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TB Notes 2, 1999

Highlights from State and Local Programs

North Dakota | Texas | California

 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 x-ray.

  • 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 cattle.

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 | California

Texas: TB Control in Correctional Facilities Satellite Broadcast

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 program.

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 audience.

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 Sheriff’s 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 or by phone at (512) 458-7447. The cost for a tape is $10 including shipping.

—Reported by Phyllis E. Cruise, Senior PHA
and Ann Tyree, Communication Specialist
Texas Department of Health



North Dakota | Texas | California

San Diego’s 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 patient’s 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 States.

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.

Pedro's Story

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 treatment.

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


Released October 2008
Centers for Disease Control and Prevention
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