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TB Notes 3, 2004
HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS
Daily Accountability and
Innovative Methods That Push Performance and Achieve Higher Outcomes
In many areas, the demand for TB control services outweighs available
resources. Such is the case in Houston, Texas. Teamwork simplifies
the processes, but how can a team of 6 to 10 supervisory and administrative
staff direct, plan, evaluate, and provide daily supervision to achieve
the program objectives of a large metropolitan TB program covering
617 square miles? Houston TB staff consistently deliver and supervise
between 1,200 and 2,000 directly observed therapy (DOT) doses per
The answer: increase accountability to ensure daily achievement
of objectives through daily administrative and supervisory
staff meetings, and implement innovative methodologies.
Accountability, Accountability, Accountability
Accountability drives improvement. Accountability enables changes
that impact outcome. How do we achieve it? Push daily accountability
and conduct daily administrative and supervisory staff meetings.
Staff come prepared to share yesterday’s outcomes, issues,
and concerns, and are ready to assess situations and offer solutions.
“You want what? DAILY staff meetings? You've got to be kidding!”
Staff were reluctant when it was first suggested. "We're too
"We don't have time to meet every day."
"Mornings are the busiest times.”
“How about meeting once a week?"
These were only a few of the many objections expressed by the administrative
and supervisory staff.
Today we wouldn't change it! Daily staff meetings provide daily
accountability for every area of the TB Bureau. This 30- to 60-minute
period has become the most important part of the day. It is the
fastest and most efficient way for staff to share pertinent information,
discuss nonadherent patients and clinic issues, distribute assignments,
brainstorm solutions to specific issues, propose new ideas, and
implement new plans. This meeting also allows staff to triage and
troubleshoot issues that impede achievement of objectives.
How many patients missed DOT doses yesterday? Not last week, not
last month! Who missed a DOT dose, why did they miss it, what are
the plans to make up the missed doses today? Was a visit made on
Saturday or Sunday to make up the missed dose? Which new suspects
and cases were not started on DOT? Which new cases or suspects who
were interviewed yesterday require expanded contact investigation
at school or work sites? Which patients are nonadherent to TB services?
All staff contribute ideas toward a comprehensive solution. Staff
leave the meeting committed to the final negotiated group decision
and ready to support it. This allows alternative plans to be implemented
immediately and to impact outcomes. This is real-time case management.
The More, the Better
This daily meeting fosters more individual and collective
accountability, more sharing of information, more collaboration,
and more creative problem-solving, which result in more and improved
services, using the same resources.
Take Care of Today, and Tomorrow Will Take Care of Itself
Daily accountability pushes higher daily achievement of objectives.
The daily check-in by each field staff member provides daily verification
that each DOT dose is successfully supervised, contacts are identified
and examined, and nonadherent patients are located and returned
to supervision. This results in no surprises. Monthly, quarterly,
and annual outcomes are known.
Contact Investigation: Divide and Strengthen
Traditionally, contact investigation was initiated by assigning
each new patient or suspect to a field staff member. The staff member
would conduct an initial interview with the patient or suspect and
proceed to locate each of the contacts identified. Tuberculin skin
tests (TSTs) were administered and read in the field and referrals
were given to those contacts in need of further medical evaluation.
Staff traveled over large geographic areas in heavy traffic to locate
all the named contacts. Caseloads exceeded 150 at any given time,
and staff spent more than half their time in the office reviewing
patient or suspect files to determine which contact needed what
and to plan visits for the day. Interviews were not being initiated
within 3 days of assignment because of conflicting priorities. When
staff returned to read TSTs, they had to make additional visits
later the same day if some of the contacts were not available for
the reading, thus interrupting other visits planned for that day.
How can you achieve objectives within specified time frames when
the same staff provide activities that compete for priority: interviewing
versus tuberculin testing and patient evaluation? The solution was
to separate the responsibilities into an Interview Team and a Follow-up
Team and dispatch assignments to the Follow-up Team.
Two public health investigators (PHIs) assigned to the Interview
Team now ensure that all new patients and suspects are interviewed
within 3 to 7 days of assignment. These PHIs are also responsible
for reinterviewing patients whose contacts have a high rate of TST-positive
reactions, whose bacteriology results remain positive more than
3 months, or who develop positive bacteriology results after initial
With the dispatch system, all named contacts are included
in a master database file. The CI Coordinator prioritizes the need
to evaluate each contact based on the date of contact interview,
infectiousness of index case, age of contact, and positive reactor
rate for the contact cohort of each index case. Individual contacts
are assigned to the Follow-up Team by geographic location
rather than by case cohort. This system increases productivity by
reducing the number of miles and driving time. A computer-generated
itinerary and the corresponding Contact Evaluation and Treatment
forms are dispatched daily to each PHI. This system allows field
staff to provide services to the highest priority contacts for the
day. The supervisor conducts a daily review with each worker to
assess the outcome of work dispatched. This process provides a high
degree of accountability and facilitates rapid assessment
and development of alternative plans for contacts not completing
examination according to the recommended schedule.
The Computer Works for You
In addition to holding daily staff meetings and redesigning the
way contact investigation services are provided, we have also recently
redesigned the information-delivery system to provide integrated,
real-time, accurate data on which to base daily patient-care decisions.
A readily accessible computer team, knowledgeable about TB and the
interrelation of program components, rapidly responds to changing
needs by tailoring the information-delivery system. This dynamic
system has become an essential tool used by all staff throughout
the program. Supervisors and managers collaborate with the computer
team to facilitate this process, which ensures a user-friendly system
that requires minimal training. The electronic Case Register card,
DOT adherence report, DOT medication card, and contact evaluation
and treatment tracking form ensure accurate patient tracking and
adherence. The use of computer-generated field staff itineraries
assists in monitoring and ensuring daily individual staff accountability.
Accountability, daily staff meetings, separation of contact investigation
interview and follow-up teams, and contact investigation dispatch,
combined with a very usable information delivery system, have been
instrumental in pushing staff performance and achievement to a higher
- The percentage of patients started on DOT increased annually
from 88.8% in 1998 to 97.6% in 2003.
- The percentage of suspects started on DOT increased annually
from 84.4% in 1998 to 99% in 2003.
- A DOT success rate of 93% to 95% is consistently maintained
- The percentage of isolates with drug-susceptibility results
was maintained at 93% to 98% annually during the last 5 years.
- The percentage of patients and suspects interviewed within
3 days of assignment increased from 45% to 79% since division
of the interview and follow-up teams in 2003.
- The percentage of time spent in the field providing direct
contact investigation services increased from 52% to 67% since
implementation of the dispatch system in September 2001.
—Reported by J. Marcos Longoria, BAS, Bureau
Mary Lou Hernandez, BS, Administration Manager
Kathy Penrose RN, MPH, Chief Nurse
Houston TB Control Program
LTBI Program Implementation
in a Substance Abuse Treatment Facility
Background: To accelerate the decline of TB in the
United States, TB programs will need to strengthen targeted TB testing
and treatment of latent TB infection (LTBI) efforts in high-incidence
communities with high-risk populations. Substance abusers are at
increased risk of developing TB, and in many poor, urban communities
they contribute substantially to the annual incidence of disease.
Staff of the New Jersey Medical School National TB Center (NTBC)
reviewed the files of 357 persons reported with TB from 1999 to
2001 in Essex County, New Jersey. Their review revealed that 26%
were HIV infected and 26% had a history of substance abuse in the
past year. Using an expanded history intake form to ask TB patients
about previous encounters with the health care system1,
NTBC learned that many newly reported TB patients had been clients
of substance abuse treatment facilities (SATFs) prior to TB diagnosis.
Subsequently, NTBC sent a Facility TB Profile2 questionnaire
to health care facilities serving clients at high risk of developing
TB disease. The responding methadone SATFs in Essex County reported
that they (1) served clients with high levels of LTBI (24%), HIV
infection (18%), and injection drug use (31%); (2) had physician
and nursing staff on site; (3) referred clients with documented
LTBI to the local health department for follow-up; and (4) were
aware of neither the follow-up TB evaluation results nor of whether
treatment for LTBI had been initiated. Applying a mathematical model
to the Facility TB Profile data, NTBC determined that a large
number of TB cases could potentially be prevented through strengthened
TB testing and treatment of LTBI in Essex County methadone facilities.
As a result, NTBC collaborated with the New Jersey State TB Program
in a project to develop and implement procedures for carrying out
onsite TB testing and treatment for LTBI in a pilot SATF. The goal
is to increase the numbers of high-risk clients who start and remain
adherent with treatment for LTBI. This pilot project is ongoing,
with some valuable lessons learned even from start-up.
Methods/Needs Assessment: Using Facility TB Profile data
as an entry or discussion point, NTBC and state TB program staff
held follow-up discussions with staff of selected SATFs and local
health departments to determine barriers to the initiation and completion
of therapy for LTBI among SATF clients. Subsequently, a detailed
needs assessment was conducted in one SATF whose medical director
was willing to explore innovative approaches without additional
funding. The needs assessment included reviews of client characteristics,
of the initial medical screening, and of current TB follow-up procedures
and problems. Following this, a collaborative plan was developed
to (1) increase the number of clients who started and completed
treatment among those infected with M. tuberculosis, (2)
address the barriers found in the needs assessment, (3) collect
data to document results, and (4) serve as a template that could
be adapted by other health facilities.
The needs assessment determined that this SATF serves about 200
clients who receive daily methadone; about 45% have been in the
program for at least one year. Most clients were of minority race
or ethnicity (70% black and 20% Hispanic), 60% were medically indigent,
and another 25% were Medicaid eligible. About 45% were injection
drug users (IDUs), 15%-20% had LTBI, 10% had HIV infection, and
20%-30% had hepatitis C.
Upon admission to the SATF, the medical screening that a client
would normally receive included (1) a physical examination, (2)
blood chemistry work-up (including liver function tests [LFTs],
complete blood count, urine analysis, RPR, and drug screening),
(3) HIV counseling and testing, and (4) a Mantoux tuberculin skin
test (TST), unless the client could produce written documentation
of a prior positive TST result. We learned that although many
clients give a verbal history of a prior positive TST result, few
can produce written documentation; hence the TST is repeated.
A client with a positive TST result would then be referred to
one of four health departments, depending on the client’s place
of residence. The local health department would refer the client
to a local radiologist or hospital for a chest radiograph or x-ray
(CXR). When the client returned, the health department chest
clinic physician would evaluate the client for TB disease and for
treatment of LTBI, including LFTs, because of the risk for liver
disease. If started on treatment for LTBI, the client would return
monthly to the health department to pick up medication and to be
monitored for toxicity. All medication was dispensed to clients
Several problems were found with these procedures:
- Clients giving a verbal history of a prior positive TST result
(but no documentation) had to be retested.
- It was time-consuming and confusing for clients to be referred
to different facilities for follow-up CXR, medical evaluation,
- There were often delays in clients getting an appointment at
the health department after the CXR was taken.
- Health departments were not consistent about starting treatment
- Health departments repeated the LFTs, even though they had
already been done by the SATF.
- Patients often failed to keep their monthly LTBI treatment
appointments at the health department.
- Clients were often not adherent with their self-administered
- Medical information (especially treatment results) was not
shared with SATF staff.
Intervention: To address these
problems, NTBC and state TB program staff collaborated with the
SATF and local health department staff to develop revised procedures,
in an attempt to achieve the following objectives:
- 95% of new clients will have a documented TST result.
- 90% of persons with LTBI will be placed on treatment, unless
- 90% of persons started on treatment will complete therapy.
In the revised procedure, all clients with a documented positive
TST result are given a voucher for a CXR at a single nearby radiology
facility. The local health department pays for the CXR, even if
the client resides outside the local jurisdiction. The radiologist
faxes the CXR reading to the SATF medical director, who then evaluates
the client for TB or LTBI without delay. If the CXR is abnormal
or if TB symptoms are present, the client is referred to the NTBC
chest clinic for further evaluation and treatment of TB disease.
If TB disease is ruled out, the SATF physician immediately starts
treatment for LTBI, unless contraindicated. Since the LFTs were
done on admission, they do not have to be repeated before therapy
is initiated. At the same time that the client receives methadone,
the SATF nurse directly observes daily LTBI treatment onsite and
monitors the client for adverse reactions. Consequently, adherence
to the medication is ensured and treatment efficacy is maximized.
SATF staff are encouraged to call specific NTBC Chest Clinic staff
with any questions or problems. At the completion of therapy, SATF
staff give the client a wallet-sized LTBI card, which reflects
the TST, CXR, and treatment regimen and completion, so these will
not be repeated by other health care providers. SATF staff record
TB risk-factor data, as well as TST, CXR, and treatment results,
on a Tuberculosis Testing, Follow-Up, and Treatment of LTBI Form
(LTBI Form). This form provides a single document on which to
record clinical and program evaluation data.
Conclusion and Lessons Learned: Persons
with TB and their contacts remain the highest priorities for health
department TB programs. With limited resources, health department
LTBI efforts should focus on building capacity in other health care
entities serving high-risk clients. We have demonstrated that this
can be done, even without additional resources. Keys to the success
of this effort included the following:
- The facility served clients with a high prevalence of LTBI
and risk factors for developing TB disease (i.e., HIV and IDU).
- The facility had a medical staff to manage clients with LTBI.
- The facility medical director was committed to the success
of the program.
- A needs assessment was conducted to determine problems and
barriers to success.
- A written plan was developed by all parties involved in its
implementation. The plan included objectives, procedures (with
clear delineation of responsibilities), and a method of evaluation.
- The facility and health department each assigned a lead individual
to oversee the project.
- A single nearby location was selected to which all clients
with LTBI were referred for CXR. The local health department was
willing to pay for all the CXRs, regardless of the clients’ areas
- Methods were implemented to ensure adherence with LTBI treatment
(i.e., DOT when client receives methadone).
- A single form was used for collecting clinical and program
These procedures were fully implemented in April 2004. Following
6 months’ experience, the NTBC will evaluate the project with regard
to carrying out the procedures and achieving the objectives. Subsequently,
we will more fully document the planning and implementation process,
develop a detailed report of the experience and lessons learned,
and post the report on NTBC’s website.
— Submitted by Chris Hayden, MPH, Consultant,
LTBI Activities, NJMS National TB Center
Karen Galanowsky, RN, Nurse Consultant, TB Program, NJ Dept
of Health and Senior Services
Eileen Napolitano, Deputy Director, NJMS National Tuberculosis
1. NJMS National Tuberculosis Center. Identifying missed opportunities
for preventing TB: a resource for TB programs. 2003. (www.umdnj.edu/ntbcweb/tbsplash.html)
2. NJMS National Tuberculosis Center. Facility TB Profile for
Targeted TB Testing and Treatment of Latent TB Infection. 2004 (www.umdnj.edu/ntbcweb/tbsplash.html)
Missouri’s TB Awareness
For more than 15 years, the State of Missouri has declared the
last 2 weeks in March TB Awareness Fortnight in honor of World TB
Day. In March 2004, a coalition of Missouri health care organizations
again sponsored an education blitz throughout the state to heighten
public awareness about TB and to provide TB education opportunities
for health care professionals.
Research continues to show that repeated efforts to educate health
care professionals regarding TB protocols are needed: Rao, Iademarco,
Fraser, and Kollef (1999) found delays in initial suspicion of TB
and in initiation of treatment in St. Louis–area hospitals, illustrating
a need for improved education of physicians about the benefits of
early initiation of TB therapy.
A 2002 survey that assessed training needs of Missouri public
health nurses found two areas of concern: knowledge of TB control
and treatment, and state policies and procedures. Another finding
was that 78% of survey participants devoted less than 25% of their
nursing time to TB. As Missouri’ s TB incidence continues to drop,
public health nurses will have even less experience with TB.
The study’s recommendation was to continue educational experiences
for health care professionals so as to maintain TB nurse consulting
and case management expertise at the state and district level (Libbus,
Phillips, and Benjakul, 2003).
A preventable-case analysis conducted by the Missouri Department
of Health and Senior Services showed that Missouri had 68 preventable
cases of active TB in 2002 and 73 cases in 2003, nearly half the
total number of cases in the state. The majority of preventable
cases (85%) involved a missed opportunity to screen patients with
risk factors, such as previous contact to TB cases, foreign-born
persons, or those having other medical or social risks. Designers
of the study concluded that physicians in Missouri need to be continually
reminded of risk factors for TB and to screen and prescribe treatment
for those at risk (Phillips and Tomlinson, 2003).
With 131 reported TB cases in Missouri for 2003 (down only 5 cases
from 136 in 2002), it is evident that TB rates are not declining
fast enough. History shows us that being lax in treatment efforts
can easily promote a resurgence of the disease. Amid decreases in
federal, state, and local public health funding, new and exotic
diseases getting disproportionate publicity, and the public’s belief
that TB is a disease of the past, Missouri struggles to keep TB
on the minds of health care providers. One of the state’s strategies
is to hold educational programs during TB Awareness Fortnight. During
this 2-week period, health care professionals are updated on the
latest TB data and treatment strategies and encouraged to continue
their perseverance in pursuit of Missouri’s 2010 TB elimination
goal. For 2004, the American Lung Association of Missouri (ALAM)
and the Missouri Department of Health and Senior Services (MDHSS)
set a goal of organizing three TB seminars around the state with
at least 30 participants per location. The objectives for seminar
attendees were as follows:
- Increase knowledge of the most up-to-date information regarding
TB infection, treatment, directly observed therapy (DOT), prevention,
- Be aware of programs and services available through ALAM and
MDHSS to assist in the diagnosis and treatment of TB.
- Be able to list risk factors for TB transmission, and gain
basic knowledge of TB disease and infection.
- Be able to describe TB trends in the United States, and list
cultural considerations when working with foreign-born persons.
- Meet present participation goals for seminars, as evidenced
by posttest score means above 90%.
The 2004 goal of three seminars with at least 30 participants
each eventually grew to six seminars averaging audiences of more
than 50 participants, led by distinguished presenters with statewide
and national reputations. Seminar topics and speakers included the
Missouri Rehabilitation Center (MRC), Mt. Vernon, March 17:
TB Infection, Diana Fortune, RN, BSN
History of TB, Dr. Ronald Williams (Chief Medical Officer,
Missouri Rehabilitation Center)
Association for Professionals in Infection Control and Epidemiology
(APIC) Meeting, St. Louis, March 18:
TB Outbreak - City of St. Louis Homeless Shelters, Lynelle
Phillips, RN, MPH (CDC Public Health Advisor, MDHSS), and Ted Misselbeck
(CDC Public Health Advisor, St. Louis City Department of Public
St. Louis County, March 19:
TB Infections & Treatment with Emphasis on the Foreign-born
and Homeless, Lynelle Phillips, RN, MPH (CDC PHA, MDHSS)
Managing TB in Homeless Shelters; St. Louis Area Statistics,
Ted Misselbeck, MA (CDC PHA, St. Louis City Department of Health)
How DHSS Can Help You, David Oeser (Health Program Representative,
TB Screening & Testing for Pre-Employment, Jenelle
Leighton, RN (St. Louis County Department of Health)
TB Disease, Risk Factors, and New Guidelines, Thomas Bailey,
MD, FACP (Associate Professor of Medicine, Washington University
School of Medicine, Medical Director of TB Control, St. Louis County
Department of Health)
ALAM Programs & Services, Vicki Tomko, RN, BS (ALAM)
Cape Girardeau, March 23:
TB in Missouri—Disease Treatment Recommendations, Philip
LoBue, MD (Team Leader, Medical Consultation Team, CDC Division
of TB Elimination)
TB Transmission, Lynelle Phillips, RN, MPH (CDC PHA, MDHSS)
DHSS Services/ALAM Services & Programs, David Oeser
(Health Program Representative, MDHSS)
TB Disease and Risk Factors, Theodore Grieshop, MD (Internal
Medicine and Infectious Disease)
Pre-Employment Testing and Screening, Lynn Tennison, RN
(TB Control Nurse, Missouri Pulmonary Medicine and Infectious Diseases,
University of Colorado School of Medicine)
Grand Rounds, St. Louis, March 25:
Diagnosis and Treatment of Multidrug-Resistant TB, Dr.
Michael Iseman (Girard and Madeline Beno Chair in Mycobacterial
Diseases; Chief, Clinical Mycobacteriology Service in the Mycobacterial
Disease Division, National Jewish Medical Research Center; Professor
of Pulmonary Medicine and Infectious Disease, University of Colorado
School of Medicine)
Kansas City Metro Coalition, March 26:
Prevalence of Incidence Trends; Special Consideration in
Diagnosis and Treatment, Dr. Ram Koppaka (CDC Division of Global
Migration and Quarantine, Atlanta, Georgia)
Cultural Considerations in the Foreign-born, Lynelle Phillips,
RN, MPH (CDC PHA, MDHSS)
Identifying and Treating LTBI/INH Side Effects, Garold
O. Minns, MD (Professor of Medicine, Department of Internal Medicine,
University of Kansas School of Medicine, Wichita; Advisory Physician
to Sedgwick County Health Department TB Program)
Identifying Active TB and Common Mistakes in Diagnosis,
Dennis Pyszczynski, MD, FCCP (University of Missouri School
of Medicine, Kansas City; Advisory Physician to the KC Metro TB
A total of 519 health care providers who work or have an interest
in TB attended the six sessions presented during TB Awareness Fortnight.
Nurses with RN degrees or credentials of advanced practice represented
more than 52% of the participants, the majority coming from the
public health field; physicians made up another 35%. Microbiologists,
social workers, epidemiologists, LPNs, and students filled out the
remaining participant lists. Evaluations from the Fortnight conference
revealed that participants felt each seminar reached its objectives
of heightening TB awareness and providing needed educational opportunities
for health care professionals. Speaker presentation ratings averaged
4.7 out of 5.0. Participant comments ranged from praises for the
excellent speakers to appreciation for the relevancy of the information.
Participants cited TB screening, testing, and transmission as the
most useful topics covered in the seminars. Topics requested for
future TB Awareness Fortnight seminars centered around administration
and reading of PPD skin tests, especially questionable readings.
Pretest assessments of general TB knowledge among 2004 Fortnight
participants had shown a mean correct score of 64.2%; particularly
satisfying to organizers was the average posttest score of 93.3%.
As Missouri lowers its reported TB case numbers for yet another
year, plans begin for next year’s TB Awareness Fortnight to again
re-educate the state’s health care professionals, as Missouri strives
toward meeting its goal of TB elimination by 2010.
—Reported by Marilyn Martin, LPN
Sinclair School of Nursing
University of Missouri-Columbia
and Lynelle Phillips, RN, MPH
CDC Public Health Advisor
Disease Investigation Unit
Missouri Department of Health and Senior Services
1. Libbus MK, Phillips L, and Wunvimul B. Assessment of tuberculosis
knowledge and practice among Missouri public health nurses. (Poster.)
American Public Health Association Annual Meeting, Philadelphia,
PA, November 2002.
2. Phillips L and Tomlinson V. Results of the preventable-case
analysis of Missouri’s 2002 TB cases: how prevalent are our missed
opportunities to prevent TB? (Abstract.) National TB Controllers
Workshop, Washington, DC, June 2003.
3. Rao V, Iademarco E, Fraser V, Kollef M. Delays in the suspicion
and treatment of tuberculosis among hospitalized patients. Annals
of Internal Medicine 1999; 130(5): 404-411.
The Clinical Management
and Outcome of Nail Salon–Acquired Mycobacterium Fortuitum
The following is a summary of a recently published article:
Winthrop KL, Albridge K, South D, et al. The clinical management
and outcome of nail salon–acquired Mycobacterium fortuitum
skin infection. Clinical Infectious Diseases 2004;38:38-44.
Mycobacterium fortuitum is one of several rapidly growing,
nontuberculous mycobacteria (NTM) that are ubiquitous in soil and
water habitats [1-5]. These mycobacteria usually cause cutaneous
infections in association with trauma or clinical procedures, but
are also known to cause pulmonary or disseminated disease . Recently,
we documented a large outbreak of community-acquired infections
at a nail salon in California, where over 115 patrons contracted
severe, lower-extremity M. fortuitum furunculosis (skin boils)
. The infections were traced to a series of contaminated whirlpool
footbaths used in the salon as part of the pedicure procedure. Since
recognition of this outbreak, additional outbreaks and similar sporadic
cases of disease have been reported from around the country [7-9].
Because these whirlpool footbath–associated infections have
only recently been described, their optimal clinical management
is unclear. To better understand the clinical and diagnostic features
of these infections, we observed the clinical course of a subset
(n=62) of patients found during the outbreak investigation.
We asked physicians of patients to complete a standardized questionnaire
that gathered clinical details from each patient; details included
medical history, treatment regimen, duration of clinically evident
infection, and disease outcome. No attempt was made to modify or
influence treatment length or choice among treating physicians,
since the study was observational in nature.
Patients receiving antibiotics against mycobacteria for at least
2 weeks were considered treated. Patients receiving no antibiotic
treatment, treatment with antibiotics typically not known to have
in-vitro activity against mycobacteria, or treatment with
antibiotics with activity against mycobacteria for less than 2 weeks
were considered untreated. Univariate and multivariate analyses
were conducted to detect relationships between disease duration
and variables that could potentially influence that duration.
Follow-up information was available for 61 of 62 patients; 60 (98%)
were female. Patient ages ranged from 13 to 53 years. No persons
were immunocompromised; three were pregnant at the time of infection.
Patients had a median of two boils each (range 1-20). All lesions
were below the knee in a distribution pattern corresponding to water
exposure from the whirlpool footbaths used during the pedicure procedure.
The clinical appearance and progression of the lesions in this outbreak
were strikingly uniform. Lesions typically first appeared as small
papules (similar to spider bites in appearance) and later progressed
to large fluctuant boils, with subsequent ulceration and scarring.
Of the 61 patients, 48 received antibiotic therapy and 13 were
untreated. No persons required surgical resection of lesions. All
treated and untreated persons eventually had resolution of disease.
One initially untreated, HIV-negative person was given antibiotic
therapy after lymphatic dissemination of infection and the development
of a large intra-thigh abscess that required drainage and was later
found culture-positive for M. fortuitum.
Overall, the mean disease duration was 170 days (range 41–336
days). Persons treated with antibiotics were treated for a mean
of 4 months (range 1–6). Clinicians most frequently used doxycycline
or minocycline alone, or in combination with ciprofloxacin. Isolates
were generally susceptible to amikacin, cefoxitin, ciprofloxacin,
doxycycline, gentamicin, and minocycline, and resistant to sulfa,
clarithromycin, and azithromycin. Persons with culture-negative
disease and those with fewer lesions had significantly shorter disease
durations. A final, multivariable linear regression model controlling
for these and other effects indicated that antibiotic treatment
was associated with shorter disease duration only when initiated
early in the disease course (in first 9 weeks after disease onset)
in persons with extensive disease (multiple boils).
In summary, this was the first study to document the natural history
of treated and untreated M. fortuitum furunculosis. Since
this initial California outbreak, it has become apparent that such
nail salon–associated NTM infections are more widespread than
previously known. Importantly, while surgical resection of lesions
has been reported by other authors in the treatment of cutaneous
infections caused by rapidly growing NTM [8,10], our experience
indicated that oral antibiotic therapy alone may be sufficient in
treating these nail salon–acquired M. fortuitum infections
and that surgical resection is not necessary. Our data suggested
that persons with more extensive disease (more than one boil) who
initiate antibiotic therapy early in their disease course benefit
most from therapy. Although untreated infection may be self-limited,
we found that dissemination of these infections can occur in healthy
individuals, and we recommend that persons who go untreated should
be followed closely to assess for such complications.
—Reported by Kevin Winthrop, MD
California Dept of Health Services PHA
1. Collins CH, Grange JM, Yates MD. A review: mycobacteria in
water. J Appl Bacteriol 1984;57:193-211.
2. Fischeder R, Schulze-Robbecke R, Weber A. Occurrence of mycobacteria
in drinking water samples. Zentralbl Hyg Umwelmed 1991;192:154-158.
3. Covert TC, Rodgers MR, Reyes AL, Stelma Jr GN. Occurrence of
nontuberculous mycobacteria in environmental samples. Appl Environ
Microbiol 1999;65: 2492-2496.
4. Wolinsky E, Rynearson TK. Mycobacteria in soil and their relation
to disease-associated strains. Am Rev Respir Dis 1968; 97:1032-1037.
5. Jones RJ, Jenkins DE. Mycobacteria isolated from soil. Can
J Microbiol 1965; 11:127-133.
6. Brown BA, Wallace RJ Jr. Infection due to nontuberculous
mycobacteria. In: Mandell GL, Bennett JE, Dolan R, eds. Principles
and practice of infectious disease. 5th ed. Philadelphia, PA:
Churchill Livingstone; 2000: 2630-2636.
7. Winthrop KL, Abrams M, Yakrus M, Schwartz I, Ely J, Gillies
D, Vugia DJ. An outbreak of mycobacterial furunculosis associated
with footbaths at a nail salon. N Engl J Med 2002; 346:1366-1371.
8. Sniezak PJ, Graham BS, Busch HB, et al. Rapidly growing mycobacterium
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Foreign-Nation TB Information
Packets Prove Useful for New Hampshire Patients and Staff Members
The proportion of U.S. TB cases occurring in foreign-born persons
has steadily increased since the mid-1980s. The State of New Hampshire
(NH) has shown a similar trend. In 2003, 85% (13/15) of the state’s
active cases and 77% (606/786) of latent TB infections occurred
in foreign-born persons.
The NH TB program is responsible for the detection and proper
treatment of persons with TB. The program is staffed by a Program
Coordinator, a Medical Secretary, a Latent TB Infection Coordinator,
and a part-time TB Controller, with seven Disease Control Public
Health Nurses (PHNs) available on an as-needed basis. TB services
in the two largest NH cities, Manchester and Nashua, are provided
through contractual arrangements with these cities’ health departments.
In the past, TB staff members have expressed frustration with their
lack of knowledge about specific countries, cultures, and health
beliefs, as well as with the lack of patient-friendly education
materials that could help them address patient concerns in the foreign-born
populations they serve.
A series of focus groups were conducted among staff to determine
cultural and linguistic barriers to effective TB prevention and
treatment. A consistent theme was that staff members wanted to know
about the foreign countries from which their clients came. In particular,
they wanted to better understand health care practices, family and
social values, religious beliefs, and languages spoken. Staff reported
that their patients’ limited or nonexistent English language skills
made it difficult to determine the patients’ understanding about
what causes TB, how it is transmitted, and how it is treated. TB
staff also believed they needed to better understand patients’ perceptions
of the burden of TB and its risk potential, in their home countries
as well as in the United States. As a result of these findings,
NH TB program staff developed TB informational packets about frequently
seen countries of origin, with information for staff as well as
for patients. When a new foreign-born patient is reported to the
TB program, a TB information packet on his or her country is made
available to the PHN who will be managing the case. Patient information
is tailored to meet an individual patient’s needs and assumes the
patient has some command of the English language. The PHN can select
specific pieces to give to a patient during visits, recognizing
that not all patients require the same level of education.
In general, each packet contains the following information:
- TB news articles reported in the home-country newspaper
- CDC annual surveillance data, Reported Tuberculosis in the
- TB cases in foreign-born persons by country of origin
- TB case rates in U.S.-born vs. foreign-born persons
- Length of U.S. residence prior to TB diagnosis
- Countries of birth for foreign-born persons reported with TB
The packets can be duplicated by other TB control programs, and
packet content is limited only by a TB program staff’s imagination.
Needed material can be compiled from numerous sources. New Hampshire’s
packets include CDC’s yearly surveillance publication, Reported
Tuberculosis in the United States. This provides statistical
information displayed in charts and graphs that clearly demonstrate
U.S. TB cases in foreign-born persons by country of origin, the
prevalence of TB in foreign-born persons over time, and the length
of residence in the United States prior to diagnosis. Our packets
also include translated educational materials to enhance patient
comprehension and understanding. The CDC’s Tuberculosis Education
and Training Resource Guide as well as various state public
health department web sites are excellent resources for translated
brochures and pamphlets on subjects such as the Mantoux skin test,
TB infection and disease, TB and HIV coinfection, and medications.
Information on cultural traditions, religious beliefs, and health
care practices that empower TB programs to work more effectively
in cross-cultural situations may be found online.
Acclimating to a new country and to what may seem to be strange
health care practices can be frightening to newly arrived immigrants.
News from home is always welcome. Articles about TB, as reported
in home-country newspapers, may be the key to convincing foreign-born
persons with TB disease or M. tuberculosis infection of the
gravity of their diagnosis and the need for starting and finishing
treatment. A simple Google search (www.google.com), entering
“newspapers in (foreign country of interest)” will provide links
to a variety of newspapers published in a particular country. Most
newspapers have a search key. Typing in the word “tuberculosis”
will display current articles on TB activities. If a TB program
has an interpreter on staff who can verify article content, then
articles written in different languages may be used. Otherwise,
many of the newspapers published in other countries are in English
and can be useful for those patients who do speak English.
As the proportion of TB in foreign-born persons increases, TB
program staff in the United States are increasingly challenged to
work with unfamiliar populations. Having readily available culturally-oriented
TB education packets helps staff understand their patients and equips
staff with the information they need to convince foreign-born patients
about the seriousness of TB and to encourage them to start and complete
—Submitted by Dianne Donovan
New Hampshire TB Program