TB Notes Newsletter
No. 2, 2005
HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS
Misdiagnosis in Rural
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
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.
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
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
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,
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
Reported by Francesca Gany, MD, MS, Director
Jyotsna Changrani, MD, MPH, Assistant
Center for Immigrant Health, NYU School
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
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
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
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 Charles.Wallace@dshs.state.tx.us
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