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Northeastern Spotlight
September 2013
Volume 8 - Number 2

GTBI News:

Changes at the Northeast Region RTMCC

On July 1, 2013 the Global Tuberculosis Institute (GTBI) officially became part of Rutgers, The State University of New Jersey. UMDNJ no longer exists, and New Jersey Medical School (NJMS) is now known as Rutgers New Jersey Medical School.

Just recently we were approved for a logo more in keeping with the Rutgers visual identity and that logo is at the top of this newsletter.  Our old logo that included the TB globe will now be redesigned as a graphic element for use with our products and materials.  We also expect that there will be changes to the look of our website, so stay tuned!

You’ll notice that our email and website addresses have also changed. What won’t change are the staff and faculty and their dedication to improving the outcomes of individuals being treated for tuberculosis through state-of-the-art care, education and research.  Though our name will change, our mission and services will stay the same!

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Training Highlights

Promoting Educational Opportunities for Clinicians

May 15, 2013 marked the 9th Annual New England TB Clinician’s Conference, Breaking the TB Cycle: Innovations in Diagnosis & Treatment.  Largely due to efforts to market the conference and broaden the reach to clinicians in training (residents and fellows) as well as providers working in community health centers and hospitals, attendance was much higher than anticipated.  Participants represented a broad range of specialties and practice settings; approximately one third were physicians. This year’s conference included topics that were both timely and relevant and addressed issues that clinicians and public health staff are facing in the field. Faculty members were all from New England with different areas of expertise that complemented one another and engaged the audience.

Dr. Mark Lobato (CDC Division of TB Elimination) gave an update on the current problem of interruptions in TB drug and tuberculin supply, including the implications for patient care and response strategies for addressing the shortages.  Dr. Edward Nardell (Harvard Medical School) discussed new considerations in TB infection control with a historical review of TB transmission dynamics and looking ahead at novel approaches in the international realm.  Dr. Lynn Sosa (Connecticut Department of Public Health) shared her clinical and programmatic experience implementing the new 12-dose regimen for treating TB infection, emphasizing successes, challenges and lessons learned. Dr. Kemper Alston (University of Vermont) presented new and emerging therapies for TB with a review of drugs currently in clinical trials and particular focus on bedaquiline. 

A panel discussion on the pros and cons for the expanded use of IGRAs led to a lively dialogue between speakers representing both sides of the debate and addressed questions or concerns that participants face on a day to day basis. Dr. Kay McGowan and Dr. Marie Turner (Lemuel Shattuck Hospital) presented several fascinating cases of varying complexity that really captured the audience interest, generated discussion, and was a perfect way to round out the conference. Participants rated this conference very highly for the expertise of the faculty, range of topics, and diversity of audience.  We’re looking forward to maintaining the momentum and working with New England to provide a successful conference again next year!

Submitted by: Anita Khilall, MPH - Senior Training & Consultation Specialist

Best Practices Webinar
Behavioral and Social Science: Implications for Tuberculosis Control Webinar
On May 16, over 150 people nationally attended the enlightening webinar, “Behavioral and Social Science: Implications for Tuberculosis Control.” This 1.5 hour webinar explored issues around the social and behavioral aspects of tuberculosis (TB), including an overview of key theories, such as the Health Belief Model, and their application to TB prevention and control.  It also highlighted specific examples to emphasize how behavioral and social science interventions can help address knowledge, attitudes, and beliefs about TB and latent TB infection (LTBI), including acceptance and completion of treatment.

Behavioral and social science research and theory play a critical role in designing, implementing, and evaluating public health interventions. Similarly, the challenge of preventing and controlling TB requires a multidisciplinary approach beyond the biomedical model. Social and behavioral methods and approaches have been valuable in understanding key issues that impact TB patient care and outcomes, including health beliefs and stigma, care-seeking behaviors, treatment adherence, and patient-provider relationships. 

  The program was skillfully moderated by Rajita Bhavaraju of the Global Tuberculosis Institute. Dr. Wanda Walton, Chief of the Communications, Education and Behavioral Studies Branch in the Division of Tuberculosis Elimination at the Center for Disease Control and Prevention (CDC) gave an overview of behavioral science and TB control. Dr. Paul Colson from the Charles P. Felton National Tuberculosis Center, at the Mailman School of Public Health at Columbia University, discussed several studies that looked at knowledge and attitude variables as predictors and outcomes.  Finally, Dr. Joan Mangan from the CDC discussed her research to identify salient messages to address BCG vaccine misconceptions. 

Overall, participants reported they enjoyed the webinar and found it very informative.  Several participants commented they would consider the framing of their message to encourage patients to take treatment for latent TB infection.  To view the archive of the webinar, visit http://globaltb.njms.rutgers.edu/educationalmaterials/audioarchives.html

Submitted by: Jennifer K. Campbell, MPH, CHES - Training and Consultation Specialist

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Recently Released Products:

TB Cultural Competency Newsletter 

Notes from the Field: Working Through Communication Challenges

Newsletter 17

The latest issue of the TB and Cultural Competency: Notes from the Field newsletter is now available.  The article highlights the story of Tina and Hao, a Vietnamese couple living in Indiana.  After several misdiagnoses, Tina was diagnosed with tuberculosis (TB) in early 2012, and Hao was later diagnosed with latent TB infection (LTBI).  There were several communication challenges in the management of their care, including language barriers and different communication styles.  However, the team at the health department was able to overcome these challenges, and Tina and Hao successfully completed treatment.  The newsletter also includes information on communication styles, open-ended questions, cultural issues and physical versus psychological TB.  To read the newsletter, visit http://globaltb.njms.rutgers.edu/educationalmaterials/tbandculturalcompetency.html

Submitted by: Jennifer K. Campbell, MPH, CHES - Training and Consultation Specialist

Online HIV Fact Sheet

Fact Sheet: Treatment of Tuberculosis in Adult and Adolescent Patients Co-infected with the Human Immunodeficiency Virus (HIV)

While our printed pocket treatment cards have always been popular, the changing tide of treatment related to people living with HIV has made it challenging for providers to keep up with the most current guidelines.  Printed versions of HIV-treatment materials become outdated very quickly!  Therefore, to balance the amount of information to be summarized with the details that are most useful, GTBI decided to switch from the pocket-card format for HIV treatment information to an online, printable fact sheet.  This new fact sheet covers the fundamental principles of treatment of patients with TB and HIV, and includes the latest information on the staggered initiation of antiretroviral medications in treatment-naive TB patients.  The two-sided fact sheet can be printed or viewed online.  Better still, it can be easily updated by GTBI staff, as guidelines change.

Submitted by: Rajita Bhavaraju, MPH, CHES Training and Consultation Specialist

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Product Updates/Revisions

In an effort to provide healthcare providers with the most current and up-to-date information regarding the management of TB in the pediatric population, we will be revising and updating two of our products:

  • Tuberculosis Handbook for School Nurses
  • Management of LTBI in Children & Adolescents

The most recent change is the addition of the 12 dose INH-Rifapentine regimen for treating LTBI. This information will be included in the revised documents. All of our products go through a rigorous review process and the final version will be posted on our website later this year. Readers will be able to print them in either booklet or single page format.

Submitted by DJ McCabe, RN, MSN - Trainer & Consultant Clinical Programs

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Faculty Profile-Amee Patrawalla, MD

Photo of Amee Patrawalla

She may be a “Jersey Girl”, but it was urban experiences that stimulated Dr. Amee Patrawalla’s interest in tuberculosis. Her medical training took place in New York City and Boston where she often saw patients with TB. After earning her MD at Mount Sinai School of Medicine in New York City, she completed an internship and a residency in Internal Medicine at Boston University Medical Center and a fellowship in Pulmonary & Critical Care Medicine at New York University Medical Center. During this time she also became interested in public health, earning a MPH in Global Public Health at New York University in 2008.
                                                                       
Fast forward to 2013, and Dr. Patrawalla, board certified in Pulmonary and Critical Care and Internal Medicine devotes approximately 10% of her time to the Global TB Institute. She is Assistant Professor of Medicine at NJ Medical School and sees TB patients in the hospital and also as out-patients at GTBI’s Lattimore Practice, where she practices twice a month. In addition, she trains Pulmonary Fellows, lectures at our webinars and courses, takes calls on the TB Info-line and attends TB Case Conference as often as possible. She admits that she would really like to focus even more on TB.

Many young physicians might quickly lose interest in an ancient disease that many do not perceive as a threat, but the challenges associated with treating this disease are perhaps what interests Dr. Patrawalla the most; challenges such as co-morbidities, long treatment regimens with unpleasant or toxic side effects, and complicated cases that often require revision of the treatment plan. Many Pulmonary/Critical Care specialists may not have the opportunity, as she does, to follow a patient from their first encounter in the hospital setting to treatment completion and cure in the out-patient setting. The biggest reward for Dr. Patrawalla is “getting people back to their lives.”

She feels that the out-patient setting here at GTBI helps dispel the stigma associated with TB. The TB clinic is located in a brightly lit area on the first floor of a beautiful new building. Friendly, helpful staff can provide patients with incentives and enablers that help increase treatment adherence. Using a team approach, they aim to treat the whole person and look at social and financial issues, not merely the clinical aspects of the disease.

Dr. Patrawalla’s spare time is spent with her family; her husband and their 1 year old daughter. Together they explore the neighborhoods of Brooklyn where they live now, and occasionally travel to upstate New York for hiking and other outdoor activities. Sometime in the future, they’d like to travel to India to visit family.

While she acknowledges that competition for diminishing TB resources and the “aging workforce” that we often hear about, makes progress toward TB elimination slow, she’s not discouraged because of what she refers to as the “depth in the field” i.e., the many young and dedicated TB clinicians, as well as recent technological advances. 

Submitted by: DJ McCabe, RN, MSN - Trainer & Consultant Clinical Programs

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New England TB Heroes Award  

Photo of TB Heroes Award

Every year, the New England Tuberculosis Consortium presents the New England TB Heroes Award to recognize an extraordinary contribution to the care or management of patients with TB and latent TB infection (LTBI) or an activity that greatly enhanced the TB prevention and control efforts of a local or state TB program. The 2013 award went to a team of TB providers for their exceptional care of a single multi-drug resistant patient: Dr. Jonathan Fine, pulmonologist at Norwalk Hospital and Patricia Carey, APRN and Darleen Hoffler, RN, public health nurses with the Norwalk Health Department.

This year’s award was unique because it was the first time that persons were nominated by a TB patient.  Excerpts from the patient’s nomination appear below and highlight the impact this team had on their care and outcome. 

“Dr. Fine patiently listened to my complaints, fears and doubts, and assured me that I would become healthy again and my life would be normal again. When I had no more inner strength left he encouraged me to fight on. I was not just another patient to him but a live person.”

“Most of what Pat Carey did for me was not in her job description. She could have just limited our contact to medicine drop-off and doctor visits but she chose a different approach. And I will always be thankful for the exceptional care she gave me.  This period in my life would have been much more miserable if Pat Carey wasn't there for me.”

The nomination for this team of TB Heroes was also supported by the Connecticut TB Control Program. “There is no doubt in my mind that this patient is alive and doing well today because of the medical, social, and psychological support received from Pat, Darleen, and Dr. Fine. Darleen and Pat have demonstrated their willingness to go above and beyond their usual public health roles and responsibilities. Dr. Fine has gone above and beyond his usual provider role to become an advocate and resource finder. Individually and together, they are dedicated, compassionate, and model providers and we are fortunate to have this team of TB heroes in Connecticut.”

Dr. Fine and Ms. Carey were recognized during a presentation at the annual TB Clinicians Conference on May 15th in Shrewsbury, MA.  Ms. Hoffler was presented her award during a meeting with TB public health peers on May 2nd.

Submitted by Lynn Sosa, MD

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Upcoming NE RTMCC Training
The New Jersey Medical School Global Tuberculosis Institute (GTBI) sponsors courses and web-based seminars on tuberculosis.  GTBI web-based seminars 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), which is served by GTBI.

Click here for the list of upcoming courses.

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Medical Consultation

GTBI faculty and staff respond to requests from healthcare providers seeking medical consultation. Consultants can be reached by calling the TB Infoline: 1-800-4TB-DOCS or by Email.

During each consultation, the GTBI consultants will advise callers about resources/TB Programs http://www.cdc.gov/tb/links/tboffices.htm 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, is available at http://globaltb.njms.rutgers.edu/services/medicalconsultation.html

Medical Consultant Web-Based Grand Rounds

Periodically, designated TB program medical consultants are invited to participate in a web-based TB case conference (Grand Rounds). Consultants are encouraged to present challenging TB cases and get feedback from their colleagues throughout the Region. TB program Medical Consultants who would like to present a case should contact Dr. Alfred Lardizabal at 973-972-8452 or lardizaa@njms.rutgers.edu.

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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 RTMCCs' resources.

TB Wire and TB-Related News and Journal Items Weekly Update appear in a new combined format. Contents include:

  • Announcements
  • Washington Update
  • Linkable Journal Abstracts
  • Resources/Training
  • Selected TB Reports 
  • Grants, Job Opportunities
  • Meetings, Conferences & Events
  • 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.

Other RTMCCs  
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 Heartland National Tuberculosis Center serves: Arizona, Arkansas, Kansas, Louisiana, Missouri, New Mexico, Nebraska, Oklahoma, and Texas.

The Mayo Clinic Center for Tuberculosis serves:  Illinois, Indiana, Iowa, Michigan, Minnesota, Montana, North Dakota, Ohio, South Dakota, Wisconsin, and Wyoming

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.

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Key Contacts

  • Lee B. Reichman, MD, MPH - Executive Director
  • Eileen C. Napolitano - Deputy Director
  • Alfred Lardizabal, MD – Associate Director
  • Reynard J. McDonald, MD - Medical Director
  • Bonita T. Mangura, MD - Director of International Activities
  • Nisha Ahamed, MPH - Program Director, Education and Training
  • D.J. McCabe, RN, MSN – Spotlight Editor

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