DEPARTMENT OF HEALTH & HUMAN SERVICES

 Public Health Service

_ 

TB Notes

No. 1, 2002

Dear Colleague:

The Advisory Council for the Elimination of Tuberculosis (ACET) met in Atlanta on

February 6 and 7, 2002. Following are a few highlights: After the NCHSTP Director’s

report, I provided updates on DTBE activities that would not be covered in the ACET

agenda, such as the first meeting of the TB Epidemiologic Studies Consortium in

December 2001, the TIMS summit with NTCA in November 2001, and progress in the

areas of education and training, outbreak investigations, and international technical

assistance. Drs. Masae Kawamura, TB Controller for San Francisco, and Mark Lobato of

the Field Services Branch then discussed the report being prepared on detention of

foreign-born TB patients by the Immigration and Naturalization Service (INS); ACET

approved the report’s recommendations to improve treatment outcomes among INS

detainees. The recommendations are as follows: “To reduce the risk of exporting or reimporting persons with active TB identified while in INS custody, ACET recommends to the

Departments of Health and Human Services and Justice that they form an interagency

policy group involving other key organizations and entities to work toward a consensus on

the following measures: 1) Explore the feasibility of treating INS detainees in the United

States until TB is cured in the least restrictive setting. Consideration should be given to

changing or amending current policies or federal laws for detainees... 2) Work with

professional correctional associations to improve adherence to local public health laws

and CDC guidelines... 3) Enact policies requiring report of cases and suspects in INS

custody prior to the transfer or deportation of an INS detainee with TB... 4) Expand the

medical hold authority of the Division of Immigration Health Services...” The report will be

revised for submission to the CDC Morbidity and Mortality Weekly Report (MMWR). Dr.

Elsa Villarino of the Research and Evaluation Branch reported that DTBE plans to

summarize the initial recommendations for using the Quantiferon® test, which was

approved last November by the Food and Drug Administration as an aid in the diagnosis

of latent TB infection. Dr. Renee Ridzon of the Surveillance and Epidemiology Branch

(SEB) discussed the meeting that was held on January 23 and 24 in Atlanta to obtain

comments from outside consultants on the proposed revisions to CDC’s “Guidelines for

preventing the transmission of Mycobacterium tuberculosis in health-care facilities, 1994"

(MMWR 1994;43[No. RR-13]). The meeting was productive; we currently have no firm

publication date for the revised guidelines. Related to this, OSHA has reopened the

docket for public comments on the section of their Standard which deals with TB infection

control. In a session on TB elimination in the Southeastern states and on racial and ethnic

disparities, Dr. George Counts of the CDC’s Division of Sexually Transmitted Diseases

reported on that division’s goal of eliminating racial health disparities as part of its Syphilis

Elimination Plan. Mr. Lex Gibson discussed the Southeast TB Strategic Plan
2

and disparity issues for African Americans. This is an important area of concern for many

TB controllers as well as for CDC, and may warrant a separate meeting in the future to

address the disparity in TB risk in African Americans and other racial and ethnic

minorities. An update on TB laboratory capacity was followed by an update from Dr. Peter

McElroy of SEB on the reported adverse events associated with taking 2 months of

rifampin and pyrazinamide (2RZ) to treat latent TB infection (LTBI). To date, CDC has

received reports of adverse events related to any LTBI treatment in 132 persons. Of these,

35 persons met the case definition for having adverse events associated with 2RZ (liver

injury from 2RZ resulting in admission to a hospital, or death). Of these 35 persons, 7 died.

To date, CDC staff members have investigated 28 cases, including 6 of the fatalities. No

risk factors for death have been identified thus far. CDC’s revised recommendations for

the use of 2RZ for the treatment of LTBI are as follows: 1) The 2-month RIF-PZA treatment

regimen for LTBI should be used with caution, especially in patients also taking other

medications associated with liver injury and those with alcoholism. 2) For persons not

infected with HIV, 9 months of daily INH is still the preferred treatment for LTBI; 4 months of

daily RIF is an acceptable alternative. Two months of RIF-PZA may be useful when the

completion of longer treatment courses is unlikely and when the patient can be monitored

closely. 3) Available data do not suggest excessive risk for severe hepatitis associated

with RIF-PZA treatment among HIV-infected persons. However, experience from trials may

not translate to all clinical practice settings, and it may be prudent to use 9 months of daily

INH for treatment of HIV-infected persons with LTBI when completion of treatment can be

assured. 4) No more than a 2-week supply of RIF-PZA should be dispensed at a time (with

a PZA dose not exceeding 20 mg/kg per day and a maximum of 2 gm/d) to facilitate

periodic clinical assessments. Patients should be reassessed in person by a health care

provider at 2, 4, and 6 weeks of treatment for adherence, tolerance, and adverse effects,

and at 8 weeks to document treatment completion. 5) Serum aminotransferase and

bilirubin levels should be measured at baseline and at 2, 4, and 6 weeks of treatment in

patients taking RIF-PZA.

CDC has several new publications available or in progress. On Friday, February 8, the

summary of U.S. TB cases reported in 2000 was published in the MMWR. The article was

initially scheduled for publication in November 2001, but was rescheduled after MMWR

required publication of updates on anthrax and bioterrorism investigations. The summary

is based on data from the national TB surveillance system and provides data for 2000 with

comparisons to previous years, through 1992. Much of this information has been published

in tabular format in the DTBE national surveillance report, Reported Tuberculosis in the

United States, 2000, and is also available on DTBE’s Web site at

www.cdc.gov/nchstp/tb/surv/surv2000/default.htm. Also, Dr. Mary Reichler has an article

entitled “An evaluation of investigations conducted to detect and prevent transmission of

tuberculosis” in the February 27, 2002, issue of the Journal of the American Medical

Association. Thirdly, the most recent statement on the treatment of TB is now in its final

draft and is scheduled for publication later this year in the American Journal of

Respiratory and Critical Care Medicine. This document, which is a joint statement of the

CDC and the American Thoracic Society (ATS) and is also
3

cosponsored by the Infectious Diseases Society of America, will update the 1994

ATS/CDC guidelines.

As previously announced, the 4th World Congress on Tuberculosis will be held in

Washington, DC, June 3-5. Cosponsored by CDC, the National Institutes of Health, and

the World Health Organization/Special Programme for Research and Training in Tropical

Diseases, the Congress will evaluate the state of the global TB epidemic since the last TB

World Congress, which was held in 1992; review the status of TB research; and identify

research gaps. The meeting, which will cover fundamental, translational, and operational

research topics, should be of interest to global TB control officials, TB researchers, health

systems services researchers, policymakers and funders, as well as infectious disease

and pulmonary physicians. The Program Committee invited researchers to submit

abstracts, which were due by March 1, and notification of acceptance will be sent out on or

about April 1. For international travelers only, a limited amount of travel support may be

available for those presenting posters or "late-breaker" talks. Detailed information

regarding the meeting program can be found at the Web site

www.niaid.nih.gov/dmid/tuberculosis/tbcongress/.

World TB Day is observed every year on March 24. This annual event commemorates the

date when Robert Koch announced his discovery of the microbe that causes TB. Around

the world, nongovernmental organizations and others take advantage of the increased

interest that World TB day generates to describe their own TB-related problems and

solutions, and to support worldwide TB control efforts. I hope that each year you are taking

the opportunity afforded by this globally recognized event to garner press coverage of your

local TB problems and concerns and to involve others in the fight to eliminate TB — a fight

that we can and must win, and that we will win, through all of our continued dedicated

efforts! Now is the time to grasp a vision; a vision of coming together on World TB Day in

the near future to celebrate the elimination of TB in this country.

Kenneth G. Castro, MD
4

In This Issue

Highlights from State and Local Programs .............................................. 5

Housing Homeless TB Patients in California ....................................... 5

Application of Aggregate Reports to Program Management in Florida ..................... 8

DTBE Staff Called to Respond to the Terrorist Attacks and Bioterrorism Threats .................. 11

Updates from the Communications and Education Branch .................................. 12

TB Education and Training Network: “Bringing Together TB Education and Training Professionals” 12

TB Information Guide CD-ROM, Version 2.0 ...................................... 13

Updates on the Program Managers Course ...................................... 14

Report from the Computer and Statistics Branch ........................................ 15

Summary of the NTCA and CDC TIMS Summit ................................... 15

International Notes .............................................................. 17

The Tuberculosis Coalition for Technical Assistance (TBCTA) ......................... 17

New U.S. Department of State Forms for Overseas Health Assessment .................. 20

Updates from the Research and Evaluation Branch ....................................... 21

Evaluating Contact Investigation Programs ....................................... 21

Updates from the Surveillance and Epidemiology Branch ................................... 24

The TB Epidemiologic Studies Consortium ....................................... 24

The Importance of DNA Fingerprinting in TB Control Efforts ........................... 25

News Briefs .................................................................. 26

Training and Educational Materials .................................................. 26

New CDC Publications ........................................................... 27

Personnel Notes ............................................................... 28

Calendar of Events .............................................................. 35

Attachment: TB Education and Training Network (TB ETN) Membership Form .................... 36

NOTE: The use of trade names in this issue is for identification only and does not imply endorsement by

the Public Health Service or the U.S. Department of Health and Human Services.
5

Number 1, 2002

HIGHLIGHTS FROM STATE AND

LOCAL PROGRAMS

Housing Homeless TB Patients

in California

Homelessness has long been recognized

as an important predictor of poor adherence

to TB therapy. During the years from 1994

to 1996, the California Department of Health

Services (CDHS), TB Control Branch

(TBCB), received Report of Verified Case of

TB (RVCT) forms that identified an average

of 339 (7.36%) TB patients as having been

homeless each year. 

Homeless patients are among the most

difficult to cure because they are often

difficult to locate. In order to ensure that

patients could be located for the

administration of consistent directly

observed therapy (DOT) and thereby

complete therapy within 12 months, TBCB

decided that a housing component should

be added to the TB control program.

In 1996, at the behest of the California

Tuberculosis Controllers Association and

the California Conference of Local Health

Officers, TBCB proposed a change to the

Governor’s budget that added $2.9 million

for fiscal year 1997/98 for a program

addressing the needs of homeless and

unstably housed TB patients in California.

The funds were also to be used to detain

persistently nonadherent patients. TBCB

allocated housing funds to local health

jurisdictions (LHJs) by a formula based on

the number of homeless patients they had

reported.

Soon after the inception of the program, it

became clear that providing housing alone

was not the solution. In addition to housing,

patients needed food, transportation, and

other services. Some homeless patients

who did not want housing could be kept on

treatment by being provided with other

incentives and enablers. Finally, it was

determined that other solutions were

needed to prevent patients from becoming

homeless in the first place, and the

problems that lead to homelessness should

be addressed. Providing additional funding

for other compliance-enhancing measures

and for less restrictive alternatives to

detention might reduce the need for

detention and improve completion of

treatment (COT).

Therefore, about 6 months into the program,

TBCB broadened the scope of services

provided to include compliance-enhancing

measures and less restrictive alternatives to

detention. The branch also extended the

target population served by this program to

include persons at risk of becoming

homeless as a result of their TB diagnosis.

TBCB increased services to homeless

patients who refused housing in an attempt

to stabilize their lives enough to improve

compliance with DOT.

Broadening the scope of services provided,

however, created a need for additional

personnel at the local level to provide these

services. Not only were homeless patients

provided with shelter and food; they now

received increased DOT, case

management, and social services. Since FY

1999, approximately 47% of the total
6 NUMBER 1, 2002

housing budget allocated to the LHJs is

currently spent for personnel who provide

direct services to clients. It supports 22.7

positions statewide (13.1 outreach, 0.9 field

investigation, 6.0 case management, 2.5

social work, and 0.2 miscellaneous;

numbers rounded to one decimal). The

remaining 53% of the housing budget is

spent on food and shelter.

Methods

TBCB collected data over the 2-year period

of January 1, 1998, through December 31,

1999, using a data collection instrument

called the Report of Homeless Tuberculosis

Patient or Suspect (RHTP). Local health

departments were asked to complete an

RHTP on each patient with known or

suspected TB who was homeless within the

12 months prior to diagnosis, at the time of

diagnosis, or at any time prior to the final

disposition of treatment, whether or not

housing was provided. The purpose was to

ascertain the outcome of housing and

treatment for every homeless TB patient or

suspect identified in the state during that

period. The RHTP collected information on

whether or not the patient had been offered

and accepted housing, how long the patient

was actually housed, the type and duration

of housing provided, and the reasons for

which the patient left housing. By linking the

RHTP to the RVCT for the same patient, the

demographic characteristics and the

outcome of therapy could be correlated to

the housing provided. Additionally, the RHTP

was linked to the system by which LHJs

invoice the State to determine the cost per

day and per patient for providing the

housing.

Results

TBCB received 620 RHTPs of suspects and

cases over this 2-year period for both

homeless cases and suspects. Of the 620

patients, 327 (52.7%) were offered housing.

However, when the analysis excludes one

jurisdiction in which only 24.2% (70/289)

were offered housing, the percentage for the

remainder of the State jumps to 73.1%.

The branch examined RHTPs to determine

the reasons for which the remaining 293

patients were not offered housing; we were

able to determine the reason for 228 of

these. Of the 228, 144 (63.1%) actually had

some form of shelter, although technically

homeless because they had no official

address. TB was ruled out in another 35

(15.4%) patients. An additional 38 either

moved, died, or were lost to follow-up,

leaving only 11 (4.8%) patients who were

not offered housing for undetermined

reasons.

Of those offered housing, 92.3% were

actually housed. In fiscal year 1998/99, the

only year for which we had complete fiscal

data, 263 patients were housed for 19,078

days at a cost to CDHS of $586,538, an

average of $2,230 (73 days) per patient and

$30.74 per day of housing. We were unable

to determine the amount of local funding

spent on housing or the number or

additional patients that may have been

housed using local funds.

The majority (73.8%) were housed in single

room occupancy (SRO) hotels. An

additional 21.4% stayed in “other” facilities.

The category “other” includes apartments,

homes, and some inpatient facilities. Only a

very few patients were housed in YMCAs

(<1.0%), rehabilitation centers (<1.0%), or

board and care facilities (4.1%).

Thirty-nine patients were offered housing,

but were not actually housed using CDHS

funds. Of these, 7.7% refused housing,

46.2% were actually housed by another

program, and 18% were detained,

incarcerated, or hospitalized. Treatment

was terminated for one patient, leaving 10

(25.6%) patients who were not housed for

various other or unspecified reasons.

We received follow-up RHTPs on 243
NUMBER 1, 2002 7

(84.3%) of the 288 patients housed by the

program. Of these, 87 (35.8%) patients left

housing because their treatment was

terminated. Another 93 (38.2%) either

moved to or were detained in other facilities.

They therefore remained housed for the

continuation of their treatment.

We attempted to determine the treatment

status of each patient at the time housing

was terminated. As mentioned above, over

35% left housing because treatment was

terminated. Another 22.2% left housing but

continued treatment in the community and

22.6% left because TB was ruled out as a

diagnosis. Only 19.3% left because they

moved out of the area or died, or for

unknown reasons. It is important to

remember that these figures do not

necessarily reflect the final outcomes of

these cases.

How well does the RVCT capture the

extent of homelessness among TB

cases? 

To better understand the magnitude of the

problem, we compared RHTP and RVCT

data for 1998, the year for which RHTP data

were most complete. Together, these two

data sources identified 287 homeless TB

patients, 45 (16%) of whom were not

identified as homeless on their RVCTs. This

suggests that the RVCT may underestimate

the number of homeless persons with TB by

16%. A possible reason is that incarcerated

patients are not usually reported as

homeless, but may actually be homeless

when released from jail. Nor does the RVCT

system capture the number of patients who

become homeless subsequent to diagnosis.

We determined patient characteristics of

585 persons with TB reported as homeless

on either the RHTP or RVCT in 1998/99.

Eighty-two percent of homeless persons

were men, and 38% were foreign-born

persons. Fifty-eight percent were nonHispanic white persons, 29% were black

persons, 8% were American Indians, 2%

were Asian/Pacific Islanders, and 2% were

unknown. In terms of substance abuse,

15% of homeless patients reported injecting

drug use, 30% noninjecting drug use, and

49% excess alcohol use in the past year.

The RHTP captured homeless patient

demographics that were significantly

different from those captured on the RVCT.

This comparison suggested that more

American Indian, Hispanic, and foreign-born

persons may be homeless prior to or at the

time of diagnosis than was previously

thought.

Trends in treatment outcomes for

homeless persons with TB identified on

RVCT.

We also looked at treatment outcomes for

homeless patients (as identified on the

RVCT) before and after the implementation

of this program. The analysis is based on

the most recent follow-up RVCT available,

and is restricted to patients who began

treatment and had no resistance to rifampin.

The rate of completion in less than 12

months had already risen from 57.4% in

1995 to 66.3% in 1996 and then to 69.2% in

1997. In 1998, the first year of the program,

the rate of completion in less than 12

months fell to 66.0%, but rose again to

69.3% in 1999. The rate of completion in

over 12 months fell from 13.8% in 1995 to

8.9% in 1996 and 8.4% in 1997, rose to

12.9% in 1998 and then finally fell to 7.5% in

1999. Similarly, the rate for the category of

“died” fluctuated between 6.3% and 10% in

these years.

Categories for outcomes that may have

been influenced by the housing program are

“lost” and “moved.” The proportion of

homeless patients listed on the most recent

Case Completion Report as “lost” has

decreased steadily from 7.8% in 1996 to

3.3% in 1999. The proportion listed on the

most recent Case Completion Report as

“moved” dropped from 8.9% among the

homeless in 1996 to 4.2% in 1999. 
8 NUMBER 1, 2002

We also analyzed the Case Completion

Report (RVCT Follow-up 2) submitted by

the jurisdiction that originally reported the

case, disregarding subsequent Case

Completion Reports submitted by other

jurisdictions into which the patient moved.

This allows us to determine the outcomes of

case management in the jurisdiction that

originally reported the case. We were

interested in determining if the provision of

housing services stabilized patients’ living

conditions so they would not need to move.

This analysis showed that the proportion of

homeless patients classified as “moved”

decreased from 14.8% in 1996 to 10% in

1998 and to 7% in 1999.

Conclusions

There is evidence to suggest that housing

patients had a positive effect on the

outcome of therapy. The implementation of

this program corresponded with a

decreasing proportion of homeless patients

whose most recent RVCT 2 indicated that

their status was “lost” or “moved.” However,

since the implementation of the housing

program coincided with the implementation

of other interventions (e.g., food, increased

incentives, enablers, social services, and

DOT), it is difficult to precisely determine the

effect of the housing program in California.

The housing program also coincided with

intensified efforts by the CDHS TB Registry

to follow up with local health departments to

ensure that “moved” was not a final

disposition. The latter intervention would not

have impacted the proportion of homeless

TB patients who move out of the jurisdiction

that originally reported them. The trend

toward decreasing movement out of the

original reporting jurisdiction suggests more

successful case management in the original

jurisdiction, which may have been aided by

the provision of housing.

Housing can be one way to improve TB

control while improving patients’ lives for at

least a short period of time. In addition, while

patients are housed, the job of providing

DOT and support services is made easier

and more cost effective by reducing the time

health workers spend searching for patients.

However, completion of therapy rates

among the homeless remain unacceptably

low. The persistent application of many

interventions tailored to the individual needs

of homeless patients is needed to further

improve treatment outcomes.

—Submitted by Steve Roger,

Cathryn Fan, and Jan Young

California Department of Health Services 

Tuberculosis Control Branch

Application of Aggregate Reports to

Program Management in Florida

The Aggregate Reports for TB program

Evaluation marked a dramatic shift towards

improved TB program management and

accountability when they were introduced in

1999. Only after completing two cycles of

the Contacts Report and one cycle of

Targeted Testing did we begin to realize the

full potential of these reports.

The reactions of the Florida Department of

Health (DOH) TB program field staff were

probably much the same as those of staff in

other states when the seemingly

complicated report formats and new

definitions first appeared. They had to learn

not just a new vocabulary and new

definitions but, in some ways, a completely

different way of looking at TB control. This

new view of affairs meant that more is not

necessarily better; that priorities must be set

and results measured. The focus is not on

numbers, but on outcomes.

Florida already had in place the nucleus of a

TB case management information system

before TIMS came along with its case

management capabilities. The Florida

system, the Health Clinic Management

System, or HCMS, contained a registration

module, a TB case management and RVCT

module, a laboratory module, and limited ad
NUMBER 1, 2002 9

hoc report generation capability. It was

logical, if not simple, to base a management

reports module for the Aggregate Reports

on this platform.

We reached the decision to automate the

Aggregate Reports after completing the

preliminary contact reports for 1999. With

the realization that Florida’s 67 county health

departments (CHDs) were required to

consult treatment records and manual

statistical tabulations on approximately 9500

contacts for nearly 1200 cases just for one

report, we had to rethink our approach to the

preparation of these reports. Through the

statewide Quality Improvement process, we

also discovered that the old CDC Program

Management Reports were being completed

and interpreted differently among CHDs.

The inescapable conclusion we reached

was the necessity of designing a system to

standardize and automate the reports.

There is no way to express in simple terms

the programming requirements for

automating these reports. It is not simply a

matter of designing a set of screens that

can be used to load the HCMS database to

produce the reports for a given cohort year.

The committee of users we convened to

assist in developing the specifications was

forced to develop decision rules applicable

to a variety of situations. For example, what

cutoffs should be used to count the contacts

to cases reported late in the cohort year

whose evaluation and treatment took place

in the next year?

The initial reports had to be tested,

compared to audit reports, and completely

validated or returned to the programmer for

correction over a period of months, in the

course of which the program identified

some stellar analytic thinkers. The Contacts

Report was completed first, followed in late

August 2001 by the Targeted Testing

Report. The system was then used to

produce the final Contacts Report for 1999,

the Preliminary Contacts Report for 2000,

and the preliminary Targeted Testing Report

for 2000. 

If this article were only about the automation

of the Aggregate Reports, it could stop here

with grateful congratulations to the project

managers and programmers who designed

the system. But happily the story doesn’t

stop here.

It is a truism more often expressed than

acted upon that data are not collected for

their own sake but to serve a purpose. The

Aggregate Reports were designed for TB

program evaluation as their title indicates,

not simply at the national or even the state

level but locally as well. Florida has

discovered that the aggregate reports can

help the CHD TB programs obtain a

snapshot of their operating efficiency. 

To serve this purpose, we have developed a

summary report that compares operating

results at the local level to state averages

and state goals. This enables each health

department TB program to see how it

compares to other health departments,

whether it is using its resources in the most

efficient way, and whether its program is

effective in meeting the highest priority

needs.

The measures used in the Contacts Report

include the following:

• Other contacts as a percentage of total

contacts

• No contacts rate for smear-positive

cases

• No contacts rate for smear-negative

cases

• Contacts per smear-positive case

• Contacts per smear-negative case

• Evaluation rate for contacts to smearpositive cases

• Evaluation rate for contacts to smearnegative cases

• Evaluation rate for contacts to “other”

cases

• Disease rates for smear-positive,
10 NUMBER 1, 2002

smear-negative, and “other” contacts

(individually)

• LTBI rates for smear-positive, smearnegative, and “other” contacts

(individually)

• Treatment rates for contacts with LTBI

• Contacts chose to stop plus contacts

lost to follow-up, as a percentage of total

contacts who began treatment

• Completion rates for contacts with LTBI

Certain assumptions underlie these

measures. First, a decision to test is a

decision to treat. And second, a decision to

treat is a decision to complete. Thus, the

program should allocate resources to

ensure completion of therapy for contacts

found to have LTBI.

Line 1, “other” contacts as a percentage of

total contacts, is measured to show the

percentage of effort given to lower-priority

contacts. The amount is not an issue as

long as the local TB program has the

resources to serve these clients, and its

evaluation, treatment, and completion rates

for higher-priority contacts meet state

standards.

In Lines 2 and 3, the goal for “no contacts” is

zero. The state program assumes that

every TB case has contacts; and the

objective of a contact investigation is to find

and evaluate those contacts. There is no

goal for number of contacts to “other” cases

that presumably have a lower priority.

The goal for lines 4 and 5 is 10 contacts per

smear-positive and smear-negative case.

For lines 6-8, Evaluation, the goal is 90%.

The whole idea of a contact investigation is

to identify and evaluate contacts for possible

disease or infection resulting from their

exposure to the index case. If the contacts

aren’t evaluated, the contact investigation is

just wasted effort.

There is no goal for lines 9 and 10, TB

disease or LTBI, but these measures do

serve a beneficial purpose. They show that

the contact investigations are achieving

tangible results. Also, the LTBI rate may

reflect the LTBI background rate in certain

population groups. Certainly if the LTBI rate

is higher than expected for that community

or population group, this may be an

indication that the contact investigation net

was not spread widely enough, particularly

when combined with a low ratio of contacts

per case or a high no-contacts rate (or

both).

Finally, the goal for lines 11 and 12,

Treatment and Completion rates, is 90% for

each category. This is the bottom line, both

figuratively and literally. 

But if line 12 fails to meet expectations, the

reason might be found in Line 13, “Contacts

who choose to stop or who are lost to

follow-up.” This rate is compared to a

standard of <10%. The rationale underlying

this measure is that all contacts receiving

treatment for LTBI should be casemanaged, and case management should

concentrate on persons who show signs

that they may not complete treatment. If

more than 10% of those who begin

treatment fail to complete it, the local

program cannot possibly meet the State’s

90% completion goal.

While the preceding analysis has focused

on identifying weaknesses in the CHD’s

contact investigation program, the reverse

also applies. Strong points are highlighted

and documented so that we also know

whom to praise for good work as well.

Clearly, it is not sufficient to simply compare

health department TB programs one to

another or to the state goals. For this

process to be useful, it should lend itself to

program analysis and management

purposes. Also, it should be reproducible at

the local level so managers can see how

they are progressing periodically. To
NUMBER 1, 2002 11

achieve the second purpose, the program

proposes to develop a special HCMS

screen that can be accessed locally to

display the summary report at any given

time for any given time period.

The first priority, program analysis and

management, is achieved by understanding

what the report shows, and the process to

that end seems self-evident. Low contacts

per case or high “no-contacts” ratios

suggest problems with the contact

identification process. This is a critical

deficiency, because persons who are not

identified cannot be evaluated.

If the evaluation rate is low, it is equally

obvious that the deficiency is critical,

because persons who are not evaluated

cannot be treated. This deficiency may

indicate problems in an aspect of the

program other than the contact identification

process. If this is the problem, the corrective

action will differ from that required if the

contacts are not being identified. One may

be an interviewing deficiency, the other a

deficiency in the follow-up procedure to

locate and test the contact.

There are also different interpretations that

can be given a finding that LTBI rates are

too low or too high. The program manager

must give some thought to the findings to

determine what, if anything, is the

significance of the variance from the

expected rates.

Persons who have LTBI associated with an

infectious TB patient with whom they have

contact should be treated. This is the only

way to interrupt the transmission of TB. If

the treatment rate is low, why is this so and

what measures are needed to improve

program performance? The same is true for

treatment completion. If a person starts

treatment, he or she should finish unless

there are clinical reasons why completion is

not possible. The percentages shown for

“contact lost to follow-up” or “contact chose

to stop” may provide an explanation as to

why treatment completion is low.

It should be evident by now that many of the

same measures can be applied to the

targeted testing report. Certainly the same

principles apply. It should be noted that the

Florida DOH chose to implement the

targeted testing report beginning with cohort

year 2000 for all clients tested or

“screened” for LTBI by the county health

departments. By doing this, we get

summary data of all TB “screening” being

done by CHDs across the state and an

indication of the degree to which targeted

testing guidelines have been implemented

throughout Florida. It seems clear that these

reports give management a powerful tool

with which to analyze their programs’

effectiveness. In a time of diminishing

resources, programs need every tool

possible to deliver measurable results.

—Reported by John T. Miller, Bureau of TB

and Refugee Health

Florida Dept of Health

DTBE Staff Called to Respond

to the Terrorist Attacks and

Bioterrorism Threats

The September 11 attacks to the World

Trade Center and Pentagon and later

bioterrorism attacks required a prompt,

extensive response from all public health

officials. The response from CDC was

massive, and persons from all over the

agency were deployed to assist in public

health efforts relating to these events.

After the September 11 attacks, all four of

the division Epidemic Intelligence Service

(EIS) Officers were in the first wave of CDC

responders. McKenzie Andre, MD, Puneet

Dewan, MD, Lisa Nelson, MD, and Lorna

Thorpe, PhD, traveled to New York City to

assist. During this deployment, the officers

worked 12-hour shifts in selected hospitals
12 NUMBER 1, 2002

conducting surveillance for disaster-related

injuries. With the long shifts at the hospital

and sometimes commutes of up to 3 hours,

the officers had time for little else besides

their work.

Shortly thereafter, with the anthrax attacks,

additional DTBE personnel were enlisted to

assist with public health efforts. Some

personnel were assigned to work in the

Emergency Operations Center at CDC in

Atlanta, while others were deployed for field

work in Connecticut, the New York City

area, or Washington, DC. DTBE personnel

who were involved in emergency

assignments either in Atlanta or the field

include the following:

• Communications and Education Branch:

Gaby Benenson, MPH, Regina Bess,

Nick DeLuca, MA, Ann Lanner, Wanda

Walton, MEd

• Surveillance and Epidemiology Branch:

McKenzie Andre, MD, Lauren Lambert,

Scott McCombs, MPH, Peter McElroy,

PhD, Renee Ridzon, MD, Philip 

Spradling, MD

• International Activities office: Tracy

Agerton, MPH, Paul Arguin, MD, Alicia

Fry, MD, Kayla Laserson, ScD,

Elizabeth Talbot, MD

• Field Services Branch: Phillip Finley,

Judy Gibson, MSN, RN, Darryl Hardge,

Michele Thomas, Peg Tipple, MD

• Office of the Director: Joe Posid

• Research and Evaluation Branch: Lorna

Bozeman

Work in Atlanta consisted mostly of

answering the many public inquiries and

other assignments in the CDC Emergency

Operations Center. Even in-house, DTBE

staff contributed to bioterrorism-related

efforts. Under a very tight time schedule,

several staff members of the

Communications and Education Branch

prepared educational materials for persons

exposed to anthrax and taking a 60-day

course of antibiotics: "What You Need to

Know About Anthrax," and "Questions and

Answers for People Who Are Taking 60

Days of Antibiotics to Prevent Inhalational

(Lung) Anthrax," and fact sheets on

doxycycline and ciprofloxacin.

In the field, division staff assisted with

environmental sampling and epidemiologic

studies. DTBE's staff expertise in aerosol

transmission of infectious agents,

respiratory protection and engineering

controls, and adherence with long-term

antimicrobial medications proved useful in

assistance with the CDC response.

All DTBE staff were affected by these

events, even those who were not deployed.

Staff members who were not assigned

emergency duties worked long hours to

cover work duties for colleagues who were

deployed. Although work on these events

has been completed, DTBE staff remain

willing to assist with further emergency

public health efforts, as needed.

—Reported by Renee Ridzon, MD

Chief, Outbreak Investigations Section

Division of Tuberculosis Elimination

UPDATES FROM THE

COMMUNICATIONS AND

EDUCATION BRANCH

TB Education and Training Network:

“Bringing Together TB Education

and Training Professionals”

The TB Education and Training Network (TB

ETN) is actively seeking new members. The

goals of the Network are to further TB

education and training by

• Building, strengthening, and maintaining

collaboration,

• Providing a mechanism for sharing

resources to avoid duplication,

• Developing, improving, and maintaining

access to resources,

• Providing updated information about TB
NUMBER 1, 2002 13

courses and training initiatives, and

• Assisting members in skill building.

Benefits of TB ETN Membership include the

opportunity to

• Network and collaborate with other TB

professionals,

• Exchange ideas, information, and

experiences,

• Access and share resources,

• Collaborate on training and education

research,

• Receive updated information about TB

courses and training initiatives,

• Build TB education and training related

skills, and

• Pilot-test and preview new

communication and education materials.

Membership is open to all persons who

have an interest in TB education and training

issues. There are two types of membership

status: 

Active member: These are individuals who

have the lead role for TB education and

training in their agencies. Active members

have the opportunity to participate in all TB

ETN activities, receive priority registration

for all TB ETN meetings and activities, vote

on TB ETN business-related issues, and

serve on subcommittees.

Information-only member: These are

individuals who do not have a lead role in TB

education and training in their agencies or

do not wish to actively participate in TB ETN

activities. Information-only members receive

information about TB ETN meetings,

activities, and other pertinent news via email postings to the membership.

Information-only members are not eligible to

vote on TB ETN business-related issues or

serve on subcommittees.

New members may join the TB ETN at any

time during the year. There are no

membership fees. In order to keep the

membership list current, the steering

committee may, on an as-needed basis,

request members to re-register. If you are

interested in joining TB ETN, please

complete the registration form at the back of

this issue and submit it to Vivian Siler by fax

at (404) 639-8960. If you have any questions

about TB ETN, please feel free to contact

Maria Fraire at (404) 639-5317 or by e-mail

at mff8@cdc.gov, or Gabrielle Benenson at

(404) 639-5320 or by e-mail at

gkb6@cdc.gov.

—Reported by Maria Fraire, MPH, CHES

Division of TB Elimination

TB Information Guide CD-ROM,

Version 2.0 

Due to the popularity of the CD-ROM

entitled TB Information Guide, the

Communications and Education Branch has

released Version 2.0 with updated contents

and improved usability. The TB Information

Guide CD-ROM includes many of the

materials found on the Division of TB

Elimination (DTBE) Web site. The CD-ROM

was designed as a quick resource for those

who do not have time to connect to the

Internet or for those who have intermittent

access to the Internet. The six sections of

the CD-ROM are as follows:

Educational Materials: Health care

provider and patient education and training

materials.

Major TB Guidelines: Guidelines from

CDC’s Morbidity and Mortality Weekly

Reports and joint statements from CDC and

the American Thoracic Society (ATS).

Morbidity & Mortality Weekly Reports:

TB-related articles from CDC’s Morbidity

and Mortality Weekly Report (MMWR). 

MMWRs are sorted by subject and by

publication year.

Surveillance Reports: Tabular and graphic
14 NUMBER 1, 2002

information about reported TB cases from

59 reporting areas. 

Slide Sets: Various slide sets developed

as accompaniments to select publications. 

Ordering Information: Information on how

to order free materials from DTBE.

For quick and easy use, the CD-ROM runs

automatically when inserted into the

computer and utilizes an Internet browser

(you do not need Internet access).Version 2

provides materials in both HTML and PDF

format. The HTML format was added to

comply with Section 508 of the

Rehabilitation Act of 1973, as amended, a

law that ensures individuals with disabilities

increased access to electronic and

information technology provided by the

federal government. Please note that this

CD-ROM does not operate on MacIntosh

computers.

The CDC TB Information Guide CD-ROM

can be requested in the following ways:

• Through the DTBE’s on-line ordering

system: www.cdc.gov/nchstp/tb

• By mailing or faxing a DTBE Educational

and Training Materials Order Form

• Through the CDC Voice and Fax

Information System by calling, toll-free,

1-888-232-3228 and requesting the TB

Information Guide, order #99-6879.

—Reported by Betsy Carter, MPH, CHES

Division of TB Elimination

Updates on the Program Managers

Course

Overview of the TB Program Managers

Course

The overall purpose of the TB Program

Managers Course is to improve the planning

and managerial capabilities of new TB

program managers throughout the country.

The course is designed for TB controllers,

program managers, public health advisors,

and nurse consultants with programmatic

responsibilities at the state, city, and

regional (within a state) levels. Optimally, a

course participant should have occupied a

TB program management position for at

least 6 months but no more than 3 years. 

2001 TB Program Managers Course

The Communications and Education

Branch (CEB) would like to thank the faculty

and participants of the October 2001 TB

Program Managers Course for making the

course such a success. CEB appreciates

the faculty’s hard work in preparing the

materials for their sessions and the

participants’ hard work during the course.

Overall evaluation results indicate the

following:

• 94% of the participants improved their

knowledge scores from precourse test

to postcourse test;

• 97% of participants rated the overall

quality of the course as excellent or

good; and

• 76% of the participants indicated that at

least 8 of the 12 knowledge, skill, and

ability (KSA) areas were adequately

covered (46% indicated that all 12 KSA

areas were adequately covered).

This year’s 5-day training was divided into

16 sessions. Each session stood alone as a

block of instruction, but was sequenced to

build logically on the sessions preceding it.

The course sessions included TB

Prevention and Control Programs in the

United States, Active Case Surveillance,

Using Epidemiology to Identify High-Risk

Groups, Effective Treatment Completion

Strategies, Appropriate Regimens and Case

Management, Infection Control and Health

Department TB Clinics, Contact

Investigations, Outbreak Investigations,

Targeted Testing and Treatment of Latent

TB Infection, Reaching High-Risk

Populations, Using Data for Program
NUMBER 1, 2002 15

Planning and Evaluation, Quality Assurance

and Monitoring Cases, Media Relations,

Coordinating Efforts through Training and

Education, Forging Partnerships, and a

Charge to Participants.

The course stressed practical application of

planning, management, and evaluation

concepts to the specific issues and

concerns of TB programs. Skills essential to

TB program management were presented,

followed by exercises that encouraged

participants to practice using the skills in the

classroom setting. At the end of each

session, participants were asked to address

specific questions in a Planning Guide, 

which required them to synthesize concepts

presented in the session and apply them to

their own programs. The Planning Guide

was a tangible product that participants took

home from the course, to serve as a record

of personal course discoveries and, more

importantly, as a road map for improving the

effectiveness of their TB prevention and

control efforts.

The 2002 TB Program Managers Course 

Plans are now underway for the 2002 TB

Program Managers Course to be held

October 21-25 in Atlanta. As you read

above, the TB Program Managers Course

is a multisession program (17 sessions are

planned for 2002) designed for TB Program

Managers, Nurse Consultants, Public Health

Advisors, and TB Controllers who have

programmatic responsibilities at the State,

city, or regional level. There are no

registration fees for attending the course,

but attendees (or their programs) are

responsible for their own travel, hotel, and

per diem expenses. The course will be held

in Atlanta at the Sheraton Colony Square

Hotel (at 14th Street and Peachtree).

As in the past, the 2002 TB Program

Managers Course will be limited to 30

participants who have been nominated by a

DTBE program consultant.

The criteria for course participants are as

follows:

• Employment as a TB Controller, TB

Program Manager, Nurse Consultant, or

Public Health Advisor,

• Programmatic responsibilities at the

state, city, or regional level,

• Six months to 3 years of experience in a

TB program management position,

• A score of 90% or greater on the

prerequisite pretest (basic TB

knowledge),

• Consultant recommendation.

—Reported by Scott McCoy, MEd, EdS

Division of TB Elimination

REPORT FROM THE

COMPUTER AND STATISTICS

BRANCH

Summary of the NTCA and CDC

TIMS Summit

The following is a summary of the

Tuberculosis Information Management

System (TIMS) summit convened and

attended by members of the National TB

Controllers Association (NTCA) and

CDC/DTBE staff on November 6 and 7,

2001, in Atlanta, Georgia. Jose Becerra, MD,

MPH, of CDC and Randall Reves, MD, of

the NTCA served as co-moderators of the

summit.

Background: To design and develop the

TIMS patient management module, CDC

conducted a thorough joint application

development process in 1993/94 that

included input from TB controllers.

Throughout the development of TIMS, TB

controllers have been concerned about the

ability of the TIMS patient management

module to fill the needs of TB control

programs. The mismatch between this

expectation and the actual product has been
16 NUMBER 1, 2002

a cause of great concern among TB

controllers, complicated by staff turnover

(both at headquarters and in the field), and

by the serious defects that plagued the first

versions of TIMS. An Information

Technology Working Group of the NTCA

was formed to work with DTBE on

addressing the need for patient

management systems that could enhance

TB control as well as addressing public

health reporting requirements. As a result of

fruitful discussions generated at a session

organized by the Information Technology

Working Group at the June NTCA meeting,

a subsequent meeting was sponsored by

CDC/DTBE in Atlanta in November. The TB

control professionals of the NTCA and CDC

who attended the TIMS summit meeting did

so for several reasons: to review the

modules that have been developed by

various local programs; to determine which

modules, or components of modules, are

the most successful and adaptable to other

programs; to prepare for the technology of

the future via discussions about the National

Electronic Disease Surveillance System

(NEDSS); and to eventually present jointly

with CDC a robust and usable product.

Meeting summary: Jose Becerra, MD, MPH,

chief of the Computer and Statistics Branch

of DTBE, presented a review of CDC’s

current activities regarding TIMS. He

indicated that representatives of the NTCA

and of CDC are exploring short-term options

to make TIMS, as is, more useful to those

low-incidence areas that may need it (e.g.,

exporting data into MS Access for reports

customization and linkages with other

databases).

Dr. Becerra then described CDC’s priorities

for future activities: “For those areas with

their own systems, we want, first, to make

sure that our TIMS import utility is more

widely tested before we put it in full

production mode; and second, to start to

work on defining a common business

process model and a core data dictionary

for TB case management.” He pointed out

that California has produced useful

documentation, including a first attempt to

correspond to the NEDSS conceptual data

model, and that Alabama is already very

close (90%) to completing a Web-enabled

system that includes HIV/AIDS, STD, and

TB data elements and seems to comply

with current NEDSS standards. He

introduced Carol Berglund as the CDC point

of contact and, in collaboration with NTCA, a

facilitator for this case management task.

He stated that a subject-matter expert on TB

case management will be provided by NTCA

and the Field Services Branch of DTBE

(editor's note/update: Stuart McMullen has

agreed to serve in this capacity). He also

introduced Dave Elmore as DTBE’s

technical lead for the transition from TIMS to

the NEDSS-TB program area module

(PAM). According to Dr. Becerra, the TIMS

surveillance module will be the first module

worked on in NEDSS; the development of a

case management module will be

considered later. DTBE staff will meet with

NEDSS project staff for a joint application

development (JAD) session at an

undetermined date.

Randall Reves, MD, of the Denver Public

Health Department, presented the NTCA’s

perspective regarding TIMS. He began by

stating that there is a long-overdue need for

a TB patient management system for many

programs and that far too many programs

have been attempting the task on their own,

patching together many different and often

duplicative "quick fixes" in order to better

and more efficiently accomplish the job of

patient care and TB control. 

He went on to state that it had been

unrealistic to expect TIMS to be able to

adequately address all patient care and TB

control issues for every program, and that a

NEDSS version developed in Atlanta might

be inadequate as well. He pointed out that

the presentations by the summit participants

from Alabama, Wisconsin, Florida,
NUMBER 1, 2002 17

Oklahoma, New Mexico, and California had

provided excellent demonstrations of how

TB controllers should have been working

toward their objectives all along: starting at

the very basic level — what TB controllers

must do to get their jobs done — and

making that set of requirements drive the

information system. He cited as a good

example the way in which the contact

investigation data management system had

been developed in Alabama, integrating

those complex data into the overall TB and

public health data management system in

the state (including such documentation as

DNA fingerprints).

Dr. Reves continued by saying that there

are many common elements in what TB

controllers do, and that there is a willingness

and need to work together to improve TB

control data management systems for those

who are not as far along in the process.

One group of persons at the meeting

worked on a comparison of the data

dictionaries that are being developed by a

number of TB control programs as a first

step toward defining those elements

common to all programs. He stated, “We

are working toward providing TB programs

with a menu of systems that have already

been developed, with the pros and cons of

each, so that programs will not have to

‘reinvent’ what other programs have already

developed for patient and program

management - whether they involve the use

of TIMS in more efficient ways, or other

systems that will provide the data on

reporting but not by direct TIMS entry (once

the import function is working). These

activities need to be fostered.” He went on to

state that some of these common elements

being developed will be of local or state

concern, but others will no doubt become

part of the NEDSS system, which will

eliminate some of the need for dual data

entry. Another group of TB controllers

attending the meeting spent some time

working with CDC staff on this issue.

For further information on the TIMS summit,

please contact Dr. Jose Becerra at (404)

639-8122, Dr. Randall Reves at (303) 436-

7297, or Dennis Minnice at (312) 746-5987.

—Reported by Jose Becerra, MD, MPH

Division of TB Elimination

Randall Reves, MD

Denver Public Health Department

and Dennis Minnice, MPH

Director, TB Program

Chicago Department of Public Health

INTERNATIONAL NOTES

The Tuberculosis Coalition for

Technical Assistance (TBCTA)

The TBCTA: As part of the global effort

against TB, six organizations involved in TB

control have formed a unique and freestanding partnership, the Tuberculosis

Coalition for Technical Assistance (TBCTA).

Each of the partner organizations has a

TB-specific agenda as well as expertise and

experience. Together, the partners of

TBCTA form a formidable force that

stimulates political commitment in the

selected countries, and provides strategic

direction and leadership, technical expertise,

and related resources to the global effort to

reduce the burden of TB. Examples of

expertise and activities undertaken by the

TBCTA include technical assistance,

assessments, assistance with program and

project development, training and

workshops, supports for intracountry and

intercountry meetings, program review

missions, and consensus-building

meetings.

Purpose: The purpose of the TBCTA is to

(1) substantially improve and expand the

capacity of the US Agency for International

Development (USAID) to respond to the

global TB epidemic by providing state-ofthe-art, context-appropriate, technically

sound and cost-effective consultation and
18 NUMBER 1, 2002

technical assistance to high-incidence

countries and USAID missions; and (2)

complement and enlarge upon existing

global TB control efforts, such as the Stop

TB Initiative, the programs of the World

Health Organization, and the activities of the

individual TBCTA partners. The ultimate

goal is to reduce the global burden of TB

and its attendant mortality, thus significantly

improving human health, well-being, and

development, particularly among the poor. 

The Partners: The World Health

Organization (WHO), headquartered in

Geneva, has a presence in virtually all

developing countries as well as having

responsibility for defining the international

health policy for TB control. It provides

technical assistance and advice to countries

on policy formulation, project planning and

implementation, and monitoring and

evaluation of TB control activities. WHO

maintains the global surveillance and

monitoring of TB incidence, drug resistance,

and status of TB control programs.

The International Union Against

Tuberculosis and Lung Disease (IUATLD), a

nongovernment organization (NGO)

headquartered in Paris, is composed of

constituent, organizational, and individual

members. There are IUATLD regional

organizations in North America, Latin

America, Africa, Europe, Asia, and the

Middle East. The IUATLD disseminates

information on TB and lung disease;

coordinates and assists the work of its

members throughout the world; and

maintains close links with WHO, other UN

agencies, and government and

nongovernment organizations in the health

and development sector. The IUATLD’s

expertise and its activities are focused on

the areas of technical assistance,

education, and research. 

The American Lung Association (ALA),

based in New York City, is the oldest

voluntary association in the United States,

having been founded in 1904, and has 78

state and local organizations throughout the

country. It is the U.S. constituent member to

the IUATLD. Its mission is the prevention

and control of lung disease and it works

primarily through public education, public

policy, and advocacy activities. The ALA

works internationally solely in the areas of

advocacy and in fostering the development

of international protocols.

The American Thoracic Society (ATS), also

based in New York City, was founded in

1905. It is a 14,000-member educational

and scientific society and is the major U.S.

medical professional organization with an

interest in TB. The ATS has considerable

experience in collaborating with the Centers

for Disease Control and Prevention (CDC)

in developing guidelines for TB prevention

and control, which are used both in the

United States and in other parts of the world.

The ATS publishes a highly respected and

widely read scientific journal. In addition, the

Society conducts an annual international

conference that attracts 15,000-16,000

attendees. The conference is a major forum

for the presentation of new information

about TB and its control, and provides an

arena for TB training and education as well.

Broad-range specific technical expertise is

represented in the organization.

The Centers for Disease Control and

Prevention (CDC), based in Atlanta, is one

of the United States’ federal public health

agencies. It promotes health and quality of

life by working to prevent and control

disease, injury, and disability. Within CDC,

the Division of Tuberculosis Elimination

(DTBE) is responsible for domestic and

international TB prevention and control

activities. These activities are carried out

along with other centers in the CDC and in

collaboration with state and local health

departments, academic and research

institutions, and other partners such as

ministries of health in foreign countries, and

domestic and international NGOs. CDC
NUMBER 1, 2002 19

provides technical assistance and

consultation in a broad range of TB control

areas.

The Royal Netherlands Tuberculosis

Association (KNCV), based in The Hague,

was established in 1903 as a unique

public-private partnership. KNCV promotes

effective and efficient TB control within

national and international contexts and acts

as an implementing agency for projects

financed by the Dutch government and other

Dutch international foundations. Since the

1980s, KNCV has contributed to the

development and implementation of

effective TB control programs in low-income

countries. It also hosts the International

Tuberculosis Surveillance Center (ITSC)

and the Tuberculosis Surveillance Research

Unit (TSRU); contributes to international

policy development, especially within its

collaboration with WHO and the IUATLD;

and collaborates with numerous

international organizations. KNCV has highly

qualified staff in a wide variety of fields of

experience and expertise, many of whom

have years of experience working or living in

developing countries.

In short, TBCTA is a unique coalition of

partners who are collectively and individually

well-positioned to mobilize political

commitment and human and financial

resources from a variety of sources, and to

ensure the quality of the TB control efforts.

Expanding the Partnership: The TBCTA

aims to contribute to the objective of

accelerating directly observed treatment,

short-course (DOTS) expansion in line with

the Amsterdam Declaration through the

current six-member coalition and through an

expansion of the partnership, especially in

high-burden countries and through their

national programs for TB control. The issue

of expansion of the partnership is twofold:

(1) Each of the current six members of the

TBCTA can make arrangements with other

partners to implement activities described in

this proposal. In order to keep the

management transparent, the TBCTA has

decided that the Coalition member is the

one responsible to the Coalition for the

proper implementation. In all cases, the

TBCTA will strive to strengthen and expand

in-country organization and human and

programmatic capacity in order to achieve

sustainable development. (2) Other donors

or agencies can apply to the TBCTA to

implement activities on their behalf. For

example, ACDI-CIDA (the Canadian

International Development Agency) and

DFID (the UK’s Department for International

Development) have already approached the

Coalition regarding this possibility. When

other donor/agency funding becomes a

reality, the Coalition will take every

precaution to ensure that the separate

management and administration of the

different donor resources will be

safeguarded. The vast experience of the

Coalition members in dealing with various

donors in the past guarantees this process.

The TBCTA envisions expanding to other

professional societies, public and private

organizations, and/or universities. This

includes both organizations already involved

in TB control at country level and

newcomers with the interest and motivation

to join the effort. Specifically, this expansion

could include organizations involved in

advocacy and lobbying. If so, such efforts

would complement the USAID resources

and build on the experience and system

established by the Coalition in contributing to

DOTS expansion.

For more information about the TBCTA,

readers can contact the following

individuals:

Dr. Peter Gondrie, Ms. Elsbeth Gosens, or

Ms. Clara Habraken

Royal Netherlands TB Association (KNCV)

Riouswstraat 7

P.O. Box 146

2501 CC The Hague, The Netherlands

Telephone: 31-70-358-7222
20 NUMBER 1, 2002

FAX: 31-70-358-4004

—Reported by Charles Wells, MD

Division of TB Elimination

New U.S. Department of State Forms

for Overseas Health Assessment

“Out with the old and in with the new” is a

common saying, but it has never been more

aptly used than for the overseas health

assessment document, Optional Form-157

(OF-157). The U.S. Department of State

has been responsible for updating the

information on the OF-157 since 1949. The

most recent OF-157, last updated in 1986,

became outdated in 1990 when the

Immigration and Nationality Act (INA) was

amended. In collaboration with the

Department of State, the Immigration and

Naturalization Service, state TB controllers,

and overseas U.S. embassy–assigned

examining physicians (panel physicians),

CDC’s Division of TB Elimination and

Division of Global Migration and Quarantine

(DQ) developed four new forms. These are

the DS-2053 (replacing the OF-157) and

three accompanying worksheets (DS-3024,

DS-3025, DS-3026). All four will now be

used during the overseas migration health

assessment. 

These four new medical forms will be

completed by the panel physicians or the

International Organization for Migration

physicians for immigrant and refugee

applicants, respectively. The DS-2053 is a

summary of the three worksheets and

contains serologic results. This form has

been updated to be in compliance with all

the changes in immigration law. It has check

boxes for easier recording and collection of

data, more space for panel physicians to

use to write comments, larger boxes for

recording laboratory findings, and a space to

show if vaccination entry requirements have

been met or waived.

The DS-2053 is designed to be used with

the chest x-ray and classification worksheet

(DS-3024), vaccination worksheet (DS3025), and medical history and physical

examination worksheet (DS-3026) to

provide additional essential health

information to the U.S. embassies, the

receiving health departments and providers,

and DQ.

The rationale behind developing the

additional worksheets was twofold:

• The worksheets will provide more

detailed and specific information about

the results of the overseas health

assessment; this is needed by receiving

health departments to provide adequate

care and follow-up.

• The worksheets can also function as a

quality assessment tool through which

DQ can monitor compliance of panel

physicians with the regulations and

Technical Instructions for the overseas

examination (developed by DQ). 

The new chest x-ray worksheet (DS-3024)

is of most interest to the TB control

programs. It provides additional information

about how the panel physician determined

the classification for a TB condition in the

immigrant or refugee applicant. It is

designed as a self-guided algorithm to help

the panel physician determine the following:

• The need for a chest radiograph,

• The classification of findings on the

chest radiograph (whether suggestive of

active or inactive TB),

• The need for sputum smears (based on

chest radiograph findings and clinical

signs and symptoms), and

• The final TB classification of the

applicant.

The chest x-ray and classification

worksheet will therefore provide a method

for determining how the physician arrived at

the TB classification in order to help DQ

identify inadequacies in the classification

process.
NUMBER 1, 2002 21

On March 28, 2001, the Department of State

notified the consular officials at U.S.

embassies of the new forms. The time

frame for implementation has been left to

the discretion of the individual U.S.

embassies. By late fall of 2001, most

countries were using these forms to report

the results of overseas health

assessments.

The forms are available at the Consular

Sections of U.S. embassies. Detailed

instructions for their use are available at:

http://www.cdc.gov/ncidod/dq/dsforms/. The

next revision of the forms is anticipated to

be in 2004, after further essential input from

TB controllers.

—Submitted by Mary Naughton, MD, MPH, TB

Medical Officer, and Susan T. Cookson, MD

Division of Global Migration and Quarantine

UPDATES FROM THE

RESEARCH AND EVALUATION

BRANCH

Evaluating Contact Investigation

Programs

The contact investigation (CI) is a key

strategy in the elimination of TB, and TB

programs have established a variety of

structures and practices to use in

conducting these investigations. Recent

studies conducted by DTBE staff and others

have shown that TB control programs vary

widely in their success in achieving

outcomes related to identifying, screening,

and appropriately treating contacts. These

findings demonstrate the need for some

programs to revise their contact

investigation procedures. But what changes

should be made? What aspects of the CI

program work well as is and what areas

need enhancement? 

To answer these questions, local TB

programs need a way to evaluate their

current program processes and practices to

appropriately plan and implement

improvements and recommendations. CDC

has developed a framework for public health

program evaluation.1 This well-researched

framework provides an adaptable six-step

process for public health programs to use in

evaluating their programs and operations.

However, for those unfamiliar with

evaluation concepts, understanding how to

apply the framework and identifying

appropriate resources can be difficult and

time-consuming.

To help local TB programs build capacity for

the evaluation of contact investigation

processes, the Prevention Effectiveness

Section (PES) of DTBE’s Research and

Evaluation Branch (REB) initiated a project

that involves partnering with two health

departments in the use of the CDC

evaluation framework and applying the

evaluation concepts to their programs. The

ultimate goal of the project is to develop a

translated version of the framework specific

for TB-program managers and staff. Such a

translated guide of the evaluation

framework will enable even those new to

program evaluation to easily identify and

apply the six-step process to a selfevaluation of their contact investigation

practices.

Over the past year, the two grantees, the

Massachusetts and New Jersey health

departments, have been designing and

conducting their evaluations. In

Massachusetts, a partnership between state

and local TB staff to facilitate CIs has been

in place for 5 years. Case managers at local

health departments coordinate with statelevel case managers to ensure that the CI

protocol is implemented. The protocol

includes use of the concentric circle

approach to identify contacts, time lines for

accomplishing tasks, and systems for

ensuring proper exchange of information

among state, local, and private providers.
22 NUMBER 1, 2002

Ensure use and 

share lessons 

learned

Gather credible 

evidence

Engage 

stakeholders

Describe the 

program

Focus the 

evaluation 

design

Justify 

conclusions

STEPS

Standards

Utility

Feasibility

Priority

Accuracy

Ensure use and 

share lessons 

learned

Gather credible 

evidence

Engage 

stakeholders

Describe the 

program

Focus the 

evaluation 

design

Justify 

conclusions

STEPS

Standards

Utility

Feasibility

Priority

Accuracy

Recommended framework for program evaluation

The state aggregates and oversees CI data

to ensure nothing falls through gaps. State

staff led the self-evaluation effort in five

local TB programs.

In Newark, the New Jersey health

department selected to self-evaluate the

implementation and effectiveness of its

specially developed protocol for conducting

expanded CIs in congregate facilities. The

protocol aims to ensure that all potentially

exposed persons are included in the

investigation, while not depleting resources

or unnecessarily testing the unexposed.

This protocol involves collaboration

between the investigator and supervisor to

determine if such a CI is necessary, a

systematic environment assessment to

determine likelihood of transmission, and a

communication / education plan to allay

fears and promote effective testing and

treatment. The evaluation process will also

document details of the protocol to facilitate

translation to other programs. 

While each program may report findings

from their evaluations at a later time, the

evaluators learned much about the

evaluation process and how it can work for

contact investigation program activities. The

lessons they have learned may help guide

other TB programs in understanding how

evaluation can be applied to their contact

investigation activities to provide them with

useful, practical information for program

enhancement. Lessons learned from each

of the six steps in the framework are

presented below. 

Step 1: When using the CDC framework,

the first step in the process is to identify

“stakeholders.” These are the people who

are interested in contact investigations and

will ultimately be affected by the evaluation.

By identifying the stakeholders, and

engaging key stakeholders throughout the

process, the evaluators ensure that the

evaluation is relevant and provides useful

information. There are three main

categories of stakeholders for contact

investigations: 1) the state and local health

department staff who conduct contact

investigations and their managers and

supervisors; 2) the persons receiving

services, i.e., TB patients or suspects,

contacts of cases, TB care providers and

other health service providers, managers or

employees at schools, jails, congregate

facilities, or private businesses, and the

general public; and 3) those who will directly

use evaluation findings to enhance the

programs and improve services.

Step 2: Once the key players have been

identified, the next step in the process is to

clearly and thoroughly describe the contact

investigation system and its relationship to

the general TB control program. This

description ensures that all participants

share the same understanding about what

contact investigations are, how they are

conducted, why they are needed, what

program resources are used in conducting

these investigations, and what effects are

anticipated for each activity. One key feature

of CDC’s framework is developing a logic

model that graphically describes how the
NUMBER 1, 2002 23

different aspects of contact investigation link

together to achieve the expected results.

The graphic serves as a communication

tool as well as explicitly showing how

activities logically result in outcomes.

Step 3: From the description and logic

model, the evaluators should then be able to

focus evaluation questions and develop their

data collection strategies. The evaluation

question selected in Massachusetts was,

“How well does our new case or suspect

assessment tool work in five participating

local TB control programs?” The evaluators

decided to conduct a process evaluation to

assess how well the new tool is being

implemented by the five programs and an

outcome evaluation comparing patient-level

outcomes collected before the new tool was

implemented and after its adoption. In New

Jersey, the evaluation question was, “How

useful and effective is our protocol for

expanding contact investigations in

congregate settings?” The evaluation

methods centered on comparing case

studies of investigations in which the

protocol was fully implemented with case

studies of investigations in which the

protocol was not implemented. Outcomes,

including those related to resource use,

were also compared.

Step 4: Identifying indicators and selecting

sources for data should be a simple

process, given the work done in the early

steps. The evaluators selected similar

indicators, including process indicators:

program organization and infrastructure,

staff training, adherence to protocol steps,

use of forms or records, staff perceptions,

intensity of resource use, and outcome

indicators: number of contacts identified,

percentage of contacts fully tested,

percentage of contacts testing positive for

disease or LTBI, percentage of contacts

started on treatment, and percentage of

contacts completing treatment. The data

sources that were selected matched each

indicator, and included policies, practice

instructions, training agendas and records,

case files or records of contact

investigations, completed forms or other

written documentation, interviews with

investigators and supervisors, and

aggregate reports or forms. All data sources

were assessed to ensure that they were

reliable and considered valid by the

stakeholders before data collection began.

Step 5: Analyzing data and determining

findings also flow from the previous steps.

Content analysis, domain analysis, and

other methods were used to analyze

qualitative data and statistical methods were

applied to the quantitative data. To ensure

that the evaluation findings could be easily

understood by all stakeholders, simple data

analysis methods were selected. With data

in hand, the evaluators once again went

back to the logic model to compare the data

collected on implementation and results

against original intentions and levels of

success defined previously. These facts

were then discussed and interpreted by the

stakeholders to provide meaning and

context. Findings were developed that

identified what objectives and goals were

met or unmet and why. 

Step 6: The most important step is an ongoing process to ensure that the findings

from the evaluation are used. Currently, the

findings are being used to

• assess contact investigation process

and practice as it is implemented,

• target areas for enhancement or

improvement,

• develop standardized tools for data

collection during interviews and field

visits,

• develop strategies to make necessary

changes to operations,

• prioritize program activities and

resources,

• identify effective policies, procedures, or

practices for replication,

• organize key information for training staff

and informing those outside the
24 NUMBER 1, 2002

program,

• garner political support by demonstrating

effectiveness of contact investigations,

• understand the implications of policy and

guidelines on the investigation process,

and

• identify areas for future research and

evaluation.

The last use completes the circular nature

of the framework. As information is

obtained, more information is needed and

more questions emerge. The process is

repeated and will become routine for the TB

programs. A learning cycle is established as

programs strive for continuous quality

improvement in their contact investigations

and in other aspects of their operations. For

more information on the Framework for

Program Evaluation in Public Health, please

see http://www.cdc.gov/eval/framework.htm

or contact Maureen Wilce at 404-639-8123. 

—Submitted by Maureen Wilce, MS

Division of TB Elimination

Reference

1. CDC. Framework for program evaluation

in public health. MMWR 1999;48(RR-11).

UPDATES FROM THE

SURVEILLANCE AND

EPIDEMIOLOGY BRANCH

TB Epidemiologic Studies

Consortium

The first meeting of the new TB

Epidemiologic Studies consortium (TBESC)

was held December 5-7 in Atlanta, Georgia.

This meeting was critical for setting the

consortium in motion. The primary purpose

of the TBESC is to design and carry out

epidemiologic, behavioral, economic,

laboratory, and operational research to

evaluate interventions to prevent TB. The

TBESC consists of 22 collaborating sites.

The ability to combine the work of

researchers with different areas of expertise

and focus on specific problems will give the

TBESC a unique ability to have an important

impact. With the task of developing a

research agenda, the TBESC will not be

working in a vacuum. Rather, it has clear

guidance from the Institute of Medicine

report which provides a framework to use in

developing the research agenda. The

TBESC is modeled as an investigatordriven collaboration of peer intellectual

contribution. The idea is that researchers

and TB controllers can do more together

than individually. We hope that the

partnerships created by TBESC will make

for more successful science.

The TBESC consists of a formal

partnership between academic centers and

TB control programs. This partnership is

distinct from other federally funded activities,

such as the relationship that NIH has with

academic centers or that DTBE has with TB

control programs through its cooperative

agreements. We hope this mixture will help

the TBESC conduct the highest quality

research with strong programmatic

relevance. DTBE has been working to bring

this concept to fruition for over 2 years. The

founding principal has been to develop a

group of experts who can be involved in all

the activities related to advancing TB

control:

• debating a research agenda

• designing and conducting research

studies

• publishing the scientific findings

• implementing the research results

• measuring the impact

The TBESC was modeled after the TB

Trials Consortium (TBTC). However, the

scientific focus of the TBTC is on clinical

trials, while the TBESC’s activities will be

more diverse. In addition, the TBTC started

from a single study and grew into a

smoothly functioning consortium; the

TBESC started out as a consortium and is
NUMBER 1, 2002 25

now developing the ground rules that will be

used to guide its activities. The TBESC will

be managed through a contractual

relationship between CDC and consortium

members.

—Reported by Scott J.N. McNabb, PhD, MS

Division of TB Elimination

The Importance of DNA

Fingerprinting in TB Control Efforts

The following was adapted from an article

presented at the meeting of the National TB

Controllers Association in June 2001.

Overview

DNA fingerprinting has been used

successfully in conjunction with traditional

laboratory and epidemiologic methods to

differentiate M. tuberculosis strains, to help

identify new TB case-patients, and to

confirm suspected laboratory contamination

events. The restriction fragment length

polymorphism (RFLP) technique, which is

based on a repeating genetic element called

insertion sequence 6110 (IS6110), is

detectable only in species of the M.

tuberculosis complex. This genetic element

occurs in varying numbers of copies and in

different positions on the chromosome, and

thus results in a unique genotype, or

fingerprint, that is useful for characterizing

the strain of M. tuberculosis that has

infected a particular individual. Though

RFLP has limitations (e.g., high cost, length

of time required to culture the organism, and

specialized training and laboratory

equipment needed), it has been used with

success to characterize M. tuberculosis

strains worldwide and to help in public

health follow-up.

Application of Genotyping to TB Control

Efforts

Genotyping technology has been used

effectively in outbreak investigations and in

the identification of TB cases falsely

reported as positive owing to laboratory

cross-contamination. Genotyping can be

used to augment traditional contact

investigations and to further our

understanding of risk factors and

transmission patterns by identifying new

contacts who would not be detected by

routine contact investigations alone; these

data could also be used to identify TB

disease attributable to relapse (versus

recent infection). In addition, DNA

fingerprinting can be used as a surveillance

tool to assess the effectiveness of TB

control programs by examining strain

variation throughout a geographic area over

time. For example, if TB control efforts were

effective, one would predict that the strains

of M. tuberculosis in circulation in the area

would not be genetically similar. This will be

particularly useful in areas with current low

incidences as we come closer to eliminating

TB in the United States.

Incorporating Genotyping into TB Control

Efforts in the US

The incorporation of genotyping

methodology into routine TB control efforts

represents a challenge. Although these

techniques may continue to evolve, those

currently in use have shown their utility as

effective tools for both epidemiologic and

program management purposes. An

educational campaign should be initiated to

disseminate information regarding current

genotyping methodology to TB controllers

and public health workers, so that they may

better interpret and use these data in routine

TB control efforts. To this end, CDC is now

providing technical assistance in the

development of a hands-on manual for TB

controllers.

Genotyping Network Update

The National Tuberculosis Genotyping and

Surveillance Network (NTGSN) was

established in 1996 as a 5-year project

involving seven regional genotyping

laboratories and sentinel surveillance sites

in the United States. M. tuberculosis
26 NUMBER 1, 2002

isolates from the TB patients at each

sentinel site were genotyped using one or

more molecular technologies. Routine

surveillance data were collected for each

culture-positive case-patient. In addition,

follow-up interviews were conducted for

case-patients that had M. tuberculosis

isolates that were genetically identical to

isolates of other patients in the surveillance

area. The project period is now at an end,

and findings from the project will be

presented later this year in a special issue

of the CDC journal Emerging Infectious

Diseases.

—Reported by Scott McNabb, PhD, MS

Division of TB Elimination

NEWS BRIEFS

The interferon gamma assay, a whole-blood

test for latent TB infection, was recently

approved by the Food and Drug

Administration. This test is an in vitro assay

for cell-mediated immune reactivity to M.

tuberculosis. Unlike the tuberculin skin test

(TST), this assay requires a single patient

visit, assesses response to both M.

tuberculosis and nontuberculous

mycobacteria simultaneously, and does not

boost amnestic immune responses. It

appears that interpretation of the wholeblood interferon gamma assay is less

subjective than is the TST, and the test may

be affected less by prior BCG vaccination

and reactivity to nontuberculous

mycobacteria than the TST. The utility of

this test in clinical practice remains to be

evaluated. (Mazurek, GH, LoBue PA, Daley

CL, Bernardo J, Lardizabal AA, Bishai WR,

Iademarco MF, Rothel JS. Comparison of a

whole-blood interferon gamma assay with

tuberculin skin testing for detecting latent

Mycobacterium tuberculosis infection.

JAMA 2001;286:1740-7).

§

The Global Alliance for TB Drug

Development has recently purchased rights

from Chiron Corporation to a promising new

compound, PA-824, which may eventually

lead to a more effective, shorter course

treatment for TB, especially in developing

countries. The drug still needs to undergo

rigorous clinical trials and FDA approval.

TRAINING AND EDUCATIONAL

MATERIALS

New Training and Education

Materials from Canada: “TB and Me”

A new patient education package for TB is

available, entitled “TB and Me.” The package

consists of the following items:

• A 15-minute upbeat video, in English,

aimed at patients or clients with active or

latent TB. The video emphasizes

adherence to treatment and explains

such basic questions as "How did I get

TB?", "Will I infect others with TB?",

"How do I get rid of TB?", "What are

these pills all about?", and "What are the

side effects of the TB pills?". The

approach is a very positive one with

emphasis on self-efficacy, taking

responsibility for one’s treatment, and

positive outcomes. The video is

appropriate for individual or group

viewing and discussion.

• Patient instructional booklets (25

included with each video order) that

reinforce the information presented in

the video. The booklets also have a

patient medication diary.

• A CD-ROM, in English, that guides

patients easily through its structured

content on a computer. This easy-to-use

CD-ROM addresses basic patient

concerns about active and latent TB and

treatment. Like the video, the CD "TB

and Me" emphasizes adherence to
NUMBER 1, 2002 27

treatment, lists possible adverse effects,

and presents a positive message to the

patient or client. The CD can be used for

individual instruction or for group instruction

with a facilitator. A posttest is built into the

program to test knowledge. The CD-ROM is

PC/Windows and Macintosh compatible.

The “TB and Me” educational materials can

be purchased as a complete package

(video, booklets, and CD-ROM) or any of the

components can be purchased individually.

To obtain an order form, please e-mail Dr.

Richard Zoutman directly with your fax

number and he will fax the form to you.

Please note that there are TWO versions of

the order form, one for Canadian orders that

takes into account Canadian sales taxes,

and one for orders from outside of Canada.

Please be sure to request the correct order

form. After you have filled out the form,

simply fax it back to Dr. Zoutman at the fax

number indicated on the form. His address

and his telephone and fax numbers are

below.

Richard Zoutman, MD, FRCPC

Internal Medicine, Infectious Diseases &

Medical Microbiology

Associate Professor of Pathology

Queen's University, School of Medicine

Director, Infection Control Services

Kingston General Hospital

76 Stuart Street

Kingston, Ontario, Canada

K7L 2V7

Tel: 613-549-6666 ext 4015

Fax: 613-548-2513

E-mail: zoutman@cliff.path.queensu.ca

NEW CDC PUBLICATIONS

Besser RE, Pakiz B, Schulte JM, Alvarado

S, Zell ER, Kenyon TA, Onorato IM. Risk

factors for positive Mantoux tuberculin skin

tests in children in San Diego, California:

evidence for boosting and possible

foodborne transmission. Pediatrics 2001;

108(2): 305-310.

Bock NN, Sales RM, Rogers T, DeVoe B. A

spoonful of sugar... : improving adherence

to tuberculosis treatment using financial

incentives. Int J Tuberc Lung Dis 2001; 5(1):

96-98.

Conover C, Ridzon R, Valway S, et al.

Outbreak of multidrug-resistant tuberculosis

at a methadone treatment program. Int J

Tuberc Lung Dis 2001;5(1):59-64.

Dale JW, Brittain D, Cataldi AA, Cousins D,

Crawford JT, et al. Spacer oligonucleotide

typing of bacteria of the Mycobacterium

tuberculosis complex: recommendations for

standardised nomenclature. Int J Tuberc

Lung Dis 2001;5(3):216-219.

Fitzpatrick LK, Hardacker JA, Heirendt W,

Agerton T, Streicher A, Melnyk H, Ridzon R,

Valway S, Onorato I. A preventable outbreak

of tuberculosis investigated through an

intricate social network. Clin Infect Dis

2001;33:1801-1806.

Johnson J, Okwera A, Hom DL, Mayanja H,

Kityo CM, Nsubuga P, Nakibali JG, Loughlin

AM, Yun H, Mugyenyi PN, Vernon A,

Mugerwa RD, Ellner JJ, Whalen CC. 

Duration of efficacy of treatment of latent

tuberculosis infection in HIV-infected adults.

AIDS 2001;15:2137-2147.

Lounis N, Bentoucha A, Truffot-Pernot C, Ji

B, O’Brien RJ, Vernon A, Roscigno G,

Grosset J. Effectiveness of once-weekly

rifapentine- and moxifloxacin-containing

regimens against Mycobacterium

tuberculosis in mice. Antimicrob Agent

Chemother 2001;45:3482-3486.

Murthy KJR, Frieden TR, Yazdani A,

Hreshikesh P. Public-private partnership in

tuberculosis control: experience in

Hyderabad, India. Int J Tuberc Lung Dis
28 NUMBER 1, 2002

2001;5(4):354-359.

O'Brien R (responsible author). Global

Alliance for TB Drug Development. 

Scientific blueprint for TB drug development.

Tuberculosis 2001;81(Suppl 1):1-52.

Range N, Ipuge YA, O’Brien RJ, et al. Trend

in HIV prevalence among tuberculosis

patients in Tanzania, 1991-1998. Int J

Tuberc Lung Dis 2001; 5(5): 405-412.

Sackoff JE, Torian LV, Frieden TR. TB

prevention in HIV clinics in New York City. Int

J Tuberc Lung Dis 2001;5(2):123-128.

Saiman L, San Gabriel P, Schulte JM,

Vargas MP, Kenyon T, Onorato IM. Risk

factors for latent tuberculosis infection

among children in New York City. Pediatrics

2001;107(5):999-1003.

Schulte JM, Valway SE, McCray E, Onorato

IM. Tuberculosis cases reported among

migrant farm workers in the United States,

1993-97. Journal of Health Care for the Poor

and Underserved 2001;12(3):311-322.

Small PM and Fujiwara PI. Management of

tuberculosis in the United States. N Engl J

Med 2001;345(3):189-200.

Tanzania Tuberculin Survey Collaboration.

Tuberculosis control in the era of the HIV

epidemic: risk of tuberculosis infection in

Tanzania, 1983-1998. Int J Tuberc Lung Dis

2001;5(2):103-112.

Taylor Z, O’Brien RJ. TB elimination: are we

willing to pay the price? (editorial). Am J

Respir Crit Care Med 2001;163:1-2.

Tuberculosis Research Centre, Chetput,

Chennai, India. Trends in the prevalence

and incidence of tuberculosis in South India.

Int J Tuberc Lung Dis 2001;5(2):142-157.

Villarino, EM and Clairy M. Tuberculosis due

to environment, biology, or both? Chest

2001;120(5):11435-1437. Editorial.

PERSONNEL NOTES

Lauri Bazerman, MS, completed her 2-year

ASPH fellowship with the Field Services

Branch (FSB) in December 2001. During

her time with DTBE, Lauri spearheaded an

evaluation of the CDC recommendations for

TB prevention and control in jails. This

project is an important contribution to

understanding the present state of TB

control in correctional settings. Lauri also

worked on evaluating the California TB

Indicators Project (TIP). For her role in that

project, Lauri was nominated for the Carl W.

Tyler, Jr., Award for Excellence in Public

Health Practice offered by ASPH and CDC.

Lauri has relocated to Providence, Rhode

Island, where she will be consulting on a

community-based needs assessment and

working to assist the community in setting

health priorities. We wish Lauri good luck in

her new public health career.

Betty Bouler joined the Epidemiologic

Studies Section of the Surveillance and

Epidemiology Branch (SEB), DTBE, as a

Program Analyst in early December 2001.

She will help develop and support the

financial side of the newly formed

Tuberculosis Epidemiologic Studies (TBES)

Consortium. Betty received her BA in

General Business from the University of

Maryland. She has worked in various

capacities in grants and contracts

organizations for over 25 years, and has

been employed at all levels of government,

including federal, state, and local as well as

for private nonprofit organizations. She has

been with CDC in the Procurement and

Grants Office for the past 17 years and

worked most recently as the Chief,

Information Technology Section, where she

and her staff were responsible for

purchasing all of the computer equipment,

software, and services required by all of

CDC’s organizations. During her time with
NUMBER 1, 2002 29

CDC she has also worked with contracts

involving scientific research and studies,

purchase and maintenance of scientific

equipment, consultant services, and

financial management systems.

Jeanne Courval, PhD, MPH, has joined

DTBE as a research statistician in the

Surveillance and Epidemiology Branch. She

graduated from Columbia University School

of Public Health in 1993 with a PhD in

epidemiology and strong training in

biostatistics and epidemiologic methods. 

Her primary area of interest is infectious

diseases, especially tropical public health,

and health needs of underserved

populations. From 1993 to 1998, Jeanne

was an assistant professor in the

Department of Epidemiology at Michigan

State University in East Lansing, Michigan,

where she participated in the development

of a masters in epidemiology program which

accepted its first students in fall 1994. 

While at Michigan State University, her

research areas included efforts to field test

newly developed malaria diagnostic

methods, analysis of clinical trials of new

treatments for severe malaria, and

investigation of associations between

consumption of sport-caught Great Lakes

fish and human reproductive health

outcomes. Another major area of interest is

the epidemiology of drug resistance,

especially application of molecular

technologies to study the occurrence and

spread of drug resistance. Her primary

focus in this research has been drugresistant malaria, but she has also had

experience with investigations of the

development of drug resistance in

amebiasis, nosocomially acquired

enterococcus, and schistosomiasis. After

relocating to Atlanta in 1998, she began

working with CDC in the Hospital Infections

Program in 1999 as a research specialist,

moved to the Division of Parasitic Diseases

in 2000 as a research epidemiologist (both

in the National Center for Infectious

Diseases), and came to DTBE in

September 2001 as a research statistician. 

Charles (“Chuck”) Woodrow Gaines retired

from CDC on January 3, 2002, after serving

many years as an effective and

knowledgeable TB control public health

advisor. Chuck joined CDC with the

Sexually Transmitted Disease (STD)

program on November 14, 1971, as a CoOp, a position which later came to be known

as Disease Intervention Specialist. His first

STD assignment was with the Detroit,

Michigan, Department of Health. Chuck’s

next move with the STD program took him

to Gary, Indiana. In 1974 he joined the

Division of TB Control and transferred to

New York City. He had a 5-year tour of duty

in NYC, where he worked as a clinic

manager at the Bedford-Stuyvesant TB

Clinic, at Kings County Hospital, at

Metropolitan Hospital, and at Staten Island.

In 1980, he transferred to Philadelphia,

Pennsylvania, as the TB program manager. 

In 1980 he assisted with the Cuban Refugee

Program at Ft. Chaffee, Arkansas. He was

also a member of the team that assisted

with the first documented outbreak of drugresistant TB that occurred in 1976/77 in

rural Alcorn County, Mississippi. In 1982, he

moved to Chicago as the assistant TB

Program Manager under John Kuharik.

Later, he returned to the STD program as

the district program manger in Toledo, Ohio.

Leaving Ohio in 1990, he served as the

assistant to the program manager in the

Jackson, Mississippi, STD program and as

assistant to the program manger for the

STD program in Richmond, Virginia, in

1993. In 1997 he came to CDC

headquarters in Atlanta, Georgia, to accept

responsibilities in the Division of TB

Elimination as a program consultant and

project officer. His work with TB control

officers and other public health officials

resulted in enhanced TB prevention and

control activities in the Western regions of

the United States. Chuck was responsible

for managing and providing consultation and

technical assistance to over 12 project
30 NUMBER 1, 2002

areas, mostly Western states, including

Alaska. He took great pride in providing

direction, leadership, and proper

stewardship of each project’s use of federal

funds in achieving national TB goals and

objectives. Chuck leaves a rich and robust

legacy of communicable disease

interventions and experience upon his

retirement from the CDC. He is looking

forward to being “captain of leisure time” as

he guides his fishing boat in search of the

Big One. We wish him great success and

happiness.

Kashef Ijaz, MD, MPH, joined DTBE in the

Surveillance and Epidemiology Branch

(SEB) on January 13, 2002. He has 7 years

of experience in public health and

community medicine and 6 years of

experience working in TB control as a

medical epidemiologist in Arkansas. Dr. Ijaz

has extensive experience in TB outbreak

investigations, public health field work, highrisk population groups (prisons, shelters and

nursing homes.), TB molecular and genetic

epidemiology and a host of other TB

experiences. He obtained his medical

degree from King Edward Medical College,

University of Punjab, Lahore, Pakistan, and

his masters degree in public health from the

University of Oklahoma Health Sciences

Center in Oklahoma City, Oklahoma. He

joined SEB as a medical epidemiologist in

the Outbreak Investigation Section.

Scott Jones of the Field Services Branch

has transferred from his position as a

Program Consultant in Atlanta after having

accepted a reassignment to Montgomery,

Alabama. He will serve as the senior public

health advisor for the Alabama Department

of Public Health. He will work closely with

Nancy B. Keenon, Director of TB Control for

Alabama, and will provide assistance and

technical support to the state. Scott has

been an outstanding Program Consultant

with Field Operations Section II of FSB

since he arrived at headquarters in

November 1998. He has provided strong

guidance, direction, and support to his

project areas over the course of the past 3

years, and has taken a very active role with

numerous assignments within the division.

Scott will bring to his new assignment his

field experiences in New Orleans, South

Carolina, Kentucky, and Texas. His report

date for Montgomery was November 18,

2001.

Dhananjay Manthripragada has joined the

staff of the Surveillance and Epidemiology

Branch as a visiting student researcher

from Duke University in North Carolina.

Dhananjay brings with him a wide range of

public health experience, including stints

with the Occupational Safety and Health

Division of the World Health Organization in

Geneva and the Government Relations

Department of the American Public Health

Association in Washington, DC. In addition,

Dhananjay has contributed to a number of

grass-roots public health initiatives in Brazil,

Greece, and India. Dhananjay has been a

part of the SEB team since the beginning of

October 2001. He has been learning about

and contributing to DTBE efforts with the

2RZ investigation, the 1998-2000

transgender TB outbreak in Baltimore/NYC,

and the ongoing investigation into the cluster

of TB cases among exotic dancers and their

close contacts in Wichita, Kansas.

Stuart McMullen has rejoined DTBE and the

Field Services Branch (FSB) after his

assignment to the Global AIDS Program.

Stuart will begin his new assignment at

headquarters as the FSB information

technology coordinator for the case

management module of TIMS/NEDDS.

Stuart has been with CDC since 1989,

beginning his career with the Sexually

Transmitted Disease (STD) program in

Miami, Florida. His next two assignments

continued with the STD program in

Philadelphia (1991/92) and Los Angeles

(1992/93). It was during his Los Angeles

(LA) assignment that Stuart joined DTBE in

June 1993. During his tenure in LA, he was
NUMBER 1, 2002 31

involved in projects relating to high-risk

populations and multidrug-resistant TB,

conducted quality assurance reviews, and

worked with nursing managers on reporting

requirements. He managed the Satellite TB

Clinic Food and Housing Homeless

Incentive Program, developed database

systems, developed incentive programs,

and carried out numerous other activities in

LA. In 1996 Stuart was promoted to the

position of senior public health advisor to the

California Department of Health Services,

TB Control Branch in Berkeley, California.

Stuart reported to Atlanta on November 28.

Sonal Munsiff, MD, has been selected as

the Director of the New York City TB Control

Program where she has been serving as

the Acting Director since December 2000.

As a Medical Officer for CDC in the Division

of TB Elimination, Dr. Munsiff will remain

with the New York City Department of

Health. She is board certified in internal

medicine and infectious diseases and has a

broad range of experience in the field of TB.

She has been with the TB Program since

the height of the recent TB epidemic in New

York City in 1992, initially as physician-incharge at the Morrisania chest clinic, then

as medical consultant for the Queens and

Bronx regions and from 1996 as Director of

the Epidemiology Unit for the program. She

became quite familiar with the epidemiology

and management of TB in the City over the

past decade. Dr. Munsiff is interested in

further developing research in the

epidemiology and treatment of drugresistant TB, clinical aspects of TB in HIVinfected persons, the global epidemiology of

TB particularly as it affects the TB incidence

in New York City, and the challenges of

identifying and treating persons with latent

TB infection who are at high risk of

developing disease.

John Seggerson, DTBE’s Associate

Director for External Relations, retired from

CDC on January 3, 2002. John is well

known as an enthusiastic and seemingly

tireless advocate of and contributor to public

health programs and especially to TB

control. His 38-year career with CDC began

in June 1963. Soon after graduating with a

major in history from St. Joseph’s College,

he joined CDC as a cooperative employee

of the Division of Venereal Disease Control

assigned to the Chicago Board of Health. In

1964-65, he was responsible for

management of the Venereal Disease

Control Unit of the Cook County (Illinois)

Health Department. His work in TB began in

1965 when he transferred to the Division of

TB Control and was assigned to

northeastern Pennsylvania to coordinate

projects in Wilkes-Barre, Scranton, and

Kingston. He transferred to Buffalo, New

York, in 1967 and for 2 years was the TB

program manager at the Erie County Health

Department. He was assigned to the

Bureau of TB Control, New York State

Department of Health, in 1968 and served

for 2 years as the manager of the statewide

program. In 1970 he was selected for the

supervisory public health advisor position in

CDC’s Region III office in Philadelphia. In

1972 he was appointed Acting Associate

Regional Health Director and Program

Director for Disease Control with

responsibility for CDC programs and

supervision of STD, TB, immunization, and

lead prevention field staff in Region III. He

became Director, Division of Prevention, in

1974 and had broad responsibility for

Region III’s CDC-funded programs and field

staff in STD, TB, immunization, lead

prevention, and rat control. In 1977 John

transferred from the regional office to the

Division of TB Control in Atlanta and served

as Chief of the Program Services Branch

for 19 years. In that capacity, he nurtured

the new TB cooperative agreements of the

early 1980s and played a major role in

managing the division’s funding of state,

city, and territorial programs. He was also

responsible for the division’s training and

education activities; programmatic,

technical, and management consultation

and assistance; national surveillance
32 NUMBER 1, 2002

system; evaluation of TB programs; and

supervision of CDC staff assigned to state

and local health departments. In recognition

of John’s unique attributes and interpersonal

skills in networking and partnership-building,

he was appointed Associate Director for

External Relations, DTBE in August 1996. In

that capacity, he lead the division’s work and

coordination with non-CDC government,

private, professional, and voluntary

organizations and agencies. Among those

groups with which John established new

and strengthened affiliations are the National

Coalition for TB Elimination, the American

Lung Association, the American Thoracic

Society, the National TB Controllers

Association, and the National TB Nurse

Coalition. He was responsible for

coordinating efforts of the Federal TB Task

Force and assisting with coordination of the

Department of Health and Human Services

Advisory Council for the Elimination of

Tuberculosis. He also provided the division’s

oversight of the three CDC-funded Model TB

Centers in New York City, Newark, and San

Francisco and played a lead role in planning

and producing the annual National TB

Controllers Conferences.

John had several special assignments,

including the Indochinese Refugee Health

Screening Program at Fort Indiantown Gap,

Pennsylvania, in 1975; the Legionnaire’s

Disease Investigation Team in 1976; the

Cuban Refugee Screening Program in

1980; and the TB Review Team in

Southeast Asia in 1986. He served on

numerous national and state committees

and task forces, was a member of several

American Lung Association–sponsored TB

program review teams, and was an active

contributor to the planning for World TB Day

from 1997 through 2000. In 1988/89, he was

President of the Watsonian Society, a CDC

organization for public health advisors that

was established in 1986.

Everyone who has worked with John

through the years knows what a loss his

departure represents. His loyalty to CDC,

dedication to the DTBE mission, and ability

to challenge and inspire his coworkers will

be greatly missed. It is difficult to visualize

the division without John. Some staff have

affectionately said that he would work until

CDC’s mission had been completed and

turn off the lights the day CDC closes. 

Although his plans for the future are not firm

at this time, he hopes to continue to be

involved in public health and TB. He said,

“TB elimination for me is more than a job - it

is a passion, and I do not intend to give it up

in retirement.” This is good news and

provides incentive to those who remain to

work toward the day when John can come

back and turn off the lights.

Erika Vitek, MD, joined DTBE’s International

Activities in November as a senior service

fellow. She received her MD from the First

Moscow Medical Academy in 1989 and

worked as an epidemiologist in the Russian

National Diphtheria Unit in Gabrichevsky

Institute, Moscow. She also worked as a

trainer for CDC epidemiology courses for

visiting epidemiologists from the former

Soviet Union. She joined the

Communications and Education Branch of

DTBE in 2000, where she assisted staff in

developing training materials for field

activities in Russia. Erika will be working on

TB prevention and control efforts in

countries in Eastern Europe and Russia

with a focus on multidrug-resistant (MDR)

TB. She will be involved in a number of

diverse activities including developing

protocols, technical papers, scientific

manuscripts, translating technical written

materials between Russian and English,

and conducting monitoring missions to field

sites to evaluate progress in programmatic

activities. 

IN MEMORIAM

Lydia B. Edwards, MD, died in Bedford,

Massachusetts, on November 7, 2001, at
NUMBER 1, 2002 33

the age of 96. She was born in Berkeley,

California, on June 6, 1905. Educated at the

Ecole Superieure in Brussels, Belgium, the

Mozarteum in Salzburg, Austria, the

University of Rome, and the University of

Paris, she graduated from Radcliffe College

in 1927 and Johns Hopkins Medical School

in 1932, where she later served as Director

of the Pediatric Outpatient Department and

Director of the Children's Tuberculosis

Clinic. In 1943 she was appointed to the

U.S. Public Health Service, at the time the

only woman to be a commissioned officer

therein, and served for the duration of World

War II in Yugoslavia. In 1946 Dr. Edwards

joined the National Institutes of Health TB

Research Program in Bethesda, Maryland,

and in 1948 was asked by the World Health

Organization to help expand the anti-TB

program throughout the world. From 1948 to

1955 she was based in Copenhagen,

Denmark, and traveled throughout Europe,

India, Russia, and Japan to support and

oversee the program. From 1955 until her

retirement as Colonel in 1973, Dr. Edwards

continued her work with the Public Health

Service in Bethesda, living in Washington,

DC. During retirement, she served as a

tutor at a public school in Washington;

lectured on epidemiology at Johns Hopkins

School of Epidemiology; and was an active

member of Friends of the National Zoo, the

Women's National Democratic Club, the

Chevy Chase Club, the Colonial Dames

Society, and Radcliffe and Johns Hopkins

alumnae/alumni groups. She was honored

by the Johns Hopkins School of Hygiene

and Public Health as a "Hero of Public

Health" and by Radcliffe College for her

work in medicine and epidemiological

research.

Richard L. Riley, MD, died December 20,

2001, in Athol, Massachusetts, at the age of

90. Dr. Riley’s work with guinea pigs at

Johns Hopkins Hospital in the 1950s proved

that particles the size of a mote of dust

could transmit TB. Although he retired in

1978, Dr. Riley consulted on various

projects until his death. His work from the

1950s and 1960s is still widely discussed,

as scientists try to understand more about

drug-resistant TB, and even how inhalation

anthrax can be prevented. Recently,

researchers gathered at CDC in Atlanta to

discuss a federally funded project that will

attempt to duplicate his TB experiments in

Witbank, South Africa. Using his model, this

project will try to determine how long people

remain contagious from TB, and will also

examine the effectiveness of using

ultraviolet light to eradicate TB germs. That

technique, which Dr. Riley pioneered at

Hopkins, is now part of a national project to

prevent the spread of TB at homeless

shelters. The project was started by Dr.

Edward Nardell, a Harvard Medical School

professor who began working with Dr. Riley

in 1983 after hearing him give a talk on

ultraviolet light. A native of North Plainfield,

New Jersey, Dr. Riley graduated from

Harvard University in 1933 and Harvard

Medical School in 1937. During World War II

naval service in Pensacola, Florida, he

became interested in the problem of how

pilots could go higher and still breathe

properly and launched his research on the

physiology of respiration. After the war, he

went to the Columbia School of Medicine in

New York but was recruited in 1950 by

Johns Hopkins. Six years later, at a time

when TB was a major national killer, he and

a team that included his former Harvard

mentor launched a 4-year experiment that

became crucial to preventing the disease. 
34 NUMBER 1, 2002

Taking over a six-room ward at the top of

the Veterans Administration Hospital in

Baltimore, Dr. Riley's team set up 150

guinea pigs in cages, and connected air

ducts from the cages to the rooms of TB

patients. The results proved that even the

tiniest particles, called droplet nuclei,

coughed up by infected people could

transmit the disease. From 1960 to 1977,

Dr. Riley was chairman of the Department

of Environmental Medicine at Hopkins, and

in 1970, the National Tuberculosis and

Respiratory Disease Association awarded

him its highest honor, the Edward Livingston

Trudeau Medal.

George Victor Tomlinson of Richmond,

Virginia, died November 24, 2001. Mr.

Tomlinson was the father of Missouri TB

Controller Vic Tomlinson. Better known as

"Tommy" to friends and coworkers, he was

a long-time employee of the Virginia

Department of Health (VDH), where he

worked for the Division of TB Control.

Tommy retired from his career at VDH as

the coordinator of the x-ray program in the

late 1980s. Tommy closed out an era in TB

Control when it was not uncommon to see 

mobile units offering x-rays at factories,

schools, and even street corners. Tommy

will be missed by all.
NUMBER 1, 2002 35

CALENDAR OF EVENTS

April 22-24, 2002

Effective TB Interviewing and Contact

Investigation

Newark, New Jersey

NJ Medical School National TB Center

Contact: Rajita Bhavaraju

Tel: (973) 972-4811

April 22-26, 2002

51st Annual Scientific Conference of the 

Epidemic Intelligence Service (EIS)

Atlanta, Georgia

April 22-26, 2002

Postgraduate Course on Clinical

Management and Control of

Tuberculosis

Denver, Colorado

National Jewish Medical and Research

Center

Contact: Catheryne J. Queen

Tel: (303) 398-1700; fax: (303) 398-1806

May 6-9, 2002

Case Management and Contact

Investigation Course

San Francisco, California

Francis J. Curry National TB Center

Contact: Training Coordinator

Tel: (415) 502-4600; fax: (415) 502-4620

E-mail: tbcenter@nationaltbcenter.edu

June 3-4, 2002

TB Case Management for Nurses

Newark, New Jersey

NJ Medical School National TB Center

Contact: D.J. McCabe

Tel: (973) 972-0978

June 3-5, 2002

The 4th World Congress on

Tuberculosis

Washington, DC

Cosponsored by NIH, WHO/TDR, and CDC

Detailed information about the program can

be found on the meeting Web site

(http://www.niaid.nih.gov/dmid/tuberculosis/t

bcongress/) 

June 18-19, 2002

2002 National TB Controllers Workshop

Alexandria, Virginia

National TB Controllers Association (NTCA)

and CDC

NTCA contacts: Walt Page or Linda Smith

(770) 455-0801

CDC/DTBE contact: Sherry Hussain

(404) 639-8989

September 24-26, 2002

TB Intensive

San Francisco, California

Francis J. Curry National TB Center

Contact: Training Coordinator

Tel: (415) 502-4600; fax: (415) 502-4620

E-mail: tbcenter@nationaltbcenter.edu

October 16, 2002

Medical Management of TB in the

Person Living with HIV

Newark, New Jersey

NJ Medical School National TB Center

Contact: D.J. McCabe

Tel: (973) 972-0978
TB Education and Training Network (TB ETN) Membership Form

Please print or type your responses.

Date: ______________

Name: ___________________________________ Degree(s): __________________________

Applying as (check one box):

~ Current member (member of TB ETN during 2001)

~ New member (have not been a member of TB ETN)

Type of membership (see back of form for more detailed information):

(check one box, even if you are a current member) 

~ Active member (has a lead role for TB education and training [E&T] in agency; active participant of TB ETN)

~ Information only (does not have a lead role for TB E&T; inactive participant of TB ETN)

Job Title: ____________________________________________________________________

Employer: ____________________________________________________________________

Address: ____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Phone: _________________________Fax: _______________________________________

E-mail: ____________________________________________________________________

Please describe your job responsibilities as they relate to TB E&T activities (limit to 5):

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

What percentage of time would you say you spend on TB E&T activities? _________________

Do you have any areas of special interest/expertise that may strengthen the TB ETN? (limit to 5)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

What do you hope to gain by membership in the TB ETN?______________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

~ I tentatively plan to attend the annual meeting and workshop in August 2002.

Additional comments:___________________________________________________________

_____________________________________________________________________________

Thank you for your interest! Please send completed form to:

Vivian Siler by fax at (404) 639-8960.