CNTC Newsletter Archive — Summer 2009
A quarterly electronic newsletter from the Francis J. Curry National Tuberculosis Center (CNTC)
About 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
Could one of history’s most famous casualties of TB have infected a friend who succumbed years later to the same disease? CNTC medical consultant Chris Spitters, MD, MPH, played “history detective” to respond to a curator’s inquiry.
A recent question submitted to CNTC by Jeffrey Cramer, Curator of Collections at the Thoreau Institute at Walden Woods, stood apart from the hundreds of consultation requests the Center receives each year. This query required Dr. Spitters to apply modern medical perspectives to a case that occurred almost 150 years ago.
Mr. Cramer wrote:
“This is probably not the typical question you get, and I hope you can answer this for me. In 1861, the American author and philosopher Henry David Thoreau, who had tuberculosis, travelled to Minnesota for his health. He died the following year. He was accompanied by a friend, Horace Mann Jr., who died in 1868 from the same disease. Would it have been possible for Mann to have contracted the TB from Thoreau in 1861 that killed him in 1868, or is that too long a period? Thank you for any light you can shed on this.”
Dr. Spitters responded:
“About 25-33% of those undergoing heavy exposure (e.g., accompanying a dying friend to Minnesota) will get infected. The incubation period from inhalation of the tubercle bacillus (Mycobacterium tuberculosis) until infection is established in roughly 2-to-10 weeks. Typically, though not always, that initial infection is an asymptomatic event. The result is a chronic latent infection with several hundred to several thousand organisms in the lung, the lymph nodes of the chest, and sometimes other parts of the body.
Ninety to 95% of such latently infected individuals go to their graves without experiencing any detectable reactivation of the infection. At some later point in life, however, the other 5-10% develops active disease with multiplication of the organism, cough, sputum, night sweats, fever, anorexia and weight loss (i.e., consumption). Other organs and structures can be affected beyond or instead of the lungs, such as the lymph nodes, spine, brain, or kidneys. The proportion of latently infected individuals developing active disease is quite a bit higher in HIV-infected and other immunosuppressed individuals (as high as 10% per year in HIV-infected patients not on anti-HIV therapy) — hence the current TB/HIV epidemic underway in Africa.
About 50% of reactivations are thought to occur within about two years of original acquisition. The remainder is spread throughout the post-exposure lifetime. In this sense, it certainly is conceivable that Horace Mann could have acquired his TB infection from Mr. Thoreau. Other possibilities do exist, though, and include acquisition from a consumptive adult in Mann’s family, work, or school environment when he was a child or young adult.
In today’s world, we have genetic testing that can be used to detect linkage between cases whose TB organisms share identical DNA fingerprints. However, in the era of Mr. Thoreau and Mr. Mann, it becomes anyone’s guess as to who gave what to whom. The calendar is suggestive, but not confirmatory in this case.”
This exchange between Mr. Cramer and Dr. Spitters reminds us how dramatically our knowledge about all aspects of TB, including its transmission, has increased in the last century — and how tenacious this ancient disease remains.
TB Control in the Western Region
CNTC Newsletter is proud to highlight TB control programs in CNTC’s Western Region of the United States. In this issue, we focus on the Wyoming TB Program.
The frontier state of Wyoming, where the Great Plains meets the Rocky Mountains, holds many distinctions. Nicknamed “the Equality State,” Wyoming was the first U.S. state to grant women the right to vote, and is home to the country’s first national park, Yellowstone. Over 90% of the Wyoming land mass is classified as “rural,” with almost half owned by the federal government. Mining and tourism dominate the state’s economy. Wyoming has fewer residents than any other state (532,000).
Given its sparse population, it is hardly surprising that Wyoming is among the lowest of the “low incidence” states for tuberculosis, logging a grand total of 89 cases since 1990, with virtually no incidence of drug resistance. In 2008, just five cases of TB were reported. However, Wyoming’s low case rates reveal only one facet of the state’s TB control story.
Alex Bowler, MPH, FACHE, has coordinated TB control in Wyoming since 1993, and he emphasizes a fundamental lesson learned from 16 years of experience: “Low case counts don’t reflect the activity level involved in keeping those rates low.” Every year nearly 19,000 people in Wyoming are tested for latent TB infection. This includes people who have increased risk for TB infection or disease, and those required to be tested by the federal Occupational Safety and Health Administration (OSHA). From 2000-2008, over 1,800 patients were treated for LTBI using medications provided by the TB Program, with average completion rates approximating 90%.
Mr. Bowler also points out that the low number of active TB cases in Wyoming also does not reflect the activity associated with patients who subsequently turn out to be infected with atypical mycobacteria. These “suspect” cases usually outnumber TB cases by six to one, and involve specimen testing by Wyoming’s Public Health TB Laboratory, dispensing of first-line TB medications pending culture results, and occasional initiation of contact investigation.
Wyoming was one of four states recently involved in a five-year research project, “Regional Capacity Building in Low Incidence Areas,” conducted by the Tuberculosis Epidemiological Studies Consortium. The project assessment report detailed Wyoming’s numerous program strengths and assets, including the work of Mr. Bowler, who is recognized as a valuable resource by health providers and jurisdictions throughout the state. Wyoming has many of the essential components for TB control in place including: legal authority and updated policies and procedures; diagnostic and treatment capacity for managing TB cases; and programmatic and clinical oversight to ensure quality improvement. The Wyoming program also shares a number of logistical barriers and challenges common to low-incidence states: difficulties in recruiting staff at the county level, travel constraints within the rural geography, and keeping lab staff proficiency strong when few specimens are processed each year.
After so many years as Wyoming’s “TB point person,” Mr. Bowler’s anticipated retirement will leave a tremendous void in the Wyoming TB Control Program. At this crossroads, Mr. Bowler offers these insights: “Long term, prevention is the key to sustained low TB case rates. Wyoming has enjoyed the luxury of being able to concentrate on identification and treatment of LTBI. Gaining the credibility needed for Wyoming providers to seek advice from the State TB Program has been a major factor in our success, as has the cooperation of county level public health nursing. Sustaining political support for TB prevention and control is an ongoing challenge.”
Upcoming Training Courses
CNTC’s schedule of upcoming training courses (through December 2009) offers a variety of courses for clinicians and public health providers.
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.
November 3-5, 2009
Ontario, CA
TTuberculosis Communicable Disease Investigator Intensive
Three-day course for communicable disease investigators (CDIs) who conduct tuberculosis contact investigations.
December 17, 2009
National Web-based Seminar
Tuberculosis and Diabetes
1.5-hour web-based seminar for clinicians in the United States who may treat or screen patients with tuberculosis, diabetes, or both diseases.
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 CNTC Newsletter presents a profile of a CNTC faculty member. In this issue we feature Karen Smith, MD, MPH.
The career paths of the most interesting and distinguished public health professionals often do not follow a predictable plot. The twists and turns in Karen Smith’s professional journey have led her to four prestigious universities, to studies and research in parasitology, infectious diseases, and epidemiology, and to public health service from Thailand to Northern California. Forsaking the “beaten path” to blaze her own trail clearly suits this widely respected physician, administrator, and educator.
Karen Smith was born and raised in Sparks, Nevada. She earned her Bachelor of Science degree in microbiology at the University of Michigan, Ann Arbor. For the next several years she applied her laboratory expertise as a Peace Corps volunteer, first in Marrakech, Morocco, and then in Petchaboon Province, Thailand. Dr. Smith recalls her transformation during this period: “I went into the Peace Corps after completing my undergraduate work in order to gain a little ‘real life’ experience before what I thought then would be working toward a PhD and a career in basic science research. By the time I came back, I was firmly committed to the public health approach to improving people’s lives. Seeing firsthand the effect that poverty and the lack of basic health and medical care has on every aspect of people’s existence had a profound impact on me.”
Following her Peace Corps service, Dr. Smith returned to the United States to earn a Master in Public Health degree in International Health at Johns Hopkins University. Her academic pursuits then led to California, where she began a doctoral program in parasitology at University of California, Berkeley. After two years, she changed course to attend medical school at Stanford University, where she earned her M.D. and completed her internship and residency. A post-doctoral fellowship at Stanford’s Division of Infectious Diseases and Geographic Medicine, with research in infectious disease epidemiology, followed.
Dr. Smith then began an eight-year affiliation with the Santa Clara County Public Health Department, where she served as a TB physician, and ultimately as Assistant Health Officer and TB Control Officer. Concurrently, she maintained an active teaching schedule, serving as clinical faculty at Santa Clara County Valley Medical Center and lecturer at Stanford University School of Medicine. Dr. Smith also spent one year as a Medical Officer at the California Department of Public Health Tuberculosis Control Branch before returning to Santa Clara County. As a county TB controller, Dr. Smith became involved with the California TB Controllers Association, and served as its President from 2003-2004.
In 2004, Dr. Smith accepted the position of Public Health Officer and Director of Public Health in Napa County, California. World famous for its wine industry, Napa County has an ethnically diverse and growing population. Local public health challenges include increasing poverty and higher than average rates of asthma, lung cancer, chronic liver diseases, and cirrhosis. Dr. Smith comments: “I have learned a tremendous amount through the much broader scope of responsibilities I have as Public Health Officer, but I still love the TB work I do!”
For over 10 years, Dr. Smith has been a valued member of the CNTC training faculty, presenting lively and engaging lectures on medical management of TB, legal and ethical issues in TB control, TB case management, diagnosis of TB, and working with private providers. She was a contributing author of the chapter on “Legal and Ethical Issues” in CNTC’s Drug-Resistant Tuberculosis: A Survival Guide for Clinicians.
Dr. Smith truly demonstrates that a successful career need not follow a “straight line.” Her talents and accomplishments have won admiration from many colleagues, including San Francisco TB Controller Masae Kawamura, MD: “A teacher, expert clinician, and a natural executive, Karen Smith is a stellar leader in public health. With every career move, she improves systems, builds infrastructure, encourages those around her to excel, and leaves her trademark of enduring quality.”
Contact Us
Francis J. Curry National 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
tbcenter@nationaltbcenter.ucsf.edu
www.nationaltbcenter.ucsf.edu
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CNTC Newsletter
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