CITC Newsletter — Spring 2013
An electronic newsletter from the Curry International Tuberculosis Center (CITC)
CITC Transitions in 2013
The year 2013 has brought several transitions to CITC: a 5-year funding award from the Centers for Disease Control and Prevention (CDC); a slightly redrawn Western Region within a newly enlarged RTMCC network; reductions in staff; and a new office location. What remains unchanged: a nearly 20-year history of outstanding service, and an ongoing commitment to excellence and innovation.
As reported late last year, CITC has been refunded by the CDC to continue serving as a Regional Tuberculosis Training and Medical Consultation Center (RTMCC) for the Western Region in a new five-year funding cycle.
In addition to CITC, the three other RTMCCs originally chosen in 2009 were also refunded: the Southeastern National TB Center (SNTC) in Florida; the Global TB Institute (GBTI) in New Jersey; and the Heartland National TB Center in Texas (HNTC). CDC also announced a fifth site within the RTMCC network: the Mayo Center for Tuberculosis at the Mayo Clinic in Rochester, Minnesota. The addition of a fifth RTMCC has resulted in a shifting of assigned states within each region. CITC’s area of service still includes Alaska, California (including Los Angeles, San Diego, and San Francisco), Colorado, Hawaii, Idaho, Nevada, Oregon, Utah, Washington, and the U.S. Pacific Island Territories. Montana and Wyoming were reassigned to the new region being served by the Mayo Clinic.
In 2013 all RTMCCs received funding cuts of approximately 25% from 2012 levels. For CITC, this reduction necessitated the downsizing of CITC staff by six members. In one of several efforts aimed at maximizing resources, late in 2012 CITC moved its offices from San Francisco to a location in downtown Oakland. CITC shares its new East Bay home with the California STD/HIV Prevention Training Center, opening opportunities for creative collaborations. The facility features a large training room with advanced audio-visual technology, and close proximity to public transportation, hotels, and restaurants.
See Contact Us for CITC’s new address and telephone number. CITC’s website URL and email address are unchanged, as is its core mission: to create, enhance, and disseminate resources and models of excellence, and perform research to control and eliminate TB in the United States and internationally.
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 state-of-the-art isolation and TB treatment facility at Olive View-UCLA Medical Center in Los Angeles.
The TB unit of Olive View-UCLA Medical Center in Sylmar, California (located in the San Fernando Valley) opened in August 2011, one of only four inpatient centers in the country specializing in tuberculosis care. Olive View-UCLA Medical Center is a publicly funded “safety net” county hospital providing care for uninsured and underinsured patients residing in Los Angeles County. A $53 million renovation of the Olive View emergency room, completed in 2011, added a 31,000 square-feet patient treatment area. An additional 10,000 square feet was devoted to construction of an adjacent high-tech isolation ward to treat patients in the event of a bioterrorism incident or a large infectious disease outbreak. The rest of the time, this isolation ward is used for TB patients requiring inpatient treatment. A pressure controlled air circulation system reduces the spread of airborne disease, and a UV light eradicates germs in air leaving the ward. Olive View’s 15 isolation rooms can accommodate the county’s most challenging TB cases, opening negative-pressure airborne isolation beds in general medicine wards at other area hospitals.
The history of Olive View has come full circle. In 1920, Olive View Sanatorium opened to relieve the crowding of TB cases in L.A. hospitals. At that time, it was the largest TB sanatorium west of the Mississippi. When effective drugs for TB were discovered and TB became curable in later decades, Olive View developed into an acute care hospital. By 1970, the facility had become Olive View-UCLA Medical Center, a teaching hospital affiliated with UCLA School of Medicine. A new 888-bed hospital was dedicated in December 1970, only to be decimated the following February by the 6.6 Sylmar earthquake. It took another 16 years to reopen Olive View-UCLA Medical Center at the Sylmar site.
The Los Angeles County hospital system has over 200 isolation beds, but when High Desert Hospital in Lancaster closed to inpatients in 2003, the County lost its only dedicated TB ward. Like the rest of the nation, L.A. County has seen TB case rates drop significantly in the last 20 years. However, while numbers have declined, the complexity of cases has intensified. In addition, a recent increase in TB incidence among homeless persons living in the Skid Row area has highlighted that TB can resurge.
As the Los Angeles Times reported last year, when the Olive View TB unit opened in 2011 the severity of the TB cases that came through caught the staff by surprise. Dr. Glenn Mathisen, director of the Infectious Diseases division at Olive View, told Times reporter Erin Loury: “Something that the average physician would only see maybe once in a lifetime, we see kind of routinely here. They're sicker than we thought they would be.”
Olive View patients are often homeless or low income, with co-morbidities that include diabetes, HIV, heart disease, substance abuse, or mental illness. Some are required by court order to remain at Olive View until they are no longer contagious. Others who are undergoing the potentially toxic drug regimens needed to cure drug-resistant TB will stay at Olive View for several months.
Caitlin Reed, MD, is Medical Director of Olive View’s Inpatient TB Unit, and comments on the facility’s special role in TB control for L.A. County: “We take on cases that other facilities are unable to manage, and we relish the challenge. A dedicated multidisciplinary team works together to cure the most difficult TB cases. We have access to therapeutic drug monitoring, second- and third-line TB drugs, and comprehensive subspecialty consultation. Our patients are medically and socially complex; we do whatever it takes to get them better.”
CDC to Release Guidance on Bedaquiline
CDC will soon release guidelines for the use of bedaquiline (BDQ), the first in a new class of drugs designed to treat drug-resistant strains of TB.
BDQ is a diarylquinoline antimycobacterial drug that works by inhibiting an enzyme needed by TB bacteria to replicate and spread. Discovered by scientists at Janssen, the pharmaceutical unit of Johnson and Johnson, BDQ is expected to be commercially available in mid 2013 under the trade name Sirturo.
On December 31, 2012, the FDA announced the accelerated approval of BDQ for the treatment of multi-drug-resistant tuberculosis, and extensively drug resistant tuberculosis. In a statement cited in the New York Times (12/31/13), Edward Cox director of the Office of Antimicrobial Products in the FDA’s Center for Drug Evaluation and Research said, “Sirturo provides much-needed treatment for patients who don’t have other therapeutic options available. However, because the drug also carries some significant risks, doctors should make sure they use it appropriately and only in patients who don’t have other treatment options.” BDQ carries a black box warning that cautions patients and health care professionals about possible disturbances to electrical activity in the heart.
In January of this year, CDC convened a multi-agency expert consultancy on BDQ to hear evidence-based data, to determine whether efficacy and safety have been shown, and if so, to provide recommendations that will inform CDC guidelines for rollout and monitoring of BDQ’s use in the U.S.
According to Sundari Mase, MD, MPH, of the CDC’s Division of TB Elimination, the CDC will work closely with experts and stakeholders to ensure that an enhanced monitoring system is in place for tracking patients who receive BDQ.
Nationwide Shortage of PPD Products Prompts CDC Alert and Recommendations
Tubersol® and Aplisol®, the two purified-protein derivative (PPD) tuberculin products licensed by the U.S. Food and Drug Administration (FDA), are either unavailable or in limited supply, and the CDC has issued three recommendations to TB programs and providers to deal with the shortages.
According to a CDC Health Alert Network communication released on April 12, 2013, Tubersol® is in shortage nationwide until at least the end of May 2013. The manufacturer, Sanofi Pasteur Limited, notified CDC that 50-dose vials of Tubersol® are unavailable and that the supplies of 10-dose vials will be limited. JHP Pharmaceuticals, LLC, the manufacturer of Aplisol®has notified FDA that the product is on allocation and is available in restricted quantity. Acute local shortages of Aplisol® are being reported to CDC by healthcare providers who switch from Tubersol® to Aplisol®.
Tuberculin skin testing (TST) is one of two immunological methods used for detecting Mycobacterium tuberculosis infection: the other is interferon-γ release assay (IGRA) blood tests.
In the April 12 alert, CDC recommended 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.
CITC on Social Media Sites
CITC Newsletter readers are invited to follow CITC on Twitter and to connect with CITC on Facebook. Don’t miss any of the timely tweets written by TB experts on CITC‘s Twitter account. Join the conversation and learn the latest updates about CITC and partners on the CITC Facebook page.
TB Program Notes
TB Program Notes highlights news, innovative activities, and other items of interest from TB programs in the Western Region. In this edition, the San Francisco TB Control Program partners with a local college health center to observe World TB Day, and the Washington State Department of Health (DOH) announces a curriculum to certify non-medically licensed staff to perform TB testing and directly observed therapy (DOT).
On March 19, the San Francisco Tuberculosis Control Section commemorated World TB Day 2013 at the City College of San Francisco (CCSF), recognizing decades of partnership with the Student Heath Center to provide access to TB screening and treatment to thousands of CCSF students. A presentation by San Francisco TB Control Director Julie Higashi, MD, PhD, highlighted the importance of supporting the TB control infrastructure, citing a 2-year trend in rising case numbers in San Francisco. Dr. Jennifer Flood, Chief of the TB Control Branch at the California Department of Public Health, noted that the Golden State annually sees the most TB cases in the nation, more than New York and Texas combined. TB survivors were also on hand at the event to discuss their experiences, and free TB and/or Hep B screenings were provided to CCSF students.
In Washington State, non-medically licensed staff may be certified to perform TB testing and DOT if they are working as part of a TB control program established by the local health officer and complete a training curriculum provided by the local health jurisdiction (LHJ) or Washington State DOH. According to State TB controller Sheanne Allen, “We felt that by providing this type of training to staff in LHJs, they may be able to provide TB care more efficiently. In order to assist our LHJs, we have created a short, self-paced curriculum for those wanting certification in TB testing, DOT, or both.” The curriculum includes learning modules, workbooks, and a practicum assignment for TB testing. Ms. Allen invites colleagues from other states to contact DOH for more information
Upcoming Training Courses
CITC‘s schedule of upcoming training courses (through October 2013) offers a variety of courses for clinicians and public health providers.
May 30, 2013
National, Web-based seminar
Affordable Care Act (ACA) Implementation on the U.S./Mexico Border:
Focus on HIV, STDs, TB, Addiction & Family Planning Concerns
1.5 hour webinar presented in association with The U.S./Mexico Border AETC Steering Team (UMBAST), which includes: The Texas/Oklahoma AIDS Education & Training Center; Pacific AIDS Education & Training Center; Mountain Plains AIDS Education & Training Center; Pacific Southwest & Gulf Coast Addiction Technology Transfer Centers; California & Dallas HIV/STD Prevention Training Centers; Cardea Services; Curry International Tuberculosis Center; Heartland National TB Center; U.S./Mexico Border Health Commission; Migrant Clinicians Network.
May 30, 2013
San Jose, CA
TB Case Study Seminar (in association with CTCA Educational Conference: Blazing New Trails in TB Control: Combating Drug Resistance and Applying Molecular Diagnostics)
Using challenging TB cases, expert faculty will discuss strategies to fight TB as cases become more and more complicated.
May 31, 2013
San Jose, CA
Perspectives on Partnerships in TB Control (in association with CTCA)
One-day training on topics geared to providers who diagnose and treat TB in California.
June 19-20, 2013
Tuberculosis Clinical Intensive
Two-day intensive for physicians and other licensed medical professionals who diagnose and treat tuberculosis.
June 21, 2013
Tuberculosis Nursing Workshop
One-day workshop for nurses, communicable disease investigators, and other licensed medical care providers who work with tuberculosis patients.
June 28-29, 2013
San Diego, CA
Treatment of HIV, STDs, TB, Hepatitis C and Substance Abuse on the Border: Focus on Reproductive Health Concerns Presented in association with Pacific AIDS Education and Training Center, California STD/HIV Prevention Training Center, Pacific Southwest Addiction Technology Transfer Center, Cardea Services, and the U.S./Mexico Border Health Commission.
October 1-3, 2013
Tuberculosis Clinical Intensive
Three-day intensive for physicians and other licensed medical professionals who diagnose and treat tuberculosis.
October 8-10, 2013
Tuberculosis Case Management and Contact Investigation Intensive
Three-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.
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 Julie Tomaro, RN, BSN.
Washington State TB Nurse Consultant Julie Tomaro is still a relative newcomer to the world of TB administration, but what she lacks in seniority is more than made up in enthusiasm and fresh ideas. She represents the new generation of TB professionals who will carry the torch toward the goal of TB elimination.
Julie Tomaro was born and raised in Wenatchee, Washington, a small city in central Washington that proudly proclaims itself as “Apple Capital of the World.” Ms. Tomaro always sought a career that would enable her to work with people, and to find a job just about anywhere – and the field of nursing fit those parameters. While earning her nursing degree at Washington State University in Spokane, she became introduced to public health during a community health clinical rotation at a county health department. Looking back, she remarks, “I went in naïve… What struck me about public health was the emphasis on prevention, which is such a common sense approach to healthcare! Once I got a glimpse of how multifaceted and important public health was, I was hooked.”
After graduating from nursing school, Ms. Tomaro spent a year working the swing shift in a local emergency room (“Enough to last a lifetime,” she ruefully recalls) and was then offered the job of TB program coordinator at Spokane Regional Health District . She readily admits she knew very little about TB at the time, but quickly found her way: “From my first day on the job I knew that TB was a perfect fit for me. The history of the disease and the pathogenesis were fascinating, but it was developing a relationship with patients and watching them get better that really captivated me,” she remembers. Ms. Tomaro credits Dr. Scott Lindquist, Washington State TB Medical Consultant, and Kim Field, then the Washington State TB Controller, as important early mentors to her TB career.
Hands down, Ms. Tomaro cites “working with patients” as the most rewarding – and challenging – dimension of TB care. “The moment when your patient, who resisted the diagnosis and taking medication, completes the final dose with a smile…there is no better feeling.” In her current position as TB Nurse Consultant, she no longer works directly with patients, but provides assistance to county health departments and private providers in diagnosing and managing their TB cases. “With all the stresses that go along with TB case management, I help providers navigate the process a little easier. Whether it’s providing education and training, being there to listen to the case manager vent, or helping to track down a missing patient, I know that I play a part in getting the patient successfully treated,” she remarks.
Since joining the CITC training faculty in 2011, Ms. Tomaro has led sessions at several courses in Washington State and California. Participants routinely applaud her dynamic presentations on topics that range from contact investigation interviewing skills to patient adherence and use of lab technology in case management.
The future is bright for Ms. Tomaro, who will soon earn her Master’s Degree in Public Health from University of Washington. Her graduate studies have emphasized global health, and she eventually wants to be involved in overseas TB work. “I look forward to continuing to educate anyone and everyone about TB until I work myself out of a job due to TB eradication!” she predicts.
Dr. Scott Lindquist has watched Ms. Tomaro’s career unfold and commends his young colleague: “Julie has a quiet tenacity about her. She has been an enthusiastic student of tuberculosis for years and it has been a pleasure working with her, but at some point she has become a leader and a source of tuberculosis experience. One word summarizes Julie, and that is ‘nerd.’ No, I am kidding – it is ‘knowledgeable.’”
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
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