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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
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
- 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
*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
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