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Northeastern Spotlight
Winter 2007
Volume 2 - Number 4


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Dear Colleague:
As some of you may know, I had surgery at the end of September and was out for a couple of months. I am now back on a part-time basis and feeling better every day. I appreciate your kind wishes. This issue features two new cultural competency courses that were conducted this Fall. During 2005, over 60 percent of TB cases in the Northeastern Region were reported among foreign born persons and the proportion is growing. Our ability to recognize and address the cultural issues that influence a patient’s adherence to lengthy therapy and participation in contact investigations will determine our success in preventing and controlling TB in these populations. Both courses received very favorable evaluations, along with helpful suggestions that will be incorporated in future cultural competency courses. This issue of Northeastern Spotlight also features a profile of my friend and colleague Dr. Bonita Mangura, GTBI’s Director of Research, who was a key player in the foundation of the NJMS National Tuberculosis Center in 1994 and in its evolution to the NJMS Global TB Institute in 2005. On October 29-30, the GTBI hosted our second TB Medical Consultants Meeting in Newark. Twenty-four physicians from 18 of the 20 TB programs in the NE RTMCC attended the meeting and all felt it to be helpful and relevant to their role as medical consultants in their areas. This issue describes highlights and feedback about the meeting. I also encourage you to read the article on the 2007 Northeast TB Controllers Conference held in September in Salem, Massachusetts which focuses on integrating research into practice across the northeastern region. And, as usual, If you have any feedback for any of us, on any TB related topic, I invite you to contact me or a member of our RTMCC staff at (973-972-3270).

Lee B. Reichman, MD, MPH
Executive Director
NJMS Global Tuberculosis Institute

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RTMCC Launches Two Cultural Competency Training Courses

The NE RTMCC recently conducted two Cultural Competency courses. These new courses were developed to address the growing number of requests for training around cultural issues and TB care. The first course, Cultural Awareness in TB Control was held in Salem, MA, in conjunction with the Northeast TB Controller’s Meeting on September 24th, 2007. This course was developed to provide a basic foundation for understanding cultural differences in health attitudes, beliefs, behaviors, and language. Utilizing lecture, open discussion, small group exercises, and video presentations, the course focused on a culture-general perspective, examining the attitudes, knowledge, and skills necessary for working with individuals from cultures other than our own, as well as a cultural competency self-assessment. Faculty from the NJMS Global Tuberculosis Institute included Nisha Ahamed, Mark Wolman Marian Passanante, and Lauren Moschetta- Gilbert. Faculty from the Charles P. Felton National TB Center included Bill Bower.

The goals of the course were to:

  • Explain how cultural factors influence patient-provider interactions
  • Describe the attitudes of a culturally competent healthcare worker
  • Demonstrate skills that can enhance cross-cultural communication
  • Identify strategies for working with interpreters

The target audience for this course was TB control staff. Most of the 18 participants were nurses working in a range of public health facilities, with TB experience ranging from 6 months to 20 years. The course received favorable reviews with many participants stating that the small group exercises and the opportunity to learn from other participants was most valuable. Future courses will be planned taking into consideration suggestions for more time allotted for role play and open discussion and more culturally diverse presenters.

The second new Cultural Competency course; Cultural Competency and TB: General Principles and Case Studies with Ecuadorian Migrants, was held October 2, 2007, in New Rochelle, NY. Twenty-eight physicians, nurses, and TB control staff serving Ecuadorian migrants in several counties in New York State attended. In the tri-state area (NY, NJ, CT), Ecuador is now among the top three countries of origin for non-US born persons with TB disease. A participant from the Massachusetts Department of Public Health also attended, because there are close connections among Ecuadorian families and health departments in areas in their state and several NY counties. This course was developed in response to recommendations from the Working Group on TB among Ecuadorian Migrants to address the need for training around general and specific cultural issues related to working with the growing number of Ecuadorian migrants in this region. The course examined general principles of cultural competency in TB control using examples specific to Ecuadorian patients and culture for a more in-depth discussion about working more effectively with these clients. A major strength of this training was the diversity of the presenters who gathered to conduct this training (See Table). Experts shared hands-on experiences, practical steps, and team approaches used to improve outcomes of case management, treatment, and contact investigations among foreign-born patients. Course format included lecture, video, small group exercises and case presentations of TB among Ecuadorian migrants.

Course topics included:

  • General Principles of Cultural Competency
  • Epidemiology of TB among foreign-born persons in the Northeast
  • Background of TB among Ecuadorian Migrants
  • The experience and world-view of Ecuadorian migrants
  • Language, Interpreting, and the Clinical Encounter
  • Improving Cultural Competence at Program Level

This course also received very favorable evaluations from participants, who rated the presenters highly and agreed that the objectives were met. The experienced training team, as well as the balance of a general cultural competency approach plus Ecuadorspecific information, were appreciated. About one-third of participants gave examples about how they plan to change their practices to implement what they had learned. The Working Group on TB among Ecuadorian Migrants will continue to meet and explore ways to improve care provided to the Ecuadorian migrant population.

For additional information about these courses, contact Lauren Moschetta (973-972-1261 or moschelb@umdnj.edu) or Bill Bower (212-939-8258 or blb3@columbia.edu).

Other cultural competency resources include:

Submitted by Lauren Moschetta
Health Educator
NJMS Global TB Institute

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Staff Profile: Dr. Bonita T. Mangura

Along with Dr. Lee Reichman and Dr. Reynard McDonald, Dr. Bonita Mangura was one of the pillars in the foundation of the New Jersey Medical School (NJMS) National Tuberculosis Center in 1994 which evolved into the NJMS Global TB Institute and its Northeastern RTMCC in 2005. As Director of Research, she oversees all clinical and epidemiologic research conducted at the Institute. She is currently the New Jersey Site’s Principal Investigator of the United States Public Health Service Center for Disease Control and Prevention (CDC) TB Trials Consortium and TB Epidemiologic Studies Task Order 2 Contact Investigation Study. She is also Professor of Medicine at the NJMS and often supervises the rotation of medical fellows, residents and students at the Institute. Dr. Mangura serves as faculty for many of the clinical courses conducted by the GTBI, provides expert TB consultation services, and sees difficult TB patients at the Lattimore Practice. She has also been significantly involved in several international TB projects.

From the onset it seems that Dr. Mangura was destined to choose medicine as a career. Her paternal grandfather was an herbalist and had hoped to send his son to medial school, but was financially unable to do so. Her father was a successful business man in the Philippines and ensured that all of his children were professionally trained. Although raised comfortably, her attendance at socially-responsible public and private schools instilled an expectation and desire to recognize and meet needs in poorer sections of the community.

Upon graduating from college with a BS in general science and psychology, she went on to obtain her medical degree from the University of Santo Tomas in Manila in 1971. Following a cardiology/open-heart surgery fellowship in Manila, she spent another 4 years in post doctoral training at the Jersey Shore Medical Center in Neptune, NJ where she served as Chief Resident in the Department of Medicine from 1977- 1978. Seeking to broaden her experience, she did an off-site elective in Infectious Diseases at NJMS-UMDNJ while at the same time applying for a Pulmonary Fellowship at Robert Wood Johnson. During her ID stint, it so happened that the ID office was directly across from UMDNJ-NJMS’s Chief of Pulmonary, one Dr. Lee Reichman. He noted that she consistently arrived at work before he did (around 6:30 a.m.) and was still on the job as he left. Coincidentally, when one of the Newark NJMS’s newly accepted pulmonary fellows dropped out of the program, Dr. Reichman learned that Dr. Mangura had applied as a volunteer and was accepted for a pulmonary fellowship at a rival institution. Impressed with her resume and apparent exuberant work ethic, he offered her the fellowship at the NJMS (at full pay) and the rest is history. Dr. Mangura’s research interest in Pulmonary Medicine at that time included central ventilation, mechanics of the work of breathing, and asthma.

Newark was at the epicenter of the HIV-related TB resurgence in the mid 1980’s. As a key member of the Newark team, under Dr. Reichman’s direction, Dr. Mangura successfully applied for and managed NIH grants to characterize the pulmonary complications of HIV and later (as Principal Investigator) NIH/CDC grants to assess the efficacy of short course treatment to prevent TB among injection users co-infected with HIV and LTBI. Since CDC initiated the Clinical Trials Consortium in 1993, which evolved into the TB Trials Consortium in 1999 (as Principal Investigator), Dr. Mangura has overseen GTBI’s participation in many important USPHS TB clinical trials to assess the efficacy and safety of various drug regimens to treat and prevent TB.

On the international front, Dr. Mangura has played a major role in conducting field research to identify issues and obstacles in implementing the DOTS Strategy among health care providers in the Philippines, as part of the USAID-funded Philippines TB Initiatives for the Private Sector (Phil- TIPS). This resulted in a GTBI strategy to strengthen public and private partnerships in preventing and controlling TB. Among the activities in this project, she collaborated in the development of a DOTS syllabus for medical schools which was taught in 10 premier Philippine medical schools as part of a Master TB Educator Award Program. She also developed a framework for replication of public-private DOTS mix and collaborated on the pilot Pharmacy DOTS Initiative to engage pharmacists in referring TB suspects to appropriate TB services. In addition, Dr. Mangura served as the technical expert in modifying and integrating the DOTS syllabus curriculum for pre-service students in allied health professional schools such as nursing, medical technology (for laboratory and x-ray technicians), and pharmacy, the four professional tracks involved in a DOTS unit. Since 11% of foreign-born cases in the U.S. are currently from the Philippines, these efforts may likely help control TB in the US.

In conjunction with the WHO Regional Office for Europe, Mangura and training experts at GTBI, carried out numerous on-site key informant interviews and developed and fieldtested a Brief Guide on TB Control for Primary Care Providers in several former Soviet states including Russia (Moscow, Chuvashia & Ivanovo), Moldova, Kazakhstan, Georgia, and Romania). As a result of translation to 9 local languages and subsequent training provided by national TB experts, this Guide has been distributed to over 10 countries, and is routinely used by primary care providers throughout the former Soviet countries and Eastern Europe. Finally, as a Technical Consultant to a USAID-funded Project Hope program in Central Asia, Dr. Mangura and others at GTBI are assessing current policies and practices, working closely with local and national governments, and making recommendations for an MDRTB Country Framework upon which policy changes and human resource development to stem the alarmingly high prevalence of MDR-TB and HIV-related TB in the Central Asia Republics.

Dr. Mangura has over 80 TB-related publications, has helped write national TB guidelines, has served on the New Mangura continued from page 3 Jersey TB Advisory Committee, is currently a manuscript reviewer for 3 major pulmonary journals, and has been active with the American College of Chest Physicians Leadership Council, and Chest Infections Network (Chair 2003-2005).

In her spare time, Dr. Mangura relaxes and finds re-creation through listening to music, reading (often mystery novels), raising orchids and jasmine (indoors), and gardening outdoors during the warmer seasons. “Gardening provides fulfillment because it’s reliably productive—something to show for my efforts; there’s always a bloom coming up.”

Needless to say, Dr. Mangura has produced many a bloom in virtually every aspect of her professional life as well—in research, in teaching, and in clinical practice. Her expertise, leadership, and “Constant Gardening” have brought the GTBI many accolades and has garnered admiration and respect from patients, students, and colleagues alike.

Submitted by Chris Hayden Consultant NJMS Global TB Institute

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2007 Northeast TB Controllers’ Conference: Integrating Research into Practice Across the Region

On September 24th and 25th, TB control program staff, public health labratorians and health care providers gathered in Salem, Massachusetts for the 2007 Northeast TB Controller’s (NETBC) Conference. Fourteen project areas from the Northeastern region were represented including: Connecticut, Delaware, Indiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, New York City, Pennsylvania, Rhode Island, and Vermont. The first day provided two tracks for program participants, one for TB Controllers and Laboratory Directors and a general training on Cultural Awareness organized by the Northeastern Regional Training and Medical Consultation Center (NE RTMCC). In the TB Controllers’ session, each project area was encouraged to give an update on current TB control developments. This exchange fostered regional dialogue and revealed common challenges.

The second day was an open session for all conference attendees with the theme, “Where the Rubber Meets the Road: Putting Research and Recommendations into Program Practice.” Dr. John Bass of the University of South Alabama opened the day by presenting an historical perspective on tuberculosis, culminating with his singing “TB Blues” written by country singer Jimmie Rodgers in 1931, who suffered from TB. Dr. Kashef Ijaz, Chief of the Field Services and Evaluation Branch in the Division of TB Elimination spoke on the CDC perspective for integrating research into program practice. Several project areas had the opportunity to highlight best practices and research developments including Suzanne Gunston’s (ME) presentation on using pediatric TB calendars to encourage adherence to LTBI therapy and Dr. Margaret Oxtoby’s (NY) presentation on contact investigation in health care facilities.

In the afternoon, a panel with representatives from Massachusetts, Connecticut, Maine and Michigan discussed the legal, ethical and social implications of TB isolation in the age of MDR and XDR-TB. This panel provoked a lively discussion about voluntary and involuntary isolation policies for preventing TB transmission and how they vary considerably from locality to locality and state to state. A National Call to Action on Tuberculosis Isolation was endorsed by conference participants. This call to action by the National TB Controllers’ Association (NTCA) requested that the CDC develop a workgroup to establish minimum legal standards and best practices for the use of enforcement powers leading up to and including the isolation of infectious TB patients. The 2007 NETBC Conference was a successful opportunity to discuss pressing issues in TB and further foster regional collaboration.

Submitted by Erin E. Howe, MPH Health Educator Northeastern RTMCC

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GTBI Hosts Its Second Annual TB Medical Consultants Meeting

On October 29-30, 2007, the GTBI held its second annual TB Medical Consultants Meeting in Newark. The meeting was attended by 24 physicians from 18 of the 20 TB programs comprising the Northeastern Regional Training and Medical Consultation Center (RTMCC). The goal of the Meeting was to provide a networking opportunity to TB program medical consultants in the Region, to acquaint them with current and pressing TB issues, and to build capacity for appropriately responding to typical and challenging requests for TB medical consultation.

The meeting commenced with a dinner on October 29, followed by a presentation by Dr. Kenneth Castro, Director of CDC’s Division of TB Elimination, on the State of TB Today and a Vision for the Future. His broad experience and candor generated spirited discussion and served to energize and focus participants for the next day’s proceedings. Dr. John Bernardo led off Tuesday morning with a talk on Pressing Issues in TB Control which was followed by case presentations and discussions on clinical issues previously identified by participants as important, including Interpreting QFT Results, Managing Drug Resistance, and Interpreting Laboratory Results. Dr. Alfred Lardizabal concluded the meeting with an overview of the NE RTMCC’s preceeding year’s medical consultation activities and led discussion on how the RTMCC could better serve TB program consultants in the future.

Based on feedback from last year’s meeting, an Optional Case Presentation Session was held after the meeting during which participants presented cases and received feedback from their colleagues and GTBI medical consultants. In their evaluations, all participants indicated that they found the meeting to be relevant to their role as TB medical consultant, agreed that the meeting objectives were met, and would recommend this type of meeting to other consultants. To improve future meetings, participants recommended a slightly longer meeting with shorter formal presentations and more time for discussion of difficult cases.

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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 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 Medical Consultation

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 Email

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.

More information about our consultation service, including downloadable Core TB Resources, can be accessed here.

Medical Consultant Web-Based Grand Rounds

Every other month, designated TB program medical consultants are invited to participate in a webbased 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 March 18 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 lardizaa@umdnj.edu.

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Upcoming TB Program Training Courses

Click here for the list of upcoming TB program courses.

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What's New

Recommendations for HIV Screening in TB Clinics. CDC’s Division of TB Elimination published this 2-page fact sheet for health care providers which summarizes revised CDC recommendations from 2006. Recommendations now suggest that HIV testing be performed for all TB patients, suspects, and contacts, unless the patient specifically declines (i.e., opt-out screening). The fact sheet can be accessed here.

Revised Adult HIV Treatment Recommendations. On December 1, 2007, the DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents released a new revision of the Guidelines for the Use of Antiretroviral Agents in HIV-1- Infected Adults and Adolescents. Although there are no new recommendations to the Mycobacterium Tuberculosis (TB/HIV Co-Infection section (p. 49-50), the Panel revised, among other things, its recommendations for when to start HIV therapy and dealing with the treatment-experienced patient. The full version of the revised Guidelines is available at here. A summary of what’s new in the Guidelines is listed on page i.

QuantiFERON®-TB Gold In-Tube Approved by FDA. The Food and Drug Administration (FDA) approved this test officially on October 10th 2007 and is currently available for use. The “In-Tube” format allows blood samples to be incubated at the site of collection and allows up to 3 days for the shipping of samples to the laboratory for analysis. Further information about this test can be found on the Cellestis website.

QuantiFERON Testing Sites. The GTBI often gets calls about where QFT testing is offered. The following website provides a list US laboratories that provide QFT testing services. These can be sorted by Name of Testing Facility, City, or State.

GTBI’s Medical Consultation Webpage. In October 2007, the GTBI added a Medical Consultation page to its website. The page presents Background about the service, Hours of Operation, a list of TB Experts at GTBI, Important Considerations for Requestors, and Consultation by TB program Medical Consultants in the Northeastern Region. The GTBI has compiled a set of Core TB Resources consisting of published guidelines from CDC and other national organizations, treatment pocket cards, TB fact sheets, and CDC or RTMCC products that TB program medical consultants can use when responding to questions from health care providers in their areas. The Resources can be accessed individually or downloaded in their entirety for storage on a hard drive of CDROM for ready access and retrieval.

RTMCC Composite Products Webpage. This webpage was developed to succinctly display and provide access to the educational materials developed by each of the 4 CDC-funded TB Regional Training and Medical Consultation Centers (RTMCCs). The four RTMCCs are the Curry International Tuberculosis Center, the Heartland National Tuberculosis Center, the New Jersey Medical School Global Tuberculosis Institute, and the Southeastern National Tuberculosis Center. Resources are available in a variety of topics and formats and can be accessed here.

Tuberculosis Facts - Updated Fact Sheet Series for Patients. The Division of Tuberculosis Elimination (DTBE) has revised the Tuberculosis Facts fact sheet series. These facts sheets provide basic TB information for persons with or at risk for TB in an easy-to-read format and are also available in PDF format for printing.

What is Tuberculosis – A New Brochure from the U.S. Committee for Refugees and Immigrants. The brochure provides general information on TB for refugees and immigrants. It discusses how TB is spread, the differences between latent TB infection and active TB disease, drug resistance, treatment, and what to do if exposed to TB. The brochure comes in eight languages: Arabic, Burmese, English, Karen, Kirundi, Russian, Somali, and Vietnamese. This brochure can be accessed here.

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On The Lighter Side - Match the Author with the Bio Sketch

Many famous writers and poets suffered from tuberculosis and often drew inspiration from their struggles with this disease.

Bio Sketch
Sample Painting
Charlotte Bronte 1795-1821 After 4 years training at a London-based hospital, he abandoned a career in medicine to follow his passion for poetry. At age 14, he cared for his mother who died of TB after a 3-month illness. Nine years later, he nursed his brother who also succumbed to TB. He himself died from TB during a trip to Rome at the age of 26, after having produced some of the most beloved poetry in the English language.
Elizabeth Barrett Browning 1809-1849 One of the leaders of the American Romantic Movement, he is best known for his tales of mystery and haunting poetry. Besides suffering from TB himself, he lost several of his family members to the disease, including his father, his mother, and his wife.
John Keats 1888-1923 Born in New Zealand, she was attended college and spent most of the rest of her life in London. Considered one of the best short story writers of her time, she spent her last years seeking unorthodox cures for her TB.
Katherine Mansfield 1792-1822 One of the major English Romantic poets, he wrote such classic poems as Ode to the West Wind, To a Skylark, and Ozymandias. Like many of his literary contemporaries, he sought to cure his TB by traveling to sunny Italy where he died tragically in a boating accident.
Percy Bysshe Shelley 1816-1855 The death of her mother and siblings weighed heavily on her and may have caused her to flee to her own imagination, resulting in such classic works as Jane Eyre. Two of her sisters also published novels. Her father had chronic TB and lived to the ripe old age of 84, but his wife, all 5 of his daughters, and only son died of TB before reaching the age of 40.
Edgar Allan Poe 1806-1861 The eldest of 12 children, she developed a “lung complaint” (probably TB) in her early teens and was considered by her family as an invalid. Her published poems caught the eye of another English poet who courted her at her bedside. Against her father’s wishes, they eloped and settled in Florence, Italy where she regained her strength, had a child (at age 43), and lived and published for another 15 years before succumbing to TB

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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.

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
  • Chris Hayden - Northeastern Spotlight Editor
  • Alfred S. Paspe - User Support Specialist/Webmaster

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