At the intersection of new technology advancements, ever-changing health policy, and fiscal constraints, public health agencies seek to leverage modern technical innovations and benefit from a more comprehensive and cooperative approach to transforming public health, health care, and other data into action. State health agencies recognized a way to advance population health was to integrate public health with clinical health data through electronic infectious disease case reporting. The Public Health Community Platform (PHCP) concept of bidirectional data flow and knowledge management became the foundation to build a cloud-based system connecting electronic health records to public health data for a select initial set of notifiable conditions. With challenges faced and lessons learned, significant progress was made and the PHCP grew into the Digital Bridge, a national governance model for systems change, bringing together software vendors, public health, and health care. As the model and technology advance together, opportunities to advance future connectivity solutions for both health care and public health will emerge.

Public health surveillance is focused on the detection of acute, chronic, and emerging threats to the health of the population to direct disease control and prevention efforts.1 Public health surveillance relies on health care providers to report to public health agencies conditions or outbreaks that may impact the broader population. This case reporting is mandated through laws and regulations at the state and local levels. Notification of cases to the Centers for Disease Control and Prevention (CDC) is facilitated by agreements between states and the federal government.2 Historically, case reporting has been based on paper reports or Internet-based entry of reports to state health department systems, but these reports are often slow or incomplete and place a substantial burden of work on health care providers and public health agencies.3 The future of surveillance is electronic case reporting (eCR), by which cases of reportable conditions are automatically generated from electronic health record (EHR) systems and transmitted to public health agencies for review and action. | eCR holds promise for enhancing the quality and effectiveness of public health surveillance.4 Greater use of eCR could result in (1) more complete and accurate case data in near real time for public health action; (2) earlier detection of cases, permitting earlier intervention and lowered transmission of disease; (3) improved detection of outbreaks to allow earlier investigation and, potentially, earlier identification of risk factors for the spread of disease; and (4) creation of a new infrastructure to support rapid reporting of newly recognized and emerging conditions. In this commentary, we review the promise of eCR and present our vision for a nationally interoperable eCR system that allows for timely reporting to public health and information sharing among jurisdictions.

RATIONALE: Biomarkers for monitoring response to anti-tuberculosis treatment are needed. We explored immune markers previously published as having predictive capability for 8 week culture status in 39 adults enrolled in a clinical trial in Kampala, Uganda. METHODS: We consecutively selected 20 HIV-negative pulmonary TB subjects with positive cultures, and 19 subjects with negative cultures at the end of intensive phase therapy. At baseline and after 8 weeks, serum was assayed for nine cytokines and soluble cytokine receptors using multiplexed platforms or ELISA. We evaluated their association with week 8 culture status first using single-variable logistic models, then using cross-validated estimates of the C-statistic, a measure of discrimination, of candidate models including 2 or 3 analytes in addition to age. RESULTS: All but one analyte decreased from baseline to week 8 (all p < 0.01). Individual biomarkers were not associated with 8 week culture status. Logistic models including increasing age, higher baseline soluble tumor necrosis factor receptor alpha 1 (sTNF-R1), and higher week 8 C-reactive protein (CRP) concentration classified subjects by culture status with up to 85% accuracy and acceptable discrimination (cross-validated C-statistic 0.76) and calibration (Hosmer-Lemeshow P > 0.2). CONCLUSION: Exploratory post-hoc models including sTNF-R1, CRP, and age, classified 8 week culture status with promising accuracy.

The development, evaluation, and implementation of new and improved diagnostics have been identified as critical needs by human immunodeficiency virus (HIV) and tuberculosis researchers and clinicians alike. These needs exist in international and domestic settings and in adult and pediatric populations. Experts in tuberculosis and HIV care, researchers, healthcare providers, public health experts, and industry representatives, as well as representatives of pertinent US federal agencies (Centers for Disease Control and Prevention, Food and Drug Administration, National Institutes of Health, United States Agency for International Development) assembled at a workshop proposed by the Diagnostics Working Group of the Federal Tuberculosis Taskforce to review the state of tuberculosis diagnostics development in adult and pediatric populations.

BACKGROUND: Rifampin has concentration-dependent activity against Mycobacterium tuberculosis. However marked inter-subject variation of rifampin concentrations occur. In this study, we evaluated rifampin pharmacokinetics in relation to tuberculosis, geographic region, race, and single nucleotide polymorphisms of human transporter genes SLCO1B1, SLCO1B3 and MDR1. MATERIALS & METHODS: Seventy-two adults with pulmonary tuberculosis from Africa, North America and Spain were evaluated during multi-drug intensive-phase therapy, and compared to 16 healthy controls from North America. RESULTS: Rifampin pharmacokinetics values were similar between tuberculosis patients versus controls (geometric mean [GM] area under the concentration-time curve (AUC0-24) 40.2 vs. 40.9 mcg*h/ml, P=.9). However in multivariable analyses, rifampin AUC0-24 was significantly affected by rifampin dosage (mg/kg), polymorphisms in the SLCO1B1 gene, and presence of tuberculosis by geographic region. Adjusted rifampin AUC0-24 was lowest in patients with tuberculosis from Africa compared to non-African patients or control subjects. Adjusted rifampin AUC0-24 was also 36% lower among participants with SLCO1B1 c.463CA versus c.463CC genotype (adjusted GM 29.8 vs. 46.7 mcg*h/ml, P=.001). Polymorphisms in the SLCO1B1 gene associated with lower rifampin exposure were more frequent among subjects of Black race. CONCLUSIONS: Marked inter-subject variation of rifampin AUC0-24 was observed, but means of AUC0-24 did not significantly vary between patients with tuberculosis and healthy controls. Lower rifampin exposure was associated with the polymorphism of the SLCO1B1 c.463C>A gene. When adjusted for patient mg/kg dosage and transporter gene polymorphisms, rifampin exposure was lower in patients with tuberculosis which suggests that additional absorption or metabolic processes affect rifampin exposure with tuberculosis disease.

OBJECTIVES: We examined trends in tuberculosis (TB) cases and case rates among US- and foreign-born children and adolescents and analyzed the potential effect of changes to overseas screening of applicants for immigration to theUnited States. METHODS: We analyzed TB case data from the National Tuberculosis Surveillance System for 1994 to 2007. RESULTS: Foreign-born children and adolescents accounted for 31% of 18659 reported TB cases in persons younger than age 18 years from 1994 to 2007. TB rates declined 44% among foreign-born children and adolescents (20.3 per 10000 to 11.4 per 100000 population) and 48% (2.1 per 100000 to 1.1 per 100000) among those who were born in the United States. Rates were nearly 20 times as high among foreign-born as among US-born adolescents. Among foreign-born children and adolescents with known month of US entry (88%), more than 20% were diagnosed with TB within 3 months of entry. CONCLUSIONS: Marked disparities in TB morbidity persist between foreign- and US-born children and adolescents. These disparities and the high proportion of TB cases diagnosed shortly after US entry suggest a need for enhanced pre- and postimmigration screening.