The National Tuberculosis Genotyping Service (NTGS) started in 2004 when state laboratories from all TB programs in the United States voluntarily started submitting Mycobacterium tuberculosis isolates from culture-confirmed patients to two CDC-contracted laboratories in Michigan and California. TB genotyping is a laboratory-based approach used to analyze the genetic material (e.g., DNA) of Mycobacterium tuberculosis. The total genetic content is referred to as the genome. Specific sections of the M. tuberculosis genome form distinct genetic patterns that help distinguish different strains of M. tuberculosis. Since 2004, use of TB genotyping results has significantly improved our understanding of TB transmission nationally and within the Heartland region.

Is the QuantiFERON-TB Blood Assay a Good Replacement for the Tuberculin Skin Test in Tuberculosis Screening? A Pilot Study at Berkshire Medical Center. Zhao, X., D. Mazlagic, E. A. Flynn, H. Hernandez, et al. American Journal of Clinical Pathology November 2009; Volume 132, Number 5: pp. 678-686.

Case History: Patient A was a 45-year old US-born white female with a six month history of illness characterized by a twenty pound weight loss, dry cough, shortness of breath (SOB), and chest pain. She was seen by a physician on December 12, 2003 to evaluate a spontaneous pneumothorax and rule out lung cancer. A Computed Tomography (CT) of her chest revealed large bilateral cavitary lesions. She underwent a bronchoscopy exam on December 19, 2003. An acid-fast bacillus (AFB) smear-positive specimen was obtained using bronchial-alveolar lavage (BAL). The sputum was culture-positive for Mycobacterium tuberculosis, and on February 20, 2004 Mycobacterium tuberculosis was isolated from her BAL and sputum. The isolated organism was pansensitive. She was started on isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB) at the time of her TB diagnosis and received nine months of treatment due to her large cavitary lesions and advanced TB disease.

The Minnesota Department of Health has recently posted a new web page called “TB Class Arrivals” that may be of interest to the states in the Heartland Region.

The Heartland National TB Center serves 13 states: Arizona, Illinois, Iowa, Kansas, Minnesota, Missouri Nebraska, New Mexico, North Dakota, Oklahoma, South Dakota, Texas, and Wisconsin. These states represent 24.7% of the total population of the United States and 22.5% of the total tuberculosis cases reported for 2008. The following are highlights as they compare to the national report, Reported Tuberculosis in the United States, 2008 released September, 2009.

T-SPOT.TB is a recent addition to our toolkit for diagnosing latent tuberculosis infection (LTBI). T-SPOT.TB is a mail-out blood test that detects the interferon-gamma response of T-lymphocytes to tuberculosis antigens: an interferon-gamma release assay (IGRA). QuantiFERON-TB GOLD is another example of an IGRA.

Fluoroquinolone Resistance in Mycobacterium tuberculosis: The Effect of Duration and Timing of Fluoroquinolone Exposure. Devasia, R., A. Blackman, et al. 2009. American Journal of Respiratory and Critical Care Medicine; Volume 180(4): pp. 365-370.

The 2007 CDC Technical Instructions (TI) required that “internationally adopted children over the age of two be tested for tuberculosis in the country of origin before a U.S. visa can be granted. If they test positive, they must be treated and determined not to be infectious before the CDC will allow them to travel to America.” These 2007 requirements were stalling overseas adoptions and creating hardships for new parents. Dr. Jeffrey Starke of the Children’s Tuberculosis Hospital in Houston was quoted as saying, “From not providing children any (TB) services, [the 2007 TI] swung over to the side of making rules that are in fact preventing children from coming into the States, children for whom it is completely safe.” Starke says. “In fact, it’s in their best interest that they be in the United States so they can be appropriately diagnosed and treated.” http://kosu.org/2009/08/cdc-tuberculosis-rule-slows-international-adoption/.

The Stop TB Partnership, a network of international organizations, governments, and individual donors, was established in 1998 to eliminate tuberculosis as a public health problem. The Partnership’s New Diagnostic Working Group (NDWG), one of the core working groups within the partnership, was created in 2001 in order to facilitate the development of TB diagnostic tools. The NDWG introduces a new website resource called Evidence-based Tuberculosis Diagnosis, available at http://www.tbevidence.org.

Tentative Trainings. Please go to http://www.heartlandntbc.org/training.asp for course information, staff contact information and registration dates for each course. Proposed topics and dates are subject to change; check the website for the latest updates.

In light of the H1N1 (swine flu) virus reaching pandemic status, the world has a heightened concern for the term infection control. Imagery of masked faces and desolate streets flashed across our television screens bring to mind past global outbreaks such as that of SARS and serve as a reminder of the public threat caused by infectious diseases. However for TB professionals such infection control precautions and the intricacies that they involve are all too familiar.

In 2008 the state of Arizona reported 227 cases of active tuberculosis resulting in a case rate of 3.5 per 100,000 population. Arizona ranked 15th in the U.S. for the highest number of active TB cases. Certain risk factors found to be associated with 2008 reported cases included male gender, Hispanic ethnicity, alcohol use, drug use, correctional residence, homelessness, and foreign-born. In Arizona, 12.8% of cases reported excess alcohol use, 5.3% reported non-injecting drug use, and 2.6% reported injection drug use. In previous years, Arizona has consistently ranked first in the nation for the percentage of cases over 15 years of age diagnosed in correctional facilities. In 2008, correctional facilities accounted for 22% of the state’s reported cases. Homelessness is another important risk factor with 6.2% of the 2008 cases reported as being homeless within 12 months prior to diagnosis with TB. In 2008, 65% of Arizona cases were born outside the U.S. and its territories. Persons from Mexico accounted for 51% of the foreign-born cases in 2008.

Please go to http://www.heartlandntbc.org/training.asp for course information, staff contact information and registration dates for each course. Proposed topics and dates are subject to change; check the website for the latest updates.

World TB Day, observed annually on March 24th, serves as a reminder to the community at large of the importance of TB control and elimination. In 2009, TB remains an epidemic in many countries around the globe. Millions of lives are affected by TB, thus World TB Day commemorates their stories and is an opportunity to raise public awareness to the face of TB.

In order to better acquaint our readers and partners with each other, we will be showcasing two states within the Heartland region in every newsletter edition. With this addition to the newsletter we hope to increase awareness and foster potential partnerships throughout the region. In this issue we will focus on South Dakota and New Mexico.

Please go to http://www.heartlandntbc.org/training.asp for course information, staff contact information and registration dates for each course. Proposed topics and dates are subject to change; check the website for the latest updates.

Heartland would like to announce the publication of its newest product — Beyond Diversity: A Journey to Cultural Competency. This facilitator-led guide is intended to build internal capacity within TB programs by assisting trainers to educate their colleagues on issues of cultural competency.

Case History: A 48 year old Caucasian male was diagnosed with pulmonary tuberculosis in May 2006. The patient's initial isolate was resistant to isoniazid, ethionamide, levofloxacin, ofloxacin, and moxifloxacin. The patient had a history of head injuries and a seizure disorder with reports of personality changes present since 1999. Patient was HIV and Hepatitis C positive. Previous history also included cocaine and alcohol dependence with IV drug use.

First is the new UTHSCT logo, which appears at the upper left corner of our website, and is a link to The University of Texas Health Science Center at Tyler website. The University of Texas Health Center at Tyler was recently designated a Health Science Center resulting in the name change.

In 2008, Heartland held its inaugural TB Program Management Course in San Antonio, Texas. The course was well received. We learned a lot from the first course and will implement many of the suggestions in future courses. We have decided to move the program management course out of Texas in 2009; and Kansas and its TB Controller, Phil Griffin, have graciously agreed to host the second course April 21-23, 2009 in Overland Park, Kansas. The training will be held on the University of Kansas Edwards Campus.

In response to a request from the Advisory Council for the Elimination of Tuberculosis (ACET), the Association of Public Health Laboratories (APHL) and CDC assembled an expert panel of consultants to discuss the applications of nucleic acid amplification (NAA) testing for TB diagnosis and control in the United States.

The CDC recently published a series of ethnographic guides entitled Promoting Cultural Sensitivity: A Practical Guide for Tuberculosis Programs. These guides are intended to promote cultural competency and increase the knowledge of TB program staff who provide services to foreign-born individuals.

Please go to http://www.heartlandntbc.org/training.asp for course information, staff contact information and on-line registration forms for each course. Proposed topics and dates are subject to change; check website for the latest updates.

Case History:
A 23 year old university student from Africa was diagnosed with active TB disease in April 2008. The patient presented with an infrequent productive cough and no other symptoms. His tuberculin skin test (TST) was 15mm and chest radiographs were abnormal. His sputum was acid-fast bacillus (AFB) smear negative but culture positive for Mycobacterium tuberculosis. His specimen was pansensitive and he was started on four drug therapy May 2, 2008. A contact investigation was started with his closest contact being a US-born roommate who was TST negative on initial testing. As a precaution, further close contacts were tested including 11 friends, 15 classmates and 5 professors. Initial and follow up testing found that 20/31 (64.5%) were TST positive.

In recent years, many international organizations and researchers within the tuberculosis community have made an effort to focus on the association between poverty, malnutrition, and TB. Available data suggests that malnutrition affects cell-mediated immunity, which is critical for controlling TB infection, and may increase the risk of active TB disease development by six to ten times.¹ Looking at the dynamics of the relationship between TB and nutritional status can help health care professionals identify individuals at high risk of developing active TB disease as well as those at risk of TB relapse and treatment failure. Thus current research and educational efforts are working to develop more effective and innovative health care practices and interventions in the case management of malnourished individuals.

As part of Heartland's commitment to designing innovative educational products, we have developed a new pocket guide to aid in the clinical assessment of a patient's weight and nutritional status. Product highlights include a Body Mass Index (BMI) chart, clinical definitions, and nutritional formulas. This pocket clinical guide is now available on the Heartland website (http://www.heartlandntbc.org/products.asp) for ordering and downloading in PDF format.

Please go to http://www.heartlandntbc.org/training.asp for course information, staff contact information and registration dates for each course. Proposed topics and dates are subject to change; check the website for the latest updates.

Heartland National TB Center is in the process of expanding and improving our mini-fellowship program. This year we offered educational training opportunities in adult and pediatric tuberculosis targeted to infectious disease fellows and TB clinicians. We also offered an intensive nursing mini-fellowship for advanced practice nurses, RNs, and LVNs. The goal of each of our mini-fellowship programs is to provide an interactive and innovative curriculum with comprehensive topics in the management of tuberculosis. In addition to these programs, we are currently developing for 2009 a programmatic mini-fellowship targeted to TB control program managers. We are also in the process of updating the application and selection process for the 2009 mini-fellowships. Please watch for more new details and information in our upcoming newsletters and on our website.

The Texas Center for Infectious Disease (TCID), located in San Antonio, Texas, is a public healthcare facility of the Department of State Health Services specializing in the treatment of tuberculosis. The facility currently includes a 72-bed hospital as well as an outpatient clinic. With the approval of a constitutional amendment appropriating funds to the new hospital project, a 75-bed replacement inpatient facility has been authorized for TCID.

Greetings Heartland Region! I would like to introduce myself as the new editor of our regional newsletter, TBeat. We hope that our newsletter will serve as an up-to-date resource and communication tool throughout the Heartland region. I also hope to incorporate relevant articles, helpful links, and interesting case presentations from around the region and beyond. With that being said, I would like to open up the newsletter to all of you. Please feel free to send us suggested topics, case studies, and regional news from your areas. We hope to have input from all 13 states. This is your regional TB education and training center, and your newsletter!
Sincerely,
Laura Muraida
Education Specialist
laura.muraida@uthct.edu
210.531.4509

Case History:
A 49 year old male was diagnosed with recurrent pulmonary tuberculosis after presenting to an emergency room with a 3 month history of malaise, chills, subjective fevers, shortness of breath, productive cough; and weight loss over the past year. A sputum specimen was positive for AFB and grew M. tuberculosis susceptible to all first line drugs. The chest radiograph was abnormal with bilateral patchy alveolar opacifications in the upper lobes and a CT scan of the chest noted tree-in-bud parenchymal opacifications and consolidation bilaterally, cavitation in the right apex and right lower lobe, and diffuse centrilobular nodules in both lungs. The patient was coughing and appeared malnourished and chronically ill. His height was 5'7 ½" and weight at diagnosis was 114 lbs. His BMI was 18 (underweight). Labs indicated anemia, with a borderline low serum folate level (3.6, normal > 5.4), and iron deficiency (iron 28, normal range 50-160).

Drug-use along with several other medical, circumstantial, and social or lifestyle factors has long since been associated with a higher incidence of TB infection and higher risk for disease regardless of the prevalence of TB infection in the community. TB programs target high-risk groups such as substance abusers in order to better implement control and prevention measures such as screening and preventative therapy; however as trends shift, certain groups not considered at risk may eventually be identified as a high priority, and vice versa. The "drug-use" category demonstrates these current shifts, as the activities of drug-users can change quickly in response to social, economic, or legal factors. Perhaps the most fluid areas within this high-risk group are the points at which drug-use converges with low-risk groups, such as young healthy adults or upper middle class university students. It is at these convergence points that public healthcare workers must be prepared for the shifts that pose a possible increased risk of TB to a new group of people.

Minnesota Department of Health's (MDH) Refugee Health and Tuberculosis Programs are pleased to offer a show about tuberculosis (TB) for the public. This show was produced by the ECHO-TV (Emergency and Community Health Outreach) collaborative. Developed as an educational and outreach tool for persons at elevated risk for TB, the DVD contains seven versions of a 20-minute show that originally aired on public television in Minnesota in March 2008.

Please go to http://www.heartlandntbc.org/training.asp for course information, staff contact information and on-line registration forms for each course. Proposed topics and dates are subject to change; check website for the latest updates. We are developing our training calendar for 2009. Please refer to our NEW Heartland Training Calendar for the latest updates as we confirm dates and locations for 2009.

Heartland National TB Center has been working with representatives from the region to develop a TB Program Management course. We are pleased to announce the first offering of what will become an annual Heartland training targeted to public health TB program managers who are actively engaged in the day-to-day responsibilities of supervising and managing a TB program at the local or regional level. November 5-7, 2008 at Heartland in San Antonio; faculty from the region will present topics on TB management structure, budgeting, CDC surveillance and data management, evaluating program performance, supervising the nursing and field staff, staffing your TB program, recruitment and retention of staff, emergency planning for TB control, Legal Authority Model Law Program, infection control, field safety, the TB pharmacy, the laboratory as a key component of TB control, asset mapping your resources and training your TB staff. Registration is now open, go to our website to apply.

The Centers for Disease Control and Prevention, Division of TB Elimination has updated the standard tuberculosis learning tool—the definitive Self Study Modules on Tuberculosis, 1-5 (Course #SS3035). They are available as downloadable and printable PDF files (see links below) or the print version can be ordered directly from the CDC using the TB Educational and Training Materials Order Form.

Case History: A 20 year old Russian university student, who had entered the United States 2½ years earlier, was diagnosed with extremely drug resistant tuberculosis (XDR TB).

Case History: A 15 month old child with active pulmonary tuberculosis became a significant management challenge to his public health nursing providers because of his consistent refusal to take medications.

The first priority in the treatment of tuberculosis is to cure the individual patient; a goal which necessitates the successful completion of therapy. As public health departments have the ultimate responsibility of ensuring adequate therapy, it is of utmost importance that public healthcare staff have a multifaceted approach to promoting treatment adherence. This is especially important when treating and monitoring children on TB medication, as potential barriers of varied complexity can prevent this vulnerable age group from completing adequate treatment. Thus due to the range of circumstances healthcare workers face with children as well as adults, successful therapy must be centered on the patient, with treatment and supervision tailored specifically to the patient's clinical and social needs.

Heartland is pleased to announce two new products that are currently being field tested. We are making them available to health care workers who are willing to provide editorial comments and feedback to us in order to finalize the products.

We are pleased to announce the Recorded versions of the following Heartland Webinars:

• TB Medications: Adverse Drug Reactions, Part 1
  Wednesday, March 5, 2008
  Presented by: Jamey "Todd" Braun, RN, BSN, MPH
• TB Medications: Adverse Drug Reactions, Part 2
  Wednesday, March 12, 2008
• National Webinar: Pediatric TB
  Friday, June 27, 2008
  Presenter: Kimberly Connelly Smith, MD, MPH

Please go to http://www.heartlandntbc.org/training.asp for course information, staff contact information and on-line registration forms for each course or webinar. Proposed topics and dates are subject to change; check website for the latest updates.

The following products (algorithms, pocket guides and manuals) have been updated and are located on the Heartland website. They are available for printing or downloading. Hard copies may be ordered directly from Heartland via an order form on the website (HNTC Product Order Form), by email (delfina.sanchez@uthct.edu) or by phone (1-800-839-5864).

The National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has issued a new report on health disparities. The report, "Health Disparities in HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases and Tuberculosis in the U.S.: Issues, Burden and Response" presents a retrospective review of CDC surveillance data for HIV/AIDS, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) during the years 2000-2004, and summarizes selected programmatic, educational, and research activities implemented to reduce disparities in these diseases.

Heartland National TB Center is finalizing dates for our upcoming 2008 training calendar. The following courses are currently planned for regional participation (ABC order by title): Contact Investigation, Multi Drug Resistant TB: A Primer to Patient Care and Treatment, Nurse Case Management, Preventing Tuberculosis on College Campuses, Outbreak Preparedness, TB 101 with Facilitator Training, TB in Correctional Facilities, TB Intensive, TB Program Managers Course and TB Updates.

The Heartland National TB Center is conducting a short customer satisfaction survey to determine the effectiveness of our training courses and products. We are asking those who have attended one or more of our courses and/or used any of our educational training products in the past two years to please fill out an online survey. This survey should take no more than 10 minutes to complete and your answers will be confidential. The Center will use the results to better serve our region in the future and to target our courses and products to more fully meet our partners' needs. Your assistance in completing this questionnaire by no later than December 31, 2007 is most appreciated. If you have any questions or concerns, please do not hesitate to call us at 1-800-TEX-LUNG (839-5864) or contact Mary Long at mary.long@uthct.edu.

Click here to take the survey:
http://www.zoomerang.com/survey.zgi?p=WEB227A29TBE8K

We are pleased to announce the Recorded versions of Heartland National TB Center's 2007 webinars: TB/HIV: Managing the Co-Infected Patient (11/27/2007), TB Medications: Recognizing and Responding to Adverse Drug Reactions (12/10/2007), Nontuberculous Mycobacterial (NTM) Lung Disease (12/13/2007) and Tuberculosis: Un Vistazo General para Trabajadores de la salud (12/17/2007).

These recorded presentations can be viewed in Windows Media Player. Continuing Education Credits will be NOT be available for viewing recorded sessions. These webinars were presented in collaboration with the Centers for Disease Control and Prevention.

Case History:
A 6-year-old girl presented to her pediatrician with decreased hearing acuity found by routine elementary-age screening. She had been adopted from a Korean orphanage at 9 months of age and had a history of poor growth there. She had scarlet fever and pneumonia prior to the age of 4, but no other recent significant illnesses since adoption. Adoption records did not indicate vaccination with BCG and she had no vaccination scar. She had four documented Tine tests (multi-puncture test for TB infection) during the adoption process, all of which were negative. She had a Tine test at a community hospital prior to presenting to her physician, results of which are unknown.

The 2006 TB Surveillance Reports contain tabular and graphic information about reported TB cases collected from 59 reporting areas (the 50 states, the District of Columbia, New York City, U.S. dependencies and possessions, and independent nations in free association with the United States).
TB surveillance reports from past years are updated and corrected when new data are received and verified. The current 2006 surveillance report contains the updated summary data for all years.

The recent National Webinar; TB/HIV: Managing the Co-Infected Patient, sponsored by Heartland with Dr. Timothy Sterling, Vanderbilt University Medical Center, was recorded and the archived presentation is now available for viewing. It can be found on the Home page of the Heartland website (www.HeartlandNTBC.org) under the NEWS section. The handouts can also be found there. The recorded presentation is best viewed using Microsoft Media Player and has audio along with the PowerPoint. No continuing education credits will be awarded for viewing the recorded presentation.

The CDC Division of Tuberculosis Elimination (DTBE) has revised the "Tuberculosis Facts" fact sheet series (http://www.cdc.gov/tb/pubs/TBfactsheets.htm). These fact sheets provide basic TB Information in an easy-to-read format and are also available in PDF format for printing.

TB Notes Newsletter, Issue No. 4 2007 is now available from the CDC Division of Tuberculosis Elimination (DTBE) (http://www.cdc.gov/tb/notes/TBN_4_07/tbn407.pdf).

Thursday, December 13, 2007
11:00 am — 12:00 pm MT, 12:00 — 1:00 pm CT
Presented by: David Griffith, MD
Assistant Medical Director, Heartland National TB Center
Professor of Medicine, University of Texas Health Center at Tyler
This webinar is intended for TB program staff and clinical personnel including physicians, nurses and healthcare workers who treat and manage patients with pulmonary infectious diseases. Priority registration will be given to personnel from the Heartland region.

Lunes Diciembre 17, 2007
11:00 a.m. — 12:00 p.m. MT, 12:00 — 1:00 p.m. CT
Presentado por: Catalina Navarro, RN
Nurse Consultant, Heartland National TB Center
Dirigido principalmente al personal de enfermería así como a otros profesionales del área de la salud comprometidos en la lucha contra la tuberculosis, en donde la tecnología (Video conferencia Web) resulta ser un medio valioso para incrementar la cobertura y difusión del conocimiento sobre esta enfermedad.

The Technical Instructions for Tuberculosis Screening and Treatment for Panel Physicians, as part of requirements for immigration to the United States, have been revised. The previous screening algorithms were issued in 1991. To prevent applicants with smear-positive tuberculosis from traveling to the United States, the 1991 system relies on chest radiograph findings and sputum smears among overseas foreign national applicants 15 years of age or older. The 1991 system misses applicants with smear-negative but culture-positive tuberculosis, as well as tuberculosis in applicants <15 years of age. Moreover, the 1991 requirements do not provide guidance specifying the quality of treatment applicants with tuberculosis should receive prior to travel.

Case History:
A twenty year old woman was evaluated as a contact of a patient who had extensive smear positive pulmonary tuberculosis (drug susceptible isolate). She denied any symptoms of cough, weight loss, fatigue, night sweats or fever. She weighed 86 pounds. A TST was positive with a 20 mm induration. A chest x-ray (CXR) showed opacification of the lower half of the left hemithorax reflective of a moderate size left pleural effusion and/or atelectasis. She had normal laboratory values. She was not able to provide a sputum specimen.

On Tuesday, November 27, 2007, Heartland National TB Center will sponsor a web seminar entitled TB/HIV: Managing the Co-Infected Patient. Dr. Timothy Sterling, Associate Professor of Medicine at Vanderbilt University Medical Center (UMC), is the Director of Epidemiology Research, Division of Infectious Disease, Vanderbilt UMC; Director of Epidemiology and Outcomes Unit, Vanderbilt-Meharry Center for AIDS Research; and Director of Tuberculosis Research with the Metro-Davidson Health Department. Dr. Sterling has extensive patient and research experience in the field of TB/HIV co-infection. This webinar is intended for TB program staff and clinical personnel including physicians, nurses and healthcare staff who care for TB/HIV co-infected individuals.

Date: December 4-7
Course: TB Intensive
Location: Tyler, Texas
Please go to http://www.heartlandntbc.org/training.asp #regional for contact and registration information for this course. Enrollment is limited and is on a first-come basis for registrants from the Heartland partner states.

On December 10, 2007 Heartland will sponsor a webinar entitled TB Medications: Recognizing and Responding to Adverse Drug Reactions. This webinar is intended for TB program staff and clinical personnel including physicians, nurses and healthcare staff who treat TB patients and seek a better understanding of the possibilities and implications of adverse reactions to the common anti-tuberculosis medications.

Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit is a resource guide and toolkit for strengthening TB elimination strategies through partnerships. The guide and toolkit are available on the CDC Division of Tuberculosis Elimination website at http://www.cdc.gov/tb/pubs/forge/ default.htm.

The Joint RTMCC Products Page lists TB-specific educational materials and resources developed by all four Regional Training and Medical Consultation Centers. The web page is physically located on the Southeastern National TB Center’s web site. It is jointly managed by all Centers and is updated as new products are completed.

Case History: Our patient is a 54 year-old male who presented to his physician for follow up of a right upper lobe carcinoma which was ressected in 1979. He complained of shortness of breath, weight loss, fatigue, chest pain and a productive cough but no hemoptysis. A chest x-ray on June 20, 2006 revealed new bilateral alveolar infiltrates. He was referred to a pulmonologist and admitted to his hometown hospital on June 20, 2006. Smears were positive for acid fast bacilli and a CT scan June 22nd showed cavitation in the left upper lobe, bilateral infiltrates and mediastinal adenopathy. He was placed on anti-tuberculosis therapy—isoniazid (INH) 300 mgs, rifampin (RIF) 600 mgs, pyrazinamide (PZA) 1500 mgs and ethambutol (EMB) 1600 mgs daily with vitamin B6 50 mgs. Directly Observed Therapy (DOT) was started on July 7, 2006; given Monday through Friday with self-administration on the weekends. His culture grew Mycobacterium tuberculosis and was susceptible to INH, RIF and EMB.

Tuberculosis is a disease that has been impacting the health of individuals, communities and nations throughout history. Long recognized as an infectious disease, early therapy was isolation and palliative care. With the advent of medications that could cure patients, management of the disease moved to include the goal of successful completion of drug therapy. This required patient cooperation; typically one third of patients on their own fail to follow their physician's advice and do not correctly follow or finish therapy. This has serious implications with TB disease where the well-being of the patient and public health interest overlap — lack of a cure means continued infectiousness and risk of exposure to others.

Heartland National TB Center has developed its training schedule for 2007. With the publication of the new CDC Contact Investigation guidelines in 2005, many health departments have begun updating their policies based on the new recommendations. Heartland has put together an interactive, skill-building course that highlights the changes and teaches the new recommendations as well as interviewing and cultural competency. There are several trainings scheduled around the Heartland region; public health workers who are directly involved in TB contact investigations or setting policy for such investigations are encouraged to attend one of Heartland's Contact Investigation courses.

Trends in Tuberculosis Incidence — United States, 2006 A CDC analysis of national tuberculosis (TB) surveillance data shows slowing progress in the efforts to eliminate TB in the U.S. In 2006, the national TB rate fell to an all-time low of 4.6 cases per 100,000 people, with a total of 13,767 active cases. However, the decline in the TB rate in 2006 (3.2 percent) was one of the smallest in more than a decade. TB continues to disproportionately affect minorities and foreign-born individuals. Extensively Drug-Resistant Tuberculosis — United States, 1993-2003 Analysis finds 49 documented cases of extensively drug-resistant (XDR) tuberculosis (TB) in the United States between 1993 to 2006. While the risk of XDR-TB remains relatively low in the U.S., cases have been widely dispersed geographically and pose a continued risk to efforts to treat and control TB.

Case History: A 67 year old Hispanic male was diagnosed with drug susceptible pulmonary tuberculosis in September 2005. He presented with a three week history of night sweats, weight loss, nausea, shortness of breath and a productive cough. A chest x-ray (CXR) showed extensive bilateral cavitary disease. He was Hepatitis C positive with elevated baseline liver enzymes; HIV testing was negative. Sputum smears were AFB positive with greater than 10 organisms per high powered field. The patient's weight at diagnosis was 96 lbs.

The Centers for Disease Control and Prevention (CDC) Division of Tuberculosis Elimination (DTBE) will be updating the URLs (webpage addresses) on the DTBE website (http://www.cdc.gov/tb). Specifically, "NCHSTP" will be removed, and long, cumbersome URLs will be shortened. DTBE plans to make the transition on April 18, 2007.

Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit has been posted on the CDC Division of Tuberculosis Elimination website and is available on the homepage (http://www.cdc.gov/tb) or directly at http://www.cdc.gov/tb/pubs/forge/default.htm. The print version should be available within the next few months. TB Notes Newsletter — download at http://www.cdc.gov/tb/ notes/TBN_1_07/tbn107.pdf ~ No. 1, 2007 (PDF - 201K)

Heartland has developed several TB training materials. In addition to the algorithms below, other products have been updated and are now located on the Heartland website in PDF format available for printing or downloading.

For today's TB health professional, staying informed and up-to-date with the ever-changing field of tuberculosis diagnosis, treatment and patient management can be a daunting task. There are several TB-specific educational and training resources that can make the job easier.

The Centers for Disease Control and Prevention (CDC), Division of Tuberculosis Elimination (DTBE) has completed their annual Surveillance Report and accompanying slide sets for "Reported Tuberculosis in the United States, 2005." The TB Surveillance Reports contain tabular and graphic information about reported TB cases collected from 59 reporting areas (the 50 states, the District of Columbia, New York City, US dependencies and possessions and independent nations in free association with the United States).

The Division of Tuberculosis Elimination (DTBE) of CDC has launched the new Stop TB in the African-American Community website (http://www.cdc.gov/nchstp/tb/ TBinAfricanAmericans/default.htm) which provides quick, anytime access to information and resources related to TB prevention, control and elimination in the African-American community. This resource has been developed for people who have an interest in the topic of TB in this community.

The following products (algorithms) have been updated and are located on the Heartland website. They are available for printing or downloading.
▣ Assessing and Managing the Risk of Liver Disease in the Treatment of LTBI (PDF ~ 266 KB)
▣ Evaluation of Pregnant Patient at Risk for TB (PDF ~ 250 KB)
▣ Management of the TB Patient at Risk of Hepatotoxicity (PDF ~ 268 KB)

Medical History A 52 year old Hispanic female presented in January 2006 with left upper quadrant (LUQ) pain. An abdominal x-ray series revealed a density in the left upper lung; there was no hilar, mediastinal or axillary adenopathy. She denied cough, fever or night sweats. She had no prior history of tuberculosis. She immigrated to the US from Mexico 20 years ago and occasionally returns there to visit family. She is a diabetic and a non-smoker. She was referred to the local public health department where a tuberculin skin test (TST) was done and had an induration of 25 mm. Three sputums were negative for M. tuberculosis by direct staining and culture. A CT scan revealed a 2.4 cm slightly irregular cavitary mass in the left upper lobe. After the negative cultures, she was started on a 9 month course of isoniazid (INH) and vitamin B6.

Please go to http://www.heartlandntbc.org/training.asp for contact and registration information for each course. Additionally, we have webinars planned on Genotyping; Pediatric TB; HIV/TB; and Adverse Drug Reactions. We will also conduct an on-line training course in the fall of 2007 on Hepatotoxicity. Proposed topics and dates are subject to change; check website for the latest updates.

Latest issue of TB Notes is currently available from the CDC Division of TB Elimination (DTBE). This is a quarterly newsletter that contains news about DTBE activities and high-lights from state and local TB programs across the country. It also contains a calendar of events describing meetings, conferences and other educational activities of potential interest to those working in the field of TB. Please go to the following webpage: http://www.cdc.gov/tb/notes/ TBN_4_06/tbn406.pdf.

Upcoming Conference: International Union Against Tuberculosis & Lung Diseases North America Region (IUATLD NAR) 11th Annual Meeting: Powering Up Political Will for TB Control. Sponsors: British Columbia Lung Association and American Lung Association of Metropolitan Chicago. Dates and Location: February 22 - 24, 2007; Vancouver, BC, Canada. For complete conference information visit: http://www.bc.lung.ca/lungdiseases/tuberculosis_iuatld.html

The United States (US) has a long history of humanitarian assistance to displaced peoples; the most common aid to refugees is admission to live in the US and apply for permanent status as a naturalized citizen. This "reflects our core values and our tradition of being a safe haven for the oppressed." Since 1975, the US has resettled 2.4 million refugees and the Refugee Act of 1980 resulted in annual admissions of 61,000 (1980) to a high of 207,000 (1983) with a yearly average of 98,000.

The Regional Training and Medical Consultation Centers (RTMCC) are supported by CDC Cooperative Agreement (COAG) funds awarded to COAG recipients in locations where the RTMCCs are headquartered. The RTMCCs work cooperatively with all states to strengthen the capacity of TB programs and other partners to prevent and control TB through improved training, education, communications, and information dissemination. Each state has designated a TB Focal Point as the go-to-person for TB trainings and communications within their area. The Focal Points are TB professionals who have a wide range of TB experience within their state. They serve as a liaison to CDC and their RTMCC; providing feedback on trainings, products and medical consultation needs. The Focal Points meet annually at the CDC's TB-ETN conference, networking with each other and serving as a sounding board for new ideas.

The World Lung Foundation and The Union have launched a new Lung Health Image Library (LHIL) that incorporates and builds on the former Stop TB Partnership Image Library, which has now closed. The LHIL is a searchable database of thousands of high- and low-resolution photographs relating to tuberculosis, TB-HIV, asthma, child lung health, tobacco control and air pollution. It also includes a wide variety of images of health workers, patients, community health education and social mobilization for lung health, primarily in low-income countries.

(REVISED Nov. 22, 2006)
Patient History: A 31 year old male was admitted to the hospital after experiencing gross hemoptysis. He had a 2 month history of productive cough, a 25 pound weight loss, night sweats, and fatigue. A chest x-ray (CXR) revealed bilateral cavitary infiltrates. The initial sputum specimen was 4+ positive for acid fast bacilli (AFB) and a genetic probe assay confirmed Mycobacterium tuberculosis. A culture was positive for M. tuberculosis which was later reported to be resistant to INH and streptomycin. The patient has a history of heavy alcohol and drug use, is HIV negative but Hepatitis B and C positive. He has a long history of cigarette use and a chronic smoker's cough. The patient resides with his wife and 3 children (2 are step-children). [Original case presentation] :: [Original newsletter]

In 2006, 33 members were recruited for the HNTC Advisory Committee. Members are a combination of TB Controllers, TB Focal Points, Program Managers, TB Supervisors and Academic and Public Health Physicians. They represent 12 of the 13 states in the HNTC region. The Advisory Committee serves a vital role in the planning and implementation of HNTC training, product development and medical consultation activities. Many have served as faculty, advisors, reviewers and advocates for HNTC services. We thank them all for their tremendous support and contributions! Please check our website for more information.

Many of Heartland's partner states have developed training and patient educational materials for TB workers that they are willing to share.

The following products (algorithms) have been updated and are located on the Heartland website. They are available for printing or downloading.
▣ Assessing and Managing the Risk of Liver Disease in the Treatment of LTBI (PDF ~ 266 KB)
▣ Evaluation of Pregnant Patient at Risk for TB (PDF ~ 250 KB)
▣ Management of the TB Patient at Risk of Hepatotoxicity (PDF ~ 269 KB)

Tuberculosis infection, whether it is active disease or latent infection, requires a delicate balancing act of diagnosis, treatment and patient care. Even the most experienced TB professional will occasionally encounter a situation that is so unique or unusual that they are unsure of the direction to take. Heartland National TB Center has as one of its goals to "...share expertise in the treatment and prevention of tuberculosis by...delivering expert medical consultation and providing technical assistance..." This medical and nursing consultation is available at NO cost to physicians, nurses and other healthcare professionals in the thirteen states that comprise the Heartland Region.

Heartland National TB Center (HNTC) is housed at Texas Center for Infectious Disease (TCID) in San Antonio. This facility has a long history as a tuberculosis hospital — at one time it was one of the largest in the nation with 908 beds devoted to inpatient TB medical care. Today the facility has 72 beds and is organized to provide patient care, scientific investigation and therapeutic and educational services supporting public health needs. Heartland’s location and relationship with TCID allows it to offer unique learning experiences to our regional medical professionals. One such opportunity is a mini-fellowship targeted to physicians and advanced practice clinicians in the HNTC region and tailored to accommodate specific learning needs and time constraints of the individual candidates.

Numerous factors have influenced the prevalence of TB along the US-Mexico border but chief among them has been the lack of access to adequate health care and socio-economic conditions that contribute to disease spread. Historically, many TB patients have abandoned their TB treatment to cross the border and this can and does lead to the development of drug-resistant TB strains. Frequently, binational TB patients are men of productive age and have other illnesses related to TB. Their exact migratory routes are often unknown, and coupled with the emergence of drug-resistance and high prevalence of TB infection along the border, the individual national TB programs have historically had difficulty managing TB disease. Consequently, under the auspices of the USMBHC, the two governments came together in 2003 to combat and control TB through the US-Mexico Binational TB Referral and Case Management Project.

Patient History: A 27-year old Hispanic female presented to hospital on January 27, 2005 with a fever of 104°, a two week history of abdominal swelling, decreased appetite and body aches. She was admitted for diagnostic testing and follow-up.

The following products (algorithms) have been updated and are located on the Heartland website. They are available for printing or downloading.
▣ Assessing and Managing the Risk of Liver Disease in the Treatment of LTBI (PDF ~ 266 KB)
▣ Evaluation of Pregnant Patient at Risk for TB (PDF ~ 250 KB)
▣ Management of the TB Patient at Risk of Hepatotoxicity (PDF ~ 269 KB)

In 2005, the CDC's Division of Tuberculosis Elimination funded four TB Regional Training and Medical Consultation Centers (RTMCCs). The RTMCCs are regionally assigned to cover all 50 states and the U.S. territories.

The RTMCCs are supported by CDC Cooperative Agreement (COAG) funds awarded to COAG recipients in locations where the RTMCCs are headquartered. The RTMCCs work cooperatively with all states to strengthen the capacity of TB programs and other partners to prevent and control TB through improved training, education, communications, and information dissemination. Each state has designated a TB Focal Point as the go-to-person for TB trainings and communications within their area.

Results from a major study of a new blood test, ELISPOT, for latent tuberculosis infection show it may be more sensitive than the TB skin test, said Dr. Peter Barnes, director of the Center for Pulmonary and Infectious Disease Control and professor of microbiology at The University of Texas Health Center at Tyler.

Check their website for multilingual patient brochures and fact sheets.

Patient History: A 55-year old female emigrated from El Salvador in the mid 1980s. She had been employed by a poultry processing plant for 15 years (high risk environment associated with TB transmission). Medical history included a diagnosis of rheumatoid arthritis which was treated with prednisone 20 mgs twice daily, methotrexate and Humira (adalimumab-a tumor necrosis factor alpha blocking agent (TNFa)).

TBeat is the quarterly newsletter for Heartland National TB Center. We would like to make this a successful and much-anticipated resource for our partners; to that end you may submit news and noteworthy items for consideration.