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TB Notes 2, 2004

Highlights from State and Local Programs

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
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