TB Notes Newsletter

No. 3, 2010

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS

Public Health Prevention Specialist Application Process: The North Carolina Experience

Background. The Public Health Prevention Service (PHPS) is a 3-year training program that assigns prevention specialists to public health organizations in order to prepare them for leadership positions in health programs.  The program provides invaluable learning experiences for the prevention specialists, as well as important assistance for public health programs willing to invest in mentoring.  The qualifications for the PHPS include a master’s degree in public health or in a management-related field, strong interest in a leadership and management career in public health, 1 year of public health work experience, and 1 year of on-the-job training at CDC.

The North Carolina TB Control Program (TCP) received a Request for Applications (RFA) e-mail from CDC in November 2008, and despite the lengthy process such applications entail, the program decided it was well worth the effort.  The TCP had a critical need for program evaluation assistance and an interest in providing a meaningful experience for the right individual. 

Description of Process. In December 2008, the TCP decided to request a prevention specialist to systematically evaluate and improve the conduct of contact investigations.  The first step was to write a Letter of Intent (LOI), which was due about 45 days after receipt of the RFA e-mail.  The purpose of the LOI is to describe the proposed assignment and the activities the prevention specialist would undertake.  Specifically, the LOI provides information about the agency, and a statement of need that describes the health problem to be addressed, the priority population, key collaborations, and details about the assignment, along with a good description of the requesting program’s organizational structure, and the supervision to be provided. Below is the information that was provided in the NC TCP’s LOI.

Health problem to be addressed

Tuberculosis (TB) remains a persistent threat to public health in the United States and North Carolina.  While the number of cases is declining gradually, public health expertise to control TB is declining rapidly. Furthermore, resources for TB control are diminishing out of proportion to the reduction in caseload, resulting in less capacity to effectively control TB.  The continuing social, public health, and economic costs of TB provide a compelling rationale for TB elimination. In 2007, 13,293 new cases of TB disease occurred in the United States, and an estimated 11 million people have latent tuberculosis infection and are at risk of future disease. Although TB incidence is at an all-time low, the remaining cases are disproportionately occurring in difficult-to-reach populations, such as disadvantaged minorities, recent immigrants, homeless persons, and persons who abuse alcohol and/or illicit drugs. Ongoing TB transmission is facilitated in these populations by poor health care access and utilization, language and cultural barriers, and suboptimal relationships with the health care system. Outreach efforts are required to interrupt TB transmission in these populations.

Identification and targeted testing of persons at high risk for latent TB infection remains a cornerstone of TB control efforts in the United States. Persons at highest risk include recent contacts to infectious TB, and latently infected persons in populations with high prevalence of comorbidities (e.g., HIV) that increase the risk of progression from latent to active TB. Once identified, high-risk individuals with latent TB can be treated, thereby preventing future cases of TB. Ensuring efficient identification of latent TB infection and subsequent adherence to latent TB treatment requires expertise and commitment on the part of local health department staff. However, funding declines have made it virtually impossible to employ or maintain adequate staff to conduct effective contact investigations, particularly in more rural areas of North Carolina.

To address these issues, North Carolina proposes to develop a team of specially trained individuals who would be responsible for assisting local TB control programs in conducting large contact investigations, responding to outbreaks of active cases of TB, and coordinating targeted outreach efforts. The prevention specialist would serve as the lead coordinator on this team.

Priority population(s) 

As stated above, the priority populations include 1) contacts to infectious cases of TB.  These contacts of active cases are at high risk of developing TB disease, and 2) populations locally identified as having high risk for latent TB infection and suboptimal health care access/utilization.  In particular, populations associated with prior TB transmission in a given community will be targeted.

Key collaborations

The prevention specialist will foster collaborations both among local health department personnel (TB nurses, TB physicians, local health department supervisory staff), and also between the state TB program (nurse consultants, medical consultants) and the local health department.  Furthermore, the prevention specialist will interact with state and local personnel involved with other communicable disease outreach efforts (e.g., HIV testing outreach staff) to optimize the efficiency and yield of outreach efforts.

Assignment Description

Major activities and performance requirements:

• Enhance the existing Outbreak Response Plan for North Carolina.  Collaborate with local health department TB program staff members, Regional TB Nurse Consultants at the state level, the TB Medical Director, and any other public health staff from other programs, along with community providers and laboratory professionals regarding conducting contact investigations.
• Partner with community groups as well as cross-disciplinary public health groups to conduct outreach efforts to find those who may have been exposed to infectious TB. The forging of partnerships with community groups will help avoid potential problems such as barriers preventing contacts from reaching proper health care.
• Evaluate contact investigation methods and results.  Collect, track, and analyze the investigation and genotyping data necessary to determine the effectiveness of contact investigation and outbreak response efforts within North Carolina.

Organizational Structure and Supervision

Assignment location. The public health prevention specialist will be housed at the TB Program Central Office in Raleigh, North Carolina.

Developmental and training opportunities. The PS will be provided all the necessary education and training appropriate to conduct activities described. Specific activities will include the introduction to TB Program Management course, attendance at the Duke TB Symposium, and the TB/Respiratory Diseases Institute conference. On-site mentoring at local health departments will also be provided. The specialist will also work with staff from other communicable disease programs such as HIV and sexually transmitted disease (STD) prevention and control.

Primary Supervisor:  Maureen O’Rourke, MS. Ms. O’Rourke is a Senior Public Health Advisor and the current TB Program Manager in North Carolina.  Maureen has been with the Division of TB Elimination since 1999 and with the North Carolina TB Program since February 2006. She has worked in several states and has a wide range of public health experiences.*

Secondary Supervisor:  Jason Stout, MD, MHS. Dr. Stout is board certified in internal medicine and infectious diseases and is an Assistant Professor of Medicine with the Division of Infectious Diseases at Duke University Medical Center in Durham, North Carolina. Dr. Stout is the TB Medical Director and TB Controller for North Carolina. He also serves as the TB Medical Consultant for the Wake County Human Services TB Program in Raleigh, NC.

Results of Activity. North Carolina’s Letter of Intent was one of 169 LOIs received.  Based on these LOIs, 100 of the 169 programs were invited to submit a full application for a Prevention Specialist; NC was among them. The full application was developed and submitted to the PHPS office by the due date of April 6, 2009. On April 13, the PHPS office sent biosketches of Prevention Specialists to the TCP. During April 27–May 8, we had the opportunity to communicate with Prevention Specialists by e-mail and phone calls.  This is called the open recruitment stage of the process, and it allows for open discussion between Prevention Specialists and the public health organizations about expectations and interests. Open recruitment also allows time to address any questions or concerns regarding the assignment.  Ten prevention specialists were interviewed by telephone during open recruitment.  We were soon notified that our agency was one of about 55 agencies selected to participate in the PHPS interview day on July 10.  North Carolina TCP staff interviewed six candidates during interview day in Atlanta.  After the interviews, both the agencies and the Prevention Specialists ranked each other using a standardized scoring system from 1 to 6 (1 being most desirable, 6 least). Agencies were then matched with Prevention Specialists utilizing both scores.  Not every agency receives a specialist; in this case, only 23 candidates were available, and no state can accept more than two specialists. The North Carolina TCP
was very excited to be matched with a Prevention Specialist, who started on-site in October 2009.

Lessons Learned (thus far).  We learned that all the work involved in applying for a Prevention Specialist is well worth it! Also, agencies need a clear understanding of the proposed assignment, as well as the financial obligations each agency will incur having a Prevention Specialist for a 2-year assignment. A well-defined and organized training plan is key to making the specialist feel welcome and to optimizing the value of the experience for both the specialist and the organization. However, it is also important to be flexible and provide the specialist with unique experiences when they arise.  For example, our specialist has done an excellent job in assisting with a large contact evaluation at a college, mapping infection by location in a dormitory.

Future Plans.  We intend for our Prevention Specialist to complete a comprehensive evaluation of TB contact investigations across North Carolina, with suggestions for program improvement.  In return, we hope that she will have obtained on-the-ground experience in public health practice and management.  Most importantly, we hope that our enthusiasm for TB control is infectious!

—Reported by Maureen O'Rourke-Futey, MS
Public Health Advisor, Div of TB Elimination

* Note from the NC TCP: Since we applied for the Prevention Specialist, Maureen has moved to a new position in California.

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TB Outreach Among Indigenous Mexican Immigrants in San Francisco

Tuberculosis has long been associated with poverty, probably due to a combination of factors intrinsic to the experience of being poor: overcrowding, substandard living conditions, malnutrition, and decreased access to health care. As TB prevalence decreases owing to good TB control practices in wealthier countries, TB cases are becoming concentrated in marginalized and impoverished sectors of society. In San Francisco, socioeconomic gaps are addressed by numerous programs, such as universal health care for all citizens and multilingual staff to serve as cultural and linguistic interpreters for our diverse clientele. Here, we describe the discovery of unforeseen and unrecognized cultural barriers that impeded a TB contact investigation among indigenous Mexican day laborers.

A 33-year-old man (case A1) from Mexico’s southernmost state of Chiapas presented to our hospital on June 20, 2006, with 1 month of productive cough, chills, night sweats, and about 11 lbs. of weight loss. He had left-sided chest pain, with radiation to his back associated with coughing, and his chest x-ray (CXR) showed multiple left upper lobe cavitary lesions with air fluid levels. Both his tuberculin skin test (TST) and QuantiFERON Gold In-Tube (QFT GIT) test result were positive and he was started on a standard four-drug TB treatment regimen.

He lived at location A, a two-story apartment with 33 other men from the same region. Each floor consisted of a shared kitchen, bathroom, and multiple bedrooms, each with several bunk beds.  Contact investigation results showed that 26 out of 32 (81%) contacts had a positive TST result, defined as greater than 5 mm induration, three had negative TST results, and the remaining three could not be reached or were unwilling to be screened. Of those 26 with latent TB infection (LTBI), 21 (81%) initiated and completed treatment. Contact evaluation found that 4 out of 33 (12%) had pulmonary TB; 2 were diagnosed initially (cases A2 and A3), and 2 more were diagnosed (case A4 and A5) 8-10 months later when they moved back to the apartment and were screened. 

Case B1 was a 31-year-old man referred from the local day labor program and seen in the TB clinic on September 25, 2007. He had cough, fever, hoarseness, and weight loss of 13–25 lbs. for 1 year. His CXR showed extensive left upper lobe and left middle lobe cavities and fibro-nodular changes. Because of his hoarseness, he was suspected of having laryngeal TB, and started on TB treatment immediately owing to the highly infectious nature of TB laryngitis.

Case B1 had emigrated from Chiapas to San Francisco in April 2007, and stayed with a roommate at two other locations before settling at Location B. Location B was the top floor of an apartment building that consisted of five bedrooms, each sleeping 4–6 persons, and a common kitchen and bathroom, housing day laborers from Chiapas. 

Out of 30 contacts screened at location B, 24 (80%) tested positive by QFT-IT blood test or had a history of positive TST. Twelve of these contacts (50%) started LTBI treatment. There was one additional case of laryngeal TB, case B2, found at this site.

Upon further discussion with the social worker, it was discovered that Case B1 had shared daily car rides with Case A1, including trips to the TB clinic, where he waited in the car while Case A1 received DOT. He was never named as a contact and, therefore, never screened. Case C, independently diagnosed and treated through the San Francisco Public Health Department, told the social worker that he was related to Case B1 and had been a previous roommate. After lengthy education about TB transmission, Case C showed the disease control investigator and social worker two more sites where he and Case B1 had lived. From this expanded investigation, one more pediatric case, Case B3, was diagnosed. All eight specimens sent for genotyping studies matched (cluster CA_414).  One other case in this cluster, in another county, originates from Chiapas, Mexico, as well. There are no other cases of this genotype in the United States.

Timeline of Diagnoses of Cases in Chiapan TB Outbreak in San Francisco

Text Only version

Case A1-A5 (color-coded yellow):  initial contact investigation associated with Case A1

Case B1-B3 (color-coded blue):  Expanded contact investigation when Case B1 diagnosed and linked to Case A1

Case C (color-coded pink):  separately diagnosed case later found to have epidemiologic links and matching genotype

Analyzing this outbreak, the unique patient aspects that led to delayed diagnoses of TB and transmission were the following: 1) coming from an isolated community that had very little sociocultural exposure outside of their village/region, and 2) having little or no spoken fluency in Spanish.  These conditions caused barriers not only to TB testing, but also to cooperating with routine contact investigation.  Most of these men had never interacted with a medical system, much less seen a doctor or received injections or phlebotomy.  The social worker realized through her interactions with these contacts that they were willing to be cooperative, but there was another layer of barrier that existed.  She discovered that they had poor Spanish comprehension; their native tongue was Tseltal, an indigenous language of Southern Mexico.  In addition, she realized after persistent questioning that they were unfamiliar with conventional items in our society that we take for granted such as mail, mailboxes, or addresses (i.e., that locations are uniquely identified by a number and street). These gaps in knowledge and communication delayed our initial contact investigation, since these young men were unable to correctly provide addresses or read their notifications in Spanish instructing them of their need for evaluation.  The social worker’s role as a cultural broker was essential to earning their trust.  She provided education on many basic things, including enrollment in the local health plan, and acted as a conduit to navigate the health system for other health concerns.

There are 36 million indigenous people in Mexico, constituting one third of the country’s population.  Most originate from the south-central states of Mexico, with 62 different languages spoken.  Day laborers and other Mexican immigrants who work in San Francisco reflect this diversity. According to an August 2008 article in the Mexican newspaper Milenio, 22,581 people died of TB in Mexico between January 2000 and June 2008 (equaling a death rate of approximately 2.7/100,000, 10 times higher than the U.S. TB death rate). TB mortality is second highest in Chiapas, after the state of Veracruz.  We realized that these indigenous groups, not fluent in Spanish, are an underrepresented minority group who face frequent unique difficulties such as rent gouging, unsafe working and living conditions, and lack of access to legal rights. They often live in overcrowded situations that violate city codes and are at increased health risks for many diseases, including TB.

Building on the trust forged by our social worker, we decided to arrange a coalition of community leaders and service providers to offer access and education to these underserved immigrants.  With access to health care and health education, we hoped these non-Spanish speaking immigrants would feel safe enough to come in for diagnosis earlier, preventing further transmission in their community.  We held our first coalition meeting on March 20, 2008, and had an overwhelming response from the community, with 21 participants from 10 associations represented. The meeting was conducted in Spanish and English, and gaps and priorities for taking care of these communities were identified.  Spanish-language educational materials from multiple sources were distributed for participants to review at the second meeting, and plans were made to develop educational outreach materials in a few indigenous languages for radio announcements or dubbed videos.  The telenovela-style material developed by the Southeast National TB Center was particularly popular (telenovelas are popular Latin television melodramas, much like American soap operas).  There were also requests for health care training for community leaders, so they could act as health advocates. Although we have not located funding for these projects to date, we are actively investigating creative partnerships to get these materials developed.

Unexpectedly, the men who were originally evaluated as contacts became our best source of outreach.  They have referred newly arrived roommates who have chronic cough or other TB symptoms to us for evaluation, lest they become re-exposed to or re-infected by yet another new case of TB.  They have walked their friends with TB to the clinic for follow-up surveillance, to ensure compliance and treatment cure. They have called our social worker with other health-related questions, to ensure that important health issues are addressed in a timely manner.  This outbreak, a unique cluster in the United States isolated to these Chiapans, has provided us with insight into the barriers to TB diagnosis and control in these challenging populations and has given us an opportunity to provide outreach to the indigenous communities in San Francisco. 

This experience has revealed to us the numerous indigenous groups from Latin America living in our region.  We may not be aware of their linguistic and cultural differences, and providing language translation may not be adequate in these persons. Although these cultural and linguistic differences may initially go unrecognized, establishing trust by assisting them with acculturation and access to general health care has been the key to garnering their cooperation, and turning them into partners for TB prevention in this tight-knit community.

—Submitted by Christine S. Ho, MD, MPH
DTBE Medical Officer, San Francisco, California

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