CNTC Newsletter Archive — Spring 2010
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.
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 Colorado Tuberculosis Program.
The Rocky Mountain state of Colorado can boast many distinctions: the highest mean altitude of all 50 states; the world’s biggest annual rodeo; the lowest incidence of obesity in the U.S.; more microbreweries per capita than any other state; and spectacular mountain scenery that inspired Katherine Lee Bates to write “America the Beautiful.” In the last decade, Colorado has been a magnet to newcomers; its population of nearly 5 million has grown 14% since 2000. Colorado’s capital city, Denver, is situated exactly 1 mile above sea level, and more than two-thirds of the state's residents live in the metro Denver area. Colorado's economy is now driven less by its traditional mining and agricultural industries than by the service sector, including medical providers, other business and professional services, and government agencies. Colorado’s population is approximately70% non-Latino white and 20% Latino.
In 2008, Colorado reported 103 cases of TB (down from 111 in 2007); the incidence of 2.1 per 100,000 was exactly half the U.S. rate of 4.2. Only 19 of the state’s 64 counties reported any TB cases in 2008; over two-thirds of the cases (74) occurred in the metro Denver area. TB in Colorado mirrors the national profile in that it affects people of color and foreign-born residents disproportionately. In 2008, 71% of Colorado’s TB cases were foreign born, with 30% of these patients coming from Mexico. Overall, TB cases that year were 34% Latino, 29% Asian, and 19% Black. Colorado’s rates of directly observed therapy (DOT) and treatment completion are impressively high (DOT is mandated by state law) and may help explain why the incidences of pediatric TB and drug-resistant TB in the state are so low.
The Colorado TB Program dwells within the state’s Department of Public Health and Environment. Mary Goggin, R.N., M.P.H., has been the state’s TB Program Manager since 2007, bringing to the position frontline TB nursing experience with the Denver TB Program. She has forged a strong working relationship between the State and the local Denver program, headed by Randall Reves, M.D., M.Sc. Another “backyard” resource for TB expertise is the venerable National Jewish Health. Colorado is an active participant in the Northern Rocky Mountain TB Controllers, a regional group that will next meet in the serene forest setting of Keystone, Colorado, August 26-27.
When asked about the special challenges faced by TB programs and providers in her state, Ms. Goggin remarks, “The distribution of TB cases in Colorado disproportionately affects Denver County, where roughly 12% of the state’s total population lives, and 23% of the TB cases in 2008 occurred. The 5-year average incidence of TB in Denver County is 7.5 cases per 100,000, while in rural areas of Colorado, average TB incidence is 5 times lower, at 1.5 cases per 100,000. Lower case rates in rural communities across Colorado lead to significant challenges in maintaining the necessary expertise among private providers and public health staff to accurately diagnosis and treat TB.”
Ms. Goggin goes on to proudly identify the special elements that enable her program to thrive: “The success of the Colorado TB program lies not only in the ability to forge strong relationships with our local partners, but also in the expertise of two key TB program staff, Juli Bettridge and Kerri McClory, who collectively bring 16 years of strong TB prevention and control experience to the program.”
Steep Decrease in 2009 U.S. TB Cases Spurs Increase in Speculation
In March the CDC reported that “the 2009 U.S. tuberculosis case rate showed the greatest single-year decrease ever recorded and the lowest recorded rate since national TB surveillance began in 1953.” The announcement sparked widespread discussion about the factors that might have contributed to the dramatic – and surprising – decline.
Published in the March 19, 2010 edition of Morbidity and Mortality Weekly Report (MMWR, 59(10);289-294) the report noted that TB case counts and rates decreased substantially among both foreign-born and U.S.-born persons, although foreign-born persons and racial/ethnic minorities continued to have TB disease disproportionate to their respective populations. The editorial note accompanying the report states: “The 11.4% decrease in the reported TB rate in 2009 is the largest single-year decrease ever recorded. From 1953 to 1993, the single largest annual percentage decrease in TB case rate was 11.1% in 1956. During 1993-2000, TB case rates decreased an average of 7.8% each year (range: 4.8%-8.5%), and for 2000-2008, the rate decreased an average of 3.8% annually (range: 2.3%-6.7%). The decrease for 2009 is unusual and unexpectedly large. CDC and the National Tuberculosis Controllers Association (NTCA) are investigating whether the decrease represents a reduction in disease rate resulting from improved TB control or population demographic shifts, or might be the result of underdiagnosis or underreporting of disease.”
NTCA surveyed its members in March about possible factors related to the sharp decrease and found that many TB Controllers point to:
- Changes in immigration, particularly refugee home countries and immigration from Mexico
- The economic recession – immigrants from Mexico not coming and leaving, varied people not seeking care, reduced resources at health departments due to layoffs and furloughs
- New technical instructions implemented overseas
- H1N1 impact, resources diverted, TB overlooked
- Pneumonia diagnosis, delaying TB diagnosis
As analysis of the 2009 data continues, CDC stresses five important points:
- The dramatic drop in reported TB cases marks continuing progress in reducing TB disease, but the data are preliminary and warrant further review after updating.
- One year does not make a trend; it remains to be seen if the decline in reported cases will be sustained over time.
- Many factors, ranging from better TB control measures to possible under-reporting, are being reviewed to determine what may have caused such a significant change in cases reported.
- CDC recognizes more can be done to prevent TB and is taking steps to address TB in the U.S., as well as working to strengthen global partnerships.
- Regardless of the reasons for the decrease, vigilance is required to maintain adequate TB infrastructure, to protect those who are disproportionately affected by TB, and to guard against the resurgence of TB, including the development of drug-resistant TB.
Read the entire MMWR article and related editorial note.
CNTC’s Drug-Resistant TB Survival Guide Now Translated into Chinese
Drug-Resistant Tuberculosis: A Survival Guide for Clinicians (2nd edition) has recently been translated into a Chinese-language version by the World Health Organization’s Western Pacific Regional Office (WHO/WPRO) and the China CDC/Clinical TB Center.
The Survival Guide was translated by Dr. LiLiang and his colleagues at the Clinical Center for TB Prevention and Control in Beijing. A first printing of 3,000 copies was produced and distributed to all 31 provincial level TB dispensaries and hospitals in China.
Download the Chinese-language version of the Survival Guide.
The original English version of the 2nd edition was published by CNTC in 2008. A Spanish-language version (Tuberculosis fármacorresistente: una guía práctica para la atención médica del paciente) was released by the Southeastern National Tuberculosis Center (SNTC) in December, 2009 (to download a copy, visit the SNTC website)
CNTC’s online presentations provide valuable learning opportunities for TB programs and providers, and now include a fully updated version of Targeted Testing and Treatment of Latent Tuberculosis Infection (LTBI).
Targeted Testing and Treatment of LTBI, written and presented by Masae Kawamura, M.D., was originally developed in 2006 and has now been re-released in a fully updated version. This 60-minute presentation covers the rationale for TB screening, the meaning of targeted testing, risk factors for TB, priority candidates for testing, and current tools for detection. Dr. Kawamura compares the tuberculin skin test with the exciting new (more specific) interferon gamma release assays, and concludes with a discussion of current treatment guidelines for LTBI and techniques for counseling and motivating a patient who is about to begin LTBI treatment. A question and answer guide, a printable PowerPoint slide file, and other useful resources are also included as supplemental materials.
See all five of CNTC’s self-study online presentations.
Upcoming Training Courses
CNTC’s schedule of upcoming training courses courses (through October 2010) offers a variety of courses for clinicians and public health providers.
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)
Half-day, case-based seminar 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
Two-hour web-based seminar for U.S.-based clinicians and others who provide services to foreign-born patients at risk for TB.
June 2-3, 2010
Two-day intensive for physicians and other licensed medical professionals who diagnose and treat tuberculosis.
June 4, 2010
Nurse Case Management Workshop
One-day update for nurses, communicable disease investigators, and other licensed medical care providers who work with tuberculosis patients.
June 11-12, 2010
Addressing the Intersection of Multiple Health Concerns for Migrant Populations: Family Planning, STDs, HIV, Tuberculosis & Substance Abuse
Two-day conference for providers who want to explore how family planning, HIV, STDs, tuberculosis, and substance abuse intersect and affect health outcomes of migrant communities in the Central Valley of California.
June 25-26, 2010
Treatment of TB, STDs, HIV, Hepatitis C and Substance Abuse on the Border: Keeping Border Patients in Care … with Limited Resources
Presented by Pacific AIDS Education and Training Center in association with Francis J. Curry National Tuberculosis Center, the California STD/HIV Prevention Training Center, the Pacific Southwest Addiction Technology Transfer Center, and the US/Mexico Border Health Commission, and Yuma Regional Medical Center.
July 9-10, 2010
Addressing the Intersection of Multiple Health Concerns for Migrant Populations: Family Planning, STDs, HIV, Tuberculosis & Substance Abuse
Two-day conference for providers who want to explore how Family Planning, HIV, STDs, Tuberculosis, and Substance Abuse intersect and affect health outcomes of migrant communities in Eastern Washington.
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.
For periodic updates on additional trainings, complete course descriptions, and application forms, view our training section.
A Call for Action on the Tuberculosis Elimination Plan
In response to stalled progress in the national fight against TB from 2000-2008, A Call for Action on the Tuberculosis Elimination Plan was recently released, laying a foundation for making specific action plans to implement recommendations made by the Institute of Medicine (IOM) in its 2000 landmark report, Ending Neglect: The Elimination of Tuberculosis in the United States.
A Call for Action was prepared by the TB Elimination Plan Writing Committee, organized by Stop TB USA in response to the overall slowing rate of decline in TB cases, a slowdown that jeopardizes the IOM’s goal to eliminate TB in the United States by 2035.
Chaired by Randall Reves, M.D., M.Sc., Medical Director of the Denver Metro TB Control Program, the Committee found that factors such as funding reductions, skilled workforce shortages, the global burden of TB, and the need for new vaccines, diagnostics, and anti-TB drugs had delayed progress toward several important goals in the IOM’s plan. The potential consequences are sobering: if trends from 2000-2008 continue, it’s estimated to take 97 years to eliminate TB in the United States.
If rates of decline accelerate, the elimination of TB in the U.S. by 2035 would result in
- 253,000 fewer tuberculosis cases
- 15,200 fewer tuberculosis-related deaths
- $1.3 billion less in treatment costs in 2006 dollars
Dr. Reves presented A Call for Action at a hearing organized by the American Thoracic Society on Capitol Hill on World TB Day in March. A PDF download of the report is available from the Stop TB USA website. To help individuals promote the plan, the CDC has created an electronic greeting card (e-card) that links directly to the report.
Writing Committee members from the Western Region included Alex Bowler, Jennifer Kanouse, Masae Kawamura, Charles Nolan, and Randall Reves. Consultants from the Western Region included Charles Daley, Kathleen Moser, Lisa Pascopella, Silvino Simsiman, Stephanie Spencer, and Thomas Weiser.
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 David R. Park, M.D.
David R. Park, M.D., is a TB physician, educator, and researcher at the University of Washington (UW) and Harborview Medical Center in Seattle. He is one of several CNTC-affiliated faculty based in Washington State (including Charles Nolan, Masa Narita, Kim Field, and Christopher Spitters) and has been a significant contributor to the region’s national reputation for TB expertise.
Dr. Park was born in Rochester, New York and raised on a farm in Williston, Vermont. As an undergraduate he studied chemistry at Williams College in Williamstown, Massachusetts, and later earned his medical degree at the University of Vermont’s College of Medicine in Burlington.
In 1988, Dr. Park ventured far west to Seattle to pursue his postgraduate studies at UW, which has been his professional base ever since. He was named Chief Medical Resident at Harborview Medical Center, and then served as Fellow with the Pulmonary and Critical Care Medicine Division at UW. Dr. Park credits Charlie Nolan, Dave Pierson, and Len Hudson as important mentors in his early career: “Dave’s list of key mentors is no surprise,” comments Lisa Chen, M.D., CNTC’s RTMCC Medical Director. “These are figures within the worlds of tuberculosis and pulmonary medicine well-respected not only for their specialty expertise, but also highly-respected as leaders in the art of medical education. Dave has clearly followed in their footsteps.”
Dr. Park’s current positions include Associate Professor of Medicine at UW, Attending Physician at Harborview Medical Center, and head of TB control at Harborview. He also chairs the Washington State TB Advisory Council. His deep commitment to clinical training and medical education is demonstrated by an exhaustive list of activities as preceptor, lecturer, tutor, and mentor. The beneficiaries of his attention and expertise range from UW medical students to Seattle paramedics and rural Washington physicians. Findings from Dr. Park’s research in lung infection and lung host defenses have been presented in numerous publications, including the Journal of Immunology, the Journal of Infectious Diseases, the American Journal of Respiratory and Critical Care Medicine, and Respiratory Care.
With CNTC, Dr. Park co-directs and teaches TB clinical intensive courses in Washington State, lectures at CNTC classroom and web-based courses in San Francisco, and provides expert TB medical consultation on the Center’s Warmline.
At this “mid-career” juncture, Dr. Park foresees expanding the geographic scope of his work, saying, "I look forward to becoming more involved with global TB control training activities.”
Masa Narita, M.D., who directs the TB Control Program in Seattle and King County, expresses high regard for his close colleague, David Park: “Not only has Dave earned a reputation as a superb clinician at University of Washington, he is also dedicated to educate and train many medical students, residents, fellows, faculty, and other healthcare professionals. His commitment to excellence has inspired me many times. In addition, he is a strong advocate for TB control locally, and I truly appreciate his efforts in our community.”
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