WIXLIB

Staff Profile4NORTHEASTERN SPOTLIGHTStaff Profilecontinued from page 3unique challenges and demands.When I first started working in thisfield, TB was still largely a disease of theelderly, infected much earlier in life; butthat no longer is the case. Populationsplagued by substance abuse and HIVnow contribute to the high TB rates, aswell as immigrant populations. As aresult, local health departments havehad to make many adjustments. Eventhose jurisdictions with long-standingmulti-cultural and multi-lingual staff arenow caring for populations unknown tomost of us a decade ago, e.g., the SomaliBantu.”What is Nancy like as a person?“I tend to be pretty quiet, but enjoybeing with family and friends. I also tendto be fairly patient, but don’t have muchtolerance for the foolishnessbureaucracies often create, and that canmake working in a government jobtricky at times. I wish we were notspending so much of our nationalresources on war. I wish we were notletting the fear of some potential ‘event’drive public health resource decisions tosuch a large extent, versus dealing withthe disease and want that already exists.”Outside of work, she says “I enjoytheater, opera and symphony. I love togarden, although I am somewhat limitedby a postage stamp size yard. I like toread especially history. I enjoy visitinglocal art galleries and museums. I love tovisit the ocean when I can. And I like towander through antique and junkstores—amazing things can be found!”What are some of the top educationand training priorities that you areworking on right now?“We are discussing how to provide formore advanced TB training beyond thebasics. This is in response to requestsfrom previously trained, seasoned staff –LHD nurses and doctors – who need sortof a TB 201, beyond basic TB 101training. We are discussing this with ourRTMCC and hope that the effort willhelp keep some local docs interested andon board with TB control. We are alsoplanning for the introduction of the newRVCT and national TB reporting systemSUMMER 2008(NEDSS TB–PAM) and for ourstatewide annual meeting in the Fall. Weare finalizing our skin test trainingschedule which offers a series of trainingsstatewide following the academic yearcalendar; instruction will be provided bya nurse we contract with through a longstanding agreement between DHMHand a local community college.”Maryland has a well-developed internaltraining capability in the area of TB.What are your expectations and visionfor TB education and training that willbe provided by the MD StateDepartment of Health?“Our state has a long history ofsupporting local TB Control programstaff. We have been fortunate in ourability to gain and keep the necessaryfunding to support nurse consultant staffthat work closely with local programsand who are able to identify and respondto training needs, including on-site oneon-one training if needed. We have beenextremely fortunate to be able to tapinto the expertise and experience oflocal academic faculty who have aninterest and background in TB; and wehave been lucky in being able to workwith a small, but critical, core group oflocal physicians who support our largerlocal TB programs.”How can we plan for who will run TBcontrol in the future, as the currentgeneration of TB leaders retires?“We need to be more involved in‘selling’ public health. In the past wecould always recruit good people fromlocal level positions; and as staff movedup, new graduates and peopleexperienced in other public healthprograms took their place. Today, peoplefeel public health does not pay enoughor offer enough opportunities forprofessional growth. We need to getinvolved in pre-service education inschools to promote careers in publichealth, but also need to advocate forbetter salaries and professional growthopportunities.”The population of Maryland includeshigh risk groups that other states alsoserve: rural poor, migrant workers, andinner city. What are the challenges youface in controlling TB in thesepopulations? How do you make sureyour programs are effective?“Availability of local resources isincreasingly problematic. We emphasizetreatment of cases to completion whenthey occur and have worked to improvecontact investigations and treatment tocompletion of high-priority contacts.More and more jurisdictions are using 4months of rifampin for the treatment ofLTBI in individuals who are transient forvarious reasons. We have limited statefunds to support incentives and enablers;and most of that money is now going towhat I would call enablers—for example,supplementing county funds to paysomeone’s rent for a couple months untilthey can return to work. We continue toreceive state funds to support thepurchase of TB medications for all localhealth departments. DOT is thestandard of care with support for its useencoded in state regulation.”As part of the DHMH’s Office ofEpidemiology and Disease ControlPrograms, Nancy’s staff participate inLHD site reviews every 18 months (ormore often if needed) where a formalreview of local TB programs takes place.They use this opportunity to supportlocal staff concerns during theirsummations and in the formal write-upsto local health officers. For example,continued emphasis to local healthofficers on the importance of decreasinglocal TB staff time committed to TBtesting for “political” versus publichealth reasons has had some measure ofsuccess.They also assist local staff dealingwith migrant populations to connectwith national TB organizations and havebeen able to support very limitedtargeted testing in some jurisdictions.Working with Baltimore City, theyparticipate in a special workgroup set upto deal with the ongoing outbreak in thecity’s homeless population. They wereable to provide state TB funds to assistwith the purchase of HEPA units for thelarger City shelters, and supported anaggressive campaign by the City TBprogram to educate shelter staff aboutTB and basic case-finding techniquessuch as the use of cough logs. “Use yourdata and share it with the localjurisdictions. A standard session at ourannual meeting includes a presentationcontinued on page 5

Staff Profile5NORTHEASTERN SPOTLIGHTStaff Profilecontinued from page 4of how the state has done in meetingnational TB program objectives andwhere we need to focus our attentionover the next year.”What do you find helpful in makingyou an effective trainer/educator?“I think it is important to have indepth discussions about what formaltraining content should include in termsof identified needs, so you can take theinformation and make it pertinent tothose you are trying to reach. Youcannot teach effectively from algorithmsalone. Being aware of local programdifferences is important. Timing iseverything–for example, we routinely askourselves if we might potentially beconflicting with flu clinic seasonactivities or pandemic flu exercises.Small regional meetings have beensuccessful and are well received by localstaff, but costs associated with travel maylimit our ability to do them frequently.Conference calls and video-conferencingcan also be effective means of getting themessage out.”“I encourage the use of the formalDHMH mechanism for notifying localTB staff about impending meetings,trainings, etc., because even though wecould communicate this information lessformally, I want the leadership at bothstate and local levels to be reminded ofTB and to be aware of new trainingbeing offered. This is a little more work,but keeps TB on everyone’s radar screen.We encourage local staff to share theirown experiences and have providedfinancial support for local staff to attendnational meetings and national trainingswhen we can. For example, this summerno one from our office will be able toattend the TB-ETN national meeting inAtlanta; but we recruited an activemember of our state’s program evaluationteam to represent us. We also give anannual award to recognize excellentwork in TB by an individual in thestate.”What about the value of training vs.technical assistance?“While formal on-going training isimportant, we have found that inSUMMER 2008jurisdictions where TB occurs rarely, youjust have to walk people through theprocess, be available for consultation,and make sure you keep in touchregarding follow-up.”“Take the time to learn what thelocal TB issues really are and make aneffort to address them. For example,even in a county that has not had a TBcase in years, there is probably a localdetention center that might be housingFederal detainees (a high-risk group);and perhaps that is a topic that shouldbe addressed. Or maybe you need toprovide the research information andprogram recommendations that localprogram staff can use to successfullyengage other local decision makers, e.g.,on the benefits of eliminatingunnecessary TB screening within thelocal schools. Ask people what they needto know and keep in touch – don’t besomeone they only hear from if thecontact data is not right or if you wantsomething.”How do you balance the ‘big picture’with the ‘day-to-day’ when workingwith LHDs?“It is always a struggle to determinethe best balance for formal training. Istrongly believe that people needexposure to the bigger picture, bothstatewide and globally, and to be at leastaware of the latest research.”“However, I also think we need to beable to give people what they need dayto day. If a jurisdiction is dealing withthe first TB case in a while and the nurseassigned is new, I would start by asking ifthey have current guidelines available –don’t assume they were left on the shelfby previous staff. Ask about the medicalprovider and if it would be helpful tohave a direct conversation with him orher. Ask if they have appropriate formsto document treatment and DOT.Review the standards of care and offer toassist with the contact investigation.Talk through their plans, as well as theircapacity to implement them. Keep thelines of communication open. If thewhole health department is in an uproar(e.g., related to a large contactinvestigation), get everyone who countsin on some of the initial conversations tohelp build trust. This is the type ofsupport DHMH nurse consultants offerroutinely to low incidence jurisdictions,as well as to the revolving door of staffassigned to work with TB in jurisdictionswhere nurses wear multiple hats andcross between programs. It is not formaltraining, but is critical to programsuccess; and I suspect very few TBprograms, including ours, do a very goodjob of documenting these activities.”“I often remind providers who don’tsee much TB that it is a very complexdisease, and that as far as I amconcerned, there is no such thing as astupid question. If I don’t know theanswer, I will do my best to find out andget back to people; and I tell them whento expect to hear from me.”“Don’t assume that people read whatyou send them. Assume the opposite. If Iwork in a rural setting dealing withmultiple programs and I get volumes ofguidelines and e-mails from all sorts ofstate and CDC programs, I will probablybe more inclined to read what ispertinent to what I have to deal withroutinely, versus what I may notencounter for months. This is a fact oflife that sometimes we tend to forgetfrom the perspective of a state office. Weneed to remember it and not be offendedwhen it occurs.”“I also think when TB is an unusualoccurrence, you need to be prepared tobe an advocate for the staff at the locallevel. If they are working with a localphysician who does not want to play bythe rules, offer to intervene or assistthem in a way that will preserve theirworking relationship. But do what ittakes to get the recalcitrant provider onboard with the plan of care.”What does the future hold?“I just read something the other daythat I think is important to keep inmind. The baby boomers (myselfincluded) learned their professionsdifferently than the generation of newproviders we are hoping to get interestedin TB prevention and control. The newgeneration of health department staffwill have grown up with computers, cellphones, I-pods, and other tools asroutine implements of daily living andwill expect to be able to use these toolsin their daily work to communicateinstantly with anyone, anywhere,continued on page 11

Spotlight6NORTHEASTERN SPOTLIGHTSUMMER 2008Spotlight on the Behavioral/Social ScienceContribution to TB ControlTuberculosis has long been viewed asresulting from the interplay of biologicaland social factors. In the late 19th andearly 20th centuries, popular belief andthe medical community approached TBas a ‘social disease,’ and emphasized thatthe environmental and behavioral basesof TB had to be addressed before a patientcould have a reasonable chance of beingcured. In fact, the emergence andevolution of TB sanatoria might beunderstood as a debate over how toadminister both the medical and thesocial cure for the disease. In morerecent times, some have suggested thatestablishing DOT as the standard of carecloses that debate prematurely, andsharply reduces the scope of the 'socialcure' to the creation of a temporarymechanism that ensures the medical cure.The 2001 Institute of Medicinereport, “Ending Neglect,” called for thecreation of “a program of research onbehavioral factors related to TBtreatment and prevention.” In response,the CDC’s DTBE convened theTuberculosis Behavioral and SocialScience Research Forum in December2003. There are several reasons why sucha research program could greatly assist TBcontrol efforts. With the overall declineof TB disease in US-born populations,TB is increasingly found in individualswith one or more major challenges suchas homelessness, substance abuse, ormental illness. Social and behavioralscientists and practitioners could helpTB controllers in understanding thesepopulations and devising effectivemeans of reaching them.Equally important is the persistenceof high TB rates among the foreign-born.Despite their minority status in the USpopulation, the foreign-born haverepresented the majority of cases withTB disease since 2001 and may representaround two-thirds of those being treatedfor Latent TB Infection. Theseindividuals originate in countries withwidely different TB beliefs and practicesfrom the US. Again, behavioral andsocial scientists can help in understanding these beliefs, leading to thedevelopment of methods to modifybeliefs and change behavior to achieveUS public health goals.Another important role for thebehavioral and social sciences is in thepromotion of treatment for Latent TBInfection (LTBI). As traditional TBcontrol efforts have focused on theidentification and treatment of activedisease, TB controllers have becomeaccustomed to having – though onlyusing as a last resort – the coercive powerof public health law to force individualsto comply with a TB evaluation, acceptDOT and complete treatment. Certainly,prudent TB programs have learned that“the carrot is better than the stick,” andlonger than that for active disease,other burdens related to long-termpill-taking, and the lack of positivebenefits from symptom relief?Both the TB control workforce andbehavioral/social scientists continue tostruggle with understanding andaddressing the medical and socialdimensions of the disease. We believethat an on-going dialogue between thesetwo groups will further the goals of bothTB control and behavioral/socialscience, and we hope that this series,‘Spotlight on the Behavioral/SocialScience Contribution to TB Control,’will contribute to that dialogue. Wewelcome your comments to the ideasBoth the TB control workforce and behavioral/social scientistscontinue to struggle with understanding and addressing themedical and social dimensions of the disease. We believe that anon-going dialogue between these two groups will further thegoals of both TB control and behavioral/social science.have placed more emphasis on enticinggood adherence than threatening direconsequences. Nevertheless, treatmentof active disease affords powers to TBcontrollers that are not available whenmanaging LTBI treatment.At the current time, completion ratesfor LTBI treatment are abysmal, far belowthe Healthy People 2010 goal of 85%.In standard clinical practice, LTBItreatment completion often falls below50%. Nationally, even among infectedcontacts to AFB-positive cases, onlyabout 70% start treatment for LTBI andamong these only 60% completetreatment. An improvement in LTBIcompletion rates will require a muchbetter understanding of patient beliefsand behaviors: What motivates an individual toaccept LTBI treatment despite conflicting information about its efficacyand the possibility of side effects? What motivates an LTBI patient tocomplete treatment despite a regimenexpressed above.In subsequent issues, we will explore: The role that behavioral and socialsciences have historically played inTB control; How behavioral/social scienceresearch informed HIV/AIDSinterventions and implications forTB prevention and control; Recent findings from TB behavioral/social science studies with practicalprogrammatic applications; and Upcoming findings from specific TBEpidemiological Studies Consortiumstudies having a behavioral/socialscience focus and how these might betranslated into practice.We welcome your comments andsuggestions on how this Spotlight seriesmight help to meet your needs.Submitted by Paul Colson, PhDProgram DirectorCharles P. Felton National TuberculosisCenter At Harlem Hospital

MEDICAL CONSULTATION7NORTHEASTERN SPOTLIGHTSUMMER 2008Northeastern RegionalMedical Consultation Service, 2007As an RTMCC, GTBI is tasked byCDC with strengthening medicalconsultation throughout the NortheasternUS. Toward this end, since 2005 theGTBI has provided expert medicalconsultation to TB program medicalconsultants and other health careproviders via 1-800-4TB-DOCS andemail. In conjunction with eachconsultation, community providers areencouraged to contact TB programmedical consultants with future requestsfor consultation. Educationally, GTBIhas convened annual TB MedicalConsultants Meetings for TB programmedical consultants in the NE Region;conducted bi-monthly web-based grandrounds at which TB program consultantspresent difficult cases and receivefeedback from colleagues; and providedtraining courses and webinars with acli

The Northeastern Regional Training and Medical Consultation Consortium is a collaborative effort of the Charles P. Felton National Tuberculosis . MBA, continued on page 2. T R A I N I N G C O U R S E S 2 NORTHEASTERN SPOTLIGHT SUMMER 2008 TB Intensive Workshop - On the Road For the first time, our popular TB . Executive Director NJMS .