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TB Notes 2, 2001

Highlights From State And Local Programs

Miami–Dade County Health Department Opens LTBI Clinic

On March 19, 2001, the Miami–Dade County Health Department (MDCHD) TB Program opened a special clinic for patients with latent TB infection (LTBI).

In January 2001, the administrative staff of the MDCHD identified clinic and office space that formerly housed the old family planning clinic and is located just a few doors away from the main TB clinic. After some minor renovations and a fresh coat of paint, the LTBI clinic opened its doors in March. The goal of the clinic is to increase the therapy adherence rates for clients receiving treatment for LTBI. All high-risk patients who have been screened and tested for LTBI and who have a positive skin test are followed up for active TB disease. At the first visit to the main TB clinic, active TB is ruled out; all clients are then educated about LTBI by the nursing staff and are encouraged to go on treatment for LTBI. Each patient is provided a one-month supply of treatment and an appointment for the new LTBI clinic in a month's time.

The LTBI clinic is staffed by two nurses and one Health Support Technician. The clinic has been decorated to make it appealing and comfortable to clients: there are plants, a couch and a TV, and educational materials in several languages. Through staff donations, refreshments are available to patients visiting the clinic.

How it works: For each scheduled LTBI patient who comes into the LTBI clinic, staff members provide counseling about adverse reactions, provide motivation regarding the importance of taking and completing their LTBI course of treatment, and give another month's supply of medication and another appointment to return to the LTBI clinic in one month. Within one workday, they call those patients who miss their appointments to reschedule the visits. If they cannot reach a patient by phone, the clinic staff employees mail a letter out within two workdays. The TB Program is currently evaluating these activities. The average length of time for each patient's visit is approximately 10 to 15 minutes (for those without adverse reactions to medication). A recent customer satisfaction survey conducted by the MDCHD documented that clients like the clinic, the specialized attention and care they are given, and especially the quick and prompt service they receive.

From March 19 through April 19, 2001, a total of 602 patients were seen at the LTBI clinic. It should be noted that these 602 clients would normally have been seen at the main TB clinic. Thus, a secondary benefit from this project is that it has lessened the patient flow at the main TB clinic, allowing patients there to be seen faster. Other preliminary data from the LTBI clinic show that 407 patients kept their appointments (68%) and 56 clients completed a course of LTBI treatment during the first month of operation.

The TB Program staff are encouraged by these preliminary results and look forward to seeing improvements as the clinic gains momentum and builds a positive reputation among the patient population of the Miami–Dade County area.

—Submitted by M.C. Desrosiers, MD
Director, TB Control Program
and Harry Stern, Senior PHA
Miami-Dade County Health Department

Florida TB Video Wins National Award

"You Can Prevent TB," a video prepared in Serbo-Croatian by the Refugee Health Program, Florida Bureau of TB and Refugee Health, has received the Award of Excellence from The Videographer Awards, a national awards organization that sets standards for the video production industry. The Award of Excellence is the highest recognition in the industry.

The Bureau of TB and Refugee Health used a script originally prepared for use in New York City, and modified it to fit the needs of Florida's Serbo-Croatian immigrant and refugee population. New York City shared it with Florida and Florida will share it with others who have Serbo-Croatian clients under treatment for latent TB infection. May International Productions of Coral Gables was the contracted producer.

A copy of the video may be requested by contacting Suzy Peters, PhD, Health Education Consultant, by mail: Florida Bureau of TB and Refugee Health, 4025 Bald Cypress Way, Mail Bin A-20, Tallahassee, FL 32399-1717; by telephone: (850) 245-4350; or by e-mail: suzy_peters@doh.state.fl.us. Following is a description of the video from Florida's TB Web site, http://www.doh.state.fl.us/disease_ctrl/tb/

"You Can Prevent TB"

Audience: People with TB infection

Length: 10 minutes

Producers: Health departments of New York City and Florida

Description: When Goran discovers he has been infected with TB, a visit to the doctor calms his fears. Goran learns the facts about TB and decides to complete preventive treatment. By taking medicine, Goran can wipe out most of the TB germs in his body before they become active, so they cannot hurt him or anyone else.

Languages: Cantonese, Creole, English, Mandarin, Russian, Spanish, and now in Serbo-Croatian.

—Submitted by Suzy Peters, PhD
Health Education Consultant
Florida Bureau of TB and Refugee Health

MDR TB in St. Louis: Lessons Learned

One of the biggest outbreaks of multidrug-resistant tuberculosis (MDR TB) in the Midwest has been occurring in St. Louis, Missouri, over the past 3 years. From March 1998 to March 2001, nine cases of MDR TB have been found. The resistance pattern consisted of isoniazid, rifampin, and streptomycin. During the year 2000, three of the nine cases were discovered. As of March 2001, 140 contacts to these nine cases had been identified and only 12 remained to be followed up. However, one or two additional cases will be interviewed again for additional contacts in the near future. So the investigation continues.

Concerns about ongoing transmission of MDR TB prompted the Missouri Department of Health and the St. Louis City TB Control Program to invite CDC to assist with investigating the MDR TB cluster. On September 11, 2000, CDC sent three staff members to St. Louis to consult with state and local staff members. The CDC investigators included Drs. Peter McElroy and Renee Ridzon from the Surveillance and Epidemiology Branch, DTBE, and Ram Koppaka with the Field Services Branch, DTBE, assigned to the State of Virginia. Eric Williamson, DTBE Public Health Advisor currently assigned to the Los Angeles County TB Control Program, also participated in the investigation. The state and local staff members involved in the investigation included Ms. Roseann Rook, Ms. Gwen Stubblefield, Ms. Madeline Nash, Ms. Paulette Robertson, Ms. Pat Carol, Ms. Deborah McGruder, Ms. Hilda Chaski-Adams, and Dr. George Emeran. At that time only seven MDR TB cases were known. The CDC investigators were able to epidemiologically link six of the seven cases; all seven were part of the same social network.

Prior to the CDC team's arrival, no more than three cases were epidemiologically linked. In December 2000, Dr. Ridzon returned to St. Louis to discuss the MDR TB problem with physicians and nurses in the area and heighten awareness about it. In addition to CDC's assistance, the Missouri Department of Health provided TB program staff to assist St. Louis City staff with the contact investigation from October 2000 through February 2001. Contacts to the MDR TB cases were placed on a regimen of pyrazinamide and ethambutol in an effort to prevent additional cases of MDR TB.

For background purposes, in February 1997, a man in his 40s was diagnosed with cavitary TB in a St. Louis hospital. The patient's sputum specimens were positive for acid-fast bacilli, and he was confirmed as having M. tuberculosis on culture. Susceptibility testing showed multidrug resistance to isoniazid, rifampin, and streptomycin. Significant risk factors for active TB included a history of homelessness, alcohol dependence, and drug use. He was unemployed and a smoker, and resided at times with relatives and at other times in a shelter. He was discharged to the home of a relative and received directly observed therapy (DOT) until he was readmitted for an unrelated complaint in March 1997. Because of the difficulty inherent in following up on a homeless person, he was committed to the Missouri Rehabilitation Center (MRC) in Mount Vernon, Missouri, to complete treatment. Subsequent to this case, there have been eight other MDR TB cases diagnosed in the city of St. Louis. The contact and social networking investigations linked this index case directly to five secondary cases. Two contacts to one of the secondary cases also developed active TB. One case was never epidemiologically linked to the others.

CDC's recommendations for addressing this TB problem were as follows:

  • Notify the infection control programs in two hospitals in St. Louis of this situation and provide a briefing on the status of this MDR TB cluster;
  • Identify all contacts who were exposed to infectious patients in this MDR TB cluster. The use of the social-network approach to contact investigations may be more successful than traditional contact investigation methods;
  • Treat the MDR TB cases with at least three drugs to which the M. tuberculosis organisms are susceptible for a period of 18 to 24 months;
  • Keep all persons with infectious MDR TB in respiratory isolation in a health care facility or in home isolation until they are found to be smear negative and relatively noninfectious; and
  • Facilitate better lines of communication with regard to ongoing care and discharge planning of TB patients admitted to the MRC. (The state health department should take the lead in facilitating better communication.) The Missouri Department of Health's TB control program began conducting collaborative case conferences (CCCs) in December 2000 based on the model that the Florida TB control program utilizes. Since December, a CCC was conducted in April and a third CCC is scheduled for September. During the CCC several TB cases are discussed by the participants. Various issues and concerns often surface and are discussed. The CCC is an excellent tool to improve and enhance communication among health professionals.

There are at least two reasons to believe that this outbreak of MDR TB may continue. First, there still may be one or more unidentified source case(s) that have yet to receive treatment. Four cases were quite advanced, as evidenced by the multiple cavities on their chest x-rays. It appears that they both had extended periods of illness and had delayed treatment. This is not uncommon. Research into TB cases in Los Angeles County found that unemployment and not knowing where to obtain care were more closely associated with a delay of treatment (>60 days) than was severity of illness. It is likely then that if other MDR TB cases exist in the St. Louis area with similar demographics, they will also delay treatment and optimize the further spread of disease.

Second, known and unknown social contacts have the potential to develop MDR TB. There are fewer treatment options for TST-positive contacts to MDR TB than there would be for contacts of TB that is susceptible to most drugs. Some of the contacts in these scenarios were treated with pyrazinamide and ethambutol for 6 months or longer; however, the effectiveness of this treatment is virtually unknown. For this reason, other close contacts are being followed with chest x-rays and symptom reviews every 6 months for 2 years. Tracking known contacts who are transient and have histories of drug use, alcohol abuse, and unemployment can be exceedingly difficult and labor-intensive and cannot continue indefinitely. In addition, one of the contacts with active disease, considered a clinical case, refused treatment after 4 months.

Lessons Learned

Contact and social networking investigations are seldom completed. Contacts to the index case were still being identified 3 years after his diagnosis. Staff at the St. Louis City Department of Health and Hospitals, the Missouri Department of Health, CDC, and MRC all played a part in eliciting contacts. Despite the repeated interviews with and questions of the index case, there are still probably unidentified infected contacts, since at least two of the cases were transient and spent time in homeless shelters.

Hospital and emergency room staff members play a key role in controlling TB. The members of the demographic group involved in this outbreak often do not have primary care providers and seek medical care from emergency rooms. Others delay treatment until disease is severe and hospitalization is required. The last two patients in this outbreak had made several office visits to physicians, and their disease had not been accurately diagnosed. In order to ensure that MDR TB cases are identified more efficiently in the future, the medical community must have a heightened awareness of the problem. The city, state, and CDC recognize the need for increasing this awareness, and the CDC staff were particularly helpful in conducting grand rounds of key St. Louis–area hospitals.

Drug-resistant TB complicates directly observed therapy and strains resources. Treatment for MDR TB is administered daily and requires intramuscular injections and/or intravenous (IV) infusion for many months. Daily DOT by a licensed nurse was required. With several MDR TB patients simultaneously needing treatment, this commitment of professional staff time was an enormous burden to a TB program with only one TB nurse case manager and nonnursing outreach workers. Now most of the outreach workers are LPNs, and the city health department is hoping for additional staffing increases. CDC is coordinating the provision of outbreak response funds to help finance IV infusion therapy and housing needs. All of the MDR TB patients were hospitalized at MRC for at least part, if not all, of their treatment, which strained the resources of this facility. All outpatient medications were provided by state funding, which led to additional financial shortages.

Missouri's inpatient treatment facility and court-order process were key to outbreak control. All but one of the MDR TB cases were hospitalized at the Missouri Rehabilitation Center. Some of the patients stayed for the entire duration of treatment under court order. Quarantine of these patients was essential for outbreak control, since several of the patients were homeless, substance abusers, and nonadherent with outpatient treatment and isolation. Hospitalization ensured that transmission was suspended at the time of diagnosis. Also, expertise in treating MDR TB is extremely limited in Missouri; however, the medical staff at MRC gained needed experience and provided consistent and state-of-the-art treatment through consultation with the New Jersey Medical School National Tuberculosis Center and the National Jewish Medical and Research Center. The MRC is now a statewide resource for the treatment of MDR TB. So far, none of the patients they treated have reactivated. Controlling this outbreak would have been extremely difficult, if not impossible, without an inpatient treatment facility such as the Missouri Rehabilitation Center.

Missouri has gone from being a low- to middle-incidence state, with little or no MDR TB, to one with nine MDR TB cases in less than 4 years. Although it is difficult to truly portray all the difficulties and frustrations involved in responding to an MDR TB outbreak, we hope that other states, particularly lower-incidence states, can benefit from our experience.

—Reported by Vic Tomlinson
and Lynelle Phillips
Missouri TB Control Program

Virginia's Traveling Spittoon Award

VA Code §18.2-322 states, "No person shall spit, expectorate, or deposit any sputum, saliva, mucus, or any form of saliva or sputum upon the floor, stairways, or upon any part of any public building or place where the public assemble, or upon the floor of any part of any public conveyance, or upon any sidewalk abutting on any public street, alley, or lane of any town or city."

Why did Virginia pass this law in 1906? Did this mean that human spitting was so out of control that legislation became necessary?

The answer to this question actually lies in Virginia's early efforts to curb the transmission of TB. At the turn of the 19th century, TB was very much a disease out of control. There were well over 6,000 cases per year in Virginia and TB was one of the leading causes of death. TB was believed to be a hereditary disease since it tended to run in families. In 1882, Dr. Robert Koch discovered the organism responsible for TB disease and even devised a test for it. By the early 1900s, TB was still running rampant through the population. In 1904, Virginia's first sanatorium treatment of TB was begun at Central State Hospital in Petersburg, Virginia. The newest cure was lots of fresh air and sunlight. Although the sunlight did contain UV radiation that killed the TB germs, people were also dying of too much exposure to the elements. People whose immune systems were strong enough upon admission were sometimes cured with the added rest and nutrition. For the vast majority, though, TB was still a disease that consumed one from the inside out and the classic symptom was the productive cough.

Since there was no cure for TB at that time, the sick continued to work and socialize until the illness overtook them. When these citizens were out and about, they found it necessary to spit as a means of disposing of the sputum that had collected after a coughing episode. The state of Virginia, as well as the other states, saw a proliferation of brass spittoons strategically placed in public locations to address this need. Personal, hand-size spittoons were also marketed to the ladies of the day so they could very politely dispose of the sputum. Virginia passed the Anti-Spitting Law in 1906 to further reduce the spread of this disease by unknowing constituents.

In present-day Virginia, we learn from the past, and we remember the early efforts of those pioneer health care workers who did the best with what they had. This year, the Virginia Department of Health (VDH) Division of Tuberculosis Control (DTC) developed and initiated an annual performance award to be given to the winning health district within each of the five health planning regions. In commemoration of those early TB control efforts, the award has been named the "Traveling Spittoon Award."

There are five "Traveling Spittoons," one for each health region. The brass spittoon is mounted on a walnut stand with a nameplate on the front and the annual winner's name on the side. The Spittoon symbolizes Virginia's early public health efforts by passing the 1906 Anti-Spitting Law. In essence, the spittoons served as our first sputum collectors. Today, we know that TB is spread through the air, but we still collect the sputum from anyone who might have TB. The sputum collectors of today look much different when compared to a brass spittoon, but the public health control measure of controlling where a person expectorates continues to be practiced.

DTC developed four objective criteria to determine the winner. The criteria are outcome based and focus on completion of curative therapy, effective use of DOT, completion of treatment for latent TB infection, and the complications associated with the case. These criteria also reflect the priority activities of the DTC. Those priorities are: detection of all cases, initiation of adequate and appropriate treatment, and completion of the treatment.

The new TB award, the Traveling Spittoon, has begun its journey from the central office to the home districts of this year's winners. Meetings were scheduled in each of the regions that included newly released TB statistics, a short TB lecture, and then the presentation of the Spittoon. These presentations will be repeated next year and the spittoon will "travel" to the winning district. Until that time, each winner has possession of the spittoon to mark its achievement.

By the way, if you are planning a visit to Virginia, just remember that any person violating the 1906 Anti-Spitting Law shall be guilty of a Class 4 misdemeanor.

—Submitted by Wendy Heirendt
Virginia TB Control

New Logo for Virginia's TB Control Program

The Division of Tuberculosis Control (DTC) at the Virginia Department of Health (VDH) announces the introduction of a new logo and a renewed focus on priorities. The message and goal of all health districts is to detect every case, treat adequately and appropriately, and complete therapy.
 
As health workers involved in the effort to protect others from tuberculosis, each one of us actively seeks to detect every person with tuberculosis living in our jurisdiction. Once that person is found, we aim to treat that individual for TB disease. We also aim to detect and treat all infected contacts of persons who have tuberculosis disease. The third focus of our job is to ensure that all patients with tuberculosis disease and their infected contacts complete an adequate and appropriate course of treatment. For each patient for whom we have successfully achieved these three priorities, Virginia gets one case closer to TB elimination. detect. treat. complete: Division of Tuberculosis Control
The new logo of the Virginia Division of TB Control is 'Detect, Treat, Complete'

The DTC Surveillance and Epidemiology Unit will be actively promoting this approach as a complement to the standard case investigation techniques. We hope to assist in the prioritization of activities when resources may be limited. Once the essentials of Detection, Treatment, and Completion have been achieved, we can turn our sights to other elimination activities such as targeted testing and treatment of latent TB infection.

—Submitted by Wendy Heirendt
Virginia TB Control

Landmark TB Legislation Enacted by the Virginia General Assembly

The legal support for tuberculosis control activities in Virginia will be strengthened owing to provisions of landmark legislation that became effective throughout the Commonwealth on July 1, 2001. The legislation, introduced at the urging of the American Lung Association of Virginia and with the endorsement of the Virginia Division of Tuberculosis Control, was enacted by the 2001 Virginia General Assembly and signed into law by Governor James Gilmore on March 20, 2001. In modifying its tuberculosis control laws, Virginia has become one of the first states to make such changes in response to one of the key recommendations contained in Ending Neglect, the Institute of Medicine's recent report on control of tuberculosis in the United States.

The Code of Virginia and the accompanying regulations have included TB on the list of reportable diseases and have for many years provided the Commissioner of Health with authority to order legal isolation of persons with "communicable diseases of public health significance." However, the practical utility of this authority was reduced by a requirement to demonstrate communicability and to prove the presence of disease by culture confirmation. As with other communicable diseases, reporting requirements for TB were limited to notification of local health authorities by laboratories and practitioners at the time of suspicion or confirmation of disease.

The Code as amended expands the legal definition of communicable TB to include not only culture-confirmed, smear-positive pulmonary TB, but all other forms of pulmonary and extrapulmonary disease as well, including cases in which smears are negative and those in which cultures are negative but disease is defined clinically. Persons with suspected TB based on positive smears can also be included in this legal definition if other sufficient evidence exists to support the diagnosis. A provision that defines TB disease, once diagnosed, as communicable until cured enables health authorities to mandate treatment to completion. These definitions greatly expand the scope and flexibility of the Commissioner's authority to compel nonadherent patients to comply, while leaving the safeguards to patient rights intact.

Reporting requirements are also expanded to include specific clinical and demographic information on the patient and the name and contact information for the practitioner who has assumed responsibility for the patient's treatment. The treating clinician is required to notify the health department not only at the time of diagnosis but periodically during treatment, and must report when treatment ceases either due to successful completion or patient default. Treating physicians are also required to develop and maintain a written plan of treatment and written record of adherence, both of which are subject to the review and approval of local health authorities. Hospitals, correctional facilities, and other inpatient facilities are required to submit treatment plans for approval prior to release or discharge. In addition to reporting isolation of M. tuberculosis from clinical specimens, laboratories are required to either report results of antimicrobial susceptibility testing or to submit isolates to the state public health laboratory so that this testing may be done. These provisions will enable local health authorities to respond more promptly and effectively to cases of TB complicated by noncompliance, inadequate therapy, or drug resistance.

An important impetus for change in the TB control laws in Virginia was the Tuberculosis Advisory Committee, created last year by the American Lung Association of Virginia at the request of the Virginia Division of Tuberculosis Control. Members of this Committee successfully lobbied members of the General Assembly to introduce the legislation. As a consequence of the close working relationship that developed between patrons of the bill and members of the committee, the Division of TB Control was given the rare opportunity to participate directly in the drafting of this legislation. In this manner, the legislation could be designed to specifically address the true needs of TB control in the Commonwealth. The Division is currently drafting the regulations that will allow implementation of the new laws and is developing a plan to educate staff of clinics, institutions, and laboratories about how to comply with the new requirements.

—Submitted by Venkatarama R. Koppaka, MD, PhD,
and Lex Gibson
Virginia Division of TB Control

 


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