CITC Newsletter — Winter 2012
A quarterly electronic newsletter from the Curry International Tuberculosis Center (CITC)
About CITC
CITC creates, enhances, and disseminates resources and models of excellence, and performs research to control and eliminate TB in the United States and internationally.
CITC is designated by the Centers for Disease Control and Prevention (CDC) as the Regional Training and Medical Consultation Center (RTMCC) for the Western Region, serving Alaska, California (including Los Angeles, San Diego, and San Francisco), Colorado, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington, Wyoming, and the U.S. Affiliated Pacific Islands.
Committed to the belief that everyone deserves the highest quality of care in a manner consistent with his or her culture, values and language, CITC develops and delivers highly versatile, culturally appropriate trainings, educational products, medical consultation, and technical assistance.
Recent transition at CITC: In December 2011 the CITC team said good-bye to Center Director Tom Stuebner. During his six-year tenure, Tom built a solid record of productivity and growth during times of cutbacks. His many valuable contributions include the network of strong partnerships and the spirit of cooperation he nurtured throughout the western region and the RTMCC family. The budget pressures that contributed to the elimination of Tom's position at the Center reflect the larger landscape of dwindling resources that currently confronts the TB control community. Tom was committed to mentoring and empowering staff; as such, his enduring legacy will be a Center that stands ready to embrace tomorrow's opportunities – and challenges – and to continue serving constituents with excellence and innovation.
TB Control in the Western Region
CITC Newsletter is proud to highlight TB control programs in CITC’s Western Region of the United States. In this issue, we feature the Washington State TB Program.
From its northwest corner on the U.S. map, the geography of Washington State is equally beautiful and diverse, ranging from rainforests on the Pacific coast to semi-desert basins in the east. Stretched between is the majestic Cascade Mountain range, which captured worldwide attention in 1980 with the eruption of Mount St. Helens. Even the drama of active volcanoes has not deterred migration to Washington; since 1970, population in “The Evergreen State” has doubled, and grew by over 800,000 in the last decade alone. Washington’s current population of 6.8 million is spread throughout the state’s 39 counties, but nearly 60% of all residents live in the metro Seattle area. Washingtonians are comprised of 72% non-Hispanic whites, 11% Hispanics (the fastest growing demographic group), and 7% Asian. The Washington economy is fueled by maritime trade in the Puget Sound harbors, lumber, retail, aircraft industry, agriculture (apples are one of many crops grown), and technology giants like Microsoft.
Washington has long been identified as a “medium incidence” state for tuberculosis. In 2010, there were 236 cases of TB in Washington, or 3.5 per 100,000, a rate that closely mirrored the U.S. incidence. Since 2000 (with the exception of spikes in 2007 and 2009), Washington TB rates have also been aligned with national downward trends. In fact, estimates for 2011 suggest a total of only 201 cases in Washington, a rate of 3.0 per 100,000, representing a 30-year low. Foreign-born residents comprised nearly 76% of Washington cases in 2010, and 43% of cases arose within the Asian community. Not surprisingly, 87% of cases came from seven counties with high population density, led by King County (Seattle area), which alone contributed 114 cases to the state total in 2010. Drug-resistance is relatively uncommon in the state’s TB caseload, but increases in the rates of pediatric TB in children under age 5 since 2006 have been a concern to local TB officials.
The Washington TB Program resides within the State Department of Health in the capital city of Olympia (60 miles south of Seattle). Sheanne Allen, MCHES, a 7-year veteran with the TB Program, assumed leadership of the program in 2011, following the retirement of longtime controller Kim Field, RN.
Ms. Allen comments on the special challenges that confront her program: “Lack of staff and resources resulting from budget cuts has been affecting TB in Washington State at all levels of government, especially at the local level. In light of these challenges, we are seeing strong partnerships develop between local health jurisdictions, private providers, corrections, and even other states.”
Always receptive to emerging methods for improving program performance and quality assurance, in 2003 the Washington TB Program embraced the concept of “Cohort Review” and has since developed a statewide cohort review model that is widely emulated by other jurisdictions.
For several years, the TB control community in Washington has partnered closely with the Curry Center on several fronts, conducting annual clinical and programmatic trainings in Seattle under the guidance of Drs. Masa Narita and Dave Park, and collaborating to present the annual Washington State TB Control meeting. TB experts affiliated with the University of Washington and the King County TB Control Program (Drs. Narita and Park, as well as Charlie Nolan, MD, Chris Spitters, MD, MPH, and David Horne, MD, MPH) also serve as faculty on the CITC Warmline medical consultation service.
Looking ahead, Ms. Allen remarks on the future of TB control in Washington: “Our program is currently making significant changes that include: revising our mission, reprioritizing our goals, enhancing cohort review, and providing more leadership, education, and technical expertise. The entire TB program is excited to share and implement these changes with all of our partners.”
U.S. Drug Shortages Impact TB Medications
Newspapers and medical journals have recently called attention to the problem of drug shortages in the United States. Unfortunately, some TB medications have also been impacted by diminished supplies and skyrocketing costs. The roots of the problem are multi-faceted, and any long-term solutions will require a coordinated approach among many players.
Shortages in first- and second-line anti-TB drugs have occurred since 2005, and essential drugs for treating multidrug-resistant TB (MDR-TB) have been difficult to obtain because of manufacturing issues, discontinuation, or restricted allocation. Additionally, over the last 4 years, costs have increased up to 2500% for some drugs. A recent National TB Controller’s Association (NTCA) survey found that 65% of respondents, representing 30 states, faced challenges obtaining anti-TB drugs and over half (58%) reported resultant treatment delays.
On October 31, 2011, President Obama issued an Executive Order recognizing the importance of this issue and directing the Food and Drug Administration (FDA) and the Department of Justice (DOJ) to:
- Broaden reporting of manufacturing discontinuations
- Expedite FDA regulatory review when it determines that this will help avoid a potential drug shortage
- Report to the DOJ if the FDA finds any price gouging or illegal stockpiling of medications
The factors that contribute to drug shortages are complex, and several stakeholders are involved in maintaining adequate drug supplies (FDA, drug manufacturers, CDC, pharmacies, physicians, etc.). Therefore, a coordinated effort will be needed to develop solutions and to address specific challenges. The Advisory Committee for the Elimination of TB (ACET) and the CDC developed an MDR-TB workgroup to address the TB drug shortage.
Individual jurisdictions are also taking steps to navigate the drug shortage problem. (See “TB Program Notes” to learn how California is approaching the issue.)
Recurrent TB: Who is Most at Risk?
A recent study addresses important questions about the factors related to recurrent TB. When Tuberculosis Comes Back: Who Develops Recurrent Tuberculosis in California? published in November 2011, describes the characteristics of “late” recurrent TB (i.e., TB occurring at least one year after treatment completion) and which patient groups are most at risk.
This study, the first large population-based assessment of recurrent TB in the U.S., was based on 23,517 pulmonary, culture-positive TB cases in California from 1993 to 2007. Of these cases, 148 (0.63%) had a second episode of TB reported at least one year after completion of therapy. Predictors of late recurrence include: Being US-born, HIV- infected, sputum smear-positive, infected with a PZA mono-resistant isolate, or started on a two-drug regimen. The low frequency of late recurrent TB in California suggests that local TB control programs are largely successful at preventing this adverse outcome. Nonetheless, the study identified subpopulations at increased risk of late TB recurrence that may benefit from additional medical or public health interventions. Lead author Lisa Pascopella, PhD, MPH, is the Senior Epidemiologist for the Surveillance and Epidemiology Section of the TB Control Branch at the California Department of Public Health.
New Online Courses Available
Two new online educational courses are now available: TB Prevention in the HIV-Infected Patient: Screening, Testing, and Treatment of Latent TB Infection and TB 101 for Health Care Workers.
Developed by CITC, TB Prevention in the HIV-Infected Patient: Screening, Testing, and Treatment of Latent TB Infection offers two modules containing case-based lessons written and presented by TB and HIV experts from the Western Region. The primary target audience is clinicians working with patients who are coinfected with HIV and latent TB infection (LTBI) and HIV or patients who are at risk of coinfection with HIV and LTBI. A modular format allows learners to tailor the learning experience to their needs; all course lessons are 20 minutes or less in length, and can be taken separately or in any order. Annie Luetkemeyer, MD, presents two lessons on “Screening and Testing for LTBI in HIV-Infected Persons.” William J. Burman, MD, Randall Reves, MD, MSc, and Robert W. Belknap, MD, serve as faculty for lessons that address “Treatment for LTBI in HIV-Infected Persons.”
Visit TB Prevention in the HIV-Infected Patient.
The CDC’s Division of Tuberculosis Elimination (DTBE), recently announced the release of the interactive online course, TB 101 for Health Care Workers. Developed as a collaborative effort between DTBE and the four RTMCCs, TB 101 is designed to educate health care workers about basic concepts related to TB prevention and control in the U.S. The target audience for the course includes newly hired TB program staff and health care workers in areas related to TB (such as individuals who work in correctional facilities or HIV/AIDS clinics). The course is divided into six sessions, covering topics that range from TB transmission, to diagnosis and treatment of latent TB infection and TB disease. Continuing education (CE) units for this course are offered free of charge for various professions.
Visit TB 101
TB Program Notes
TB Program Notes highlights news, innovative activities, and other items of interest from TB programs in the Western Region. In this edition, the San Francisco TB Program bids farewell to Masae Kawamura, MD; the Alaska TB Program announces its new program manual; and the California TB Control Branch reaches out to local programs grappling with TB drug shortages.
In December 2011, the San Francisco TB Program bid a fond and reluctant farewell to longtime TB Controller Masae Kawamura, MD, now working as Senior Director of Scientific and Medical Affairs with Qiagen (which recently acquired Cellestis, the company that developed the QuantiFeron®blood-based LTBI test). In an email announcing her career change, Dr. Kawamura noted that her new position with the global diagnostics company will enable her to “bridge the gap between public health and corporate biotech” and will keep her in close proximity to the TB community at major TB conferences. Dr. Kawamura will continue to volunteer at the San Francisco TB Clinic and remain an active member of the IUATLD, ATS, and the National Society of TB Clinicians. On January 25, 2012, the San Francisco TB Program announced that Santa Clara County TB Controller Julie Higashi, MD, PhD, was chosen as the new Director of TB Control.
Credit: FirstCare Medical Centers
Karen Martinek, RN, MPH, reports the completion of a new Alaska Tuberculosis Program Manual, now available on the program’s website.
The comprehensive document was developed from a template originally devised by CITC, a template that several other states have also used as the basis for their TB manuals. In the Alaska Manual, Dr. Bruce Chandler of the Anchorage Department of Health wrote a special section on “Diagnosis and Treatment of Latent Tuberculosis Infection and Tuberculosis Disease in Children (under 16 years of age).” Program forms are posted separately for users to easily to find and download the forms they need.
In response to the nationwide TB drug shortage problem, the California Tuberculosis Control Branch MDR-TB Service is offering assistance to California programs and providers to obtain second-line TB drugs. In order to document the extent of the problem and impact on treatment, the Branch is also interested in learning about any challenges local health departments are experiencing. Providers or facilities experiencing any difficulty obtaining anti-TB medication in California are encouraged to contact the MDR-TB Service Nurse Coordinator, Lisa True, RN, MSN, (510) 620-3054.
Upcoming Training Courses
CITC’s schedule of upcoming training courses (through May 2012) offers a variety of courses for clinicians and public health providers.
February 14-16, 2012
San Francisco, CA
Tuberculosis Clinical Intensive
Three-day intensive for physicians and other licensed medical professionals who diagnose and treat tuberculosis.
February 22, 2012
San Antonio, TX
Joint RTMCC training at IUATLD-NAR Conference: Advances in the Diagnosis and Treatment of Tuberculosis
The goal of the pre-conference is to enhance the expertise of providers in the diagnosis and treatment of their patients with, or at risk of, tuberculosis. This course is intended for clinicians who diagnose and treat TB and LTBI.
April 2-5, 2012
San Francisco, CA
Case Management and Contact Investigation Intensive
Four-day training for nurses, communicable disease investigators, and medical social workers.
April 19, 2012
San Francisco, CA
TB Cohort Review
One-day training for TB control program staff involved in cohort reviews. Multidisciplinary teams from programs are encouraged to apply.
May 14-16, 2012
Los Angeles, CA
46th CTCA Educational Conference –The Cutting Edge of TB Control: New Tools, New Strategies
Three-day conference featuring sessions on the new short-course INH/rifapentine LTBI regimen; cost effectiveness of LTBI treatment; laboratory advances and challenges; and HIV/AIDS screening in the TB program patient population.
May 16
Los Angeles, CA
Focus on TB Nurse Case Management
One-day workshop, held in cooperation with CTCA’s annual educational conference, featuring sessions on case management issues for challenging TB cases, as well as information on incorporating new tools into patient diagnosis and care.
For periodic updates on additional trainings, complete course descriptions, and application forms, view our training section.
Faculty Profile
To better acquaint our readers with the corps of TB experts that comprise our training and medical consultation faculty, each issue of CITC Newsletter presents a profile of a CITC faculty member. In this issue we feature Robert Belknap, MD.
The metro Denver area in Colorado has a solid reputation for TB expertise, thanks to outstanding institutions like National Jewish, the University of Colorado, and Denver Public Health. Small wonder that the region attracts such top medical talent, and “Exhibit A” is Bob Belknap, MD. Dr. Belknap, Assistant Professor at University of Colorado and Infectious Disease Physician at Denver Public Health, represents the latest generation of clinicians and academics who will lead the field of TB care and prevention in the decades ahead.
Dr. Belknap was born and raised in the small town of New Philadelphia, Ohio. Studying zoology and pre-med, he graduated summa cum laude with a Bachelor of Science degree from Kent State University in Ohio, and then proceeded to Ohio State University College of Medicine in Columbus to earn his medical degree.
Venturing west, Dr. Belknap settled in Denver, Colorado, where he completed his internship and residency in Internal Medicine at University of Colorado Health Sciences Center (UCHSC), followed by a year of service as a Hospitalist with Inpatient Services. Dr. Belknap then underwent a three-year fellowship in Infectious Diseases at UCHSC, after which he began working at Denver Public Health. He remains on faculty at UCHSC as a member of the Infectious Diseases Division. Looking back, he comments on the lasting impact of the fellowship and the mentors with whom he worked: “I developed an interest in tuberculosis through exceptional mentoring by Drs. Randall Reves, Bill Burman, and David Cohn who taught me the intricacies of treating TB and introduced me to TB epidemiologic and clinical research.”
The last decade has provided not only a breadth of clinical practice to Dr. Belknap, but also extensive research experience. He served as the local principal investigator (PI) for two projects sponsored by the Tuberculosis Epidemiologic Studies Consortium (TBESC): TB Mortality in the U.S. – Epidemiology and Prevention Opportunities; and Evaluation of New Interferon–γ Release Assays in the Diagnosis of Latent Tuberculosis Infection in Health Care Workers. In 2005 he became co-principal investigator for the Tuberculosis Trial Consortium (TBTC) site in Denver, a project investigating new medication regimens for the treatment of active and latent TB. Dr. Belknap now serves as PI for the ongoing trials in Denver.
Dr. Belknap’s list of publications include articles in the International Journal of Tuberculosis and Lung Disease, Clinical & Vaccine Immunology, and the Journal of Medical Case Reports. He recently co-authored “Identification of false-positive QuantiFERON TB Gold in-tube assays by repeat testing in HIV-infected patients at low risk for tuberculosis,” published in Clinical Infectious Diseases.
Dr. Belknap’s lectures on diagnosis of TB and treatment of latent TB infection are enthusiastically received by participants at CITC clinical courses, and he is a featured presenter in the Center’s new online course: TB Prevention in the HIV-Infected Patient. Since 2009 Dr. Belknap has provide expert TB consultation on the CITC Warmline service.
With many years ahead in his career, Dr. Belknap is ready to embrace new challenges on his professional horizon: “I am looking forward to an expanded role in both the TBTC and TBESC in helping to design and conduct studies to evaluate new tools and strategies for improving the diagnosis and treatment of active and latent TB.”
Randall Reves, MD, Medical Director of the Denver Metro TB Control Program, holds Dr. Belknap in high regard: “We consider ourselves fortunate to have Bob at Denver Health. Bob is a clinician with superb clinical skills and the knack for applying these in a public health context. In addition to providing compassionate and effective patient care, Bob’s patient-based approach to teaching and learning is highly effective.”
Contact Us
Curry International Tuberculosis Center
3180 18th Street, Suite 101
San Francisco, CA 94110-2028
Telephone: 415-502-4600
Fax: 415-502-4620
Warmline TB medical consultation: 877-390-6682 (toll-free) or 415-502-4700
CurryTBCenter@ucsf.edu
www.currytbcenter.ucsf.edu
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CITC Newsletter
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