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TB Notes 2, 2004

Highlights from State and Local Programs

A Multi-Jurisdictional TB Outbreak Among Seasonal Agricultural Workers From Oaxaca, Mexico

Year round, California employs more than 900,000 migrant and seasonal agricultural workers, 90% of whom are Mexico-born.1,2 In the past two decades there has been a rapid increase in the number of indigenous migrant workers in California: in 2003, approximately 50,000 to 100,000 agricultural workers were of Mixtec descent, originating from the Mexican states of Oaxaca, Puebla, and Guerrero. Mixtecs are Mexicans of indigenous (American Indian) descent. The group consists of many different communities with their own cultures and dialects of the Mixtec language. Catastrophic soil erosion and resultant crop failures in these areas have forced Mixtecs and other indigenous groups to migrate through Baja California and the western United States in order to find work.

Challenges for migrant populations in general are magnified in indigenous groups: they face discrimination from other migrant groups and employers, they receive the lowest wages for the least desirable jobs, and many, particularly the women, speak only their native language and cannot communicate effectively in Spanish or English with employers or health care providers.3

In June 2003, a local health jurisdiction (LHJ) requested assistance from the California TB Control Branch (TBCB) Outbreak Response Team (ORT) to contain an outbreak of TB among Mixtec seasonal agricultural workers. The LHJ had found five persons with TB (3 adults and 2 children) in several related households. The group came from one small village in Oaxaca and traveled frequently among six LHJs in California and one in Washington state. The index case was a young Mixtec male who had a self-reported history of TB treatment in 2002 in Oaxaca. In March 2003, he arrived in California and was subsequently diagnosed with smear- and culture-positive pulmonary TB in May. Despite exhaustive efforts to promote adherence, including detention in a health facility, the index case was lost to follow-up in June 2003. A newly identified secondary case was also lost to follow-up at that time, before being informed of her TB diagnosis. Additionally, a tuberculin skin test (TST)-positive, symptomatic 18-month-old was lost to follow-up before initial evaluation could be completed. The LHJ requested ORT assistance to locate lost cases and suspects, and to identify additional contacts for evaluation. 

Challenges to outbreak containment included frequent client movement between Mexico, California, and Washington; sociocultural, economic, language, and transportation barriers to accessing health care; and difficulty in establishing trust between health departments and clients. Contacts were difficult to elicit, locate, evaluate, and treat, primarily owing to clients’ fear of health authorities because of their undocumented status. To contain the outbreak, the Outbreak Response Team (ORT) facilitated a coordinated approach with the participation of all involved entities, including state TB control programs in California and Washington, affected LHJs, community- based organizations (CBOs), CureTB, and TBNet

To assess the extent of the outbreak, LHJs surrounding the outbreak county and those with known concentrations of migrant workers were canvassed for Oaxaca-born TB cases diagnosed in 2003. A TB outbreak alert was distributed to all Health Officers in California and community health care providers within affected LHJs, requesting rapid reporting of anyone from Oaxaca newly diagnosed with TB. Isolates from persons from Oaxaca with culture-confirmed TB with known or suspected epi-links were genotyped by CDC. The TBCB ORT, State of Washington TB Control, and LHJs held regular meetings and teleconferences to set outbreak investigation priorities and exchange information. A centralized outbreak database was maintained by the TBCB ORT and used to track patient movement and evaluation status. 

In cooperation with the Fresno Health Department Communicable Disease Outreach Program, the Binational Center for Indigenous Oaxacan Development (CBDIO) in Fresno, California, provided TB education and outreach to Mixtec audiences. This was accomplished through radio and TV broadcasts in Spanish and Mixtec and  a TB patient education audiotape that was recorded and distributed to health departments. Mixtec interpreters were located through CBOs, including the CBDIO and California Rural Legal Assistance. Oaxacan community leaders were enlisted and the TBCB provided additional funds to the primary outbreak LHJ to hire a Oaxacan consultant to enhance LHJ cultural and language competence. LHJs and the TBCB ORT worked with TBNet to improve continuity of care as patients moved between US locations by enrolling them in the TBNet program.

It was also necessary to coordinate TB care in Oaxaca for persons with TB disease returning home before completion of treatment. Access to health care in the home village is limited, with the nearest clinic four hours away by bus. CureTB coordinated closely with health care staff in the home village area, who in turn coordinated with village leaders to ensure continuing therapy for persons with TB disease.

As of December 2003, 68 individuals were identified through this outbreak investigation and 56 completed evaluation. Ten (18%) have TB disease (5 culture-confirmed adults with pansusceptible disease, 5 clinically diagnosed pediatric cases), two (4%) are TB suspects, and 34 (61%) have latent TB infection. Eight of 10 outbreak cases and one TB suspect moved one or more times during evaluation and treatment. The index case was found in his home village in Mexico and was restarted on treatment; however, after only about 2 months of therapy it was reported that he had left his village and was returning to California. Efforts are currently underway to locate him. Thanks to information obtained through our active surveillance efforts, the lost secondary case was located in Washington state and started on therapy in August 2003. She returned to California in September and subsequently went back to Mexico in October, where her treatment continued as a result of close coordination between CureTB and health care providers in Mexico. In January 2004, she returned to California where therapy continues. The 18-month-old was located and evaluated in August 2003 and remains on treatment for clinically diagnosed TB.  All other cases remain on treatment.

Genotyping results on isolates from the five culture-confirmed adult outbreak cases show an identical DNA fingerprint among four of the isolates, suggesting transmission between these individuals or from a common source, or a TB strain endemic to the home village. Additionally, an isolate from a 2001 pleural case diagnosed in Washington state who came from the same village has a matching RFLP pattern with this outbreak strain.

This outbreak revealed a very high proportion of tuberculin skin test-positive individuals (80% of those evaluated). Interruptions in treatment, delays in diagnosis, and crowded living conditions contributed to extensive transmission in this outbreak. Breaks and delays in treatment were related to fear of authorities, lack of financial resources, lack of transportation, long work hours, language barriers, lack of TB knowledge, and frequent movement. Results from this investigation highlight the difficulties in containing TB outbreaks in migrant workers and indicate the importance of collaboration between community partners and health jurisdictions at local, state, and national levels for containment of an outbreak among a highly mobile population. Involving community leaders, providing adequate interpretation, and using all available media to communicate key messages are effective methods for creating awareness and establishing trust within a hard-to-reach population, and thus decreasing lost cases and suspects and halting transmission. 

The genotyping results and anecdotal information obtained from case interviews suggest that in addition to U.S.-based transmission, there may be ongoing TB transmission in the home village. Continued coordination with health authorities in Mexico will be critical to ensuring containment of the outbreak on both sides of the border.

—Submitted by Tina Albrecht, MSPH, Public Health Advisor
and D’Arcy Richardson, RN, PHN, MS, CNS,
TB Outbreak Response Officer/Nurse Epidemiologist
California State TB Control Branch


1. Migrant and Seasonal Farmworker Enumeration Profiles Study – California. September 2000.

2. California Institute for Rural Studies, Rural California Report. Who Does California Farmwork. Fall 2001; vol 12 (3).

3. Zabin C, Kearney M, Garcia A, Runsten D, and Nagengast C. Mixtec migrants in California agriculture: a new cycle of poverty. Davis, CA: California Institute for Rural Studies; 1993.


Georgia TB Outreach Worker Training

The American Lung Association of Georgia (ALAG) and the Georgia Department of Human Resources, Division of Public Health, Prevention Services Branch, Tuberculosis Program (Georgia TB Program) collaborated to develop and implement the Georgia TB Outreach Worker Training course. The first session was held on September 25 and 26, 2003, at ALAG’s office in Smyrna, Georgia. Although Georgia’s TB cases are decreasing (from 577 cases in 2001 to 533 cases in 2002) and directly observed therapy has been the standard of TB care in Georgia since 1995, timely TB treatment completion rates and treatment completion for latent TB infection still fall short of national target goals. It is essential for local TB programs to be able to educate and retain a cadre of case managers, outreach workers, and field staff needed to achieve critical TB program outcomes such as timely completion of TB treatment and thorough contact investigations. This workshop was developed to build the skills and competencies of these critical public health staff.

A core planning committee, which consisted of staff from the Fulton County Department of Health and Wellness, the ALAG, and the Georgia TB Program, met several times over 4 months to gather information and materials developed by CDC, the Francis J. Curry Model TB Center of San Francisco, California, and the Georgia TB Program to plan the curriculum and teaching methods. A variety of teaching methods were incorporated over the 2-day training course, which included lecture, role-play, and group and individual activities. The curriculum included TB Epidemiology, TB 101/Case Management, Contact Investigation, Interviewing Skills/Clustering Techniques, Directly Observed Therapy, Infection Control, Safety in the Field, Documentation/ Confidentiality/ HIPAA, and Cultural Competency. The workshop also included instruction in sputum collection procedures focusing on interpreting sputum laboratory results. Emphasis was also placed on developing rapport with the patient and community. Presenters were from the Fulton County Department of Health and Wellness, the ALAG, and the Georgia TB Program.

The planning committee decided to pilot test this first training course mainly within the Metropolitan Atlanta districts. The training included 25 participants from the counties in the Metropolitan Atlanta area, as well as from Athens, LaGrange, and Savannah. Participants were required to attend both days of the training and to complete a pretraining questionnaire or self-assessment tool, a pretest, a posttest, and an evaluation. The job titles of the participants included Disease Investigation Specialist, Communicable Disease Specialist, Outreach Worker, Public Health Technician, and Public Health Nurse. All participants were from public health settings and had less than 5 years’ experience in public health. The evaluations were favorable, with the majority of the participants offering “no suggestions” for changes needed for future workshops. The participants indicated that the training “was very beneficial, a lot was learned, very informative, and quality materials.” On a Likert scale of 1 to 5 with 1 being poor and 5 being excellent, the overall score for the workshop was 4.4, with scores ranging from 4.2 to 4.6. The average pretest score was 63%, and the average posttest score was 80%. This reflects an average 17% increase in knowledge. District TB coordinators provided informal verbal feedback expressing their appreciation for having well-trained field staff and requesting future outreach worker training.

ALAG and the Georgia TB Program will present this training to districts outside of the Metropolitan Atlanta area as regional workshops. In October and November 2003, a needs assessment of the remaining districts was conducted. Out of the 12 districts assessed, 8 districts reported a need for outreach worker training. Owing to the positive response, the ALAG and the Georgia TB Program are investigating potential sites for the training outside Metropolitan Atlanta. Both the ALAG and the Georgia TB Program feel that providing quality targeted educational opportunities for TB staff is vital to the public health workforce.

—Submitted by Connee Martin, RN, BS, Carolyn Martin, RN, Karen Buford, RN, MS, Kathy Kolaski, RN, MSN, Ann Poole, RN, Desiree Nesbitt
Georgia Department of Human Resources/Division of Public Health/TB Program
Beverly DeVoe, Georgia TB Program Manager
and Pamela Collins, MSA
Director, Adult Lung Disease Programs
American Lung Association of Georgia


Inaugural Meeting of the Pacific Island TB Controllers Association

The CDC National TB program includes not only the 50 states, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands, but also three additional U.S. territories and three independent U.S.-affiliated nations. These additional territories and independent nations are referred to by CDC as the Pacific Island Jurisdictions (PIJs). The U.S. territories are Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands. The three independent U.S.-affiliated nations are the Republic of Palau, the Republic of the Marshall Islands, and the Federated States of Micronesia (Pohnpei State, Kosrae State, Chuuk State, and Yap State). Each of these three independent states has entered into a Compact of Free Association with the United States. Under these compacts, these countries are fully sovereign in domestic and foreign affairs, but give responsibility for their defense to the United States. All six of these territories and nations are members of the Western Pacific Regional Office (WPRO) of the World Health Organization.

Roughly half a million people live in these six jurisdictions. The individual populations are as follows: Guam, about 155,000; American Samoa, 57,300; Northern Mariana Islands, 69,000; Palau, 19,100; Marshall Islands, 52,000; and Micronesia, 107,000. The total land area of all the PIJs is equivalent to two thirds of Rhode Island, our smallest state (1,545 square miles). Land is scarce, but the ocean resources are vast, encompassing 20 times more area than the total square miles of land. While all these islands have the ocean as a major asset, they also have relatively few other natural resources. Eighty percent of the islands' basic needs must be imported, making harbors and airports the lifelines of island communities. These island nations deal with many challenging dynamics that include reaching and supporting prevention activities in locations separated by vast expanses of ocean, highly mobile populations, a lack of

Image: map of the area

primary health care providers and facilities, variable economic and social conditions, and the challenge of adequately managing the migration and movement of regional and international visitors and workers. Through territorial agreements with the United States, PIJ citizens are able to immigrate to the mainland without overseas screening for health conditions as is required of those permanently resettling from other foreign countries.

With limited surveillance information, the World Health Organization (WHO) Western Pacific Regional Office (WPRO) has estimated the year 2000 TB incidence rate for these PIJs to be 87/100,000 population. While each PIJ is unique, they all share common challenges in supporting a TB control program. To address these challenges as well as to share solutions to unique problems, DTBE’s Field Services and Evaluation Branch (FSEB) partnered with the Pacific Island Health Officers Association (PIHOA) to host the inaugural meeting of the Pacific Island TB Controllers Association (PITCA). This historic meeting brought together representatives from the six PIJs; the State of Hawaii TB Control Program and Public Health Laboratory; Hawaiian, Continental, and Aloha airlines; eDOTS International Development Projects; the University of Guam; the WHO WPRO; the Secretariat of the Pacific Community; the US Public Health Service (USPHS); the CDC Division of Global Migration and Quarantine; and DTBE. The meeting was held in Honolulu, Hawaii, from December 2 through 4, 2003.

During the first 2 days, PIJs described their major concerns with respect to TB program administration and laboratory activities. Facilitators worked with PIJ representatives to identify regional and local solutions. These solutions were compiled into a PIJ-specific action plan for calendar year 2004. Proposed major solutions at this inaugural meeting ranged from public health service cross-training, management and leadership training, continuing education requirements for health department staff, training in laboratory quality control, continued access to laboratory supplies and equipment, developing shipping protocols, and program evaluation.

The final day focused on updates regarding shipping of TB specimens to reference laboratories. While all mainland programs include the full spectrum of TB laboratory services in their program effort, most of the PIJs (with the exception of Guam) do not have the resources to support TB culture and susceptibility testing. These programs are implementing the WHO DOTS protocol (focus on AFB-smear microscopy); however, few have the resources to implement a mainland-type program. The ability to provide TB culture and susceptibility testing will help these programs provide appropriate TB treatment to patients as well as accurate information regarding resistance levels in this region.

In summary, this inaugural meeting was an invaluable process for formalizing collaborations among many partners. Participants left the meeting extremely motivated to reduce the impact of TB in their respective PIJs. Each PIJ created action plans, and with technical assistance from FSEB and PIHOA, PIJs will be monitoring their progress in meeting these action items. The most critical priorities across these PIJs for 2004 were continuing to improve laboratory quality control, ensuring quality AFB smear microscopy at the local program level, and maintaining an adequate provision of laboratory reagents.

To continue supporting improvement in PIJ program development activities, PIHOA and CDC are collaborating with the PIJs to host a second PITCA meeting, scheduled for later in 2004 in the State of Pohnpei of the Federated States of Micronesia.

—Submitted by Subroto Banerji, MPH, Public Health Advisor
Andy J. Heetderks, MPH, Team Leader
Gregory W. Andrews, Section Chief
Zachary Taylor, MD, Branch Chief, FSEB
Div of TB Elimination


1. U.S. Department of the Interior, Office of Insular Affairs,

2. World Health Organization, Western Pacific Regional Office,


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