Transcript: World TB Day California Media Call

March 24, 2010

RESULTS Educational Fund
Conference call for California journalists
On the release of the World Health Organization report on drug-resistant Tuberculosis

March 23, 2010, 10:30 am Pacific Time

Moderator: Margo Sidener
Dr. Ernesto Jaramillo, Stop TB Department in WHO
Dr. James Watt, Chief of TB Control in the California Department of Public Health
Dr. Frank Alvarez, TB Controller, L.A. County
Rachel Orduno, former TB patient

Operator: Good afternoon. My name is (Teprika) and I will be your conference operator today. At this time I would like to welcome everyone to the World TB Day Conference Call. All lines have been placed on mute to prevent any background noise.

After the speakers’ remarks there will be a question-and-answer session. If you would like to ask a question during this time, simply press star then the number one on your telephone keypad. If you would like to withdraw your question, press the pound key.

Thank you, Miss Sidener, you may begin your conference.

Margo Sidener: Thank you. Well, I want to welcome everyone here today. I’m Margo Sidener. I’m the president and CEO of Breathe California of the Bay Area. And Breathe California is a federation of five nonprofits in California that were originally organized a century ago to fight tuberculosis.

World TB day is observed each year on March 24 to commemorate the date in 1882 when Robert Koch announced the discovery of Mycobacterium tuberculosis, the bacterium that causes tuberculosis.

Worldwide, TB remains one of the leading causes of death from infectious disease, killing approximately 900 million, I mean, nine million people become ill and two million actually die. So it’s a very serious topic for today. And we have people who are ready to explain what we can all do to make that different.

I would like to just quickly tell you the speakers who will be on the call. And then they will be introduced more at length one at a time. So today you will be hearing Dr. Ernesto Jaramillo, who is with the Stop TB Department in WHO; Dr. James Watt, who is Chief of TB Control in the California Department of Public Health; Dr. Frank Alvarez, who is the TB Controller in L.A. County; and Rachel Orduno, who is a former TB patient who dedicates herself to patient advocacy efforts.

I would like now to call upon Dr. Ernesto Jaramillo. Dr. Jaramillo is the drug resistance task manager at the Stop TB Department in WHO. He is a Columbian medical doctor with a Ph.D. in health education from the University of London. He has devoted all of his professional career to TB care and control, beginning at the dispensary level in slums in his country while working in clinical and programmatic management of TB and MDR-TB and doing research in social science issues like stigma, discrimination, gender, and help-seeking behavior.

Global policy on MDR-TB control and care and support WHO partners and countries to adopt and adapt these policies have been at the center of his work for the last 10 years, serving the Green Light Committee secretariat and the MDR-TB Working Group of the Stop TB Partnership and training consultants on MDR-TB management. Welcome, Dr. Jaramillo.

Ernesto Jaramillo: Thank you very much for paying attention to a major tragedy that is happening everyday in the lives of at least 4,000 people that die every day of tuberculosis in the world. You have said very clearly we are dealing with an epidemic that has not disappeared.

(Inaudible) is less of an issue but in many, many other countries this is a major, major problem that is not only contributing to reducing the work force because the disease affects mostly people between 15 and 44 years. But it also is affecting the quality of life of families.

WHO has launched a new report on government-assisted surveillance and the response to the epidemic. (Inaudible) treatment and we have made a lot of progress in recent years to decrease the impact.

However, a major effect has emerged and it is the resistance to the drugs that are used to treat TB. This is what we call multidrug-resistant tuberculosis or MDR-TB. It’s a form of TB that is most severe, that is more difficult to treat. It is more costly to treat, and where the chances to cure are substantially reduced.

What we are finding in our studies and that we are reporting to the world is in unknown expanse of MDR-TB in (inaudible) countries. For example, in some regions in Russia, we are finding that one of each four cases of TB are having multidrug-resistant tuberculosis. This is something never, ever before found.

It’s not only unique in this (inaudible) Mr. Williams in Russia and in many other countries, particularly of the former Soviet Union. We also find then that the response to MDR-TB in many countries in making progress but it is still very much hampered by the techniques, the tools that are available which are really obsolete.

We are using methods for diagnosing and treating TB that have not fundamentally changed in the last 40 or 50 years and continuing to make of the response to TB and MDR-TB something really cumbersome in the field, particularly in less-developed countries, a low results seconds.

The engagement of things societies don’t do fundamentally we want to improve the response and help countries to provide tools for people to diagnosis early in the disease and to receive treatment. Treatment [for MDR-TB] that lasts for two years and these are difficult [for the MDR-TB patient] to adhere to. Thank you.

Margo Sidener: Thank you, Dr. Jaramillo, for sharing those necessary but startling facts. And now we will turn to the U.S. and specifically to California, which has the same challenge to funding infrastructure, to control TB especially with the (inaudible). So I would like to introduce Dr. James Watt.

James Watt is chief of the Tuberculosis Control Branch at the California Department of Public Health and will be speaking about the 2009 California data. Dr. Watt attended medical school at the University of California, San Diego, and completed a pediatric residence at Oakland Children’s Hospital.

He received a master’s in public health degree from the University of California, Berkeley, completed a residency in preventive medicine at the California Department of Public Health and served as an epidemic intelligence service officer at the Centers for Disease Control and Prevention.

Prior to taking his current position he was a full-time faculty member for five years at the Johns Hopkins Bloomberg School of Public Health, where his research focused on the epidemiology and prevention of bacterial respiratory diseases in Native American and developing country settings.

Dr. Watt remains an adjunct faculty member at the Johns Hopkins Bloomberg School of Public Health and is an associate clinical professor at the University of California, San Francisco, School of Medicine.

Dr. Watt will present our state TB data and analysis of the data and identifying factors that contribute to the recent drop in TB cases. Welcome, Dr. Watt.

James Watt: Thank you very much and good morning. Let me start out with the data from California. In 2009, the number of new cases of TB dropped significantly from the previous year. And this is very good news. Fewer cases of tuberculosis means that the risk of becoming infected in California is reduced, and across the state the air that we all breathe is safer. Last year, there were 2,472 cases of TB reported in California. This represents an 8.6 percent decrease from 2008, and is the lowest incidence of TB on record.

Nevertheless, we must continue to be vigilant. In 2009, it has been the pattern for several years; approximately three-quarters of persons with TB in California were born outside the United States. These persons come from more than 80 different countries in every corner of the globe. California is an international crossroads and TB is truly a global disease. As a result, California is significantly affected by the global TB epidemic that you just heard about. What this means is that we will continue to see TB in California for many years to come, and we must continue our efforts to prevent the spread of disease.

We are also touched by the situation of drug resistance globally that was just presented. Every year, we identify 30 to 40 cases of serious multidrug-resistant TB in California. These cases are difficult to treat, very costly, and have a greater likelihood of death compared to drug-susceptible disease. We also identify one to two cases of the most worrisome, extensively drug-resistant TB in most years. We are looking closely at the data from 2009 to better understand the reasons for the decline in cases. One striking feature is that we have seen large declines in TB in persons who have been in the United States for less than two years.

I believe that there are two reasons for the decline in this group. First, the Centers for Disease Control Prevention, or CDC, is phasing in a new system for screening persons for TB before they come to the United States. This new system is much more effective in identifying persons with TB and making sure they are adequately treated before arrival. I’m very proud of this new system, because several persons in our group at the California Department of Public Health have worked closely with CDC to identify the need for a new system, to implement it and to measure its impact.

Second, there have been major changes in immigration in California over the past few years. When fewer people arrive from countries where TB is common, we will see less TB in recent arrivers. But it’s important to note that immigration fluctuates. Should immigration increase, it’s possible that we will see corresponding increases in TB. This is yet another reminder that we have to remain vigilant and continue our efforts to prevent disease.

Now what exactly is involved in the prevention of TB? Well, this is difficult and labor-intensive work. TB prevention means finding people with possible TB and making sure that they’re properly diagnosed. It means getting people on the right treatment so that they become non-infectious. It means making sure that patients have an appropriate place to stay while they are infectious so they do not expose others. It means making sure that patients complete treatment and do not relapse or develop drug resistance.

It means finding and evaluating exposed persons to identify additional cases. It means treating infected contacts who are not yet sick to prevent them from developing TB. And it means working with many partners, including laboratories, private providers, and community organizations. This is a difficult financial time for many city and county health departments who do this critical front-line tuberculosis control work. Staffing for TB prevention has been reduced in many jurisdictions. In this environment, it is critical that we pay close attention to TB disease patterns to look for signs of increase in transmission or any resurgence of disease. It’s also critical that we look for new ways to engage with partners who can help in this important work. Thank you.

Margo Sidener: Thank you for the good news and for the call of state vigilance. Now we will hear about how those numbers play out in local jurisdictions, where the cases are treated by private practitioners and public providers who rely on one another. We have with us today Dr. Frank Alvarez, who is director and TB controller at the Los Angeles County Department of Public Health Tuberculosis Control Program. L.A. County has the second-highest number of cases after New York City for a local health jurisdiction in the United States.

This local jurisdiction has more TB cases than all but four states in the U. S., or a higher number than 46 states. Dr.Alvarez is board-certified by the American College of Preventive Medicine and holds a master’s degree in public health from the University of California, Berkley. He has extensive training in epidemiology and disease prevention. In Los Angeles, Dr. Alvarez provides leadership and expertise to the program’s multi-disciplinary team. He also fosters and maintains cohesive relationships with many internal and external partners to support TB disease control and prevention activities, which will be the topic of his comments. Dr. Alvarez.

Frank Alvarez: Thank you. I’d like to say, fortunately, the trend in Los Angeles County is similar to that of our national and state levels. We’ve also experienced a reported 10.9 percent decline of TB cases from 792 in 2008 to 706 in 2009, but with guarded optimism. As Dr. Watt mentioned, we must remain vigilant. However, it does appear that our investments over the last several decades are showing some hopeful returns, but certainly, it’s no time to become complacent. We must continue to move toward TB elimination by maintaining a solid framework of TB control, which locally starts and ends with our mutual public-private health care working partnerships.

I would like to take a few minutes to illustrate the local complexity and critical need for public-private partnerships by detailing a fairly common TB case scenario we see these days. This example involves a 52-year-old individual who was initially admitted to a county hospital for a TB diagnostic work up in isolation. And by using our advanced TB diagnostic test, available at our public health lab, TB was rapidly identified and TB therapy initiated.

The individual was privately insured and eventually transferred to a private hospital for continued care and therapy and eventually discharged and managed in the private health care community. Unfortunately, he became unemployed and uninsured and care was transferred to one of our public health TB specialty clinics for ongoing therapy. Eventually the individual regained employment and insurance and successfully completed care with a private physician with public health oversight.

This illustrates the many touch points to both private and public health care. A TB patient might have over the course of a lengthy TB therapy regimen, typically six to 12 months in (pan) sensitive cases. This story is not uncommon in L.A. County and its – and its – with its approximately 116 private hospitals, of which over 60 reported a case of TB at some point in time in 2009. Over 50 percent of reported cases come from a private provider source, either hospital-based or clinic, so it’s far from strictly a public health care system issue.

However, it certainly remains a public health and safety issue in the larger scale, but mutual responsibilities for patients, patient families and their communities throughout L.A. County. Fortunately, our goals are aligned. First and foremost, patient care and TB cure, which involves rapid identification, isolation, therapy, and consequently termination of ongoing transmission to close contacts, for example, both TB control and elimination.

Our medical provider community expects cure as norm for most TB cases, with dual management and oversight. We’re fortunate that the vast majority of our TB patients complete the full course of therapy in LA County.

So together we provide the safety net as we manage our patients and our close contact through our health care assistance.

After a case is identified to the public health department by either a private or public health care provider, the essential support of public health providers are most often very busy medical providers with the assurance of continuity of patient care to navigate these gaps in our systems.

We facilitate specialized TB consultations, patient therapy, access to advanced laboratory tests, and close contact investigation and follow up. We also provide (Gill Field) public health nurses and community works to support patient education and Directly Observed Therapy [DOT] to enhance treatment completion rates.

Our public health direct patient education and treatment management oversight has been shown to dramatically improve our success rates. So in closing it has clearly been demonstrated that strong public/private collaboration has insured improvement in TB outcomes.

And hopefully with ongoing support for our TB control resources we will continue to see dramatic declines in TB rates and transmissions throughout our county. Thank You.

Margo Sidener: Thank you for that real-life explanation and Cough for Collaboration. Our call now has come full circle to the patient. A partner in TB control who is sometimes overlooked, Rachel Orduno will be joining us. Rachel is a former TB patient who dedicates her volunteer time to patient advocacy efforts.

A bi-national multicultural and multilingual first-generation Mexican-American, Rachel graduated with a B.A. in Spanish literature from the University of Texas at Austin and worked with the University’s Minority Recruitment and Support Services, receiving her teacher’s certificate from the Region 19 Alternative Certification Program in 1997.

She currently works as a high school teacher for the Socorro Independent School District in El Paso. After her diagnosis with TB in 2006, Rachel became a patient activist with the TB PhotoVoice Project, and has attended and presented at meetings in many states and countries. The TB PhotoVoice Project joins the persons affected by TB with health professionals in capturing the TB experience through photos and is a grassroots approach to photography and social action.

Following the guidelines of the Call to Action to Eliminate TB, which calls for the visibility and participation of persons affected by TB across levels to endeavors, Rachel is a member of the advisory board for the Border Voices and Images TB Photovoice Project, a member of the board for the Clinica Guadelupana, where she was diagnosed with TB, and vice president of the board of the TB PhotoVoice Project. I give you Rachel.

Rachel Orduno: Thank you, everyone. And I am so proud to be representing persons affected by TB and having a chance to voice concerns.

Picking up from where Dr. Alvarez left off, with patient education, and being a teacher myself, I put a lot of emphasis on having the public at large know and be more aware of the symptoms of TB, how to get treatment, where to go for screening, and once we do get the proper diagnosis – in my case it took three years.

I actually was first diagnosed in 2002 with diabetes and had to do follow-up checkups, and in 2003 I started presenting the classic profile for TB, coughing, losing weight, night sweats, and having loss of appetite, a lot of fatigue, and for three years, unfortunately, I kept going back to the same doctors and they would misdiagnose me with different respiratory ailments ranging from allergies to laryngitis, sinusitis, pneumonia, and so for three years I was medicated for a lot of other things.

Once I finally started my medication for TB, there was a vast difference and quite a quick recovery. But in those three years, I infected a lot of people, seven of which were my family members. So the statistics show that a person who is active and untreated can infect up to 50 people. So I may have up to 45 people on my conscience that I may have infected.

But that is also a big motivator for me to get the word out. Once you do get diagnosed you need to complete your treatment. You need to stop TB and do your part in encouraging others to do the same — to get screened, to complete the treatment and to spread the word. Ultimately, spread the fact that TB is curable and there is a treatment for it. Each person then, each TB survivor, is a model of a successful treatment completion.

And they not only do a public health service in protecting the spread of TB in their community, they’re also protecting their loved ones, in a sense ensuring that they stop the TB and that they don’t spread it to the people that they spend the most time with. TB elimination needs to be a team effort and inviting TB survivors helps them to be health promoters and they can serve as liaisons and be better communicators between those that are affected by TB and the medical providers. So in a sense as Dr. Jaramillo was saying, the public at large, the civil society needs to be involved.

And just like we, as TB-affected persons, have infected others, I would like to say that I want to affect others to motivate them to act, to be on the lookout for TB and to do whatever is in their power to keep spreading the word that TB is treatable, curable and nobody has to die from it. Thank you.

Margo Sidener: Thank you, Rachel. We’re privileged to have heard this unique perspective, which provides innovative approaches worth investigating. Thanks so much. This concludes our presentation section, which I might add has been brought to us by our sponsor, RESULTS Education Foundation. We’re thankful to them for that. And we are now going to proceed with a question-and-answer session. Operator, can you please remind questioners of the procedure?

Operator:At this time, I would like to remind everyone in order to ask a question please press star then the number one on your telephone keypad. We’ll pause for just a moment to compile the Q&A roster. Again, if you have a question or a comment, you may press star one at this time. At this time, there are no questions.

Margo Sidener: Well, while someone thinks of a question, I would like to remind the reporters that they can go to for contact information for today’s speakers, in case you want post interview information.

Operator: This concludes today’s teleconference. You may now disconnect.

Margo Sidener: Thanks so much for everyone’s participation.


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