CITC Newsletter — Summer 2014

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

About CITC

CITC creates, enhances, and disseminates resources and models of excellence, and performs research to control and eliminate TB in the United States and internationally.

CITC is designated by the Centers for Disease Control and Prevention (CDC) as the Regional Training and Medical Consultation Center (RTMCC) for the Western Region, serving Alaska, California (including Los Angeles, San Diego, and San Francisco), Colorado, Hawaii, Idaho, Nevada, Oregon, Utah, Washington, and the U.S. Affiliated Pacific Islands.

Committed to the belief that everyone deserves the highest quality of care in a manner consistent with his or her culture, values and language, CITC develops and delivers highly versatile, culturally appropriate trainings, educational products, medical consultation, and technical assistance.

TB Control in the Western Region

CITC Newsletter is proud to highlight TB control efforts in CITC‘s Western Region of the United States. In this issue, we feature the Guam TB Control Program.

Guam landscape

From Hawaii, fly 8 hours west. Or from Tokyo, fly 3 hours east and you’ll reach the beautiful island of Guam, the largest island in Micronesia. As the westernmost U.S.-affiliated Pacific Island (USAPI) territory, Guam’s official motto is no surprise: “Where America’s day begins.”

Guam’s 212 square miles (a drive of only 30 miles from end to end) are home to 161,000 Guamanians. Inhabited by the indigenous Chamorro people for 4,000 years, colonized in the early 1500s by Spain, taken over by the U.S. in 1899 and briefly held by the Japanese during World War II, Guam today is a true melting pot of cultures. Native Chamorros still comprise 37% of the population; 26% are Filipino; 11% other Pacific Islanders; 7% white; and 6% other Asian. Two engines drive Guam’s economy: tourism (visitors from Asia and around the world flock to Guam’s beaches) and U.S. defense spending (American military bases cover 29% of the island). Guam is divided into 19 municipalities called “villages.”

Guam state shield

Compared to the United States, Guam has high rates of TB. At nearly 30 cases per 100,000 in 2013, Guam’s rate was 10 times the U.S. incidence, and almost 4 times higher than Hawaii. The problem of TB in Guam must also be viewed in the context of even higher rates in the entire USAPI region (81 cases per 100,000 in 2013). For example, Guam’s close neighbor, the Federated States of Micronesia (FSM), had a 2013 TB case rate of 124 per 100,000. The free movement of people among Micronesian countries contributes to Guam’s TB burden; in fact, nearly 1 of 4 TB patients in Guam came from another USAPI. The high prevalence of diabetes throughout the Pacific Islands is another factor that complicates TB control in Guam. Reports indicate coexistent diabetes in 30-75% of TB cases in adult Pacific Islanders, a co-morbidity associated with increased risk of progression to active TB, slower response to treatment, and higher mortality. Timely diagnostic services are also a challenge in the USAPI region. Sputum smear microscopy remains the primary method of local diagnostic testing. Samples are routinely forwarded to Pacific TB Reference Labs (such as in Honolulu) for full-scale testing.

The strong efforts of the Guam Department of Public Health and Social Services (DPHSS) have resulted in dramatic decreases in case numbers in recent years - from 102 cases in 2009 to 48 cases last year (with no significant increase in the total population.) TB control is supported by Guam Public Laws (GPL) focused on case investigations, isolation, quarantine, and testing. The use of GeneXpert® in Guam helps to shorten the time to diagnose drug-resistant strains of TB.

Guam TB control team
Guam TB control team (l to r): O. Miranda, C. Arciaga, J. Manglona, L. Nisay, H. Narcis, A. Manolo, L. Bamba, R. Realica, B. Cruz

Now in her 31st year as the Tuberculosis/Hansen’s Disease Control Program Manager for Guam, Dr. Cecilia Arciaga has witnessed many changes in the TB landscape on her island. In 1984 Dr. Arciaga had just immigrated to Guam from the Philippines with her baby daughter, when she was hired as the first (and then only) CDC-funded TB control staff person, assisted by 2 locally-funded staff. The Guam TB team has since grown to 8 CDC-funded staff, and Dr. Arciaga is justifiably proud of their achievements: “The program has a 98-100% completion rate for active TB through the strict implementation of the universal Directly Observed Therapy program, successful TB/Hansen’s Disease contact investigation, TB outbreak investigations, and cohort review. Our LTBI therapy completion rates are 85%.”

Dr. Cecilia Arciaga
Dr. Cecilia Arciaga

As she considers the ongoing challenges of TB control in Guam, Dr. Arciaga cites the need for additional TB program, clinic, and pharmacy staff to continue the important work ahead. She also looks forward to the day when her program can implement an automated TB case management system, construct a TB isolation room, and secure a fully operational digital x-ray machine.

Dr. Arciaga reflects on the contributions of many partners during her long career: “I am so blessed to have worked with a great TB team who had such heart and passion for their work. Our accomplishments would not have been possible without the tremendous support and guidance from my previous and current Department of Public Health Bureau of Communicable Disease Administrators, CDC Project Officers and their team at the CDC TB Elimination Division - Christopher Hayden, Paul Schwartz, Greg Andrews, Andy Heetderks and Derrick Felix, to name a few. I also thank the amazing staff at the Curry International TB Center. ”

New Radiology Cases and Image Library

Chest X-ray Image

CITC has recently released two new online radiology products: Tuberculosis Radiology Practice Cases and the Tuberculosis Radiology Image Library, both produced in collaboration with the Firland Northwest Tuberculosis Center.

Tuberculosis Radiology Practice Cases are brief, interactive self-study case studies that allow the user to practice locating areas of radiographic abnormalities using real-life clinical scenarios. Watch for more cases to be added.

Tuberculosis Radiology Image Library is an open-access resource library of radiographic images of tuberculosis. These images can help users to gain an appreciation for the broad spectrum of radiographic manifestations of tuberculosis. The images are free to download and share for non-commercial educational purposes.

To create these radiology products, CITC collaborated with the Firland Northwest Tuberculosis Center, a partnership between the University of Washington and the Firland Foundation, that promotes TB education, research, and patient care in the northwest region and beyond

Unaccompanied Immigrant Children and TB Control

Unaccompanied Immigrant Children

In early August, the CDC’s Division of TB Elimination shared two letters with the public health community to provide information about TB control efforts for unaccompanied children who come into the care and custody of the U.S. Department of Health and Human Services after being apprehended by immigration authorities.

Providers who have any questions or concerns about this issue can contact the CDC TB Program Consultant who is assigned to their jurisdiction.

Letter from DTBE about TB in Unaccompanied Children

Letter to TB controllers from ORR

Masa Narita and Randall Reves Receive NTCA Awards

In June, two of CITC’s distinguished faculty and Warmline medical consultants were honored with awards at the annual conference of the National TB Controllers Association (NTCA) in Atlanta, GA. Masa Narita, MD, was named “TB Controller of the Year,” and Randall Reves, MD, received the William Stead TB Clinician Award.

Drs. Masa Narita and John Bernardo
Masa Narita (left) with NTCA President John Bernardo

Dr. Narita, Director of the TB Control Program for Seattle and King County, was given NTCA’s highest award, the TB Controller of the Year, which honors an outstanding contribution and impact on TB prevention and control at the local, state, regional, or national level.

Randall Reves (left) with NTCA President-elect Robert Belknap
Randall Reves (left) with NTCA President-elect Robert Belknap

Dr. Reves, who served as Director of the Denver Metro TB Control Program from 1990 until his retirement in February 2013, was chosen as “TB Clinician of the Year.” The award is named for Dr. William Stead (1919-2004), a longtime TB controller for the State of Arkansas, to recognize outstanding commitment and performance by a clinician providing tuberculosis care, leadership, or mentoring.

CITC applauds Dr. Narita and Dr. Reves for their dedication and outstanding contributions to public health and academic medicine.

Read more about all recipients of the 2014 NTCA awards.

Federal Training Centers Collaboration Launches Website

The Federal Training Centers Collaboration (FTCC) recently announced the launch of a website to provide “one-stop shopping” for health care providers seeking resources and training opportunities. The website features an introductory video describing how nine federally-funded training and technical assistance networks have joined forces to serve the health care workforce engaged in reducing health disparities.

CITC is one of five Regional TB Training and Medical Consultation Centers (RTMCC), funded by the Centers for Disease Control and Prevention. The RTMCC group is only one of several other federally-funded training networks with complementary missions that have banded together to form the FTCC.

In addition to the RTMCCs, FTCC members include: AIDS Education and Training Centers (AETCs); National Network of STD/HIV Prevention Training Centers (NNPTC); Title X Family Planning National Training Centers; Addiction Technology Transfer Centers (ATTCs); Viral Hepatitis Education and Training Projects (VHNET); STD-related Reproductive Health Training and TA Centers (STDRHTTACs); Capacity-Building Assistance for High-Impact HIV Prevention; and Disease Investigation Specialist Training Centers.

Members meet regularly to plan collaborative trainings and to share information and resources. Visit the new FTCC website.

Upcoming Trainings

CITC’s schedule of upcoming trainings (through November 2014) offers a variety of courses for clinicians and public health providers.

September 24, 2014
Webinar, 10:00-11:30 am Pacific

Sharing the Care: Working Together on LTBI Treatment and Management
For physicians and other licensed medical professionals who diagnose and treat latent tuberculosis infection (LTBI). The training will focus on risk assessment, diagnosis, and treatment options for LTBI. The 75-minute presentation will be followed by a 15-minute Q & A session.

September 30, 2014
Oakland, CA

Focus on LTBI Pilot
One-day pilot curriculum for physicians, nurses, communicable disease investigators, and other licensed medical professionals who diagnose and treat infection.

September 30-October 3, 2014
Oakland, CA

Tuberculosis Clinical Intensive
Four-day intensive for physicians and other licensed medical professionals who manage patients with or at risk for tuberculosis.

October 8, 2014
Webinar, 10:00-11:00 am Pacific

Pediatric Tuberculosis: The Essentials with Dr. Ann Loeffler
This webinar will cover some of the basics of diagnosing tuberculosis and tuberculosis infection in children. Dr. Loeffler will discuss the key differences in clinical presentation, infectiousness, diagnosis, and treatment in children versus adults; techniques for children's medication dosing; pediatric patient monitoring; and strategies for working with parents. The 45-minute presentation will be followed by a 15-minute Q & A session.

October 20, 2014
Webinar, 1:00-1:45 pm Pacific

Staying Safe: Preventing TB Transmission in Health Care Facilities with Dr. Kevin Fennelly
For nurses and other health care workers who interact with TB patients or who supervise staff working with TB patients in a health care facility. Dr. Fennelly will address common tuberculosis infection control concerns among health care facility staff. The 30-minute presentation will be followed by a 15-minute Q & A session.

November 7, 2014
Webinar 9:00-10:30 am Pacific

Mycobacterium bovis: Epidemiology, Diagnosis, and Treatment
For physicians, other licensed medical professionals, and public health professionals involved in M. bovis community prevention strategies and M. bovis case contact investigations. The training will focus on the epidemiology, transmission, diagnostic methods, and treatment of M. bovis. The 75-minute presentation will be followed by a 15-minute Q & A session.

November 18-21, 2014
Oakland, CA

Tuberculosis Case Management and Contact Investigation Intensive
Four-day training for nurses, communicable disease investigators, and medical social workers.

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

Faculty Profile

To better acquaint our readers with the corps of TB experts that comprise our training and medical consultation faculty, each issue of CITC Newsletter presents a profile of a CITC faculty member. In this issue we feature Shou-Yean Grace Lin, MS.

Shou-Yean Grace Lin

Ms. Lin, Research Scientist at the Microbial Diseases Laboratory, California Department of Public Health, personifies the critical role that lab scientists serve in TB care and control. Too often, laboratorians are unsung heroes of TB control, and in 2010 the National Tuberculosis Controllers Association established the “Ed Desmond Award” to annually recognize a TB laboratorian for outstanding lab services. Upon accepting the inaugural award, Ms. Lin blinked back tears of gratitude and humbly described herself as “a little soldier on the TB battleground.” During a 30-year career in the lab, the work of this “little soldier” led to cutting-edge molecular techniques for diagnosing TB and detecting drug resistance.

Grace Lin was born and raised in Taipei, Taiwan. Interested in science from an early age, she credits two middle school science teachers with spurring her fascination with biology and chemistry. As an undergraduate at National Taiwan University, she earned a B.S. degree in Medical Technology. In 1976, Ms. Lin immigrated to the United States with her husband, Yutang Lin, who was pursuing a PhD in mathematical logic at University of California, Berkeley.

Ms. Lin began her laboratory career at Kaiser Regional Laboratory in Berkeley. She focused initially on serology and hematology until she transferred to microbiology in 1987. There, she met Yvonne Jang, who became her lifelong mentor and taught her clinical mycobacteriology, a field that soon became her passion. Ms. Lin relishes her role in clinical care: “Most rewarding to me are the times when I provide physicians with the information they need to treat their patients and help them to embrace new technologies and optimize the utilization of laboratory services.”

In 2001, Ms. Lin joined the Microbial Diseases Laboratory (MDL) at California Department of Health Services in Berkeley (now called the California Department of Public Health [CDPH] and located in nearby Richmond). According to her longtime MDL colleague and mentor Ed Desmond, PhD: “Grace made a bold step to accept a ‘soft’ money temporary position in MDL to work on validation and implementation of a real-time PCR assay with molecular beacon probes to enable rapid detection of TB and drug resistance directly in patient samples. This project proved much more challenging than expected, but Grace (in collaboration with Will Probert) was able to modify the method and make it work well. What followed was the first implementation of direct detection of drug-resistant TB in clinical samples as a routine service. This was a game-changer because detection of drug-resistant TB could then be done in one day, as opposed to the then standard turnaround time of one to two months.”

Dr. Desmond describes Ms. Lin’s next important contribution: “While working with the molecular beacon assay for several years, Grace observed the limitations of this probe-based method. She set about to develop an assay using pyrosequencing (PSQ) technology that could determine what specific mutations associated with drug resistance are present in clinical specimens. She took a step further to study the range of the minimal inhibitory concentration (MIC) associated with each mutation. This led to the currently available PSQ service in MDL, which can rapidly detect resistance to rifamycins, isoniazid, fluoroquinolones, and injectable drugs, and predict the level of resistance. Physicians may use the information to formulate regimens which might be best for treating individual cases.” [Note: A recent article about the PSQ assay by Ms. Lin appears in the Journal of Clinical Microbiology.]

Shou-Yean Grace Lin
Ed Desmond congratulates Grace Lin for her NTCA award in 2010

Ms. Lin has delivered several presentations on lab methods at CITC clinical courses, and her obvious enthusiasm for her subject matter has been described by participants as “infectious.” Ms. Lin is also a key contributor to the joint CITC/CDPH publication, Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, now being updated in a third edition.

In the global arena, Ms. Lin served as co-investigator of a project sponsored by the National Institute of Health to investigate four rapid methods for detecting XDR-TB in three sites: India, Moldova and South Africa through the Global Consortium for Drug-resistant TB Diagnostics (GCDD). She helped in the building of a new TB lab in Pyongyang, North Korea. She also gave talks at the annual conference of the Union-North America Region in 2009, at the Taiwan CDC in 2006 and 2012, and at the 50th anniversary of the Medical Technology School of the National Taiwan University, and participated in training at a symposium in Shanghai China in 2012, sponsored by the Shanghai CDC, the Institute Pasteur International Network, Fu-Dan University and UC Davis.

Looking ahead, Ms. Lin says her focus is on nurturing the next generation of scientists - the public health microbiologists, post-doctorates, and APHL fellows - to whom she can someday “pass the baton.” Continuing challenges in TB lab work still command her attention as well: “I hope to resolve problems with ethambutol and pyrazinamide susceptibility testing. I also want to establish susceptibility testing for new drugs such as bedaquiline.” With her eye on international consulting work, Ms. Lin is not planning an idle retirement.

Dr. Desmond has abundant praise for Ms. Lin‘s contributions to laboratory methods, but also highlights her dedication to assisting providers on the front lines: “Grace has consulted with TB clinicians and TB control staff on hundreds of cases over the years. Countless times she has stayed late, worked on weekends, and exerted extraordinary personal effort to help individual patients and TB control.”

Contact Us

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

Warmline TB Medical Consultation: 877-390-6682 (toll-free) or 415-502-4700
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CITC Newsletter

Principal Investigator/ Medical Director:  Lisa Chen, MD
Associate Medical Director: Ann Raftery, RN, PHN, MS
Deputy Director: James Sederberg
Director of Education: Kelly Musoke, MPH
Program Manager: Jeannie Fong
Epidemiologist: Baby Djojonegoro, MS, MPH
Newsletter Editor: Kay Wallis, MPH
Web Developer: Mari Griffin, MS
Program Assistant: Dominique Reminick, MA

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