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Northeastern Spotlight
Summer 2012
Volume 7 - Number 2

The New Jersey Medical School Global Tuberculosis Institute is the TB Regional Training and Medical Consultation Center (RTMCC) for the northeastern region of the United States, funded through the New Jersey Department of Health and Senior Services with funds awarded through Cooperative Agreement U52/CCU200506, Centers for Disease Control and Prevention. 

RTMCC Communications Sub-Committee: Bill Bower, MPH • Nickolette Patrick, MPH
Newsletter design by Judith Rew

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Dear Colleague:

Summer is finally upon us, and for many of us that means reuniting with members of our TB “family” at the National TB Conference in Atlanta. For myself and my colleagues here at the Global TB Institute, this is one of the few times each year when we have the opportunity to convene as a region and discuss the challenges you’re facing in your project areas and what we can do to support you. 

The National TB Conference had a panel called “The Faces and Voices of TB” which included Jigna Rao, and Raquel  Orduno, both of whom who became powerful patient voices for TB after being diagnosed with the disease.  Jigna and Raquel are highlighted in the two newest issues of our TB & Cultural Competency Newsletter. These issues explore the role of patients in global TB control and elimination efforts, and you can read more about them in this installment of the Northeastern Spotlight. 

Also in this issue of the Northeastern Spotlight, we delve into research around the growing challenge of Latent TB and Type 2 Diabetes in Mexican-Americans. Two of our most popular webinars from this spring—TB Among the Homeless and Head to Toe: Case Studies of Extra-Pulmonary TB—are now archived on our website.  We also take a closer look at the Philadelphia World TB Day event as well as an entertaining appraisal of TB in TV episodes in the Lighter Side segment.

While being interviewed for her profile in this issue, Lisa Paulos remarked that “It’s been so great meeting people at the NTCA and TB PEN conferences, and having the chance to call other states and ask them questions.... This is a big reason why I really like my job.” I’d like to echo Lisa’s sentiment: Collaborating with so many wonderful partners is one of the best parts of our work. I hope you have an enjoyable summer, and my colleagues and I look forward to seeing many of you at the TB-ETN/TB-PEN Conference in September.

Lee B. Reichman, MD, MPH
Executive Director
Northeastern RTMCC and the
Global Tuberculosis Institute

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Product Spotlight: TB & Cultural Competency Newsletters

This spring, two issues of the Northeastern RTMCC’s newsletter TB and Cultural Competency: Notes from the Field explore the role of persons affected by TB in global TB control and elimination efforts.  Each issue features a woman who emerged from a solitary struggle with TB diagnosis and treatment to build a support network around her, reshaping her experience with TB into a powerful voice for the global community of people affected with TB. 

TB patients and others affected by TB have the potential to raise public and political awareness of problems and promote solutions to them. They can educate diverse audiences on social, medical, and scientific factors affecting TB control and elimination.  Patients can also advocate  to  promote both individual-level solutions to the challenges of TB control, such as providing navigation for patients to access social services while on TB treatment, as well as global solutions, such as mobilizing funding support for new anti-TB drug development. Both women highlighted in the recent newsletters came from cultures where there is much fear and stigma around TB, and both discovered the strength to move past this stigma and share their stories in order to affect change and raise awareness about TB.

Issue # 14, Finding My Voice, shares the moving story of Jigna Rao, who was diagnosed with pelvic TB after struggling with a series of long and difficult fertility treatments.  Although Jigna made a full recovery from the disease, the experience changed her life. She had to give up her dreams of motherhood and accept that she would not become pregnant. Moreover, she experienced how the stigma associated with TB can increase patients' sense of loneliness and isolation, making it more difficult to reach out for the knowledge and support needed for good treatment outcomes.  Over the past several years Jigna has spoken to patients, health care providers, and reporters to share her experience and raise awareness of TB and its impact on women.

Issue  #15 of the newsletter, From Isolation to Vocation,  highlights the experience of Raquel del Consuelo Orduño, who grew up on both sides of the U.S.-Mexico border in a bicultural, bi-national family. Although TB incidence along the border is higher than the national average in either Mexico or the United States, she heard little about TB from family members or healthcare providers as a child and then as a teacher in El Paso, Texas. In her mid-thirties, after three years of misdiagnoses with other pulmonary infections, respiratory infections, and asthma, Raquel learned she had pulmonary TB. Her physical health began to improve once she started treatment, but it seemed all other aspects of her life were thrown into jeopardy by the diagnosis.

The newsletter describes Raquel’s personal journey, and her experiences with an innovative strategy called Photovoice, which promotes advocacy by people who have been affected by TB.  Photovoice projects bring together a small group of people directly impacted by a social issue to document the issue in their own lives and communities through photography over the course of several weeks.  Based on their photographs and important themes emerging from them, the group members shape their own interpretation and representation of the problem.  The group then presents its photo project in public settings to raise awareness and inform policy development on the issue it addressed. 

TB Photovoice projects in the US, Thailand, Brazil, the US-Mexican border, South Africa, the Philippines, and Kenya have brought the experiences of people who are treated for TB into local, national, and international policy discussions, and help put a human face on the complex, persistent challenges of TB around the world. 

The experiences of Jigna and Raquel reveal how advocates from communities and subpopulations most affected by TB can help providers develop their competency to work effectively with these populations.  Both stories highlighted in TB and Cultural Competency demonstrate the value of advocacy inspired and informed by deep, experiential knowledge of the cultural and social contexts within which people receive a TB diagnosis and undergo treatment. 

Issues of the TB & Cultural Competency Newsletter are available on the Global TB Institute website at http://www.umdnj.edu/globaltb/products/newsletter.htm

Submitted by Julie Franks, PhD
Health Educator and Evaluator
Charles P. Felton National TB Center, ICAP, Columbia University

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Behavioral/Social Science Article: Latent TB and Type 2 Diabetes in Mexican-Americans

There is growing awareness of the association of tuberculosis and diabetes, with the risk of TB attributable to Type 2 diabetes mellitus estimated to be between 15% and 25%.1 In the United States, this association appears to be more common in certain minority groups, including Mexican-Americans*. This article will review information about the prevalence of these two diseases, with special attention to knowledge and attitudes in Mexican-Americans.

Latent TB Infection Rates in Mexican-Americans

Because of the movement of individuals across the southern border, Mexican-Americans comprise the largest foreign-born group affected by TB in the US. A study using data from the National Health and Nutrition Examination Survey found that 9.4% of Mexican-Americans had LTBI (representing almost 2 million individuals), compared to 5.7% in the general US adult population, a difference that remained statistically significant after controlling for income.

Diabetes Rates in Mexican-Americans

There are more than 25 million diabetics in the US, almost all (95%) of whom have Type 2 diabetes mellitus (DM2), formerly called "adult-onset" diabetes. DM2 is characterized by recurrent or persistent hyperglycemia, measured by levels of glycated hemoglobin (HbA1c). HbA1c levels greater than or equal to 6.2% indicate poor glucose control.

The prevalence of DM2 is significantly higher in people with low socioeconomic status (SES), as is poor glucose control, undiagnosed DM2, and DM2 complications. Mexican-Americans are almost twice as likely as non-Hispanic whites to be diagnosed with DM2; the prevalence rate is 10.4/100,000 compared to 5.2/100,000 in non-Hispanic whites, standardized by age and sex. Mexican-Americans have higher rates of DM2 complications such as end-stage renal disease, and they are 50% more likely to die from DM2 as non-Hispanic whites.

Studies exploring the prevalence of DM2 in Mexican-Americans point to the relation between poor glucose control and such SES variables as lack of health insurance and low levels of education. Hispanic populations share the same risk factors for DM2 as other groups: obesity, lack of exercise, excess calorie intake, and unhealthy diet choices. But while there may be an unexplained role for genetics, Hispanic populations are more likely to have a sedentary lifestyle and to be overweight or obese in comparison to non-Hispanic whites. In a study of Mexican-Americans in south Texas, approximately 75% were found to have poor glucose control.

TB Knowledge, Attitudes, and Beliefs among Mexican-Americans

The health psychology literature suggests that health-protective behaviors, such as the decision to accept or adhere to treatment, are influenced by diverse cultural factors including individuals' knowledge, attitudes, and beliefs (KAB). Deficiencies in knowledge, misperceptions, and negative attitudes toward TB may serve as significant barriers to the acceptance and completion of LTBI treatment. Conversely, greater patient understanding of TB etiology, transmission, and disease management has been associated with positive health-seeking behaviors and better individual experiences with TB. These have been linked to more favorable health outcomes such as higher rates of treatment adherence and completion.

A small set of qualitative studies with small samples have examined KAB specifically in Mexican-American populations. McEwen and colleagues note 2, 3 that the treatment of TB and LTBI varies greatly between the US and Mexico. Because TB is so prevalent in Mexico, nearly all citizens receive the Bacille Calmette-Guerin (BCG) vaccination and TB is viewed as a fatal disease, leading to a great deal of stigma. BCG is viewed as offering lifelong protection for TB and even against other diseases such as chicken pox and measles.  Individuals are told that positive Tuberculin Skin Test (TST) results are due to BCG vaccination and are generally unaware of the distinction between disease and infection (a misconception which is common in many other groups).

Misconceptions about transmission through kissing, food, and sharing of utensils were found.4, 5 Evidence of stigma was substantial as some respondents reported that they would isolate themselves if found to have TB. Additionally, many said that after TB patients die, all their belongings should be burned. While most viewed TB as a serious disease, those who did not speak English were more likely to underestimate their risk.4

Impact on Adherence/Completion: Several studies reported barriers to treatment for Mexican-Americans, including lack of transportation, clinic hours, cost, inconvenient clinic location, and communication problems with staff.4 Because of conflicting information about TB/LTBI received in Mexico and America, McEwen found Mexican-Americans to be suspicious of LTBI treatment suggestions from US health care providers. Some participants reported doubts but did not want to take the risk of developing active disease, thereby deciding to comply with LTBI treatment.2 Others reacted to subtle coercion to take LTBI treatment by engaging in "false compliance" – these patients were willing to begin treatment but gradually stopped taking the medicines without telling their doctor. McEwen and Boyle3 suggest that this constitutes a way for people of low socioeconomic status to assert control against more powerful medical providers. Those who do report non-adherence often use medical language (claiming such side effects as elevated blood pressure) to explain why they stopped treatment.

Diabetes Knowledge, Attitudes, and Beliefs among Mexican-Americans

Few studies have examined knowledge, attitudes, and beliefs (KAB) about diabetes (DM) in Mexican-Americans. A study of DM patients' knowledge of HbA1c levels found that Hispanics were significantly less likely to know their level of glucose control when compared to other groups. However, the study acknowledged that this finding was confounded by Hispanics' lower education levels.6 In general, only 25% of Hispanic study participants could accurately report their HbA1c level, while 66% could not offer a number.6 Knowing one's HbA1c level was associated with better knowledge of DM care, better provider communication, and higher education levels. However, some researchers suggest that improving knowledge about a particular disease may not have much impact on improving adherence to medications or other medical directives. In Heisler's study,6 knowledge of HbA1c was not associated with such outcomes as DM care self-efficacy or reported self-management behaviors.

In terms of attitudes, DM patients tend to be motivated by their perceptions of the likelihood of certain outcomes, the impact on their daily lives, personal control, and treatment efficacy. While health psychology studies have generally shown that perceptions of disease seriousness are associated with treatment acceptance and adherence, DM studies have shown mixed results, with high perceived threat often associated with poor adherence and non-attendance at clinic. These studies were not specific to Mexican-Americans, but they suggest that certain attitudinal factors, along with poor knowledge, may play a role in poor control of DM in this population.

Conclusion

As the number of diabetics increases, much more needs to be learned about the association of TB and diabetes, particularly in minority populations in the United States. Further concern comes from the fact that certain groups, such as Mexican-Americans, are viewed as poor adherers to both LTBI and DM2 treatment, separately. Patients undergoing LTBI treatment typically take a daily pill of isoniazid for nine months, despite not having symptoms, and must visit their healthcare provider monthly. DM2 patients are on life-long treatment, which includes varying amounts of medications, self-testing, self-care, and dietary and exercise mandates.

While adherence studies of TB and DM2 co-therapy have not been conducted, it would seem that optimal adherence to both regimens will be difficult to achieve. Certainly, factors other than KAB (eg. health care access, communication between TB and DM2 providers, community awareness) play an important role and need to be studied. Further, innovative, culturally-tailored interventions are needed to provide support for individuals undergoing treatment for both conditions.

Submitted by Paul Colson, PhD, Program Director, and Julie Franks, PhD, Health Educator and Evaluator
Charles P. Felton National TB Center.
Thanks to Blanca Restrepo, PhD, UTHealth, School of Public Health - Brownsville

References
1.       Restrepo BI, Camerlin AJ, Rahbar MH, Wang W, Restrepo MA, Zarate I, et al. Cross-sectional assessment reveals high diabetes prevalence among newly-diagnosed tuberculosis cases. Bulletin of the World Health Organization. 2011;89(5):352-9. Epub 2011/05/11. doi: 10.2471/BLT.10.085738. PubMed PMID: 21556303; PubMed Central PMCID: PMC3089389.
2.       McEwen MM. Mexican immigrants' explanatory model of latent tuberculosis infection. Journal of transcultural nursing : official journal of the Transcultural Nursing Society / Transcultural Nursing Society. 2005;16(4):347-55. Epub 2005/09/15. doi: 10.1177/1043659605278943. PubMed PMID: 16160197.
3.       McEwen MM, Boyle J. Resistance, health, and latent tuberculosis infection: Mexican immigrants at the U.S.-Mexico border. Research and theory for nursing practice. 2007;21(3):185-97. Epub 2007/09/14. PubMed PMID: 17849651.
4.       Joseph HA, Waldman K, Rawls C, Wilce M, Shrestha-Kuwahara R. TB perspectives among a sample of Mexicans in the United States: results from an ethnographic study. Journal of immigrant and minority health / Center for Minority Public Health. 2008;10(2):177-85. Epub 2007/06/09. doi: 10.1007/s10903-007-9067-5. PubMed PMID: 17557205.
5.       Poss JE. The meanings of tuberculosis for Mexican migrant farmworkers in the United States. Social science & medicine. 1998;47(2):195-202. Epub 1998/08/28. PubMed PMID: 9720638.
6.       Heisler M, Piette JD, Spencer M, Kieffer E, Vijan S. The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management. Diabetes care. 2005;28(4):816-22. Epub 2005/03/29. PubMed PMID: 15793179.

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Profile—Lisa Paulos, RN, MPH, Pennsylvania TB Program Manager

Lisa Paulos, TB Program Manager for Pennsylvania, started her career in healthcare as a candy striper at a local hospital during high school. “Both of my parents were teachers, but they strongly discouraged me from becoming a teacher,” Lisa recalls. “I always liked science so I looked into becoming a doctor, nutritionist, or dietician, but I ultimately went with nursing because of the holistic approach to caring for people.” 

For the next 25 years, Lisa worked as a nurse in hospital, outpatient, and primary care settings, first in Seattle and then in Wisconsin. She had always had an interest in public health, and in 2007 she decided to transition out of direct patient care and enrolled in a Masters of Public Health program at the University of Wisconsin. Her family moved to York, PA in 2008 due to her husband’s job, and Lisa continued her MPH studies at Johns Hopkins while working part time at a mobile clinic.

“I had never heard of a mobile clinic before, but I wanted to work with the population it served—the uninsured.  And I think a mobile clinic is kind of cool! There was an MD/NP, myself, and an assistant who drove the vehicle and did the administrative work. We saw a lot of immigrants and people recently released from prisons, and we carried stock medications and vaccines and did basic lab testing in the vehicle. It would go different places in two counties--some places we’d go every week and other places we’d visit once or twice a month. It was a very tiny space, so I had to get used to working in very close quarters, and I was constantly squeezing by and bumping into people.  We did a lot of referrals and connecting people to other sources of low cost care, such as Federally Qualified Health Centers. We are also fortunate to have the Healthy York Network, a program for people who don’t qualify for Medicare but can’t afford medical insurance. Patients can be seen by a network of physicians, as well as three hospitals where patients can get lab tests and imaging studies. A big part of my job was hooking patients into all the resources available in the community.”

In 2010, Lisa graduated with her MPH and became TB Program Manager for Pennsylvania. She took the position because it offered variety—epidemiology, program management, evaluation, and interaction with the field staff. “It was challenging to learn about TB while simultaneously supporting the staff at all the state health centers and local health departments, because each case is so different. And then figuring out how to implement the NTIP indicators and roll those out across the state—I didn’t learn to do this in school!”

Despite being in her position for just over a year, Lisa is already able to point to some early successes. “A big focus of my first year was reaching out to field staff and making connections with them. I’ve enjoyed getting staff trainings up and going for them. The staff feels it’s such a complex disease, and they’re really appreciative of the guidance and support we offer.”   Lisa’s next project is to roll out cohort reviews in Pennsylvania. “We did a webinar earlier in the year introducing cohort reviews and going over what the objectives are and why we do it. Most of the state health centers and local health departments do an annual audit with a doctor other than the one who provided care, and I’ve been presenting this process as being similar and providing even more focused feedback. It’s a year-long process to get cohort reviews up and running, but it’s fun because it’s a great tool and we’ll benefit from it.”

When she’s not nurturing the TB program, Lisa enjoys tending her garden. “I don’t do so well growing flowers!” Lisa says, laughing. She generally sticks with fruits and vegetables, especially tomatoes and basil. She’s so used to the produce from her garden that she can’t buy tomatoes from the grocery store anymore. She tries to grow enough that she can freeze some for later. “When I eat them, it feels like springtime in the middle of winter.”

Baking is another hobby, and Lisa has a family tradition of making a birthday cake of her children’s choice on their birthday—they pick the flavor and she makes it from scratch. “One year my son requested a Reese’s Peanut Butter Cup cake, but homemade. This was a while back, and I couldn’t find a recipe for homemade peanut butter frosting so I had to make it up.”

One fun fact about Lisa is that she used to be a competitive long distance runner in high school and college.  A couple years ago Lisa’s kids were in cross country at school, and Lisa and her husband decided it would improve their health if they started running as well. They began in June on the track, one lap at a time, with a goal of running the Turkey Trot in November. “It hurts a lot more than it used to,” Lisa lamented, “but it’s still very fun. There are a lot of hills around here which makes it challenging to run. We like to run around the neighborhood or go down to the Heritage Rail Trail, which are old railroad tracks that have been graveled over. It’s nice and flat, so we’ll go there when we need a break from the hills!”

Community is important to Lisa, and it’s something she really appreciates working in TB. “It’s been so great meeting people at the NTCA and TB PEN conferences, and having the chance to call other states and ask them questions. Working with the field staff and physicians and the RTMCC has been a positive experience across the board, and everyone I’ve worked with has been great. This is a big reason why I really like my job.”

We’d like to extend a big thanks to Lisa for being such a caring and enthusiastic member of the TB community!

Submitted by
Nickolette Gaglia, MPH
Training and Consultation Specialist
NJMS Global Tuberculosis Institute

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Recently Archived Webinars on TB Among the Homeless and Extra-Pulmonary TB

As noted in the last issue of this newsletter, GTBI archives completed webinars to ensure continued access, as well as access for those who miss the live webcast. We are pleased to announce that we have added two recently conducted webinars to the archives web page: http://www.umdnj.edu/ntbc/audioarchives.htm

On February 7th, over 400 people nationally attended the eye-opening and informative webinar, “TB Among the Homeless: Dealing with Unique Challenges.”  This 1.5 hour webinar explored tuberculosis among homeless persons and successful prevention and control strategies.  It also highlighted the partnership between health departments and shelters to improve the coordination of clinical care and contact investigation outcomes.

Homeless persons suffer disproportionately from a variety of health problems, including tuberculosis. There is increased risk for TB transmission in shelters, especially in situations of crowding and poor ventilation.  Detecting, treating and preventing TB in this population benefits not only individual patients but also the larger community. Shelters can help control TB by screening clients, improving ventilation and building relationships with their local health departments.  Health departments should build respectful relationships and establish trust with their local shelters.  

The program was skillfully moderated by Bill Bower of the Charles P. Felton National TB Center.  Dr. James O’Connell of the Boston Health Care for the Homeless Program gave an overview and historical perspective of homelessness and TB.  Dean Carpenter from the Tumaini Center in Detroit, Michigan discussed a shelter’s perspective.  Finally, Monica Heltz from the Marion County Health Department in Indianapolis discussed a case study of a homeless man with TB disease.  Monica highlighted many of the unique challenges with TB and homelessness and offered practical solutions for serving homeless clients with TB.

Overall, participants reported they enjoyed the webinar and found it very informative.  Several participants commented they felt inspired to reach out to their local shelters to begin building a relationship.  This webinar is available at: http://www.umdnj.edu/globaltb/audioarchives/homeless.html

More unique challenges were discussed in the March 15th webinar “Head to Toe: Case Studies of Extra-Pulmonary Tuberculosis.” Approximately 20% of all cases of TB in the United States are extra-pulmonary, and this webinar highlighted the clinical presentation, diagnosis, and treatment of extra-pulmonary TB through a series of case presentations.

Moderated by Dr. Alfred Lardizabal, the program began with a case of TB lymphadenitis presented by Dr. Elizabeth Talbot of Dartmouth University/FIND Diagnostics. Despite being one of the most common sites of extra-pulmonary disease, TB lymphadenitis poses challenges both in terms of preferred methods for diagnosis as well as potential treatment complications. Dr. Lynn Sosa of the Connecticut TB Control Program presented two cases of genitourinary TB, both of which resulted in miscarriage. Her presentation underscored the importance of testing pregnant women at risk for TB and ensuring appropriate follow-up. Dr. Michelle Paulson of SAIC—Frederick, National Cancer Institute presented a case of TB of the pleura and central nervous system, highlighting the clinical challenges of treating a patient who is also HIV positive.  Finally, as promised in the title of the webinar, Dr. Dana Kissner of the Detroit Department of Health & Wellness Promotion concluded the program with her case presentation of TB of the big toe. This webinar can be viewed at: http://www.umdnj.edu/globaltb/audioarchives/headtotoe.html

Submitted by:
Jennifer K. Campbell, MPH, CHES, Training and Consultation Specialist
and Nickolette Gaglia, MPH, Training and Consultation Specialist
NJMS Global Tuberculosis Institute

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Philadelphia Honors World TB Day with New Partners

On March 21, 2012 the Philadelphia Department of Public Health honored Robert Koch’s discovery of the M. tuberculosis organism by holding a World TB Day Update for TB control staff in the city and surrounding counties.  Over 80 participants came to The Friends Center to participate in the event, which was jointly sponsored by the Charles P. Felton National TB Center, New Jersey Medical School Global Tuberculosis Institute, and UMDNJ-CCOE, in collaboration with Drexel University School of Public Health – a new partner in RTMCC  TB training.

The program included updates on clinical, social, and programmatic aspects of tuberculosis.  Speakers from the Philadelphia Tuberculosis Control Program included Barry Dickman, MPA – TB Program Director; Christina Dogbey, MPH – Epidemiologist; David Schlossberg, MD – Medical Director; Jane M. Gould, MD – Pediatric TB Consultant; Daniel Dohony, MPH – CDC Public Health Advisor; and Marcelo Fernandez-Viña, MPH – PCSI Coordinator. 

Additionally, Dolly Katz, PhD, MPH – Senior Epidemiologist, CDC Division of Tuberculosis Elimination – discussed the soon to be released CDC Guidelines for Prevention and Control of TB in Foreign-Born Persons in the United States.  This was followed by a discussion with panelists Natasha Kelemen, MSS – Coordinator of the Philadelphia Refugee Health Collaborative and Refugee Health Coordinator at the Nationalities Service Center and Dr. Marc Altshuler – Director of Thomas Jefferson Hospital’s Center for Refugee Health to explore implementation of these guidelines in clinical and community-based organizations in Philadelphia.

More than half of the attendees were nurses, with other health professionals and physicians also well represented.  They came from the many hospitals and social services agencies in Philadelphia and nearby counties. A total of 72 respondents completed an online evaluation, giving overwhelmingly positive responses.  About half said they would seek additional information on the topics and 22% said they would change their practices.  Many stated their desire to have programs like this be longer and more often.  This World TB Day Update was recorded in full and will be available on the website of the Philadelphia Department of Health.

Submitted by
Bill L. Bower, MPH, Director of Education and Training
Charles P. Felton National Tuberculosis Center

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The Lighter Side: More TB on TV

In this issue of the Spotlight we continue with an amusing look at some TB-related plot twists from TV shows.

Road to Avonlea: Thursday’s Child

Set in the early 1900s, eldest daughter Felicity’s plans to head to Teacher’s College might be derailed because she has absolutely, positively nothing to wear in her closet full of clothes. Meanwhile, middle child Cecily has fallen ill with TB, but no one notices because they’re listening to Felicity’s sartorial melodrama. Finally annoyed by Cecily’s cough, the family calls a doctor who promptly announces that “all symptoms point to consumption, or as my colleagues now refer to it, tuberculosis.”

Cecily’s parents are concerned not only for their daughter, but also for their livestock. As the issue of bovine TB isn’t exactly a hot topic on prime-time TV, the discussion of TB testing for cattle and restrictions on milk from tubercular cows must have struck many baffled viewers as just another “quaint” belief of the era rather than sound practices.

As word of Cecily’s diagnosis spreads, the general store where Felicity works is flooded with townsfolk worried about “galloping consumption” and stocking up on lye and disinfectant to scrub their homes.   Rather than indulge in a lye-buying extravaganza, Felicity decides to educate herself about the disease by going to see a nearby TB doctor.  When she returns home, Felicity tells her parents that the expert doctor advises sending Cecily to a sanatorium. Felicity also announces that she has decided to go to medical school, but I did not watch the next episode to see if it begins with Felicity complaining she has nothing to wear to medical school.

Off the Map: Saved By the Great White Hope

In this medical drama, a new crop of young doctors arrives at a remote jungle clinic, setting the stage for 45 minutes of Adventures in Cultural Incompetency.  Dr. Tommy is more interested in vacationing than doctoring, so he’s a little upset when the attending immediately orders him to make a house call on a patient with TB, accompanied by a local thirteen year-old named Charlie to act as translator. After trudging over several mountains, Tommy and Charlie arrive at the patient’s house, only to find that she has died of TB and her husband and two young children are coughing and feverish.

Through Charlie, the husband says that the antibiotics given by the previous doctor were poisoning his wife; the husband counseled her to stop taking the medicine, but her body couldn’t recover and she died. This is the cue for a long rant from Tommy ending with the words “It’s your damn fault your wife is dead!” Tommy looks at Charlie expectantly, waiting for him to translate. But even a thirteen year-old boy can recognize that calling the husband a killer is not beneficial to building a strong doctor-patient relationship, and Charlie refuses to translate.

Tommy, in a real display of professionalism, storms out of the house and hikes back to the clinic, only to be ordered to go back and treat every last family member or else leave the country.

Tommy and Charlie arrive back at the house, and Tommy discovers the daughter’s symptoms have worsened. When the husband again refuses treatment, Tommy has a mental breakdown. “Stop saying no, damn it! You’re a proud man, I respect that. I’m a proud man too. I don’t listen to anyone. My parents told me to go to college and study hard, and I just partied.”

Tommy recounts his first world problems to the impoverished widower and his dying children, all in English. Then the husband agrees that his family can take the TB medication. Who knows what changed the husband’s mind: Maybe he was tired of listening to the doctor drone on in English and just wanted him to leave. Maybe he speaks some English after all, and is impressed by the doctor’s epic tales of college parties. At any rate, Tommy returns to the clinic, proud of himself for his accomplishment. 

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Medical Consultation

GTBI faculty and staff respond to requests from providers seeking medical consultation through:

  • Our toll-free TB Infoline: 1-800-4TB-DOCS and
  • Email

During each consultation, the GTBI consultants 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 such as MDR/XDR-TB, pediatric TB in children <5, or potential outbreak situations.

More information about our consultation service, including downloadable Core TB Resources, can be accessed at Medical Consultant Web-Based Grand Rounds (http://www.umdnj.edu/globaltb/consultation.htm).

Periodically, 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 grand rounds will be held this Fall and we will notify TB programs when a date and time have been established. TB program medical consultants who would like to present a case should contact Dr. Alfred Lardizabal at 973-972-8452 or lardizaa@umdnj.edu.

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Upcoming NE RTMCC Training Courses

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 if a 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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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.

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.

Regional Training and Medical Consultation Centers' TB Training and Education Products
This website provides a searchable list of all 4 RTMCCs' resources.

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
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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.

Other RTMCCs

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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Key Contacts

  • 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
  • Nickolette Gaglia - Northeastern Spotlight Editor
  • Alfred S. Paspe - User Support Specialist/Webmaster

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