CITC Newsletter — Summer 2013
An electronic newsletter from the Curry International Tuberculosis Center (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 Division of Mycobacterial and Respiratory Infections at National Jewish Health in Denver, Colorado.
National Jewish Health’s 114-year history as a leading respiratory hospital began in 1899 when the “National Jewish Hospital for Consumptives” opened its doors. The TB sanitarium was urgently needed to serve the many indigent “consumptives” who flocked to Denver for its supposed healing climate. With the motto, “None may enter who can pay–none can pay who enter,” the facility was funded by the local Jewish philanthropic community and was open to all religious denominations. National Jewish can no longer offer free services to all patients, but it continues to provide a significant amount of free or heavily subsidized care to patients in need.
From its noble beginnings, the institution now known as National Jewish Health has evolved to become a world-class clinical and research center for many respiratory, immunologic and related disorders. The Division of Mycobacterial and Respiratory Infections at National Jewish continues to provide state-of-the-art care for patients with tuberculosis, with a special focus on those with drug-resistant disease. Charles L. Daley, MD, who played a central role in developing and directing the Curry Center’s training and medical consultation programs during its first decade, has been Division Chief since 2004. In recent years, the Division has expanded its services to include all patients with infectious diseases, particularly patients with nontuberculous mycobacterial (NTM) infections and other respiratory pathogens.
As many TB clinicians can attest, NTM infections can be difficult to diagnose and challenging to treat. The Division faculty manages patients infected with commonly encountered species as well as those that rarely cause disease. NTM frequently cause lung infections but can involve soft tissues, bones or lymph nodes, and often require surgery to treat. The Division works closely with thoracic, plastic, and orthopedic surgeons in the management of select cases. The surgical expertise that is available is unparalleled.
In 2010 the NTM Center of Excellence was created at National Jewish to develop new diagnostic tests and improve current approaches for the diagnosis of NTM infections. Currently, the Center is developing and validating molecular diagnostic tests that identify species/strains of NTM. The Center is also working to discover and implement companion diagnostic tests that will identify antibiotic-susceptible and resistant strains that will enable personalized therapy for patients with NTM.
The Division’s clinical services include a unique day unit where each year some 500 patients with mycobacterial and other respiratory infections spend one to two weeks. In addition, approximately 10 outpatient clinics are operated. Providers across the country can receive expert consultations for their cases from the Mycobacterial Consult Service (800-652-9555 or firstname.lastname@example.org).
Laboratories associated with the Division use cutting-edge methods to identify mycobacterial species; test for antimicrobial susceptibility (including line probe assays); and measure serum drug concentrations. The Mycobacterial Reference Lab is directed by Max Salfinger, MD, who works closely with Shaun Berning, PharmD to lead the Pharmacokinetic Reference Lab. The Molecular Diagnostics Laboratory (directed by Preveen Ramamoorthy, PhD) offers high-complexity molecular diagnostic tests for rapid and accurate speciation of mycobacteria.
In the training arena, Dr. Daley proudly notes that his Division’s biannual “Denver TB Course” is now in its 50th year, making the acclaimed postgraduate course the longest-running in the U.S. NTM courses are also presented in alternating years. The Division offers a rotating monthly fellowship for pulmonary and infectious disease fellows (including a stipend).
Visit the Division’s website to learn more about its outstanding educational, clinical, and investigational resources.
Symposium on a Century of Progress in Tuberculosis Control
In December, scientists and public health experts will commemorate 100 years of advances in the response to tuberculosis in California with a day-long symposium in San Francisco. The event marks the centennial anniversary of the creation of the state’s “Bureau of Tuberculosis” within the State Board of Health.
In December 1912, a legislatively-established Commission on Tuberculosis released a report with recommendations for addressing tuberculosis in California, leading to the establishment of the new Bureau in September 1913. An excerpt from the Preliminary Abstract of the Final Report published in the January 1913 Monthly Bulletin of the California State Board of Health conveyed the toll of tuberculosis on California families early in the 1900s:
“The Loss Which is Greater Than Money. The one great fact which overshadows all else is the needless amount of suffering, sorrow, and human heartache endured by those who are daily dropping out of their successful careers, just begun, and from their happy homes amongst us, to drift awhile, before the victory of the tubercle bacillus is complete and they are required to leave a young family destitute, or unprepared and probably similarly infected.”
The December symposium will also be an occasion to celebrate the 20th anniversary of CITC (1994-2014). Details about the date, location, and symposium program will be available soon on the CITC website.
Nationwide Shortage of PPD Products Continues
In the wake of continuing nationwide shortages of Tubersol® and Aplisol®, the CDC has reiterated three recommendations for programs and providers to cope with the scarcity of purified protein derivative (PPD) solutions for use in tuberculin skin testing.
In April 2013, the CDC alerted the health care community that Tubersol® and Aplisol® , the two PPD tuberculin products licensed by the U.S. Food and Drug Administration (FDA), were either unavailable or in limited supply, and estimated that normal production would resume in June. However, reports from numerous states indicate continuing production delays of Tubersol. In a memo released on August 12, 2013, Philip LoBue, MD, FACP, FCCP, Associate Director for Science, for the CDC’s Division of Tuberculosis Elimination said, “The 50-test preparation may not be available and the 10-test preparation may only be available in limited supply leading to restricted allocations on customer orders by the supplier. The current projection for restorldqation of normal production of Tubersol is sometime in the fall, perhaps October. Even though we are not aware of any problems with Aplisol production, the shortage of Tubersol has resulted in increased demand for Aplisol, resulting in shortages of both PPD solutions.”
While the shortages persist, the CDC continues to recommend any of three approaches for addressing the shortages of TST antigens:
- Substitute IGRA blood tests for TSTs. Costs associated with IGRA blood tests can be greater than the cost of TSTs. The blood tests require phlebotomy, preparation of blood specimens, and specific laboratory services for analysis. Clinicians who use the IGRA blood tests should be aware that the criteria for test interpretation are different than the criteria for interpreting TSTs.
- Allocate TSTs to priority indications, such as TB contact investigations. This might require deferment of testing some persons.
- Substitute APLISOL® for TUBERSOL® for skin testing. This approach may ultimately not be feasible, as shortages of APLISOL® are expected to become more widespread.
Surveillance programs that rely on routine serial TSTs are advised that switching products or methods might make serial changes in test results difficult to interpret: the apparent conversions of results from negative to positive or reversions from positive to negative could be caused by inter-product or inter-method discordance. In settings with a low likelihood of TB exposure, providers might consider deferring routine serial testing, in consultation with public health and occupational health authorities.
Upcoming Training Courses
CITC‘s schedule of upcoming training courses (through November 2013) offers a variety of courses for clinicians and public health providers.
October 1-3, 2013
Tuberculosis Clinical Intensive
Three-day intensive for physicians and other licensed medical professionals who diagnose and treat tuberculosis.
October 16, 2013
Via the web, 10:00-11:00 am (PT)
Drug-Induced Liver Injury On–Demand Webinar
Christopher Spitters, MD, MPH, MA, leads this live online session on hepatitis and liver injuries that may result from prescribed TB medication. This is the initial installment of CITC’s On-Demand Webinar series.
October 23, 2013
Washington State Annual TB Educational Conference
For more information, visit the WA State Dept. of Health website
November 12-14, 2013
Tuberculosis Case Management and Contact Investigation Intensive
Three-day training for nurses and other healthcare providers involved in the delivery of TB case management or contact investigation in the Western Region of the U.S.
For periodic updates on additional trainings, complete course descriptions, and application forms, view our training section.
Each issue of CITC Newsletter presents a profile of a faculty member from the CITC training and medical consultation corps of experts. In this issue we feature Karen Martinek, RN, MPH.
The life and career of Alaska TB nurse consultant Karen Martinek reads much like the plot of an adventure novel. A native New Yorker vows in childhood to never become a nurse, then ventures to the Alaskan wilderness and builds a remarkable 35-year career in public health nursing. “The Karen Martinek Story” – opening soon at a theatre near you.
Karen Martinek was born in Brooklyn and raised in Staten Island, New York. Her mother’s career as a nursing executive engendered in her daughter a strong ambition from an early age: “I will never be a nurse.” As an undergraduate at Marquette University in Milwaukee, Ms. Martinek studied liberal arts for a year, but she inevitably felt drawn to the field she had pledged to avoid. She soon discovered that public health nursing was a world apart from her mother’s career in acute care. “The public health approach of ‘meeting people where they are’ was perfect for me,” she explains.
Ms. Martinek remembers one day in college when she browsed the employment notices at the back of the American Journal of Nursing. One advertisement caught her eye: the State of Alaska was recruiting applicants for “dog-sled public health nursing.” The prospect of working in the Alaskan wilderness captivated her: “I planned to have my Alaskan nursing adventure for a few years, and then pursue my real goal of a career in international health,” she recalls.
Ms. Martinek was initially assigned to a rural area in the Alaskan interior, where she served a population of 2,500 people inhabiting a region as large as West Virginia. Usually traveling by car on icy winter roads or occasionally in small aircraft (rather than by dog sled) to provide nursing services in her region, she quickly learned to work within extreme conditions, braving winter temperatures of 60 degrees below zero, and venturing to remote villages with no sewers or running water. “In this environment, we must always have a Plan B,” she says. In fact, Ms. Martinek’s own plan to remain only a few years in Alaska changed course once she met her future husband and they established a life and home together in the Copper River Basin.
Ms. Martinek returned to school in the early 1990s to earn her Master in Public Health Degree from the University of Alabama at Birmingham. Upon her return to Alaska, she transferred to the Alaska Department of Health and Social Services, Division of Public Health, Section of Epidemiology in Anchorage to focus on HIV/AIDS surveillance. In the following years, Ms. Martinek assumed increasingly responsible managerial positions in units that dealt with breast cancer early detection, and children with special healthcare needs. In 2004, Ms. Martinek became a nurse consultant with the TB and infectious diseases program. “Although I primarily manage a great team of nurse consultants and support staff, I still cherish any opportunity to get out to the villages for ‘TB sweeps,’” she explains. Patients from native Alaskan tribes present many cultural and linguistic complexities to TB care; Ms. Martinek considers the rich diversity of these communities as one of the most rewarding aspects of her work.
Ms. Martinek joined the Curry training faculty in 2008, and has presented or facilitated sessions for “Case Management and Contact Investigation” and “Nurse-to-Nurse” courses. In 2010 she became a nurse consultant for CITC’s Warmline service. A special chance to extend her skills internationally arose in 2011 when she consulted with the Ministry of Health for Suriname to teach nurse case management and develop TB guidelines.
As Ms. Martinek and her husband ponder the possibility of retirement, they look forward to relocating to their “little yellow house“ in southern Florida for their post-Alaska chapter. Idleness is not on Ms. Martinek’s retirement agenda: “Once I retire, I’ll finally have the time to pursue my interest in international health and TB.” Clearly, the Karen Martinek story has many exciting plots twists ahead.
Alaska State TB Controller Michael Cooper, MD, shares these words of praise: “While Karen‘s impact on Public Health Nursing in Alaska, and on TB control specifically, is substantial, her impact on the people with whom she has come into contact over her career may be even more impressive. From coworkers, colleagues and members of the public, she has touched many lives, always in a very fair, thoughtful, and compassionate way, and almost always with a smile and a touch of humor. Her impact on those around her, and her ability to bring out the best in those around her, will certainly be felt and appreciated long after she leaves Alaska.”
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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Principal Investigator/ Medical Director: Lisa Chen, MD
Deputy Director: James Sederberg
Associate Medical Director: Ann Raftery, RN, PHN, MS
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