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TB Notes 2, 2002

Highlights from State and Local Programs

The “Goldwater Era” Ends in New York

For nearly a decade, Goldwater Memorial Hospital, located on Roosevelt Island in the East River between Manhattan and Queens, served as a long-term detention and treatment facility for a very special population of nonadherent TB patients. These individuals, who were unable or unwilling to complete treatment on their own, were detained in Goldwater’s Secure Tuberculosis Treatment Unit by order of the Commissioner of Health. Goldwater’s detention ward was a unique facility in the country and the “Goldwater Era,” which began in September 1993, ended in November 2001 when the last patient was discharged.

Approximately 220 patients had been admitted to this facility by the time it closed at the end of 2001.  Many of the patients detained at Goldwater had psychological, alcohol, substance abuse, or other problems. The Secure Tuberculosis Treatment Unit functioned as both a medical facility and a therapeutic setting where patients could gain insight into the circumstances that led to their detention. At Goldwater, the patients learned to take responsibility for their actions and work toward resolving some of their problems. An interdisciplinary staff provided psychosocial, medical, recreational, educational, therapeutic, and substance-abuse services. Although this was not an easy population to work with, the staff felt rewarded when patients demonstrated hidden talents, acquired new skills, and in the process gained self-esteem.  

Every month the discharge committee, consisting of both Goldwater and Tuberculosis Control Program Regulatory Affairs Unit staff, met to assess patients for the possibility of early discharge before completion of treatment.

In December 2001, Sonal Munsiff, MD, Director of the New York City TB Control Program, wrote a letter to Laurie Nathan, PhD, Coordinator, and Prem Srivastava, MD, of Goldwater’s Secure TB Unit, thanking them for their “creative vision and commitment to public health.” By setting up the Secure TB Unit, Goldwater Hospital had “provided a unique and critical public health service to the City of New York,” Dr. Munsiff wrote. The care received at the Secure TB Unit “made it possible for patients to take up their lives again with improved vocational and social skills.”

Secure TB Unit patients had access to amenities such as telephones, television, exercise equipment, and laundry and kitchen facilities. They were escorted to off-ward activities such as the library, gym, or computer room, and they could receive visitors, including children. Patients had access to dental care, which, according to staff, helped improve many patients’ self-esteem. While detained, patients had the opportunity to interact with one another. Some even formed close personal relationships, which sometimes continued after they completed treatment.

The Regulatory Affairs Unit is grateful to Goldwater — and to the New York City TB Control Program staff — for all the hard work and years of dedication that they invested in making the program work. Having a resource like Goldwater saved the lives of many patients who otherwise would have discontinued treatment, would have continued to present a public health risk, and most likely would have died from TB disease.

The number of previously nonadherent patients needing involuntary hospitalization has steadily declined since the detention unit was instituted. Originally a 28-bed facility, Goldwater’s detention unit became a 14-bed facility as the numbers declined, and in the final days housed only one patient. The TB Control Program is now exploring possibilities for an appropriate setting in which to hospitalize small numbers of nonadherent patients as necessary.

—Submitted by Roberto Acevedo,
Regulatory Affairs Coordinator,
Ruth Wangerin, TB Times Editor, and
Loretta Bennett, Public Health Advisor,
New York City TB Control Program


TB in Colorado Jumps 42% in 2001

Colorado reported 138 new cases of active TB in 2001. This represents a 42% increase from the 97 cases reported in 2000 and the third consecutive yearly increase. The last time Colorado reported more cases was in 1979, when there were 168 cases. Colorado, categorized as a low-incidence state, now has a case rate of 3.2 per 100,000 population, which is far above the Healthy People 2010 objective of #1.0 case per 100,000 population. In 1998, the case rate was at a low of 1.9 per 100,000 population.

The increase in cases in Colorado is occurring throughout the state. Though 70% of the cases were reported from the Denver metropolitan area, 22 of the state’s 64 counties reported new cases of TB. Three counties reporting cases this year had not had a case in the past 5 years.

Since 1999, over 50% of the TB cases in Colorado were among persons known to have been born outside the United States. Of the 138 cases reported in 2001, 85 (62%) were in persons born in other countries. Though 35 of these persons were born in Mexico, there have been cases reported in persons born in 25 other countries. In addition, minority groups are overrepresented: 80% of the cases occurred in minority racial or ethnic groups. Of great concern are the 11 cases in children less than 5 years of age.  The increase in TB cases is currently being analyzed to determine ways to halt and reverse this trend.

—Reported by Barbara Stone, MSPH
TB Program,
Colorado Dept of Public Health and Environment


TB Challenges in Ohio

Introduction

Why are Ohio's TB case rates and numbers of TB cases going up when overall the nation's are going down, and what can be done to reverse the trend? By 1993, the number of TB cases in the nation and the national TB case rate had resumed their steady declines; in 2000 there were 16,377 cases nationally with a case rate of 5.8 per 100,000 population. The good news is that Ohio met the Healthy People 2000 TB elimination goal, which was to reduce the case rate to less than 3.5 per 100,000 population. Having met that goal, Ohio is considered a low case rate state for TB morbidity. However, this masks a significant morbidity problem in Ohio. Since 1998, Ohio has seen a steady increase in the numbers of TB cases as well as in the case rates. The overall goal for TB elimination is a case rate of #1 per 1,000,000 population and, to that end, Ohio faces a challenge. The following chart shows the increase:

Reported TB Cases in Ohio

Yr

95

96

97

98

99

00

01

No

280

301

286

230

317

338

306

Demographically for the year 2001, there was an inordinate burden of disease among the black population. While this group constitutes approximately 11% of the  population in Ohio, almost 50% of the TB cases reported in 2001 were in black, non-Hispanic persons. Asian or Pacific Islanders represent 0.02% of the general population but 12% of the reported TB cases. Persons of Hispanic ethnicity, of any race, represent 2% of the general population yet 4% of the reported TB cases in Ohio. TB cases reported in white persons make up 41% of the incidence for 2001 and represent the majority population in Ohio at approximately 87%. Part but not all of the increase in TB cases in the black population can be attributed to TB in foreign-born persons. Significantly, the increase in foreign-born persons parallels the increase in cases since 1998.

Activities Toward TB Elimination

To bring Ohio TB incidence back to the 1998 low point and lower, strategies to achieve TB elimination must be prioritized to best utilize existing resources in the local TB programs. First, active TB cases must be identified and adequately treated. The national goal for completion of treatment is 90% in <365 days when the disease-causing organism is not resistant to rifampin. The following table shows Ohio’s performance for the past 5 years:

Completion of Treatment, 1996-2000

Year

Cases

Comp. <365 Days

Comp.
Overall

Percent
Complete
<
365 Days

Percent
Comp.
Overall

2000

338

219

249

73

83

1999

317

191

237

73

90

1998

230

154

182

79

92

1997

286

193

223

82

94

1996

301

196

224

82

93

*Data for 1999 and 2000 are incomplete. Percentages are computed as of 4/19/2002. Not all patients started treatment.

Second, contact investigations for all pulmonary TB cases must be conducted to identify, evaluate, and treat persons with untreated TB disease and persons with latent TB infection (LTBI). The data from contact investigations show that Ohio has done quite well with respect to identifying and evaluating contacts. Identification of at least three contacts per case is a generally accepted minimum standard for contact investigations of TB cases. The following table shows Ohio results for the past 4 years:

Identification of Contacts, 1997-2000

Year

No. Identified

Avge Contacts per Case

2000

2871

20.9

1999

2351

17.5

1998

2223

9.7

1997

4245

14.8

The national objective for evaluation of contacts is that at least 95% of contacts to TB cases will be evaluated for infection and disease; for 1999, Ohio achieved 88%. However, data for completion of treatment for contacts with LTBI indicate a challenge. The national objective for infected contacts completing treatment for LTBI is at least 85%; Ohio achieved 45% in 1999 and 50% in 2000.

Conclusion

The core activities for TB elimination are identifying and treating persons with TB disease; identifying and treating contacts who have LTBI; and targeted testing and treatment for LTBI for individuals at high risk of developing TB disease. The data show that Ohio has done well in finding patients and starting them on treatment for TB and LTBI but needs improvement in ensuring that cases and contacts complete treatment, and in the length of time recommended. Recent increased TB incidence has challenged some TB programs, necessitating reallocation of resources to meet the challenge of ensuring core activities. Increased numbers of cases among foreign-born persons highlight a need for effective communication skills among TB program staff and patients. Language and cultural barriers must be overcome to provide care in a culturally competent manner. Appropriate interpreters and language systems should be utilized to assist with communicating effectively with multicultural populations. The Ohio Department of Health stands ready to collaborate with local partners to build and strengthen TB elimination efforts in the face of continuing challenges.

—Reported by Jimmy Keller, MA,
Shirley Dobbins, BA, RN,
Elizabeth Koch, MD, MPH&TM,
and Debbie Merz, MS,
Ohio Department of Health TB Program


“Cross-Cultural Issues in TB Prevention and Control in Minnesota”

While the number of TB cases reported nationally has declined steadily since 1993, the incidence of TB is increasing markedly in Minnesota. From a historical low of 91 cases (2.1 per 100,000 population) in 1988, the number of new cases reached 201 (4.3 per 100,000) in 1999, the largest number reported since 1980. In 2000, the number of new cases dropped to 178, but increased 34% to 239 cases (4.9 per 100,000) in 2001.

The epidemiology of TB in Minnesota represents a magnified version of TB trends nationwide, reflecting both the global incidence of TB and recent immigration patterns. While the number of TB cases among U.S.-born persons in Minnesota generally is decreasing, the number of cases among persons born outside the United States is increasing sharply. For the past 2 years, more than 80% of TB cases in Minnesota have occurred in foreign-born persons. The increasing incidence of TB in Minnesota largely is owing to immigration from high-incidence areas (e.g., Somalia, Ethiopia, Laos, Vietnam, and Mexico). The TB cases reported in Minnesota in 2001 were in persons who originated from 30 different countries. While the vast majority (83%) of cases occurred in the seven-county Twin Cities metropolitan area, 28 of the state’s 87 counties reported at least one case in 2001.

The large proportion of diverse foreign-born TB patients in Minnesota increases the challenge of providing adequate clinical and public health TB prevention and control services, particularly in rural areas, which often lack access to cross-cultural resources. Foreign-born TB patients often have complicating factors such as drug resistance, extrapulmonary disease, problems adhering to prescribed therapy, socioeconomic hardships, and cultural and linguistic barriers. In order to meet these additional needs, public health nurses, outreach workers, and clinicians need more than sound clinical knowledge of TB; they need to develop and practice cross-cultural competence.

In December 2001, the Minnesota Department of Health (MDH) TB Prevention and Control Program used federal cooperative agreement funds from CDC to contract with the Minneapolis-based Center for Cross-Cultural Health to present a workshop, presented in two half-day sessions, titled “Cross-Cultural Issues in TB Prevention and Control in Minnesota.” The Center for Cross-Cultural Health is a community-based organization whose mission is “to integrate the role of culture in improving health.”  MDH TB Program staff worked with the center’s director, Dr. Okokon Udo, to tailor these workshops specifically for public health professionals working on the front lines with TB patients in Minnesota. A metropolitan area workshop was held at MDH in Minneapolis. A similar workshop targeted to rural professionals was held in St. Cloud, Minnesota, and simultaneously broadcast as a live videoconference at 11 sites statewide. (The conference was videotaped, and MDH has made free copies of the videotape available to local public health agencies, clinics, and others statewide as a training tool.) Dr. Udo was the facilitator and presenter at both sessions. We scheduled two separate workshops to maintain a reasonable number of participants in order to facilitate interactive discussion and to meet the unique cultural competency needs of both rural and urban providers. Continuing nursing education credits were offered for participants. 

Prior to the workshops, MDH surveyed the target attendees to determine their cultural competency needs. These public health professionals statewide reported a need to improve their skills, knowledge, and expertise in the following areas:


  • Understanding and implementing methods of communication to achieve cultural competency,
  • Involving culturally diverse clients in their own health care decisions,
  • Being aware of the resources available locally for culturally diverse populations and being able to assist clients in accessing those resources, and
  • Knowing and understanding the history, cultural beliefs, and practices (especially related to health) of their clients.

The survey also indicated that public health professionals in rural Minnesota differ significantly from those in urban/suburban areas. For example, rural respondents rated themselves markedly lower than did their urban/suburban colleagues in the following areas:

  • Being able to define culture and how it affects health,
  • Understanding the need for cultural competency in health care,
  • Being familiar with and able to effectively use different communication styles with clients, including nonverbal communication, and
  • Being comfortable working with clients who cannot speak English or whose communication style is different from your own.

The ethnic/cultural groups represented among foreign-born TB clients differ between the rural and urban populations, with more African and Southeast Asian persons in urban areas and more Hispanic/Latino persons in rural areas.

The vast majority of workshop participants were public health nurses. Other participants included physicians, outreach workers, and nurses in other settings such as meat packing plants that employ large numbers of foreign-born persons. Both workshops were very well attended. Dr. Udo did an excellent job tailoring each workshop to the participants’ needs, engaging the participants, and using TB-related examples to illustrate the challenges and importance of cultural competence in health care. Participants completed evaluation forms following the workshops, and their responses were overwhelmingly positive. The majority of participants provided comments such as the following on their evaluation forms:

“Very applicable, I will use (this information) daily/hourly.”

“This was a great workshop and I will take (these concepts) home to use every day – some very new, smart ideas. Thank you.”

“I appreciated… the quote (which is my idea of a healthy community and healthy people)…‘value all of our differences and co-create a healing environment’.”

Some participants also expressed a desire for more specific information about the culturally diverse populations living in their area or more clinical information about TB.

The MDH TB Program was delighted to be able to offer these unique and highly useful workshops for our partners in TB prevention and control at the local level. We were impressed by the participants’ eager receptivity. We look forward to exploring additional ways of continuing our collaboration with the Center for Cross-Cultural Health and of pursuing other means of enhancing the capacity for cultural competence statewide. In the future, we would like to offer a similar workshop or forum targeted to communities of persons most affected by TB so that, just as providers work at developing their own cultural competency, community members themselves can do the same. In the recent workshops, Dr. Udo articulately emphasized the (sometimes overlooked) corresponding need for individual patients from diverse cultures to gain knowledge and expertise needed to understand and adapt to the distinct “culture” of health care and public health systems in the United States. Providing continued opportunities to enhance the cultural competence of both providers and patients is an important step in enabling both groups to meet half-way along the road toward implementing effective and mutually acceptable TB prevention and control strategies.

—Submitted by Marge Higgins, L.S.W.
TB Program Refugee and Immigrant Coordinator
MDH TB Prevention and Control Program


"Tuberculosis: Multiple Perspectives on a Global Health Emergency"

The above was the title of a course taught by Richard Fluck, Ph.D., in the Woodrow Wilson School of International and Public Policy at Princeton University during the fall semester of the 2001-2002 academic year. The course was a response to Princeton students' interest in a course about TB. Subsequent conversations with Princeton Project 55's Tuberculosis Initiative and Dr. Lee Reichman, Executive Director, New Jersey Medical School National TB Center, led Princeton University to invite Dr. Fluck to teach the course. The 13 students in the course included majors in Ecology and Evolutionary Biology, Molecular Biology, Politics, Psychology, and the Wilson School (Public Policy).               

The heart of the course was a semester-long paper or community-based project. The paper topics included cross-cultural issues in TB control; gender and TB; U.S. aid in global TB control; procurement agencies; an analysis of the STOP-TB virtual forums on TB/HIV and DOT; and the molecular biology of the immunological response in TB. Two students, working with Mr. Kenneth Shilkret, Manager of the TB Program, New Jersey Department of Health and Senior Services, performed an epidemiological analysis of TB cases in Middlesex County, New Jersey, a county with a high number of immigrants from South Asia, Mexico, and the Phillippines. Two other students, also working with Mr. Shilkret, performed a community assessment of a town in Middlesex County with a large South Asian population. The community-based projects were facilitated by Trisha Thorme of Princeton University's Community-Based Learning Initiative. Three visitors made substantial contributions to the course as well: Larry Geiter (vaccine development); William Jacobs, Jr. (molecular genetics); and Lee Reichman (multidrug-resistant TB).

For more information on the course, you can contact Richard A. Fluck by mail: Dr. E. Paul & Frances H. Reiff Professor of Biology, Dept. of Biology, Franklin and Marshall College, P.O. Box 3003, Lancaster, PA 17604-3003, USA; by telephone at (717) 291-4152; by fax at (717) 358-4548; or by e-mail at r_fluck@fandm.edu.

—Reported by Richard Fluck, PhD
Franklin and Marshall

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

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