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TB Notes 3, 2002

Highlights from State and Local Programs

World TB Day and TB Awareness Fortnight in Missouri

Each year the Missouri Department of Health and Senior Services’ TB Control Program commemorates World TB Day on March 24 and TB Awareness Fortnight in Missouri for a period of 2 weeks during the latter part of March. During this time, efforts are made to raise awareness throughout Missouri regarding the signs and symptoms of TB, the availability of treatment, and the importance of seeing a private physician or the local health department if a person has those signs and symptoms or has come in contact with someone who has TB disease. From March 14 through March 31, 2002, the following activities occurred in Missouri:

  • On March 14, just prior to the official start of TB Awareness Fortnight, Dr. Richard J. O’Brien, Chief, Research and Evaluation Branch, DTBE, CDC, made a presentation entitled "Advances in the Diagnosis and Treatment of Tuberculosis" at the University of Missouri-Columbia. Approximately 100 health professionals, mostly physicians, attended this presentation. The American Lung Association (ALA) of Eastern Missouri sponsored the presentation.
  • On March 19, state TB program staff provided an update on TB for nurses in local health departments in the southwestern part of the state. The update was conducted at the Southwestern District Health Office in Springfield, MO.
  • On March 19, Governor Holden signed a proclamation declaring the period of March 17 through March 31, 2002, as TB Awareness Fortnight in Missouri. Representatives from state and local health departments, as well as the lung associations, attended this ceremony.
  • On March 22, a nurses’ seminar entitled "TB in the 21st Century: A Seminar for Health Professionals" was held at St. Louis University. It was sponsored by the ALA of Eastern Missouri.
  • On March 25, a reception was held to commemorate World TB Day in the state TB program’s central office in Jefferson City for employees of the Missouri Department of Health and Senior Services.
  • On March 26, an in-service entitled "Tuberculosis in the Community, School, and Hospital" was provided in Poplar Bluff, MO, in the Southeastern District Health Office for health professionals in the private and public sectors.
  • On March 28, a presentation entitled "Tuberculosis and the War: What You Should Know" was provided for health professionals on the Ft. Leonard Wood army base.
  • On March 29, Dr. John Carlile conducted grand rounds at Cox North Hospital in Springfield, MO. The ALA of Western Missouri sponsored this session. Also on this date the mayor of Springfield, MO, issued a proclamation on TB Awareness Fortnight.

The Missouri Department of Health and Senior Services issued a news release during March regarding World TB Day and TB Awareness Fortnight. As a result of this release, nine media interviews were conducted across the state.

In summary, activities such as those noted above are conducted each year in Missouri to raise awareness about a disease that some people think has virtually disappeared.

—Submitted by Vic Tomlinson, Jim Pruitt and David Oeser
Missouri Department of Health and Senior Services
TB Control Program

California’s Efforts to Ensure Performance of Routine AFB Smear Examinations

In the fall of 2001, the California Department of Health Services (CDHS) TB Control Branch (TBCB) was notified by a local health department (LHD) that a large commercial laboratory that performs TB laboratory testing for many California health care providers was not performing routine microscopic acid-fast bacilli (AFB) smear examination on specimens sent to the laboratory for mycobacterial culture.

This matter was brought to the attention of the TBCB when a patient who had a specimen submitted to this laboratory for mycobacterial culture alone had no AFB smear performed. Since smear microscopy was not performed, the infectious status of this patient was not known until 3 weeks later when the culture grew M. tuberculosis. At that time, the laboratory reported the patient to the LHD as a TB case, follow-up specimens were examined for the presence of AFB in the sputum smears, and the patient was subsequently found to be AFB smear-positive.

At the time of specimen collection, the private medical physician caring for the patient started the patient on a nonstandard regimen of anti-TB therapy, failed to report the suspect case to the LHD, and failed to ensure that the patient maintained home isolation. During the 3-week period of waiting for the patient’s culture results, the public’s health was compromised because the patient did not stay isolated at home and instead continued to work. This situation was especially problematic because the patient was a health care worker who worked with high-risk, immunocompromised patients.

Microscopic examination of smears for AFB in specimens from suspected TB patients is critical to TB control activities. The 1996 review article "How Infectious Is Tuberculosis?" states that "…numerous meticulous community-based studies have demonstrated repeatedly that a single variable — the AFB smear status of the source case — strongly predicts which patients are the most contagious."1 In addition, the 1995 publication Mycobacterium tuberculosis: Assessing Your Laboratory recommends: "Routine procedures for the examination of any specimen for TB culture should include AFB smear examination."2

Testing for and reporting the presence of AFB in smears from the specimen(s) of patients suspected to have TB allows TB programs to ensure that these important activities occur:

  1. The patient is isolated to prevent transmission
  2. Anti-TB drug therapy is promptly initiated in the patient
  3. A contact investigation is promptly initiated
  4. The infectiousness of the patient is monitored

The California Code of Regulations requires both laboratory staff and health care providers to report confirmed and suspected TB cases to the LHD. Had the laboratory performed an AFB smear examination for this patient and found it to be positive, it would have been required to report these findings immediately to the LHD. Receipt of a laboratory report of a positive AFB smear would have allowed the LHD to begin TB control measures in a timely manner. Had the patient’s infectious status been known earlier, or had the suspected case been reported earlier, this lengthy TB exposure and the subsequent large contact investigation could have been avoided.

Upon learning of the problem, the TBCB consulted with the CDHS Microbial Diseases Laboratory’s Mycobacteriology and Mycology Section to verify laboratory standards of practice and request assistance with the situation. The CDHS Laboratory contacted the microbiology supervisor at the commercial laboratory, provided references describing the importance of performing AFB smears on all specimens submitted for mycobacterial culture, and requested that they perform AFB smear microscopy on all specimens from suspected or confirmed TB patients. The TBCB then sent the commercial laboratory a letter to reinforce the CDHS Laboratory’s message and to reiterate the request for a change in practice. The commercial laboratory's problem had been a reluctance to perform testing not specifically ordered by the health care provider. However, with the authoritative citations and letter provided by CDHS, the commercial laboratory was able to define the routine performance of AFB smears to be the standard of practice, with adequate documentation for health insurance auditors.

We are pleased to report that the commercial laboratory has since updated its policy and procedures, and now performs routine AFB smear examination on all specimens sent for mycobacterial culture. The LHD that first notified the TBCB of the problem will monitor the laboratory’s practices and will notify us of any lapses in the new policy. The LHD has also followed up with the private medical provider regarding recommended TB treatment regimens, and laws that require timely reporting of all suspected and confirmed TB cases. Lastly, the TBCB and CDHS Laboratory are working together to propose a modification of state law to require AFB smear examination of all specimens submitted for mycobacterial culture.

In this situation, collaboration among the LHD, TBCB, and CDHS Laboratory was vital towards achievement of the commercial laboratory’s change in practice. Public health laboratories are key partners in our efforts to control TB and can serve as helpful resources for TB control programs in identifying and solving problems relating to laboratory standards of practice.

—Submitted by Anne Cass, MPH
California Dept of Health Services TB Control Branch
and Edward Desmond
California Dept of Health Services Microbial Diseases Laboratory


  1. Sepkowitz, KA. How infectious is tuberculosis? Clin Infect Dis 1996 Nov;23(5):954-962.
  2. Mycobacterium tuberculosis: Assessing Your Laboratory. The Association of State and Territorial Public Health Laboratory Directors and the Public Health Practice Program Office, Division of Laboratory Systems, Centers for Disease Control and Prevention. Atlanta: CDC; March 1995: 66.


Investigating Clusters of TB Among the Homeless

In the last 5 years (1997-2001), homeless persons have accounted for 102 cases of TB in San Diego County. While this represents only 6.4% of the county’s total cases, the estimated case rate for homeless persons in 2001 was 173/100,000. In comparison, the overall case rate for San Diego County was 11.8/100,000. Owing to poor nutrition, crowded conditions at shelters, and comorbidities that weaken the immune system, homeless persons are among the groups at increased risk for TB. In addition, shelters create ideal conditions for TB transmission, which may in part explain why homeless cases are seen to form clusters more often than TB cases in general.1,2,3 In San Diego County, homeless persons are implicated in nine clusters discovered since 1997.

Of the 102 homeless persons with TB found since 1997, nearly all (90%) are male and are aged 25-64. The racial and ethnic breakdown for these persons is as follows: 32% are white, 22% are black, and 38% are Hispanic. About one third (34%) of homeless persons with TB were born outside the United States. In contrast, 69% of the total TB cases in San Diego County in the last 5 years were in foreign-born persons.

Thirty-one of the 102 homeless patients appear as part of nine genetic clusters. Nearly all (97%) of clustered patients are male, and 90% are between the ages of 25 and 64. Following is the racial and ethnic breakdown of these cases: 32% are white, 23% are black, 38% are Hispanic, 5% are Asian, and 2% are American Indian. Two other persons who were part of these clusters were not homeless.

The nine clusters were discovered through mycobacterial genetic comparisons. Restriction fragment length polymorphism (RFLP) analysis identified the clusters, ranging from 2 to 9 cases per cluster. Epidemiologic links were more difficult to discern (see Table 1).


Table 1: Clustered Homeless TB Cases in San Diego County, 1997-2001


Number of Cases

RFLP bands





Homeless shelter I












1 stayed at shelter I; 1 stayed at shelter III




7 stayed at homeless shelter I; 1 ate lunch at homeless shelter I, no link for 1








Named contacts








2 stayed at homeless shelter II; 2 others were siblings; no link for 1




*confirmed by spoligotype 0009

For the 31 clustered homeless patients, a total of 506 contacts were identified. Of these, 360 were tested, and 2 were found to have active TB disease, while 84 had latent TB infection. Twelve started LTBI treatment and three completed treatment. Seven are still on treatment.

County TB control staff have worked together with homeless shelter staff to control this outbreak. The County’s largest shelters all require skin testing of residents upon intake, with follow-up chest x-rays if necessary. Staff at these shelters have received specialized TB training. Staff at Shelter I now conduct a TB symptom review with all residents at intake, and at 30 and 60 days into their stays. In addition, the County offers LTBI treatment in two downtown shelters using traditional INH and short-course rifampin therapies.

San Diego County TB Control has expanded the contact investigation interviews conducted with homeless patients in order to elicit more details about shelters frequented, services accessed, and "hangouts" visited. When an active case is discovered in a homeless shelter resident, County TB control conducts extensive follow-up skin testing. However, contacts have often already moved out. The County is working with the homeless shelters to implement a "red flag" system that will notify shelter staff to complete contact follow-up when these individuals return to the shelter. Finally, the County is discussing a system of using chest x-rays for all entering shelter residents.

This transient population is difficult to reach with educational, diagnostic, and therapeutic interventions. Comorbid conditions such as HIV infection, alcoholism, and drug abuse put many shelter residents at increased risk of contracting TB and of moving from latent infection to active disease. There is also a high potential for transmission in a shelter environment. Unfortunately, many shelter residents have become familiar with TB screening tools, and can avoid the trouble of a TB evaluation by answering "no" to symptom review questions. Homeless patients may be unwilling or unable to name their contacts, as many homeless persons use multiple names. Finally, many shelter clients with LTBI are uninterested in participating in treatment programs or have medical contraindications to treatment. In this investigation, only 14% of identified contacts with LTBI began treatment. Several clusters lack identified epidemiologic links, which points to the potential for missed cases.

We will continue to investigate these outbreaks and to genetically type new cases in homeless persons to determine whether they belong to any of the nine existing clusters. By continuing to train and collaborate with shelter staff, we hope to keep TB at the top of everyone’s agenda. Educating shelter residents and offering them LTBI treatment are integral components of TB control in this setting.

—Reported by Katharine E. Witgert, MPH, CDC Prevention Specialist
Wendy N. Betancourt, MPH, Research Specialist
Philip A. LoBue, MD, CDC Medical Epidemiologist
Kathleen S. Moser, MD, MPH, Tuberculosis Controller
San Diego County Tuberculosis Control Program


  1. Barnes PF, Yang Z, Preston-Martin S, et al. Patterns of tuberculosis transmission in Central Los Angeles. JAMA. 1997 Oct 8;278(14):1159-63.
  2. Gutierrez MC, Vincent V, Aubert D, et al. Molecular fingerprinting of Mycobacterium tuberculosis and risk factors for tuberculosis transmission in Paris, France, and surrounding area. J Clin Microbiol. 1998 Feb;36(2):486-92.
  3. Lemaitre N, Sougakoff W, Truffot-Pernot C, et al. Use of DNA fingerprinting for primary surveillance of nosocomial tuberculosis in a large urban hospital: detection of outbreaks in homeless people and migrant workers. Int J Tuberc Lung Dis. 1998 May;2(5):390-6.

Bilingual-Access Phone Cards: An Incentive to Completing LTBI Treatment Among Foreign-born Persons, Alabama, 2001

In July 2001, a textile worker in rural Alabama was diagnosed with active TB. This index patient was Hispanic, as were a large number of employees at the plant. Very few of the Hispanic employees spoke English, which hindered communication. Interpreters were employed to help explain the need for contact investigation and for the placement of tuberculin skin tests. In addition to the use of interpreters, pamphlets and other educational materials (in English and Spanish) were distributed.

Although a large number (>300) of "worried well" presented for the screening, only 46 workers were actually targeted to receive therapy for LTBI. Interpreters were again employed to help explain the need for chest x-ray and the use of INH for treatment of LTBI. Of this targeted group, 13 were considered "close" contacts, while the balance (33 persons) were considered to be "less than close." All persons in the target group were foreign born, with Mexico as the predominant birth nation. Given the high risk for progressing to disease among recent (< 5 years) arrivals, the decision was made to direct additional resources to this effort.

Initially, INH was provided twice weekly and was directly observed. This was done to ensure tolerance and adherence with the regimen. Unfortunately, after 2 months of DOT, a shift change at the plant created additional difficulties and our staff were forced to institute monthly distribution of INH. Recognizing that the twice-weekly reinforcement was lost, our staff proposed that patients who returned to clinic as scheduled would receive prepaid phone cards as an incentive. The cards were given to adherent patients at 2, 4, and 6 months.

The Division of TB Control, Alabama Department of Public Health (with financial assistance from the American Lung Association of Alabama) made a bulk purchase of bilingual-access phone cards. TB Control field staff negotiated with the vendor to purchase cards at $3.80 per card for 60 international minutes.

Results, while less than optimal, were encouraging. Nearly half (46%) of the 13 close contacts were considered to have completed therapy (e.g., received >80% of total doses within 9 months) and 42% of the less-than-close contacts completed an adequate course of therapy as well. Complicating factors during therapy included two layoffs at the plant (on September 20 and October 11, 2001) and the resulting loss of contact with 17 workers. Additionally, nine other workers failed to start or complete therapy.

Discussion with our field staff suggests that the use of bilingual-access phone cards as an incentive for adherence was an important contributing factor in this effort. In providing incentives, care should be taken to choose the most effective approach for the targeted group.

—Reported by Racine Waddell, RN, Area TB Program Manager,
and Nancy B. Keenon, MPH, Director
Alabama Division of TB Control


Florida Utilizes New Public Health Advisors for Outbreak Response and Special Assignments

In January 2001, four new CDC public health advisors (PHAs) were assigned to the Florida Bureau of TB and Refugee Health (BTBRH). One PHA was assigned to Orange County (Orlando), one to Broward County (Ft. Lauderdale), and two were assigned to Palm Beach County (West Palm Beach). The assignments were made based on morbidity, local needs, and local capacity to train and utilize the new staff. Although all four assignees have benefitted greatly from the day-to-day work in the county health departments, opportunities for temporary duty assignments within Florida have been provided by BTBRH to ensure a complete TB training experience. In turn, the PHAs have provided Florida with a very valuable resource: qualified staff who can respond quickly to potential outbreaks and other special assignments.

The first opportunity occurred in a rural county in the Florida panhandle. Regina Gore, the PHA assigned to Palm Beach County, was sent to the county for one week to assist with a complicated contact investigation of an HIV-positive client with infectious, pulmonary multidrug-resistant TB. The client had many social connections and traveled frequently between three Florida counties, but initially identified very few contacts when interviewed by local staff. Ms. Gore’s experience with TB interviewing and contact investigations, as well as her extensive HIV/STD background, made her a good match for this assignment. Ms. Gore reinterviewed the client several times and identified several additional contacts, including HIV-infected persons and young children. The client was voluntarily transported that week to A.G. Holley State Hospital to receive expert TB and HIV medical care. Because several close contacts were HIV infected and young children had been exposed, this contact investigation needed to be handled quickly and efficiently to prevent a possible "outbreak." With only one nurse and no outreach workers available to conduct this three-county investigation, Ms. Gore was an important and effective resource.

A second opportunity arose in October 2001. Tina Albrecht, the PHA assigned to Broward County, was sent to the Miami-Dade County Health Department for 2 weeks to assist local TB program staff prepare the Aggregate Report for Program Evaluation (ARPE) LTBI report for cohort year 2000. Because the TB staff in Broward County had just finished their preliminary 2000 report, Ms. Albrecht was knowledgeable about the data system used by Florida to produce the ARPEs and had experience in identifying some key problematic issues. The assignment objectives were to perform an analysis of the current ARPE report to identify reporting or data entry issues; assist management staff in coordinating the activities for producing a comprehensive, annual ARPE LTBI report; and evaluate the current data entry responsibilities of TB staff to ensure an accurate report for the next year.

Ms. Albrecht spent the first few days observing the day-to-day activities of clerical, nursing, and field staff to assess their usage of the data system used to produce the ARPEs. She discovered several issues that affected the accuracy of the report, including data entry errors, misinterpretations of data fields, the need for additional training, and a lack of procedures identifying which staff were responsible for entering specific data. Additional analysis provided more details on the issues, and a final written report of the findings and recommendations was given to local management staff. Ms. Albrecht’s assistance was well-received by local management staff and implementation of the recommendations began before the assignment ended. She is currently working in Miami-Dade County 2 days per week assisting with surveillance activities and she will also assist local staff with the production of the ARPEs due in August 2002.

In April 2002, an unexplained increase in TB cases was identified in a very low-morbidity, rural county in the Florida panhandle. Ted Misselbeck, the other PHA assigned to Palm Beach County, went to the county with two state office employees as an outbreak response team sent to work with local staff to investigate this possible outbreak situation. Mr. Misselbeck’s experience with TB interviewing and contact investigation and his investigative skills were very useful in this investigation. Lack of local staff was also an issue in this investigation. The county had only one nurse, a Nursing Director, and no outreach workers in the entire health department.

The team worked with local staff to develop objectives for the investigation, reviewed the contact investigation documentation and medical records for the four recent TB cases, conducted patient reinterviews, referred contacts in for evaluation, documented contact evaluation results for each case using a concentric circle diagram, plotted all TB cases and infected contacts on a city map to show the geographic distribution, requested DNA fingerprinting from the state laboratory for all cases, ensured all information was entered into the statewide TB data system, and prepared a final written report. Mr. Misselbeck, in collaboration with state and local staff, provided a thorough evaluation and investigation of a series of TB cases for which no epidemiologic link was identified. DNA fingerprint results are still pending.

The new CDC PHAs are a valuable resource for Florida’s state and local TB control programs. They provide the knowledge, enthusiasm, mobility, and flexibility that are needed to supplement and enhance local TB program operations and respond to potential TB outbreaks.

—Submitted by Heather Duncan, Senior PHA, Regina Gore, PHA,
Tina Albrecht, PHA, and Ted Misselbeck, PHA
Florida Bureau of TB and Refugee Health


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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