Dear Colleague:
I hope that you all had an enjoyable summer. We at GTBI, like many of you, spent part of our summer preparing our submission for the 2010 CDC Cooperative Agreements. This year’s Cooperative Agreement had interesting new additions and requirements around Program Collaboration and Service Integration (PCSI), program evaluation, and cohort review. In 2010 we will continue to conduct cohort review training and will be working with the TB Program Evaluation Network (TBPEN) on identifying training needs around program evaluation. We have also worked successfully on securing funding for some exciting PCSI training activities with other federally-funded training centers (FTCs) in the Northeast planned for 2010, and will share details of these in upcoming newsletters.
This newsletter includes a staff profile of Jeanette Rodman, the TB Program Manager from Delaware, as well as another article in our series on Behavioral Research in TB Control. We also highlight a newly posted audioarchive from our website and a training course for clinicians conducted this summer in Washington DC, the southern reaches of the Northeast region.
As always, thanks for all your efforts, and we look forward to working with you in 2010 as implementing the plans submitted in next year's Cooperative Agreements.
Lee B. Reichman, MD, MPH
Executive Director
Northeastern RTMCC and the
Global Tuberculosis Institute
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Staff Profile: Jeanette Rodman's Long Trek to the TB World
Jeanette (Jeannie) Rodman, the Tuberculosis Nurse Consultant for the Delaware Division of Public Health, came to work in Tuberculosis through a very roundabout path. She grew up in bucolic Salem, New Jersey, “where they grow tomatoes and mosquitoes.” After working as a printer and a salesman, she eventually went to nursing school at the age of 37 and then moved to Delaware to work in one of the state’s big nursing homes as a woundostomy and continence nurse/supervisor.
Delaware doesn’t have a lot of nurses with both an MSN and community health experience, so when a position opened up four years ago in the TB Program, someone from the communicable disease bureau called and asked if she’d like to interview for the position. Jeannie decided she had nothing to lose, and was interviewed by two nursing supervisors, the program administrative support person, and Dr. Jackson, the communicable disease bureau chief.
“Dr. Jackson looked a bit like an oversized Andy Warhol, but as soon as I saw him I knew he’d be an important person in my life,” Jeannie recollected. “It was the most fun I’d ever had on a job interview, and I was so impressed with the people that I decided I’d take the job if offered.”
Jeannie enjoys working in a field where there are always new challenges and the learning never stops. The Delaware TB Program consists of two people: Jeannie and Robin Saxton, the Administrative Assistant. “Sometimes it’s easier to do things in a small state, because you know everyone and can personally keep track of all the cases,” Jeannie says.
“Our first case of 2009 started out with a panicked call from a local hospital on New Year’s Eve. They had a suspect who was threatening to leave against medical advice, and they were wondering if they had a legal right to make him stay. In Delaware we can’t legally restrict anyone unless they’ve been definitively diagnosed as having active TB disease and are a threat to the public health, or have been given several chances to comply with testing, treatment, etc. and failed. But I told the hospital to try and convince him to stay there for another 30 minutes, then got on the phone to one of the TB clinic nurses who immediately went running off to the hospital. Fortunately the patient was still there, and she drew his blood and ran a QuantiFERON test over the long weekend, which turned out positive. His skin test, read the following week, was negative, so he could have slipped through the cracks had we not caught him in time.”
The poultry processing plants in the southern part of the state have been a particular challenge for the TB Program. “Because of OSHA guidelines, the workers rotate to different stations, so when a case pops up in a processing plant, there are a huge number of contacts,” Jeannie explained. Delaware also collaborates with the plants on a targeted testing program for the workers, among whom are many immigrants. As a condition of employment, those who test positive must complete a course of treatment.
In her spare time, Jeannie likes to bird-watch, kayak, and garden. This summer she grew five different varieties of potatoes, rainbow chard, green beans, flowers, and the obligatory “pole limas” (the bush variety of lima beans are scorned in Delaware, despite being easier to grow).
Jeannie also recently acquired five Welsummers, a heritage breed of chicken that lays dark brown speckled eggs. “Soon after I got the chickens, a big craze for heritage breeds started and the hatcheries sold out. Little did I know I’d be so trendy!” Jeannie says.
She converted part of her backyard shed into a chicken coop, and the chickens run free in the backyard. “They’re fun to watch, and I get fertilizer and breakfast from them.” Her husband, Cliff, was initially reluctant to get chickens, but he has since warmed up to them.
One day this summer, Jeannie looked out her window and saw Cliff sitting on a chair in the backyard with the chickens on the chair arms and his lap, sharing an ice cream cone with him. Unlike her husband, Jeannie’s tomcat was extremely excited when the chickens arrived. He started stalking one of the chickens, but then the chicken whipped around and started chasing after the tomcat! The cat ran away, and hasn’t tried to turn a chicken into lunch since.
Jeannie also loves to travel—she was inspired by a book she read to go to Scotland, and she has since been back five more times. After high school, Jeannie took an extended trip through Europe. She lived in a cave on the Canary Islands, fishing out of a lake and eating almonds. Then she took a boat to Morocco and hitchhiked across the Sahara desert, and finally ended up in Liberia, where she taught phonics at a Catholic school. On a related note, Jeannie says, tongue firmly in cheek, that she regularly wins awards for “Most Eccentric Employee.”
Submitted by Nickolette Patrick
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Pushing it Up a Notch: Advanced TB Training for Clinicians
As TB cases are declining but getting more complex and expertise is waning, we have heard from our stakeholders that a different kind of TB training is needed. Many TB programs have done the traditional “intensive” or “comprehensive” courses geared to immersing clinicians in all topics related to TB, but not exclusively focusing on one or two areas. What do you do when there are experienced clinicians who seem to know all there is to know about the basics? You create a tailor-made course for the experienced clinician! This idea lead to the Advanced TB Training for Clinicians, a one-day course which took place in Washington, DC on July 10, 2009.
The Advanced TB Training for Clinicians course was a joint venture, conceived by the District of Columbia Department of Health – TB Control Program, Maryland Department of Health and Mental Hygiene, the Baltimore City Department of Health - TB Program, and the NJMS Global Tuberculosis Institute. The three TB control programs in the group, along with the Virginia TB program, co-manage many cases along their common borders. Their existing relationship made for a very effective planning process.
This course was designed for experienced TB physicians and nurses with at least one background course in TB fundamentals, and attendance was by invitation of the participating TB programs. Advanced topics in TB were addressed using a lecture and interactive, case-based approach. Topics included an overview of recent TB guidelines as well as management of adverse reactions, drug intolerance, and co-morbidities. In addition, there was also a breakout session for medical management issues (drug resistant TB and radiography) and nurse case management issues.
We were fortunate to have faculty who brought expertise from the four project areas represented. Not only did faculty teach, but they sat around the table with the participants and engaged in discussion and questions, also learning from the experience of the whole group. There were twenty invited participants (nine physicians and eleven nurses).
Participants enjoyed the course and particularly valued the case-based approach. There are plans in the works to extend this model to other parts of the RTMCC region using the same customized approach, as well as offering another training in the Maryland, Baltimore, DC, and VA area.
Submitted by Rajita Bhavaraju and DJ McCabe
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New Archived Webinar: Working Effectively with Diverse Populations
We are pleased to announce that a new web-based seminar has been added to the GTBI audio archive. The well attended Best Practices in TB Control: Working Effectively with Diverse Populations web-based seminar, originally broadcast on March 26, 2009, is now available. The web-based seminar (webinar) explores topics around understanding cultural differences in health attitudes, beliefs, behaviors, and language. A better awareness of these differences helps health care providers and other TB program staff work more effectively with patients from other cultures.
The webinar began with a presentation by Bill Bower, Director of Education & Training at the Charles P. Felton National TB Center. Bill presented an overview of TB epidemiology in the Unites States, including TB in non-US born individuals, and an introduction to cultural competency and why it is important in providing TB care.
Sapna Pandya, Director of Programs for the South Asian Health Initiative at New York University School of Medicine’s Center for Immigrant Health, followed with a lively and interactive presentation covering differences in naming systems, generalizations versus stereotypes, a discussion of barriers to care faced by immigrants, and individual- and programmatic-level suggestions for addressing these barriers.
Finally, Jane Moore, the Assistant Director/Nurse Consultant for the TB Control and Prevention Program, Division of Disease Prevention in the Virginia Department of Health, shared the experiences of the Virginia TB Program with using technology to improve communication. Jane described the need to develop materials that could be used to work with TB patients from other cultures and gave a live demonstration of the online patient education tools in a number of different languages that were developed in conjunction with Healthy Roads Media.
The webinar was very well evaluated and participants were very enthusiastic about using the online tools. The archived audio, presentations, and supporting materials can be accessed at: http://globaltb.njms.rutgers.edu/educationalmaterials/audioarchives.html
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Bacteria with Fangs: The Story of the New England Vampires
Coughing up blood, weight loss, lethargy, night sweats— today we urge anyone with these symptoms to “think TB.” But 18th and 19th century Americans had an alternate diagnosis for these symptoms: vampire attack.
Vampires were thought to be dead people who slept in their graves during the day and were transformed into blood-sucking monsters at dusk. They preyed on the living, particularly any of their friends or family members, slowly draining their victims of blood until they died. The symptoms of TB closely mirrored the folkloric traits of vampires, a belief that immigrants from Europe brought with them to America.
The idea quickly took root among settlers in the New England countryside as a rationalization for the TB epidemic spreading through their communities. Crowded living conditions, poor nutrition, and a long-held belief that drafts and fresh air were unhealthy meant that TB spread easily and frequently turned into active disease.
Desperate to stop more people from wasting away and dying, New Englanders conducted contact investigations. To be considered a suspect, you had to be in close contact with the person who was ill, just like contact investigations today. But their list was narrowed down rather quickly, since in order to be a suspected vampire you also had to be dead.
Fortunately this meant the suspects were easy to locate, as most sat nicely labeled in the local graveyard. The suspected vampires were then exhumed and their remains examined for signs of vampirism. Diagnostic criteria included well-preserved remains, blood in the heart, bloating, and hair and fingernail growth after death. However, these were not hard-and-fast rules. If the level of suspicion was high enough, even the most desiccated, bloodless corpse could be declared a vampire.
Once you had a vampire, the next order of business was to kill it. This was rather challenging: How do you kill something that already appears dead? The plucky New Englanders came up with a variety of methods they determined effective, including burning the heart, severing the head and leg bones, and decapitating the head and creating a “skull and crossbones” arrangement. If the New Englanders were feeling particularly industrious, they went ahead and burned the body entirely.
After the vampire was proclaimed dead, the next task was to cure anyone the vampire had preyed upon. A frequent remedy was burning the heart of the vampire and feeding the ashes to those afflicted. Presumably they had poor treatment outcomes, but the tradition continued for a couple centuries for lack of any better ideas.
One of the last documented cases of vampirism in the United States occurred in 1892 in Rhode Island (at one point known as “the Transylvania of America”). George Brown watched as his wife and two daughters slowly wasted away and died. When his son Edwin fell ill, a group of friends and neighbors approached George and offered to help dig up his dead family members to determine which one was the vampire preying on Edwin. George didn’t believe in the theory of vampire attacks, which by this time had just about died out. But when Edwin’s condition worsened and the doctors couldn’t do anything to help him, George decided he had nothing to lose and might as well give the vampire killing thing a try.
Accompanying George and his well-meaning friends and neighbors at the exhumation was Dr. Harold Metcalf, a medical examiner who remained unconvinced that vampires were behind Edwin’s illness. George’s wife and one daughter were exhumed first, and both bodies were well-decomposed. But when the second daughter, Mercy, was unearthed, the crowd was astonished to see the corpse in very good condition.
Dr. Metcalf pointed out that Mercy’s condition was completely normal—the other two women died about ten years ago, while Mercy had only been dead for nine weeks. Also, it was the middle of winter, and you don’t need any fancy degrees to know that not a lot of decomposing takes place when it’s freezing. But it seems logic and reason don’t hold much sway when you’re debating with a crowd of enthusiastic vampire hunters, and despite Dr. Metcalf’s hesitation, Mercy’s heart and liver were removed and examined.
When blood started dripping from Mercy’s organs, George finally became convinced his dead daughter was feasting on his living son. He took Mercy’s organs to a nearby rock and burned them, then fed the ashes to poor dying Edwin, who promptly died a few weeks later.
Mercy Brown’s grave can still be seen in Chestnut Hill Cemetery in Exeter, Rhode Island. The headstone is bolted to the ground, in case anyone is tempted to run off with a souvenir from one of America’s many TB victims and one of its last suspected vampires.
For more information, check out the book Food for the Dead: On the Trail of New England’s Vampires by Michael E. Bell (http://www.foodforthedead.com)
Submitted by Nickolette Patrick
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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 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 (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 in the 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@njms.rutgers.edu.
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Upcoming NE RTMCC Training Courses Planned for 2009
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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TB Program Training Courses Planned for 2009
Click here for the list of upcoming TB program 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.
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
- Nickolette Patrick - Northeastern Spotlight Editor
- Alfred S. Paspe - User Support Specialist/Webmaster
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