TB Notes Newsletter

No. 1, 2010

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS

Nurse and Outreach Worker Recognized with 2nd Annual TB Heroes Award

Each year, the New England TB Consortium presents the TB Heroes Award to one or two individuals who make an extraordinary contribution to the care or management of patients with tuberculosis (TB) or for an activity that greatly enhanced TB prevention and control efforts. This year, the award committee received 25 nominations. The recipients selected for the 2009 New England TB Heroes Award are Florence Grant, RN, a public health nurse with the Cambridge Public Health Department in Massachusetts, and Helen Wu, an outreach worker for the Bridgeport Health Department in Connecticut.

Florence Grant, RN (left), receives the TB Heroes award from Sue Etkind (right), joined by nomination committee members Jill Fournier and Mark Lobato

Florence Grant was presented her award at the New England TB Intensive course in Manchester, New Hampshire. Sue Etkind, Director of the Massachusetts Division of TB Prevention and Control, thanked Florence for her hard work and read from the eloquent nomination letters submitted on her behalf. Florence’s colleagues spoke of her commitment and energy in working with TB patients. When it comes to contact investigations, one of Florence’s nominators wrote, “The key first step is to get in the door, to establish trust and relationships. Florence keeps trying until she gets in. It’s not that she doesn’t take no for an answer—it is that, eventually, even the most determined patient stops saying no to Florence!”

Florence addresses whatever obstacles to effective treatment she observes in a patient’s life—lack of privacy, family issues, hygiene, nutrition, or cultural perceptions about TB. “She may be making a DOT visit, but when she discovers that the patient has not eaten, she comes back later with soup! Whatever obstacles the patient faces, they become part of Florence’s care plan.”

Florence’s dedication to her patients continues even after treatment has ended. “Florence’s patients are never ‘completely discharged’. Years after they complete their TB treatment, they will call her whenever they need something—an appointment with the dentist, an appointment with a primary care provider. TB clinic patients past and present never hesitate to ask Florence to make a phone call to their lawyer or to call an agency over an unpaid bill.” Florence's dedication and accomplishments are inspirational, and she serves as an example of a true TB Hero.

Helen Wu accepts a citation from Bridgeport Mayor Bill Finch, January 5, 2010. At far left is Danielle Orcutt from the Connecticut TB control program. Photo: Christian Abraham/Connecticut Post

Flanked by two case managers as well as friends from Connecticut, Helen Wu received the TB Heroes award at the Community Health Worker TB Conference in Shrewsbury, MA. Dr. Mark Lobato, DTBE consultant to the New England region, gave credit to all of the outreach and community TB workers in attendance as day-to-day TB heroes. Yet, even among exemplary and dedicated staff, there are individuals who exhibit the qualities that we strive to live by and who encourage us to go beyond the customary job requirements. Helen is that type of person.

Helen is well-known in the community. From the clinic to the streets of Bridgeport, CT, she provides the drugs that cure the dreaded TB. As she carries out her duties, Helen combines the rare qualities of caregiver and social worker. Helen’s contributions serve as a model of what it means to go above and beyond the call to duty in her desire to eliminate TB. In the words of her nominator, “Helen’s compassion is unwavering. She exemplifies professionalism in all she does. Her title is TB outreach worker, yet her knowledge of tuberculosis treatment is so vast that physicians call her for treatment advice. Helen familiarizes herself with her patients and anticipates their needs.” Self-sacrificing, “She visits patients on weekends, holidays, or evenings if that is what their case dictates.” Even in the face of adversity, Helen perseveres. “The recent budget crisis has not hindered Helen; she collects soda cans from her fellow employees to distribute to her patients.” At the same time, “Her patients maintain their dignity, as they don’t feel like they are receiving ‘hand outs’.”

On January 5, 2010, Helen received a citation from the city by Mayor Bill Finch at the Bridgeport health department. To read an account of the citation ceremony, see “City worker honored for 'heroic' efforts to fight TB.” Known for her leadership, dedication, and creativity, Helen is one of those consummate TB outreach workers from whom we all can learn.

—Reported by the New England TB Consortium:
Nickolette Patrick (Northeast RTMCC),
Kathy Hursen (Massachusetts Division of TB Prevention and Control),
 Danielle Orcutt and Margaret Tate (Connecticut TB Program),
and Mark Lobato (Division of Tuberculosis Elimination, CDC)

 

California’s Multidrug-Resistant Tuberculosis Service
An Example of State and Local Jurisdictions Collaborating on Effective Management of Drug-Resistant Tuberculosis

Overview: California continues to shoulder the greatest burden of multidrug-resistant tuberculosis (MDR TB) in the nation, with 30 to 40 new MDR TB cases and 1 to 2 extensively drug-resistant TB cases annually. As observed nationally with MDR TB, a majority of cases in California occur within its growing immigrant and foreign-born communities. During 2000 to 2007, California reported 277 MDR TB cases; 249 (90%) of these occurred among foreign-born residents.

The MDR TB Service of the California Department of Public Health Tuberculosis Control Branch was established in 2002 to respond to the increasing threat of drug-resistant TB.  This service coordinates and oversees management of the State’s MDR TB cases and provides technical assistance to local health jurisdictions. By providing early consultation and close collaboration with local TB programs, the service aims to increase case management capacity at the local level, halt transmission, and ensure the best chance for cure for each MDR TB case in California.  The service makes an effort to use the consultation as a training opportunity for local staff on the principles and practice of managing MDR TB.

The MDR TB Service typically begins its consultation by assembling a working partnership of local TB program staff and acute care facility providers who are involved in the management and care of an MDR TB case.  This team meets monthly via teleconference to examine clinical and administrative aspects of diagnosis, management, and long-term monitoring and care.  The service tailors its support to the needs of the patient and local program. A full consultation consists of scheduled teleconferences and specific written clinical recommendations and updates.  The service regularly helps the local program plan for and access needed laboratory services, provides case management tools and templates, explores creative options with the team to secure second-line anti-tuberculosis drugs, and facilitates entry to Patient Assistance programs. The service also works closely with local staff to evaluate contacts, and recommends regimens for MDR latent TB infection (MDR LTBI) and monitoring for infected contacts.  For programs with experience in managing MDR TB, less intensive support is provided.

Throughout this collaborative process, a close working relationship develops between the MDR TB Service and local staff.  Local staff contact the service frequently between teleconferences with specific questions and requests to ensure quality continuity of care.  The State has assisted jurisdictions onsite with complex contact investigations, conducting patient interviews, and addressing communication challenges and overall planning.  As the case arrives at 6 months post–culture conversion and injectable therapy is completed, the service usually ends its monthly collaboration and continues its support on an ad hoc basis. Local staff may continue to contact the service as needed for specific guidance and will provide quarterly written updates to the service for the remainder of treatment.  The service monitors progress of the case by these updates and contacts the local TB program staff for clarification as needed.  The service also conducts annual cohort reviews of all MDR patients statewide to monitor outcomes and evaluate the service.

Case Study: In 2008 a local jurisdiction in California reported a new MDR TB case to the MDR TB Service.  The patient, a middle-aged foreign-born woman, had poorly controlled diabetes and no prior TB diagnosis or treatment.  The patient had resided in the United States for many years and was hospitalized with cough. Acid-fast bacilli were detected by sputum smear microscopy, and right upper lobe cavities were seen on chest radiograph.  A DNA probe of her sputum specimen identified M. tuberculosis, andthe patient started a standard four-drug regimen.  After 2 weeks, she was discharged to home isolation.  Approximately 3 weeks after treatment initiation, a conventional drug susceptibility test revealed isoniazid (INH) and rifampin resistance.  Because the patient had not received TB treatment previously and was not from a country with high primary MDR TB prevalence, the local TB program did not have confidence in the laboratory result.  Moreover, a large complement of contacts to this case was emerging that included several children aged 5 years and younger.  The local program requested a molecular beacon test be performed at the California Department of Public Health Microbial Diseases Laboratory (MDL) for rapid confirmation of the resistance and to support the best course of action for this patient and her contacts.  The molecular beacon test detected mutations associated with INH and rifampin resistance.  The local TB program lacked experience with MDR TB case management and requested assistance from the MDR TB Service.  The patient was re-hospitalized to initiate MDR TB therapy.

The MDR TB Service, local TB program staff, and acute care facility providers held an initial teleconference to develop a treatment, monitoring, and contact investigation plan.  Additional drug-susceptibility tests from the local laboratory and MDL revealed resistance to streptomycin and ethionamide, and susceptibility to levofloxacin, capreomycin, pyrazinamide (PZA), and ethambutol (EMB). The service recommended treatment and followed up with a written consultation that planned an expanded regimen of moxifloxacin, capreomycin, pyrazinamide, ethambutol, and cycloserine.  The service further recommended specific treatment efficacy and toxicity monitoring, a detailed approach to case management and coordination, and a plan for evaluating, treating, and monitoring contacts.  During the initial 10 weeks on the MDR TB treatment regimen, the local staff contacted the service frequently for additional guidance between monthly teleconferences.  

The MDR TB Service and local staff worked together closely to evaluate the large group of contacts to this case.  The contact investigation identified 16 adult contacts, 10 of whom were tuberculin skin test (TST) positive and had normal chest radiographs.  Based upon drug-susceptibility results of the source case, the service recommended a 9-month MDR LTBI regimen of ethambutol and moxifloxacin for these adult contacts in whom recent transmission from the index case was highly suspected.  The investigation also identified 17 children aged 15 years and younger, of whom seven were TST positive and had normal chest radiographs.  The service recommended a 9-month MDR LTBI regimen of PZA and EMB for the pediatric contacts. Of 33 contacts, 17 (52%) accepted MDR LTBI treatment; their follow-up is ongoing. 

The contact investigation also identified two pediatric contacts with active TB.  One child, who had an episode of fever and was otherwise asymptomatic, had peri-hilar lymphadenopathy and calcifications seen on chest radiograph.  The second child was asymptomatic with mediastinal lymphadenopathy and an upper lobe nodule seen on CT scan.  The MDR TB Service consulted infectious disease pediatricians in the MDR TB Expert Network, a national association of MDR TB practitioners, to develop consensus regarding pediatric treatment regimens and monitoring.  Both cases were treated with a regimen of amikacin, levofloxacin, ethambutol, PZA, and vitamin B6.  The service assisted the TB program in encouraging compliance with the family of one case whose treatment is delivered by a home health service, and whose management has proved to be particularly challenging.

Currently, the index case continues on treatment without complications.  Her sputum remains smear and culture negative.  The pediatric cases have improved by radiologic criteria and continue on their treatment regimens.

After nearly a year of accrued experience and close guidance from the MDR TB Service, the local TB program staff of this jurisdiction now manage and monitor three MDR TB cases and 31 contacts with enhanced capacity.  California’s experience with MDR TB case management contributes significantly to the growing body of expert MDR TB knowledge and practice.  The timely consultation and skill transfer between the State and local TB programs has resulted in enhanced local management capacity, and represents an increased opportunity for cure of California’s MDR TB cases.

As of 2009, the staff of California’s MDR TB Service consists of Cheryl Scott, MD, MPH, Lead; Lisa True, RN, MS, Nurse Coordinator; Leslie Henry, RN, PHN, Nurse Consultant; Gayle M. Schack, RN, BSN, Nurse Consultant; Gisela Schecter, MD, MPH, Physician Consultant; and Corrine Stuart, Communicable Disease Representative.

—Reported by Cheryl Scott, MD, MPH
Div of TB Elimination