CNTC Newsletter – Winter 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 focus on the Alaska TB Control Program.

Alaska, the 49th state, is also known as “America's Last Frontier” and the nickname is apt. Alaska is not only the largest U.S. state by area (over twice the size of Texas), it is also the least densely populated (1.1 person per square mile.) During the 1700s, Russian whalers and fur traders were the first non-natives to settle in Alaska. In 1867 the United States paid Russia two cents per acre to purchase the massive Alaska land parcel (365 million acres), one-third of which lies within the Arctic Circle. Alaska contains no fewer than 3,000,000 lakes, 100,000 glaciers, and 3,000 rivers. The state's largest city is Anchorage, home to nearly half of the state’s population; the capital city, Juneau, is the only U.S. capital accessible only by boat or plane. The oil and gas industry dominates the Alaskan economy, as evidenced by the 800-mile Trans-Alaska Pipeline running from Prudhoe Bay to Valdez. Alaska’s population of approximately 680,000 is nearly 70% white, and the largest minority group (16%) is comprised of Alaska Natives and American Indians.

With 50 TB cases recorded in 2008, Alaska’s TB case numbers may seem low, but given its sparse population, the state’s TB rates rank among the nation’s highest. In both 2007 and 2008, the incidence of TB in Alaska was 7.4 per 100,000 (compared to a U.S. incidence in 2008 of 4.2 per 100,000). From 1998-2007, pediatric (age 0-14) TB rates in Alaska (13%) were twice the national average (6%). In a recent interview with the Anchorage Daily News, Alaska TB Control Officer Elizabeth (Beth) Funk, MD, MPH, pointed out that Alaska Native elders, widely infected with TB as children in the 1940s and 1950s, suffer disproportionately from TB today. During the last decade, 65% of Alaska’s 601 TB cases occurred in Alaska Natives. Overall during the same time period, TB in Alaska has followed a downward trend.

Dr. Funk is now entering her 15th year with the Alaska Division of Public Health. Board certified in internal medicine and infectious diseases, she worked in private practice, in academic medicine, and as a hospital epidemiologist in Charleston, West Virginia. Although she had cared for several TB patients and had lectured medical students about the disease, Dr. Funk believes her “real understanding” of TB developed after she moved to Alaska in 1995: “I was amazed to see tuberculosis patients diagnosed and treated in remote communities without x-ray equipment or running water, accessible only by small aircraft when the weather cooperated. Systems set in place over 50 years ago are still being used effectively today.”

During her tenure as TB Control Officer, Dr. Funk has steered her program through many challenges, including a 2006 outbreak among the homeless in Anchorage, and two village outbreaks (2003 and 2008) in the vast Yukon-Kuskokwim Delta area. Even day-to-day TB control tasks in Alaska can involve herculean efforts. Picture public health nurses delivering TB medications in minus 30-degree weather, traveling to tiny villages, miles from the nearest paved roads, where the patients might speak one of over twenty Native Alaskan languages.

Dr. Funk praises the diverse health care providers and organizations in her state that effectively diagnose and treat Alaskans with TB. “There are no counties in Alaska, and only Anchorage has a tuberculosis clinic. The Alaska Division of Public Health serves as both a state and local health department for the rest of the state. Alaska Native Health Care Corporations (which have replaced the federal Indian Health System in Alaska), state public health nurses at regional public health centers, and private providers are all partners in the care of TB patients.”

Looking ahead, Dr. Funk reflects on the future of TB control and public health in Alaska: “We are making gradual progress. Our strategies are working, but it is slow going. Given the unique challenges Alaska presents to the control of TB, it will be another generation or more before rates of TB equal those of the U.S. We are grateful to all of the public health nurses throughout the state who have been the eyes and ears of the TB Program. We could not do this work without them.”

International Standards for TB Care (ISTC) 2nd Edition (2009)

The International Standards for Tuberculosis Care (ISTC) 2nd Edition (2009) and the accompanying ISTC TB Training Modules debuted at the 40th Union World Conference on Lung Health in Cancun, Mexico, in December 2009.

The purpose of the ISTC is to describe a widely accepted level of care that all practitioners, public and private, should seek to achieve in managing patients who have, or are suspected as having, tuberculosis. The ISTC is intended to facilitate the effective engagement of all care providers in delivering high quality care for patients of all ages, including those with sputum smear-positive, sputum smear-negative and extra-pulmonary TB, TB caused by drug-resistant Mycobacterium tuberculosis complex organisms, and TB combined with HIV infection and other co-morbidities.

The first edition of the ISTC was launched in 2006. Because of changes in epidemiology and available technology, the ISTC was revised for this second edition. Both editions of the ISTC were developed by the Tuberculosis Coalition for Technical Assistance (TBCTA) with funding from the United States Agency for International Development (USAID). Production of the ISTC materials was coordinated by the American Thoracic Society (ATS) with assistance from CNTC. The ISTC 2nd Edition contains key changes in all major areas of the document. In part, these changes were made to be consistent with revisions of WHO recommendations and new guidelines. The accompanying ISTC TB Training Modules include thirteen teaching slide sets covering a full range of TB topics that have been updated and expanded to complement the ISTC 2nd Edition.

View all ISTC materials.

Learning How to Better Serve the Western Region

CNTC thanks all the state and big city TB program representatives who participated in CDC’s evaluation of the RTMCCs between November 2009 and February 2010, and looks forward to their participation in CNTC’s upcoming regional needs assessment.

This assessment activity, which CNTC conducts every five years, helps guide the Center’s work and ensures that the products, courses, medical consultation, and technical assistance offered continue to be as helpful as possible to the programs and providers within the Western Region. All four RTMCCs will utilize the same assessment tool, for analyses at both regional and national levels. The survey will begin in February/March 2010.

CNTC Products

CNTC’s online presentations provide valuable learning opportunities for TB programs and providers, and now include a new offering, Practical Solutions for TB Infection Control: Infectiousness and Isolation, and a fully updated version of Medical Management of Tuberculosis.

Practical Solutions for TB Infection Control: Infectiousness and Isolation is a new 60-minute online course that provides healthcare workers with information on how to determine if TB patients are infectious and demonstrates practical ways to prevent TB transmission in the clinic, in transit, and in the patient's home. Presenters Heidi Behm, RN, MPH, Acting TB Controller for the State of Oregon, and Janet Abernathy, RN, BSN, Assistant Director of Quality at the San Ramon Regional Medical Center in California, based the course content on the TB community’s input from a national survey last spring.

Medical Management of Tuberculosis, presented by Karen Smith, MD, MPH, was originally developed in 2006 and has now been re-released in an updated version. This 30-minute presentation covers the basic principles for the medical management of TB cases, the role that each of the four first-line drugs plays, adverse reactions, and ways to monitor TB patients. Dr. Smith is Public Health Officer for Napa County, California.

See all five of CNTC’s self-study online presentations.

Upcoming Training Courses

CNTC’s schedule of upcoming training courses courses (through June 2010) offers a variety of courses for clinicians and public health providers.

February 23-25, 2010
San Francisco, CA
TB Clinical Intensive
Three-day intensive for physicians and other licensed medical professionals who diagnose and treat tuberculosis.

March 16-19, 2010
San Francisco, CA
Case Management/Contact Investigation Intensive
Four-day training for nurses, communicable disease investigators, and medical social workers.

May 5-6, 2010
Long Beach, CA
CTCA Educational Conference – TB in Your Practice: Focus on Co-Morbidities
This year’s conference will focus on TB co-morbidities and the importance of working effectively with private medical care providers to manage TB in the context of other risk factors and diseases.

May 7, 2010
Long Beach, CA
CNTC’s Challenges in Pediatric Tuberculosis (in association with CTCA Educational Conference)
This half-day, case-based seminar is for physicians and other licensed medical professionals who diagnose and treat and/or manage pediatric tuberculosis disease or infection.

May 12, 2010
National Web-based Seminar
Global TB: What U.S. Providers Need to Know
1.5-hour web-based seminar for physicians, nurses, and allied health professionals who work with foreign-born patients with TB or LTBI.

June 2-3
Seattle, WA
Clinical Intensive
This two-day intensive is for physicians and other licensed medical professionals who diagnose and treat tuberculosis.

June 4
Seattle, WA
Nurse Case Management Workshop
This one-day course is for nurses who work with and/or manage patients with TB disease or LTBI.

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 Renee Simmons-Wilkins.

Are you a patient reluctant to reveal details about your intimate contacts? Are you a public health nurse struggling to locate certain patients? Are you a TB controller confronted with a massive and complicated contact investigation? If so, look no further than Renee Simmons-Wilkins. With over 20 years of service to the State of California, she is a public health professional who combines her invaluable experience working on the frontlines of TB control with a rare gift for training, guiding, and motivating others.

Born and raised in Stockton, California, Ms. Simmons-Wilkins recalls that her original career ambitions leaned toward education or nursing. Upon graduating from high school, she was dismayed to encounter a job market flooded with teachers and nurses. Ever the pragmatist, she pursued business administration at San Jose State University, but the appeal of healthcare lured her to part-time work at Planned Parenthood in San Jose, where she became experienced in all aspects of front and back office work. After college Ms. Simmons-Wilkins returned home to San Joaquin County, where she worked in a private practice medical group, and then joined the staff of the San Joaquin County Health Department. In 1988 her position with the County fell under the auspices of the California Department of Health Services, now called the California Department of Public Health (CDPH).

Ms. Simmons-Wilkins played a lead role in the innovative Community Health Outreach Project, which provided field-based communicable disease testing, treatment, and contact follow-up services to high-risk patients. She counseled teens in juvenile detention wards, educated women in jails, and trained sex workers in public parks how to teach other sex workers to reduce their risk of syphilis. Eight years “in the trenches” of sexually transmitted disease services solidified her expertise in establishing patient rapport, trust, and cooperation.

In 1994 Ms. Simmons-Wilkins assumed her current role as Consulting Communicable Disease Representative for the CDPH TB Control Branch, providing programmatic oversight and technical assistance to TB control programs, consulting with medical and field investigative staff, conducting TB trainings, and assisting with outbreak investigations. She recalls that the transition from STDs to TB required her to adjust (and soften) her encounters with patients, given that STD interviews are often one-time opportunities, and visits with TB patients can extend over several months of treatment, allowing her more patience to “tease out the truth.”

For the past decade, Ms. Simmons-Wilkins has enlightened, engaged, and delighted participants at CNTC’s Contact Investigation and Case Management courses with her sessions on “Interviewing Skills.” Even a cursory review of the remarks in her participant evaluations reveals an abundance of exclamation points:

• “Renee was fantastic! The tools she provided are priceless to my work. I absolutely loved it!”
• “Awesome!”
• “You can tell Renee likes her job and that she has been in the trenches. She kept us awake!”
• “Wish she was on my team!”
• “Exciting, fun, breath of fresh air!”
• “Renee’s STD background is clearly an important foundation to get to those contacts.”
• “Thank you for being so authentic!”
• “Engaging and motivational speaker who explains real-life situations. Loved her examples, and enjoyed this presentation immensely!”

Rocio Agraz-Lara, RN, PHN, MSN, who worked with Ms. Simmons-Wilkins at CDPH and is now a public health nurse with San Joaquin County Public Health Services, offers these words of praise and admiration for her colleague: "Renee is the ‘Public Health MacGyver.’ She is intelligent, optimistic, laid-back, resourceful, quick-witted, and an innovator. Renee – armed with pen, paper, and a single interview – is able to locate TB patients who were deemed intractable."

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