North Dakota | Texas
Mycobacterium bovis in North Dakota
Background. On February 17, 1999, the North Dakota
State Veterinarian's office received notification that an animal
with lesions consistent with TB had been traced to a dairy herd
in the state. The cow with the lesions was found during routine
USDA inspection at a Minnesota slaughter house.
On February 23, the owner of the dairy herd was
contacted and skin testing on the remaining cattle in his herd
was initiated. A total of 115 animals were tested; 54 (47%) were
negative, and 61 tested positive (53%). The USDA purchased four
of the cows that tested positive from the owner of the herd and
shipped them to the State Veterinary Diagnostic Laboratory for
postmortem exam for TB. Initial testing showed three of the four
animals had histologic lesions consistent with TB and one had
acid-fast organisms. The remaining 57 cattle that tested positive
were subjected to comparative testing to distinguish between M.
avium and M. bovis infection because of the frequency of M. avium
infection in cattle. Results from the comparative testing revealed
that 15 were positive for M. avium, 11 were M. bovis suspects,
and 31 were M. bovis reactors.
On March 10, the State Board of Animal Health declared
the herd to be TB infected. The entire herd was destroyed and
a quarantine of approximately a 5-mile radius was placed on the
area surrounding the infected dairy herd. The quarantine restricts
movement of livestock into or out of the area unless a permit
is issued by the state veterinarian. With assistance from the
USDA, every herd in the quarantined area is being tested for TB,
a process that will likely take several months to complete. In
addition, extensive investigations have been initiated to trace
sales of cattle from the infected herd to other areas, as well
as to ascertain the source of infection.
Human Implications. The North Dakota Department
of Health (NDDH) was notified by the state veterinarian on March
2 about possible human exposures to M. bovis in a dairy herd.
The NDDH began working closely with the North Dakota Department
of Agriculture to determine risk factors and exposed populations.
The owner of the dairy herd sold milk from the cattle to a local
cheese processing plant. The plant does not pasteurize the milk
product, but instead ships it out of state where further processing
is done. Individuals considered at risk for M. bovis exposure
included persons who had ingested or handled unpasteurized dairy
products, as well as individuals having direct contact with infected
cattle (i.e., the owner of the dairy farm and his family). The
following recommendations were provided for suspected exposures:
Exposed persons should have a baseline tuberculin
skin test (TST). An induration of 5 mm is considered positive.
Those persons who test negative should be retested in 10 -
12 weeks after the last exposure.
All exposed persons with positive TST results
should have a review of symptoms, a physical exam, and a chest
Children who were exposed and are TST positive,
and young children age 4 and under who were exposed (regardless
of TST result) should have a chest x-ray. Children with positive
(5-mm) reactions should receive INH prophylaxis. Children
£ 4 years should receive INH
prophylaxis until a negative result is confirmed by a retest
administered 10 - 12 weeks following last exposure.
INH prophylaxis for 6 - 9 months should be prescribed
for those exposed and TST positive (5 mm), children included.
A total of 106 individuals were skin tested; 101
(95%) tested negative, and five (5%) tested positive. Of the five
individuals who tested positive, two were foreign-born individuals
who had never been tested, one was an elderly person who may have
been exposed to pulmonary TB as a child, another was exposed to
the dairy herd, and the fifth person worked at the plant. Two
of the five individuals had consumed unpasteurized dairy products.
Postexposure testing will continue for 10 - 12 weeks following
last exposures for those at risk. We conclude that there was no
definitive correlation between the infected persons and the infected
Testing of cattle in the quarantined area continues.
To date, 3,051 animals have been tested from 32 different herds;
27 herds tested negative and four are pending. Only the one initial
herd has been identified as infected.
Submitted by Ruth Vogel, TB Program Mgr
North Dakota Department of Health
North Dakota | Texas
Texas: TB Control in Correctional Facilities
On February 24, 1999, the satellite program "Tuberculosis
Control in Correctional Facilities" was broadcast nationwide.
There were 467 sites that registered before the conference. Some
of the site coordinators passed on information about the broadcast
to other sites in their area; as a result, an additional 39 sites
accessed the conference and returned sign-in rosters and evaluations
of the broadcast. To date, 2,431 participants signed a roster
sheet that has been returned to the broadcast organizers. In addition,
many sites recorded the broadcast on tape for later viewing, further
increasing the total number of people who were able to view the
During the introduction to the broadcast, the moderator
Shari Perrotta from the Texas Department of Health gave information
to allow the audience to call in, fax, or e-mail questions. The
speakers answered as many of the questions as possible between
the program segments.
The program began with an overview by Dr. Jonathan
Weisbuch, Chairman of the National Commission on Correctional
Health Care, on the reasons why TB is a special concern in correctional
facilities. Next Dr. Newton Kendig, Medical Director for the Federal
Bureau of Prisons, talked about the conditions under which TB
is and is not transmitted. He also discussed the primary methods
institutions use to prevent transmission of TB. The proper way
for an individual to put on a respirator was demonstrated. Dr.
Stephen Weis, Professor of Medicine at the University of North
Texas Health Science Center and TB Controller for the Ft. Worth
Tarrant County Health Department, talked about the special
problems that correctional facilities have in arriving at a diagnosis
of TB. He also discussed ways to ensure that treatment is successful
by using direct observation and developing a close relationship
with the appropriate health department to provide continuity of
care if the inmate is released to the community while still under
therapy. The first three speakers then answered questions from
The second section of the program started with a
discussion by Dr. Michael Puisis, Regional Medical Director in
New Mexico for Correctional Medical Services, on the basics of
a screening program, including the different approaches used by
long-term and short-term correctional facilities. Captain Marcia
Withiam-Wilson, Chief U.S. Public Health Service Officer at the
U.S. Marshals Service, spoke to the audience concerning the new
policy of the U.S. Marshals Service that requires inmates to have
documentation (Federal Form 553) certifying that they have been
cleared for TB before they can be placed on the airplanes of the
Justice Prisoner and Alien Transport System. She also discussed
the precautions that can be taken if an inmate with infectious
TB must be transported. Ms. Mae Pasquet, Director of Correctional
Health Services for the John Peter Smith Health Network (health
care provider agency for the Ft. Worth Tarrant County Jail),
explained the steps a facility can take to develop a written plan
for their TB control and prevention protocols. This group of speakers
then took questions from the audience.
The third and final segment of the program began
with a discussion by Dr. Orlando Pile, Chief of the Communicable
Diseases Unit for the Los Angeles County Sheriffs Department,
regarding how to establish a TB training program for correctional
facility staff. Dr. Michael Kelley, Director of Preventive Medicine
for the Texas Department of Criminal Justice, explained how to
conduct a contact investigation within a correctional facility
when a person with active infectious TB may have exposed other
inmates and correctional employees. Dr. Brian Smith, Regional
Director for the Texas Department of Health Public Health Region
11, explained the role that the local health department plays
in finding the people in the community who may have been infected
by someone within the correctional facility. The program concluded
with another question-and-answer period. The participants
and site coordinators evaluations, which have been forwarded
to the Texas Department of Health TB Elimination Division, are
currently being analyzed for internal use.
If you missed the program and would like to order
a tape of the broadcast, please contact Ray Silva via e-mail at
email@example.com or by phone at (512) 458-7447. The cost
for a tape is $10 including shipping.
Reported by Phyllis E. Cruise, Senior
and Ann Tyree, Communication Specialist
Texas Department of Health
North Dakota | Texas
San Diegos CURE-TB:
U.S./Mexico Binational Referral System
CURE-TB is the U.S./Mexico binational referral system
that was funded in June 1997 by the State of California Department
of Health Services and is operated by the San Diego County TB
Control Program. The system was built upon a referral infrastructure
that existed for years between San Diego and various Mexican TB
programs. The number one priority of CURE-TB is to improve continuity
of care for active TB patients. This system provides guidance
and education to patients moving between Mexico and the United
States during the course of their treatment. CURE-TB also offers
a link between health providers in Mexico and the United States
by notifying them of a patients arrival to their communities
and by facilitating the exchange of patient clinical information.
CURE-TB is the only health department-based system offering referrals
nationwide between Mexico and the United States.
In June 1998, CURE-TB and the Mexican National TB
Program reached an agreement on how to improve and expand the
use of CURE-TB referral services to all Mexican states. Recommendations
from the National TB Program were implemented in daily CURE-TB
procedures. In 1999, information on CURE-TB services was included
on the Mexican national patient treatment card, the Carnet, which
is provided to TB patients throughout the country. Currently,
CURE-TB notifies national, state, and local providers of the patients
who move from the United States to Mexico and vice versa. In less
than 2 years, CURE-TB has established extensive communications
between the Mexican Health Department sector (Secretaria de Salubridad
y Asistencia) and U.S. TB programs. An active database has been
developed and implemented to evaluate and document the referral
process. The CURE-TB toll-free number, available to both countries,
has enabled patients and providers from Mexico to contact CURE-TB
directly when a patient is traveling from Mexico to the United
As states across the United States have become aware
of CURE-TB, they have begun to request binational referral services.
In September 1998, CURE-TB services were outlined in the NTCA
newsletter, The Red Snapper. The program has gained rapid acceptance,
and as of June 1999, TB programs from 21 U.S. states have used
CURE-TB services to send referrals to 29 of the 32 Mexican states.
In 1997, these 21 states reported 71% (1,200/1,685) of all Mexican-born
TB patients in the United States.
One of the most important roles of the CURE-TB Binational
Referral System is educating TB patients about their disease and
the importance of finishing the prescribed treatment. Pedro's
story is an example of how CURE-TB helps patients finish their
Pedro was diagnosed with TB in April of 1998 in
a northern California county. He was started on medications and
left for Jalisco, Mexico, a week later. The California doctor
sent a referral to CURE-TB and CURE-TB staff contacted Pedro in
Jalisco via telephone. At the same time, CURE-TB notified the
Mexican National TB Program of Pedro's arrival in Jalisco.
Pedro informed CURE-TB staff that upon his arrival
he had visited a local clinic where he was evaluated using available
diagnostic procedures (sputum smear tests and a clinical evaluation)
and was told that he did not appear to have TB. CURE-TB staff
asked Pedro for the local clinic's number in order to provide
his physician with Pedro's past medical history. CURE-TB counselors
immediately called Pedro's physician to provide information on
Pedro's previous diagnostic studies, which included culture results
positive for M. tuberculosis, and his treatment course while in
the United States. Pedro's physician appreciated this information
and decided to continue Pedro's treatment. CURE-TB staff communicated
with Pedro again to let him know that he needed to visit his physician
as soon as possible.
A month later, CURE-TB staff received the final
results on Pedro's TB drug resistance tests from the California
clinic: Pedro's TB isolate was resistant to one drug, isoniazid.
This was immediately communicated to Pedro's physician, who added
ethambutol to his original three-drug regimen. Pedro finished
his treatment in November of 1998 and is one of the success stories
of the CURE-TB referral system. The completion of his treatment
was also communicated to the county in California where Pedro
currently resides after returning from Jalisco.
Had this exchange of information between CURE-TB,
Pedro, and his providers in the United States and Mexico not taken
place, Pedro's treatment would likely not have been continued,
and he may have gotten sicker, and possibly infected people around
him. Cases such as Pedro's are common to the CURE-TB system. Exchanging
information between providers and educating and guiding patients
are essential factors in completing treatment for TB patients
moving between the United States and Mexico. CURE-TB staff are
committed and eager to continue providing these services. To send
a referral or find out more about CURE-TB, call Ms. Sonia Contreras
at (619) 692-5710.
Reported by Kathleen Moser, MD, MPH
San Diego Co. Dept of Health Services