Treating a person instead of a disease

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• Treating a person instead of a disease
• I will remember that there is art to medicine as
  well as science, and that warmth, sympathy, and
  understanding may outweigh the surgeon's knife or
  the chemist's drug.
• I will remember that I do not treat a fever
  chart, a cancerous growth, but a sick human
  being, whose illness may affect the person's
  family and economic stability. My responsibility
  includes these related problems, if I am to care
  adequately for the sick.
• -Hippocratic Oath

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Acknowledgments

• Former and Current San Francisco TB Control and
  Curry Staff
• Gisela Schecter, SF TB Controller 1984-1996
• Max Salfinger, Wadsworth Center, New York State
  Department of Health

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Leadership and Tuberculosis Control

• L. Masae Kawamura, M.D.
• Director, TB Control Section
• San Francisco Department of Public Health
• Francis J. Curry National TB Center

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Overview

• Share San Franciscos local experience and
  lessons learned
• Current challenges to TB control in the U.S.
• Looking within
• Defining success

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SF TB Control

• Mission
• Our mission is to control, prevent and finally
  eliminate tuberculosis in San Francisco by
  providing compassionate, equitable and supportive
  care of the highest quality to all citizens
  affected by this disease.
• VisionThrough its patient-centered approach,
  research, and collaboration with communities, the
  San Francisco TB Control Program will remain a
  resource of innovation and excellence for other
  public health programs.

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Program Description

• Vertical Program
• Centralized TB Clinic with 2 satellite
• treatment/testing sites
• Health worker/DCI model for field DOT and CI
• Team approach to DOT
• Clinicians are UCSF faculty
• Integrated, ongoing training program for
• medical residents and fellows
• Integrated research
• Annual Budget 3.8 million U.S. (53 local,
• 37 federal, 10 state)

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SF TB Control Guiding Principles

• Find and treat all cases to completion
• Stop transmission
• Prevent TB in those at greatest risk of disease
• Emphasis on surveillance, data analysis and the
  use of TB program indicators to measure program
  performance, target efforts and assess
  interventions

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San Francisco TB Control Core Values

• Patient-centered approach
• Patients Come First
• Innovation
• Push the Envelope
• Standards of excellence
• Polish and Refine

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SF TB Control Program Built Over Time

• 1900-1950
• TB treatment moved from general wards to
• segregated wards
• Advocacy Local TB Association organized by
• prominent SF physicians
• Holistic approach with the use of social
  workers
• Early infection control policies established
• (based on observational data)

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SF TB Control Built Over Time

• 1950-1970 TB declines in the era of antibiotics
• Shift from hospital-based to outpatient
  treatment
• San Francisco outpatient program becomes
• a model for the nation
• Concepts of compassionate, community-
• based accessible TB care pioneered

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TB Cases in San Francisco1970 - 1980
No of cases
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San Francisco TB Control1970s Loss of federal
funds and Southeast Asia political upheaval

• Collapse of South Vietnamese government, rise of
  Khmer Rouge led to surges of refugees into SF
  1975, 1979-1981
• New hospital built without dedicated TB wards.
  TB
• Control Clinic becomes outpatient based.
• 1979 rudimentary DOT begins with health
• workers hired from refugee populations

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TB Cases in San Francisco1980 - 1990
No of cases
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San Francisco TB Control1980s Southeast Asian
refugee influx

• Focus on completion of therapy and contact
  investigation
• - Formal DOT program implemented
• - Modern 6-month short course treatment piloted
• Active case finding (focus on newcomers to US)
• - Refugee TB screening program begins
• - Follow-up on immigrants entering with
• B- notifications

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TB Cases in San Francisco1990 - 2000
No of cases
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San Francisco TB Control 1990s Era of HIV-TB
coinfection, outbreaks, and transmission

• TB Control taken to the streets
• Period of intensification
• Use of DNA fingerprinting
• New screening/treatment site opens near
• TB epicenter
• Demonstration Project Housing for
• homeless patients with comprehensive
• social services

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San Francisco TB Control 1990s Era of HIV-TB
coinfection, outbreaks, and transmission

• Community TB Task Force formed
• 1. Focus on homeless TB transmission
• - Guidelines for shelters and low cost hotels
  developed
• Contact investigation
• 1. Focus on decreasing the number of cases,
  with no contacts through training
• 2. Aggressive screening and treatment of HIV
  infective contacts

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San Francisco TB Control 1990s Era of HIV-TB
coinfection, outbreaks, and transmission

• Active case finding Focus on HIV and HIV at
  risk
• -Strict HIV residential screening guidelines
• -Methadone clinics Screening of IDUs
• -Collaboration with UCSF researchers in
• screening HIV homeless individuals
• Aggressive campaign to treat all HIV and TST
• until completion
• -DOPT (directly observed preventive therapy)

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TB Cases in San Francisco 2000 and beyond
No of cases
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San Francisco TB Control2000 and Beyond
Maintain infrastructure, control, retool and
reduce the reservoir of infection

• Update and improve surveillance and patient
  management
• through new database system and information
  technology
• Improve community targeted testing and
  treatment in high
• TB incidence areas and among high-risk
  populations
• Improve and update contact investigation
• with available tools
• Create and strengthen key community
  relationships through
• outreach and education

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2005 A pivotal year

• Implementation of new relational database
• Implementation of mandatory homeless screening
  policy
• Implementation of QFT-Gold
• Birth of important relationships in target
  communities TARC and Chinese Newcomers Program
• New training coordinator (0.1 FTE) Needs
  assessment and creation of a strategic plan for
  TB education of staff and community

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The Next Five Years Benchmarks

• GO BELOW THE 100 CASE MARK
• Zero cases in shelter system within the next 5
  years
• DNA clustering rate reduced to 5 percent
• Incorporation of social networking techniques and
  DNA fingerprinting in contact investigation
• Routine use of blood-based testing for LTBI
  diagnosis citywide
• Electronic and Website access to all SF TB
  Control reports and guidelines
• Most highly TB trained staff in the nation

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Strategies

• TARGETED TESTING
• Sharper tools QFT-Gold and beyond
• Target new provider groups who are caring for
  populations at risk rheumatology offices,
  transplant programs, internists caring for
  diabetics, renal dialysis units, etc.
• CHINATOWN
• Closer collaboration with Chinese Hospital,
  Chinatown health plan and Newcomers Program
• Focus on earlier diagnosis of active TB work
  with radiologists at Chinese Hospital/St. Francis
  and health plan pulmonologist
• HOMELESS and HIV TB
• Evaluate TB policies citywide for HIV and
  homeless clinics, residential settings, jails and
  drug rehab programs.
• Develop surveillance system for homeless with
  Dept of Human Services
• Strengthen collaboration Systematic TB training
  of new shelter staff, SROs and homeless providers

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Leadership Lessons from San Francisco

• Centerpiece Patients come first, highest
  quality patient-centered care
• Credibility commitment to excellence, use of
  data, program indicators and self-evaluation
• Flexibility and adaptation to technology,
  resources and epidemiology
• Commitment to maintaining and passing on
  expertise mentoring, training and education
• All-for-one and one-for-all attitude Sharing,
  learning and participating in TB control
  activities and organizations at every level

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CHALLENGES TB is a disease of poverty, migration
and ignorance

• Tide pools and stubborn pockets
• TB disparities among minorities
• Difficult to reach urban poor
• New and old immigrants
• Poor control of TB outside of the US
• International travel, immigration, global economy
• Increasing global MDR-TB and drug resistance

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2 billion infected!
Active TB incidence, all forms (per 100 000
population per year) 2004Source WHO Stop TB
Department, website www.who.int/tb
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Active TB Case Rates, United States, 2005
D.C.
15 million infected!
3.64.8
4.8 (national average)
Cases per 100,000.
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Reported TB Cases United States, 19822005
No. of Cases
Year
Updated as of March 29, 2006
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Number of TB Cases inU.S.-born vs. Foreign-born
Persons United States, 19932005
No. of Cases
Updated as of March 29, 2006.
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Completion of TB Therapy United States,
19932003

Percentage
Updated as of March 29, 2006. Healthy People
2010 target 90 completed in 1 yr or less. Note
Persons with initial isolate resistant to
rifampin and children under 15 years old with
meningeal, bone or joint, or miliary disease
excluded.
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TB Control success

• US TB control programs are experts on effective
  behavioral strategies to improve adherence and
  patient/provider relations
• Patient centered DOT
• National reporting and surveillance system
• National guidelines have standardized care
• National program for training, education and
  medical consultation (RTMCCs)
• Communication and advocacy national, state and
  regional TB controller organizations

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Coalition Leadership is better than going it alone

• Local Taskforce
• Regional State and regional TB organizations
• National NTCA, ACET
• Teaming up of minds leadership to tackle local,
  regional and national issues

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US TB incidence is at an all time low but take a
closer look

• FB cases essentially unchanged (24 Mexican-born)
  
• US born cases are dominated by African Americans
  and minorities
• Case rates in inner cities and in poor
  communities in the SE US are as high as rates in
  developing countries
• Outbreaks continue all over the US despite
  contact tracing
• Imported MDR and XDR continues and can expect to
  worsen

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We have done so much but it is not enough

• Long way to go in engaging patients, providers,
  communities and society
• undocumented persons, hidden HIV and those living
  on both sides of the US-Mexico border
• Minority communities
• New and old immigrants
• Making targeted testing and LTBI treatment a
  primary care issue
• Improving adherence to LTBI treatment beyond
  traditional approaches of education, incentives
  and enablers

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Whats left to do?

• Continue to use what works
• Move ahead implement available technology to
  eliminate old problems such as treatment in the
  dark and poor specificity and return rates of
  the TB skin test
• Develop new drugs and a vaccine
• Push for policies that decrease health
  disparities
• Address global TB and importation of active
  disease and LTBI
•  

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MDR-TB Global RatesZignol, Dye et al, JID
2006194

• 2004 estimates 424,203 (4.3)
• 2002 estimates 272,906 (1.1)
• Estimated 43 of global MDR-TB cases have had
  prior treatment
• China, India and Russian Federation accounts for
  62 of the MDR burden
• China 5.3 of new cases (27.2 previously
  treated)

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2006 Global Distribution of MDR-TB among
previously treated cases Source Zignol, Dye et
al, JID 2006194
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Cost of MDR-TB

• Average US range 89,594 (survivor)717,555
  (died), Rajbandary et al, IUATLD,Vol.88,
  1012-1016(5) 2004
• Treatment is long, difficult and toxic
• Long periods of isolation (sometimes lifelong)
• Higher rate of death
• May be incurable
• Higher rate of depression

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Preventing drug resistant tuberculosis

• Turning off the tap Drug susceptibility testing
  (DST), proper treatment/ case management, and
  ensuring adherence
• Short term Implementation of rapid DST, new drug
  development.
• Long term Development of a vaccine

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Delay in susceptibility testing will lead to
treatment failure

• Shortening turnaround times for identification,
  and susceptibility testing should be a priority
• Molecular beacons, line-probe assays, strip
  tests Technology that currently exists with a
  TAT of
• CDC recommends that the TAT for growth detection,
  identification and susceptibility testing of the
  M.tb should be available within 2-4 weeks after
  receiving the specimen

ASPHLD-CDC 1995 Styrt et al. JCM 1997
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Microscopy - LJ - Broth-based
Detection Identification Drug resistance Genotypin
g
Molecular
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Diagnosis of tuberculosis infection
QuantiFERON Blood Test (QFT)
TB Skin Test (TST)
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Targeted testing and LTBI treatment Laser vs.
flashlight

• Shift of LTBI diagnosis from clinic to lab with
  new blood-based tests for TB
• QFT-G is highly specific and eliminates false
  positives from BCG, atypical mycobacteria and
  lack of technical skills needed to perform the
  mantoux test
• QFT-G has many operational advantages over TST
• May be ultimately cheaper and safer for the
  public by preventing unneeded CXRs, clinic
  visits, and treatment

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A good leader takes action

• Sometimes the only things seen are the road
  blocks and not the road ahead. What remains now
  is making sure there is a road to follow.

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One of the problems

•  
• The absence of adverse public health events is
  the most commonly taken-for-granted outcome of
  our successful work.
•  
• Kenneth Castro
• Director, DTBE, CDC
• April 4, 2006

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Apathy and ignorance

• Lack of interest, apathy, competing interests
• If TB doesnt affect the middle class and rich
  personally who cares!

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The Competition and hype

• Flavor-of-the-month diseases Bird Flu, SARS,
  West Nile, Lyme disease
• Transform the competition into opportunities to
• Promote the importance of public health
• Compare quoted statistics to TB

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The Competition . (2)

• Terrorism and the war in Iraq
• Transform the competition into opportunities
• Public health warriors
• Compare quoted mortality statistics to US deaths
  from TB and HIV and lives saved from TB and HIV
  treatment

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Fear of change

• Decreasing resources, rising costs
• Old tools despite available new technology
• Perceived threat of program dollars diverted to
  research

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Decreasing resources and rising costs

• Caution Fear often causes finger pointing and
  face-offs between local, state and federal
  programs as well as academic and public health,
  SPEAK WITH ONE VOICE TO UPHOLD PRINCIPLES, and
  JUSTIFY THE RESOURCES YOU HAVE with data
• Be creative, smart, and develop policies that
  promote TB control
• Use data to fight your battles locally and
  statewide
• Have a vision, goals and plan

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Conclusions

• Success in TB control must be achieved for the
  sake of the
• public and the global community
• Our leadership locally, regionally and
  internationally must be
• based on sound public health principles,
  clinical expertise
• and equitable, patient-centered care
• During this period of declining resources, we
  must avoid
• being divisive within the TB Control community
  and stand
• together with one voice to demand what is
  needed
• We must make our voices heard by advocating for
  our
• patients, our frontline staff and public
  health
• Sharing our expertise through international
  technical
• assistance will be critical in the fight
  against global
• TB, HIV-related TB and rising drug resistance

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Success depends on each and every one of us

• Success cannot be defined as eliminating TB alone
  
• Success is curing one patient at a time and
  preventing future cases
• Successful leadership can be determined by the
  way we mentor others to the very essence of
  public health recognizing health as a basic
  human right while caring for individuals,
  communities and populations

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• Your stand against TB is a stand against poverty,
  inequity and injustice.