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Highlights From State and Local Programs

TB Outreach Educator Honored

Image of Juan Valerio Recipient of the 2007 Manuel Carballo Governor’s Award for Excellence in Public ServiceJuan Valerio, TB Outreach Educator for the Massachusetts Division of TB Prevention and Control, was recently honored as part of the Commonwealth of Massachusetts Performance Recognition Program. This program recognizes the outstanding contributions of individuals and groups of state employees who play a major role in the successful delivery of quality services to the citizens of Massachusetts. Juan, as well as nine other state employees across all state agencies, was a recipient of the 2007 Manuel Carballo Governor’s Award for Excellence in Public Service. This award is named in honor of the late Secretary of Human Services of Massachusetts and is given annually to no more than 10 employees of state agencies who exemplify the highest standards of public service. Nominations are screened by a selection committee comprised of the Massachusetts Speaker of the House, the President of the Senate, and gubernatorial appointees from business, labor, community groups, academia, and the media. The selection criteria include exceptional accomplishments; exemplary leadership, initiative, or dedication; and creativity or innovation. Juan was honored at a special awards ceremony on October 5 at the Sheraton Boston, where he was given his citation by Governor Deval Patrick.

The Massachusetts TB Division is extraordinarily proud of Juan. He is on the “front lines” of TB control every day, serving what are sometimes the hardest-to-reach populations in Massachusetts. He has given 19 years of service to the TB Division as a fulltime Outreach Educator covering the Boston neighborhoods and TB Clinic sessions at Boston TB clinics. In that role he has worked with Hispanic as well as non-Hispanic TB patients, their families, and others in the community to provide TB education; monitor patients who are on treatment for TB; provide patients with directly observed therapy (DOT) and social service support; provide interpreter services at the very busy TB clinic at the Boston Medical Center; make home visits to patients to gather information and perform services for patients as needed; assist in monitoring patients for factors such as drug compliance and medication side effects; follow up and track patients who miss their TB clinic appointments; and identify contacts of TB cases and refer them for evaluation.

Beyond the usual outreach duties described above, outreach education has always been more than just a job to Juan. For example, he orients others to the role of the TB Outreach Educator in Massachusetts, and physicians often “shadow” him on patient home visits to see first hand what public health community work is like. He is the first to volunteer for TB-related activities that may be outside of his traditional outreach role. Last fall, Juan volunteered to assist the TB Division’s Outbreak Response Team by working as an interpreter and educator at one of the state prisons in follow up to a cluster of reported TB cases.

It would be impossible to calculate the number of extra hours that Juan puts into his public health work. He often sees patients for DOT as early as 6 am before they go to work or in the evening or on weekends as needed, and he is always available to his patients whenever they call. He does all this with no expectation of extra compensation. It’s just “part of the job,” and he sees patients wherever it is convenient for them — on street corners, in shelters, in hospitals, under bridges, in economically depressed neighborhoods, or anywhere else.

In addition to taking care of the job-related TB aspects of his patients’ lives, Juan recognizes that TB is just one of their health and social service needs. He recognizes that it is impossible to take care of TB alone without addressing the other patient concerns that may interfere with completion of TB treatment. Juan is as much a social service worker as he is a TB care provider and educator. Juan’s dedication to public service extends beyond the TB Division office walls or the walls of the sites where he sees his patients. He understands the importance of community in moving the public health agenda and he understands the importance of giving back to the community.

As a community leader, and on his own time, Juan often speaks to the Latino community on issues such as TB, HIV, and other health-related topics via TV and public radio programs. Juan was also a guest on the live call-in weekly Spanish radio program, La Salud y Usted, co-sponsored by the Office of Minority Health at the Massachusetts Department of Public Health; he was also selected to participate in Por Christo (a volunteer medical service organization) for a community health TB project in Quito, Ecuador. He is the founder and president of a non-profit organization called FUNDARCO (Fundacion Del Arte y la Cultura Dominicana), which promotes the arts and culture of the Dominican Republic, and has written numerous health-related articles. He is on the board of various community organizations, newspapers, and his own neighborhood health center, and is an active member of his church. He recently received recognition for his outstanding performance as a poetry reader in the Community Reading Program of the Hispanic Writers Week.

To quote from his nomination, “In summary, in his quiet, unassuming way, Juan Valerio promotes public health and public service every day in every aspect of his private and public life. He is a very caring person who is devoted to his family and dedicated to his job, his patients, and his community. He is also well known and respected in the Latino community for his achievements, leadership, interpersonal skills, and humanitarian heart.”

Juan’s colleagues in the Division are honored and proud to know and work with Juan each day.

—Submitted by Sue Etkind
Director, Division of TB Prevention and Control
Massachusetts Department of Public Health

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TB Legal Forum for Southwestern Border States

The U.S.-Mexico Border Health Commission, Arizona Outreach Office, hosted a day-long TB legal forum in Phoenix, Arizona, at the Arizona Department of Health Services (ADHS) on October 3, 2007. The purpose of the forum was to foster an understanding of U.S. TB control laws and policies in the areas along the U.S.-Mexico border and to discuss cross-jurisdictional legal issues in TB control. The meeting will serve as a starting point for a proposed border health Legal Forum with Mexico to discuss cross-national TB cases, TB care standards, and TB legal statutes.

Participants included legal counsel and public health officials from the four U.S. states that border Mexico (Arizona, California, New Mexico, and Texas). Also attending were staff from the U.S.-Mexico Border Health Commission; the U.S. Department of Health and Human Services, Office of General Counsel and Centers for Disease Control and Prevention (CDC); the U.S. Department of Homeland Security, Office of Health Affairs and U.S. Immigration and Customs Enforcement (ICE); the Tohono O’Odham Nation; and the ADHS Native American Liaison.

The participants were asked to describe the public health laws pertaining to TB in Arizona, California, New Mexico, Texas, Arizona Tribal Nations, and the United States. They were asked whether the laws were TB-specific, the source of the legal authority, the criteria used to initiate and continue legal action, and whether U.S. residency status affected TB care and court-mandated case isolation and quarantine.

A number of interjurisdictional TB issues were discussed. These included the admissibility of evidence in a jurisdiction other than where it is collected, the varying rules of evidence between states for documentation of nonadherence with treatment, the need for regionalization, areas in which the four states can improve cooperation, communication between states and Native American tribes, and tribal inclusion in collaborations.

Several binational case management challenges were discussed. These included funding and care issues for TB and MDR TB patients from another country, and the fact that CDC cooperative agreement funds are based on the number of U.S. cases without including the burden of treating TB cases from other countries. Attendees also discussed the increasing numbers of MDR TB cases along the border, the lack of second-line TB drugs in Mexico and Central America, and the need for tribal inclusion in binational and border TB control activities.

Attendees discussed the problem of ICE being unable to routinely retain people in custody to completion of TB therapy due to the fact that the statutory authority for ICE custody and detention is to facilitate repatriation. Other immigration enforcement issues discussed included statutory limits on duration of ICE custody, ethical considerations of providing treatment in the least restrictive setting, and civil liberties considerations. ICE will consider requests for stays of removal in special circumstances (e.g., MDR TB) in order to delay repatriation until after treatment completion; however, local jurisdictions would have to bear the cost of treatment and case management if ICE were to grant a stay of removal and the patient were released to the community or another secure facility.

A formal summary of the meeting is being compiled. It will include specific recommendations for addressing the multitude of issues that were discussed. The report of this meeting will be shared with a broad range of local, national, and international organizations that will need to work together to solve these challenges.

—Submitted by Karen Lewis, MD, TB Control Officer,
Arizona Department of Health Services, and
Diana L. Schneider, DrPH, MA, Senior Epidemiologist,
Department of Homeland Security, U.S. Immigration and Customs Enforcement

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Effecting Acute Isolation of TB Patients Utilizing Chicago Department of Public Health Emergency Quarantine and Isolation Regulations

Background

For the first time in a decade, the Chicago Department of Public Health (CDPH) has promulgated and enforced regulations regarding communicable disease (PDF). On May 6, 2003, the City of Chicago Board of Health and the Public Health Commissioner developed new regulations that highlight the process by which quarantine, isolation, directly observed therapy (DOT) and other disease control interventions can be initiated. These regulations were later revised on February 18, 2004 .

Court-ordered Directly Observed Therapy

In 2005, a cab driver was diagnosed with smear- and culture-positive pan-susceptible TB. The standard care was provided, including DOT, case management, and incentives and enablers as field staff deemed appropriate. The patient, however, was nonadherent with his treatment regimen. A directive indicating the expected treatment, follow-up, and infectious disease precautions for the patient was issued by CDPH.

Although the individual signed the directive, he continued to drive a cab while infectious, and thus was a threat to public health. CDPH notified Municipal Prosecutions and the Department of Consumer Services (DCS). The DCS is responsible for licensing and monitoring taxi cab drivers and companies. Chicago police are assigned to work with that department, so as to be easily engaged if needed.

A court hearing was scheduled and conducted, and DOT was court ordered. Regarding the hearing, we were told that we could not bring a person with TB into the Daley Center (where the circuit court of Cook County hears the majority of its cases). Thus, the hearing was held at a West Side Center for Disease Control conference room with HEPA filter and masks for the judge, patient, court reporter, and others. This was the first activation of communicable disease regulations in a decade. At subsequent hearings, it was noted that the patient was adherent, and he has since successfully completed treatment.

Enforced Isolation

1st Case: Female with multidrug-resistant (MDR) TB attempting to leave jurisdiction on plane to China via O’Hare International Airport

In November 2005, a CDPH physician became aware of the possibility that a smear- and culture- positive MDR TB patient, then in voluntary isolation at a Chicago hospital, might become nonadherent to therapy and could pose a flight risk. CDPH regulations allow for the detention of a person with infectious communicable disease prior to legal hearing, based on established clinical criteria for infections, provided the patient’s culture had not converted. Thus, orders were drafted and were also translated into the patient’s native language.

In January 2006, CDPH was alerted to the patient’s possible intentions to leave the country. Multiple conversations with CDC’s Division of Global Migration and Quarantine (DGMQ) Officer, CDPH, and municipal prosecutors ensued. Although DGMQ could not physically stop a person from leaving, they could and would assist in other ways, including having a staff person monitor the check-in list for the patient and escorting CDPH staff to the gate to positively identify and intercept the patient. The patient was intercepted at the gate and brought to a hospital’s emergency department.

After proper fit testing of respirators, the attorneys, judge, and court reporter held a hearing in the patient’s room. As an outpatient, the patient continues to do well on therapy.

2nd Case: Female without proper visa and active TB attempting to enter US through O’Hare International Airport

In February 2006, the CDC Quarantine Officer gained knowledge from Customs and Border Protection (CBP) that a woman had attempted to enter the U.S. illegally from Paris, France. Travel had originated in Gabon (NW Africa) and was to end in California. A search of individual luggage yielded chest radiographs, TB medications, and masks. The Quarantine Officer was contacted and the individual was taken to the nearest hospital.

CDPH became involved the following day after further activity between CBP and DGMQ. A conference call was convened involving the CDC Quarantine Officer, CDPH, the Illinois Department of Public Health (IDPH), and representatives from the hospital, including the head of Infectious Diseases, the Chief Executive Officer, and the Infection Control Nurse. Although the patient was voluntarily staying in the hospital at this time, CDPH began to prepare an isolation order written in English and French.

The following day, the patient was served and signed the isolation order. She remained in the hospital on treatment until she became noninfectious and could travel.

Lessons Learned

Regulations, communication, and multi-jurisdictional collaboration are critical in effecting isolation orders. By virtue of this being a matter of court record, patient confidentiality cannot be assured. In an effort to minimize the risk of breaching patient confidentiality, we did not publicly announce our successful interventions and outcomes.

Related areas of legal intervention that need improvement include ongoing capacity building for legal counsel and the courts, better coordination between city, state, and federal jurisdictions, and the ability to pay for forced holdings and inpatient treatment.

—Submitted by Susan Lippold, MD, MPH (CDC/CDPH)
Wendi W. Wright, MJ, JD (CDPH) and
William Clapp, MD (CDPH).
With special thanks to Sena Blumensaadt (DGMQ)

 
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