TB-Related News and Journal Items - Week of June 12, 2000

>The CDC Center for HIV, STD, and TB Prevention provides the following
>information as a public service only. Providing synopses of key scientific
>articles and lay media reports on HIV/AIDS, other sexually transmitted
>diseases and tuberculosis does not constitute CDC endorsement. This update
>also includes information from CDC and other government agencies, such as
>background on Morbidity and Mortality Weekly Report (MMWR) articles, fact
>sheets, press releases, and announcements. Reproduction of this text is
>encouraged; however, copies may not be sold, and the CDC HIV/STD/TB
>Prevention News Update should be cited as the source of the information.
>******************************************************
>"Radical Steps Urged to Help Underserved"; Science (www.sciencemag.org)
>(06/02/00) Vol. 288, No. 5471, P. 1563; Enserink, Martin
>
> Pharmaceutical executives, public health experts, and researchers
>recently met at the request of President Clinton to discuss roadblocks in
>the development of HIV, tuberculosis (TB), and malaria vaccines. The
>participants came up with proposals for budget increases and more funding
>for vaccine initiatives. Vaccines are needed to cut AIDS deaths, and reduce
>tuberculosis and malaria cases, especially in Africa. The National
>Institutes of Health (NIH) spends about $6.5 million annually to find a new
>TB vaccine and $25 million for malaria; AIDS vaccine research will receive
>about $250 million this year. Low returns and patent violations have kept
>companies from funding vaccines. While no recommendations were developed
>at the meeting, Dr. Anthony Fauci, head of the National Institute of Allergy
>and Infectious Diseases, said his group will send a summary to Donna
>Shalala, the secretary of Health and Human Services. Some participants were
>disappointed at the lack of more definite conclusions; however, most were
>optimistic that results would be seen soon, and Malegapuru Makgoba of the
>Medical Research Council of South Africa noted, "I'm confident that we'll
>see an AIDS vaccine in the next five or six years."
>***************************************************
>ALASKA: "State Battles New Surge in TB"; Anchorage Daily News Online;
>(06/13/00);Campbell, Larry
>
>A tuberculosis (TB) outbreak in southwest Alaska has health officials
>worried. There have been 21 active cases of TB reported in several villages
>since April, and 56 other people have tested positive for TB exposure. In
>Anchorage, 20 people have been diagnosed with TB since January, versus just
>14 cases in all of 1999. To help control the outbreak, all patients
>diagnosed with active TB or testing positive for TB exposure are being flown
>to Kanakanak Hospital in Dillingham for treatment. Dr. Beth Funk, head of
>Alaska's infectious disease program, said 373 cases of active TB have been
>recorded in Alaska in the past five years, with up to 45 percent of the
>cases occurring in Anchorage. Funk noted that while Anchorage's TB rate per
>capita is similar to that seen in the rest of the United States, some rural
>areas of the state have much higher TB rates.
>*********************************
>"WHO Chief Urges Fight Against Diseases"; Reuters (06/13/00).
>
>Gro Harlem Brundtland, director-general of the World Health Organization,
>has called for more action to fight such diseases as measles, malaria,
>tuberculosis, and AIDS, which kill 14 million people a year. Brundtland, who
>spoke Tuesday at a board meeting of the Global Alliance of Vaccines and
>Immunization
>(GAVI) in Oslo, noted that vaccines could have saved 3 million of those
>lives, as almost 1 million children die of measles alone each year. GAVI's
>Global Fund for Children's Vaccines expects to begin disbursements next
>month, aided by a $750 million grant from the Bill and Melinda Gates
>Foundation.
>*******************************************
>"IOM Report a Blueprint for Elimination of TB"; Journal of the American
>Medical Association (www.jama.com) (06/07/00) Vol. 283, No. 21, P. 2776;
>Stephenson, Joan.
>
> A new report for the Institute of Medicine (IOM) recommends strong
>measures to end traces of diseases like tuberculosis (TB) in hard-to-reach
>populations. The blueprint for TB eradication includes screening immigrants
>for infection before entering the United States. The report called for
>these measures in order to avoid a TB resurgence as seen in the 1980s. The
>IOM panel of experts stated that while cases are decreasing, TB can stay
>dormant and resist detection, later causing an outbreak. In 1999, 43
>percent of new cases of active TB in the United States were in immigrants
>from nations with high TB rates, up from 27 percent in 1992. The new
>proposal allows immigrants with positive skin test results to enter the
>nation, but no permanent resident status would be given until they obtained
>additional evaluation and treatment of latent infection. While the proposal
>would mean administering skin tests to about 250,000 people annually and
>treating individuals with latent infection, for a cost of about $23 million,
>Dr. Morton N. Swartz, the chair of the report panel, asserts that "in the
>long run, this would be cheaper than the cost of treating the individuals
>and others they infect." The report recommended helping other nations fight
>the disease and increasing research funding for TB, and it also called on
>the U.S. government to develop better tools to combat TB. The National
>Institutes of Health and the Centers for Disease Control and Prevention
>spend between $60 million and $80 million on TB research each year, and the
>IOM report recommended increasing such funding at NIH, the CDC, and other
>federal agencies to $280 million annually.
>*********************************
>ALABAMA: "Insurance Program for State's Children Has Healthy Results"
>Birmingham News Online (www.al.com/bhamnews/bham.html) (06/15/00);
>Sznajderman, Michael.
>
> The Children's Health Insurance Program (CHIP), started in 1998, has
>reduced the number of uninsured children in Alabama by 41 percent in two
>years. A total of 69,000 children have received health coverage through the
>program, according to the annual report of the state health department. The
>report also showed that tuberculosis (TB) cases in the state have reached a
>record low, and syphilis and gonorrhea rates have also fallen. State Health
>Officer Don Williamson said the reduction in sexually transmitted diseases
>is hopeful, although the number of chlamydia cases reported increased.
>Health officials attributed the decline in TB cases to directly observed
>therapy, but they noted that cases among children ages 14 and younger have
>not decreased as adult cases
>have.*************************************************************
>OTHER NEWS ITEMS:
>*****************************
>Salt Lake Tribune: Misuse of Antibiotics Making Them Obsolete; Tuesday,
>June 13, 2000; ASSOCIATED PRESS
>
> WASHINGTON -- Resistance to antibiotics threatens to undermine
>decades of advances in modern medicine, said officials from the World Health
>Organization and the U.S. Centers for Disease Control and Prevention (CDC)
>on Monday. In their first comprehensive report on infectious diseases, the
>two highly respected health organizations warned that antibiotics are
>becoming less effective in curing major diseases that continue to ravage
>large swaths of the developing world. An estimated 13 million people die
>annually from treatable infectious diseases such as malaria, tuberculosis,
>pneumonia and measles. David Heymann, executive director for communicable
>diseases at WHO, said the increasing ineffectiveness of antibiotics stemmed
>from their overuse in developed nations and their underuse and misuse in the
>developing world. Health officials called for a worldwide campaign to
>educate doctors and patients so that the effectiveness of existing
>antibiotics can be maintained until new, stronger medicines are developed.
>"We are literally in a race against time," he said. "Antibiotics were not
>available for our grandparents, and we don't want the same for our
>grandchildren." For instance, penicillin has now become virtually useless
>in fighting mutant strains of gonorrhea, a venereal disease. Common strains
>of dysentery and tuberculosis that were once controlled with inexpensive
>generic drugs now require some of the strongest antibiotics in the world's
>medicine chest. Tuberculosis treatments, for example, once cost between
>$20 and $30. But with the growth of resistant strains of TB, new drug
>combinations needed to fight the disease cost 100 times that much, putting
>them beyond the health-care budgets of many poor nations, Heymann said......
>*****************************************
>Toledo Blade; Bovine tuberculosis in Michigan expected to affect testing in
>Ohio; June 15, 2000; JANE SCHMUCKER.
>
> .... Regulators say they expect the U.S. Department of Agriculture to make
>long awaited changes in Michigan's bovine tuberculosis status that will lead
>Ohio to change its rules for health tests required of animals from Michigan.
>Michigan had been rated tuberculosis-free in 1979, but diseased livestock
>and wildlife have been found in northern Michigan. A USDA public hearing on
>the nation's bovine tuberculosis eradication efforts is to be held in
>Lansing tonight. What the changes will mean for farms that operate in both
>Ohio and Michigan and routinely move animals across the state line is
>uncertain..... Bovine tuberculosis is transmissible to humans, primarily
>through ingestion of unpasteurized milk from infected animals. But laws
>throughout the United States require pasteurization, and the only cases of
>bovine tuberculosis in humans in Michigan are among people who contracted
>the disease out of the country, said Dr. Chaddock, the Michigan
>veterinarian...... The regulations resulting from the tuberculosis outbreak
>have pushed breeding cattle prices in the state down 15 to 20 per cent, he
>estimated. "We're not gonna have any markets other than Michigan," said Mr.
>Kaercher, who has 30 beef cattle northeast of Kalamazoo. State and federal
>taxpayers will pick up much of the bill for testing animals and eradication
>efforts. Dr. Chaddock estimated Michigan taxpayers probably will spend more
>than $25 million over several years and USDA will give the state $6 million
>for the next fiscal year. Testing all 1.3 million animals in Michigan's
>17,000 herds of beef and dairy cattle will take the state until 2003 to
>accomplish, Dr. Chaddock said....... he nation has had a bovine
>tuberculosis elimination program since 1917, but the disease now appears to
>be limited to Michigan and Texas. It appears to be spread to cattle when
>wild deer sample their feed, leaving saliva on what they do not eat.
>*************************************************
>WORLD BANK: Lesotho undertakes health reforms; Wednesday, June 14, 2000.
>
>JUN 14, 2000, M2 Communications - WASHINGTON - The World Bank today approved
>a US$6.5 million credit to assist the Kingdom of Lesotho in improving access
>to quality preventive, curative and rehabilitative health care services.
>Lesotho has made impressive gains in the improvement of health status over
>the past 20 years, yet more recently, the demands associated with HIV/AIDS
>and tuberculosis have strained the capacity system which suffers from high
>staff attrition, and inadequate management systems. The project will respond
>to building the capacity of the health system to perform cost-effectively
>and assist institutions to design and undertake strategies which will enable
>the health system to anticipate and cope with the increasing demands upon
>it.
>***********************************
>Reuters Medical News: T-Lymphocyte Subpopulations Affected in Childhood
>Tuberculosis; C Vidyashankar, MD.
>
>DELHI, May 23 (Reuters Health) - The proportion and number of CD3+ and CD4+
>T lymphocytes decrease in children with tuberculosis, but the cells revert
>to normal with treatment, according to researchers from Chennai, India. Dr.
>Soumya Swaminathan, from the Tuberculosis Research Center in Chennai, and
>multinational colleagues evaluated the T-cell subpopulations during initial
>immune response to Mycobacterium tuberculosis in 22 children diagnosed with
>pulmonary tuberculosis. The children were between the ages of 5 and 8 years.
>Seventeen healthy tuberculin-positive children served as controls. In the
>May issue of Indian Pediatrics, Dr. Swaminathan's team reports that both the
>total lymphocyte count and CD3+ and CD4+ counts were significantly lower in
>tuberculosis patients than in controls. The decrease was not related to the
>type of lesion and was present in all cases of tuberculosis. In contrast,
>the total number of CD8+ and gamma delta T cells was similar in the two
>groups. Further, the researchers noted that "patients with both
>malnutrition and tuberculosis had the lowest CD3+ and CD4+ T-cell [counts]
>compared... with tuberculosis alone or malnutrition alone." They observed
>that these changes reverted to normal on completion of anti-tuberculosis
>treatment. "The reversible reduction in CD3+ and CD4+ suggests that it is
>directly related to tuberculosis," the researchers write. They note that
>previous studies of T-cell subpopulations in tuberculosis have involved
>adults. "Because most adults were infected in the distant past, the
>distribution of T-cell subpopulations during the initial response to
>infection cannot be assessed." Dr. Swaminathan and colleagues conclude
>that "though the exact mechanism by which tuberculosis decreases CD3+ and
>CD4+ cells need further research, the possible mechanisms could be
>tuberculosis-induced apoptosis of peripheral T cells or a peripheral
>reduction in CD3+ and CD4+ due to recruitment of these cells at the site of
>disease." Indian Pediatrics 2000;37:489-495.
>*************************************************************
>OTHER JOURNAL ITEMS:
>**************************************************************
>Journal of the American Medical Association; Vol. 283; No. 22,
>283:2968-2974; June 14, 2000; Spread of Mycobacterium tuberculosis in a
>Community Implementing Recommended Elements of Tuberculosis Control; Daniel
>P. Chin, MD, MPH; Charles M. Crane, MD, MPH; Mukadi Ya Diul, MD, MPH; Sumi
>J. Sun, MPH; Rocio Agraz, BS; Sirlura Taylor, PHN; Edward Desmond, PhD;
>Francie Wise, PHN, MPH.
>
>Report notes that despite improvements in tuberculosis (TB) control during
>the past decade, Mycobacterium tuberculosis transmission and resulting
>disease continue to occur in the United States. This is a report of a
>population-based, molecular epidemiological study to determine the primary
>reasons for disease development from a particular strain of M tuberculosis.
>The study was done in an urban community in the San Francisco Bay area of
>California with recommended elements of TB control in place. Authors say
>seventy-three TB cases were reported in 1996-1997 that resulted from 1
>strain of M tuberculosis as identified by TB genotyping and epidemiological
>linkage. They report seventy-three (33%) of 221 TB case-patients in this
>community resulted from this strain of M tuberculosis and thirty-nine (53%)
>of the 73 case-patients developed TB because they were not identified as
>contacts of source case-patients; 20 case-patients (27%) developed TB
>because of delayed diagnosis of their sources; and 13 case-patients (18%)
>developed TB because of problems associated with the evaluation or treatment
>of contacts; and 1 case-patient (1%) developed TB because of delay in being
>elicited as a contact. They observed that, of the 51 TB cases identified
>with sources, 49 (96%) were infected within the 2 years prior to diagnosis.
>They conclude their results indicate that in a community that has
>implemented the essential elements of TB control, TB from ongoing
>transmission of M tuberculosis will continue to develop unless patients are
>diagnosed earlier and contacts are more completely identified.
>**************************************
>American Journal of Respiratory and Critical Care Medicine; Volume 161,
>Number 6, June 2000, 1786-1789; Increased Levels of Circulating
>Interleukin-18 in Patients with Advanced Tuberculosis ; GEN YAMADA, NORIHARU
>SHIJUBO, KATSUNORI SHIGEHARA, HARUKI OKAMURA, MASASHI KURIMOTO, and SHOSAKU
>ABE.
>
>Report notes that interleukin-18 (IL-18) has recently been identified as an
>interferon- -inducing factor and it plays an important role in the Th1
>response. Authors measured serum levels of IL-18 and interferon- (IFN-) in
>43 patients with pulmonary tuberculosis and 25 healthy control subjects and
>found significantly increased levels of circulating IL-18 and IFN- in
>pulmonary tuberculosis as compared with those in healthy control subjects.
>They report circulating IL-18 and IFN- correlated with the extent of disease
>in pulmonary tuberculosis and they found significantly increased levels of
>circulating IL-18 and IFN- in the patients with high-grade fever. They
>conclude that circulating IL-18 significantly correlated with circulating
>IFN-. IL-18 may play an important role in immune response to human infection
>with Mycobacterium tuberculosis.
>*****************************
>Journal of the American Medical Association; 2000;283:2979-2984; Public
>Health Law in a New Century; Part II: Public Health Powers and Limits;
>Lawrence O. Gostin, JD, LLD.
>
>Gostin notes the Constitution allocates public health powers among the
>federal government and the states while federal public health powers include
>the authority to tax, spend, and regulate interstate commerce. He points out
>these powers enable the federal government to raise revenues, allocate
>resources, economically penalize risk behavior, and broadly regulate in the
>public's interest. He notes the states have an inherent authority to
>protect, preserve, and promote the health, safety, morals, and general
>welfare of the people, termed police powers which enable states to preserve
>the public health in areas ranging from injury and disease prevention to
>sanitation, waste disposal, and environmental protection. Gostin points out
>the Rehnquist Court has emphasized the limits of federal powers and the
>primacy of states in public health issues affecting local concerns. Gostin
>observes that the Constitution safeguards individual interests in autonomy,
>privacy, liberty, and property. He comments that the Supreme Court often
>does defer to public health authorities in matters of public health, but
>engages in strict scrutiny if government interferes with fundamental
>freedoms or discriminates against a suspect class. He believes the Court
>should cede to agencies the power to act for the communal good provided that
>they act justly and reasonably to avert a serious health threat.
>
>*************************************
>British Medical Journal; 2000;320:1680, 17 June, Reviews, Minerva; Kenya.
>
>Report notes a grim picture of work in a rural hospital in Kenya is painted
>in the East African Medical Journal (2000;77:185-8) where overall
>attendances have fallen slightly but the number of new patients needing
>treatment for HIV infection has risen from 95 in 1993 to 315 in 1997; the
>number of patients with tuberculosis has risen from 145 to 215 in the same
>time although malaria remains the most common diagnosis.
>*************************************
>NEW ATS/CDC STATEMENT:
>******************************************************
>MMWR Recommendations and Reports, Volume 49, Number RR-6: June 09, 2000 /
>49(RR06);1-54; Targeted Tuberculin Testing and Treatment of Latent
>Tuberculosis Infection; Statement was developed by the ATS/CDC Statement
>Committee on Latent Tuberculosis Infection: Co-Chairs - David L. Cohn, M.D.
>and Richard J. O'Brien, M.D.; Writing Group - Lawrence J. Geiter, Ph.D.;
>Fred M. Gordin, M.D.; Earl Hershfield, M.D.; C. Robert Horsburgh, Jr., M.D.;
>John A. Jereb, M.D.; Theresa J. Jordan, Ph.D.; Jonathan E. Kaplan, M.D.;
>Charles M. Nolan, M.D.; Jeffrey R. Starke, M.D., Ph.D.; Zachary Taylor,
>M.D.; M. Elsa Villarino, M.D., M.P.H.: Members - Nancy J. Binkin, M.D.,
>M.P.H.; Naomi N. Bock, M.D.; Kenneth G. Castro, M.D.; Richard E. Chaisson,
>M.D.; George W. Comstock, M.D.; Mark S. Dworkin, M.D.; Wafaa El-Sadr, M.D.,
>M.P.H.; Paula I. Fujiwara, M.D., M.P.H.; Jeffrey C. Glassroth, M.D.; Peter
>Godfrey-Faussett, M.D.; Mark J. Goldberger, M.D., M.P.H.; James L. Hadler,
>M.D., M.P.H.; Philip C. Hopewell, M.D.;Michael D. Iseman, M.D.; Richard F.
>Jacobs, M.D.; Mack A. Land, M.D.; Mark N. Lobato, M.D.; Richard I. Menzies,
>M.D.; Giovanni B. Migliori, M.D.; Bess I. Miller, M.D., M.Sc.; Alwyn
>Mwinga, M.D.; Edward A. Nardell, M.D.; James Neaton, Ph.D.; Noreen L.
>Qualls, Dr.P.H.; Lee B. Reichman, M.D., M.P.H.; David N. Rose, M.D.; Shelley
>R. Salpeter, M.D.; Holger Sawert, M.D., M.P.H.; Patricia M. Simone, M.D.;
>Dixie E. Snider, Jr., M.D., M.P.H.; Joel Tsevat, M.D., M.P.H.; Andrew A.
>Vernon, M.D.; Christopher C. Whalen, M.D.; Timothy C. Wilcosky, Ph.D.
>
>This American Thoracic Society(ATS)/Centers for Disease Control and
>Prevention (CDC) statement "Targeted Tuberculin Testing and Treatment of
>Latent Tuberculosis Infection" is available in PDF and HTML formats.
>
> · Click here for Adobe PDF format: ftp://ftp.cdc.gov
> · /pub/Publications/mmwr/rr/rr4906.pdf
> · Click here for HTML (web) format:
>http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/rr4906a1.htm
>
>Continuing Education Available - This issue contains a continuing education
>activity for physicians, nurses, and other health professionals.
>
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>
>This report was published in MMWR with the permission of the American
>Thoracic Society and as a courtesy to the MMWR readership. It is an
>adaptation of a report published in the American Journal of Respiratory and
>Critical Care Medicine 2000;161:S221--S247.
>*************************************************************
>
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