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TB Notes Newsletter

No. 2, 2005


Misdiagnosis in Rural Colorado

Background. Colorado is a low-incidence state, with a 2004 tuberculosis (TB) case rate of 2.8 per 100,000 population. However, the number of reported cases increased from 111 cases in 2003 to 127 in 2004. The Denver metro area typically reports 70% to 75% of the state’s active TB cases each year. Though the metro area accounts for most of the cases, misdiagnosis still occurs if physicians do not “think TB” or if they have never seen a TB case before.  In 2004 three rural counties in Colorado reported at least one active case of TB for the first time in at least 8 years. These counties have few health care facilities available and no TB expertise locally.

Case Report. On April 29, 2004, the Colorado Department of Public Health and Environment TB Program (CDPHE) received a call from an infectious disease (ID) physician in Denver.  The physician was very concerned after diagnosing TB in a patient referred to her from a rural community clinic. This patient had sought care repeatedly and was misdiagnosed over a 4-month period of time. A discussion with the physician ensued regarding the consequences of the loss of TB diagnostic expertise in low-incidence areas such as Colorado, but especially in rural communities.

The patient was a 35-year-old female who had traveled to the United States from Uganda with an 18-month worker’s visa. She arrived in a rural county in the Rocky Mountains of Colorado in December 2003. Her employer’s international office actively recruits employees from around the world, including many from countries with a high incidence of TB. No health screening or tuberculin testing is required upon employment.

The patient sought care with the community clinic 11 times from December 2003 through April 2004. The clinician at this rural community clinic treated the patient repeatedly for pneumonia. The patient received several rounds of antibiotics and inhalers before being referred to the ID physician in Denver. The patient’s symptoms included cough, chest pain, weight loss, and fever. The patient states her symptoms started approximately 1 week after arrival in Colorado, although she did not feel well on the flight over. Chest x-rays of December 2003 and March 2004 showed left upper and lower lobe infiltrates. The chest x-ray of April 2004 exhibited worsening infiltrates with cavitation. The patient had a history of a negative HIV test in 1998.

The ID physician immediately hospitalized the patient in Denver after her evaluation. Sputa collected were reported as 4+ on smear and four-drug therapy with INH, rifampin, ethambutol, and PZA was initiated. The rural county nursing service was contacted and the suspected TB case was reported to the nursing director and the public health nurse on April 29, 2004. The public health nurse, though experienced in nursing, was new to public health and had just finished her tenth day on the job. This rural county had not reported an active case of TB in over 10 years.

The CDPHE TB program nurse consultant immediately provided the community clinic staff with an educational inservice training; information included TB diagnosis and treatment and the contact investigation process. TB educational materials, including the CDC tuberculin skin testing video, guidelines for the treatment of TB, and the Colorado State TB Manual, were distributed during this session. A county commissioner was noted among the audience. Discussions took place to answer questions and alleviate concerns. The TB program nurse consultant found that meeting with the community clinic staff was useful in the long and arduous process of contact investigation and case management of patients.

Many concerns and questions came from the private clinicians and public health staff, as well as the community. The CDPHE TB program nurse consultant made many trips to the county (a 200-mile round trip) to provide assistance and consultation. Building relationships improved the comfort level of the providers in the community to ask questions and follow recommendations. However, it was difficult for a low-incidence state such as Colorado to provide the assistance required to a small rural county and maintain all program functions.

The patient completed 6 months of directly observed therapy for culture-confirmed and drug-susceptible Mycobacterium tuberculosis on November 5, 2004. She exhibited severe joint and muscle pain at times while on treatment, although this did not interrupt her therapy. The patient was determined to complete her therapy regardless of side effects. The public health nurse offered encouragement to the patient and arranged appointments with the patient’s private care provider for evaluation of symptoms and follow-up. As treatment continued, the patient regained 20 pounds of her weight loss and other TB symptoms resolved. She was extremely thankful for the treatment and care she received from the public health nursing service. She refused HIV testing though it was offered several times. Her reasoning was that she could not handle any additional bad news and would refuse treatment even if the test proved positive. The patient recounted knowing others who had died of HIV/AIDS in Uganda.

Contact Investigation. Owing to the length of time the case was misdiagnosed and to the patient’s work and living environment, an extensive contact investigation was performed. It quickly became apparent that the patient had become very involved in the community since her arrival.  The investigation included the work site, on-site housing, work site day care, high-risk patients from the clinic waiting room, the patient’s church, and a Girl Scout troop. The public health nurse began tuberculin testing of the contacts; however, the need for support was soon recognized. As the numbers of contacts and sites increased, the state TB program offered assistance. Several CDPHE TB program staff assisted, as did a communicable disease epidemiologist.

The CDPHE TB program nurse consultant’s visits to the county provided opportunities for additional education to those who needed it, including local public health staff, contacts, providers, and community members. Being on site was invaluable in understanding the anxiety created as the numbers of sites and contacts grew. It also provided the opportunity to assess new problems as they arose, make quick decisions, and give directions. The CDPHE TB program nurse consultant was able to obtain immediate guidance while on site from the expert physicians at Denver Public Health when needed.

A total of 321 people were initially tested, and a list of 267 true contacts was developed for the follow-up testing. A large number of the contacts were foreign-born persons, coming from many countries around the world, including high-incidence countries. This added confusion to the task of determining transmission and controlling the scope of the investigation.

Local clinicians were contacted and given recommendations regarding follow-up of their patients who were named as contacts. Questions and discussion were encouraged. 

Results of the contact investigation identified one additional person with active TB. She was treated by DOT with 4 months of therapy since she had a negative culture but clinical improvement. This patient was also from Uganda and traveled with the index case.

There were 56 contacts identified with latent TB infection (LTBI), of which 38 were started on treatment with INH; 39 of these contacts were foreign-born persons. To date, 30 contacts continue their therapy. Several patients returned to their home countries during the investigation. Referrals were made where possible.

BT Exercise

The local public health nursing director requested assistance from the bioterrorism (BT) program in conducting the contact investigation. The bioterrorism (BT) program felt the follow-up tuberculin testing would be an excellent opportunity to carry out a response exercise. Testing was accomplished at several clinics set up at the sites where contacts were identified. The BT program and rural public health agency gained experience in putting a plan together, initiating the plan, and making calls for assistance from the community, the surrounding counties, and the State TB and BT Programs. Public health nurses as well as support staff from many surrounding counties and the state responded to help with the testing clinics. 

The nurses who responded not only received updated information on tuberculosis and testing procedures, but also were able to fulfill many objectives related to bioterrorism grant funding. The responders gained experience in how an actual event could evolve and a response would occur. The community and surrounding counties were able to practice the ability to put a plan together and modify it as the event progressed. The members of the BT exercise planning team gained experience in working together. It was beneficial for all involved to appreciate the effectiveness of program and regional collaborations.

One caveat or limitation of the TB/BT collaboration was that participating in the planning, initiation, and execution of the exercise increased the workload of both the CDPHE TB Program and the local public health agency. Those responders who were assigned to place and read skin tests were trained appropriately and monitored, with adjustments in assignments made as needed. The local public health nurse was responsible for arranging the clinics and making staffing assignments as responders volunteered. The public health nurse, who was assigned the role of incident commander, was responsible for the adjustment of staff before and during the clinics.

The participants in the event came away with new skills, new associates, and a sense of collaboration within public health and the community.

Submitted by Gayle M. Schack, RN,
Nurse Consultant and
Juli Bettridge, Health Professional III
Colorado Department of Public Health and Environment


Thinking Outside the Box to Control TB in the Foreign-born: Taxi Workers in New York

The data in this article were previously reported in the following publication:
Gany F, Trinh-Shevrin C, Changrani J. Drive-by readings: a creative strategy for tuberculosis control among immigrants. American Journal of Public Health January 2005; 95(1):117-119.

While current strategies to find persons with TB and their close contacts are effective for US-born populations at risk for TB, there are missed opportunities in reaching communities disproportionately burdened with latent TB infection (LTBI). There is a large segment of the population, recent immigrants from high TB prevalence areas, for which targeted testing and treatment is needed.     

To effect TB control in immigrant communities, the Center for Immigrant Health (CIH), New York University (NYU) School of Medicine, in partnership with the New York City Department of Health and Mental Hygiene, implemented the "Community Tuberculosis Prevention Program" (CTPP). CTPP provides LTBI community outreach, education, screening, and case management. Most of CTPP’s clients are recent immigrants with no prior health care access. CTPP uses creative approaches that consider immigrant communities’ unique circumstances.

There are over 40,000 taxi drivers in New York City. The members of this largely immigrant workforce work long hours and face multiple challenges to maintaining health, including occupational, economic, linguistic, and cultural barriers. Taxi workers often hail from countries where TB is endemic. As such, they are at risk for LTBI.

John F. Kennedy Airport (JFK) is a major site of taxi activity. Drivers await their turn to pick up passengers in JFK’s Central Holding Lot, in some cases for several hours. Staff of CIH saw this as a key window of opportunity for intervention: an at-risk, mobile population, now a captive audience.

To reach this group, six multilingual CIH staff provided TB education and screening to 123 taxi drivers in the Holding Lot. To accommodate the drivers’ way of life and their concerns that a loss in driving time is a loss of income, the readings were held 2 and 3 days later in the fire lane at a centrally located municipal hospital. The drivers drove through the lane and held their arms out for TST measurement. If their result was negative, they were given a letter stating the result, and drove on. If positive, they were given appointments for follow-up.

In this manner, 123 taxi drivers from over 25 countries were tested for LTBI. Most of the drivers (97%) were born outside of the United States, with two thirds of the 123 being from four countries: Pakistan, India, Haiti, and Bangladesh. As many as 102 (83%) of the drivers had no health insurance. Only 26 (21%) drivers had a family doctor. Nearly two thirds (81/123) of the drivers had never before been tested for TB.

We found that 48 had TST-positive results, which was nearly 62% of the 78 who returned and approximately 39% of the 123 total individuals screened. Over 40% (15/34) of those scheduled for an evaluation on a day other than the reading did not get one, most because of concerns about convenience or cost, and one because he was advised by his private physician that he did not need it. In addition, 64% (16/25) of those who received a full physician evaluation were advised not to start treatment for LTBI.  Of these individuals, 37.5% (6/16) had reported co-existing medical conditions or TB exposure associated with a high risk for TB; nine individuals were advised to start treatment for LTBI; eight individuals initiated treatment; 50% of them completed. Those who did not complete treatment cited as reasons having side effects, and leaving the country for a prolonged period of time.

This program demonstrated that innovative approaches to reaching at-risk immigrant populations can be effective. However, such programs must similarly include ease of follow-up after screening and provider education to ensure that patients are receiving care according to CDC guidelines.

Reported by Francesca Gany, MD, MS, Director
Jyotsna Changrani, MD, MPH, Assistant Director
Center for Immigrant Health, NYU School of Medicine


Ten Against TB Initiative

After discussions at the US-Mexico Border Health Association meeting in 1995, the state health officers from the ten US-Mexico border states decided that it was necessary to change the way border states work to manage their public health issues. The lack of a strong communication infrastructure throughout the entire region often caused fragmentation in efforts to coordinate public health activities. The health officers agreed to begin the process of developing a system whereby states would communicate across border jurisdictional lines and build the linkages necessary to expedite interventions when public health events occurred.

Tuberculosis was identified as a public health condition common to all ten border states that would serve as an excellent public health issue around which to begin building a framework for cross-state and cross-border communication links. The ten state health officers were joined by representatives from both US and Mexican federal governments, and nongovernmental organizations including the Pan American Health Organization (PAHO), the American Lung Association, the Texas Medical Association, Rotary International, and the Migrant Clinicians Network.

For the past 10 years, the Ten Against TB Initiative has used limited funding from the U.S. Health Resources and Services Administration to host meetings. It carried out various operational aspects of the initiative with some fiscal support from the Texas Medical Association and the Pan American Health Organization. Since the inception of the initiative in 1995, the Texas Department of State Health Services has supported the personnel costs associated with its coordination and administration.

The Ten Against TB Initiative recently produced a strategic plan for the prevention and control of TB along the US-Mexico Border. The Ten Against TB Initiative Strategic Plan describes action steps to (1) enhance TB epidemiology, surveillance, and case finding; (2) strengthen laboratory infrastructure to enhance identification and confirmation of TB; (3) increase health promotion, training, and communication for TB awareness; and (4) improve TB case management.

The US-Mexico Border Health Commission recently selected the Ten Against TB Initiative as its official advisor on binational and border TB issues.

For additional information on the Ten Against TB Initiative, please contact the coordinator, Jose A. Gomes Moreira, at (512) 458-7447.

Reported by Jose A Gomes-Moreira, MA, Coordinator
Ten Against TB Initiative
Phyllis Cruise, CDC Senior PHA, and
Charles E. Wallace, PhD, MPH, Manager
Infectious Disease Intervention and Control Branch
Texas Department of State Health Services


Rotary International Confronts TB on the Texas-Mexico Border

Rotary International is a worldwide organization of business, government, and professional leaders who provide humanitarian services, encourage high ethical standards in all vocations, and help build good will and peace in the world.  Approximately 1.2 million Rotarians belong to more than 31,000 Rotary Clubs located in 166 countries.

Several Rotary districts in Texas and Mexico have joined in the fight against TB on the Texas-Mexico border. Texas Rotary Districts 5520, 5790, 5810, 5840, 5870, and 5930 and Mexican Rotary Districts 4110 and 4130 have come together to develop the Rotary Strategic Plan Against Tuberculosis on the Texas-Mexico Border. Three Rotary officials have been working with the Texas Department of State Health Service Tuberculosis Program to initiate the campaign against TB on the border: Dr. Clift Price, past Rotary District Governor and retired Associate Commissioner of the Texas Department of Health; Mr. Armando Avalos, President of the Corpus Christi, Texas, Sunrise Rotary Club and a charter member of the Ten Against TB Initiative; and Ms. Elaine Hernandez, Rotarian and Director of the Office of Border Health for the Lower Rio Grande Development Council. The campaign began with Rotary International establishing a Proclamation stating that the Rotary International Border districts on the Texas-Mexico Border are committed to making a difference in the prevention and control of TB in this sector of the two nations.

In McAllen, Texas, on October 2004, the Rotary International Border districts held the Rotary Binational TB Submit. The purpose of the Summit was to (1) raise awareness among Rotarians on the causes of TB along the border, (2) encourage Rotary Clubs to adopt TB projects, (3) demonstrate to the official health departments of Texas and of Tamaulipas and Nuevo Leon in Mexico that civic organizations can partner with governments to address public health concerns, and (4) strengthen relationships among Rotarians from districts in Texas and Mexico to work together on TB projects. This Rotary Campaign against Binational TB has been endorsed by two past presidents of Rotary International, Dr. Carlos Conseco and Mr. Frank Delvin, who are well known leaders in the International Polio Plus Campaign.

The Rotary Binational TB Summit had the support of the Honorable Luis Manuel Lopez Moreno, Consul of Mexico; Dr. Gerardo Garcia Salinas, Secretary of Health for the State of Tamaulipas, Mexico; Ms. Eva Moya, Executive Director of the US-Mexico Border Health Commission; and Dr. Adrian Rendon, Director of the Center of Excellence in Tuberculosis, Monterrey, Mexico. Also represented were Mr. Bill Martin, President of the McAllen Rotary Club; Rev. George Dawson, Governor of Rotary District 5930; Mr. Jose Verduzco, Governor-Elect for Rotary District 5930, and Mr. Polo Rodriguez, Past District Governor of Rotary District 4130. The Summit received greetings from Congressman Ruben Hinojosa of Texas and a host of other state and national leaders.

For additional information on the Rotary International Binational Tuberculosis Campaign, contact Dr. Charles Wallace at

Submitted by Charles Wallace, PhD, MPH, Manager
Infectious Disease Intervention and Control Branch
Texas Department of State Health Services, and
Jose A. Gomes-Moreira, MA, Coordinator
 Ten Against TB Initiative


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