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TB Notes 4, 2002

Highlights from State and Local Programs

Chasing the "Big Case" in Missouri’s State Correctional System

In July 2001, the Potosi Correctional Center, a 2,000-bed maximum-security prison in Missouri, noted an increase in skin-test conversions among its inmates. Staff and inmates are skin tested each year on their date of birth. Of 72 people tested in July, 5 conversions were found. This compared to a single converter in a typical month, or zero in some months. Prison staff immediately assumed that this represented recent TB transmission from an inmate or staff member with active TB who was or had been at that facility. To place this situation in context, in 2000 an active case had been found in another correctional center in the state only after an exhaustive search had been conducted and over 100 inmates and six staff had become infected. The memory of that experience was still fresh in the minds of all involved.

In August 2001 the Department of Corrections staff decided to conduct mass testing in the Potosi facility after consulting with the Department of Health and Senior Services’ TB program staff. Of 545 tuberculin skin tests placed, 24 were positive. Upon making this troubling discovery, the medical staff at the Potosi facility conducted reviews of signs and symptoms of the previous positives and tried to collect sputum samples from them. The staff also gave chest x-rays to those with new positive skin tests, and evaluated them. However, the source case still was not identified. The medical staff of the facility began obtaining chest x-rays on all inmates who were considered high risk, even if they were not recent converters. High risk was defined as HIV-positive persons, diabetics, elderly persons, and those with other chronic ailments. Also, anyone with any possible signs and symptoms had a chest x-ray; even old x-rays were reviewed again. The chase for the source case continued. The state TB program staff and the correctional medical staff spent hours together trying to determine any links. The continual movement of inmates within the facility and to and from other correctional centers made it difficult, at best, to conduct a case-finding investigation.

In the mean time, 31 additional converters of 222 tested were found from September through December 2001 in the same facility. Throughout this process, at least two inmates were thought to be the source case. One of them was an HIV- infected man who had said he had been coughing, and another was an elderly inmate who had converted in the past and had been treated for latent TB infection. However, neither of these individuals had active TB disease.

In January 2002, the teams from the state TB program staff and the correctional medical staff met jointly to review the actions that had been taken thus far and to assess what else could be done to find the suspected source case. A recommendation was made to determine if the recent converters had been housed in the same area or the same work program. Also, chest x-rays with the slightest abnormality were reread by a physician with expertise in tuberculosis; approximately 40 such chest x-rays were read by this expert. But still, an active disease case was not found. Also, no common links could be established for identifying a source case. The group even briefly considered screening visitors for signs and symptoms of TB. However, the teams decided that this would only be a last resort if all other approaches failed. TB control staff asked if prison staff had changed antigens, but they were still using the same product (Tubersol). When asked about the employees who were administering and reading the skin tests, prison staff replied that they were experienced nurses who were competent with their skin testing techniques. The group attempted to identify the lot numbers that they used, but found that the nursing staff members had not been recording the lot numbers, given the number of tests that they administer.

A decision was made to consult with other experts regarding the search for the source case. The individuals contacted included an infectious disease physician in Springfield, Missouri, and Dr. John Bass, chair of the Department of Internal Medicine at the University of South Alabama in Mobile, Alabama. Dr. Bass said that in a low-prevalence area such as Missouri, false positives are always a possibility. The infectious disease physician recommended repeating the tests on all the recent converters, using the Tubersol product. Determined to investigate every possibility, the prison/health department team proceeded with the retesting. The results of this effort showed that only 12 of the 50 retested inmates had positive results. Based upon this finding, the state TB control staff and correctional medical staff decided that the increase in converters was probably attributable to false positive skin tests.

This situation in Missouri involving false positives gives further evidence that the skin test is far from perfect, and reminds us that a number of factors can cause false-positives. While the exact cause of the false positives remains unknown, the theory that seems most plausible to those who were involved is that there was some irregularity with the reagent lot. The steps being taken to address this situation are as follows:

  • The group will recommend that lot numbers be recorded when skin tests are administered.
  • As a precaution, not because the nurses’ techniques appeared to be at fault, the nurses in the Potosi correctional facility and other correctional facilities received a refresher course on administering and reading Mantoux skin tests.
  • Guidelines on storing reagents will be distributed to medical staff in the state correctional facilities.
  • A work group of TB experts (including state health department and prison representatives) will develop an action plan to address similar problems in the future.

Although this episode was lengthy and frustrating, it is believed that it proceeded as smoothly as it did because of the congenial relationship between the prison staff and the health department staff. This long and successful collaboration is considered to be an important key in Missouri’s TB control efforts.

—Submitted by Vic Tomlinson
and Lynelle Phillips, R.N., M.P.H.
Missouri Department of Health and Senior Services
TB Control Program

TB Monitor. 2002 (April); 9 (4): 39-42.


U.S.-Mexico Patient Referral System: Collaboration for Completion

In 2000, persons from Mexico accounted for 24% of the nation’s TB cases among foreign-born persons. Completion of therapy among segments of this population is especially challenging because of the movement of patients across state or national borders owing to work, family, or immigration issues. Two organizations, the San Diego County TB Program (SDCTBP) and the Migrant Clinicians Network (MCN), have developed U.S.-based systems to assist mobile patients continue care and are working with the CDC, the Mexican National TB Program, and other partners, such as Proyecto Juntos in Ciudad Juarez, Mexico, to create a comprehensive bilateral referral network.

MCN is a private, nonprofit organization based in Austin, Texas, that, since 1984, has been working with health professionals serving migrant populations. The TBNet tracking and referral system, started in 1995, is one of the health tracking projects of MCN and is coordinated by Jeanne Laswell, RN, BSN. The SDCTBP operates the CureTB referral system as part of the county TB program’s Binational Unit with Alberto Colorado, BS, as the project coordinator. CureTB has been offering referral services to all American states since 1997.

In April 2002 the SDCTBP and MCN signed a memorandum of understanding (MOU) to clarify roles and to promote collaboration between the two systems. The MOU key elements are as follows:

  • TB cases referred from Mexico to the United States will be referred via CureTB.
  • TBNet will retain operations as currently in place for migrant populations moving within the United States.
  • TB cases referred from the United States to Mexico will be referred via CureTB (exceptions are most cases originating in Texas or New Mexico, or those where TBNet has followed the patient for >2 months of treatment in the United States).
  • Referrals related to the Immigration and Naturalization Service (INS) will follow the existing geographic division of labor.
  • TBNet will refer to destination countries other than Mexico.

Referral data for TB cases (not LTBI or contacts) in 2001 are summarized in the table below.




U.S. to Mexico referrals



Mexico to U.S. referrals



U.S. interstate referrals



U.S. to countries other

than Mexico



*No longer offered by CureTB

Although not addressed by the MOU, each program offers other TB referral and information services. For example, TBNet tracks LTBI therapy among mobile U.S.-based migrant groups, while CureTB tracks all Class A immigrants originating in Mexico. Both systems can assist with contact referrals within their area of focus. For more information about TBNet contact Jeanne Laswell at 1 (800) 825-8205 and, for CureTB, contact Alberto Colorado at (619) 692-5710. Referral forms currently in use by the programs are available by request.

A project to evaluate aspects of the U.S.-Mexico referral process is currently being funded by the CDC under the direction of Dr. Kayla Laserson in DTBE’s International Activities office. As part of the process, Mexico has expressed its intention to develop and implement a counterpart referral unit in the near future. It is hoped that current efforts will result in improved continuity of care for mobile patients and a strengthening of collaboration between all partners, and will become a model for other types of public health referrals and for referrals between other nations.

—Submitted by Kathleen Moser, MD, MPH,
Chief, San Diego County TB Program,
Edward Zuroweste, MD,
Medical Director, Migrant Clinicians Network,
Fernando Gonzalez, MD, MPH,
Director, Project Juntos,
and Kayla Laserson, ScD, Div of TB Elimination


FSB’s Cohort 2001 Public Health Advisor Recruitment Plan

From 1993 until 2000, there was no CDC-wide recruiting effort for the public health advisor (PHA) series. As a result, DTBE encountered increasing difficulty in identifying candidates for GS-9 and GS-11 positions in the diminishing pool of PHAs. To compound the problem, some of DTBE’s senior field PHAs were being selected for headquarters positions, some had transferred to other CDC programs, some had retired, and others were approaching retirement eligibility. At the same time, the demand by state and local health departments for assignment of PHAs to serve as on-site technical program consultants and management assistants had not decreased.

In late 2000, the Field Services Branch (FSB) initiated a pilot PHA recruitment program with the hiring of ten persons into entry-level positions. The new PHAs began their assignments in the New Jersey, Florida, and Chicago TB control programs on January 14, 2001. The plan was to develop the PHAs over an initial training period, for up to 2 years, with on-the-job training and experience in TB elimination methods and program activities.

The new PHAs began their assignments working at the clinic level, gaining experience in surveillance and program operations. This included providing directly observed therapy, conducting contact investigations, and participating in targeted screening and treatment for latent tuberculosis infection. The new PHAs also learned to develop liaisons with public and private health care providers, hospitals, and laboratories. They participated in patient and public health education activities, such as health fairs and World TB Day activities at their sites.

The PHAs have been warmly accepted by their host areas. The areas have recognized that fostering the training experience is a benefit to their program. FSB is managing the program and is responsible for providing guidance, leadership, course work, and quality assurance during the training period.

Upon successfully completing the 2-year training program, the PHAs will transfer to other field duty stations for additional experience leading to development of competencies in TB program management. So far in 2002, promotions include reassignment to Columbia, South Carolina; Trenton, New Jersey; Berkeley, California; and Tallahassee, Florida. It is expected that the remaining cohort members will be reassigned soon. To date, the retention rate is 70% with the departure of two employees owing to personal circumstances and one transferring into another CDC program.

FSB expects to fill some of the open training positions with assignments to Chicago and Florida, and will continue to recruit as long as funds and positions are available.

—Reported by Rita Varga
Div of TB Elimination


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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