CNTC Newsletter – Summer 2010
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.
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 feature the Nevada Tuberculosis Elimination and Control Program.
Asked to describe the state of Nevada, random bystanders might paint a superficial portrait: Desert. Casinos. Easy marriages and quick divorces. The reality of life in the “Silver State” is certainly richer and more complex than common stereotypes, and the state’s extremities and contrasts are noteworthy. Nevada’s 17 counties cover 110,540 total square miles, making it the 7th largest state in land area. Encompassing the Mojave Desert in the south and the Great Basin in the north, Nevada is the most arid state in the nation, and among the most mountainous. Nevada’s economy was historically based in mining and ranching, and is now dominated by gambling and tourism. The vast majority of Nevada’s land mass is considered “rural” or “frontier” and holds only 10% of the population. Over 85% of Nevada’s 2.6 million total residents live in the metro Las Vegas and Reno areas. The three Nevada counties classified as “urban” (Clark, Washoe, and Carson City) have experienced dramatic population growth in the last 20 years. Clark County is home to one of the nation's largest school districts (over 300,000 K-12 students). The U.S. Census estimates Nevada’s 2008 racial/ethnic proportions as: 57% White, non Hispanic; 26% Hispanic; 8% Black, and 6% Asian. The percentage of Nevada residents who are undocumented immigrants (estimated at 8%) is among the highest in the U.S. Add to the equation the annual influx of over 39 million tourists, and the implications for controlling communicable diseases like tuberculosis are sobering.
With 106 active cases of TB reported in 2009, Nevada’s TB rate (3.9 per 100,000) was nearly identical to the national rate (3.8 per 100,000). TB disproportionately impacts the foreign-born in Nevada (65% of cases, compared to 60% nationwide). Factors that complicated TB management in Nevada in 2009 included diabetes co-morbidity (12% of TB cases); alcohol abuse (11% of TB cases); and age (19% of TB cases were 18 years old or younger). Nevada has not experienced extensive drug resistance; since 2001, the state has seen 18 MDR-TB cases. An outbreak in August 2008 among a group of foreign-born illicit drug users in Las Vegas spawned a massive contact investigation spanning multiple calendar years and uncovering 8 active cases and 542 contacts to date. This year Nevada is facing a similar situation with a different group of drug users in which the contact investigation is just underway and 5 active cases have already been identified.
Susanne Paulson
TB control in Nevada is a team effort that involves the Nevada State Health Division (NSHD), three local health districts (Southern Nevada Health District, Washoe County Health Department, and Carson City Health and Human Services), the public health laboratory, the NSHD Frontier and Rural Public Health Services Program, and the Department of Corrections. Susanne Paulson is the TB Controller for NSHD, and comments on the most pressing challenges faced by her program: “Tuberculosis in America has been dubbed ‘the most overlooked tragedy.’ Because of this oversight, Nevada, like all states, is challenged by TB and the high-risk individuals most commonly affected. In Nevada, this group has expanded to include young children associated with drug users and incarcerated individuals. Nevada also suffers from inadequate capacity to implement treatment compliance strategies with uncooperative patients. The tools Nevada currently possesses to respond to this ‘TB tragedy’ are not sufficient to effectively prevent and control TB, especially with the emergence of more resistant TB strains.”
Laurie Hickstein (left) accepts
“TB Nurse Award” from NTCA Executive Director Carol Pozsik
In spite of this, according to Ms. Paulson, one of the greatest strengths of Nevada’s TB program is the expertise and dedication of staff members like Laurie Hickstein, RN, a public health nurse with the Southern Nevada Health District who was recently honored with the inaugural “TB Nurse Award” at the National TB Controllers Association’s Annual Meeting. Ms. Hickstein has worked for a decade in the health district’s TB treatment and control clinic. “She is an excellent TB educator for our public safety departments, for health care workers, and for patients,” said Dr. Lawrence Sands, Chief Health Officer at the Southern Nevada Health District. “Her experience…provides us with a wealth of knowledge of past TB cases and contact investigations that help us to help our patients more efficiently and effectively.”
To further enhance the capacity of nurses working in TB control in Nevada, in December the Nevada TB Program will collaborate with CNTC to conduct a “Nurse to Nurse” training conference in Reno. As Nevada’s public health challenges continue to evolve, Ms. Paulson looks ahead with optimism and resolve: “The TB challenges facing Nevada are confronted by a dedicated staff whose focus is to assemble the tools required to overcome the existing and emerging obstacles. With our persistent and committed staff, we are confident the challenge of eliminating TB in Nevada will be met with success.”
CDC Releases Updated IGRA Guidelines
In June, the CDC released the much-anticipated update to its 2005 guidelines for using the QuantiFERON-TB Gold test (QFT-G). The new report covers all FDA-approved interferon gamma release assays (IGRAs), including the QuantiFERON-TB Gold In-Tube test (QFT-GIT) and the T-SPOT.TB test (T-Spot).
Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection – United States, 2010 was published in Morbidity and Mortality Weekly Report (MMWR) on June 25, 2010. This report guides public health officials, health-care providers, and laboratory workers in their use of FDA-approved IGRAs in the diagnosis of M. tuberculosis infection in adults and children. In brief, tuberculin skins tests (TSTs) and IGRAs (QFT-G, QFT-GIT, and T-Spot) may be used to help diagnose M. tuberculosis infection, to conduct surveillance, and to identify persons likely to benefit from treatment. Additional recommendations address quality control, test selection, and medical management after testing. For example, the guidelines describe:
- Situations in which an IGRA is preferred but a TST is acceptable;
- Situations in which a TST is preferred but an IGRA is acceptable;
- Situations in which either a TST or an IGRA may be used without preference; and
- Situations in which testing with both an IGRA and a TST may be considered.
The authors stress that although studies of IGRAs to date have not revealed major deficiencies involving various populations, additional research that focuses on the value and limitations of IGRA is needed.
Read the MMWR report.
New NTCA President Cites Accomplishments and Challenges
Now in its 15th year, the National Tuberculosis Controllers Association (NTCA) installed Kim Field, RN, MSN, of Washington State, as NTCA president for 2010-2011 at its annual meeting in June in Atlanta. CNTC Newsletter invited Ms. Field to comment on the organization’s accomplishments, the many challenges facing its members, and the main issues she’d like to focus upon during her term.
Kim Field, RN, MSN
What do you consider to be NTCA’s major accomplishments to date?
“NTCA has exerted tremendous focus and effort over the last decade on advocacy and working with Congressional delegations. As Phil Talboy, Deputy Director of the CDC’s Division of TB Elimination (CDC-DTBE) stated, ‘Thanks to NTCA advocacy work, the U.S. Congress has at least tripled their support for TB elimination and our efforts are making a difference.’ I agree with the sentiments of Phil Griffin, NTCA Past President, when he said, ‘NTCA has continued to take on a more substantial role on the landscape of public health nationally.’
The NTCA Board has engaged with partners such as the National Alliance of State and Territorial Aids Directors (NASTAD), in order to discuss strategy for TB funding for patient care and TB medications. NTCA has also established a closer collaboration with CDC-DTBE staff in the field and in headquarters in Atlanta, successfully partnering to review and update the formula funding applied to the federal cooperative agreement grants.
Another noteworthy accomplishment was the formation in 2008 of the National Society of TB Clinicians (NSTC) under the leadership of Dr. Ron Karpick, TB Controller in Virginia. The focus of this committee is to have a forum for clinicians that deliver care to TB patients.”
What do you consider the most pressing challenges facing TB programs and providers in 2010?
“The decrease in State and local budgets overall has resulted in less funding for public health, which is related to the decrease in filling public health workforce positions.
My colleagues and I are also concerned about the lack of strategic planning for tuberculosis prevention and control in national health care reform, specifically, the Patient Protection & Affordable Care Act (PPACA), passed by Congress and signed into law in March, 2010.
Finally, we need a patient-centered care facility for national care of patients with multidrug-resistant TB (MDR-TB).”
What issues would you like to focus upon during your tenure as NTCA president this year?
“During the June NTCA Board Retreat in Atlanta, we developed an ambitious agenda for 2010-2011. My highest priority is to incorporate optimal TB prevention and control into national health care reform (PPACA).
Additionally, NTCA’s Patient Care Committee will partner with the National Association of City and County Health Officials (NACCHO) to meet with the U.S. Department of Health and Human Services about the need for resources for TB medications, and to identify gaps in patient care and to draft model policy addressing those gaps.
This year, the NTCA Board will further enhance its current focus on TB advocacy and address A Call for Action on the Tuberculosis Elimination Plan by Stop TB USA.
We also want to continue acknowledging the outstanding work of TB professionals nationally by expanding NTCA’s Annual Recognition Awards and developing an electronic nominations process through the NTCA website.”
Amikacin and Kanamycin Shortages Announced
Amikacin, a second-line TB drug, is once again in short supply, and is currently unavailable from either of the two remaining U.S. suppliers, according to the CDC. California TB officials also report a shortage of kanamycin, another second-line TB medication.
In an email message sent July 22, Dr. John Moran of the Division of Tuberculosis Elimination at CDC cited the American Society of Health System Pharmacists website with the news that both suppliers of amikacin are experiencing manufacturing delays; Bedford cannot estimate a release date, and Teva estimates a release date of late July 2010.
“It is not clear how widespread the shortage is, but the DHHS Supply Service Center at Perry Point is out of stock as is Henry Schein, a large medical supply retailer. For most patients, capreomycin can be used in place of amikacin,” Dr. Moran stated.
Immediately following the CDC’s announcement, the TB Control Branch of the California Department of Health Services (CDPH), alerted the state’s TB controllers that there also continues to be a shortage of kanamycin (manufactured by APP Pharmaceuticals).
Dr. Pennan Barry, CDPH, stated in a July 22 email message: “Alternatives to amikacin and kanamycin for tuberculosis patients requiring treatment with an injectable agent include streptomycin (only if the isolate is documented to be susceptible and the patient has had no prior treatment with streptomycin) and capreomycin. According to the manufacturer of capreomycin (Akorn Pharmaceuticals) there are currently sufficient supplies of capreomycin available in inventory.”
The U.S. Food and Drug Administration website can be consulted for continuing updates about drug shortages.
CNTC’s CME Program Wins Highest Reaccreditation Recognition
As a provider of Continuing Medical Education (CME) credits, CNTC must periodically submit its CME program for an exhaustive review from the Accreditation Council for Continuing Medical Education (ACCME) for accreditation renewal. ACCME recently notified CNTC that its decision was Accreditation with Commendation, the highest award given by the organization and one that bestows a six-year term of renewal.
The ACCME award letter to CNTC Director Tom Stuebner stated: “Accreditation with Commendation is awarded to providers that demonstrate compliance in all 22 criteria. The ACCME congratulates you and commends your organization for not only meeting the ACCME’s accreditation requirements, but for demonstrating that yours is a learning organization and a change agent for the physicians you serve. You have demonstrated an engagement with your environment in support of physician learning and change that is a part of a system for quality improvement.”
Mr. Stuebner acknowledged CNTC staff members James Sederberg and Jeannie Fong for managing the arduous reaccreditation submission, and noted: “The final decision by ACCME is a testament to CNTC’s focus on our clinical audience and our dedication to excellence.”
Upcoming Training Courses
CNTC’s schedule of upcoming training courses (through October 2010) offers a variety of courses for clinicians and public health providers.
August 17-20, 2010
San Francisco, CA
Tuberculosis Program Manager's Intensive
Four-day intensive for nurses, physicians and other health professionals working as tuberculosis program managers.
September 21-23, 2010
San Francisco, CA
Tuberculosis Clinical Intensive
Three-day intensive for physicians and other licensed medical professionals who diagnose and treat tuberculosis.
October 12-15, 2010
San Francisco, CA
Tuberculosis Case Management and Contact Investigation
Four-day training for nurses, communicable disease investigators, and medical social workers.
Winter 2010 (date to be announced)
National Web-based Seminar
Alcohol and TB (tentative title)
Details to be announced
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 Gayle M. Schack, RN, BSN, PHN
With 30 years of nursing experience and over two decades working in TB control, Gayle Schack belongs to a special group of public health professionals: the expert TB nurse consultants. Their contributions to the field of TB control too often go unsung, but their experience, talent, and wisdom are indispensable. When the goal of TB elimination is finally reached, TB nurse consultants like Ms. Schack will deserve much of the applause.
Gayle Schack was born and raised in Phoenix, Arizona. She earned her Bachelor of Science in Nursing from Arizona State University, and spent the early years of her career in Southern California. Ms. Schack worked as a public health nurse in Los Angeles County and Orange County, and as a school nurse in Santa Ana. Looking back on these frontline nursing experiences, she comments: “Working as a public health nurse in the field, with various cultures and in a TB clinic, gave me an amazing base and understanding of the work involved in caring for patients, their families, and the community. These early experiences were extremely beneficial in my work as a nurse consultant in TB control.”
In 1994, Ms. Schack moved to Colorado, where she worked as a TB Control Nurse for the Boulder County Health Department for several years before moving up to the state level as Nurse Consultant for the Colorado Department of Public Health and Environment. During her decade with the State of Colorado, Ms. Schack sharpened her expertise in all aspects of consultation, technical assistance, case management, policymaking, and training. She recalls this period fondly: “I am very proud of my participation with the Four Corners TB/HIV annual conference planning committee, my visits to Capitol Hill to speak with legislators about TB, and the guidelines and policies I wrote as the Nurse Consultant for Colorado. The interactions I had with nurses and physicians were especially meaningful to me, and I am honored to have many friends across the state as a result of these consultations.”
Ms. Schack’s affiliation with CNTC began in 2004 when she became a consultant for the Center, sharing her special talents in TB nursing consultation, training, and education with CNTC constituents throughout the Western United States. With her CNTC colleague Ann Raftery, Ms. Schack was a key developer of the Center’s heralded “Nurse to Nurse” program, which has provided direct and customized TB training to nurses working in the field in jurisdictions such as Wyoming, Hawaii, Oregon, and California. “One of my favorite activities is providing education to nurses regarding TB. Helping nurses to improve their understanding of all case management activities contributes to better patient care and outcomes,” she remarks.
The scope of Ms. Schack’s work has not limited been to the United States. In 2005 she participated in a TB project evaluation in Bangladesh, and in 2007 served as lead facilitator in a pilot training program for nurses in Botswana. These experiences left a lasting impression upon her: “I developed such a huge respect for the nurses and physicians I met in these countries. I will never forget the physician in Botswana who asked me how many TB patients we treat in Colorado. When I answered that it was about 100 per year, he gave me a perplexed look and said that in his country, one clinic will see that many patients in one morning. It is an amazing person who provides care to an overwhelming number of patients on a daily basis with few supplies and few co-workers and does it with the commitment and determination that I witnessed in these developing countries.”
In 2008 Ms. Schack joined the staff of the California Department of Public Health, TB Control Branch, as a Nurse Consultant and Program Liaison. Always seeking new knowledge, she has simultaneously returned to graduate school to pursue a Masters of Nursing degree in Advanced Community and International Nursing at University of California, San Francisco.
Among Ms. Schack’s many professional admirers is Tammy Hort, RN, Communicable Disease Coordinator for the Northeast Colorado Health Department, who shared this praise of her colleague: “I deeply appreciate the expertise Gayle has provided the medical providers in rural northeast Colorado. One great piece of advice she gave me long ago was to always include the patient in the treatment process. Having the patient as my ‘partner’ has significantly increased our DOT completion rates and improved LTBI completion rates as well.”
Back Issues of CNTC Newsletter Now Archived Online
Previous issues of CNTC Newsletter (reaching back to Summer 2006) are now available on the CNTC website. Visit the archives.
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 Investigator: Elizabeth Fair, PhD
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
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