TB Notes Newsletter

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No. 1, 2009

Highlights From State and Local Programs

Rotary International Working to Prevent and Control TB on the Texas-Mexico Border

Rotary International is known for its extraordinary work around the world against polio.* Currently, Rotary clubs in several Texas-Mexico districts are working diligently in collaboration with the TB binational projects to help prevent and control tuberculosis (TB) on the Texas-Mexico border. The binational projects, which receive CDC funding for personnel and infrastructure, treat Mexican patients who have complicated TB and who are frequent border crossers. The four projects are located in the Mexican states of Tamaulipas and Chihuahua, in the border cities of Matamoras, Reynosa, Nuevo Laredo, and Juarez.

In one Rotary project called TB Plus, the Rotary clubs in the area are helping patients enrolled in the TB binational projects receive adequate nutritional support while receiving their TB medications. This assistance is critically important for children being treated for TB. Rotary clubs in Texas and Mexico also support the binational projects by providing supplies and equipment. The Dallas Rotary Club is a good example; the club has been a very significant partner and ally to the binational projects in the Rio Grande Valley area of Texas, whose population is predominantly Hispanic. The members have provided medical equipment and computers to the projects; in addition, they provide school supplies to the children and nutritional support such as Ensure® to the patients.

In August 2008, in another collaborative effort, members of Rotary International met with the Methodist Healthcare Ministries (MHM) and the General Board of Global Ministries (GBGM) of the United Methodist Church (UMC) in the Rio Grande Valley of Texas to discuss how they could work together to strengthen efforts to prevent and control TB on the Texas-Mexico border.

Also of note, the Rotary clubs in Texas joined those in Mexico to apply for funding from the Rotary Foundation to assist in the establishment of a TB laboratory in Reynosa, Mexico. The Rotary Foundation approved the application and funded the project with a $300,000 grant, one of only 17 grants given worldwide by the Rotary Foundation. The Mexican state of Tamaulipas received approval from its Health Commissioner to construct the new laboratory building; the Rotary Foundation funds will be used to outfit this laboratory with equipment and supplies, and the Texas Department of State Health Services will provide training to the laboratory personnel working in the new laboratory. Currently, the Texas Department of State Services laboratory provides diagnostic services for the TB binational projects in Reynosa and Matamoras. Working with the state laboratory in Tamaulipas, Mexico, the grant will enable the Reynosa laboratory to provide smear and culture capacity. This will have the positive effect of decreasing the number of specimens for the Texas laboratory to process and analyze.

To provide some context, Reynosa is a sister city to McAllen, Texas, in Hidalgo County, where over 40% of the residents live below the federal poverty level. Hidalgo County has over 900 colonias, unincorporated communities in the border region lacking adequate infrastructure such as water, sewer services, and paved roads. The housing in these communities is substandard; in some cases, the structures are made of cardboard. The only health interventions in these colonias are those provided by promotoras, community health workers who enter the colonias to perform TB case finding and contact investigations. Rotary is working to support those families on both sides of the border with the best TB laboratory services available.

—Reported by Charles Wallace, PhD
Texas TB Control Program

Denver Metro TB Clinic: Update for Civil Surgeons on the New TB Technical Instructions

Civil surgeons are physicians appointed by local offices of the Bureau of U.S. Citizenship and Immigration Services (USCIS) to perform the medical examinations of aliens, or noncitizens, already residing in the United States. Noncitizens who require medical examination include persons applying for adjustment of immigration status (e.g., nonimmigrant visa holders applying for citizenship) and other persons requiring a medical examination as determined by the Department of Homeland Security.  The USCIS released new guidelines for civil surgeons and a new I-693 form on May 1, 2008. 

In July 2008, the Denver Metro TB Clinic, in collaboration with the Francis J. Curry National TB Center and the Colorado Coalition Against TB, held a course for civil surgeons in the Denver area to update them on TB and the new TB component of the Technical Instructions for the Medical Examination of Aliens in the United States.

The course was held in the evening, from 5:45 pm to 8:30 pm to allow physicians to attend after completing their office hours.  The topics included information on the epidemiology of TB, the new overseas TB screening requirements for immigration, a review of the new I-693 technical instructions for TB screening, identification of suspect and active TB, and management of latent TB infection (LTBI).

Upon completion of the course, participants would be able to-

1. Complete the I-693 form correctly and completely;
2. Explain when, where, and how to refer patients with suspect or active TB;
3. Describe the roles of the panel physician, the civil surgeon, and the U.S. public health physician in the prevention and control of TB; 
4. Explain which immigrants are at greater risk for drug-resistant TB;
5. Interpret chest x-ray findings and differentiate between latent TB infection and TB disease; and
6. Explain when and how to treat LTBI.

Physicians received a light dinner, continuing education credits, and a packet of materials. The materials included copies of the course slides, the new technical instructions, and a variety of educational materials on TB and the medical screening of immigrants and refugees. 

If you would like more information or copies of any of the handouts, please contact Carolyn Bargman, RN-C, MA, at cbargman@dhha.org .

—Submitted by Carolyn Bargman
Denver Metro TB Clinic

Construction Beginning on New TB-Care Facility in San Antonio

The following is an excerpt of an article that was featured in the Texas Department of State Health Services (DSHS) Staff News, an online publication of the DSHS. This excerpt is reprinted with permission from the author, Ms. Shelly Ogle. Permission to use photos was granted by the subjects.

After 13 years as superintendent of the Texas Center for Infectious Disease (TCID), Jim Elkins is delighted that a new patient-care building—the hospital’s first one in more than 55 years—is being constructed at the San Antonio facility.

TCID is the only TB hospital in Texas and is one of just six TB centers in the nation. It’s designed to treat patients for the duration of their treatment—6 months to 2 years. Fifty years ago, when Texas had 21 such facilities, TCID was known as the San Antonio State TB Hospital and housed nearly 1,000 patients.

Tuberculosis is no longer so prevalent; last year, the hospital treated 78 patients with TB. It also provided outpatient care for 17 patients with Hansen’s disease.

“TCID’s services are still needed to support the state’s TB treatment and indigent-care systems,” says Elkins. “I am glad that the hospital is relevant.”

Its relevancy is proven by the state’s commitment to pay $23 million for a new two-story, 82,000-square-foot hospital that’s set to be completed in May 2010.

On Dec. 15, Elkins hosted a ground-breaking event at TCID for the new building. Guests included professional colleagues, members of the DSHS leadership team, representatives from the construction firm, and local dignitaries.

“I really appreciate the people who work here for their talents and devotion to a different type of patient care than is found in most modern hospitals,” says Elkins. “I’m grateful to see up-to-date facilities built in which they can continue to serve the patients who are treated here.”

The new building will hold 75 single-patient rooms designed with safety features specifically for TB patients. Because TB bacteria can be airborne, the air drawn into the patients’ rooms is exchanged every 10 minutes and is never expelled into hallways or other common areas. The building will also contain nurses’ stations and medication rooms.

“The present design uses the best of all previous plans,” says David McCormick, manager of the DSHS Hospital Construction Unit. “We all feel very good about this design and are looking forward to the anticipated completion in 2010.”

Three other existing buildings adjacent to the new patient-care building will be renovated for clinical-support, diagnostic, therapy, administrative, and food-service spaces. Studies are under way to determine whether the buildings that now house patient-care units can be converted to other uses by DSHS.

TCID is a specialty hospital without emergency services, operating rooms, or intensive-care units. Patients needing such acute-care hospital services are transferred to an area hospital for care and treatment and then returned to TCID for hospitalization.

Patients stay at TCID until their TB is cured or they are stabilized enough to be returned to their communities to continue outpatient TB treatment at home.

—Contributed by Shelly Ogle, Editor
Texas DSHS Staff News

Indiana: Outbreak Planning in Low-Incidence Areas

Shameer Poonja, a CDC Public Health Advisor assigned to Indiana for 2.5 years, reported to DTBE on the results of outbreak planning activities in that state.

Although Indiana continues to be listed as a low-prevalence state (case rate 2.0 per 100,000), it has had several outbreaks in its northeast area. Between 1999 and 2007, Kosciusko County had 43 cases linked either through genotype or epidemiologic associations; 10 of the 43 cases were reported in 2005. Five other Indiana counties have also reported cases in this cluster. Many of these case patients had extensive alcohol use, with a smaller number of persons being current drug users. Some of these cases have been linked through social networks that included bars, work sites, and public buildings.

As in previous situations, the 2005 Kosciusko outbreak quickly overwhelmed resources at both the local and state health departments. DTBE provided supplemental funding as well as technical assistance from an Epi-Aid team in fall 2005. The recommendations of the Epi-Aid team were to 1) pursue case findings around this cluster, 2) conduct thorough contact investigations, 3) continue to provide directly observed therapy (DOT) to TB patients until treatment completion, 4) treat contacts having latent TB infection (LTBI), and 5) educate local health care providers about TB to ensure early diagnosis and start of treatment. This report focuses on the program’s actions surrounding improving overall outbreak identification and response, and improving contact investigations (recommendation 2).

In early 2006, the state procured additional funding to add a full-time TB epidemiologist to the program to oversee the reporting of contact investigation activities. For every pulmonary TB case reported, the reporting jurisdiction is required to submit a preliminary and final contact investigation form. With the addition of the TB epidemiologist to oversee these activities, the TB program has been proactive in establishing infectious periods and reviewing information relating to potential sites of exposure. Reported TB suspects and cases that have epidemiologic linkages, including those in congregate settings (e.g., homeless shelters, schools, or correctional facilities), or cases that have greater than 25 contacts identified, are deemed “high priority” for investigation. Guided by this high-priority list, the TB program has been able to work with the local health departments on a daily basis to follow up on these types of investigations. This list is reviewed monthly by the TB epidemiologist, TB Program Director, and CDC PHA during case management sessions to prioritize any additional resources needed, including manpower and funding, and ensure adequate and timely follow-up.

Many TB programs throughout the country have benefited from the use of genotyping of TB isolates to find clusters of cases that may otherwise not be detected through traditional investigative activities. In Indiana, the process begins when all newly cultured isolates identified as M. tuberculosis through the Indiana State Laboratory are sent to the Michigan reference laboratory for genotyping. The submitted isolate undergoes genotyping via spoligotyping and mycobacterial interspersed repetitive unit (MIRU) analysis. When the results become available, all necessary demographic case information is entered into the newly created database along with the laboratory results received from the Michigan laboratory. A cluster number is assigned to all isolates with the same spoligotype and MIRU numbers. Any provider-diagnosed or clinical case that is linked epidemiologically within a cluster may also be added to ensure that the investigation includes all counted cases.  From this information, basic timelines and reports can be generated to look at similarities between cases and establish links. All information is shared with local case managers and reviewed internally by program staff to review all possible linkages between cases or to establish an epidemiologic link between cases. If an epidemiologic link does not exist, or cannot be established, a secondary patient interview or chart review at the local health department may be required.

In addition, the TB program has also established a formal TB outbreak response plan. The purpose of the plan is to define a working definition of an outbreak and establish a set of procedures to follow in response to a TB outbreak or an expanded screening in a community.

As a direct result of these initial actions, the Indiana TB Control Program has been able to provide extra guidance in two small outbreaks and several expanded screenings throughout the state. In one investigation that involved three genotypically related TB case patients living and working in two different counties, the outbreak plan enabled the various case managers to work together to narrow potential sites of exposure and focus the investigation on a common worksite. As a result of initial conference calls, additional interviews were conducted with all three patients, and links were established between two cases. This particular situation also emphasized for the local case managers the importance of detailed case investigation interviews.

Overall, these activities have resulted in—

1. The establishment of a high-priority list of contact investigations that ensures critical investigations are conducted;
2. The establishment of a working definition of an outbreak to ensure a more rapid reaction when new linkages are established;
3. The creation of clear timelines for actions to ensure that potential sites of exposure are investigated and reviewed with the local case manager and, when necessary, the County Health Officer is alerted; and
4. The assurance that resources needed to complete tasks will be assessed earlier and, if necessary, additional resources will be made available.

In order to improve the early identification of TB transmission in Indiana, the State Health Department recognized the need for dedicated resources to oversee contact tracing. Initially the TB epidemiologist was assigned to take on the established program practice of sending out contact investigation forms for all pulmonary TB cases. However, the TB epidemiologist has incorporated the use of genotyping to collect and analyze data in order to establish links between cases. Having dedicated personnel enabled the TB program to emphasize the prioritization of contacts to ensure that the high-risk contacts are identified, evaluated, and treated appropriately.

In terms of our outbreak process, the program has since removed the expanded screening component of the plan and included it into a newly drafted contact investigation protocol. We have also reviewed and updated our contact investigation forms and timelines for reporting. Several education sessions with local health department staff have already taken place to highlight these changes. Continued emphasis and training will be placed on improving contact investigation activities by illustrating contact identification, evaluation, and completion rates as outlined in the CDC Aggregate Reports for TB Program Evaluation (ARPE). 

The program plans to annually revisit the outbreak plan process to incorporate new findings.

—Reported by Shameer Poonja
Div of TB Elimination

A Tale of One Patient, a Very Resistant Bug, and Two Different Public Health Systems

Bruce Heath, a CDC Public Health Advisor assigned to Texas for 3 years, reported to DTBE on drug-resistant TB in a foreign national who crossed the border many times while infectious.

Background
On April 16, 2007, a “be on the lookout” alert (lookout) was issued by the El Paso Quarantine Station for a Mexican national who had “a very dangerous and contagious strain of TB.”  The lookout listed the subject’s name and date of birth.  The lookout also stated that the patient was a businessman who traveled into the United States frequently.  The Texas TB program learned of this patient on April 18, 2007, when the lookout was sent to the state TB program by another office in the Texas Department of State Health Services (DSHS) who thought we should be aware of the situation. I immediately checked to determine if the patient was receiving treatment from the Juntos Binational TB Project (a program funded by CDC to provide treatment of patients with complicated TB cases along the U.S./Mexico border). I learned that the patient had been enrolled in Juntos on April 18, 2007.

The lookout requested that anyone with information regarding the patient contact the CDC quarantine station in El Paso.  I contacted the medical officer at the station and learned that he had been instrumental in initiating the lookout and, in fact, had been quite involved with the patient’s case before the lookout was issued.  The medical officer was employed by the Texas Department of State Health Services in El Paso before becoming a CDC employee and was very involved in the management of the Juntos program.  He continues to work with Juntos, serving as a member of the Juntos MDR TB review committee.  Owing to this unique relationship with Juntos, he had been aware of the patient, the patient’s travel history, and the possibility that the patient may have had MDR TB. 

During the conversation with the medical director of the El Paso Quarantine station and other conversations with the Juntos project coordinator, I learned that this patient had a long history of being treated for TB.  He began his trek towards MDR TB in April 2001 when he was first diagnosed with TB by a health care provider in the City of Chihuahua and placed on unsupervised treatment in Mexico.  He was treated with Rifater, a one-pill combination treatment of isoniazid (INH), rifampin (RIF), and pyrazinamide (PZA). In April 2002, the patient continued his MDR journey when his cough returned and he went to a health clinic in the City of Chihuahua. He was again prescribed Rifater, and again was not placed on directly observed therapy (DOT).  After this, the patient began taking Rifater intermittently whenever he became symptomatic. (Note:  TB medications can be purchased over the counter in Mexico.)  The patient also reported taking ofloxacin for “fevers.” 

The patient was then not seen in the Mexican public health system until January 2007, when he presented with TB again to the Juarez City Health Department. The group Juntos provides support to the Juarez TB program by processing cultures, as there is no capacity to perform culture in Juarez.  (The Juarez TB program can only perform smears.)  The Juarez TB program started the patient on a four-drug regimen in January 2007, and this time placed him on DOT.

In March 2007, the culture reports confirmed that the patient had MDR TB (resistant to INH, RIF, PZA, and ofloxacin), and his case was referred to Juntos for review by the MDR committee.  The patient’s case was enrolled in Juntos on April 18, 2007.

It is important to note that Juntos provides services to patients on the Mexican side of the border in Juarez, Chihuahua, which is the sister city to El Paso, Texas.  Although medications are provided by the state of Texas and project personnel are supported through the TB cooperative agreement, Juntos patients are Mexican patients, reported as Mexican morbidity, and ultimately fall under the responsibility of the Mexican public health system.

The contact investigation
After determining that the patient was receiving treatment from Juntos, I communicated frequently with the Juntos project coordinator to ensure that a complete and comprehensive contact investigation was performed in a timely manner. During these communications, I discovered that not only was the project coordinator communicating with the patient on a regular basis, the medical director of the El Paso Quarantine Station was also speaking with the patient, as was the chief of the Juarez City Health Department.  The purpose of the conversations was to advise the patient against crossing the U.S. border and against traveling by air, and to attempt to gather information to conduct a contact investigation. 

It became very clear that the patient was not telling all that he knew about his travels and contacts.  I consulted with the senior PHA in Texas and the manager of the Texas TB program.  We all decided that I should try to interview the patient in person; however, the Juarez City Health Department declined my offer to assist in the interview/contact investigation process.  The health director stated that he felt that an interview by me would put too much pressure on the patient.

During this time, the patient maintained possession of his border-crossing visa. The previously mentioned lookout remained in effect.  However, the name on the lookout did not exactly match his correct name on the visa, and the patient was able to continue traveling into the United States (land and air travel), even after he had been advised not to do so. 

I continued to communicate with the Juntos project coordinator to provide guidance in the interview process.  The patient’s entire household was skin-test positive. However, they all had negative chest X-rays.  They had not been tested for TB during the patient’s previous TB episodes.

The project coordinator was finally able to convince the patient to bring in some business records and was able to establish some contacts to investigate.  A total of 11 business contacts were investigated in the United States, in many different states.  Of these contacts, one was skin-test positive and one refused to be tested; the remainder were skin-test negative. The positive contact was a person with whom the patient worked on a regular basis. 

Is isolation a possibility?
During the process of the contact investigation and in the first few weeks, it was clear that the patient was not heeding the “no traveling” advice of Juntos, the Juarez Health Department, and the El Paso Quarantine Station.  He was also being evasive and uncooperative regarding the contact investigation.  We began discussions regarding the possibility of isolation, including isolation in Mexico.  According to the public health officials, there are laws in existence that allow involuntary isolation.  However, the president of Mexico must approve any involuntary isolation. This has never been done. 

After it was determined that the patient could not be isolated using Mexican public health law, we consulted with the DSHS Office of General Counsel to explore any options in the Texas public health code.  Texas has no authority to isolate foreign nationals.  If the patient were to cross into the United States illegally, he would fall under the authority of Immigrations and Customs Enforcement (ICE).  ICE will only hold infectious TB patients until they are treated sufficiently to become noninfectious.  Patients are then deported to their country of origin. 

Involvement of multiple U.S. organizations
This case gained much attention very quickly.  I participated in many meetings and conference calls with representatives from the Texas TB program, the Department of Homeland Security, Customs and Border Protection, the U.S. Department of State, and CDC (DTBE and DGMQ).  As a result of these meetings, the patient was placed on a national “Do not board” list. 

Customs and Border Protection staff members were also able to assist in obtaining a listing of each time the patient crossed the border. Through this list, we were able to officially confirm what we had already concluded earlier: that the patient had entered the United States multiple times after he had been advised not to travel. 

We were also able to convince the patient to voluntarily surrender his border-crossing visa, with the agreement that the U.S. Department of State would hold his visa rather than revoke it.  This compromise guaranteed that the patient could not legally travel to the United States, but did not formally revoke his visa. 

Conclusions and lessons learned
The patient has since completed adequate treatment, administered via DOT by Juntos staff.  His treatment was based on consultation with Texas TB experts. Staff of Juntos reported that he remained compliant throughout his treatment.  He has been removed from the “no fly” list and is allowed border-crossing privileges again.  Thankfully, there were no additional cases associated with this case. 

There were many lessons learned as a result of this case.  I think that the most important lesson is that we need to continue to work closely with the El Paso Quarantine Station to enhance communication regarding border TB (and other infectious disease) issues.  Also, the state TB office should have been notified of the lookout posting before it was issued.  This would have alerted us of the issue and allowed us to work with health authorities in Mexico, through Juntos, to ensure a unified case management and contact investigation.

Another very important lesson learned from this case is that we have extremely limited options for isolation when a binational patient becomes noncompliant. Mexican public health laws do not support involuntary isolation, and Texas has no authority for patients who are not Texas residents.  This one case exposes a serious flaw in public health safety along the border.  It asks the question:  “What if this patient were infectious with a virulent form of influenza during an epidemic?” 

Another major issue demonstrated by this case is the extreme difference in the two public health systems in the management of TB.  The Mexican public health system definitely placed a very high priority on this individual patient’s rights versus the health of the public.  This was demonstrated by the way in which the interviews were handled.  The interview process was not assertive, even after it was determined that the patient was being untruthful. My offers to provide assistance in the interview were declined.  The patient was basically allowed to manage his own contact investigation. 

Although this is the case that has been brought to our attention, it is most likely not the only case of its kind along the U.S./Mexico border. There are thousands of border crossings each day, and many cases of TB and resistant TB in the Mexican border states.  We are fortunate that this patient was enrolled in Juntos, thus allowing us to obtain information on him.  If this link had not been made, it is likely that information regarding this patient’s resistant TB and treatment would have been much slower getting from the Quarantine station in El Paso to the Texas TB office. 

With so many binational issues (isolation, individual rights vs. public health, etc.) regarding ONE patient, what happens when we have 20, 40, 100, or more infectious patients attempting to enter the United States for business or to seek medical care?  How will we coordinate between the two nations?  How will we ensure that the public’s health is protected on both sides of the border?

—Reported by Bruce Heath
Div of TB Elimination

Evaluation Workgroup Retreat

The Tuberculosis Evaluation Work Group (EWG) Strategic Planning Retreat convened in Atlanta, Georgia, on November 13–14, 2008, and included more than 30 participants from state and city TB control programs, Regional Training and Medical Consultation Centers (RTMCCs), the National TB Controllers Association (NTCA), the Advisory Council for the Elimination of TB (ACET), and DTBE. The purpose of the retreat was to open the next chapter of the evaluation capacity-building efforts of TB control and prevention programs. Attendees set the stage for the future of program evaluation in TB by discussing their accomplishments and challenges in building evaluation capacity and practice over the last 4 years.

During the retreat, attendees reviewed the impact of the EWG Strategic Plan for 2004–2008; determined challenges and barriers to the implementation of the plan; determined current needs and expectations for program evaluation capacity building and technical assistance; and developed the next EWG Strategic Plan for 2009–2013. After sharing the lessons learned and the challenges in bringing evaluation into program management over the last 5 years, attendees discussed the future role of the EWG and the responsibilities of membership in the EWG.

One outcome of the retreat was a new moniker: the group has been renamed the TB Program Evaluation Network (TB PEN), reflecting its evolving goals and objectives. The TB PEN Steering Committee was formed to

1. Review program evaluation findings and assess applicability and generalizability of findings;
2. Direct evaluation efforts;
3. Promote evaluation projects for funding; and
4. Determine needs for evaluation training, technical assistance, and evaluation tools.

Retreat attendees agreed that establishment of evaluation focal point positions in state and big city TB programs was imperative to the future of program evaluation in these TB programs. The evaluation focal point will serve as each TB program’s point of communication with CDC and will be responsible for overseeing evaluation initiatives in their area, providing updates to CDC, and sharing lessons learned with other programs. This focal point, serving as a subject-matter expert, will also oversee and participate in evaluation research. Identifying and appointing an evaluation focal point will be a requirement in the TB cooperative agreement for the upcoming years.

Partnerships with other organizations were discussed, and several exciting collaborative opportunities were identified, such as working with

1. The TB Epidemiologic Studies Consortium in the development of an evaluation tool;
2. The RTMCCs to jointly develop a training curriculum on TB program evaluation;
3. The TB Education and Training Network (TBETN) in support of a joint annual meeting for TB PEN.

The retreat was deemed successful and productive by DTBE. For more information about the retreat, please contact Linda Leary (LLeary@cdc.gov).

—Reported by Linda Leary
Lakshmy Menon, and
Vidya Venkataramanan
Div of TB Elimination