordinated responseto the MDR TB outbreaks. The Task Forcewas created and moved quickly, and inJanuary 1992 brought together more than 400experts to develop the National Action Plan toCombat Multidrug-Resistant Tuberculosis(published in April 1992). The Action Plancalled for a total federal TB budget of$610,280,000, of which CDC’s need was$484,000,000. Along with many of ourpartners, we were successful in getting federalappropriations increased. We were successfulin getting enough resources to meet ourimmediate needs, but not enough to allow thesuccess of our 1989-stated mission ofelimination. We had reached out to some newpartners in the Task Force and through theNational Coalition to Eliminate TB, but again,after the crisis was over, we had not builtenough effective community partnerships ornew and long-lasting coalitions to help achievethe level of resources needed. Also, while wewere in the process of obtaining increasedfederal funding, we saw many state or localareas reduce the amount of local resourcesgoing into TB control efforts. In 1990 thePublic Health Foundation reported that 13%of TB funds at the state and local levels werefederal dollars. In 1998, however, the NationalTB Controllers Association reported that 42%of budgets were now composed of federal

dollars. We succeeded in making state andlocal programs too dependent upon federaldollars; this is a concern known all too well bythose of us who remember the overnightelimination of categorical federal TB funds in1972.

Decision point: March 1998. I had theopportunity to participate in an ad hoccommittee of the Global TuberculosisProgramme of WHO, convened in London, toevaluate TB control in the 22 countries thatrepresent 80% of the global TB burden. Thecommittee concurred that most of these 22countries would not meet their Year 2000goals. The committee also outlined what wasbelieved to be shared constraints to progress.These included 1) weak political will andcommitment towards TB control efforts;2) lack of adequate funding; 3) inability to hireand keep trained staff; 4) organizational andmanagement issues, such as health sectorreform, public and private sector interactions(or lack thereof), and integration anddecentralization issues; 5) an inadequate supplyof quality TB drugs; and 6) lack of adequateunderstanding of the magnitude of theproblem and of the possibility of successfulinterventions. I believe all but item number 5are also continuing threats to our national,state, and local TB programs.

You and I stand at some unique moments ofdecision in 2000. If each of us does not acteffectively, we will have missed someopportunities to move the fight against TBinto the final rounds. Some of the decisionmoments at hand:• The National Academy of Science’s

Institute of Medicine (IOM) will issue areport on TB control in the UnitedStates. How will you and I use theresults to evaluate and strengthen ourprograms? How will you use the IOMreport and local data to secure adequatepolitical will at your state or local levelto secure necessary resources?


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• The HIV/AIDS and TB epidemicscontinue to work together to createunnecessary devastation, bothdomestically and especially in someinternational communities. Yet wetend to still work mainly within our“TB family.” How will we work betterwith our colleagues in HIV to developeffective collaborations to help those atrisk of TB and HIV/AIDS?

• There is growing interest and concernabout TB both at the federal level andin many state and local areas. How willyou and I create new partnerships andopportunities to build on the existinginterest to ensure a firm base foroperations and programs?

• The Surgeon General has appointed aBlue Ribbon Committee to look intothe development of a TB vaccine.How will you and your TB advisorycommittees work to support such aneffort?

• There are areas of social mobilizationand community empowerment thathave not been adequately addressed bythe TB community. How will wework with not only lung associations,but other partners as well, to mobilizeagainst TB?

• WHO is hosting a “STOP TB”partnership to create a new globalcampaign against TB. How will youand I support these critically neededglobal activities and still ensure strongdomestic programs?

I am aware there are many, many otherdecision points that we all will face. Many ofthese opportunities last for very briefmoments of time. I urge each of us to seizethose moments, and if necessary move outsideour areas of comfort, in order to be able totruly eliminate TB in the United States and seeTB control in the world early in this century.

Carl Schieffelbein, in his first TB controlassignment (1967), adjusting x-ray equipment


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Description of DTBE Training and EducationResources

Resources for Health Care Providers

Automated information systemsCDC Fax Information System. CDC devel-oped a fax information system for health careprofessionals and others who would like toreceive health information by fax. Telephonecallers first access the main CDC menu andthen select TB-related topics. Designed toanswer many routine questions about TB, thesystem can provide up-to-date information byfax or mail. Callers can choose to receivegeneral information about TB or specificinformation about treatment, diagnosis, BCG,infection control, or screening. The FaxInformation System can be accessed by dialingtoll free 888-CDC-FAXX (888-232-3299). Toreceive a listing of documents available by fax,request document number 250000. The faxsheet may also be viewed on DTBE’s Web siteat http://www.cdc.gov/nchstp/tb.

CDC Voice Information System. CDCdeveloped a voice information system forhealth care professionals and others who callfor specific disease information. Callers firstaccess the main CDC menu and then selectTB-related topics. Designed to answer manyroutine questions about TB, the system canprovide up-to-date information by voice, fax,or mail. Callers who choose to listen to thevoice recordings can receive general informa-tion about TB or specific information abouttreatment, diagnosis, BCG, infection control,or screening. Callers who would like writteninformation can choose from a variety oftopics and then receive information sheets byfax or specific educational materials by mail.The TB component of the Voice InformationSystem can be accessed by dialing toll free 888-CDC-FACT (888-232-3228), then pressingoptions 2, 2, 1, 5, 2.

DTBE Home Page. DTBE has a Web site onthe Internet. The site provides access to TB-related Morbidity and Mortality Weekly Reports(MMWRs), educational materials, and guide-lines. The DTBE home page can be accessedat http://www.cdc.gov/nchstp/tb/

DTBE On-Line Ordering System. DTBEeducational and training materials can now beordered via the Internet. The on-line orderingsystem provides a convenient way to orderDTBE materials. Highlights of the systeminclude order confirmation via the Internetand, if an e-mail address is provided, orderconfirmation when the order has been filled.The on-line ordering system can be accessedon DTBE’s Internet home page at http://www.cdc.gov/nchstp/tb.

MaterialsControlling TB in Correctional FacilitiesBooklet and Slides - 1995. This booklet andaccompanying slide set, developed in 1995,have been updated in regard to the AdvisoryCouncil for the Elimination of Tuberculosis(ACET) statement with recommendations forjails and prisons. It also provides a comprehen-sive basic reference on TB specifically forcorrectional facility staff. The booklets areavailable from each state TB office or theDTBE. Slide sets were distributed to all stateand big city TB programs; however, additionalslide sets are available for purchase ($75 perset) from the National Technical InformationService (800-553-6847 or 703-605-6000), itemnumber AVA19830SS00. The slide set canalso be viewed and downloaded from DTBE’sWeb site at http://www.cdc.gov/nchstp/tb.

Core Curriculum on Tuberculosis Bookletand Slides - 1994. The Core Curriculum onTuberculosis was originally developed in 1990with the American Lung Association for usein preparing and planning educational activi-ties or as a reference for the practicing clini-cian caring for patients with TB or TB infec-tion. The Core Curriculum covers TB epidemi-


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ology, diagnosis, treatment, prevention, andinfection control. This document and accom-panying slide set were revised to includecurrent recommendations for the diagnosis,treatment, and control of TB in 1994. Thenewest revision will be available in 2000. Thebooklet is available from each state TB officeor DTBE. Slide sets are available for purchase($62 per set) through the National TechnicalInformation Service (800-553-6847 or 703-605-6000), item number AVA19830SS00. TheCore Curriculum may also be viewed onDTBE’s Web site at http://www.cdc.gov/nchstp/tb.

Forging Partnerships to Eliminate TB - 1995.This print-based, self-study module was devel-oped in 1995 for TB program managers toprovide information on forming partnerships,resource acquisition, marketing, and mediarelations. The module includes informationfrom the Mobilizing for TB Eliminationworkshops, along with a selected bibliographylisting other available resources. This moduleis available from each state TB office or theDTBE.

Guidelines for Preventing the Transmissionof Mycobacterium tuberculosis in Health CareFacilities, 1994 Slide Series. A slide seriesbased on the 1994 MMWR supplement Guide-lines for Preventing the Transmission of Myco-bacterium tuberculosis in Health Care Facilitieswas developed in 1995 for use in traininghealth care workers, infection control practi-tioners, and others on how to effectivelyimplement the guidelines. A limited numberof sets of the slide series were distributed toTB control programs. Additional copies areavailable for purchase ($80 per set) through theNational Technical Information Service (800-553-6847 or 703-605-6000), item numberAVA19824SS00. The slide set can also beviewed and downloaded from DTBE’s Website at http://www.cdc.gov/nchstp/tb.

How You Can Assess Engineering Controlsfor TB in Your Healthcare Facility - 1999. Avideo and viewer’s guide developed by theFrancis J. Curry National TB Center aboutbasic techniques that can be used to evaluateengineering controls, including instructionsfor bringing an isolation room into compli-ance with CDC recommendations.

Improving Patient Adherence to TuberculosisTreatment Booklet - 1994. DTBE developed aguide for TB health care providers to helpimprove patient adherence to medication andfollow-up care. This 1994 booklet replaces thebooklet Improving Patient Compliance inTuberculosis Treatment Programs. It is avail-able from each state TB office and the DTBE.

Mantoux Tuberculin Skin Testing Wall Chart(1990) and Videotape (1991). Developed in1989, the videotape and wall chart are designedfor use by health department TB staff inteaching tuberculin skin testing to other healthcare workers who are providing services topersons at risk for TB (e.g., STD clinic staff,drug abuse treatment staff, correctional facilitystaff, nursing home staff, etc.). Providers areencouraged to contact their state TB programto obtain these materials and to arrange fortraining. The wall chart was revised in Septem-ber 1990 to reflect the latest recommendationsof the Advisory Council for the Eliminationof Tuberculosis. These materials are availablefrom each state TB office or the DTBE.

Multidrug-Resistant Tuberculosis - 1994. 8-page article on causes, treatment, and controlof drug-resistant TB.

Reported TB in the United States - 1998. Themost recently reported statistics on TB casesand case rates.

Self-Study Modules on Tuberculosis (Modules1 - 9). In 1995 DTBE developed a series of fiveself-study modules to train and educate new


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outreach workers. Modules 1-5 cover transmis-sion and pathogenesis of TB, epidemiology ofTB, diagnosis of TB infection and disease,treatment of TB infection and disease, andinfectiousness and infection control. DTBEsubsequently developed a second series, mod-ules 6-9, consisting of four modules that covercontact investigations for TB, confidentialityin TB control, TB surveillance and case man-agement in hospitals and institutions, andpatient adherence to TB treatment. Both seriesof modules are available from DTBE. Themodules are also available through the PublicHealth Training Network for continuingeducation credit, free of charge; call toll free800-418-7246 to register.

Self-Study Modules on Tuberculosis broad-casts on videotape. Satellite Primer on Tuberculosis: Modules 1-5 (1995), and TB Frontline- Satellite Primer Continued: Modules 6-9(2000). DTBE’s first five Self-Study Moduleson TB were used as the basis for a series of livebroadcasts via satellite entitled A SatellitePrimer on Tuberculosis, conducted in May andJune 1995. The second set of modules served asthe basis for a satellite training course entitledTB Frontline-Satellite Primer Continued, Mod-ules 6-9, conducted in January and February2000. Each broadcast provided information tosupplement the training modules and allowedparticipants to telephone their specific ques-tions to the presenters. Additional videotapesof A Satellite Primer on Tuberculosis are avail-able for purchase through the Alabama De-partment of Public Health at 334-206-5618, orby FAX 334-206-5640. Videotape copies of TBFrontline-Satellite Primer Continued, Modules 6-9 are available on a limited basis from DTBEat 404-639-8135.

Self-Study Modules on Tuberculosis on theWeb - 1999. The Web-based version of theSelf-Study Modules on Tuberculosis provides abase level of TB knowledge accessible world-wide through the Internet. The Web-basedcourse builds upon existing products: the

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print-based Self-Study Modules on Tuberculosisand the Satellite Primer on Tuberculosis. TheWeb-Based Self-Study Modules on Tuberculo-sis course has interactive features such asanimation, study questions, case studies, andlinks to other TB-related sites. The course canbe accessed at http://www.cdc.gov/phtn/tbmodules.

TB Facts for Health Care Workers - 1997.This 14-page booklet is based upon the TBFact Sheet that was originally developed in1984. It was updated in 1993 to include infor-mation on MDR TB and again in 1997 toinclude current screening and treatmentrecommendations. The booklet contains thekey points to remember about the diagnosis,treatment, and prevention of TB. The in-tended audience is health care professionals.This booklet is available from each state TBoffice or DTBE. It can also be viewed onDTBE’s Web site at http://www.cdc.gov/nchstp/tb.

TB Notes. This quarterly newsletter is distrib-uted to state and big city TB control officers,directors of pulmonary and infectious diseasetraining programs, state epidemiologists,public health laboratory directors, and manyother people involved in (or just interested in)TB in the U.S. and worldwide. State and bigcity TB control officers are encouraged toduplicate copies for TB workers throughouttheir jurisdictions. TB Notes contains newsabout DTBE activities as well as highlightsfrom state and local TB programs across thecountry. It also contains a calendar of eventsdescribing training courses, meetings, confer-ences, and other educational activities ofpotential interest to those working in TB.Current and previous editions of TB Notes arenow available on the DTBE Internet homepage at http://www.cdc.gov/nchstp/tb.

Think TB Poster. This poster was reprintedby the DTBE in 1992 with permission fromthe Mississippi State Department of Health,


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the original designer of the poster. Preparedfor health care providers and other serviceorganizations serving high-risk populations,the poster lists signs and symptoms of TB, andit reads, “Recognize possible signs and symp-toms of TB. Early diagnosis and treatmentreduce spread. Contact your health depart-ment or physician for more information.”DTBE collaborated with the MississippiDepartment of Health on the development ofa Spanish version of the Think TB poster in1993. Both the English and Spanish versionsare available from each state TB office orDTBE.

Tuberculosis Training and Education Re-source Guide. This resource guide was pro-duced by the CDC National PreventionInformation Network (NPIN) in collabora-tion with DTBE, and provides informationavailable through NPIN databases and otherresources on topics relating to TB. The re-source guide includes educational materials,consensus guidelines, journal articles, Internetresources, and funding organizations. Formore information on NPIN services call 800-458-5231 (800-243-7012 TTY) or visit theNPIN Web site at http://www.cdcnpin.org.(This information is made available as a publicservice. Neither CDC nor NPIN endorses theorganizations and materials represented. It isthe responsibility of the user to evaluate thisinformation prior to use based on individualneeds and community standards.)

Resources for Patients and the GeneralPublic

Automated information sytemsCDC Fax Information System. CDC devel-oped a fax information system for personswho would like to receive health informationby fax. Callers first access the main CDCmenu and then select TB-related topics. De-signed to answer many routine questionsabout TB, the system can provide up-to-date

information by fax or mail. Callers canchoose to receive general information aboutTB or specific information about treatment,diagnosis, BCG, infection control, or screen-ing. The Fax Information System can beaccessed by dialing toll-free 888-CDC-FAXX(888-232-3299). To receive a listing of docu-ments available by fax, request documentnumber 250000.

CDC Voice Information System. CDCdeveloped a voice information system forpersons who call for specific disease informa-tion. Callers first access the main CDC menuand then select TB-related topics. Designed toanswer many routine questions about TB, thesystem can provide up-to-date information byvoice, fax, or mail. Callers who choose tolisten to the voice recordings can receivegeneral information about TB or specificinformation about treatment, diagnosis, BCG,infection control, or screening. Callers whowould like written information can choosefrom a variety of topics and then receiveinformation sheets by fax or specific educa-tional materials by mail. The TB componentof the Voice Information System can beaccessed by dialing toll-free 888-CDC-FACT(888-232-3228), then pressing options2, 2, 1, 5, 2.

MaterialsQuestions and Answers about TB Booklet -1994. A patient education booklet for personswith TB disease or infection, it providesinformation on TB transmission, pathogenesis,diagnosis, treatment (including medicationsand side effects), infection control, and follow-up care. This booklet is also appropriate foruse in educating those who provide services topersons with or at risk for TB (for example,staff of drug treatment centers, correctionalfacilities, homeless shelters). This booklet isavailable from each state TB program and theDTBE. This publication can also be viewed onDTBE’s Web site at http://www.cdc.gov/nchstp/tb.


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Stop TB! Poster and Tear-Off Sheets - 1994.This pictorial poster was developed to educatepersons with or at risk for TB. The posterdisplays the transmission of TB, progressionfrom infection to disease, treatment, andprevention. A smaller version of the posterwas developed for patients to take with them;this is available as tear-off-pads of 40 8 ½” x11" sheets per pad. The poster and tear-off-pads are available from each state TB programand DTBE.

TB Fact Sheets - 1997. This series of five factsheets was developed for persons with or atrisk for TB. The fact sheets include “TB Facts— You Can Prevent TB” (item number 00-5981); “TB Facts — TB and HIV (the AIDSVirus” (item number 00-5982); “TB Facts —Exposure to TB” (item number 00-5983); “TBFacts — The TB Skin Test” (item number 00-5984); and “TB Facts — TB Can be Cured”(item number 00-5985). Each pad of 40 tear-offsheets is available from each state TB programand the DTBE. The fact sheets are also avail-able in Spanish.

TB: Get the Facts! - 1991. This pamphlet isfor persons with or at risk for TB. The pam-phlet provides general information about TB,including signs and symptoms, risk factors,infection versus disease, skin testing, andpreventive therapy. It is available in Englishand Spanish from each state TB office orDTBE.

Tuberculosis: The Connection between TBand HIV (the AIDS virus) - 1990. Thispamphlet is intended for use with persons atrisk for HIV-related TB. The pamphlet coversthe TB/HIV connection and screening andprevention for HIV-related TB. The TB/HIVpamphlet is available in English and Spanishfrom each state TB office or the DTBE.


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Think TB! - Centers for Disease Control and Prevention · TB Notes 2000 Christmas Seal Campaign,...

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