ABSTRACT 1
Possible Transmission of a New TB Strain in a
New York City Hospital Emergency Department
Jillian Knorr, MPH; Bianca R. Perri, MPH; Shama D. Ahuja, PhD, MPH;
Douglas C. Proops, MD, MPH; Jeanne Sullivan Meissner, MPH
New York City Department of Health and Mental Hygiene, New York, New York
Rationale: Since 2001, the New York City (NYC) Bureau of Tuberculosis Control (BTBC) has
conducted universal genotyping to better understand tuberculosis (TB) transmission. In 2012, BTBC
identified a new strain of TB in NYC and conducted an outbreak investigation.
Methods: BTBC defines a genotype cluster as two or more TB patients who have isolates with
matching genotypes (spoligotype and IS6110-based restriction fragment length polymorphism
results). Clusters are routinely investigated to establish epidemiologic links between patients and
identify possible sites of TB transmission. This investigation entailed data collection, medical chart
review, and patient re-interview.
Results: From January 2010 to May 2012, four patients with matching TB genotypes were
identified. All were United States (US)-born, non-Hispanic black males between the ages of 52 and
56. Three patients had pulmonary disease. Two patients had a history of homelessness and three
had a history of substance abuse. Patient A was evaluated for TB in 2010 while incarcerated but
was released before TB culture confirmation and treatment initiation. He was found one year later
but died without starting TB treatment. Three patients were diagnosed from March to May 2012.
Patients did not name each other during contact investigation or re-interview. During the outbreak
investigation, BTBC learned that Patient A and another cluster patient frequently visited a NYC
hospital emergency department (ED) for medical care, including treatment for alcohol withdrawal.
Patient A had multiple ED visits during the year that he was lost and infectious, two of which
overlapped with the other patient’s ED visits. Both patients and a third cluster patient also spent
considerable time in the same two-block area during several years before TB diagnosis.
Conclusions: Strong epidemiologic links among these US-born patients indicate recent transmission
in NYC of a new TB strain. Homelessness and substance abuse are known TB risk factors, and EDs
are frequently a source of care for individuals with these risk factors. While transmission of this
strain in the ED is not definitive, this investigation highlights the need for providers to be vigilant
for TB, particularly in recurrent ED patients or patients with TB risk factors.
ABSTRACT 2
Changes in the TB Care System during the Economic
Downturn in Washington State 2009 – 2013
S. Carlson; S. Allen; S. Lindquist
Washington State Department of Health
Objective: To examine how capacity for TB care within Washington State local health jurisdictions
(LHJs) has changed at a time when public health resources are decreasing.
Method: In 2009, a survey was sent to the 35 local health jurisdictions (LHJs) in Washington State
to determine the current capacity that was being utilized in caring for tuberculosis in their
community. In 2013, a slightly revised version of the same survey was sent to the same LHJs. The
surveys were then compared to see how capacity for TB care in public health has in Washington
State changed over the past 4 years.
Results and Findings: The 2009 survey received an 83% response rate from LHJs, compared to
70% in 2013. Of those who responded, in 2009 95% of Washington State’s population was
represented, while 2013 yielded a 90% representation. Some of the significant findings from the
survey include: Nursing staff dedicated to TB decreased 44% from 2009 to 2013; In 2013, 83% of
LHJs shared their TB program staff with other programs within the LHJ; LHJs referring patients
to community health centers for LTBI care increased 37% from 2009 to 2013; IGRAs are more
commonly used in foreign-born and those who have BCG than in 2009. Limited resources are being
focused on mainly: management of pulmonary disease, MDR, DOT for smear positive pulmonary
cases and LTBI testing of contacts to active cases. Cost and reimbursement for IGRAs remain a
problem. There are a lack of isolation resources for active TB cases. There remains a need for
provider oversight of patients with both LTBI and TB disease at the LHJ level that includes:
examination of each patient, standing orders, and protocols for dealing with adverse events.
Conclusions: The information gathered from this survey is shared with our Local Health Officers in
each of the LHJs. The intention is for the LHJs to be aware of what the trends in TB care are in
Washington, how their organization compares to what is being done around the State and how it has
changed over the past few years. At the State level, we intend to take the information gathered
from the survey to focus education efforts around issues LHJs are experiencing in their work to
eliminate TB within their communities.
ABSTRACT 3
Increasing Treatment Completion of LTBI in High-Risk International University Students
Sue Madeja, RN, MSN; Amy Anderson, RN, BS-N
Bethlehem Health Bureau
Medication compliance and regimen completion are common issues for latent tuberculosis (TB)
treatment in patients. Latent tuberculosis infection (LTBI) requires 9 months of isoniazid (INH)
and the one most commonly used by local TB clinics for LTBI treatment. New CDC approved
treatment regimens are of significantly shorter duration, making treatment initiation more
successful and treatment completion more possible. A better solution was needed, and with the
2011 CDC approval of a 12-week INH/rifapentine regimen, another treatment option for this group
of patients existed that could increase treatment compliance and completion rates.
Conversations were held between the state and local health departments and university staff, a
catalyst for discussions about implementation of the new 12- week regimen for university students.
Meetings in 2012 with the state department of health, TB program, local health department nursing
staff and the university health center began. It was decided that the new university students
would have two voluntary options: the new CDC approved 12 week regimen and the traditional 9
month regimen resulting in better completion rates. The new treatment regimen had a slightly more
successful completion rate but a higher initiation rate meaning more high-risk students completed
treatment. Satisfaction with the new regimen was positive for most students. All students in 2012
chose the new CDC approved 12- week regimen despite the requirement for weekly appointments
for directly observed therapy. Completion of LTBI treatment is an important goal for this high-risk
population ensuring a reduction in TB disease in these individuals.
ABSTRACT 4
TB Screening in Oregon Healthcare Workers: Coming to Consensus
Heidi Behm, RN, MPH TB Control, Oregon Health Authority; Stephanie Ryan, MPH Oregon Health
and Science University; Lindsey Lane, MPH TB Control, Oregon Health Authority; Trung Vu, Oregon
Health and Science University; Kevin Winthrop, Oregon Health and Science University
TB Control, Oregon Health Authority (TBOHA) has received an increasing number of calls over the
past few years from health care facilities regarding implementation of TB testing programs for
health care workers (HCWs) and the interpretation of individual employee TB test results. Despite
the high volume of phone calls, TBOHA did not have complete information on who facilities were
testing or how TB testing was being conducted.
To learn more, a 29 question survey was emailed to employee health and infection control programs
at hospitals, clinics and long term care facilities. 56 individuals responded. 83.9% (47) were from
inpatient settings, 48.2% (27) outpatient settings and 10.7% (6) other settings. The number of beds
per facility ranged from 19‐554 with a good representation of large and small as well as rural and
urban facilities. Most (53) of the reporting facilities stated they are in a low risk classification for
TB and accordingly only 5.8% (3) still test employees annually.
100% (54) of respondents screen new employees for TB upon hire with 58.5% (31) utilizing a risk
factor questionnaire with baseline screening. For baseline screening, 59 % (31) use a TB skin test
(TST), 32% (17) QuantiFERON, and 0% T‐SPOT. 15% (8) reported using both TST and
QuantiFERON for baseline screening. In the comments sections, a number of respondents
expressed concern regarding false positive tests with QuantiFERON and confusion on how IGRAs
may best be utilized.
Accepting tests from other facilities was another area where practices varied. 90% (45) of
respondents stated their facility accepts prior negative TB screening results from other facilities
and negative chest x-ray results, but the age of the results acceptable varied greatly among
respondents. Comments also indicated confusion about testing requirements for groups such as
contractors, vendors and credentialed non employees.
After results were tabulated and disseminated, 5 stakeholder group meetings were commenced to
discuss key areas of discordance in practice among facilities as found in the survey. A set of
guidelines addressing these specific areas were developed which are unique to Oregon that reflect
the survey findings and the concerns of the stakeholder groups.
ABSTRACT 5
Implications of Decreased Funding for Domestic TB Programs: NTCA Survey Findings
S Burkholder1, S Saephan2, J Kanouse3, J Flood2, M Lobato4, M Burgos5, J Warkentin3, 6, D Nilsen7,
J Rodman8, K Farrell9
1
Indiana State Department of Health, TB/ Refugee Health Division, Indianapolis, IN; 2California
Department of Public Health, Center for Infectious Diseases, Division of Communicable Disease
Control, Tuberculosis Control Branch, Richmond, CA; 3National Tuberculosis Controllers Association,
Atlanta, GA; 4 Division of TB Elimination, Centers for Disease Control and Prevention, Hartford, CT;
5
University of New Mexico, Department of Internal Medicine; TB Program, New Mexico
Department of Health; 6 Tennessee Department of Health, TB Elimination Program; 7NewYork City
Department of Health and Mental Hygiene, Bureau of TB Control, Queens, NY; 8Delaware’s Division
of Public Health TB Elimination Program, Dover, DE; 9TB Control Section, Bureau of Communicable
Diseases, Division of Disease Control & Health Protection Department of Health, Delray Beach, FL.
Background: To describe capacity changes of TB programs across the nation since 2009, the
National TB Controllers Association (NTCA) conducted a survey of state and local public health TB
program staff in January 2013. The survey measured changes in staffing, funding, TB cases,
program capacity, services, and patient outcomes.
Methods: An electronic survey was distributed to TB Controllers of all 50 states. A snowball
sampling method was used to further distribute the survey to jurisdictions within each state.
Results: A total of 277 survey responses were collected. Respondents included all 50 states, 23
regions, 187 counties, and 17 cities including 9 federally-funded cities.
Since 2009, 57% (27 of 47) of states reported decreased budgets and decreased staffing. Among
federally funded cities, 100% (7 of 7) had decreased budgets as well as decreased staffing. Of the
27 states with deceased budgets, 17 (63%) experienced increases in TB cases at any time during
the 2010-2012 year-period. Seventy-nine percent (34 of 43) of states reported an increase in the
proportion of complex cases (i.e., homelessness, HIV infection, diabetes, drug resistance, substance
abuse, refugee, and non-English speaking).
Nearly 20% (7 of 38) of states reported decreased ability to provide directly observed therapy
(DOT) to pulmonary TB patients while 46% (15 of 33) had a decreased ability to provide DOT to
high-risk patients with latent TB infection. One-third (14 of 42) of states reported decreased
capacity to conduct contact investigations; approximately 27% (12 of 45) of states reported
decreased capacity to perform outbreak investigations. Thirty responses described sub-optimal
care by private providers leading to one or more of the following patient outcomes: delays in
diagnosis, misdiagnosis, ongoing TB transmission, ineffective treatment, outbreaks, and death.
Conclusion: The majority of U.S. TB programs have experienced a decrease in TB control resources
since 2009. Reduced resources and staffing, coupled with increases in complex cases, has put a
strain on TB programs across the nation. The impact of these reductions has resulted in reduced
capacity for important interventions such as contact investigations.
ABSTRACT 6
Can New York City Meet the National Target for TB Treatment Completion by 2015?
Darlene Bhavnani, PhD, MPH1,2; Nicola Lancki, MPH1,2; Iris Winter2; Michelle Macaraig, DrPH, MPH2
1
Centers for Disease Control and Prevention (CDC), Council for State and Territorial
Epidemiologists, Applied Epidemiology Fellowship
2
New York City (NYC) Department of Health and Mental Hygiene (DOHMH) Bureau of Tuberculosis
Control, New York, NY, USA
Background: One of the national TB program indicators established by the CDC is treatment
completion within 12 months for 93% of eligible patients by 2015.
Objective: To examine treatment completion among TB patients in NYC.
Methods: We reviewed TB cases counted in NYC between January 2009 and June 2010. Patients
were excluded if they failed to start treatment, died before diagnosis or during treatment, had
meningeal TB or a rifampin resistant strain, or were <14 years old with disseminated TB per CDC
recommendations. Patient treatment outcomes were categorized as completed treatment in ≤12
months (timely completion), completed treatment after 12 months (delayed completion) or
incomplete treatment. Patients with timely completion were compared to patients with delayed
completion and incomplete treatment. Poisson regression with robust error variance was used to
measure adjusted risk ratios (aRR) for dichotomous outcomes.
Results: Timely treatment completion occurred in 91% (921/1008) of eligible patients, while 5%
(48/1008) had delayed treatment, and 4% (39/1008) had incomplete treatment. Of 804 patients
with timely completion and known provider, 477 (59%) were treated by a DOHMH-provider.
Compared to patients with timely completion, patients with delayed completion were less likely to
have a DOHMH-provider (aRR: 0.5, 95%CI 0.3-0.9), and more likely to have extra-pulmonary TB
only (aRR: 2.3, 95%CI 1.1-4.9), history of TB disease (aRR: 4.5, 95%CI 1.8-11.4), non-rifampin drug
resistant TB (aRR: 4.5, 95%CI 1.4-15.0), and multiple hospitalizations (aRR: 1.1, 95%CI 1.0-1.2).
Seventy-nine percent (723/921) of patients with timely completion were on directly observed
therapy (DOT). Compared to patients with timely completion, patients with incomplete treatment
were less likely to be on DOT (aRR: 0.4, 95%CI 0.2-0.8) and more likely to have extra-pulmonary TB
only (aRR: 3.0, 95%CI 1.5-6.2). Nearly half (40/87) of all patients with delayed completion or
incomplete treatment were explained by patient refusal to continue treatment.
Conclusions: In NYC, timely TB treatment completion is high. However, increased efforts to enroll
patients on DOT and educate patients on the importance of treatment adherence, particularly
those managed by non-DOHMH providers, are needed to achieve the national target.
ABSTRACT 7
Mobilizing to Increase TB Community Awareness and Advocacy
Samuel Caballero, MA; Jessica Quintero, BAAS; Catalina Navarro, RN, BSN; and
Barbara Seaworth, M.D., FIDSA, FACP; Heartland National TB Center, San Antonio Texas
Background: Decreasing TB rates accompanied by declining knowledge of and interest in TB have
led to funding cuts for TB care and research. Although case numbers are lower, drug resistant
strains are increasing globally and in the U.S. as are cases complicated by medical co-morbidities.
TB lacks a strong advocacy group but has benefited from association with Treatment Action Group
(TAG). Heartland National TB Center (HNTC) and the Texas Center for Infectious Disease (TCID)
treat the most complicated TB cases. A daylong event was designed to bring together providers,
those affected by TB, researchers and community groups to raise awareness and encourage
advocacy.
Methods: HNTC engaged TCID volunteers along with TB Trials Consortium in San Antonio and
Houston, and the San Antonio City Chest Clinic (SACCC). Plans were developed to encourage
participation of those impacted by TB (patients/families), community groups serving those at risk
of TB, and health care providers in the private and public sector. Planning included TB education, a
discussion of the ethics of TB care, and a fitness event followed by a social activity. Donations
were sought from community.
Results and Findings: The TB Update had 65 live and 70 webcast participants. Topics included TB
and Substance Abuse, Interferon Gamma Release Assays, Rifapentine Dosing in Children,
Implementation of the 12 Dose HP Regimen, and a Laboratory Update. An outdoor presentation of
The Photo Voice Project and Ethical Considerations in TB Care allowed persons with TB to
participate. After presentations by local community and TB leaders, 193 persons participated in a
5K Fun Walk/Run. A barbeque picnic and band greeted finishers. Community support included
donations and HNTC, American Lung Association, SACCC, San Antonio AIDS Foundation, Baptist
Health System and Texas Department of State Health Services sponsored booths. Patients
enjoyed the social activities and anticipate participating in Photo Voice.
Conclusions: Results suggest that educational activities combined with social activities increased
TB community awareness and patient interest in their disease. The Photo Voices Project
photographs are displayed at TCID with plans to begin the project.
ABSTRACT 8
Eliminating TB in the U.S. One Neighborhood at a Time
Peter Cegielski, PhD; CDC/DTBE
David E. Griffith, MD, U.T. Health Sciences Center, Tyler, TX (UTHSCT)
Paul K. McGaha, DO, MPH, TX Dept State Health Services (DSHS), Tyler, TX
Melanie Wolfgang, MPH, CDC/DTBE
Patricia A. Clark, RN, UTHSCT
Willis L. Hassell, RN, UTHSCT
Charles Wallace, PhD, DSHS, Austin, TX
Objectives: We evaluated a strategy for preventing tuberculosis (TB) in communities most
affected by it.
Methods: In 1996, we mapped reported TB cases (1985–1995) and positive tuberculin skin test
(TST) reactors (1993–1995) in Smith County, Texas. We delineated the 2 largest, densest clusters,
identifying 2 highest-incidence neighborhoods (180 square blocks, 3153 residents). After extensive
community preparation, trained health care workers went door-to-door offering TST to all
residents unless contraindicated. TST-positive individuals were escorted to a mobile clinic for
radiography, clinical evaluation, and isoniazid preventive treatment (IPT) as indicated. To assess
long-term impact, we mapped all TB cases in Smith County during the equivalent time period after
the project.
Results: Of 2258 eligible individuals, 1291 (57.1%) were tested, 229 (17.7%) were TST positive, and
147 were treated. From 1996 to 2006, there were no TB cases in either project neighborhood, in
contrast with the pre-intervention decade and the continued occurrence of TB in the rest of Smith
County.
Conclusions: Targeting high-incidence neighborhoods for active, community-based screening and
IPT may hasten TB elimination in the United States.
ABSTRACT 9
Discordant Drug Susceptibility Results and the Role of
Molecular Drug Susceptibility Testing When Ruling Out MDR-TB
Erick Cortes, MPH, New Jersey Department of Health; Reynard MacDonald, MD, Global TB
Institute, UMDNJ; Barry Kreiswirth, PhD, Natalia Kurepina, PhD, Elena Shashkina, PhD, and Liang
Chen, PhD, Public Health Research Institute, UMDNJ
Background: The partnership between The New Jersey Department of Health and the Public
Health Research Institute (PHRI) continues to provide “molecular susceptibility” testing (MDST),
sequence of target genes, for first-line anti-M.tb drugs, fluoroquinolones, and aminoglycosides. In
October of 2012, MDST was requested for a potential MDR-Mtb Case. MDST was performed at
PHRI and CDC, with conventional susceptibility testing from the NJ State Public Health Laboratory
(PHEAL) and National Jewish Health.
Methods: In October 2012, an LJ slant culture was sent to PHRI for Mtb strain genotyping. The
isolate was genotyped using IS6110 analysis and the RFLP pattern was compared against the
archived PHRI image database (over 10,000 images, 31,000 Mtb isolates) for strain identification.
The DNA was also analyzed for mutations in the following known drug resistance targets: rpoB.
katG, gyrA, and pncA correlated with resistance to: rifampin (RIF), isoniazid (INH), fluorquinolones
(FQ), and pyrazinamide (PZA). A sputum specimen from October 2012 was sent to the CDC TB
Reference Lab for MDDR testing, INH and RIF only: locus rpoB (RRDR) inhA (promoter), katG
(ser315 codon).
Results: The specimen sent to PHRI showed genetic alterations in rpoB and katG correlating to
resistance to RIF and INH with no mutations in genes gyrA and pncA finding that predicts
susceptibility to FQ and PZA. The specimen sent to CDC yielded no MTBC amplifications in rpoB and
inhA, with a mutation on katG AGC>ACC; Ser315Thr, correlating to resistance to INH but cannot
rule out resistance to RIF. Conventional first line drug susceptibility results from PHEAL yielded
resistance to only INH and RIF, while National Jewish Health provided a first and second line drug
susceptibility pattern of resistance to only INH and STR.
Conclusions: Molecular DST results from both PHRI and CDC were available 10 days after the
requests were submitted. Following the MDST pattern issued by PHRI, the patient received 8
weeks of treatment for MDR-TB before conventional DST results confirmed resistance to INH
and RIF. MDST analysis is able to rapidly determine the presence of an extremely drug resistant
M.tb isolate, in contrast to the slow phenotypic analysis which commonly takes two-three months.
ABSTRACT 10
Tuberculosis Follow-Up Examination for Immigrants and Refugees who
Relocated to the U.S. with TB Conditions, 2011
Kendra Cuffe, MPH (CDC/NCEZID/IRMHB)
Nekeia Gray, MPH (CDC/NCEZID/IRMHB)
John Painter, DVM, MS (CDC/NCEZID/IRMHB)
Rossanne Philen, MD, MS (CDC/NCEZID/IRMHB)
Background Statement of Problem or Objectives: The Electronic Disease Notification system
(EDN) notifies state and local public health officials of immigrants and refugees identified with
suspected tuberculosis (TB) during their overseas examination. Local TB programs may conduct
follow-up examinations of these immigrants and refugees and report the results to CDC through
EDN. Among foreign-born persons, most TB cases occur during the first year after arrival. We
evaluated EDN data to determine the follow-up rate and final diagnosis.
Methods: We analyzed EDN follow-up evaluation reports for persons with an overseas diagnosis of
Class B TB who arrived in the United States during 2011. The Class B TB definition includes having a
chest radiograph consistent with TB but having negative sputum smears (1991 TB technical
instructions [TI]) or negative cultures (2007 TB TI); or children 2-14 years of age with latent TB
infection (LTBI) (2007 TB TI); or being a contact of a TB case-patient (both 1991 and 2007 TB TI).
Results and Findings: In 2011, EDN notified states of 22,273 arrivals with Class B TB. Of these,
80.0% were immigrants, 19.1% were refugees, and 0.9% held other U.S. visas; the Philippines was
the country of origin for 38.4%. The overseas examinations were done according to the 2007 TB TI
for 91.1%. Follow-up evaluation outcomes were reported for 79.1%. Of those, 83.2% were
completed, 4.7% were initiated but not completed, and 12.1% were not initiated. Of those with a
completed evaluation, the final diagnosis was 1.2% with active TB and 42.0% with LTBI.
Conclusions, consistent with the background and findings: The high percentage of TB and LTBI
diagnosed in this sub-population highlights the importance of timely and thorough follow-up
examinations. To increase the number of TB and LTBI case-patients identified and treated,
efforts should be increased to address any challenges or barriers to follow-up examination and
reporting.
ABSTRACT 11
U.S. Destinations of Immigrants and Refugees Classified with
Suspect TB during Overseas Medical Screening, 2011-2012
Kendra Cuffe, MPH (CDC/NCEZID/IRMHB)
Deborah Lee, MPH (CDC/NCEZID/IRMHB)
Nekeia Gray (CDC/NCEZID/IRMHB)
John Painter, DVM, MS (CDC/NCEZID/IRMHB)
Rossanne Philen, M.D., M.S. (CDC/NCEZID/IRMHB)
Background: To successfully obtain a U.S. visa, U.S. -bound refugees and immigrants are legally
required to undergo medical screening overseas. From 2011 to 2012, 45,244 immigrants and
refugees classified with suspect tuberculosis (TB) under the 2007 TB technical instructions
(TBTI’07) during overseas medical exams were relocated to the United States and its territories.
The Electronic Disease Notification (EDN) system notifies U.S. health departments of these
arrivals with suspect TB and provides them with both scanned and electronic copies of the overseas
medical examination results for post-arrival follow-up examinations.
Methods: We analyzed data in EDN for refugee and immigrant destinations to determine which
areas in the United States received the most immigrant and refugee arrivals with suspect TB.
Destination data were mapped by using ArcGIS software by county level and aggregated at the
national level. States were grouped into regions to compare the number of arrivals with suspect TB
in 2011 with 2012. Analysis was further stratified to determine areas that had the highest number
of TB Class arrivals from the top three countries of origin.
Results: From 2011 to 2012, health departments were notified of 45,244 arrivals with suspect TB
under the TB TI ‘07 Most of the arrivals relocated to Region 9 (Calif., Ariz., Nev., Hawaii) for both
years, 2011 (39.5%) and 2012 (36.3%). The top three countries of origin were the Philippines
(36.5%), Mexico (11.6%), and Vietnam (9.9%). For both years most TB Class arrivals from the top
three countries of origin relocated to Region 9 (52.4%), followed by Region 6
[N.M.,Tex.,La.,Ark.,Okla.] (11.2%). Overall, most Filipino arrivals with suspect TB relocated to Region
9 (57.1), followed by Region 4 [Ky., Tenn.,Miss.,Ala.,Ga.,Fla.,S.C.,N.C.](6.9%).
Conclusion: To prevent the spread of TB, efforts should be made to strengthen the capacity of
health departments instates receiving large numbers of new arrivals with suspect TB, to monitor,
track, and provide timely TB follow-up examinations.
ABSTRACT 12
Evaluating the Revised CDC TB Program Managers’ Course
M. Dowling and A. Maiuri, Division of TB Elimination, Centers for Disease Control and Prevention
Background: The Centers for Disease Control and Prevention (CDC), Division of Tuberculosis
Elimination (DTBE), TB Program Managers’ Course (PMC) is a long-standing course designed to
improve the planning and managerial capabilities of new TB program managers throughout the
United States. To ensure that the course continues to provide appropriate content and meet the
educational needs of TB program managers in the current TB environment, DTBE conducted a needs
assessment of the PMC. Based on the results, the PMC was revised. The revised course was held
January 28 – February 1, 2013 in Atlanta, GA. The 5-day training was divided into 20 sessions.
Each session stood alone as a block of instruction but was sequenced to build logically on preceding
sessions.
Methods: Course participants completed pre-course and post-course tests, session evaluations, and
an overall course evaluation. The self-administered pre-course test consisted of 30 knowledge
questions (true/false and multiple choice) and 18 self-efficacy statements (rated on a 5-point
Likert scale). The post-course test consisted of the same 30 knowledge questions and 18 selfefficacy statements. Participants will complete a follow-up evaluation six months after the course
(July 2013).
Results Twenty participants attended the revised PMC. Sixteen participants completed both the
pre-course and post-course test. Twelve participants’ post-course test scores increased, one score
remained unchanged, and three scored lower. The results of the self-efficacy statements
increased overall (mean change .74). In particular, participants increased their self-efficacy in the
following topics: implementing a case management system (mean change 1.06), distinguishing
between a contact and an outbreak investigation (mean change 1.06), and investigating the causes
for failing to complete treatment (mean change .94). Majority of participants agreed that “as a
result of this training, I feel more confident in my capacity as a TB Program Manager.”
Conclusions: The revised course provided a comprehensive introduction to TB program management.
Because the course increased the participants’ TB program management knowledge and selfefficacy scores from pre-course to post-course, this merits that the course continue to be offered
in the future. These evaluation results will guide the continued revision of this course to best meet
target audience needs.
ABSTRACT 13
Texas Center for Infectious Diseases (TCID): 2013
James N. Elkins, FACHE, Texas Department of State Health Services
David E. Griffith, M.D. FACP, FCCP, and Barbara Seaworth, MD, FIDSA, FACP, The University of
Texas Health Sciences Center at Tyler
Background Statement of Problem or Objectives: Texas ranks second in the U.S. in the number of
new TB cases annually. Community-based directly observed therapy (DOT), the standard for TB
care, is challenging because Texas has a higher incidence compared to other states of alcohol
dependency (19.9% vs. 12.4%), TB in corrections (9.5% vs. 4.3%), non-injecting drug use (10.6% vs.
7.6%). Successful outpatient TB care is also hindered by HIV, diabetes, psychiatric illness, and
homelessness. TCID, operated since 1953, manages hard-to-treat TB in a new special purpose
hospital opened in 2011. Staff and facilities demonstrate efficacy of design, construction and
programs focused for successful treatment completion.
Methods: Care is patient centered and interdisciplinary in a safe environment. Physician-led regular
interdisciplinary conferences and rounds is the framework for all care and treatment. A “virtual”
hospital concept targets on-site services to those that are regularly needed while using over 100
contracts, 25 shared programs, and electronic health records and networking systems for
specialized services. TCID has 75 individual isolation rooms designed to prevent transmission and
effectively treat patients who require prolonged hospitalization.
Patients isolated during the infectious period have unlimited access to outdoor activities, medical
co-morbidities are addressed, a secure environment is available for court ordered management, and
dental, optical and hearing services are provided. Incentives encourage patients to remain in
treatment (large campus, day/weekend passes for voluntary patients, work program, educational
resources, and recreational activities on/off campus).
Results and Findings: A total of 147 TB patients have been admitted to the new TCID facility in
the last 2 years. In this period, 68 % had signficant substance abuse. 18 % of patients had either
MDR or XDR TB. The average LOS during that time was 182 days. Over that time, 90 % of
patients were successfully treated or sent back for successful community-based DOT. No TCID
staff had TST conversions or active TB in the past 2 years. No patients with drug resistant TB
have acquired further resistance while under treatment at TCID.
Conclusions: Inpatient TB care is necessary for good outcomes for some persons.
ABSTRACT 14
Tuberculosis and Homelessness in Texas, 2002-2011
Evert N., Schuster D., Vassell, B., Morris S., Filipowicz R.
Texas Department of State Health Services, Austin, TX, USA
Background: The overall number of Tuberculosis (TB) cases decreased during the 2002-2011
decade; however, there have been several TB outbreaks involving homeless persons in the United
States and Texas which threaten TB prevention and control activities. This narrative describes and
compares the characteristics of homeless and nonhomeless TB cases in Texas.
Methods: All verified TB cases reported to Texas Department of State Health Services (DSHS)
between 2002 and 2011 were included in the analysis. A case was defined as homeless if they had no
home or lacked customary and regular access to a conventional dwelling or residence. In order to
identify differences between homeless and nonhomeless TB cases, prevalence ratios with 95%
Confidence Intervals and p-values were calculated for various response variables, using
homelessness as a predictor.
Results: From 2002-2011, there were 15,094 TB cases reported to DSHS. Among these cases, 768
(5.1%) were homeless and 14,326 were nonhomeless (94.9%). Homeless cases were more likely to be
US Born [PR: 1.7; 95% CI: 1.69, 1.76], Males [PR: 1.4; 95% CI: 1.36, 1.44). Homeless cases were more
likely than nonhomeless cases to report alcohol abuse [PR: 3.2; 95% CI: 2.93, 3.41], intravenous drug
use [PR: 4.5, 95% CI: 3.49, 5.70] and non-intravenous drug use [PR: 3.7; 95% CI: 3.26, 4.28].
Clinically, homeless cases were more likely to have pulmonary [PR: 1.2; 95% CI: 1.14, 1.2], sputumsmear positive disease [PR: 1.3; 95% CI: 1.18, 1.33]. Homeless cases were more likely than
nonhomeless to be infected with HIV [PR: 1.8; 95% CI: 1.56, 2.13] and have a previous TB diagnosis
[PR: 2.6; 95% CI: 2.03, 3.38].
Conclusion: In Texas, TB disease in the homeless population represents a small percentage of the
overall TB cases. However, these cases were more likely to have sputum-smear positive, pulmonary
disease, indicating a higher degree of infectiousness. Homeless cases were more likely to be
infected with HIV and report substance abuse, which are facilitators of transmission and factors
associated with rapid progression to TB disease. These findings indicate the need for targeted
interventions to interrupt TB transmission in the homeless population and prevent future outbreaks
from occurring.
ABSTRACT 15
Correctional Signposts for Success: TB at the Crossroads
Fortune, D1; Bur, S2; Chee, C3; Murray, E4; Sittig, A5; Vassell, B6
New Mexico Department of Health1 ; Federal Bureau of Prisons2 ;Arizona Department of Health
Services3 ; Southeastern National Tuberculosis Center 4 ;Minnesota Department of Health5 ; Texas
Department of State Health Services6
Background: Beginning January 2012, the National TB Controllers/National TB Nurse Coalition
(NTCA/NTNC) Correctional Committee (CC) has developed and implemented a national action plan to
improve TB recognition, prevention and control in correctional facilities (CF).
Methods: A task force was convened that refined the Mission Statement, developed a Work Plan
with specific goals, objectives and activities. Three work groups were formed: Surveillance for
Action, Education & Training, and TB Correctional Liaison.
Results: The Surveillance for Action work group’s purpose is to enhance surveillance reporting
among TB cases in CF. Goals are to improve completeness, accuracy, and timeliness of TB data
collection in CF; to improve data analysis and dissemination at the local, state, and national level; to
optimize detection of potential outbreaks and identification of trends heralding epidemiologic
shifts that impact the spread of TB in CF and the community at large. First year achievements
include a corrections slide set (CDC) and clarification of the RVCT CF variable.
The Education & Training Workgroup’s primary focus was to compile and vet existing educational
materials and to identify a central location for easy accessibility for TB programs and CF. On-going
collaboration with the RTMCC’s and DTBE will set priority projects including training for TB
correctional liaisons and Correctional Staff.
The Correctional Liaisons work group’s initial mission was to identify a TB liaison in each state & to
enhance their knowledge of TB in corrections. The list was successfully utilized by the CC to
provide essential information concerning drug shortages to programs and CF.
In December 2012, the Advisory Committee on Elimination of TB approved a TB and Corrections
resolution that included recommendations by the CC for increasing DTBE’s focus on coordination for
TB and corrections, improving surveillance, expanding education and ensuring continuity of patient
care.
Conclusion: The CC is poised at the crossroads to have a dramatic impact on the road ahead of
controlling and eliminating TB in CF.
ABSTRACT 16
Ease of Implementing the INH/RPT Regimen
Karen Galanowsky, RN, MPH and Patricia Woods, RN, MSN
New Jersey Department of Health, TB Program
Background: The use of INH/RPT regimen was initiated, May, 2012, in NJ public health clinics.
Goals were to improve treatment completion rates for Latent Tuberculosis Infection (LTBI) among
high risk populations, determine acceptability in patient population, and closely monitor tolerability
and safety of medication.
Methods: Policies and procedures were written and adopted by the Medical Advisory Committee,
including eligibility criteria, dosage/adverse drug reactions, monitoring, and procedures for
implementation. Medication was procured by the New Jersey State Health Department and
distributed by Nurse Consultants after training. Training tools were developed for staff and
physicians. On-site trainings and webinar were provided. An access program for data collection was
developed for evaluation.
Results and Findings: Thirty seven individuals were started on this regimen. Evaluation indicates
no one was lost to follow-up, four adverse drug reactions (ADR) occurred, one patient was removed
due to pregnancy and false positive Quantiferon-TB Gold result, nineteen successfully completed
treatment, and remaining individuals are progressing without incident. One person refused the
regimen due to the large number of tablets. Despite education of physicians, resistance among a
few physicians occurred pending future data. Limited staffing for directly observed therapy (DOT)
is an on-going challenge to increased enrollment of patients. Possible use of electronic device for
DOT is a consideration for the future.
Conclusion: The educational component is critical to implementation, monitoring and safety of the
regimen. The findings indicate acceptability by patients, increased compliance for LTBI treatment,
and low incidence of ADR. There is potential for implementation in other settings.
ABSTRACT 17
Early Therapeutic Drug Monitoring for Isoniazid and Rifampin
Among Diabetics with Newly Diagnosed TB in Virginia
Scott Heysell 1, Jane L. Moore2, Debbie Staley2, Denise Dodge2, Eric R. Houpt1
1
University of Virginia, Division of Infectious Diseases and International Health
Virginia Department of Health, Division of Disease Prevention- TB Control
2
Background: Slow responders to tuberculosis (TB) treatment in Virginia have therapeutic drug
monitoring (TDM) performed for isoniazid and rifampin. Early TDM at 2 weeks after TB treatment
in diabetics was instituted given the high risk of slow response in this subset of the state TB
population.
Methods: Charts were reviewed for all patients in whom TDM was performed for the period of
early TDM, 08/01/2011 to 11/31/2012. Diabetes was categorized by self-report and patients
screened for use of insulin. All patients with diabetes had early TDM for isoniazid and rifampin at
the time of estimated peak serum concentration (C2hr) and a single dose adjustment performed if
below the expected range. For diabetics with pulmonary TB, the time to sputum culture conversion
was assessed as a marker for prevention of slow response.
Results: Twenty-one diabetics had early TDM and 14 non-diabetics had TDM for slow response. The
median time to early TDM after treatment initiation in diabetics was 23.4 ±16 days and differed
significantly from slow responders, 88 ±54 days (p=0.003). Fourteen (67%) of diabetics had a low
isoniazid C2hr compared to 6 (50%) slow responders (p=0.29). Rifampin concentration was low in 12
(60%) diabetics, including 7 (70%) of insulin-dependent diabetics, compared to 5 (41%) of slow
responders (p=0.31). Overall, 16 (76%) of diabetics had a low isoniazid or rifampin C 2hr, but no
additional risk factors were identified. Fifteen had follow-up concentrations after dose adjustment
and 12 (80%) increased to the expected range (including all for rifampin). Of 16 diabetic patients
with pulmonary TB, 14 (88%) converted their sputum culture to negative in <2 months. Including the
diabetics that failed to culture convert in <2 months, the mean number of slow responders was 1.07
per month (12.5% diabetic), decreased from pre-intervention rates of 1.62 per month (40%
diabetic).
Conclusion: Early TDM in diabetics found the majority to have a low C2hr level of isoniazid or
rifampin that corrected to the expected range with a single dose increase, and diabetics with
pulmonary TB had a favorable time to sputum culture conversion. Early TDM for diabetics can be
considered in settings of high diabetes/ TB co-prevalence where slow response or prolonged
treatment duration is a programmatic concern.
ABSTRACT 18
Tuberculosis in the United States, 1993-2012: Changing Trends and Averted Cases
Andrew Hill PhD, Michael Chen PhD, Chad Heilig PhD, José Becerra MD, MPH
Centers for Disease Control and Prevention
Background: Annual incident cases and rates of tuberculosis (TB) in the United States have been
decreasing since 1993. The decline in cases in 2009 was the largest single-year drop reported since
surveillance began in 1953. The annual percentage change (APC) in the incidence rate from 2008 to
2009 was −11.4%, compared to −3.8% average from 2000 to 2008. Two questions arise: Was there a
change in baseline level of incidence between 2008 and 2009? In view of the continuing downward
trend, how many cases of TB were likely to have been averted?
Methods: Case and population data for 1993-2012 were obtained from the National Tuberculosis
Surveillance System. In order to analyze the decline in 2009, we used a statistical method that
identifies sudden drops in a regression model. We utilized segmented regression for TB cases from
1993 to 2012 with change in trend (but no drop) at 2000, as identified in previous analyses, and a
sudden drop in 2009. Cases averted for each year after 1993 were calculated as the difference
between cases in 1993 and the regression estimate of cases for that year.
Results: APC in incidence rate was −7.0% (1993-2000), −3.8% (2000-2008), −5.6% (2009-2012).
Beyond the expected −3.8% APC from 2008 to 2009, there was an additional single-year drop in
incidence of −7.0% (95% credible interval −8.2, −5.9). Had incidence rates remained at the 1993
level, more than 200,000 extra TB cases would have occurred.
Conclusions: The continued success of TB control in the United States has markedly reduced the
burden of TB morbidity over the last 20 years following the resurgence in the late 1980’s and early
1990’s. Estimation of the number of cases averted over this time period serves as a starting point
for cost-effectiveness studies of control efforts. Until 2009, surveillance reports did not suggest
a sudden drop in incidence and analyses hitherto employed were not designed to detect one. The
change point analysis presented here allows for simultaneous estimation of the change in baseline
incidence as well as in trend.
ABSTRACT 19
Morbidity Reports in an Electronic World: Do they Still Work?
Kearns, Cheryl, MPH, Phillips, Barbara, Klemfuss, Christopher, Flynn, Colleen, RN. New York State
(NYS) Department of Health Bureau of Tuberculosis Control (BTBC)
Background: For many years, BTBC has produced quarterly morbidity reports, including line listed
data for all cases/suspects, that counties must update and return to Central Office. In 2009,
these reports were revised to add some newly required RVCT questions. The reports include coded
information, and require proper instructions and training to complete. As NYS requires electronic
reporting via the Communicable Disease Electronic Surveillance System (CDESS) of all
cases/suspects, this process may no longer be the most effective means of updating data and
ensuring accurate reporting.
Methods: As an indicator of data completeness, laboratory data on 2011 CDESS case reports was
reviewed on the final Monday of January 2012. Emails were sent to regional staff for all cases with
missing data. A conference call was held to obtain information regarding county perceptions of the
current process and suggestions for revisions.
Results: Approximately 30% of cases had at least one missing lab result at the time of the review.
Answers for all missing results were obtained within 4 days of email request, indicating available
results had not been effectively updated using the current morbidity report. Counties complained
of the duplicative process of updating paper reports and submitting information electronically via
CDESS. Additional confusion was encountered when CDESS was updated prior to the morbidity
reports with older information arriving in BTBC Central Office via mail. In recent years, BTBC has
emphasized performance on some National TB Program Objectives by adding them to individual
county contracts and including in cohort reviews. To respond to these issues, we developed a new
“National Objective Data Update” report which was introduced in June 2012. This one page per
patient report includes all variables required to calculate these national objectives. The report is
provided quarterly to each county with missing data and data are updated electronically. County
response has been positive. A review of laboratory data for 2012 cases indicated that only 15% had
missing information.
Conclusions: Data completeness using the new report has increased but still has room for
improvement. Additional methods, to include monthly emails regarding key RVCT variables, will be
introduced in 2013.
ABSTRACT 20
The Double-edged Sword: Diabetes Mellitus and Tuberculosis in Georgia, 2009-2011
Foote M, Kempker RR, Magee MJ, Maggio DM, Ray SM.
Emory University Schools of Medicine and Public Health and
GA State TB Program, Department of Public Health, Atlanta, GA
Background: Diabetes mellitus (DM) confers a significant risk of developing active tuberculosis
(TB), yet severity of disease at the time of presentation and infectious risk are unknown in this
population. This report compares diabetic and non-diabetic pulmonary TB cases reported to the
Georgia TB Program, from 2009-2011.
Methods: All verified TB cases reported from 2009-2011 were reviewed using data from the state
TB surveillance database. Associations between DM and TB characteristics were assessed using chisquare, t-tests, and multivariable logistic regression. We analyzed demographic and clinical
variables including: age, sex, race, ethnicity, country of birth, HIV status, sputum AFB smear, and
culture, chest radiography results, drug resistance, and death. DM and end-stage renal disease
were self-reported risk factors.
Results: Among 1,329 reported TB cases in Georgia, 158 (12%) had DM and 756 (57%) were sputum
culture positive (cPTB). Among cPTB patients, those with DM (n=91) were similar in age and racial
distribution and had lower prevalence of HIV (2.3% vs. 14.2%, p<0.05) than those without DM
(n=665). After adjusting for HIV, age, sex, race, foreign-born, renal failure and drug resistance,
DM was independently associated with a positive AFB smear at diagnosis (aOR 1.5, 95% CI 1.1-2.2)
and cavitary disease (aOR 2.2, 95% CI 1.5-3.1). There were no significant associations between DM
and race/ethnicity, drug resistance, or mortality.
Conclusions: TB patients with DM have evidence of more severe disease at the time of presentation
and may also pose a higher infectious risk given the association with sputum smear positivity and
cavitary disease. Future research may determine if the increased severity may be due to faster
progression or later recognition of disease in these patients. DM detection and control should be
an essential adjunct to TB control efforts.
ABSTRACT 21
Development of Latent TB Infection (LTBI) Treatment Fact Sheets to
Educate Patients to Recognize and Respond to Signs of Possible Adverse Events
Kimberley Chapman, MPH, CHES1, Gloria Oramasionwu, MD, MPH2, Joan Mangan, PhD, MST3
1
Clinical Research Branch
International Research and Programs Branch
3
Communications, Education, and Behavioral Studies Branch
Centers for Disease Control and Prevention (CDC), Division of TB Elimination, Atlanta, Georgia
2
Background: Educating patients to recognize and respond to signs of possible adverse events (AEs)
due to LTBI treatment is critical for preventing detrimental outcomes. Pilot testing was conducted
on draft patient education fact sheets to: (1) assess patient comprehension, (2) gather suggestions
for improvement, and (3) identify preferences for three regimen-specific fact sheets or one (all
inclusive) fact sheet for CDC recommended LTBI regimens.
Methods: The Systematic Process for Health Education was used to guide the development and
evaluation of the facts sheets. A convenience sample of patients recently diagnosed with LTBI and
providers was recruited from two public health tuberculosis clinics. Investigators observed clinical
visits where providers introduced the fact sheets to patients. Following the clinical visit,
investigators interviewed patients and providers using a structured guide.
Results and Findings: Eight patients were interviewed: six were diagnosed with LTBI during the
clinical visit and two had begun LTBI treatment within the last month. Patients’ median age was 41
years, with the majority being female (75%), and black, non-Hispanic (75%). Providers were nurses
(n=3), physicians (n=4), or clinic administrators (n=2).
Most patients understood the need to call a provider in the case of an AE. For scored questions
assessing patient comprehension, all patients correctly reported the name of their medication,
duration of therapy, and the need to avoid alcohol during treatment. A total of 27 (79%) correct
answers were obtained in response to five questions about missed medication doses, stopping the
medication, and calling a provider in the event of side effects.
Providers indicated the fact sheets would be improved by clarifying the importance of not
“doubling-up” the amount of medication taken following a missed dose. Patients and providers also
indicated the fact sheets would enhance patient education sessions. Patients nullified concerns
that the one page fact sheets contained too much information. Sixty-seven percent of patients and
56% of providers preferred the regimen-specific fact sheets over the fact sheet that included all
regimens.
Conclusion: The pilot test helped optimize the development of this educational resource. The
regimen-specific fact sheets have been revised and are available through the CDC website
(http://www.cdc.gov/tb/publications/factsheets/treatment.htm). Spanish language versions of
these materials are forth-coming.
ABSTRACT 22
Drug-Associated Reactions (DAR) Among Persons Receiving the Three-Month Regimen of
Rifapentine plus Isoniazid for Treatment of Latent Tuberculosis Infection (LTBI)
Moro R1, Sterling TR2, Phillips E3, Shepherd G4, Adkinson NF5, Weis SE6, Villarino ME1 and the TB
Trials Consortium
1
Division of TB Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Vanderbilt University School of Medicine, TN, USA
3
Centre for Clinical Pharmacology & Infectious Diseases, Murdoch University, Australia
4
Weill Medical College of Cornell University, New York, NY, USA
5
Asthma & Allergy Center, Division of Allergy & Clinical Immunology, Johns Hopkins University
6
University of North Texas, TX, USA
2
Introduction: PREVENT TB was a randomized open-label trial of 3 months once-weekly rifapentine
(900 mg) plus isoniazid (900 mg) (3HP) versus 9 months daily isoniazid (300 mg, 9H) for treatment
of LTBI. Early in the trial there were unanticipated reports of suspected drug hypersensitivity
(HS).
Objective: To assess adverse events previously reported as attributed to study drugs,
Methods: We analyzed all reported AE-ASD. Events with hepatotoxicity or rash only, known nondrug cause, toxicity grade <2, or that did not result in permanent discontinuation of therapy, were
excluded. AE-ASD were then evaluated using the Naranjo Score (Highly Probable, Probable,
Possible, Doubtful) for likelihood of being an Adverse Reaction to Study Drugs (AR-SD). We
analyzed syndromic presentation, severity, and risk factors for Highly Probable or Probable AR-SD
events that met ≥1 of two possible HS criteria: a) hypotension (systolic BP<90), urticaria,
angioedema, acute bronchospasm, or conjunctivitis; or b) > 4 of these symptoms concurrently:
weakness, fatigue, nausea, vomiting, headache, fever, aches, sweats, dizziness, shortness of breath,
flushing, or chills. Severe events involved hospitalization, hypotension, grade 4 toxicity, or
anaphylaxis.
Results: Among 7,799 persons, there were 156 highly probable or probable AR-SD events that met
possible HS criteria, called Drug-Associated Reactions (DAR): 140/4,040 (3.5%) 3HP versus
16/3,759 (0.4%) 9H (P<0.001). DAR cases were 63% female and 35% white-non-Hispanic. There
were 140 (93%) non-severe and 16 severe DAR events [15 in the 3HP arm (0.25 % of 4,040) and 1 in
9H]. Median time for DAR resolution was 24 hours. Neither major dermatological events nor deaths
due to DAR occurred. Associated risk factors for DAR in 7,799 persons, with P < 0.001, were
regimen 3HP, white-non-Hispanic, female sex, and age > 35. The only factor associated to severity
was the administration of any non-study concomitant medication (P=0.02).
Conclusions: Among PREVENT TB participants, DAR was associated with 3HP, white race, female
sex, and increased age. Most cases were mild and recovered within 24 hours. Severe DAR was rare
and associated with polypharmacy. As 3HP is used in clinical practice, monitoring for DAR is needed,
particularly in the patient groups described.
ABSTRACT 23
Restricted Travel ≠ Restricted Training:
Using Video Conferencing to Provide TB Training
Ellen Murray1, RN; Elizabeth Karpoff2, RN; Tommy Black3; Karen Simpson1, MSHSE
1
Southeastern National Tuberculosis Center, University of Florida
Arkansas Department of Health TB Program
3
Arkansas Department of Health IT Services
4
Little Rock Diagnostic Clinic
2
Background: The current fiscal climate faced by state and local health departments (LHDs) and
the resulting travel restrictions have the potential for restricting access to HRD training
opportunities for TB program staff. The Arkansas’ TB Program has migrated to using a videoconferencing system as a mechanism to connect the state program with LHDs around the state.
This has been an effective method to disseminate information to staff but had never been utilized
to provide training content or to convene public health staff with their external partners. When
the Arkansas program partnered with the Southeastern National TB Center (SNTC) to deliver
training related to tuberculosis in correctional settings, this system was selected as a costeffective mechanism to deliver content and maximize participation.
Methods: A total of 13 remote sites with video conferencing capabilities were selected by the TB
Program. Key personnel from the public health office, local jails and prisons were invited to
participate in the training. Site coordinators were identified to monitor the technology and to
facilitate the on-site exercises. The SNTC staff provided technical assistance to increase the
coordinators’ comfort levels and capabilities as facilitators. T1 line feed from the primary site
(Little Rock), with two-way capabilities, allowed the course faculty to interact with all 13 sites
during the 4.5 hour training. Exercises, conducted at each site, were interspersed between
presentations which encouraged open communication in a more intimate setting and created
opportunities for strengthening relationships between the LHD and corrections teams.
Results: A total of 93individuals participated across the 14 sites. The majority were from
correctional facilities (74%) and nurses (66%). 78% stated the course was excellent/very good and
fulfilled all main goals & objectives, 93% stated the program offered new knowledge/information/
skills to provide better patient/client care and 66% indicated that they would make changes to
their practice as a result of this training.
Conclusion: Overall, the evaluation indicates that this video conferencing mechanism provides an
alternative format to effectively deliver content and reach a geographically diverse audience in this
era of fiscal constraints. In addition, the use of local settings provided opportunities to “build
bridges” between the LHD and corrections teams.
ABSTRACT 24
Public Health Laboratory Expansion of NAAT for Detection and Drug Resistance
Determination of Mycobacterium tuberculosis: Long Term Impact and Sustainability
W. Murtaugh1, C. Hagan1, K. Wroblewski1,
1
Association of Public Health Laboratories
Background: In 2011 APHL, through funding made available by CDC, awarded $2.1 million to 53
public health laboratories via six month sub-grants (January- June 2011). The purpose of the
funding was to expand nucleic-acid amplification test (NAAT) services for Mycobacterium
tuberculosis and covered costs of reagents, instrumentation, assay validations, referral service
contracts, courier systems, and training. Final reports were received in July 2011. Due to the timing
of the funding period, many grantees were unable to make significant progress on the objectives of
their projects during the project period. In 2013, APHL conducted follow-up with a sub-set of
award recipients to evaluate the long-term sustainability and impact of the awards.
Methods: In February 2013, APHL requested a follow-up interview with 13 select grant recipients
with questions about the continued impact of the award on general TB NAA testing practices, as
well as progress related to ongoing objectives described in final reports submitted to APHL. The
respondents provided responses to 9 standard questions, plus 1-3 project specific questions. All
questions were developed by APHL. APHL conducted 10 phone interviews, and received 3 sets of
written responses.
Results: Twelve of the 13 laboratories had current NAAT testing capabilities. Seven laboratories
had transitioned to a new NAAT method (n=4) or were in the process of validating a new NAAT
assay (n=3), and 1 previously referring NAAT services established in-house capacity since the end
of the grant period. Of these eight laboratories, 4 chose the Cepheid GeneXpert MTB/RIF assay.
During the grant period, five laboratories expanded eligibility criteria for NAAT as well as access
to new providers or submitters, which they reported as resulting in increased volume of specimens
received for NAAT.
Conclusions: Although initial progress of the selected laboratories was limited by the six-month
grant period, laboratories continued efforts to incorporate TB NAAT into testing algorithms with
increased efficiency, while sustaining new demand for the testing services. The success and
challenges of the laboratories efforts to expand utilization of NAA testing services will guide
future recommendations made to laboratories for mycobacterium tuberculosis detection and drug
resistance determination.
ABSTRACT 25
Maintaining Continuity of TB Care in the Aftermath of “Hurricane Sandy”
Christine Chuck, MPA; Yevgeniya Vilnyanskaya, MS; Diana Nilsen, MD; Felicia Dworkin, MD;
Joseph Burzynski, MD
New York City Department of Health and Mental Hygiene (NYCDOHMH), Bureau of Tuberculosis
Control (BTBC)
Background: Bellevue Hospital, one of the oldest public hospitals in the nation, is a 25 floor, 700
bed facility located on the lower east side of Manhattan. On October 29, 2012 as Hurricane
Sandy pummeled New York City (NYC) and the surrounding regions, flooding and power outages
caused the evacuation of several hospitals in the highest flood risk areas, including Bellevue
hospital and its outpatient clinics. This displaced six TB patients hospitalized under civil
detention orders, 2 other infectious TB patients, and 27 outpatients from Bellevue’s directly
observed therapy (DOT) program.
Methods: On November 2nd, the Medical Director of Bellevue’s chest clinic notified BTBC that
outpatient services were closed, and hospital inpatients were being evacuated. The TB clinic
could not provide medication or outpatient services. NYC BTBC staff contacted each patient,
and offered follow up services at a BTBC clinic. Detained patients were sent to another public
hospital. Two infectious patients went to other hospitals.
Results: Within 5 days of request, BTBC field staff located all 27 DOT patients; 25 were
evaluated at a BTBC clinic and 2 at public outpatient clinics. All were issued anti-TB medications
and continued DOT with BTBC or Bellevue staff. Four patients completed therapy while at the
BTBC clinics; after Bellevue reopened its outpatient clinics on February 7, 2013, another 4
patients decided to continue their care at the BTBC clinic.
Six detained inpatients were transferred to Lincoln Hospital to continue therapy. BTBC staff
continued case management until they were released from detention and discharged, or
transferred back to Bellevue Hospital when it reopened. Two infectious TB patients were
transferred to hospitals in upper Manhattan.
Conclusion: Despite closure of a major medical facility, continuity of care for inpatient and
outpatients with tuberculosis was maintained, due to coordinated efforts of Bellevue and NYC
BTBC staff. Coordinated efforts between public health agencies and community providers can
ensure high quality patient care during daily activities in emergency situations .
ABSTRACT 26
TB Laboratory Tests: An Introduction and Interactive Guide
Richard Stancil, Bureau Chief, Houston Department of Health and Human Services (HDHHS)
Bureau of TB Control; Gregory R. Dufour, MPH, Microbiologist Supervisor, HDHHS Bureau of
Laboratory Services; Latricia Lewis, Microbiologist III, HDHHS Bureau of Laboratory Services;
Barbarah Brissette, RN, Chief Nurse, HDHHS Bureau of TB Control; Ted Misselbeck, Public Health
Advisor, CDC; Patrick Ndibe, Public Health Advisor, CDC; Nydia Palacios, Public Health Advisor, CDC
Background: Access to efficient tuberculosis (TB) laboratory testing is an essential component of
effective TB control programs. TB officials base programmatic decisions, such as, reporting a TB
case to the State, prioritizing contact investigations, or changing TB medication regimen, on
laboratory results. The field staff routinely collects specimens and receives laboratory results and
would appreciate a greater understanding of the specific tests or processes involved in producing
them. In an effort to make laboratory education accessible to Houston Bureau of TB Control
(HTBC) field staff and to reinforce the importance of collecting quality specimens, we created a
user-friendly teaching tool. Topics include: explaining TB laboratory processes, proper methods of
quality specimen collection, and how laboratory results affect programmatic decisions.
Methods: First, we met with laboratory subject matter experts (SMEs) to learn about TB-related
tests performed at the HDHHS Laboratory. We toured the TB laboratory with our SMEs to get a
start-to-finish view of testing (including taking pictures of specific laboratory equipment). Second,
we met with field SMEs and referred to existing field processes to learn about proper collection
methods for common field specimens, specifically sputum and blood. We also included helpful tips
for specimen collection.
The educational tool used to present the material includes lesson plans, visual media, and handouts
for staff.
Results: We developed an effective educational tool that will be presented to HTBC staff at
trainings throughout the year. The tool raises field workers’ awareness of the complexity of
laboratory processes. Education should reduce the number of unsatisfactory specimens submitted
to the laboratory. Finally, collaborating with our TB laboratory colleagues strengthened our
relationship.
Conclusions: The HBTC has developed a user-friendly teaching tool to provide field workers with a
big-picture view of the specimen collection process. The tool raises educational awareness of the
importance of laboratory tests and of their specimen collection duties. In turn, field workers can
motivate patients to provide the best specimens possible. The teaching tool will be made available
to other local and State TB programs that can modify it to suit their staff training needs.
ABSTRACT 27
Assessing the Success of a Local Level TB Surveillance Data Quality Training
Palmer AE, Donovan M, Miazad T, Cronin WA, Baruch N. Maryland Department of Health and Mental
Hygiene, Baltimore, USA
Background: Following decentralization of tuberculosis (TB) surveillance data entry in 2009,
Maryland completed its first state-wide data monitoring project in early 2010. Results revealed
numerous problems with specific variables. Training targeted to these variables occurred in 2011.
This study assesses success of that training.
Methods: Replicating the 2010 study, TB case report forms (Report of Verified Case of
Tuberculosis or “RVCT”) were compared with patient medical records for completeness and
accuracy from four medium to high morbidity counties. RVCT responses were quantified as
incorrect (differed from the patient record), missing (no response on RVCT), or not documented (no
documentation in the patient record) and then compared to prior study data.
Results: Of 2133 applicable responses for 29 patients, 38 (2%) were incorrect, 77 (4%) were
missing, and 10 (0.5%) were not documented, as compared with the first study (4184 responses for
59 patients) of 267 (6% incorrect; p<0.001), 229 (6% missing; p=0.001), and 135 (3% not
documented; p<0.001). Greatest increases in accuracy of responses were as follows: incorrect for
“Date Reported” decreased from 59% (29/49) to 3% (1/29), missing for the sub-category “Evidence
of Miliary TB” decreased from 47% (16/34) to 13% (2/24), and not documented for “Excess Alcohol
Use” decreased from 28% (15/53) to 7% (2/29).
Conclusion: Significant improvements were seen, but training did not eliminate errors in
problematic RVCT fields. This highlights the need for ongoing, sustainable training, tools, and
support for local staff, as well as ongoing internal data monitoring by state and local programs.
ABSTRACT 28
Descriptive Title: Return on Investment: Public Health Funding Reductions Threaten
Tuberculosis Control Efforts Among Foreign Born
Andrew Waters, MPH RS, Karen Nagy, LPN, Jessica Noto, MPH CHES, Lindsay Pappas, RN BSN,
Mindy Sekhon, MPH - Lexington-Fayette County Health Department
Background: Tuberculosis (TB) control and prevention continues to be a core public health function.
However, the increased risk and cultural barriers that exist with foreign born populations are
placing increased strain on public health. The inverse divergence of funding and incidence increases
the burden of TB in local communities and increases the risk to the public’s health.
Methods: Data was collected on foreign born active and latent TB patients between 2008 and 2012.
Data was analyzed for cost of treatment and completion rates for both active and latent TB
infections. Patients were also classified on risk and future cost to the public health infrastructure.
Results: From 2008 to 2012, the number of foreign born TB patients has increased ¬¬¬¬13.9% and
the number of latent infections has increased by 1.4%. In that same time frame, funding from
federal and state sources has decreased by 15.6%. Case treatment for active TB is 4380% more
expensive than LTBI treatment. Completion rates among active cases are exceptional at 88.9%, but
completion rate among latent infections is 43.0%. Aggregate risk of developing active TB to the
community is 1.1% per 100 residents with potential lifetime public health financial burden of
$1,242,632.
Conclusions: Public health funding reductions threaten the health of the community by reducing
the ability of the local health department to focus on prevention activities. Reductions in clinical
functions and staffing that are the result of funding reductions will adversely affect the
communities by displacing cost to future generations. While treatment of active TB has been the
primary focus of local TB control efforts, more efforts should directed toward successful
completion of latent treatment in order to realize a better return on investment. Collaborative
efforts between the local health department, refugee/immigrant support agencies, and primary
care medical homes should be strengthened to ensure treatment completion and more lifetime risk
reduction.
ABSTRACT 29
Implementation of the 12-dose Weekly Isoniazid plus Rifapentine Regimen for Treatment of
Latent Tuberculosis Infection in Arkansas: A Preliminary Report on Adverse Events
Patil N., Mukasa LN., Karpoff E., Egbe XM., Smith N., Bates JH.
Background and Rationale: Arkansas is one of several sites in the U.S. that are collaborating
under CDC guidance, to assess adverse events (AEs) associated with the 3-month
isoniazid/rifapentine (3HP) regimen for treating latent tuberculosis infection (LTBI). We are
reporting our preliminary findings for the period July 1, 2012 to March 31, 2013.
Methods: All cases of LTBI are reportable to the TB Control Program. Directly observed therapy
(DOT) is used for 3HP. The CDC developed a form to capture AEs data that is completed by a nurse
at each weekly visit. We downloaded LTBI data from the TB Registry and the AEs data from the
CDC designed Access database. The AEs were grouped by clinical syndromes as used in Study 26.
Results: Since July 2012, a total of 796 cases of LTBI have been reported; the majority with a
positive IGRA test. Of these, 465 (58.4%) cases were offered 3HP, and 331 (41.6%) received the
9-month isoniazid regimen. For the 50 cases on 3HP with complete outcome information, 45(90.0%)
completed the regimen; 3 stopped treatment due to AEs, and 2 were lost to follow-up. The
frequencies of AEs were: flu-like illness 24.0% (10 0f 12 completed), gastrointestinal 24.0% (11 of
12 completed), and cutaneous 14.0%. There have been no deaths or hospitalizations associated with
3HP. The 50 cases on 3HP with complete outcome information are similar to the 415 pending cases
in terms of median age, but different by gender, and race/ethnicity.
Discussion: The completion rate of 90.0% for 3HP in this study is comparable to the completion
rate of 82.1% for 3HP in Study 26, and is significantly higher than the average 55.0% completion
rate for the 9-month isoniazid regimen that we have reported in Arkansas for the past 5 years. The
frequencies of AE in Study 26 (abstract 2013) were much lower than what we have reported here;
that is, 2.2% with flu-like illness, 0.2% gastrointestinal, and 0.6% with cutaneous manifestations. A
possible explanation is that our project is specifically designed to assess these AE, whereas Study
26 was not. Arkansas has increasingly offered 3HP to LTBI cases, helped by the price of
rifapentine dropping from $71 to $50.
ABSTRACT 30
Arkansas Tuberculosis Control Program: Looking to the Future
Patil N, MD MHSA., Mukasa LN, MBChB PhD., Karpoff E, BSN RNP., Bates JH, MD MS.,
Smith N, MD MPH.
Background and Rationale: Arkansas implemented three fundamental initiatives in 2012: 1)
replacing the tuberculin skin test (TST) with an interferon gamma release assay (IGRA), specifically
T.SPOT-TB, 2) using the recently approved 3-month isoniazid/rifapentine (3HP) regimen for
treatment of latent tuberculosis infection (LTBI) instead of the 9-month isoniazid regimen, 3)
incorporation of the GeneXpert MTB/RIF assay for rapid identification of Mycobacterium
tuberculosis. We describe the process we undertook in order to share our experience with other
tuberculosis (TB) control programs.
Arkansas TB Control Program: The Arkansas Department of Health (ADH) is a centralized
administrative structure: all local health units in 75 counties are part of the Health Department. All
TB cases are monitored by the State TB Control Officer, and all LTBI cases are reportable. Prior
to 2012, on average 110,000 TSTs were conducted annually, costing the program $400,000 in PPD
solution and supplies. Individuals screened included TB contacts and varied targeted testing groups
(including some at low risk).
Change in Policy and Timeline
January 1, 2012:
 ADH ceases to provide chest radiographs to non-ADH employees and students.
July 1, 2012:
 ADH transitioned from TST to T.SPOT-TB;
 ADH ceased supplying of PPD to our partners;
 ADH introduced 3HP regimen for LTBI statewide.
Implementation Strategy
 A one-year statewide education effort of partners before implementation of policy.
 Secured support from senior ADH management to change Board of Health regulations and
state statutes and stop screening of previously defined subpopulations, now at low risk for
TB.
 ADH to offer 3HP regimen to all patients testing positive on IGRA free of cost.
Outcomes to Date
 Savings in nursing time for administering TST;
Rapid diagnosis with GeneXpert MTB/RIF potentially saving lives of TB patients.
ABSTRACT 31
Investigation of the Decline in Number of Reported Tuberculosis Cases: Georgia, 2011
Antoine Perrymon, MPH; David M. Maggio, MPH; Rose-Marie Sales, MD, MPH
Affiliations: Georgia Department of Public Health
Background: From 2010 to 2011, Georgia reported the largest single-year percentage decrease in
the number of reported tuberculosis (TB) cases since 2001 – a 15.6% decrease from 411 cases to
347 cases. Compared to the overall national 5.9% decrease in TB cases reported in 2011, we were
concerned about potential unidentified TB cases due to under-reporting.
Methods: Cases reported in Georgia’s State Electronic Notifiable Disease Surveillance System
(SendSS) were cross-matched with patient records that had an ICD-9 code for TB in the 2011
Georgia Hospital Discharge Database (GHDD). All records that matched were considered to be
reported and confirmed cases of TB in SENDSS and were not included in the investigation. The
remaining unmatched records were potential unreported cases and were investigated to confirm
whether TB was ruled out or confirmed. Hospital infection control practitioners were asked for the
final diagnosis of patients with unmatched records that had ICD-9 codes most predictable for TB.
We reviewed the hospital charts of patients where TB was not ruled out to decide if they met the
definition of a reportable case. Also, a random sample of 23 clinics across the state that provided
HIV care were surveyed to collect names of patients that the clinics diagnosed with TB in 2011 and
cross-matched these with TB cases reported in SendSS.
Results: Among 352 GHDD cases with ICD-9 TB codes, 169 (48%) were not reported in SendSS.
Among the 169 unmatched cases, 131(78%) cases had ICD-9 codes most predictable for TB and
were considered potential unreported TB cases for review. A single unreported lymphatic TB case
in 2011 that completed TB treatment was identified. There were no unreported TB cases among
the 23 HIV care clinics sampled.
Conclusion: This investigation found no evidence of systemic underreporting. We are working with
the GHHD database manager to explore ways of filtering GHHD data to exclude TB suspects for
whom TB has been ruled out by laboratory procedure results. We will conduct surveillance
investigations of unreported cases periodically to apply corrective measures whenever underreporting is identified.
ABSTRACT 32
TB Personal Stories Pilot Project
Nicole Richardson-Smith, MA, Centers for Disease Control and Prevention, Atlanta, GA, USA
Ann Lanner, Centers for Disease Control and Prevention, Atlanta, GA, USA
Background: Personal stories are an effective means to move beyond the numbers and connect to
audiences. Compelling personal stories help public health agencies convey how TB programs work and
why they are successful; they demonstrate the importance of what TB programs do. Most people in
the U.S. have never known anyone who had TB, nor do they understand how debilitating it can be.
The goal of this project is to raise awareness about TB in the U.S. by highlighting the following
points:
 TB still exists and it poses serious health consequences if not controlled,
 People in the U.S. still get TB every day and have been helped with treatment, and
 Most importantly, public health provides the critical support that TB patients need in
order to be diagnosed and cured of TB.
Methods: Authors spoke to leadership from CDC’s Division of Tuberculosis Elimination, the National
TB Controllers Association, and other organizations and asked for assistance in locating potential
participants. Participants included persons diagnosed with TB disease or TB infection and
successfully treated, with assistance from their local TB program. Authors contacted and
interviewed interested participants and developed written stories. A pilot video was taped at two
county health departments in Georgia and at CDC’s broadcast studio. The written stories were
posted on DTBE’s website March 18 and the pilot video debuted March 22 at the 2013 CDC World
TB Day Observance. Evaluation of the pilot video is underway, with electronic evaluations
administered April 1-April 10, 2013. Throughout this project, Web and social media metrics will be
compiled to determine the number of Web views, distribution, and other outcomes.
Results and Findings: Results from the evaluation will influence revisions to the video and future
video vignettes with TB patients. Web metrics from March 18, 2013, when the print stories
launched, to April 9, 2013, indicate 1,309 page views.
Conclusions: This pilot project provides products that can be used to publicize achievements in
public health. Stories told by TB patients put a “face to the numbers” by sharing personal
experiences and highlighting the important work of TB programs.
ABSTRACT 33
Baseline Analysis of Documented Sputum Culture Conversion and
Duration of Treatment in New Jersey (2004—2010)
Frank Romano, MPH
New Jersey Department of Health
Background: Between 2004 and 2010, approximately 50 percent of sputum culture positive TB
cases in New Jersey had sputum culture conversion (SCC) documented within 60 days of treatment
initiation. This study sought to 1) identify common risk factors for not having documented sputum
culture conversion (SSC) within 60 days of treatment initiation and 2) compare the median duration
of treatment of those with SCC documented to those without SCC documented.
Methodology: A statistical analysis of New Jersey TB surveillance data stored in the Tuberculosis
Information Management System (TIMS) was performed for cases reported from 2004–2010.
Findings: A disproportionate number of cases managed by private medical doctors (PMDs) in New
Jersey did not have SCC documented. While PMD cases represented only 15.8 percent of cases in
the study cohort, they accounted for 24 percent of all cases without SCC documented within 60
days of treatment initiation. χ2(1, N = 1178) = 58.52, p < .0001 ; OR=3.87 (95% CI: 2.70—5.56)



Among all cases, the duration of treatment for those without SCC documented was
significantly (5 weeks) longer than that of cases with SCC documented. t(1176) = 5.48, p <
.0001;
Cases with SCC documented had twice the odds of completing Tx in ≤ 30 weeks than cases
without SCC documented. χ2(1, N = 1178) = 51.54, p < .0001; OR=2.35 (95% CI: 1.86—2.99)
On average, the duration of treatment for cavitary cases without SCC documented was
significantly (7 weeks) longer than that of cavitary cases with SCC documented.
t(408) = 4.46, p < .0001
Conclusions: While cases without SCC documented had a significantly longer duration of treatment,
it is difficult to make the causal inference that the absence of documented SCC within 60 days of
treatment initiation leads to extended therapy. Other factors, such as clinical response to
therapy, radiographic evidence, and non-compliance to therapy play a major role in determining the
appropriate duration of treatment for TB case-patients.
The guidelines state that the 4-month continuation phase should be used in the large majority of
patients. During the observed time period, the duration of treatment for nearly half (48.4%) of
cases was more than 30 weeks. The observations and findings in this analysis may best be
interpreted as baseline values; a standard by which to compare the relative impact of future TB
interventions in New Jersey.
ABSTRACT 34
Identifying Common Questions about LTBI Treatment for the
Development of a Live “Ask the Experts” Webinar
Sederberg, J. 1, Raftery, A.1, Kanouse, J.1, Musoke, K.1, Chen, L.1
1
Curry International TB Center (CITC), Oakland, CA
Background Statement of Problem or Objectives: As funds for public health programs diminish,
treatment of LTBI is increasingly the purview of community health clinics and primary care
providers. Despite this, LTBI treatment for those patients who are at high risk for developing TB
disease once infected remains a priority for most jurisdictions. CITC’s Curriculum Advisory
Committee concluded that a national webinar that would help answer some of the most common
LTBI treatment questions not clearly addressed in current CDC guidelines would be timely for both
public health and community health providers. The first step in the planning process was to identify
what those questions were.
Methods: An electronic questionnaire was included in course registration materials. By assessing
this feedback from registrants prior to final content development, curriculum designers were able
to incorporate the most commonly asked questions into planning discussions. As results of the
questionnaire were tabulated and FAQs were identified, an agenda was created and subject matter
experts on each identified topic area were recruited.
Results: An analysis of responses indicated the top four topic areas: LTBI regimens, whether or
not to initiate treatment, interruptions in therapy/counting doses, and patient monitoring
(especially for those with co-infections or other associated conditions). Faculty incorporated these
questions into their presentations. After the four presentations concluded, time was allowed for
real-time questions from course participants. This also helped to quickly clarify points of confusion
and fed into the panel discussion.
Conclusions: The responses to the pre-course survey demonstrated that areas of confusion still
exist around LTBI treatment and that expert advice is needed. Evaluation results indicate that
allowing learners to help guide course content is an effective method for meeting the needs of the
target audience and for improving participants’ knowledge and self-efficacy. Course planners and
faculty were able to adjust the agenda and session content late into the planning process to best
respond to the needs of the target audience. This ongoing dialogue between planners, faculty, and
learners offers a level of learner input into curricula that often is missing in stand-up learning
activities and enhances the efficacy of this training method.
ABSTRACT 35
Tuberculosis Treatment Outcomes Among Individuals Born in Mexico and Central America
Compared with Other Foreign-Born Persons in California, 2000-2009
Katherine Robsky 1, Neha Shah1,2, Marisa Moore 2,3, Lisa Pascopella1, Pennan Barry1, Jennifer Flood1
1
Tuberculosis Control Branch, Division of Communicable Disease Control, Centers for Infectious
Diseases, California Department of Public Health
2
Centers for Disease Control, Division of Tuberculosis Elimination
3
San Diego County Health Department, Tuberculosis Control Program
In 2011, 78% of California tuberculosis (TB) cases were foreign-born, one-third of which were from
Mexico or Central America. Differences in demographics, clinical characteristics, and risk factors
between Mexican- or Central American-born (M/CAB) and other foreign-born (OFB) TB cases may
adversely affect TB treatment completion.
This analysis assessed if TB treatment outcomes differ between M/CAB and OFB and identified
characteristics associated with poor treatment outcomes.
Adult foreign-born TB cases alive at diagnosis with pulmonary, culture-positive disease reported in
California during 2000-2009 were included. Surveillance data were stratified by birth country:
Mexico and Central America and all other non-U.S. countries. To assess differences in poor
outcomes (moving/being lost to follow-up and death compared to treatment completion) between
M/CAB and OFB, Cox proportional hazards models estimated adjusted hazards ratios (aHR) with
95% confidence intervals (CI). Stratified models identified factors associated with poor outcomes
among M/CAB and OFB. Models were adjusted for potential confounders identified as significant
(p<0.1) in bivariate analyses.
During 2000-2009, there were 13,692 foreign-born TB cases, of which 5,122 (37%) were M/CAB.
M/CAB were more likely to move/be lost (11%,n=540) compared to OFB (5%,n=453); this risk
remained in the adjusted model (aHR:1.6;CI:1.4,1.8). A smaller proportion of M/CAB (6%,n=321) died
compared to OFB (8%,n=639); however in the adjusted model, M/CAB were at increased risk for
death during treatment (aHR:1.2;CI:1.1,1.4). An increased risk of moving/being lost among M/CAB
was associated with being a migratory worker (aHR:1.6;CI:1.3,2.0) and being diagnosed in a
correctional facility (aHR:5.7;CI:4.0,8.3). An increased risk of death among M/CAB was associated
with being homeless (aHR:2.1;CI:1.4,3.0) and having pyrazinamide mono-resistant TB
(aHR:1.6;CI:1.1,2.4). Time between immigration and TB report was not associated with death among
M/CAB (aHR:1.2;CI:0.8,1.7), but OFB recent arrivers (<6 months) were at decreased risk for death
(aHR:0.5;CI:0.3,0.7).
M/CAB are at increased risk for poor treatment outcomes compared to OFB. To improve treatment
outcomes, targeted programs should focus on the characteristics associated with poor treatment
outcomes among M/CAB, including recent immigration, homelessness, migrant work, incarceration
and pyrazinamide mono-resistance (associated with Mycobacterium bovis infection). Intensified
public health and community interventions may be needed to strengthen TB control for M/CAB in
California.
ABSTRACT 36
Hepatotoxicity of TB Drugs in the Elderly
Jennifer Hosford1, MPH1, Michael von Fricken, MPH2, Kevin Fennelly, MD, MPH1,
Michael Lauzardo, MD1, Jonathan Shuster, PhD3, Jennifer Ann Lyon4, Susan Nayfield, MD5
1
Southeastern National Tuberculosis Center and Emerging Pathogens Institute, Department of
Medicine, University of Florida, Gainesville, FL, USA
2
Department of Global Health, Emerging Pathogens Institute, University of Florida, USA
3
Clinical and Translational Science Institute, University of Florida
4
Health Science Center Libraries, University of Florida
5
Department of Aging and Geriatric Research, College of Medicine, University of Florida
Background: TB occurs at an increased rate in older individuals. Unfortunately, these individuals
are more likely to have adverse events to the toxic drugs used to treat the disease. The goal of
this investigation was to conduct a systematic literature review in order to determine if older age
was a risk factor for hepatotoxicity resulting from treatment with first line drugs used to treat
active and latent tuberculosis. We hypothesized that older patients would have higher rates of
hepatotoxicity.
Methods: Studies were identified from an electronic search of MEDLINE (1966-2011), Cochrane
Controlled Trial Registry (1898-2011), CINAHL® (1961-2011), and Science Citation Index Expanded
(1900-2011). We defined” elderly” as being 60 years of age or greater. Our main outcome of
interest was elevation in LFTS >3–5 times the upper reference level and/or symptoms of hepatitis.
Results: Three-hundred and twenty-one full text selections were reviewed in full-text format.
Many did not meet the study criteria, leaving 38 studies, including with 40,034 participants with
1,208 cases of hepatotoxicity. Based on the random effect model, we obtained the overall mean
effect size of 0.534 (95% CI: 0.215 to 0.853), that is equivalent of an odds ratio of 1.71 (95% CI:
1.24 to 2.35). Our analysis reveals that patients older than 60 had significantly more
hepatotoxcities than patients 60 years or younger (p < 0.001, chi-square test).
Conclusion: A significantly increased number of hepatotoxic events occurred in those over the age
of 60. Further research examining alternative TB treatment dosing schedules and regimens for the
60+ population are necessary to ensure patients receive the proper quality of care.
ABSTRACT 37
A Description of Culture-Confirmed TB Cases with False-Negative
Interferon-Gamma Release Assay Results in Washington State
Terri Simpson, University of Washington
Julie Tomaro, Washington State Department of Health, TB Services
Scott W. Lindquist, Kitsap Public Health District
Background: In 2009, the Centers for Disease Control and Prevention (CDC) added information on
Interferon-Gamma Release Assay (IGRA) results to the national TB surveillance database. The
information reported for IGRAs, and potential factors associated with false-negative IGRAs in
culture-confirmed TB cases, remain unexplored.
Methods: Using a retrospective design we analyzed verified, culture-confirmed cases of TB with
positive or negative IGRA results reported to the CDC between January 1, 2009 and December 31,
2011, in Washington State.
Results: Few (n = 2, 1%) of the 152 TB cases with IGRA results lacked a collection date. IGRAs
collected for the remaining 150 cases ranged from 57 days after, to 885 days before, obtaining a
sputum or tissue culture. IGRA collections ranged from 27 days after, to 724 days before,
initiating treatment. Twenty-two (15%) of the 150 TB cases with an IGRA collection date had
negative IGRA results. False-negative IGRA cases were older (M = 59, SD = 23 yrs) than truepositive cases (M = 45, SD = 22 yrs) (t = 2.655, df = 148, p = 0.009). More men (n = 17/73, 23%)
than women (n = 5/77, 6%) had false-negative IGRA results (χ2 = 8.445, df = 1, p = 0.004). A
greater than expected proportion of false-negative cases (n = 5/22, 23%) died before completion
of therapy, compared with true-positive cases (n = 6/120, 5%) (χ2 = 8.175, df = 1, p = 0.014). Falsenegative cases were more likely to be immunocompromised (n = 9/22, 41%) than true-positive cases
(n = 25/128, 19%) (χ2 = 4.895, df = 1, p = 0.027). Country of nativity and site of TB disease were not
associated with IGRA results.
Conclusions: A specified, short window of time before or after culture confirmation of TB is
recommended for reporting IGRA results of verified cases to minimize confounding of IGRA results
with latent TB infection. IGRA results reported after treatment initiation may inflate estimates of
false-negative IGRAs. Further analysis is warranted to determine whether age, gender,
immunocompromise, and treatment outcomes are associated with false-negative and true-positive
TB cases in the United States.
This study was funded by a grant from the Firland Foundation.
ABSTRACT 38
Use of 12-dose Isoniazid and Rifapentine for the
Treatment of Latent TB in Connecticut
Kelley Bemis, MPH1,2, Mark Lobato, MD3, Lynn Sosa, MD4
1
Centers for Disease Control and Prevention/Council of State and Territorial Epidemiologists
Applied Epidemiology Fellowship, 2Erie County Department of Health, 3Division of Tuberculosis
Elimination, Centers for Disease Control and Prevention, 4Connecticut Department of Public Health
Background: In December 2011, the Centers for Disease Control and Prevention (CDC)
recommended a new option for the treatment of latent tuberculosis infection (LTBI) consisting of
12 weekly doses of isoniazid (INH) and rifapentine (RPT) given by directly observed therapy (DOT).
Studies performed in persons at high risk for progression to TB disease (e.g., contacts to pulmonary
TB cases) indicate the INH-RPT regimen is as effective as 9 months of daily INH and is more likely
to be completed. However, use of this regimen has not been assessed in a broader population.
Methods: The Connecticut Department of Public Health (CDPH) has requested that all providers
obtain INH-RPT for the treatment of LTBI from the CDPH, free-of-charge. To monitor the
proportion of patients who complete treatment, adverse drug effects, and feasibility of using INHRPT in Connecticut, active surveillance is performed on all reported cases prescribed INH-RPT and
DOT logs are requested for each patient. A descriptive analysis was conducted on patients
reported since implementation of the regimen in March 2012.
Results: In Connecticut, 82 patients started treatment for LTBI using 12 doses of INH-RPT. The
median age was 39 years (range: 14–90); 41 (51%) were male. Among patients with known data, 11/75
(15%) were non-Hispanic black, 17/75 (23%) were non-Hispanic white, and 15/75 (20%) were Asian;
32/75 (42%) were Hispanic. Country of origin was known for 73 patients; 49 (67%) were foreign
born.
Of 82 patients, 36 (44%) are currently on treatment or have planned start dates. Among the
remaining 46 patients, 39 (85%) completed treatment and 7 (15%) stopped treatment. Six patients
stopped due to either nausea, diarrhea, rash, lightheadedness or elevated liver function tests. One
patient stopped due to an event unrelated to treatment.
Conclusions: Based on tolerability, safety and treatment completion, the early stages of
implementing weekly 12-dose INH-RPT for the treatment of LTBI in Connecticut suggest the
regimen is a promising alternative to 9 months of daily INH.
ABSTRACT 39
Model Performance Evaluation Program (MPEP): A Continued Effort to Ensure
Accurate Drug Susceptibility Testing for Mycobacterium tuberculosis Complex
C. Stafford, L. Diem, M. Yakrus, B. Metchock, A.M. Starks
Centers for Disease Control and Prevention, Atlanta, Georgia
Background: The Model Performance Evaluation Program (MPEP) is a voluntary CDC program used to
assess a laboratory’s drug susceptibility testing (DST) practices for M. tuberculosis complex
(MTBC) biannually. In 2012, the coordination of the program shifted solely to the Laboratory
Branch (LB) of the Division of Tuberculosis Elimination.
Methods: LB selected and shipped a panel of five MTBC isolates in November 2012 to each
participating laboratory for DST. Self–reported DST results were submitted via an online tool
(Snap Survey) and were analyzed by site and in aggregate.
Evaluation: Eighty-nine laboratories submitted results for the November 2012 panel. For rifampin,
laboratories achieved 99.8% agreement, and for isoniazid, 98.5%, compared to expected results.
However, only 79.4% agreement for ethambutol (EMB) and 87.2% for pyrazinamide (PZA) was seen.
The discordance for EMB was noted across all methods reported, while PZA discordance was
primarily noted for MGIT 960.
Conclusions: Issues remain with conventional DST methods for EMB and PZA, two of the first line
drugs used to treat tuberculosis. LB continues to refine data collection techniques and provide
challenging isolates and address issues related to MTBC DST across the country.
ABSTRACT 40
Failure to Convert or Failure to Collect – An Analysis of Sputum Conversion in Virginia
Staley, D., Moore, J.
Virginia Department of Health
Background: An evaluation of sputum culture conversion was undertaken for 2011 cases, as only
54.4% of respiratory (pulmonary, pleural or laryngeal) TB cases converted sputum within 60 days
during 2010. Discussion during cohort review of 2010 cases repeatedly underscored factors that
may contribute to failure to achieve sputum conversion within 60 days of treatment initiation.
Objectives for the evaluation included: determining the portion of the cases that failed to convert
due to extensive disease; determining the portion of cases that failed to convert where sputa was
not collected in a timely manner; evaluating factors that impacted sputa collection and
identification of interventions to improve performance.
Methods: Surveillance data were used to determine 2011 sputa culture positive cases. Interviews
were conducted with nurse case managers (NCM) to verify the date of conversion; identify
circumstances that were a barrier to sputa collection; obtain additional dates of sputa collection;
and review other factors that may have delayed conversion. Information was then analyzed for
collection of sputa between days 55 -60, a timeframe determined to be optimal to document
conversion within 60 days for purposes of this investigation.
Results: In 2011 there were 118 culture positive respiratory cases. Twenty-seven (22.9%) failed to
demonstrate sputum culture conversion within 60 days of treatment initiation. One case left the
country prior to day 60, leaving 26 cases for investigation. Sputa were collected between 55-60
days after treatment initiation for 10 cases; however, none had a full cluster of 3 specimens. Of
the 26 without culture conversion, 11 remained culture positive after 60 days, 10 did not have
timely collection of sputa but were culture negative on the first specimen collected after day 60,
and 5 had no documentation of follow-up sputa collection.
Conclusion: This study documented that failure to document sputum culture conversion was in part a
failure to collect specimens in a timely manner. Staff training, scheduling sputa collection at day
55-60 upon treatment initiation, active intervention with clients who refuse to provide sputa, and
increased NCM “ownership” of clients who are in facilities or that relocate within the U.S. would
improve performance.
ABSTRACT 41
Global Health in Philadelphia: The Philadelphia Refugee Health Collaborative
Gretchen Wendel, Philadelphia Refugee Health Collaborative at Nationalities Service Center
Background: Formed in September 2010, the Philadelphia Refugee Health Collaborative (PRHC) is a
regional coalition consisting of Philadelphia’s three refugee resettlement agencies and eight refugee
health clinics. The core mission of the Collaborative is to create an equitable system of refugee
health care in the Philadelphia region that ensures a consistently high standard of care for all
new refugees and improves the health outcomes of Philadelphia’s refugee population.
Methods: Each year, PRHC provides domestic health screenings, primary care and access to
laboratory, radiology and subspecialty services to newly arrived refugees. These services are
provided through strong partnerships between local resettlement agencies and hospital based
academic medical practices. Through an innovative, collaborative approach, the PRHC provides high
quality care to refugees as well as opportunities for pediatric and primary care residents, nursing,
medical and occupational therapy students and other allied health professionals opportunities to
practice global health locally.
Results: Prior to the formation of the Collaborative, refugees often waited up to 80 – 90 days for
an initial screening appointment. Delays in accessing health care also delayed entry into
employment, affecting overall integration negatively. Currently, newly arrived refugees to
Philadelphia are seen in average of less than 20 days to appointment. The Collaborative also
coordinates closely with the Philadelphia Department of Public Health to provide health orientation
to newly arrived refugees and follow up on infectious disease treatment including monitoring of
latent tuberculosis in adults and children. In 2012, the Collaborative coordinated access to primary
and specialist health care for over 800 newly arrived refugees in Philadelphia. Incoming refugee
groups have included Bhutanese, Burmese, Congolese, Cuban, Eritrean and Iraqi populations.
Conclusions: Partnering with local university health systems provides an effective means to ensure
access to timely primary and specialist medical care for newly arrived refugees. As chronic health
conditions increase in the U.S. population (including newly arrived refugees), unique models of care
will be needed to address these health issues. Being able to meet the evolving health care needs of
refugees with different models of care has the potential to lead to improved health care outcomes
for all refugees in the US.
ABSTRACT 42
Operation Red Snapper: Contact Investigation in the Homeless of Minneapolis
Dean Tsukayama, Carol Klitz, Randy Ottoson, Gretchen Krawczynski, Dianne Finn, Shannon Sinkel
In 2008 we became aware of a MTB genotype that was caused disease in 4 homeless individuals in
Minneapolis. It was ultimately found in 9 homeless individuals over a 3 year period. Encountering
many problems with contact investigation in this population we decided to change our approach. This
abstract describes the changes that were made and the results.
We met with representatives of homeless shelters and other gathering places for the homeless
across Minneapolis and St. Paul as well as with the Minnesota Department of Health We were able
to obtain rosters of persons who had stayed at the shelters at the same time as our index cases.
We defined our closest contacts as 279 persons who had spent the most nights with the index
cases.
Identifying the contacts still left the problem of finding and evaluating them. We held evening
screening clinics at two of the shelters that were the most prominent in our investigation. The
incident command system was implemented to quickly execute our plan. Evaluation included symptom
review and physical examination, rapid HIV testing and IGRA testing. We pre-arranged for CXRs to
be performed immediately at Hennepin County Medical Center (HCMC) Emergency Department. 391
individuals were screened, with a Quantiferon positive rate of 13.6%. However only 24% percent of
our high-risk contacts were captured in these clinics. Noting that 36 of these contacts had used
the HCMC Emergency Department or Urgent Care clinics, and taking advantage of our shared
electronic medical record, we placed alerts on their charts, asking for latent tuberculosis testing,
chest x-rays and a clinic appointment to the Hennepin County Public Health Clinic. An additional16
contacts were identified and evaluated through the alerts. Overall we evaluated or otherwise
accounted for 53% of the high risk contacts. No additional cases of active tuberculosis were found.
Creative methods can improve outcome, but contact investigation in the homeless remains a
daunting problem.
ABSTRACT 43
Time to Negative Sputum Cultures in Pulmonary Tuberculosis
Dean Tsukayama, Manoj Ray, David Johnson
Culture negativity had two months after treatment for pulmonary tuberculosis indicates that
treatment duration does not need to be prolonged and has been used as a indiicator for
consideration to decrease the duration of standard therapy given. Some studies to study treatment
courses indicate that up to 30% of patients do not convert for their sputum cultures to negative
after two months of therapy. We performed a retrospective review of 89 consecutive patients with
pulmonary tuberculosis treated in our clinic over a four year period to evaluate time to culture
negativity. Among study patients, the mean time to negative culture was 29.1 days (SD=26.6). We
found that patients that had positive sputum smear tests had significantly longer times to negative
culture vs. those with negative smear tests (37.9 days vs. 18.3 days, p=0.001). In addition, patients
that presented with a cough had significantly longer times to culture than those without a cough
(34.3 days vs 20.2 days, p=0.026). No significant differences were observed by foreign-born status,
sex, age or gender. We found that culture negativity at 60 days was achieved in 82% of patients
and within 75 days in 96%. The main reason for not being able to documenting culture conversion at
two months after initiation of therapy was not obtaining a culture at 60 days. In contrast to what
has been reported in the literature, in an urban setting in the United States, culture-negativity at
two months is achieved in almost all patients.
ABSTRACT 44
Aggregate Report of Laboratory Data from
CDC TB Elimination Cooperative Agreement (CoAg)
F. Tyrell, T.L. Dalton, C. Stafford, M. Yakrus, and A.M. Starks
Centers for Disease Control and Prevention, Atlanta, Georgia
Background: Methods, workload, and turnaround time (TAT) data are reported in CoAg narratives
by 58 public health laboratories (PHL). These data are analyzed and compiled in a biennial aggregate
report. Data are used for monitoring adoption of new technologies, assessing progress in meeting
national recommendations for TAT, and peer-group comparison.
Methods: Self-reported data, unless noted otherwise, were analyzed on a per patient basis. Trends
for calendar years 2008–2011 were analyzed and some data were compared with U.S. national
surveillance data.
Evaluation: PHL saw a decrease of 19% in specimen volume and 11% in patients for whom a clinical
specimen was submitted. A significant increase in direct nucleic acid amplification testing (NAAT)
was noted. TATs remained stable for AFB smear, identification of Mycobacterium tuberculosis
complex, and drug susceptibility testing (DST). However, meeting recommended TAT for DST and
specimen delivery remains challenging. PHL contributed a significant proportion of DST results
compared to private sector laboratories.
Conclusions: National TAT recommendations should be re-evaluated. Individual laboratories should
use the report to benchmark their own TAT and other trends. PHL will continue to require
significant support to maintain or improve testing competencies.
ABSTRACT 45
False Positive QuantiFERON Gold In-Tube Assays In HIV Patients
R.M. Webb1, W. Changhong2, L. Zhang3, M. Holcombe3, P. Byers3, T. Dobbs3
1
University of MS Medical Center - Jackson, MS/US, 2University of Mississippi - Hattiesburg,
MS/US, 3Mississippi State Department of Health - Jackson, MS/US
Rationale: The Mississippi State Department of Health (MSDH) expects HIV patients with latent
TB infection (LTBI) to take LTBI treatment. In 2009 when QuantiFERON Gold-in-Tube (QFTGIT)
testing began being used for HIV patients and results reported to MSDH we noted increased
positive(+) tests among patients with prior negative tuberculin skin tests and no new known
exposure to TB. In response to concerns for false positives(fp), MSDH repeated the QFTGIT
twice in the MSDH lab before making a determination of LTBI and recommending LTBI treatment.
Methods: We retrospectively reviewed the MSDH database from 2009-2012 for HIV+ patients
with a QFTGIT+ result that had a repeat QFTGIT that was positive (LTBI+)or two repeats that
were negative . Demographics and TB risk factors among patients labeled as LTBI+ versus fpLTBI
after repeat testing were reviewed by multivariate analysis. An independent t-test was conducted
to compare TB AG–nil for initial QFTGIT+ result in LTBI+ and fpLTBI.
Results: 101 patients with QFTGIT+ results reported to MSDH had repeat testing. Sixty-eight%
were male and 92% were black; average age was 43 years. Thirty-two% had a CD4 less than 350
and 80% were on HAART. Of the 101 QFTGIT+ on initial test, 24 were positive on one of two
repeat tests (LTBI+) and 77 were negative on two repeat tests (fpLTBI). LTBI+ was associated
with known prior LTBI or active TB p<0.0001. CD4 count, viral load, use of HAART, gender, race,
diabetes and alcohol use were not associated with QFTGIT+ results. . There was a statistically
significant difference in the TBAG-Nil values for LTBI+ (mean=4.474, SD=5.530) and fpLTBI
(mean=1.231, SD=2.146); t (21) = 2.567, p = .018. No TB cases have resulted from fpLTBI not
treated for LTBI at this time.
Conclusion: When no new TB exposures or TB risk factors can be documented in HIV patients with
+ QFT tests repeat QFT testing might be warranted. Positive results lower in value may be more
likely to be fpLTBI. Repeat testing not only prevented overutilization of nursing, medical and drug
resources but prevented unwarranted use of LTBI treatment with exposure to potential adverse
reactions in HIV patients.
ABSTRACT 46
Successful Use of 3HP for Latent TB Infection in a Statewide TB Program
R. Webb1,2, M Holcombe2, R. James2, S. Quilter2, C. Ho3, L. Zhang2, T. Dobbs1,2
1
Mississippi State Department of, 2University of Mississippi Medical Center, 3Centers for Disease
Control and Prevention
Background: Completion rates (CR) for latent TB infection (LTBI) treatment in 2010, Mississippi
State Department of Health (MSDH), were 69%. MSDH piloted the 3-month isoniazid and
rifapentine regimen (3HP) in June 2011. Other LTBI regimens used included 9-month daily or twiceweekly isoniazid and 4-month daily rifampin regimens (non-3HP).
Methods: Patients treated with 3HP had a positive result for QFT or TST, were > 12 years, not
pregnant, or HIV-infected on anti-retroviral treatment. Patients received medications by DOT and
clinical assessments weekly and monthly laboratory monitoring. We reviewed reasons for incomplete
treatment, June 2011–March 2013. CR for patients receiving 3HP and non-3HP during 2011– 2012
were compared. Adverse reactions (AR) resulting in treatment discontinuation were reviewed.
Results: 547 patients started 3HP, with 107 still taking the regimen. Of 440 patients eligible to
complete therapy, 362(82.7%) did, including 47/61(77%) homeless cases, and 51/59 (86%) foreignborn patients.
22/547 (4%) stopped therapy for reasons unrelated to AR (Pregnancy-3, Refusal-5, Lost-8 Moved6); 56/547 (12.6%) due to AR. 14/56 (25%) had serum transaminase concentrations 3-5 times
above the upper limit of normal and five had associated gastro-intestinal (GI) symptoms. All
recovered normal liver function. One had treatment-associated thrombocytopenia. 42/56 (75%)
stopped for non-hepatitis AR: syncope(1); low blood pressure(2); rash(4); urticarial reaction(4); or
constitutional symptoms including fatigue, myalgias, fever, headaches, and/or chills(11). Twenty had
GI symptoms without elevated serum transaminase concentrations, 14 also had constitutional
symptoms.
2/547 patients went to the ER with GI symptoms and syncope. 6/547(1%) patients were
hospitalized during treatment for flu-like symptoms and/or GI symptoms; two with hepatitis.
Length of stay ranged from 2 to 12 days (median 4); no vasopressor use, organ failure, or deaths
occurred.
CR for patients on 3HP were higher than for non-3HP regimens overall (83% vs. 58%, p<0.001) and
for contacts (88% vs. 64%, p<0.001).
Conclusion: MSDH successfully implemented 3HP for LTBI therapy statewide with an overall
completion rate of 83%. CRs for 3HP was 25% higher for all patients and 24% higher for contacts,
than those on a non-3HP regimen. While AR resulted in discontinuation of 3HP in 12.6% of patients,
no deaths or permanent impairments occurred.
ABSTRACT 47
A Congregate Setting Contact Investigation and the Insufficient
Evidence for a Rush to Judgment
Wolman M, Napolitano E
New Jersey Medical School Global Tuberculosis Institute
Background: Effective contact investigations are an essential component of TB Control. Routine
investigations may reveal exposure in congregate settings. Common types of congregate settings
include social and recreational, schools, shelters, houses of worship, correctional and the workplace.
When effective, these investigations may lead to the identification of large numbers of contacts.
When ineffective the investigations can be a poor use of program resources.
Methods: July 2012 Index case #1: 27 y/o diagnosed with pulmonary TB. 3 week cough. Cxr
abnormal/non-cavitary. Sputum smear 2+. MTB. Pansensitive. Church member during infectious
period. Irregular attendance in bible study classes and church services. 2 household contacts
identified. QFT negative. No church contacts identified. Investigation closed.
November, 2012 Index case #2: 39 y/o diagnosed with pulmonary TB. 3 month cough. Cxr
abnormal/non-cavitary. Sputum smear 2+. MTB. Pansensitive. Attended same church as case #1.
Irregular attendance in bible study classes and church services. 7 household contacts identified. 6
QFT negative. 1 LTBI. No church contacts identified pending outcome of DNA fingerprinting
comparison analysis between cases 1&2. If genotype match is evident investigation to proceed with
contact identification. If match is not evident investigation will close.
Results: DNA analysis demonstrated that strains from cases 1&2 are from the same B family.
However, there is a 3 band difference which indicated that this was not an exact match suggesting
that transmission did not occur between cases 1&2 at the church. As a result, contact investigations
were officially closed.
Conclusion: DNA genotyping has evolved into an indispensable tool for TB Control programs. When
used judiciously, the practical applications of this molecular approach coupled with the expertise
required in conventional contact investigations offers the potential to provide a vital and decisive
role in assisting and guiding program staff in decision-making during contact investigations. As
illustrated, without access and proper interpretation of genotype results it may have been
presumed that transmission in the form of an outbreak had occurred in the church resulting in a
rush to judgment and the unnecessary testing of church members.
ABSTRACT 48
TBNet - TB Treatment Completion on a Global Scale
Edward L. Zuroweste, MD, Chief Medical Officer, Ricardo Garay, Health Network Manager,
Deliana Garcia, Director International Project, Migrant Clinicians Network
Background Statement of Problem or Objectives: Transnational tracking is critical to treatment
completion for TB among migrants. For 18 years, Migrant Clinicians Network has provided global
case management to thousands of TB patients traveling across the world through its project,
TBNet.
Methods: Analysis of TBNet cases enrolled from January 1, 2005 to December 31, 2011 was
conducted by the Chief Medical Officer (CMO). Final case classification was provided by the
treating clinician or through clinical review by the CMO. A second analysis of 2011 cases was also
conducted.
Results and Findings: A total of 1,145 cases were referred by Immigration centers and health
departments across the United States. The destination country did not recommend treatment for
34 case. treatment was recommended for 1,111 cases.. Thirteen patients died, not all from TB. Of
the remaining 1,098 patients, 112 patients were lost to follow up and 64 refused treatment. TBNet
documented successful outcomes for 922 patients resulting in a treatment completion rate of 84%.
Analysis of 2011 data indicates that 167 cases were referred between January 1 and December 31.
Treatment was not recommended for 4 cases by the destination country. Of the remaining 163
cases, 5 patients died, not all from TB, 13 were lost to follow up and 10 refused treatment. TBNet
documented a treatment completion rate of 85.4%
Conclusions Consistent with Background and Findings: The World Health Organization target for
tuberculosis treatment completion is 85% of smear-positive cases. In 2009, the last year for which
data are available, 88% of patients requiring treatment of less than one year successfully
completed their treatment in the United States. Treatment success rates among difficult-to-follow
or mobile populations typically range far below that level. Very little data exists regarding patients
who migrate internationally. Typically, when patients cross national borders, there is no mechanism
to track their treatment outcome.
TBNet has worked with more than 5,000 participants. While many have stayed in the US the
majority of cases returned to their country of origin. Whether assisting to transfer a patient
across the Texas/México border or from the USA to one of seventy other countries, TBNet has
proven to be an innovative approach to tuberculosis management in migrating patients.