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TB Notes Newsletter
No.
1, 2008
Highlights From State and Local
Programs
TB Outreach Educator Honored
Juan 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
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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)
Last Updated:
07/01/2008
Last Reviewed: 05/18/2008 Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Last Reviewed: 05/18/2008 Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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