CNTC Newsletter Archive - Spring 2009
A quarterly electronic newsletter from the Francis J. Curry National Tuberculosis Center (CNTC)
CNTC creates, enhances, and disseminates resources and models of excellence, and performs research to control and eliminate TB in the United States and internationally.
CNTC 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. Pacific Island Territories.
Committed to the belief that everyone deserves the highest quality of care in a manner consistent with his or her culture, values and language, CNTC develops and delivers highly versatile, culturally appropriate trainings, educational products, medical consultation, and technical assistance.
Learn About TB
TB clinicians, take note: Recent research sheds new light on the impact of diabetes on TB, as well as how TB treatment can affect diabetic control.
Gisela Schecter, MD, MPH, a CNTC Warmline consultant and MDR-TB consultant with the California TB Control Branch, has shared with CNTC Newsletter a summary of recent studies that increase our understanding of the complexities of co-managing TB and diabetes. A few highlights of her review:
- There is increased risk of progression to active TB among patients with diabetes. A Harvard meta-analysis (Jeon and Murray, 2008) looked at 13 observational studies that included over 1.7 million participants and found that the relative risk (of active TB) 3-fold higher among those with diabetes.
- In presentation and diagnosis, there is an increased likelihood of lung lesions confined to the lower lobes. In one study (Alisjahbana, et al, 2007) this difference was from 2.4% without diabetes, to 23.5% with diabetes. Diagnosis may be delayed because the radiologist and treating physician may not "think TB" without upper lobe abnormalities present.
- Response to treatment: The old dogma used to be that despite the increased risk of LTBI progressing to active TB among diabetics, these patients did just as well on treatment. A Texas study (Restrepo, et al, 2008) found that diabetics on average achieved sputum culture conversion 5 days later than non-diabetics. A study in Taiwan (Wang, et al, 2008) showed significantly higher mortality among diabetics. Of note, about 1/3 of their TB patients had diabetes.
- Effect of TB treatment on diabetes: It is widely known that Rifampin affects the levels of anti-retrovirals used to treat HIV through its effect on the CyP450 enzyme system. Both sulfonorylureas (such as glipizide) and thiozolidinediones (such as Avandia or Actos) are metabolized by this same system, so blood levels of these drugs may be lower when Rifampin is being used and therefore diabetes control may suffer. Careful monitoring is required.
- Diabetics also have a higher incidence of peripheral neuropathy while taking INH for active TB or LTBI. To protect against this complication, give vitamin B6 at a dose of 25 to 50 mg daily routinely to diabetics whenever INH is prescribed.
Later this year, CNTC will be presenting a national webinar on diabetes and TB to share additional clinical perspectives about this important topic.
Alisjahbana B, Sahiratmadja E, Nelwan EJ, Purwa AM, Ahmad Y, Ottenhoff TH, Nelwan RH, Parwati I, van der Meer JW, van Crevel R. The effect of type 2 diabetes mellitus on the presentation and treatment response of pulmonary tuberculosis. Clin Infect Dis. 2007 Aug 15;45(4):428-35.Epub 2007 Jul 5.
Jeon CY, Murray MB. Diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. PLoS Med. 2008 Jul 15;5(7):e152
Restrepo BI, Fisher-Hoch SP, Smith B, Jeon S, Rahbar MH, McCormick JB; Nuevo Santander Tuberculosis Trackers. Mycobacterial clearance from sputum is delayed during the first phase of treatment in patients with diabetes. Am J Trop Med Hyg. 2008 Oct;79(4):541-4.
Wang CS, Yang CJ, Chen HC, Chuang SH, Chong IW, Hwang JJ, Huang MS. Impact of type 2 diabetes on manifestations and treatment outcome of pulmonary tuberculosis. Epidemiol Infect. 2008 Jun 18:1-8. [Epub ahead of print]
TB Control in the Western Region
CNTC Newsletter is proud to periodically highlight TB control programs in CNTC's Western Region of the United States. In this issue, we focus on the San Diego TB Control Program.
A snapshot of San Diego County, California, presents a large and complex image. The county is comprised of 4,200 square miles of terrain that ranges from world famous coastline to forested mountains and deserts. Over 3,000,000 residents live within its 18 incorporated cities and 17 unincorporated communities, making San Diego County the sixth most populous county in the U.S. The county contains not only 16 military facilities and 18 Indian reservations, but also the world's busiest international land border: the U.S.- Mexico crossing between San Diego and Tijuana.
Now in her 20th year as TB Controller in San Diego County, Kathleen Moser, MD, MPH, is well aware of how her county's unique geographic and demographic profile creates a challenging scenario for TB control: "We have the social challenges of urban centers, the access problems of rural regions, and a dynamic population characterized by large numbers of refugees, immigrants and, of course, our strong linkages with Mexico."
In 2008, San Diego County reported:
- 264 cases of active TB (8.4 per 100,000, or double the U.S. rate of 4.2 per 100,000). This represents a 6% decrease from 2007 (280 cases).
- Just over half (52%) of the TB cases were Hispanics, and 31% were Asian/Pacific Islanders.
- TB cases born outside of the U.S. comprised 71% of San Diego County's cases (compared to 58% nationally). Of the 187 foreign-born cases, almost half (47%) were from Mexico, 43% were from Asia, and 5% were from Africa.
- TB drug susceptibility information was obtained on 100% of the 226 culture-proven cases. Resistance to at least one of the four major first-line drugs was found among 21% of these specimens. MDR-TB strains were found in 1.3% of the cases, which mirrors the national rate. During 1999-2008, a total of 40 MDR TB cases were reported in San Diego and none were extensively drug-resistant (XDR).
Each year, approximately 10% of TB cases in San Diego are due to Mycobacterium bovis, which is usually contracted through the consumption of unpasteurized dairy products. Person-to-person transmission is also believed to occur, and strategies to address both modes are important to overall TB control efforts in the area.
San Diego County is a leading partner in a number of U.S.-Mexico collaborative initiatives, including:
CureTB: Binational TB Referral Program (telephone: 619-542-4013), which facilitates the continuity of care for active TB cases and their contacts who travel between the U.S. and Mexico, and supports the exchange of information between health care providers from both countries. CureTB also provides guidance and education to patients and/or their contacts about their TB risk and need for diagnostic or treatment services. (Note: CureTB does not provide medications or direct services to patients.)
Puentes de Esperanza - Binational Alliance for the Treatment of MDR-TB in Baja California. This binational collaboration, started in 2006, was created to support and enhance the treatment of MDR-TB in Baja California. Over 20 patients have been treated thus far through strategies to provide access to laboratory diagnosis, second-line medications, and community-based observed therapy. Education of providers and creation of a sustainable cross-border exchange of expertise are essential parts of the Puentes initiative.
The San Diego TB Control Program pursues innovative approaches to address the unique challenges posed by its mobile and widely dispersed patient populations:
- Video-DOT, which consists of using a real-time video telephone to remotely observe patients ingesting medication. The program saves staff and transportation costs while providing more scheduling flexibility for patients.
- Centralized, team-based case management, whereby TB program nurses, disease investigators, and DOT workers collaborate to assure each patient has a successful outcome.
- Partnerships with businesses in contact investigation, a strategy that leverages the health care access provided by employers.
Dr. Moser reflects on the elements that have contributed to her program's success: "We have committed and energetic staff who are always ready to do what needs to be done. We are always trying to develop ways to do things even better, smarter, and more efficiently. Our community partners - from the San Diego State University School of Public Health, the American Lung Association, University of California, San Diego Medical Center to shelters, refugee resettlement agencies, and community health centers - are vital parts of our success in controlling TB in San Diego."
Upcoming Training Courses
CNTC’s schedule of upcoming training courses (through October 2009) offers a variety of courses for clinicians and public health providers.
June 10-11, 2009
Tuberculosis Clinical Intensive
Two-day intensive for physicians and other licensed medical professionals who diagnose and treat tuberculosis.
June 12, 2009
"Do You Speak TB?" Tuberculosis Nurse Case Management Workshop
One-day update for nurses, communicable disease investigators, and other licensed medical care providers who work with tuberculosis patients.
July 21-24, 2009
San Francisco, CA
Tuberculosis Program Manager's Intensive
Four-day intensive for nurses, physicians and other health professionals working as tuberculosis program managers.
September 1-3, 2009
San Francisco, CA
Tuberculosis Clinical Intensive
Three-day intensive for physicians and other licensed medical professionals who diagnose and treat tuberculosis.
October 6-9, 2009
San Francisco, CA
Tuberculosis Case Management and Contact Investigation
Four-day training for nurses, communicable disease investigators, and medical social workers.
For periodic updates on additional trainings, complete course descriptions, and application forms, view our training section.
To better acquaint our readers with the corps of TB experts that comprise our training and medical consultation faculty, each issue of CNTC Newsletter presents a profile of a CNTC faculty member. In this issue we feature Ann Raftery, RN, PHN.
It is no simple task to summarize Ann Raftery's 27-year career as a nurse, trainer, and educator. Her work history includes delivering TB medications in minus-40-degree weather in the Canadian wilderness, managing an MDR-TB outbreak in a rural California community, and training nurses throughout the Caribbean on the complexities of TB-HIV. Ann Raftery is nothing short of a public health nursing dynamo, and she shows no signs of letting up.
Ann Raftery's life story was tied to TB even before she was born: "You could say I owe my life to TB as my parents met at a TB hospital in Florida," she recalls. Born and raised in Port Huron, Michigan, Ms. Raftery earned her Bachelor of Science in Nursing from the College of Mount St. Joseph in Cincinnati, Ohio. "I've had an affinity for public health since my clinical rotation, but it was my nephew, who developed TB meningitis at the age of 5, who influenced my commitment to the field of TB and TB education." After a few years of hospital-based nursing in the Pacific Northwest and Michigan, Ms. Raftery moved to Alberta, Canada. For the next 14 years she gained extensive experience in TB and other communicable diseases in nursing, research, and administrative positions, often working with "First Nations" indigenous communities. Ms. Raftery cites Dr. Anne Fanning and Dr. Donald Enarson as "remarkable TB mentors" during her early career in Canada. "My nurse heroines were Elaine Benjamin and Denise Whittaker, TB nurse experts in Alberta, who guided me through my first TB outbreak investigation," she adds.
The next chapter of Ms. Raftery's professional journey began with the new millennium (2001) when she joined the State of California's TB Control Branch as the Outbreak Response PHN and Program Liaison for 42 low-incidence counties. Later, as coordinator of MDR-TB Services for the Branch, she started her affiliation with CNTC as a faculty member and Warmline consultant. Since 2006 when Ms. Raftery fully joined the CNTC staff as a Nurse Consultant, one of her crowning achievements has been the creation of the "nurse-to-nurse" training program, which customizes off-site training sessions to the unique situations of nurses in different jurisdictions. Gayle Schack, RN, was a co-creator of the program with Ms. Raftery and praises her colleague: "Working with Ann over the past several years has been a joy and an amazing adventure. Ann has ensured that the process of developing the nurse-to-nurse trainings is fun, from the planning sessions to the training itself. She has an incredible knack for working with others and collaborating on projects. Ann only seems to see the best in others, and it inspires you to reach for a higher level within yourself. It's a privilege to work with her and count her as a friend."
Ms. Raftery has also played a lead role in providing technical assistance to a multi-agency effort to assist collaboration between TB and HIV programs in nine Caribbean countries. Two major partners in the project express their admiration of her. Shelia St. Thomas, MA, is Caribbean Regional Program Manager for the International Training and Education Center on HIV (I-TECH) at University of Washington: "We are indebted to Ann Raftery for her technical leadership role in the USAID-funded TB/HIV Initiative. Ann's professionalism, warmth, diplomacy and collaborative style have been key components in helping to advance the Initiative despite barriers of limited resources and competing interests in the region. She's developed strong partnerships with the Caribbean HIV/AIDS Regional Training (CHART) network as well as the Caribbean Epidemiology Research Centre (CAREC) and has modeled best practices for providing respectful and relevant technical assistance."
Brendan Bain, DM, MPH, is Director of the CHART Regional Coordinating Unit (RCU): "What strikes you on first meeting Ann is her pleasant and welcoming demeanor. Quite soon, you experience someone who is determined to accomplish her mission and to get the job done thoroughly. She constantly shared with me her vision of strong professional networks linking parts of the Caribbean and linking the Caribbean and the U.S., serving the common purpose of improving prevention and treatment of TB. She represents the Curry Center with dignity, integrity, and professionalism."
In addition to her national and international work, Ms. Raftery amazingly finds time to serve as Secretary/Treasurer for the International Union Against Tuberculosis and Lung Disease - North American Region, and as a member of the National TB Nurses Coalition.
CNTC's director, Tom Stuebner, is well-acquainted with Ms. Raftery's remarkable scope of work, and shares his applause: "I met Ann four years ago when I had just become the CNTC director and Ann was set to moderate and present at a large TB training. My guidance to Ann was simple, "Dazzle me!" Working with Ann is like climbing Mt. Everest - she leads us to unthinkable heights and from Ann's lofty perspective, the views and possibilities are amazing. Since that first day and every day since, Ann continues to dazzle!"
Francis J. Curry National Tuberculosis Center
3180 18th Street, Suite 101
San Francisco, CA 94110-2028
Warmline TB medical consultation: 877-390-6682 (toll-free) or 415-502-4700
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CNTC Principal Investigator: Philip C. Hopewell, MD
RTMCC Co-Principal Investigators: Philip C. Hopewell, MD, and L. Masae Kawamura, MD
Task Order #1 Principal Investigators: Philip C. Hopewell, MD
Task Order #19 Co-Principal Investigators: Elizabeth Fair, PhD, and Christine Ho, MD
RTMCC Medical Director: Lisa Chen, MD
CNTC Director: Tom Stuebner, MSPH
Training Administrator: James Sederberg
Research Administrator: Baby Djojonegoro, MS, MPH
CNTC Newsletter Editor: Kay Wallis, MPH
CNTC Web Developer: Mari Griffin, MS