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TB Notes Newsletter

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No. 3, 2005

Highlights from State and Local Programs

Mycobacterium bovis in New York City—an Unexpected TB Investigation

A full description of the investigation of human M. bovis infection in New York City was published in the MMWR: CDC. Human tuberculosis caused by Mycobacterium bovis—New York City, 2001–2004. MMWR 2005 June 24; 54(24): 605-608.

Background. In January 2001, the New York City Department of Health and Mental Hygiene (DOHMH) Bureau of TB Control (BTBC) began genotyping isolates from all culture-positive TB cases using two methods, IS6110-based restriction fragment length polymorphism (RFLP) and spoligotyping. A protocol was developed for conducting cluster investigations when two or more isolates shared the same RFLP and spoligotype, with the goal of identifying previously unrecognized epidemiological links between the cases.

In February 2002, a cluster of three cases of TB due to the same strain of Mycobacterium bovis (M. bovis) was detected, and a cluster investigation was initiated. Over the next 18 months, several more cases sharing the same spoligotype were detected, as were additional clusters of M. bovis with different spoligotypes. No human-to-human transmission linkages were established within any of the clusters, but two significant observations were made. First, it was noted that the patients were mostly Mexico-born, many from the Puebla region of Mexico. Second, several US-born children were included in the largest cluster of M. bovis cases, all of Mexico-born parents.

In September 2004, a case of fatal peritonitis due to M. bovis in a 15-month-old child came to the attention of the Director of the BTBC. The case highlighted the question that had been asked but not yet answered during the cluster investigations, “Why would a US-born child have TB due to M. bovis?” Even before universal genotyping in NYC, M. bovis was the presumed source of infection for a handful of pyrazinamide-resistant patients each year; however, the cases occurred in non–US-born adults from countries where bovine TB and unpasteurized dairy products were prevalent, and the disease was regarded as reactivation of latent infection acquired outside of the United States.

The US-born children with TB due to M. bovis challenged our typical thinking about the source of this infection. Were the children traveling out of NYC and becoming infected in the country of birth of their parents, Mexico? Were the children exposed to infectious pulmonary cases of TB due to M. bovis in NYC? Was there a foodborne source of infection in NYC, as investigators in San Diego postulated for their pediatric TB cases? In San Diego, health officials attributed pediatric TB due to M. bovis to the readily available unpasteurized Mexican cheese across the border, but transborder traffic could not as easily account for M. bovis in NYC.

Investigation
In addition to the usual source-case investigations conducted for all pediatric TB cases and the cluster investigations underway based on genotyping, we re-interviewed all available patients (or parents of patients) to try to identify the source of M. bovis infection. We also began an investigation into foodborne transmission, an endeavor which was new to the usual scope of work of the BTBC. With the assistance of staff of DTBE and the National Center for Infectious Diseases (NCID), we developed contacts within the US Food and Drug Administration (FDA) and the US Department of Agriculture (USDA). In addition, we partnered with the NYC DOHMH Bureau of Communicable Diseases and the New York State Department of Agriculture and Markets (NYS Ag and Markets). Finally, we sought laboratories best able to test samples of Mexican cheese for the presence of M. bovis.

Results
Through our interviews, we learned that most of the US-born children had never traveled outside of the country, and had no history of exposure to the few pulmonary TB cases due to M. bovis that had occurred in New York City. We also found that many of our patients had consumed Mexican-produced cheeses while living in New York City. They had obtained these products from friends or family who had transported it in luggage, through courier agencies, from Mexican grocers, and from door-to-door vendors. 

From the USDA and the NYS Ag and Markets, we learned that cattle in New York State and surrounding states are certified “TB-free” and that dairy products sold in retail stores in New York State must be pasteurized. Also from the USDA, we learned that couriers arriving from Mexico with packages intended for individual consumption may bring dairy items into the United States, but are prohibited from bringing in produce, chicken, and pork. Though couriers ostensibly bring packages into the country for individual consumption, they may bring large quantities of food that has the potential to be sold commercially. From the FDA, we learned that cheeses imported for retail sale must be pasteurized unless aged greater than 60 days. We also learned that imports of soft cheeses arrive daily in the United States and that most of these imports are not inspected owing to lack of resources.

Our search for a laboratory that would work with us led us beyond the mycobacteria lab we were familiar with. We learned that laboratories must have a Biosafety Level 3 certification to attempt to isolate this organism from food. This excluded the FDA laboratory. The NYC TB lab, though familiar with mycobacteria, did not work with food products. The DOHMH environmental lab was willing to attempt to grow the organism from cheese, but was more familiar with common foodborne bacteria and less familiar with the properties associated with mycobacteria. They developed a protocol for testing cheese samples but have not had success at growing the organism to date. The USDA laboratory in Ames, Iowa, was experienced in working with this organism through efforts in bovine TB eradication in Texas, New Mexico, Michigan, and California, and they were willing to work with us. The Ames laboratory agreed to develop a protocol for testing cheese samples for the presence of the M. bovis, and also for comparing the genotyping of our human cases with bovine cases in the Ames database.

Conclusion
While we knew that human TB due to M. bovis was not uncommon in regions of the world where dairy pasteurization is not universal and bovine TB remains problematic, we did not expect to find it in US-born children in New York City. We were not familiar with investigating foodborne transmission, and we had to adapt what we learned from investigations of other foodborne pathogens such as Listeria monocytogenes and Salmonella sp. to M. bovis which has a potential latency far in excess of these organisms. We have learned that within a certain subset of our population, the Mexican community, it is not difficult to obtain food items that are produced outside of the United States and that may not meet federal and state standards for food safety. We have had to review and revise the materials available to providers and to the public regarding TB disease to include the possibility of foodborne transmission of TB.

The investigation of M. bovis in New York City is ongoing. We continue universal genotyping of isolates of all culture-positive TB cases. We are collaborating with the USDA laboratory in comparing human M. bovis isolates with M. bovis isolates from cattle in the United States and Mexico, and in testing of cheeses obtained in New York City and produced in Mexico. We have partnered with Mexican community groups and are disseminating information about M. bovis to the community. In addition, we are planning to investigate the prevalence of latent TB infection among US-born children of Mexican parents and the prevalence of consuming Mexican-produced cheeses among these children.

Though we did not anticipate a foodborne-transmission investigation as part of our mandate in TB control, the M. bovis investigation has alerted us to a mode of TB transmission that is rare overall in industrialized nations, but is significant within certain segments of our population.

—Submitted by Ann Winters, MD,
Michelle Macaraig, MPH,
Carla Clark, MPH, Cynthia Driver, DrPH,
Sonal Munsiff, MD, and Carolina Pichardo
New York City Department of Health and Mental Hygiene, Bureau of TB Control
Dr. Munsiff is also affiliated with DTBE

 

School-Based TB Curriculum to Reach High-Risk Youth

Tuberculosis (TB): Education for Adolescents and Young Adults is a curriculum developed for high school students in response to data showing a high prevalence of TB disease and M. tuberculosis infection in specific adolescent populations. In 2003, San Diego County, California, reported 316 TB cases, of which 209 (66%) were in foreign-born persons. There were 11 cases (2.6% of total cases) in the 5- to 14-year-old age group and 43 cases (9.3% of total cases) in the 15- to 24-year-old age group. A school-based targeted testing project confirmed other local data sources showing rates of 20%-30% skin test positivity among high school–aged students born outside the United States, and 10%-15% positivity among US-born Latino teens.

An initial goal in San Diego County was to develop targeted testing and treatment programs within school districts having a large at-risk student body. While successful outcomes were realized in several schools, the models were difficult to sustain. Moreover, funds for targeted testing and treatment were discontinued after 2004. In anticipation of the end of formal testing and treatment programs, the San Diego TB Program sought to develop educational tools that could be used by schools to create awareness among students to increase TB knowledge, assess their own risk, and promote testing and treatment.

The curriculum was developed and implemented through a collaboration between the County of San Diego Health and Human Services Agency TB Control Branch, the American Lung Association of San Diego and Imperial Counties, and the Sweetwater Union High School District. This school district is in southern San Diego County, a region with a large Latino population and a TB case rate of 20.1 per 100,000 population.

Implementation consisted of the following steps:

  • Determine high schools with large populations of students in TB risk groups
  • Create TB educational materials and an instructor’s manual
  • Focus on health classes in which teachers can incorporate the curriculum into existing communicable disease sessions
  • Provide classroom observations to refine health teachers’ techniques in delivery of the material
  • Evaluate and elicit feedback from health teachers to refine course materials and content

Using a variety of methods, including lectures, interactive exercises, and group discussions, the students became actively involved in the learning process. Classroom kits contain easy-to-use materials including a poster, handouts, a TB education video, and a CD of the curriculum. Other available materials include the following:

  • Educational slides and notes
  • Activities and extra-credit materials
  • Parent letter (optional)
  • Pretest and posttest to evaluate students’ increase in knowledge
  • Risk-assessment form
  • Learning chart
  • Glossary of terms
  • Abbreviations list
  • Evaluation form for teachers
  • TB resources
  • Resources for medial care

Students who complete the curriculum will be able to

  • Describe the difference between latent TB infection and active TB disease
  • Recognize the signs and symptoms of TB disease
  • Identify behaviors that reduce the risk of disease or transmission
  • Self-assess for risk of TB
  • Discuss issues related to TB with teachers, staff, and medical professionals
  • Understand and demonstrate behaviors that prevent disease and speed recovery from illness

An evaluation component was conducted to assess the effectiveness of the curriculum. Evaluation from teachers demonstrated improved knowledge, increasing their ability to effectively teach the course; student involvement in group discussion; a 63% increase in student knowledge; and an increase in student ability to self-assess risk, identify symptoms, and access health care.

The school curriculum appears to be a useful tool for promoting and guiding training and education efforts for the control of TB. A future goal is to achieve sustainability by increasing the number of school districts that incorporate the TB curriculum into their standard health classes.

For more information on the curriculum, please contact Sacsy Sukcharoun by telephone: (619) 542-4105 or by e-mail: sacsy@lungsandiego.org or Diana Lobo by telephone: (619) 692-8627 or e-mail: Diana.lobo@sdcounty.ca.gov.

—Reported by Sacsy Sukcharoun,BS,
Diana Lobo, BS, and
Kathleen Moser, MD, MPH
San Diego TB Control Program

 

Second Meeting of the Pacific Island TB Controllers Association

In a previous issue of TB Notes (No. 2, 2004), we informed our partners of outcomes from the inaugural meeting of the Pacific Island TB Controllers Association (PITCA).  Building on that successful meeting, we held the second meeting on December 7-9, 2004, convening again in Honolulu. We report on the outcomes from the second meeting.

The second PITCA meeting provided another invaluable opportunity for regional staff, technical consultants, and supporting agencies to network and to discuss program and laboratory accomplishments since the inaugural meeting. In an effort to maximize the meeting’s effectiveness and to address other important public health issues for the region, this meeting was organized to allow for greater participation from regional staff and consultants from Pacific Island jurisdiction (PIJ) HIV/AIDS programs. As a result of this combined effort, participation in this second meeting was close to 100 persons, doubling last year’s attendance. Representation included staff from the six US-affiliated PIJs (American Samoa, Republic of the Marshall Islands, Federated States of Micronesia, Republic of Palau, Guam, and Commonwealth of the Northern Mariana Islands), the State of Hawaii TB Control Program and Public Health Laboratory, the State of California Microbial Diseases Laboratory, the Federal Aviation Administration, the Diagnostic Laboratory Services of Honolulu, the World Health Organization (WHO) Western Pacific Regional Office (WPRO), the Secretariat of the Pacific Community (SPC) TB Section, the US Health and Human Services (HHS) Region 9 Office of Pacific Health and Human Services, the CDC Office of Global Health, the CDC Division of HIV/AIDS Prevention, and DTBE. The Pacific Island Health Officers Association (PIHOA) again provided conference support.

During the first day of the meeting, participants were provided an overview of health-related activities support by the HHS Region 9 Office of Pacific Health and Human Services for the region. This was followed by an update on the status of TB and HIV in the region. Keeping in line with core conference activities, several partners provided updates regarding laboratory practices for TB and HIV, the newly established PIHOA regional laboratory initiative, shipping protocols, and International Airline Transportation Association (IATA) regulations. The first day provided an excellent opportunity to present certificates of appreciation from CDC Director Julie Gerberding, MD, to several partners (Dr. Edward Desmond, State of California, Microbial Disease Laboratory; Duain Muraoka, Courier Corporation of Hawaii; Thomas Goob, Diagnostic Laboratory Services; and Patsy Ideue, PIHOA) who have been instrumental in supporting key activities in the region that have led to improved TB control practices for these jurisdictions and their communities. The first day closed with several presentations focused on health education activities for TB and HIV programs.

During the entire second day as well as half of the third day, HIV/AIDS program representatives met separately while the TB participants broke into program and laboratory working groups to review area-specific activities. Laboratory session participants focused on discussions and exercises related to AFB-smear microscopy quality assurance, and set up a mini-laboratory for program staff to use to conduct basic smear microscopy. Program session participants were provided an update by representatives from WHO, SPC, and CDC regarding an agency collaborative training session held in Yap State, Federated States of Micronesia, in November 2004. This included a presentation from Dr. Zachary Taylor regarding a proposed protocol for treatment of TB patients in the Pacific region, based on a hybrid of WHO and CDC protocols and driven by the ability for PIJ TB programs to consistently use TB culture and susceptibility testing. Dr. Masae Kawamura gave a presentation on the role of the Advisory Council for the Elimination of TB (ACET) as well as on the proposed scope of training and medical consultation services available from the San Francisco Center of Excellence (COE). Working sessions were held, during which program and laboratory participants from the PIJs as well as DTBE reported back on respective 2004 accomplishments and goals for 2005.

Table 1. Tuberculosis in the US-Affiliated Pacific Islands, 2004

Jurisdiction

2004
Cases
2004
Case Rate
Population

US Pacific Basin1

163

41.4

394,000

Commonwealth of the Northern Mariana Islands

55

70.5

78,000

Guam

51

30.7

166,100

Republic of the Marshall Islands

41

74.0

55,400

Federated States of Micronesia2 -- Yap State3

8

71.4

11,200

Republic of Palau

5

24.2

20,700

American Samoa

3

4.8

62,600

Hawaii4

116

9.2

1,262,840

United States4

14,511

4.9

293,655,404

  1. Pacific Basin denominator excludes population estimates for the FSM states Chuuk, Kosrae, Pohnpei
  2. CDC TB case reporting from FSM this year was limited to Yap State and thus reflects an undercount for FSM
  3. Denominator data for Yap State obtained from www.fsmgov.org/info/people.htm
  4. Provisional TB surveillance data for 2004, CDC, DTBE

The afternoon of the third day allowed for HIV/AIDS and TB representatives to regroup and update each other on the activities from the last day and half. This was an excellent opportunity for staff of these disease-specific programs to come out of historically established working “silos,” and allowed each program within the PIJs to not only hear about activities and accomplishments but also to set the framework to allow for increased collaboration within the PIJ HIV/AIDS and TB programs. Prior to concluding this workshop, Dr. Taylor presented accomplishment awards on behalf of DTBE and Dr. Castro to the PIJ TB program and laboratory staff to recognize program and laboratory accomplishments in 2004. 

One of several important accomplishments in 2004 involves the reporting of TB cases from the PIJs to CDC TB surveillance system. Unlike the US jurisdictions, the six PIJs report TB case data to multiple health agencies: CDC, SPC (www.spc.int), and the WHO WPRO (www.wpro.who.int). Several of the PIJs implement the WHO DOTS protocol, which is also supported by the SPC, while other PIJs implement a more US-based approach. The WHO protocols, developed for resource-challenged programs, are different from the CDC/ATS/IDSA guidelines. As a result, the collection and reporting of TB surveillance data is not always as uniform across the PIJ programs as it is in the US jurisdictions.

During 2004, a total of 163 confirmed cases were reported in this region. This reflects case reports received from all PIJs with the exception of the States of Kosrae, Chuuk, and Pohnpei, which are part of the Federated States of Micronesia. The US Pacific Basin TB case rate (41.4/100,000) is 9 times greater that the reported US case rate (4.9) and exceeds by 5 times the TB rate of Hawaii, the closest US jurisdiction. The TB rate ranged from 4.8 in American Samoa to 74.0 in the RMI. Among the 163 cases reported in the PIJs in 2004, five patients (3%) were diagnosed with multidrug-resistant (MDR) TB, the most dangerous form of TB disease.

The PIJ TB control programs are an important component of our domestic TB control and prevention agenda. Given this disparity in TB rates among PIJs when compared to US jurisdictions with similar case counts or similar populations, the DTBE Field Services and Evaluation Branch (FSEB) has initiated program and laboratory improvement efforts to intensify TB control in these regions which are challenged not only owing to their geographical separation from the United States but also to the limited health care resources available in these PIJs as compared to the US jurisdictions.

The FSEB PIJ TB improvement project includes

  1. Providing technical assistance to collaboratively develop the respective national TB programs (DOT, surveillance, patient management, contact investigation, treatment protocols, and program evaluation with performance indicators);
  2. Improving and sustaining local laboratory capacity (AFB-smear microscopy);
  3. Supporting off-island reference laboratory testing (culture and sensitivity testing);
  4. Fostering regional networking;
  5. Collaborating with other Pacific-focused partners such as WHO, SPC, the Pacific Regional Laboratory Initiative (www.pihoa.org), HHS Region 9 Office of Pacific Health and Human Services, HHS Health Attaché for the PIJs, State of Hawaii TB Program and Laboratory Services, State of California Microbial Diseases Laboratory, and the Francis J. Curry Center of Excellence.

To continue supporting the need for regional networking, PIHOA and CDC are collaborating with HHS, San Francisco COE, SPC, WHO, and the State of California to plan a third PITCA meeting December 6–8, 2005, and a separate training workshop for PIJ TB clinicians, scheduled for December 1–2, 2005, in Honolulu, Hawaii. For information regarding this proposed meeting, please contact Subroto Banerji (sbanerji@cdc.gov) or Andy Heetderks (aheetderks@cdc.gov) or send an e-mail to pitca@cdc.gov.

—Submitted by Subroto Banerji, MPH, PHA
Andy J. Heetderks, MPH, Team Leader
Gregory W. Andrews, Section Chief, and
Zachary Taylor, MD, Branch Chief
Div of TB Elimination

 


Released October 2008
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