CITC Newsletter Fall 2018

An electronic newsletter from the Curry International Tuberculosis Center (CITC)

 

Continuity of care at the U.S.-Mexico border: HIV providers learn from TB colleagues

Nogales, AZ on the map

In October, a unique meeting assembled a bi-national group of HIV and TB providers in Nogales, Arizona, to develop a pilot program for linking and enhancing continuity of HIV care in the border region between Arizona and the Mexican State of Sonora.  Representatives from the Arizona Department of Health Services (ADHS), the Ministry of Health of Sonora TB programs, U.S. Immigration and Customs Enforcement (ICE), and the ADHS Office of Border Health Office shared “lessons learned” from their successful collaboration to promote continuity of care for TB patients deported from the U.S. to Mexico.

us border crossing in nogales, arizona

U.S. border crossing in Nogales, Arizona
Credit: John Moore / Getty Images

The TB care community has well-established protocols in place (via TBNet and CureTB) for referring and tracking patients who cross between the U.S. and Mexico and other Central American countries.  In addition, state and local TB officials in Arizona work closely with their Sonoran counterparts, ICE Health Service Corps, and the ADHS Office of Border Health to facilitate a process in which any patient with TB who is being deported will be connected directly with a public health representative from the Ministry of Health of Sonora waiting on the other side. Arizona HIV providers see this highly successful “meet and greet” approach as a promising model for HIV patients who are deported from Arizona to Sonora.

Arizona TB Control Program Manager Kristen Herrick, MPH (l) moderates a bi-national panel  discussing continuity of care.
A bi-national panel discusses continuity of care.
(l to r) Kristen Herrick, MPH - ADHS; Griselda Razo - Pinal County Public Health;
Jehan Bonizú Alvarez Meza, MD – Secretaria de Salud de Sonora; Robert Guerrero, MBA – ADHS Office of Border Health

On Day 1 of the event, participants conducted a cross-border tour of HIV medical facilities in Nogales, Sonora, including a visit to the local CAPASITS (HIV/STI ambulatory clinic). On Day 2, the “Enhancing Continuity of HIV Care in Arizona and Sonora” summit featured bilingual presentations and discussions aimed at developing recommendations for a pilot program to facilitate the continuity of high-quality HIV care between Arizona and Sonora. The meeting was organized by the Arizona AIDS Education and Training Center with funding support from Ryan White Part B, the ADHS Office of Border Health, and the ADHS Office of HIV Prevention. 

 

New guide helps nurses manage side effects to drug-resistant TB treatment

CITC and the International Council of Nurses (ICN) recently released their collaborative project, Nursing Guide for Managing Side Effects to Drug-resistant TB Treatment.

CITC Nursing Guide for Managing Side Effects to Drug-resistant TB Treatment cover

The 89-page, user-friendly guide was developed by nurses with experience in the clinical care and programmatic management of tuberculosis (TB) and drug-resistant tuberculosis (DR-TB) in both high- and low-resource settings.

Patients on treatment for DR-TB face many challenges, most notably difficult side effects such as nausea, hearing loss, and fatigue. These side effects impact the patient’s quality of life, capacity to work, and ability to continue activities of daily living. Medication side effects have been cited as a major factor linked to patients stopping treatment. The 2018 WHO Global TB Report noted with alarm that only 55% of patients with DR-TB successfully complete treatment.

Nursing Guide for Managing Side Effects to Drug-resistant TB Treatment back cover

According to CITC Associate Medical Director Ann Raftery, RN, PHN, MS: “Nurses commonly see DR-TB patients daily for treatment delivery and monitoring. They are often the first to hear of a patient’s side effects during treatment. With this guide as a resource, nurses are empowered to help their patients.” 

The guide is designed as a reference and job aid, so nurses can quickly:

  1. Identify symptoms that may indicate a side effect related to DR-TB treatment or antiretroviral medication
  2. Assess for severity and other potential contributors
  3. Intervene appropriately to minimize patient discomfort, reduce side effect progression, and ultimately support successful treatment completion

 Chinese, Bahasa Indonesia and Spanish editions of the guide are in development.

Download the guide

 

WHO Rapid Communication previews new DR-TB recommendations

World Health Organization (WHO) logo

In August 2018 the World Health Organization (WHO) released a Rapid Communication to inform the TB community about key changes expected in WHO recommendations for treatment of multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB).  Changes to WHO guidelines, based on fresh results from trials and other studies on the effectiveness and safety of treatment regimens for MDR/RR-TB, are being finalized by an independent Guideline Development Group convened by WHO. The detailed changes to WHO policy guidelines will be released in December 2018; in the meantime, WHO released the Rapid Communication to alert national TB programs and other stakeholders to key changes that will have major implications on future MDR-TB treatment.  

According to an FAQ sheet prepared by WHO’s Global TB Programme, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Global Drug Facility of the Stop TB Partnership, the most important changes are:

  • An all-oral regimen of 18-20 months’ duration is the preferred option for most patients and the injectable agents kanamycin and capreomycin are no longer recommended for use in treatment.
  • Based on the latest evidence, the priority ranking of medicines to design a longer regimen has changed substantially, with bedaquiline, linezolid and clofazimine rising in importance, and ethionamide and prothionamide and the injectable agents - amikacin and streptomycin - becoming less important. Inclusion of drugs is decided upon a balance of benefits to harms and guided by drug-susceptibility testing (DST).
  • The 9-month shorter MDR-TB regimen recommended by WHO since 2016 may still be used but its role is now impacted by additional requirements for DST and close monitoring of patients’ response to treatment. Kanamycin is systematically replaced by amikacin in the shorter MDR-TB regimen.
  • More emphasis is placed upon DST, active TB drug safety monitoring and management (aDSM), monitoring for treatment response, operational research and continued data collection and sharing, and support to all patients to complete therapy.

 Read the Rapid Communication.

 

CDC’s 2017 TB surveillance data now available

The CDC has released its full report of 2017 TB surveillance data: Reported Tuberculosis in the United States, 2017.

CDC Reported Tuberculosis in the United States, 2017

Key findings include:

  • There were 9,105 TB cases reported in the United States in 2017, which represents a 1.6% decrease from 2016.
  • The overall annual TB incidence decreased to 2.8 cases per 100,000.
  • People born outside of the United States continue to bear the burden of TB, largely because of reactivation of latent TB infection that occurred in their country of origin.
  • About 13% of U.S. TB cases with genotype data are attributed to recent transmission.

 

UN General Assembly High-Level Meeting on TB: High hopes and mixed results

On September 26, 2018, the United Nations General Assembly held the first-ever high-level meeting on the fight against tuberculosis, under the theme “United to end tuberculosis: an urgent global response to a global epidemic.”

UN General Assembly High-Level Meeting on TB

Meeting organizers noted that the event was only the fifth time a health condition was the focus of a U.N. high-level meeting (the other four were HIV/AIDS, noncommunicable disease, antimicrobial resistance, and Ebola). In the run-up to the meeting, TB advocates held high hopes that world leaders would demonstrate a strong political will to accelerate efforts to end TB; the meeting was heralded as a rare opportunity to increase awareness and obtain firm commitments to enact policies and raise funding. As the meeting unfolded, two factors dimmed initial expectations: the low turnout of government leaders; and among the officials who did attend, few offered specific promises to fund and enact the political declaration.  

Key participants offered mixed reviews:

National TB Controllers Association (NTCA): 

“The majority of countries did not make bold claims on how they would operationalize the declaration.  While falling short of what the TB advocacy community had initially envisioned, [the declaration] is the first ever agreed upon statement about the enormity of the TB burden and outlines concrete steps to end TB which have been endorsed by all member nations! The meeting is a huge step forward, but much remains to be done as we work to end TB!” 

[9-27-18 NTCA email report]

WHO Director General Tedros Adhanom Ghebreyesus

Tedros Adhanom Ghebreyesus

Credit: http://www.who.int/dg/en/

WHO Director General Tedros Adhanom Ghebreyesus, PhD:

"We need 3 things to #EndTB:
1. Political commitment from the highest levels & action to back it up;
2. Increased investments, especially in R&D for new medicines, vaccines & diagnostics;
3. To hold each other accountable for the promises we are making today" [9-26-18 on Twitter]

Sharonann Lynch, on behalf of Doctors Without Borders/Médecins Sans Frontières’ (MSF) Access Campaign:

“The good news is this historic meeting happened at a time when the world is equipped with new, more effective medicines and diagnostics to fight TB and has a real shot at radically improving treatment and the lives of people affected by this global health emergency. The bad news is that global leaders failed, once again, to make people with TB a priority, further stalling progress in this fight. Out of the 193 UN member states, fewer than 30 leaders chose to attend the meeting today. Leaders missing from this critical meeting include many from high-burden TB countries and donors that have been promising to help fund the fight to ‘end TB.’ But just because…leaders have stepped off the world stage doesn’t mean they can return to business as usual. They have to take advantage of this momentum and truly commit to significantly increasing investments and mobilizing the research community…”  

[9-26-18 statement]

Hank Tomlinson, PhD, Director of the Division of Global HIV & TB, CDC:

“Is where we are right now where we want to be? Not exactly. Is where we are at historic? Yes.” [Dr. Tomlinson quoted in the Huffington Post, 9-27-18]

Treatment Action Group (TAG):

“Despite pressure, and securing several concrete pledges on expanding service delivery, the declaration falls short in its response to the leading infectious killer worldwide and the leading cause of death for people with HIV around the world.”  [On 9-26-18 TAG and other global organizations with the Health Gap Global Access Project issued a release with 12 specific steps detailing “What is missing from the UN political declaration on tuberculosis”.]

Eric Goosby, MD, U.N. Special Envoy for Tuberculosis and UCSF Professor:

, U.N. Special Envoy for Tuberculosis and UCSF Professor

Eric Goosby, MD

“TB is a disease we can prevent, we can treat, and we can cure. Now we must all be held accountable. There’s a light at the end of the tunnel ― but it is a long tunnel.”

[Dr. Goosby quoted in the Huffington Post, 9-27-18]

 

 

 

 

TB Free California website launched

TB Free California logo

The TB Free California initiative, a partnership among the California Department of Public Health (CDPH), community clinics and health departments throughout California, recently launched a website.

TB Free California is committed to reducing the burden of TB in the state by partnering with organizations to increase awareness and testing and treatment, particularly within communities who are at high risk of developing TB. The website is a hub of information and resources for individuals and groups working to eliminate TB in California, where 2,057 TB cases were reported in 2017, the highest total number of any state in the nation.

 

Upcoming conferences of interest

24th Annual Four Corners TB/HIV Conference
November 6-7, 2018
Santa Fe, New Mexico

Washington State TB Educational Conference
November 7, 2018
Seattle, WA

End TB 2019: 23rd Annual Conference of The Union-North America Region
February 21-23, 2019
Vancouver, British Columbia, Canada

California TB Controllers Conference
“Road Trip to TB Elimination: Packing Essentials”
March 12, 2019
Sonoma, CA

National TB Controllers Association National TB Conference (in partnership with APHL)
April 23-26, 2019
Atlanta, GA

 

Upcoming trainings

CITC’s schedule of upcoming trainings (through December 2018)  offers a variety of training opportunities for clinicians and public health providers.

Tuberculosis and LTBI in Alaska
November 8, 2018
Bethel, Alaska

Ending TB in the Last Frontier
November 10, 2018
Anchorage, Alaska

CDC Technical Instructions: What Civil Surgeons in Washington Need to Know
November 14, 2018
Kent, Washington

Identify, Evaluate, and Treat! Steps to Improve TB Contact Investigations in the Pacific
November 27-30, 2018
Chuuk, Federated States of Micronesia

It Takes a Village: Community Providers as Vital Partners with Public Health in the Management of ICE Detainees with Suspected TB Disease
December 4, 2018 (11:00 am – 12:00 pm Pacific)
National webinar

Screening and Treating Students for TB at Colleges and Universities
December 6, 2018 (12:00 - 1:15 pm Pacific)
National webinar

For periodic updates on additional trainings, complete course descriptions, and application forms, view our training section.

 

About CITC

 

CITC logo

CITC creates, enhances, and disseminates resources and models of excellence, and performs research to control and eliminate TB in the United States and internationally. The Curry Center opened in 1994 and is now designated by the Centers for Disease Control and Prevention (CDC) as a TB Center of Excellence (TB COE) for the Western Region, serving Alaska, Arizona, California (including Los Angeles, San Diego, and San Francisco), Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, 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, CITC develops and delivers highly versatile, culturally appropriate trainings, educational products, medical consultation, and technical assistance.

 

CITC staff

Principal Investigator / Medical Director: Lisa Chen, MD
Associate Medical Director/Nurse Consultant: Ann Raftery, RN, PHN, MS
Deputy Director: James Sederberg
Director of Education: Kelly Musoke, MPH
Program Manager: Jeannie Fong
Program Manager: Amelia Alonis
Epidemiologist: Baby Djojonegoro, MS, MPH
Web Developer: Mari Griffin, MS
Special Projects Manager/Newsletter Editor:
Kay Wallis, MPH

 

Contact us

Curry International Tuberculosis Center
University of California, San Francisco
300 Frank Ogawa Plaza, Suite 520
Oakland, CA 94612-2037
510-238-5100

Warmline TB Medical Consultation: 877-390-6682 (toll-free) or 415-502-4700
CurryTBCenter@ucsf.edu
www.currytbcenter.ucsf.edu
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