CITC Newsletter — Fall/Winter 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.
Symposium Explores a Century of Progress in TB Control
On December 5th, nearly 200 scientists, public health professionals, and policymakers from around the country met at a day-long symposium in San Francisco to commemorate 100 years of advances in the response to tuberculosis in California. Coinciding with the centennial anniversary of the creation of the state’s “Bureau of Tuberculosis” within the State Board of Health in 1913, the event showcased the innovations and complex science and public health interface required to achieve success in the century ahead.
Keynote speaker Peter Small, MD, from the Bill and Melinda Gates Foundation, delivered an eloquent presentation titled, “Past, Present and Future Perfect.” In his remarks, Dr. Small emphasized the importance of investing in implementation science, recognizing that “one size fits none” and urging participants “to move from accepting empiricism to demanding certainty.” Citing the development of several new TB medications, Dr. Small said, “The next few months will be among the most exciting in the last hundred years of TB medicine.” Gesturing to the large audience, he recalled himself joking twenty years ago that “You could fit the entire TB community into a minivan. Now you fill auditoriums with bright young people with new ideas.” Dr. Small cited a lesson learned from his early mentors: “Destiny is a matter of choice, not chance.” One of these mentors, CITC Co-founder Phil Hopewell, MD, from University of California, San Francisco (UCSF), spoke later in the program and echoed Dr. Small’s emphasis on the importance of embedding research in TB control programs.
California TB Controller Jennifer Flood, MD, MPH, presented a fascinating overview of the conditions that led to California becoming the first state in the country to develop a categorical disease program. Later in the day, Jonathan Mermin, MD, MPH, Director of the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention at CDC, provided insights on future directions in public health and TB control on the national level. San Francisco TB Control Director Julie Higashi, MD, PhD, and Henry Chambers, MD, from UCSF adroitly debated the provocative question, “Are Health Departments Needed for TB Elimination?”
The impressive roster of symposium speakers also included Charles Daley, MD, from National Jewish Health; David Dowdy, MD, PhD, ScM, from Johns Hopkins University; Jonathan Fielding, MD, MPH, MBA and Mitchell Katz, MD, from Los Angeles County Department of Health; Ron Chapman, MD, MPH, James Watt, MD, MPH, and Gisela Schecter, MD, MPH from CA Department of Public Health; and George Rutherford, MD, from UCSF.
TB Drug and Biologic Shortages: The new norm?
During 2013, TB patients and programs experienced unprecedented challenges in securing basic drugs and tests. The most pressing challenges included nationwide shortages of isoniazid, one of the oldest and most effective anti-tuberculosis drugs, and purified protein derivative (PPD) solutions for use in tuberculin skin testing. Second-line TB drugs, especially the injectable agents, have been in short supply chronically over the past few years. The cost of some TB drugs is prohibitive for patients and resource-strapped health departments. In response to these issues, the National TB Controllers Association (NTCA) has convened a drug shortage work group and created a web-based notification system.
Presently, there are shortages of TUBERSOL® and APLISOL® (the two antigens used for tuberculin skin testing) and clofazimine. Sanofi Pasteur reports that the supply of TUBERSOL® has improved and will steadily improve for the remainder of the year. There have also been reports of price increases for pyrazinamide and isoniazid.
Health departments have spent hours trying to mitigate the impact of these shortages on patients, but in some instances, TB testing and treatment of individuals have been delayed. The recent shortages have raised a number of troubling questions, including: Are these rare events or should TB control staff expect future shortages? Who is responsible for maintaining an adequate drug supply for TB control in the United States? What can be done to prevent TB drug shortages?
In order to better understand TB drug shortages and address these questions, NTCA has convened a drug shortage work group and created a web-based notification system that allows reporting of drug access issues, including cost escalations. The goals for this reporting/tracking system are to:
- Provide an interim notification system for drug and diagnostic supply issues until a national system by FDA or CDC is in place
- Collect systematic/standardized information on challenges in the U.S. for accessing drugs and diagnostics over time
- Describe the frequency and distribution of shortages and cost escalations over time in the U.S.
- Describe the impact on patients, programs, and TB control efforts in the U.S.
- Describe the response/actions taken to mitigate/resolve access problems
- Provide summary data periodically to NTCA, CDC, policy makers, advocacy groups, and manufacturers working towards a continuous, affordable drug supply
- Provide documented evidence of price escalations to the U.S. Department of Justice for a federal investigation into the reported cost increases for TB drugs and diagnostics
TB controllers in states, big cities and territories are encouraged to report any challenges in accessing TB drugs or cost escalations online. Email questions or comments about the TB Drugs and Diagnostics Reporting Form and system to: TBshortages@tbcontrollers.org.
[This article was written by Lisa True, RN, MS, who is MDR Nurse Coordinator/Program Liaison at the TB Control Branch, Center for Infectious Diseases, California Department of Public Health.]
Provisional Bedaquiline Guidelines Published
On October 25, 2013, Morbidity and Mortality Weekly Review (MMWR) published “Provisional CDC Guidelines for the Use and Safety Monitoring of Bedaquiline Fumarate (Sirturo) for the Treatment of Multidrug-Resistant Tuberculosis.” The report provides guidance on use of bedaquiline (BDQ), the first in a new class of drugs designed to treat drug-resistant strains of TB.
BDQ is an oral diarylquinoline antimycobacterial drug that works by inhibiting an enzyme needed by TB bacteria to replicate and spread. In late 2012, the U.S. Food and Drug Administration approved bedaquiline for treatment of multidrug-resistant tuberculosis (MDR TB) in certain persons under the provisions of the accelerated approval regulations for “Serious or Life-Threatening Illnesses.” Sundari Mase, MD, MPH, Chief of the CDC’s Division of TB Elimination Medical Consultation Team, is the lead author and point of contact for these guidelines.
Read the MMWR Guidelines.
Federal Training Centers Collaboration
CITC Newsletter readers are likely aware that CITC is one of five Regional TB Training and Medical Consultation Centers (RTMCC), funded by the CDC. The RTMCC is only one of several other federally-funded training networks with overlapping or related missions that have banded together to form the Federal Training Centers Collaboration (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); and the STD-related Reproductive Health Training and TA Centers (STDRHTTACs).
Members meet biannually to plan collaborative trainings and to share information and resources. A document that provides an overview of the FTTC members and their services is now available.
Western Region TB Control in the Local Press
Advocates for TB control funding often stress the importance of maintaining visibility for the disease in local media. Two recent examples from the Western Region aptly demonstrate this concept: a Colorado newspaper article covering a CDC report about successful LTBI treatment completion rates following a high school TB case; and a column written by the Santa Barbara (CA) Deputy Health Officer about the TB patient-provider relationship, published in her local newspaper.
On October 8, 2013, the Longmont Times-Call (Colorado) highlighted the high percentage of Longmont High School students, staff and teachers completing treatment for latent tuberculosis (96%), a figure that far exceeded state and national rates, as reported in the October 4, 2013 MMWR. The story began in January 2012, when Randall Reves, MD, then Director of Denver TB Control, announced that a Longmont High School student had been diagnosed with active TB, spurring a massive contact investigation and testing of 1,249 individuals. Among the 162 who tested positive for latent TB: 3 patients began and completed a nine-month treatment of isoniazid; 88 of 91 people who started a four-month daily treatment of rifampin completed it; and 61 of 65 patients who took the weekly treatment of isoniazid and rifapentine (newly-approved at the time) completed that 12-week regimen. The Times-Call article quotes Dr. Reves: “I never really thought we’d get over 90 percent. I was very impressed with that…I do think the shorter regimens made a huge difference.”
Twice a month Charity Thoman, MD, MPH, Deputy Health Officer for the Santa Barbara County (CA) Public Health Department, writes a “Health Matters” column in the Santa Barbara Independent, and on October 16, 2013, her column was titled, “Lessons from Tuberculosis Clinic: Pulling Down the Curtain Between Doctor and Patient.” With sensitivity and humility, Dr. Thoman explained how her patients’ vulnerability helps her shed her “starched doctor role” and better understand the unique barriers that each patient faces. She wrote, “Somehow, the intimacy of these encounters fills my need—the intrinsic need most doctors have – to truly connect with and attempt to heal another human being.” Read Dr. Thoman’s column.
Upcoming Training Courses
CITC’s schedule of upcoming training courses (through April 2014) offers a variety of courses for clinicians and public health providers.
February 25, 2014
Los Angeles, CA
Training planned and delivered in collaboration with Charles Drew University, UCLA Pacific AIDS Education and Training Centers and the CA STD/HIV Prevention Training Center.
April 1-4, 2014
Tuberculosis Program Managers Intensive
Four-day intensive for nurses, physicians, and other health professionals working as tuberculosis program managers.
April 24, 2014
Los Angeles, CA
CTCA Educational Conference
April 24, 2014
Los Angeles, CA
TB Case Study Session (in association with CTCA)
Using challenging TB cases, expert faculty will discuss strategies to fight TB as cases become more and more complicated.
April 25, 2014
Los Angeles, CA
TB Update (in association with CTCA)
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 David J. Horne, MD, MPH.
Seattle, long famous as a hub of the aircraft industry and innovative technology in the Pacific Northwest, can also boast a critical mass of expertise in tuberculosis medicine and research. Whether they work within the Washington State Department of Health, Seattle-King County TB Control, or the University of Washington (UW) Haborview Medical Center, these TB experts have created a magnetic force field to attract new talent to the region. Dr. David Horne, Assistant Professor in the Division of Pulmonary and Critical Care Medicine at UW, is a prime example of the emerging group of academic physicians who will lead the field of TB care and research in the years to come.
David Horne was born and raised in Chicago, Illinois. His father (an immigrant from Wales) and his mother (born in Jamaica) both worked as nurses and instilled in their son an early interest in the wide world beyond Chicago. When he began his undergraduate studies at Stanford University, Dr. Horne had no particular interest in medicine as a career path, focusing instead on international development and human biology. After graduating from Stanford, Dr. Horne worked for a few years at the Water Management Division of the Environmental Protection Agency in San Francisco. His work on storm water runoff projects did not deter him from medical school indefinitely, but it did provide valuable experience in environmental health and lessons about the inner workings of governmental bureaucracies.
As a medical student at University of California, San Francisco, Dr. Horne was first introduced to tuberculosis medicine during rotations at San Francisco General Hospital. His interest in TB was further kindled when he took time off from medical school to work overseas in Honduras and Zambia: “TB was a certainly a disease of significance in these low-resource settings,” he recalls. “While in Zambia, the mother of a nurse on staff, who had become my friend, died from TB. This had a profound impact on me.” Dr. Horne pursued his post-graduate training at Yale-New Haven Hospital, with an internship and residency in internal medicine. As chief resident at Yale, he felt drawn to pulmonary medicine, and in 2005 accepted a fellowship at UW’s Division of Pulmonary and Critical Care Medicine, which has been his professional home ever since. Dr. Horne credits the following colleagues as important mentors during this time: Masa Narita, MD; Tom Hawn, MD, PhD, and Randy Curtis, MD, MPH. In 2009, Dr. Horne burnished his research credentials with a Masters in Public Health in Epidemiology from UW.
Dr. Horne’s growing list of publications includes manuscripts in the Journal of Clinical Microbiology, the Journal of Infectious Diseases, and The Lancet Infectious Diseases. His latest article, “Challenging Issues in Solid Organ Transplantation,” appears in the November 2013 issue of Clinical Infectious Diseases. Dr. Horne joined the Warmline medical consultation faculty in 2010, and has lectured at several Curry clinical intensive courses in Seattle and San Francisco.
When asked about the most rewarding aspects of his work, Dr. Horne responds: “I really like the variety of my work, and coming up with cool ideas for the next project. And I definitely enjoy my colleagues.” On the downside, Dr. Horne expresses a lament often heard in academic medicine: the constant rigor of seeking grant funds, a pursuit that pulls him in many different directions.
The future holds great promise for Dr. Horne as he starts his role as Medical Director for the Firland Northwest Tuberculosis Center, a new clinical and translational science research and clinical education unit in the Department of Medicine at UW. The Center is described as a “virtual think tank” and will surely contribute to the gravitational pull of top TB talent to the Seattle area.
Masa Narita, MD, is Director of the Seattle and King County TB Control Program, and clearly holds his colleague in high regard: “Dave has dedicated himself to making a difference in the TB world. Dave became a crucial member of the TB team in Seattle as he excels in fostering collaboration, and through the Firland Northwest Tuberculosis Center, he is leading us to the next level with his forward-thinking.”
Curry International Tuberculosis Center
University of California, San Francisco
300 Frank Ogawa Plaza, Suite 520
Oakland, CA 94612-2037
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Principal Investigator/ Medical Director: Lisa Chen, MD
Deputy Director: James Sederberg
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