Greetings from Geneva: I’m sure that readers of this newsletter, like myself, have been receiving many questions recently from members of the public, friends, family, concerned citizens, and media organizations regarding the recent case of an XDR TB patient who traveled on several overseas flights and was placed under a federal isolation order by the CDC. This case should should remind us all that the STOP TB slogan for this year's World TB Day: "TB Anywhere is TB Everywhere", is completely true! This fellow with XDR TB, besides becoming the most famous person in the world for a time (unfortunately), reminds us that anybody can get TB, and that good TB control cures TB and prevents MDR TB and XDR TB. This case and the resulting interest provides us with a unique opportunity to highlight just how important effective TB control is.
In this issue we report on some of our efforts to strengthen TB control efforts in the United States through training and education, including an update on our 3 Pocket Cards on the Treatment of TB, which have just been revised to reflect the most recently published guidelines. These have been, by far, our most frequently requested educational products. They include Standard Therapy for Active Disease in Adults and Adolescents, Standard Therapy for Active Disease in Children, and Treatment of TB in Adult and Adolescent Patients Co-Infected with HIV.
This issue also features a profile of the new TB Program Director for the Indiana State Department of Health, Sarah Burkholder, RN, MPH. She brings with her a wealth of communicable disease experience, both internationally, as well as at the local health department level. Her education and experience should serve her well in achieving her goal of “sustaining a vibrant TB program in a low incidence state.”
In February 2007, the GTBI conducted its second TB Intensive Workshop. First conducted last year, this popular course provides physician and nurse clinicians with an in-depth review of the principles and application of TB transmission, diagnosis, and treatment, as well as the management of TB in special populations. This issue reviews the origin and evolution of this course and how we plan to use feedback to make further revisions.
In closing, all of the efforts made by TB program staff and by partners in the Northeastern RTMCC are key in the effort to eliminate TB Let us use the recent events to remind ourselves just how important these efforts are!
Lee B. Reichman, MD, MPH
Northeastern RTMCC and the
Global Tuberculosis Institute
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Most Wanted Remains Most Current : Revised TB Treatment Cards
The NJMS Global Tuberculosis Institute pocket cards on TB treatment are among the most requested TB-related educational products in the United States. This has been verified by requests for these cards on both treatment of disease and infection at the GTBI as well as through the training needs assessments from our sister RTMCCs. This year, the GTBI is updating its cards to ensure their continued usefulness. The following cards will be updated:
- Treatment of Tuberculosis: Standard Therapy for Active Disease in Adults and Adolescents
- Treatment of Tuberculosis: Standard Therapy for Active Disease in Children
- Treatment of Tuberculosis in Adult and Adolescent Patients Co-Infected with the Human Immunodeficiency Virus (HIV)
The 3 pocket cards on treatment of latent TB infection, produced by our partners at the Charles P. Felton National Tuberculosis Center at Harlem Hospital, are also being revised this year and will be highlighted in a future RTMCC newsletter
While there has not been a revised consensus statement on TB treatment since the one issued in 2002 by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America, changes published in other national guidelines have been incorporated. A new edition (2006) of the American Academy of Pediatrics Committee on Infectious Diseases Red Book has been issued as part of its three-year update cycle. Additionally, updated Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents from the Panel on Antiretroviral Guidelines for Adult and Adolescents were released in October of 2006. Finally, there have been a number of studies related to drug usage and toxicities which have changed practice and, therefore, what we print on our cards. Some of these changes include:
- Recall of the second-line drug gatifloxacin
- An increase in the maximum dosing for rifapentine (10-15 mg/kg [600-900 mg maxium])
- Addition of 2 new antiretroviral drugs for HIV infection, darunavir and tipranavir, in the protease inhibitor category
In addition, we have made formatting changes and expanded on some details based on feedback from requestors, stakeholders, and expert reviewers.
Programs who wish to adapt the card are welcome to do so. In a number of cases, we have provided the graphics file of the cards to programs who have included program-specific information on their version. This can be an effective method for marketing a state, county, or city TB program and providing relevant guidance appropriate to local practice and regulations.
If you wish to order the cards or adapt them, please contact us at 973-972-0979. The new cards can be downloaded here.
Submitted by: Rajita Bhavaraju, MPH
Training and Consultation Specialist
NJMS Global Tuberculosis Institute
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Staff Profile: Indiana: Sarah Burkholder, RN, MPH
Sarah Burkholder may be new on the job, but she’s far from inexperienced. As TB Program Director for the Indiana State Department of Health since January 2007, she brings with her a background in both nursing and public health. Most recently she worked for the Marion County (IN) Health Department where she served as HIV Nurse Epidemiologist for a little over a year. From there she was recruited by the state to head up the TB Program. She also served for 8 years as Manager of the Community Health Nursing Division for the Elkhart County Health Department, overseeing communicable diseases (including TB), screening programs, and outpatient clinics.
So, how did Sarah Burkholder, a native of Virginia, wind up being the TB Controller for the State of Indiana? As a very young girl, she knew she wanted to become a nurse and work with the Native American population. In 1976, she received a BS degree in Nursing from the Medical College of Virginia in Richmond (now Virginia Commonwealth University) and immediately went to work in a surgical intensive care unit.
However, in the late 1970’s and early 1980’s, she spent six years living and working in Bolivia as a nurse volunteer. She was affiliated with the Mennonite Central Committee, which she explained is based on a community development model, much like the Peace Corps, incorporating education, health, and agriculture. She first became familiar with tuberculosis in Bolivia - not to mention polio, malaria, pertussis, measles, and neonatal tetanus! During the first three years, Sarah was assigned to a very rural part of the country, working with “health promoters” - what we might refer to as outreach workers or neighborhood advocates. For the remainder of her stay there, she assumed an administrative role as Director of the Mennonite Central Committee’s Health Program working in conjunction with the Bolivian Ministry of Health.
She was particularly fascinated by the effect that certain public health interventions had on the country’s morbidity. As an example, she recalled that the institution of sterile instruments to cut umbilical cords and the application of gentian violet significantly decreased the rate of neonatal tetanus. This experience eventually led Sarah to pursue an advanced degree in Public Health at the University of Michigan where she completed the Master of Public Health Program.
In her new position as TB Program Director, some of her responsibilities include:
- Analyzing surveillance data to identify trends
- Acting as a resource for the state’s TB Nurse Consultants
- Developing a three-year TB Strategic Plan
- Developing and revising TB policies and protocols
Probably the most significant challenges she faces are “sustaining a vibrant TB Program in a low incidence state and increasing communication between local and state health departments”. To achieve these objectives, Sarah visits local health departments to meet face to face with the nursing staff. She also attends TB meetings in the four regions of the state. In addition, she has created a newsletter, “TB Tidbits” which provides information about outbreaks in Indiana and neighboring states, highlights certain aspects of the annual report, and announces upcoming TB-related events.
When not at work, Sarah enjoys reading. Recent novels she’s read are the “Kite Runner” and the “Secret Life of Bees”. She also enjoys traveling and her “most treasured experiences” are trips to places that are off the beaten track. She’s hiked the Inca Trail in Bolivia where the terrain ranged from mountain tops to the rain forest.
It will come as no surprise to hear that Sarah’s long-term goal is to “get back into international public health”. But in the meantime, her adopted state of Indiana is fortunate to have someone with her passion and commitment to healthcare heading up their TB Program!
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TB Intensive Workshop
In an era of declining TB incidence, a major challenge to the successful control of tuberculosis is maintaining clinical expertise. Continued progress toward the elimination of TB requires improvements in existing clinical and public health practices. According to the Centers for Disease Control and Prevention, new guidelines and recommendations are more effective when supplemented with targeted education. In particular, clinicians should understand the significance of local epidemiology and be able to identify and treat high-risk patients with LTBI, evaluate, report, and treat patients with suspected or confirmed TB disease, and collaborate with local health jurisdictions.1
The TB Intensive Workshop was developed to address these needs, as well as those identified in the RTMCC needs assessment conducted in 2005. We first offered this as a two-day course in June 2006. In response to participant suggestions for improvement, the course was expanded to two and a half days in February 2007. The workshop covered TB epidemiology, transmission and pathogenesis, diagnostic techniques, treatment of LTBI and TB disease, TB genotyping, interpretation of chest radiographs, TB contact investigations, TB-HIV co-infection, management of MDR-TB, pediatric TB, and surgical approaches to TB treatment. Case studies of varying complexity were presented at the end of each day to synthesize didactic and practical experiences, in which participants offered strategies for diagnosing and treating TB patients.
In order to provide diverse perspectives, the faculty included highly qualified TB experts from various disciplines and geographic locations (New Jersey, New York City, and Philadelphia). The course was attended by 35 physicians and nurses who came from TB programs in Indiana, Maryland, New Jersey, New York State, and Vermont as well as one observer from the Division of Tuberculosis Elimination at the Centers for Disease Control and Prevention. Participant feedback about the course content and faculty members was favorable. The sessions on interpretation of chest radiographs, pediatric TB, TB/HIV co-infection, multi-drug resistant TB and surgical approaches to TB treatment were particularly well received. Participants indicated they would use the information learned from the course in the management of TB patients, share the material with colleagues, and recommend the course to co-workers. A number of individuals suggested increasing the duration of the workshop to enable them to ask more questions and therefore, better assimilate the extensive information presented. The pre and post tests findings showed that there was an overall increase in knowledge about TB. As a result of the course, participants could more effectively list the differences between TB infection and TB disease, identify the uses of genotyping, interpret TST positivity among different groups, and differentiate between primary and secondary drug resistance.
The success of the course was due in great part to the faculty expertise, participants’ interest in the topics, and relevance of the content to participants’ duties. This workshop will be offered again in the fall and may be extended to 3 full days. Individuals who would like more information on the course, including specific dates, location, and applications may check the following website.
1. Centers for Disease Control and Prevention. Controlling Tuberculosis in the United States: recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR 2005;54(No.RR-12):3-27.
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Medical Consultation Services: NE RTMCC physicians respond to requests from providers seeking medical consultation through:
- Our toll-free TB Infoline: 1-800-4TB-DOCS and
During each consultation, the NE RTMCC physicians will advise providers of TB Program resources for consultation in their jurisdiction. In addition, TB programs will be informed of TB cases with public health implications.
Medical Consultant Web-Based Grand Rounds: Every other month, designated TB program medical consultants are invited to participate in a web-based TB case conference (or grand rounds). Consultants are encouraged to present challenging TB cases on which they would like feedback from their colleagues throughout the Region. The next conference is scheduled for June 26 at 4:00 p.m. TB program medical consultants who would like to present a case should contact Dr. Alfred Lardizabal at 973-972-8452 or email@example.com.
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NE RTMCC Training Courses Planned for 2007
Courses are open to participants in the 20 project areas (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, NJ, New York State, New York City, Pennsylvania, Michigan, Indiana, Ohio, West Virginia, Delaware, Maryland, Washington DC, Detroit, Baltimore, and Philadelphia) which are served by the Northeastern National Tuberculosis Center.
Individuals outside of this region who wish to attend our training courses, should first contact their Regional Training and Medical Consultation Center to check whether the same or similar course is being offered. If this is not the case, the out-of-region participant may then register for this course.
Click here for the list of upcoming courses.
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TB Program Training Courses Planned for 2007
Click here for the list of upcoming TB program courses.
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CDC TB Website Address (URL) Change On April 18, 2007, the website addresses (URLs) on the CDC Division of TB Elimination's (DTBE) website were changed to remove the National Center for HIV, STD, and TB Prevention’s abbreviation “NCHSTP” from the URLs. The new address for CDC TB homepage is http://www.cdc.gov/tb. All HTML pages have redirects from the old pages to the new pages. Because PDF pages cannot be redirected, they cannot be accessed using the old URLs. Click here if you need help in locating a particular DTBE webpage.
Forging Partnerships to Eliminate TB: A Guide and Toolkit, 2007 This new publication from CDC’s Division of TB Elimination emphasizes reaching and involving nontraditional partners in TB prevention and control efforts. The purpose of the guide is to provide TB controllers and state and local TB programs with the basic information they need to create and sustain productive TB partnerships. The purpose of the toolkit is to make it easier to implement the tips and strategies provided in the guide.
This product can be accessed at http://www.cdc.gov/tb/pubs/forge/default.htm.
New Fact Sheets on Extensively Drug-Resistant Tuberculosis (XDR-TB) CDC’s Division of TB Elimination has published following new fact sheets on XDR-TB:
• Extensively Drug-Resistant Tuberculosis (XDR-TB)
• CDC’s Role in Preventing XDR-TB
Updated Information From CDC on XDR-TB (Including US Traveler with XDR-TB) CDC’s Division of TB Elimination posts late-breaking news and guidelines related to XDR-TB, including the investigation of a U.S. traveler who may have exposed other passengers during two overseas flights. Information can be accessed here.
WHO Bulletin Devotes May Issue to TB Tuberculosis is the special theme for the May 2007 issue the WHO Bulletin (International Journal of Public Health). International TB experts and researchers present timely articles on such topics as TB control planning; promising new tools for prevention, detection and cure; how reliable are the data?; The Global Drug Facility; barriers to completing treatment; supervised administration of treatment; round table discussion on drug resistance; public health classic: lessons from the past; and an interview with Jorge Sampaio, UN special envoy to Stop TB. The entire issue can be accessed at this website.
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On the Lighter Side - Match the Composer
Many famous classical composers of the West suffered from and likely died from tuberculosis. Before the era of chemotherapy, it was commonly believed that TB bestowed upon its victims an enhanced capacity for inspiration and creativity. Given the enduring works produced by the composers listed, it’s hard to deny such a theory.
||1770-1827 Born in Germany, he moved to Vienna in his early 20s, studied with Joseph Haydn, and gained a reputation as a virtuoso pianist. Despite gradual hearing loss beginning in his twenties, he continued to produce notable masterpieces throughout his life, even when he was almost totally deaf, including Symphony No 5 in C minor.
||1743-1805 He was a classical era composer and cellist from Italy whose music retained a courtly and galante style while he matured somewhat apart from the major European musical centers. He is mostly known for one particular minuet from his String Quintet in E, Op. 11, No. 5, and the Cello Concerto in B flat major (G 482).
||1810-1849 Born in Poland, he is widely regarded as one of the most famous, influential and prolific composers for piano. At age 20, he moved to Paris where he made a career as performer, teacher and composer. He made significant innovations in forms of the piano sonata, waltz, nocturne, and etude. His TB seems to have shaped his music in which he transformed personal suffering into lyrical beauty. From 1837 to 1847 he had a turbulent relationship with the French writer George Sand who movingly recounted his continual struggle with TB.
| Ludwig Van Beethoven
||1843-1907 He was a Norwegian composer and pianist who composed in the romantic period. He is best known for his Piano Concerto in A minor, for his incidental music to the play Peer Gynt (including Morning Mood and In the Hall of the Mountain King), and for his collection of piano miniatures Lyric Pieces. Sticken with TB at age 17, he was forced to limit his international travel and create music that was specifically Norwegian.
||1782-1840 He was an Italian violinist, violist, guitarist, and composer. He is one of the most one of the greatest violinists who ever lived, with perfect intonation and innovative techniques. It was rumored by his contemporaries that he had sold his soul to the devil for his unbelievable ability.
||1659-1695 He is considered to be one of England's greatest composers. He incorporated Italian and French stylistic elements, but devised a peculiarly English style of Baroque music. His death at age 36 was probably due to galloping consumption. Three of his 6 children died in infancy, probably also from TB.
||1882-1971 Born in Russia, he was naturalized first in France and then in the US. Considered by many in the West to be the most influential composer of 20th century music, his most famous works include Firebird and The Rite of Spring. He also achieved fame as a pianist and a conductor. Despite recurring bouts of TB (including 5 months in a sanatorium), he lived a long and productive life.
Adapted from information obtained from Jacques Chretien’s Tuberculosis: The Illustrated History of a Disease, and Wikipedia.
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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.
TB Education and Training Resources Website
This website is a service of the Centers for Disease Control and Prevention (CDC), Division of Tuberculosis Elimination. It is intended for use by TB and other healthcare professionals, patients, and the general public and can be used to locate or share TB education and training materials and to find out about other TB resources.
TB Education & Training Network (TB ETN)
The TB Education and Training Network (TB ETN) was formed to bring TB professionals together to network, share resources, and build education and training skills.
TB-Related News and Journal Items Weekly Update
Provided by the CDC as a public service, subscribers receive:
- A weekly update of TB-related news items
- Citations and abstracts to new scientific TB journal articles
- TB conference announcements
- TB job announcements
- To subscribe to this service, click here
TB Behavioral and Social Science Listserv
Sponsored by the DTBE of the CDC and the CDC National Prevention Information Network (NPIN), this Listserv provides subscribers the opportunity to exchange information and engage in ongoing discussions about behavioral and social science issues as they relate to tuberculosis prevention and control.
The Curry International Tuberculosis Center serves: Alaska, California, Colorado, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington, Wyoming, Federated State of Micronesia, Northern Mariana Islands, Republic of Marshall Islands, American Samoa, Guam, and the Republic of Palau.
The Heartland National Tuberculosis Center serves: Arizona, Illinois, Iowa, Kansas, Minnesota, Missouri, New Mexico, Nebraska, North Dakota, Oklahoma, South Dakota, Texas, and Wisconsin.
The Southeastern National Tuberculosis Center serves: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, Puerto Rico, and the U.S. Virgin Islands.
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- Lee B. Reichman, MD, MPH - Executive Director
- Reynard J. McDonald, MD - Medical Director
- Bonita T. Mangura, MD - Director of Research
- Eileen C. Napolitano - Deputy Director
- Nisha Ahamed, MPH, CHES - Program Director, Education and Training
- Chris Hayden - Northeastern Spotlight Editor
- Alfred S. Paspe - User Support Specialist/Webmaster