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No. 1, 2011

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS

New Englanders Eliminating TB: Nurse and Laboratorian Honored with Third Annual New England TB Heroes Awards

The New England TB Heroes Awards were presented in September 2010 at the Northeast TB Controllers Conference. Each year, requests for nomination are circulated through the New England states of individuals who have made exemplary contributions to the care of patients with TB or who have been instrumental in enhancing TB prevention and control efforts. Eighteen nominations were received, and two outstanding nominees were selected from this pool. 

At the conference’s plenary session in Annapolis, MD, the award recipients were announced to great applause. The awardees appeared grateful and appreciative as they came onstage to receive their plaques.

Alex Sloutsky, Sue Etkind, Jill Fournier, Mark Labato
Alex Sloutsky with Sue Etkind
(Massachusetts),
Jill Fournier (New Hampshire),
and Mark Lobato (CDC)

The first recipient was Alexander Sloutsky, PhD, director of the Massachusetts Supranational TB Reference Laboratory (MSRL) and assistant professor of medicine at the University of Massachusetts Medical School. Dr. Sloutsky has led international collaborations that now enable some countries with high TB rates to detect drug-resistant TB at the local level. Under his direction, the MSRL, which is part of an international network of 28 supranational reference laboratories, collaborates with the World Health Organization (WHO) to provide support and guidance for TB laboratories in Peru, Haiti, the Caribbean, and other areas with a high burden of TB.

Alex was nominated for the TB Hero Award by the Medical Advisory Committee for the Elimination of Tuberculosis in Massachusetts, which described him as a “true leader and innovator, constantly working to improve existing laboratory methods, to bring in entirely new state-of-the-art methodologies, and to develop his own novel TB diagnostics platforms.” Citing Sloutsky’s international leadership in clinical mycobacteriology, the nomination commended him for “functioning in an advisory capacity to bodies like the WHO and bringing his expertise to resource-limited settings to help with mycobacteriology laboratory set-up and management. His work has truly made a huge impact on the care of TB patients at multiple levels.” The University of Massachusetts Medical School newsletter UMass Now reported on the award and recognized Dr. Sloutsky’s many contributions to TB control.

Jeanne Ellis, Sue Etkind, JillFournier, Mark Lobato
Jeanne Ellis with Sue Etkind,
Jill Fournier, Mark Lobato

The second recipient was Jeanne Ellis, RN, nurse at the Getchell-Ward TB Clinic located in Worcester, MA (population 783,000).  One of Jeanne’s nominators commented that “On a functional basis, Jeanne has been the heart and soul of the Worcester TB Clinic for more years than she is likely willing to admit! I believe she has seen every single patient with active TB in Worcester for the last 30 years. She has been an exemplary model for the delivery of care to an impoverished, ethnically diverse, multilingual patient population.”

Ellis‘s colleagues recognize her as a tremendous asset, both for clinic activities as well as training future TB practitioners. One of the clinic doctors shared that “When I first met Dr. Ward [then head of the TB Clinic] in 1990, he explained to me that the clinic functions extremely well because of his excellent nurse, Jeanne Ellis, and she could guide me and teach me everything I needed to know and more.  Jeanne directs the clinic and its staff to make sure every provider is well-informed and every patient has the best possible care.”

Congratulations to Jeanne Ellis and Alexander Sloutsky!

On behalf of the New England TB Consortium, we thank them for their outstanding efforts.

—Reported by Nickolette Patrick (TB Educator, Global TB Institute); Sue Etkind, RN, MS (Director, Massachusetts Division of TB Prevention and Control); Jill Fournier, RN, BSN (Program Manager, New Hampshire TB Program); Lynn Sosa, MD (Connecticut TB medical epidemiologist); Mark Lobato,  MD (CDC medical officer)

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Regionalization: A Strategic Partnership between DTBE and State TB Programs

The six New England states collaborate through the New England TB Consortium (NETBC), in partnership with DTBE and the NJ Medical School Global Tuberculosis Institute, focusing on joint programmatic activities, education, and operational research. This strategic step is in response to recommendations by the Institute of Medicine and the Advisory Council for the Elimination of Tuberculosis that CDC develop models to foster regional collaboration between state programs and DTBE.1,2

In addition, the 2010 Tuberculosis Elimination Plan for the United States prominently features regionalization as a proactive method to maintain and enhance TB expertise and programmatic infrastructure and to promote efficiencies through collaborations. The TB Elimination Plan derives one lesson from the regionalization experience affirming that TB control “…within each state can be enhanced when tuberculosis program staff collaborate in a multistate regional tuberculosis elimination effort.”3

The experience in New England demonstrates that regional partnerships are productive and desirable. Some examples from the NETBC enhancement collaborations follow and are further described at the New England TB Consortium.

Development of a Leadership Team
The leadership of each state TB program, including the program manager and key staff, comprise a coordinating team for the New England TB Consortium. This team guides regional activities and sets priorities for initiating new projects. The team also provides collective problem solving to state and regional concerns. Without the buy in, commitment, and participation of the individual programs, collaboration would be reduced to communication without the shared purpose that regionalization entails.

Creating an Infrastructure and a Plan
Relying on voluntary participation, each program contributes to various aspects of the regional collaboration. The consensus strategic plan serves as the framework for collaboration. Joint activities are discussed, organized, and implemented through work teams composed of members from the programs. These efforts have evolved into a more formal structure, the NETBC. A retreat in May 2009 reconfirmed the programs’ commitment and reached consensus on a new plan for 2010–2014 (Resources about Regional Collaboration).

Education
Regionalization’s first impact was to expand the expertise available to each program. Education of public health nurses and community providers along with workforce development have been a top priority. Having a health educator from the Global TB Institute based in the region is an immense benefit.

Educational initiatives in 2010 include four web-based case presentations to almost 300 health-care professionals through “Eliminating TB Case by Case” for providers and “TB Talk,” a discussion forum led by and for nurses, case managers, and outreach staff. In collaboration with the Global TB Institute, a regional outreach conference, a TB Clinician’s Conference, and state-specific educational conferences were supported and attended by other states, and a website with archived educational materials was developed. In addition, a project of the Massachusetts’ medical advisory committee resulted in posters for the Emergency Department that were shared with all programs.

Universal Genotyping
An exciting development is the discussion of shared genotypic clusters in the region. After a start up period of sharing how each program collects and organizes genotyping data, the genotyping team and NETBC leadership have discussed clusters with the goal of 1) defining the strains that are in the region, 2) learning about cluster investigations from one another, and 3) determining if there has been intra-state and inter-state TB transmission. To date, limited interstate transmission has been found within a family and in one outbreak. Programs continue to evaluate shared contacts between states in instances where the contact may live and work in a different state or the contact and source case live in different states. The most recent calls related to cluster investigations have included New York State and New York City. Latest steps included working with DTBE on testing TB-GIMS in a low-incidence state and studying predictors for clustering in Connecticut.

Outbreak and Case Management Consultation
An immediate advantage of having a DTBE staff person on the regional team is access to consultation for TB outbreaks, large contact investigations, and case management. By having someone on the ground, DTBE was able to respond early to a community-wide outbreak with nine cases after an inmate whose TB went undiagnosed was released from prison. Another state benefited from technical support from a DTBE team when they had three simultaneous high-volume (school and work places), highly visible investigations. New Hampshire is currently working with DTBE on linking its LTBI database to TB databases to evaluate CDC’s LinksPlus software and to determine if additional risk factors can be identified for developing active disease.

Public Health Law
A new development is the New England Public Health Law Project. The NETBC has partnered with the Harvard JD/MPH program to review the laws pertaining to involuntary isolation of TB patients. The goal is to expand the role of the TB Treatment Unit at Lemuel Shattuck Hospital in Boston as a regional TB referral center. The NETBC is working on such an Agreement.

Program Evaluation and Cohort Reviews
The New Hampshire program has been an important member of the TB Program Evaluation Network. At present, two programs are members of the national steering committee. We are considering plans to perform an evaluation at a regional level.

The NETBC in partnership with the Global TB Institute held a one-day TB cohort review course. More than 30 TB program staff attended the course led by Bill Bower (GTBI) and assisted by Kim Field (Washington State) and Dawn Tuckey (DTBE program consultant). The course was followed up by a webinar on how to use findings from the cohort review with presentations by four programs and Bill Bower.

Research
Massachusetts actively engages in TB research through the TB Epidemiologic Studies Consortium. Over the last 10 years, they have had CDC public health prevention specialists work on a partnership with leaders in the Haitian community. Connecticut had a CSTE/CDC fellow focus on improving medical follow-up of refugees and immigrants, an EIS officer who presented a prize-winning poster about access to care for foreign-born TB patients at the 2009 national TB meeting, and MPH students who led studies on provider practices for TB screening among school-aged children and a regional laboratory survey of mycobacterial testing capacity. The Connecticut EIS officer currently is analyzing data on TB-related deaths. Rhode Island recently coauthored an analysis of genetic clusters in the state.

Lessons learned
The New England TB Consortium demonstrates in practice that successful regional collaboration is possible and adds value to TB prevention and control efforts. As stated in the recently released evaluation of the NETBC conducted by Maureen Wilce, “Central to the consensus framework are a written strategic plan, a formal, signed memorandum of agreement, regular conference calls among state program managers, a New England TB Consortium website, and in-person meetings.” To extend the regional model, DTBE will have to discuss how best to use its field staff to achieve the most efficient integration of state-based and regional activities.

Future plans
The latest step is to hold quarterly calls between the TB programs and the public health mycobacterial laboratories. A recent webinar for New England public health nurses resulted from collaboration with the Connecticut and New Hampshire labs.

The NETBC plans to extend the regional model into a broader concept of program collaboration and services integration (PCSI) by integrating HIV, STD, and viral hepatitis programs with TB program activities. First efforts of regional PCSI collaboration included a conference for outreach workers in 2009 and a regional educational conference for providers in 2010.

The NETBC has helped facilitate orientation of new program managers in several member states and integrated members into the national TB elimination movement. Members have increasingly taken on leadership positions in the areas of advocacy, evaluation, and education through all of the national TB organizations including STOP TB USA.

—Reported by TB Program Managers Sue Etkind (MA), Jill Fournier (NH), Michael Gosciminski (RI),
Heidi Jenkins (CT), Adriene Rister (ME), Susan Schoenfeld (VT), and Mark Lobato (CDC)

References
1. Institute of Medicine. Ending Neglect: The Elimination of Tuberculosis in the United States. Washington, DC: National Academy Press; 2000.
2. CDC. Progressing toward tuberculosis elimination in low-incidence areas of the United States: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR. 2002;51(No. RR-5):1–14.
3. Stop TB USA Tuberculosis Elimination Plan Committee. A Call for Action on the Tuberculosis Elimination Plan for the United States. Atlanta, GA: Stop TB USA; 2010. Access at http://stoptbusa.org/tepfull.pdf

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TB Investigation in a Tribal Community, July 2010

Background
In June 2010, a case of pulmonary tuberculosis (TB) was diagnosed in a resident of a tribal community in the western United States. Contact investigation revealed two pediatric cases and numerous contacts with latent TB infection (LTBI). Subsequently, the tribal community, in concurrence with the Indian Health Service (IHS) and the state health department, requested onsite CDC assistance. As a member of a three-person DTBE Technical Assistance Team, I was charged with the responsibility of ensuring that a thorough contact investigation would be done; and that, if warranted, the contact investigation would be expanded. I was also asked to conduct basic TB training sessions for area public health workers, including Community Health Representatives (CHRs), nurses, physicians, and hospital administrative staff.

Activities
In the course of this assignment, I and two other members of the CDC Technical Assistance Team reviewed available medical records of all three TB patients and their contacts in order to better understand their demographic, social, and medical characteristics. I met regularly with host officials and kept the line of communication open at all times. I also shadowed the nurses as they visited patients’ homes for DOT and DOPT. I travelled to interview and re-interview the index patient at a nearby medical facility. I conducted a site visit at the location where the index patient worked during his infectious period and interviewed his supervisor, who was the only person to be diagnosed with LTBI at that site. I also interviewed several of the index patient’s family members, with special focus on those who were TST positive, in an effort to explore other exposure sites. I visited and interviewed a previous TB patient from the same community whose TB genotype was the same as that of the index patient. I also visited a local nursing home where both the previous and the present TB patient worked in the mid 1980s. Over the course of 2 days, I conducted TB training at the tribal health department with medical and nonmedical staff. The areas covered included fundamentals of TB, contact investigation, treatment guidelines, and DOT/ window prophylaxis.

Observations
The tribal community holds sacred a rich history of traditions and customs passed down from one generation to the next. For example, it would not be uncommon for a tribal member to request that family members be present while she or he discussed confidential health matters with public health workers. Consequently, public health professionals who are charged with conducting TB interviews and contact investigation in this community must strike a delicate balance between respecting clients’ wishes and safeguarding their confidentiality.  The point here is that given the richness and complexities of the traditions and customs of the tribe, it would seem prudent for health care providers addressing issues such as disease and medicine to develop diversity and cultural sensitivity that is unique to this tribal Nation. After all, a trusting relationship with the community is (and should be) the foundation of all public health activities. And I believe that when we, as public health professionals, develop and sharpen our cultural sensitivity competencies, we become better equipped to serve our clients, regardless of socioeconomic status.

One cannot overemphasize the importance of a prompt TB interview relative to TB control. TB interviews are not just about identifying contacts who need testing. Interviews also provide an excellent opportunity for the health care worker to begin the process of building rapport with the patient, and providing education about TB disease. Interviewing patients also facilitates effective and efficient contact investigation. It is, for example, during interviews that infectious periods are determined, and in the absence of a good infectious period estimate, chances are that the health department would end up testing people who should not be tested, and omitting people who should be tested. Thankfully, after we established the index patient’s infectious period, we did not miss any contacts. However, we found that a few contacts who were tested probably did not have to be tested. In this time of progressively dwindling resources, TB programs should strive, as much as possible, to limit TB testing and evaluation to true contacts. In the course of this two-week assignment, I conducted training on TB interviewing; however I believe that a more structured TB interviewing training for nurses in the tribal community would be beneficial. 

It appeared that both the previous TB patient and the index patient acquired LTBI in the 1980s, when they worked at a local nursing home. Neither took LTBI treatment, and both subsequently broke down with TB disease after being diagnosed with diabetes. According to the Indian Health Service Division of Diabetes Treatment and Prevention, in 2008, approximately 16.3% of American Indian and Alaska Native adults were diagnosed with diabetes compared to 8.7% of non-Hispanic whites1. Further, an estimated 30% of this population had pre-diabetes. Given the high prevalence of diabetes in this sub-group, one can expect people with LTBI to reactivate disease quickly- especially if diabetes is (or becomes) a concurrent morbidity. I believe that an effective strategy would be for the TB program in the community to encourage and emphasize LTBI treatment as a potent tool for preventing future progression to TB disease among this high risk population.

The index case was infectious for a very long time (a total of 164 days). During his TB interview, the index patient gave a history of productive cough for 2–3 months prior to hospitalization. His family members and co-workers also confirmed that he was always coughing. However, neither the index case, nor his family members, nor his co-workers thought it could be tuberculosis. As a result, the index case remained infectious and was able to infect a lot more people. In light of this, I recommend a community-wide campaign (as funds permit) to educate the population about TB and its signs and symptoms. Hopefully, such a community-based outreach effort would sensitize people to think TB, and to seek care early.

The opportunity I was given by DTBE to work in the tribal community will be remembered as one of the highlights of my public health career. I thoroughly enjoyed working with both tribal and IHS staff. I did not, for a moment, feel like a stranger throughout the 2 weeks I worked on the reservation. The people were simply awesome, and I count myself privileged to have worked with them.

—Reported by Patrick Ndibe, MA
Public Health Advisor
Houston Department of Health and Human Services

Reference
1. IHS. Website, 2008. Diabetes in American Indians and Alaska Natives: facts at-a-glance. [online] (page last updated June 2008). [Accessed on September 14, 2010.]

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The Pacific Island Tuberculosis Controllers Association (PITCA) Annual Workshop, Honolulu, HI

The 8th annual Pacific Island Tuberculosis Controllers Association (PITCA) workshop was held November 29 through December 3, 2010, at the Queens Conference Center, Honolulu, Hawaii.  The sponsors for this workshop were CDC, the Pacific Island Health Officers Association (PIHOA), the Pacific Chronic Disease Coalition (PCDC), Diagnostic Laboratory Services (DLS), and the State of Hawaii Tuberculosis (TB) Control Program.

Over 120 individuals attended this meeting, with representatives from the state of Hawaii and each of the six U.S.-affiliated Pacific Islands (USAPIs) (American Samoa, Guam, the Commonwealth of the Northern Marianas Islands, the Federated States of Micronesia, the Republic of the Marshall Islands, the Republic of Palau). USAPI representatives at the 2010 PITCA meeting included TB administrators, doctors, nurses, and laboratory staff.  This year, PITCA participants again benefited from professional faculty from a variety of organizations, including CDC’s Division of Tuberculosis Elimination in Atlanta, Georgia; DLS, based in Honolulu, HI; PIHOA; the U.S. Health Resources and Services Administration, National Hansen’s Disease Program; the World Health Organization’s Western Pacific Regional Office based in Manila; the Australian Respiratory Council; and the Curry International TB Center based in San Francisco, California.

The 2010 PITCA meeting started with an opening address by Dr. Seiji Yamada, Clinical Associate Professor of Family Practice and Public Health, University of Hawaii, John A. Burns School of Medicine. Among other topics, Dr. Yamada discussed local challenges to health care for Pacific Islanders in Hawaii. Other sessions presented at the meeting included implementation of web-based reporting for USAPI TB cases, recognizing and treating TB and diabetes co-morbidity, TB genotyping, TB cohort review, treatment of multidrug-resistant TB (MDR TB) cases and contacts, health workforce development, molecular testing for TB and drug resistance, shipping and supply, case studies of complex TB cases, emerging clinical TB issues for the USAPI, and a Grand Rounds presentation entitled “Outbreak of MDR TB in the Pacific Islands: Is Hawaii at Risk?”

The successful format for this year’s PITCA workshop consisted of 3 days of plenary sessions and 2 days of breakout sessions. The first day of plenary sessions included “reports back” from all of the USAPIs and represented agencies. The jurisdictions provided updates on the status of their respective goals and objectives that were identified during the previous (2009) PITCA workshop. During the workshop, the USAPI representatives developed 2011 goals, objectives, activities, and measures for evaluation. They will report back on their achievements at the next PITCA meeting (2011) and will also submit various required progress reports. The 2 days of breakout sessions were held concurrently and included sessions specific for the laboratory, nursing, and clinical staff.  Most concerns and issues raised during the sessions were discussed with the expert faculty present at the meeting and many important clinical, laboratory, and program related issues were successfully addressed prior to the conclusion of the PITCA workshop. Remaining unresolved issues and concerns are now being addressed, with the aim for resolution by the next PITCA meeting.

Relatively high rates of TB and diabetes are found in the USAPI. Therefore, this year’s meeting addressed the interaction between these two diseases. During the plenary session there was a unanimous vote to approve, endorse, and implement new Pacific Interim TB/Diabetes Guidelines. These guidelines were the product of collaborative work from numerous stakeholders after discussions about developing such guidelines began at the 2009 PITCA meeting. The guidelines will be distributed to the TB programs and are likely to be used to guide clinicians in the treatment and care of patients with TB and diabetes.

PITCA 2011 will probably be held in November or December in either Palau or the Republic of the Marshall Islands. Further information about PITCA is available from PIHOA.

—Reported by Andy Heetderks, MPH; Al Forbes;
Derrick Felix; and Richard Brostrom, MD

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Navajo Nation Plans TB Information Campaign for World TB Day

The Navajo Nation TB Control Program has been working with the New Mexico Department of Health (DOH) and the Northern Navajo Medical Center in creating and implementing the “2011 Navajo Nation TB Information Campaign.” This campaign was planned for March to coincide with World TB Day, March 24. Following are some of the activities:

  • Symptoms of TB Disease: protecting ouf future generations - coughing up blood, fever, chest pain, feeling tired or weak, weight loss, lump(s) in neck, night sweatsA media event about TB in the Navajo was held in Gallup, New Mexico, on March 10 at the University of New Mexico, in the campus gymnasium.
  • PSAs both in English and Navajo are being sent to at least 44 radio stations in and around Navajo communities.
  • Posters* are being placed in most Navajo communities and chapter houses.
  • Billboards* are being placed at the following locations:
    • One on HWY 64 between Shiprock and Farmington
    • One on HWY I-40 near Fire Rock casino
  • A 3–5 minute informational video is being created on TB prevention and treatment
    • Copies will be made available to all Navajo Area Service Unit facilities for in-house education.
  • Working with Four Directions Studio in the Northern Navajo Medical Center in Shiprock, a 30-minute documentary is being created on TB in Navajo Country, showing the history of TB in this area, as well as information about TB, contact investigations, and TB treatment.
    • We anticipate that a trailer for this documentary will be available for showing at the June 2011 National TB Conference in Atlanta, Georgia.
    • A 30-minute video is expected to be completed for October 2011 showing at the Four Corners TB/HIV Conference in Santa Fe.
    • New Mexico DOH staff and Navajo Nation TB Control Program staff met on March 1, 2011, in Santa Fe to discuss World TB Day and to plan a video script

*CDC carryover dollars provided the funding for the posters and the billboards

Editorial note: In a future issue of TB Notes, we will have a follow-up article describing how the concepts and messages for the PSAs and billboards were developed and the collaborative efforts that resulted in these important educational projects.

—Reported by Sarah Yazzie
TB Control Program Coordinator
Navajo Nation TB Control Program

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