This was a busy summer for us starting with four training courses that were held in June. I was delighted to attend for the first time the annual New England TB Clinician’s Conference in Amherst, Massachusetts on June 2nd and enjoyed networking with faculty, TB program staff and other partners from the region. We also held a clinical course in conjunction with the Pennsylvania Department of Health in Harrisburg, PA, a customized training for the Office of Refugee Resettlement in Washington, DC, and rounded out the month of June with a training on TB Interviewing for Contact Investigation in Newark, NJ. You can read more about these courses in the training highlights section.
This edition of the newsletter also features a profile of Mark Wolman, MPH who many of you have worked with over the years and have come to rely on his systematic approach to TB contact investigations based on many years of experience working in the field. We also highlight the two recipients of the New England TB Hero award and our newest consultant for the GTBI TB consultation service.
Finally, I would like to announce the homecoming of a member of our GTBI family. We are thrilled that Rajita Bhavaraju has rejoined us as the new Deputy Director and will be overseeing the operations at GTBI. She brings new vision to the Institute as we continue to work with you all in developing approaches to meet emerging challenges in the areas of TB training and consultation.
Accelerating the Decline of TB: Focusing on TB Infection and High Risk Populations - Harrisburg, PA
The Pennsylvania Department of Health along with GTBI co-sponsored a one-day conference focused on providing updates for the diagnosis and treatment of TB infection as well as addressing TB among high-risk groups.
The training was held on June 8th and attended by 72 TB healthcare professionals from local health departments in the State. The topics were carefully chosen based on an assessment by the PA Department of Health to determine local training and education needs. Conference content addressed current diagnostic and treatment modalities for TB infection, TB testing among persons on immunosuppressive therapy, management of TB and diabetes, TB-HIV co-infection, TB contact investigations and the role and interpretation of molecular diagnostics. The faculty consisted of experts from Cooper Medical School of Rowan University (Camden, NJ), GTBI, Pennsylvania Department of Health (Harrisburg, PA), Pinnacle Health System (Harrisburg, PA) University of Pittsburg School of Medicine (Pittsburgh, PA), and Wadsworth Center, New York State Department of Health (Albany, NY).
A large number of clinicians attended the conference which was a testament to the targeted and intense marketing. The attendees enjoyed the well balanced conference as it incorporated both clinical and public health perspectives. Conference feedback indicated that the audience was very willing to change their workplace practice and focus on screening TB patients for diabetes and HIV.
Submitted by Arpita Jindani, MSW, MA – Health Educator
TB: Miasmic Maladies of Migrant Minors - Washington, DC
This training was designed and provided for key staff at the Office of Refugee Resettlement (ORR) Administration for Children and Families on June 15th. ORR is responsible for the care of unaccompanied children. As part of general health care, all children undergo examinations for communicable diseases including tuberculosis. Although TB constitutes a minority of the health problems for unaccompanied children, it makes up a large fraction of the health-related workload based on all the difficulties that TB entails.
The training addressed diagnosis of latent TB infection, basics of chest radiography, laboratory methods, contact investigations, and strategies for collaborating with the local health department. The course increased the participants’ understanding of TB and will influence how they do their jobs. Major strengths of the training included the small group format, relevant material, access to subject matter experts, and presentation of content. This customized training may be replicated in other areas for staff who work at shelters where unaccompanied children are housed and receive medical care, including evaluation for TB.
Submitted by Anita Khilall, MPH – Program Director, Education & Training
GTBI held a four-day interactive, skills-building training to improve the abilities of both new and experienced staff who are responsible for conducting TB interviews as part of contact investigations. The workshop was held on June 21-24, 2016. The standardized course was developed in collaboration with the CDC and the Regional Training and Medical Consultation Centers.
Speakers were carefully chosen based on their experience conducting contact investigations and TB interviews and included staff from CDC, GTBI, New Jersey Department of Health, the New York City Department of Health and Mental Hygiene, and the Middlesex County Chest Clinic. Topics included communication skills, cultural and diversity considerations, introduction to the contact investigation process, interviewing for TB contact investigation and special circumstances.
The course also included many role-play activities and small group work in order to focus on strengthening skills of the attendees. The course utilized standardized patients (SPs) who are actors trained to portray the role of a TB patient for the purpose of training healthcare workers. During the role-play activities, the SP played the role of a TB patient, the participant played the role of the interviewer, and the experienced facilitator observed the process to provide feedback to the interviewer. Although many participants initially feel nervous about this process, they frequently find the experience invaluable in enhancing their interviewing skills. The course was well-received and participants valued the faculty expertise, chance to practice their skills using real-life scenarios and opportunities for networking with and learn from colleagues in other TB programs.
Submitted by Jennifer K. Campbell, MPH, CHES - Training and Consultation Specialist
Mark Woman, MPH is the Program Manager of TB Control at the Global Tuberculosis Institute (GTBI) as well as the in-house contact investigation expert. In his role as program manager, some of his responsibilities include taking the lead in all congregate setting investigations, initiating legal intervention, as well as working with nurse case managers to address contact investigation and airborne isolation. He lends his expertise not just to folks in New Jersey but also throughout the Northeast region of the United States.
Mark Wolman standing outside the Global Tuberculosis Institute
Remarkably, Mark has been in the field of TB for 45 years and counting! Mark has contributed to training around TB prevention and control activities since GTBI was a Model TB Center in the mid-nineties in response to the TB resurgence. He helped develop content which was later used to train lead staff in CDC’s Program Manager’s Course, as well as nationally-released multi-format materials on TB interviewing and contact investigation. Mark was also a member of the working group for the 2005 CDC/NTCA Contact Investigation Guidelines and instrumental in the development of content for the current CDC and RTMCC standardized 4-day course on TB interviewing for contact investigation. He continues to provide training for physicians, nurses, public health staff, fellows, and students in the health professions, and even teaches a course at the Rutgers School of Public Health called, “TB: A View from the Trenches.”
Rajita Bhavaraju, Deputy Director of GTBI, who has worked with Mark for many years to develop trainings and educational materials, remarks “When Mark is in front of a room, he often can’t get through an entire lecture without being flooded with trainee questions - it is clear that many folks in public health don’t have access to his type of expertise and experience. Mark is eager to entertain questions of all types and has a way of providing explanations which one can apply to his or her own individual environment.”
Contact investigation is based on scientific and epidemiological evidence, but spending time with Mark makes one realize that it is also an art!
Mark describes his path to public health as an accidental one. He received a Bachelor of Science from St. Peter’s College (Jersey City, NJ) and then took a position as a field representative in TB Control at Jersey City Department of Health. He worked in that position from 1971-1976 and then applied for a state position where he was assigned to big cities in Northern New Jersey including Jersey City, Paterson, Elizabeth, and Newark. While working for the State, Mark simultaneously completed a Master in Public Health from Hunter College (New York, NY). His expertise in disease control was much needed at the height of the TB resurgence. In 1994, Mark was transferred to the then New Jersey Medical School National TB Center (now GTBI) and eventually a position opened up for a TB Control Program Manager ─ he has been here ever since.
Saying that Mark is passionate about TB contact investigations would be an understatement. He actually thrives on contact investigations. In his words, “The more complex the situation, the more interesting I find it. The deciphering, analyzing, and piecing together bits of information is like piecing together a puzzle. It is the detective work which gets me going.”
According to Mark, one of the biggest challenges in TB control is the lack of standardization. “In my opinion, there is an epidemic among TB control programs in the United States of identifying and excessively testing low-risk contacts and the ‘worried well.’ There is no simple formula to address this. We need to maintain a certain standard while conducting contact investigations. In my opinion, the best approach, although not perfect, is to use the concentric circle model; start small, and expand the investigation if needed.” Mark strongly feels that in many instances, TB control staff succumb to external pressure and test a large number of people. This approach utilizes more resources and staff time and may not always yield the best outcome. Mark uses every opportunity to emphasize that “there is no magic bullet for any contact investigation;” it is a process, and one needs to carefully consider the duration and frequency of the exposure among other factors such as environmental and contact risk factors in the decision-making process.
In his 45 years of TB experience, Mark has numerous stories to share from his time in the field, but one particular incident really stands out. Mark recollects the case of an infectious TB patient from a decade ago, who spent a lot of time at a particular bar. According to the bar owner, the patient sat at the same spot each time he visited. Mark and the local health officer went to the bar on Friday night and again Saturday night so that they could identify more contacts. On Saturday night around 10:00pm, Mark and the health officer left the bar as the cigarette smoke was very strong and it was getting unbearable. When Mark came to the office on Monday, all his colleagues surrounded him and asked him about his wellbeing. Mark was taken aback and was surprised to learn that there was a shooting at the same bar shortly after he left. His colleagues had read about it in the newspaper, though Mark was completely oblivious to the shooting incident. With a big grin on his face Mark says, “It was the end of that contact investigation and despite less than ideal circumstances, I was able to get my job done.”
Mark’s colleagues are full of praise for him. Dr. Lee Reichman, founding Executive Director of GTBI remarks, “Mark is the heart and soul of GTBI as the guts of TB control lies in finding the cases and their contacts. He has acquired unique authority in terms of TB management and he, in his quiet and professional manner, keeps TB in check.”
Karen Galanowsky, the TB nurse consultant for the State of New Jersey has worked with Mark since 1992 and she emphasizes, “Mark really stands out as a TB control person as he takes charge of a situation and he looks at contact investigation very analytically. He knows how to ask the right questions and strategies to find the contacts. And my favorite thing about Mark is that he really has a great sense of humor, he can handle any TB control situation.”
Even though TB control plays a vital role in defining Mark, according to him, “My family truly defines me. I may be a TB control person for a few hours a day but I am a father and husband 24 hours a day. I consider my role as a husband and father my greatest achievement in life.”
On a parting note, Mark shares his views on TB elimination, “I am not optimistic that we will achieve that goal due to the high burden of TB globally. TB elimination can only be achieved if we start treating TB infection globally.”
Mark’s words of wisdom for health professionals new to the TB, “Read a lot on TB but make sure you latch onto someone who has a lot of experience and learn from them. You can read a ton of books and gain theoretical knowledge but there is no substitute for spending time in the field and learning from experience.”
Submitted by Arpita Jindani, MSW, MA - Health Educator
It is with great sadness we announce the passing of Dr. Reynard J. McDonald. Dr. McDonald was a Professor of Medicine and Pulmonary Medicine at the New Jersey Medical School and the Medical Director for the Global Tuberculosis Institute and Waymon C. Lattimore Practice for two decades. He retired from GTBI and the University in 2014. Dr. McDonald was a colleague, mentor, teacher and friend and everyone who had the privilege of working with him always found him a pleasure to work with. He will be profoundly missed by everyone whose lives he touched! You can read more about Dr. McDonald in a bio or a previous newsletter feature article.
Announcements and Awards: New England TB Hero Award 2016
The New England TB Hero Award was launched in 2008 by the New England Tuberculosis Consortium to acknowledge individuals who embody the highest qualities of public health care and service. The award also demonstrates the New England TB Consortium’s appreciation for the recipient’s dedication to their patients and their exemplary manner. The award recipient may be a member of a TB program, health department, a community clinic, hospital practitioner, or the lay community. He or she need not be a health care professional.
Please join us in congratulating the two award recipients for the 2016 New England TB Hero Award: Darlene Morse, a public health nurse from New Hampshire and Dr. Linda Shipton, an infectious disease physician from Massachusetts.
New Hampshire Award Recipient
Darlene Morse is the Public Health Nurse Manager at the Bureau of Infectious Disease Control for the State of New Hampshire. Darlene has over 38 years of nursing experience and has spent 11 years in public health practice.
In the picture (left to right): Elizabeth Talbot, MD, TB Controller and Award Recipient Darlene Morse, RN, MSN, M.Ed., CHES, CIC
Darlene’s knowledge of TB and her willingness to teach, educate, and support staff have consistently eased the transition for those who are new to TB. In her current position, she provides leadership in nurse case management, mentoring, and training. She educates public health nurses, health care providers, and patients on TB safety and care. Darlene is an invaluable resource in TB control and management. She goes above and beyond in helping the local public health departments throughout NH in conducting contact investigations and case management of patients with latent TB infection and active TB disease.
According to Bobby Baglet, Director of the Division of Public Health and Community Services, “Darlene exemplifies the mission, values, and goals of the state’s TB control program. The State of NH has benefited greatly from Darlene’s excellent leadership and guidance at the Infectious Disease Bureau. Darlene is truly a TB Hero and a Champion for the State of New Hampshire!”
Submitted by Lindsay J. Pierce, M.Ed. – Chief, Injection Disease Prevention, Investigation & Care Service Section, New Hampshire Division of Public Health Services, Department of Health and Human Services
Massachusetts Award Recipient
The second award recipient, Linda Shipton, MD, is an infectious disease physician and the lead clinician for the TB Clinic at Cambridge Health Alliance (CHA) in Massachusetts. In this role, she leads a team of physicians and public health nurses. Together with her team, Dr. Shipton provides patient centered care by working with each patient to be sure that they understands the diagnosis and treatment recommendations.
In the picture (left to right): Jennifer Cochran, MPH, Award Recipient Linda Shipton, MD
Dr. Shipton has managed very complex patients, including individuals with multi-drug resistant TB and patients with complex co-morbidities compounded by social problems, supporting them through their long course of treatment. In addition to the above, Dr. Shipton has been an exceptional teacher who is committed to the ongoing development of her team.
Jennifer Cochran, TB Program Manager for Massachusetts adds, “Dr. Shipton’s outstanding commitment to patient care shows through in every situation. Recently, Dr. Shipton evaluated a patient who was referred to the Cambridge TB clinic. Dr. Shipton pursued her clinical sense that TB was the cause of the patient’s worsening clinical presentation; she continued to navigate her patient through a longer-than-usual diagnostic period. Her doggedness was validated when, after several negative labs, a specimen not only grew M.tuberculosis but subsequent drug susceptibility results showed the infection to be multi-drug resistant TB. She was persistent in her approach, committed to her patient and addressing her patient’s fears to keep the individual engaged in care through diagnosis and treatment.”
Submitted by Jennifer Cochran, MPH – Director, Division of Global Populations and Infectious Disease Prevention and Pat Iyer, RN, MSN – Director of Patient Management, Massachusetts Department of Public Health
Maunank Shah, MD Joins GTBI TB Consultation Service
In June of this year, Maunank Shah, MD, joined the group of seven expert physicians who currently serve as volunteer medical consultants for GTBI’s TB consultation service. Dr. Shah is an Assistant Professor in the Division of Infectious Diseases, Center for TB Research and Center for Clinical Global Health Education at Johns Hopkins University and the Medical Director for the Baltimore City Health Department TB Program. Dr. Shah trained in infectious diseases and is a clinical investigator with primary interests in TB diagnostics, HIV transmission, teaching and mentorship and domestic TB. He has served as faculty at a number of trainings and conferences throughout the region and we are pleased to count him as one of our consultants!
GTBI has over 25 years of experience in offering TB clinical care, prevention and education services. Our experts are available to answer a wide variety of TB-related questions, including clinical, nursing, public health, and programmatic issues. Consultants can be reached by calling the TB Info-line (1-800-482-3627) or by email (mailto:firstname.lastname@example.org)
GTBI sponsors courses and webinars on tuberculosis. Webinars are open to all participants in the United States. For in-person courses, GTBI prioritizes participants from the Northeast Region (Baltimore, Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York City, New York State, Pennsylvania, Philadelphia, Rhode Island, Vermont, and Washington, DC). Click here for a list of upcoming trainings.
Links - Other TB Resources
Division of Tuberculosis Elimination The mission of the Division of Tuberculosis Elimination (DTBE) is to promote health and quality of life by preventing, controlling, and eventually eliminating tuberculosis from the United States, and by collaborating with other countries and international partners in controlling tuberculosis worldwide.
Find TB Resources Website
This website provides a central, comprehensive searchable database of international, national, state, and local TB-related education and training materials for TB healthcare workers, health professionals, patients, and the general public. Users can also submit their education and training materials as well find information on funding opportunities, TB organizations, TB mailing lists, and TB images.
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Content include announcements, current journal articles, available resources and training activities, upcoming meetings and conferences, etc. To subscribe to this service, click here
The Curry International Tuberculosis Center serves: Alaska, California, Colorado, Hawaii, Idaho, Nevada, Oregon, Utah, Washington, Federated State of Micronesia, Northern Mariana Islands, Republic of Marshall Islands, American Samoa, Guam, and the Republic of Palau.
The Southeastern National Tuberculosis Center serves: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, Puerto Rico, West Virginia, and the U.S. Virgin Islands.