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U.S. Department of Health and Human Services

  

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TB Notes 1, 2001

Updates from the Field Services Branch

DTBE Resumes Public Health Advisor Recruiting and Training Program

Ten persons were hired into entry-level public health advisor positions in November 2000 and assigned to the New Jersey, Florida, and Chicago TB programs on January 14, 2001, for 2 years of initial training. The new staff will work at the clinic level and gain experience in conducting surveillance; program operations, including directly observed therapy, contact investigation, and targeted screening and treatment for latent TB infection; liaison with public and private health care providers, hospitals, and laboratories; patient and public health education activities; and public awareness campaigns. Upon successfully completing the 2-year training program, they will be transferred to other field duty stations for additional experience leading to development of competencies in TB program management.

A unique feature of the long, productive partnership between DTBE and state and local health departments is the assignment of CDC-trained public health advisors to assist with the management of TB programs in the United States. Since the early 1960s, many of DTBE's public health advisors have come from CDC's Division of Sexually Transmitted Disease Prevention (DSTDP), where they received basic public health training and experience in field assignments. Others with TB experience in health departments and organizations such as the Peace Corps have been hired directly by DTBE. In 1993, DTBE initiated and operated a 2-year entry-level training program for public health advisors in collaboration with the TB Control Program, New York City Department of Health. This was the first venture in training a new cohort of public health advisors in a program other than DSTDP. Although it was very successful, it was discontinued because, subsequent to a CDC review of the public health advisor series, CDC placed a moratorium on recruiting public health advisors in 1994. There was no CDC-wide recruiting for the public health advisor series after 1993, until last year. As a result, DTBE encountered increasing difficulty identifying candidates for GS-9 and GS-11 positions in the diminishing pool of public health advisors in DSTDP. To compound the problem, some of DTBE's senior field public health advisors have been selected for headquarters positions, others have transferred to other CDC programs, some have retired, and others are approaching retirement eligibility. The declining numbers notwithstanding, the demand by state and local health departments for assignment of public health advisors to serve as on-site technical program consultants and management assistants has not decreased.

DTBE's planning for resumption of the recruiting and training program began in 1999. In a letter dated August 27, 1999, state and local TB control officers and managers were informed of the plan to resume recruiting and were invited to submit a proposal, if they were interested in having new staff assigned to their health department for a 2-year training period. Criteria that had to be met were as follows: there must be a CDC senior TB public health advisor on assignment who is willing to take on the added responsibility of managing an entry-level training program; the TB control officer and other officials must agree to participate with DTBE in the training venture; and the jurisdiction served by the health department must report at least 200 new TB cases per year. Proposals were received from 10 state and city health departments. The proposals were evaluated by six independent reviewers representing the Office of the Director and the Prevention Support Office, NCHSTP; the Communications and Education Branch, the Surveillance and Epidemiology Branch, and the Computer and Statistics Branch, DTBE; and the Training and Health Communications Branch, DSTDP. The proposals were ranked through a thorough evaluation process. The top three, New Jersey, Florida, and Chicago, were selected as the training locations. On June 28, 2000, the CDC Human Resources Management Office posted internal and external vacancy announcements for ten GS-9 public health advisor positions in Jersey City and Edison, New Jersey; Orlando, Ft. Lauderdale, and West Palm Beach, Florida; and Chicago, Illinois. Approximately 100 applications were received. Interviews and evaluations were conducted in September and October, and selections and job offers were made in November.

The new staff will work with experienced clinic and outreach staff in their assignment areas and acquire the basic public health experience that is the essential foundation for a career in TB program operations and management. Ken Shilkret in New Jersey, Heather Duncan in Florida, and John Kuharik in Chicago are the state/city supervisors of the program. The Field Services Branch is managing the program and is responsible for providing guidance, leadership, course work, and quality assurance during the training period.

See the "Personnel Notes" section of this issue for the names of and brief statements about the new staff.

-Reported by H. Mack Anders
Division of TB Elimination

New OSHA Guidelines to Prevent Needlesticks

On November 6, 2000, the President signed the Needlestick Safety and Prevention Act, Public Law 106-430, which requires the Occupational Safety and Health Administration (OSHA) to revise its bloodborne pathogens protection standard within 6 months of the law's enactment. Congress was prompted to take action in response to growing concern over bloodborne pathogen exposures from sharps injuries. CDC has estimated that health care workers in hospital settings sustain 384,325 skin-piercing injuries each year. When nonhospital health care workers are included, the estimate increases to over 580,000 workers.

OSHA has revised the standard in compliance with the Act. The revised standard was published in the Federal Register on January 18, 2001, before becoming effective on April 18, 2001. The following Web site includes the OSHA citations and the Federal Register text:

The revisions clarify that safer medical devices are considered to be engineering controls under the new standard. The term "engineering controls" includes all control measures that isolate or remove a hazard from the workplace. The expanded definitions reflect the intent of Congress for OSHA to clarify the original standard, and to reflect the development of new, safer medical devices since that time. The revised standard does not reflect any new requirements being placed on employers with regard to protecting workers from sharps injuries.

The standard calls for employers to select safer needle devices - such as sharps with engineered sharps injury protections and "needleless" systems - as they become available, and to involve employees in identifying and choosing the devices. Employers are also required to annually review their exposure control plans to reflect consideration and use of safer medical devices that are commercially available.

The Act mandates that employers create a sharps injury log containing detailed information about any sharps injuries that occur in the workplace. The requirement for a sharps injury log will not take effect until January 1, 2002, at the earliest. Therefore, employers must keep a separate sharps log from the effective date of this rule until that time.

In addition, the Act establishes a new clearinghouse within CDC's National Institute for Occupational Safety and Health (NIOSH) to collect data on engineered safety technology designed to prevent the risk of needlesticks and other sharps injuries. NIOSH will have access to the sharps injury logs in order to carry out these duties. The clearinghouse would also create a model training curriculum for employers and health care workers. To carry out these duties, NIOSH has been authorized $15 million in new funding.

The Act recognizes that no one medical device is appropriate in all circumstances of use. For purposes of this standard, an "appropriate" safer medical device includes only devices whose use, based on reasonable judgment in individual cases, will not jeopardize patient or employee safety or be medically contraindicated. OSHA recognizes that a safer device may not be available for every situation. If an employer finds that an appropriate device is not available in the marketplace, the employer is required to document that fact in the annual exposure control plan. The employer must indicate in the plan what device was tried, what the results of the assessment were, and what is being done in lieu of using a safer medical device, such as not recapping needles. The employer must also state in the plan the intention of continuing to evaluate new devices until an appropriate one can be found.

The 23 states and two territories that have their own occupational safety and health plans are required to adopt a comparable standard within 6 months of the publication of the final federal OSHA standard. These states and territories include the following: Alaska, Arizona, California, Connecticut (for state and local government employees only), Hawaii, Indiana, Iowa, Kentucky, Maryland, Michigan, Minnesota, Nevada, New Mexico, New York (for state and local government employees only), North Carolina, Oregon, Puerto Rico, South Carolina, Tennessee, Utah, Vermont, Virginia, Virgin Islands, Washington, and Wyoming.

We have received questions about this new standard from one state TB control program with concerns that the new and safer needleless devices may not be appropriate when administering a Mantoux TST. To learn about these devices, check the following Web site, which contains information on a variety of equipment suppliers: http://www.med.virginia.edu/medcntr/centers/epinet/products.html. Please be aware that the technology is evolving, and additional devices will be available. Readers are advised to keep up with new products that come on the market. In addition, we suggest you contact the local Occupational Safety and Health office or, if there is not one in your area, the federal Occupational Safety and Health Administration for guidance on mandated activities. We will continue to collect information on TST-related questions regarding this new standard.

-Reported by Judy Gibson, RN, and Paul Tribble
Division of TB Elimination

Announcement of a New DTBE Records System for Outbreak Response

DTBE is frequently notified by state and local health departments about potential TB outbreaks. In a joint project between the Field Services Branch and the Surveillance and Epidemiology Branch, DTBE is implementing the evaluation of a new system for receiving and formally recording reports of suspected TB outbreaks. The new system includes standard records of notifications and responses. With this documentation, DTBE will be better able to account for instances requiring additional interventions by state and local health departments, and collaborative efforts between CDC and state/local health departments. These data will be used for planning purposes and to support advocacy for additional resources for prevention and elimination. The documentation will also assist in procuring one-time funding for cooperative agreement sites responding to outbreaks.

At this time, DTBE is not requesting changes in the ways that state and local health departments share information about suspected outbreaks; this change relates to the way DTBE receives the information. The program consultants in the Field Services Branch will continue to discuss these situations with state and local TB control personnel as they have for years. Suspected outbreaks can be brought to the attention of the program consultants by calling (404) 639-8125.

-Reported by John Jereb, MD
Division of TB Elimination

MMWR Addresses TB Prevention and Control on the U.S.-Mexico Border

In 1999, 43% of the TB cases reported in the United States occurred among the foreign-born and 23% of these were persons born in Mexico. This can be attributed to converging factors that have elevated TB incidence and complicated case management in the American states bordering Mexico. In order to develop specific strategies to meet these new challenges, DTBE convened a working group of TB control officials from the border states affected - Arizona, California, New Mexico, and Texas - in June 1999. The working group's deliberations can be found in the Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports (R&R) dated January 19, 2001. The text of this and other MMWRs can be accessed on-line at http://www.cdc.gov/mmwr/mmwr_rr.htm.

The recommendations outline steps that local, state, and federal TB programs can take to improve TB prevention and control in border areas. CDC supports the working group proposals and is committed to taking the next steps toward strengthening tuberculosis prevention and control efforts along the U.S.- Mexico border.

This report contains comprehensive recommendations for four main topics:

Surveillance, which may include a binational case registry and a uniform case definition to enable standardized data collection and increase accuracy in data analyses and comparisons

Case management and therapy completion, which includes addressing the complexity of case management across international borders through prompt diagnosis, close monitoring of medical regimens, assurance of adherence to treatment, and identification and evaluation of close contacts

Performance indicators, which should include targeted TB testing among border populations, linkage of laboratory data regarding binational TB patients diagnosed in Mexico, and evaluation to facilitate the most effective means of contact tracing

Research, to address the needs of two groups: binational patients and their close contacts, and patients who acquired TB in Mexico or Central America and their contacts in the United States; research findings should be used to develop sound strategies for active case finding as well as for targeted testing and treatment of populations at risk for TB infection, and promotion of regional TB control efforts along the U.S.-Mexico border

Improving TB prevention and control along the border will require that we and our partners sustain existing programs and address new challenges.

-Submitted by Mark Lobato, MD
Division of TB Elimination

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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