CITC Newsletter - Spring 2017

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

About CITC

CITC creates, enhances, and disseminates resources and models of excellence, and performs research to control and eliminate TB in the United States and internationally. CITC 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, Nevada, Oregon, Utah, Washington, and the U.S. Affiliated Pacific Islands. 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.

 

TB project in the Marshall Islands attracts Western Region volunteers

A massive TB screening project of over 5,000 Ebeye Island residents aims to identify, treat, and prevent TB in the Marshall Islands. Western Region TB control nurses, physicians, and epidemiologists joined volunteers from throughout the nation to assist local staff during a 9-week intensive effort through April 2017, all toward creating a “TB-Free Ebeye.”

Aerial view of Ebeye

Aerial view of Ebeye (credit: A. Kabua)

The Marshall Islands – officially named the Republic of the Marshall Islands (RMI) – is a chain of volcanic islands in the central Pacific Ocean, midway between Hawaii and the Philippines. RMI is one of the U.S.–affiliated Pacific Island (USAPI) territories. Most of the country’s 54,000 residents live in the urban centers of Majoro (the capital) or on nearby Ebeye island, where roughly 10,000 residents (half under age 18) live on just 80 acres of land. Majuro and Ebeye were identified by CDC as “TB hotspots” in the USAPI region with annual case rates in recent years averaging 200-300 per 100,000.

In the last 15 years, there has been modest success in reducing TB in the USAPI, but even a 20% drop in incidence still leaves rates nearly 100 times higher than the current U.S. rate. In remote territories where health resources are stretched thin, TB can take a devastating toll on Pacific Island communities. TB control in the region is also complicated by high rates of diabetes, a co-morbidity that increases the risk of latent TB infection converting to active disease.

A community parade kicks-off Ebeye’s TB screening projec

A community parade kicks-off Ebeye’s TB screening project. (credit: PIHOA)

With planning assistance from the CDC, World Health Organization (WHO), and the Pacific Island Health Officer Association (PIHOA), the RMI Ministry of Health launched a massive screening project at Ebeye Island. Dr. Jake Nasa, Chief of Staff at Ebeye Hospital, describes the project objectives: “Our main goal for the screening is to detect TB cases early in order to improve treatment outcomes and reduce TB transmission. Secondly, we want the Ebeye TB program to concentrate more on case management and contact identification by mentoring support groups like the community health workers, who are a vital link to the community. This way, we can shift to a community health workers-based DOTS system, allowing the TB nurse coordinators to supervise the health workers and spend more time preparing updates to the stakeholders in a staff-starved system. We need to maximize and update all the support structures we have to keep up with the changing tide of TB in the Pacific.”

Phase 1 of the ambitious project took place in November-December of 2016, with a general survey of all Ebeye residents. Fingerprinting registration enabled the Ministry of Health to digitize residents’ records to improve tracking and management of patients. The survey identified a target population of 5,669 individuals (age 15 years and older) for the TB case finding operation to follow in early 2017.

Dr. Jake Nasa (front row, center) with local staff and the first of 3 groups of volunteers.

For a tiny island health program to screen so many people within a 3-month period, reinforcements were needed. The RMI Ministry of Health issued a call for volunteer health professionals to help implement the immense operation, and several TB control staff from CITC’s Western Region eagerly stepped forward. Working pro bono in 3-week stints (airfare and modest lodging provided), the volunteers joined forces with Ebeye and Majuro TB program staff to perform all the tasks involved with active case finding, further work-up, directly observed therapy (and preventive therapy), and contact tracing. Screening activities also included testing for diabetes and high blood pressure, and selective examinations for Hansen’s disease.

Ebeye community health workers role-play how to manage difficult patients. Credit: J. Nasa

Ebeye community health workers role-play how to manage difficult patients. (credit: J. Nasa)

As of April 16, 2017, with one week left on the project timeline, Dr. Nasa reported that 85% of the target audience had been reached, and at least 60 new possible TB cases were discovered. He praised the efforts of volunteers and local staff alike: “We express our heartfelt appreciation for all the volunteers, including CDC and WHO, who joined us in making this screening program so successful. The Community Health Workers were the backbone of this program. Without their support, passion and commitment, I was a bit skeptical about how we could achieve the target goal. We are grateful for all-out support from the Minister of Health (Kalani Kaneko), Secretary of Health (Kennar Briand, MD) and our Assistant Secretary of Health for Ebeye Hospital (Glorine Jeadrik). Our TB staff worked evenings and weekends to guarantee the success of the screening program.” Project organizers hope to replicate the Ebeye effort in Majuro (22 miles away) in 2018.

Dr. Richard Brostrom reviews new TB cases with the clinical team

Dr. Richard Brostrom reviews new TB cases with the clinical team. (credit: PIHOA)

As the Ebeye operation drew to a close, Dr. Richard Brostrom, CDC’s TB Medical Officer for the Pacific Region, head of the Hawaii TB Program, and a prime mover behind the project, expressed high praise for the volunteer teams: “We more than doubled the rate of TB that the program usually identifies each year. That was difficult, sometimes grinding work…The program has been significantly re-organized and expanded to better manage their TB caseload, and we are hopeful that those changes will continue to keep TB ‘on the run’ in Ebeye. In addition to the new active cases, several recent contact investigations demonstrated a high case rate for active TB disease and identified more than 40 priority contacts who have now started TB prevention. This experience has helped the program to make contact investigations a new priority. The long-term impact of our work on TB rates will not be properly assessed for a few years. The volunteers’ impact on the program, however, has been immediate. I witnessed each talented volunteer, and each cohesive team, leave their indelible mark on the program.”

RMI Minister of Health, Kalani Kaneko

Kalani Kaneko (credit: H. Hosia, The Marshall Islands Journal)

RMI Minister of Health, Kalani Kaneko, applauded all project participants: “On behalf of the RMI Government and our people, we want to thank all the volunteers, stakeholders, partners, PIHOA, WHO, and CDC for all their hard work and dedication during this mission. Without them, it would be difficult for the Ministry of Health to accomplish it alone. If it takes a community to conduct such an operation, then it will take the entire global community to eradicate such diseases. We are fortunate to have these amazing people on our team who volunteered during the mass screening operation.”

Randall Reves, MD, MSc, is Chair of Stop TB USA and a longtime Denver-based TB clinician and researcher. He says he volunteered for the project because, “I was particularly interested in being directly involved in the TB prevalence survey through universal case-finding in such a high TB risk population. I thought the Ebeye population would be similar to the visa applicant populations in whom I have been involved in TBESC research studies in Vietnam and the Philippines.” Dr. Reves spent much of his time interpreting chest radiographs and screening for Hansen's disease among male Ebeye residents. Among his fondest memories of the experience will be “the ukulele-accompanied songs performed by the Ebeye staff the day we left.”

Ebeye staff and the first volunteer team


Nevada TB Controller Camy Retzl, MPH, was a member of the first volunteer team: “TB-Free Ebeye was an experience far beyond what I had imagined. The people and culture were very welcoming, and the work was diverse and extremely rewarding. The volunteer teams had an undeniable connection both with each other and with all those who worked on the project or were part of the screening. My memories from Ebeye will outlast and outshine many other work experiences I have had in my career; and for that I will be forever grateful to have participated in this opportunity.”

Karen Martinek, RN, MPH, a nurse epidemiologist who recently retired from the Alaska Department of Health and Human Services, says she helped the Ebeye program to develop and implement sustainable, integrated TB case management. Her lasting memories? “All the wonderful people I was so lucky to work with, laugh with, and share the experience with! And many thanks to Dick Brostrom for his vision and perseverance.”

Side-by-side nursing:  Volunteer Lana Tyer (l) works with Ebeye nurse Ruthann Maika

Side-by-side nursing: Volunteer Lana Tyer (l) works with Ebeye nurse Ruthann Maika. (credit: N. Witten)

Lana Tyer, RN, MSN, Nurse Consultant for the Washington State TB Control Program, believed she gained just as much as she contributed during her 3 weeks in Ebeye: “I learned that it’s really important for nurses to reach out for experiences like this – especially TB nurses from high-resource environments. In Ebeye I learned what really matters in that moment. Guidelines are just guidelines – what is the one thing that will be most important right now?” Amidst challenging conditions, Ms. Tyer recalls, “I had a few high-resource to low-resource meltdowns,” but the experience overall was deeply rewarding. “I’ve never laughed so much in my whole life,” she says. “I hope the project continues next year in Majuro -- many of us are ready to volunteer again!”

 

World TB Day highlights

CITC’s Western Region partners observed World TB Day (March 24, 2017) in memorable ways, in settings that ranged from Capitol Hill to a San Francisco homeless shelter; and two physicians and two TB programs in the region were named “2017 TB Elimination Champions” by the CDC.

ATS Briefs Congressional Partners

(l to r) Charlotte Colvin, Robert Belknap, Philip  LoBue, Tanwa Owolabi

(l to r) Charlotte Colvin, Robert Belknap, Philip LoBue, Tanwa Owalabi (credit: ATS)

The American Thoracic Society (ATS) and several partner organizations held a briefing in the U.S. House of Representatives to commemorate World TB Day. Titled, “Tuberculosis: The Leading Global Infectious Killer,” the briefing featured a panel chaired by Robert Belknap, MD, with the Denver Metro TB Program, and Past President of the National Tuberculosis Controllers Association; Tanwa Owolabi, a TB survivor; Philip LoBue, MD, Director of the CDC’s Division of TB Elimination; and Charlotte Colvin, PhD, Senior Technical Advisor with the U.S. Agency for International Development (USAID).

(l to r) Charlotte Colvin, Robert Belknap, Philip  LoBue, Tanwa Owolabi

Dr. Chris Keh (l) and Lessy Benedith

The San Francisco TB Control Section observed World TB Day by honoring its partnership with Multi-Service Center (MSC) South Shelter in San Francisco, operated by St. Vincent de Paul Society, the largest homeless shelter in Northern California. San Francisco TB Control Director, Dr. Chris Keh, presented a “Public Health Hero” certificate to MSC Program Director Lessy Benedith, commending the shelter's "unwavering dedication and selfless commitment to serving San Francisco's most vulnerable population."

2017 CDC U.S. TB Elimination Champions from the Western Region

As a part of its World TB Day activities, the CDC’s Division of Tuberculosis Elimination (DTBE) announced the 2017 CDC U.S. TB Elimination Champions. These individuals and organizations are recognized as making tremendous strides in expanding testing and treatment for latent TB infection. Four awardees came from the nine-state Western Region served by CITC:

2017 CDC U.S. TB Elimination Champions from the Western Region

 

Upcoming trainings

CITC’s schedule of upcoming trainings (through October 2017)  offers a variety of training opportunities for clinicians and public health providers.

May 5, 2017
National webinar
Pediatric TB Radiology: It’s Not Black and White

May 8-11, 2017
Palau
TST Train-the-Trainer

May 12, 2017
Palau
TST Training

June 22, 2017
Seattle, WA
Focus on LTBI

June 23, 2017
Seattle, WA
Tuberculosis Nursing Workshop

September 11-15, 2017
Honolulu, Hawaii
Pacific Island TB Controllers Association Conference (in partnership with the Mayo Clinic Center for Tuberculosis)

October 17, 2017
Oakland, CA
Focus on LTBI

October 18-20, 2017
Oakland, CA
Tuberculosis Clinical Intensive

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

 

Faculty profile

Neha Shah, MD, MPH

To better acquaint our readers with the corps of TB experts that comprise our training and medical consultation faculty, each issue of CITC Newsletter presents a profile of a CITC faculty member. In this issue we feature Neha Shah, MD, MPH, CDC Field Medical Officer, assigned to the California Department of Public Health, TB Control Branch. Dr. Shah spoke with CITC Newsletter on March 27, 2017.

Where did you grow up? Early in life, who influenced your educational interests?

I grew up in Cleveland, Ohio. My parents taught us about public service and encouraged us to travel the world and learn about different cultures and inequalities. I think my path in life was guided by a series of encounters and influences from different people. I had several philosophy and religion teachers who were big influences in my life. My sister very much encouraged me to find what I truly liked doing.

As an undergraduate, you studied Religious Studies and Psychology at Washington University in St. Louis…did you already know you wanted to be a physician?

In college I completed all the pre-med requirements, but I wasn’t sure where I was headed. I had a religion teacher who taught me how to think critically and be confident in my own thoughts. During a gap year after college, I was an AmeriCorps volunteer with the American Lung Association in Chicago. Doing asthma education and outreach in Chicago public schools introduced me to public health, and it really opened my eyes to health disparities.
However, I didn’t truly understand yet that public health was its own professional field until I got to medical school [New York Medical College] and met people who were working in women’s reproductive rights in New York City.

As part of my residency at Boston Medical Center in the primary care track, we had the ability to choose a second primary care clinic. Given my interest in international work, I chose the Refugee Clinic. Not only did the clinic provide specialty primary care to survivors of torture who were seeking asylums, but we also wrote affidavits for them and testified in court.

After earning your MD and MPH degrees, and doing your residency in Boston, how did you decide to go to the CDC?

When I went into residency, I knew I wanted to get back into public health. CDC Epidemic Intelligence Service was the first thing I wanted to do.

One of my first projects at CDC took me to Thailand to study sexual risk behaviors and HIV prevalence in clients and partners of female sex workers. There I was – interviewing sex workers in dingy alleyways around Bangkok – and I was a little surprised to realize I liked the work, and felt I was doing the right thing.

What is most rewarding about your work?

I truly enjoy what I do, and I believe in the importance of public health. But what makes it enjoyable and rewarding are the people I work with and the wide variety of projects I can pursue.

And least rewarding?

The least enjoyable part of my work is that public health is not often given high priority by policy makers.

What’s ahead for your career?

I am not sure what’s next. I have been learning about public policy and there’s a need for more people who have been in the field to participate in policy – and also health communications. Or [laughing]…maybe I’ll become a barista.

[Jennifer Flood, MD, MPH, is Chief of the CDPH TB Control Branch, and applauds Dr. Shah’s special contributions to her team: “Neha is exuberant, fun, brilliant, and very dedicated to helping tuberculosis patients through cure. She is the perfect combination of careful attention to clinical details that matter and big population view. We are so lucky to have her leadership and expertise in California!”]

_____________________________________________________________________________________________

Dr. Shah is a Commander with the U.S. Public Health Service and works with the MDR-TB Service team at the CDPH TB Control Branch. Her research articles have appeared in publications such as Emerging Infectious Diseases, International Journal of STDs and AIDS, Morbidity and Mortality Weekly Report, Journal of Immigrant and Minority Health, and Journal of Urban Health. Dr. Shah joined the CITC training faculty in 2010; her presentations on topics such as drug-resistant TB, LTBI diagnosis and treatment, and M. bovis have been enthusiastically received by participants in CITC’s webinars and clinical intensive courses.

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
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CITC staff

Principal Investigator / Medical Director: Lisa Chen, MD
Associate Medical Director: 
Ann Raftery, RN, PHN, MS
Deputy Director:
 James Sederberg
Director of Education:
 Kelly Musoke, MPH
Program Manager: 
Jeannie Fong
Epidemiologist: 
Baby Djojonegoro, MS, MPH
Epidemiologist: Cecily Miller, MPH, PhD candidate 
Special Projects Manager / Newsletter Editor: Kay Wallis, MPH
Web Developer: Mari Griffin, MS
Program Assistant: 
Saeda Lars