Elimination of TB in the US: 2021 Updates (Toub, 8/4//2021)

Many thanks to Dr. Danny Toub, a family physician, teacher, and public health professional-- who so often bridges the impossible gaps that exist between individual patient care conundrums and public health. While this bridge may seem intuitive, it is often rickety and not always clear how to begin to build it-- look to Dr. Toub, though, he always shows us the way. 

A recording of his presentation is available HERE. 

This week's topic was Tuberculosis (TB), a global behemoth; the original and ever-present airborne illness that still kills 1.4 million people worldwide per year, more than HIV/AIDS While we sit in the middle of a harrowing COVID-19 Pandemic and the words N-95 have become every day jargon, TB is still global problem. And while we have made great progress in the US with TB eradication, TB still unnecessarily killed 542 Americans in 2018, 200 of which were right here in California.

TB, much like COVID, disproportionately affects people who are living in poverty, people of color, and those who have less access to stable housing and health care services.

What is our responsibility as primary care providers?

• Screen ALL patients for TB Risk
• Screen HIGH RISK patients with a Tuberculin Skin test (TST) or interferon gamma release assay (IGRA)
• Treat Latent TB infections (LTBI)
• Report to Public Health any active TB cases and/or any LTBI in children or recent converters (<2 years)
• Oh, and don't forget to have TB on your ddx for other acute/subacute illness presentations!

If we break that down,

1) Screen ALL patients for TB Risk using the California TB Risk Assessment Tool which can be found HERE and is pictured below as well. 

Remember to AVOID testing low risk folks for LTBI (this form alone counts as a screen!) and if you have limited resources, prioritize those who are most likely to convert from LTBI to active TB. Key risk factors include being foreign born/immigrant from certain regions, immunosuppression, and those who have been in close contact with someone with TB. 

Important additional risk factors include, recent conversion, substance use disorder, patients with DM, patients with CKD, those with autoimmune conditions, people who smoke, people with cancer, and more. 

The point of screening is to prevent a future conversion to active TB by treating people before they get sick. Low risk patients have ~10% lifetime risk of converting. Higher risk (e.g. people with diabetes) have ~ 30% lifetime risk, and highest risk folks (e.g. HIV + LTBI) have a 7-10% per year risk of converting. 

2) Screen HIGH risk patients with TST or IGRA. The best TB test depends on your pretest probability. Here is a good cheat sheet.

• Low risk patient--> do not screen
• Asymptomatic child--> use the California Pediatric TB Risk Assessment
• Asymptomatic adult--> use the CA Adult TB Risk assessment
• Volunteer for school without risk factors--> use the CA Schools TB Risk Tool
• College or University student--> use the CA College tool
• Health care worker--> use CDC guidelines#
• Pregnant woman--> pregnancy itself is not a risk factor
• 2 year old foreign-born patient--> TST*
• Foreign born >2 year old, hx BCG--> IGRA**
• Patient experiencing homelessness--> IGRA
• Patient to start TNF alpha blocker--> IGRA
• Patients with >4 weeks cough, 5 pound weight loss--> Chest Xray
• SE Asian smoker with RUL cavity, and a1c>9%--> sputum (x-pert MTB)+

#Note that the CDC no longer recommends annual TB testing for healthcare workers!! Official recommendations released in 2019 are available here and recommend a risk based technique. Maybe that means YOU don't need that annual TST!

*TST: tuberculin skin test, **IGRA: interferon gamma release assay (often referred to as quantiferon gold). There is limited data in IGRA in children <5. IGRA are more specific than TST in pts with a history of a BCG vaccine.

+Remember, a negative IGRA or TST does NOT rule out active TB (you need sputum!)

3) Treat LTBI infection. Treatment for LTBI has been shortened and simplified over the last decade. It does not involve routine lab work (except in high risk folks) or directly observed therapy (DOT). 

Dr. Toub recommends this handy LTBI pocket card to help simplify your decision-making and treatment regimen planning. The image below to too small to actually read, but follow the link for specifics on indications, completion criteria, considerations, etc. 

Briefly, prior to initiating LTBI treatment, you want to be sure to r/o pregnancy, check for pre-existing peripheral neuropathy (which can be a side effect of tx), screen for liver disease risk factors (e.g. alcohol use disorder, NASH, HCV). 

Baseline LFTs are only indicated for patients with HIV, known liver disease, regular alcohol use, pregnancy or < 3 months postpartum, and other risks for liver disease.

And, Dr. Toub reminded us to remind your patients that EVERYthing will be orange (sweat, tears, and urine). Also be sure to check for drug drug interactions on any tool that you use for this purpose, as there are many. 

4) Report to SoCo Public Health any active TB cases and/or any LTBI in children or recent converters (<2 years). 

5) Oh, and don't forget to have TB on your ddx for other acute/subacute illness presentations! Remember TB can show up just about anywhere. 

For local assistance, you can utilize the Sonoma County TB Control Guidelines, which you can find at the bottom of this webpage. And if you ever have any TB questions, reach out to our local TB Control program at 707-565-4567.

And, finally, a list of trusted resources from Dr. Toub:

Mental Health Disparities in Latinx (Flores, 7/29/2020)

A big thanks to CEDAWG and Dr. Yvette Flores, clinical psychologist and professor of Chicano/a studies at UC Davis, who gave a powerful and heartfelt Grand Rounds presentation this week on how to consider and approach the mental health of marginalized groups, particularly Latinx , in this time of COVID. Again, it is hard for me to give her words justice in summary, but the following is my attempt.

Dr. Flores started with "stating the obvious": 1) That racism, sexism, homophobia and other forms of discrimination affect the mental health of those who experience them, 2) That stress affects well-being and 3) That yes, in fact, we are all in this together.

If I don't wear a mask, I affect you.

If my grandchildren don't wear a mask, it affects me.
We are all a little anxious, depressed, and experiencing past traumas as we live this pandemic.

We all need to be in this together, including in mental health.

Dr. Flores spent some time reviewing the important effects of stress on mental health.

Social stress: stress is produced not only by personal events but also by the social conditions that surround us-- and for all our patients, their intersectional identities (gender, class, nativity, immigration status, length of residence in the US). 

Minority stress: high levels of stress faced by members of stigmatized minority groups (race, gender, sexuality, linguistic ability, physical/mental abilities), including:

• lacking proper social supports
• socioeconomic status (SES)
• interpersonal discrimination

Marginalized status affects physical and mental health.

Good stress vs. bad stress: a little stress has been found to improve performance, but a lot of stress can become problematic. In what ways is minority stress a risk factor? And how may minority stress also be a protective factor?

I love considering the possibility that the very minority stress our patients are experiencing may make them simultaneously vulnerable and resilient. 

What has COVID-19 Revealed?

1) Health disparities have been made more visible

2) Xenophobia and hate crimes against Asian Americans

3) Disregard for these disparities from politicians at the highest levels

4) People of color disproportionately work in front line jobs

5) Disproportionate unemployment rates for Latinx and African Americans

6) Ageism (are old people important enough?)

How can we translate scientific data in a way that people can understand?

How do we frame the message?

"There is no one to blame here, but we all have responsibility."

Role of Gender: For the working class, life and work are often synonymous. How does unemployment affect men? How does unemployment impact women who are single parents and have to work? People of  color will often go to work despite the risk because of their gender or cultural mandate that it is their obligation to provide. But this is also a class issue (always need to think intersectionally).

What are the protective factors in communities of color that might mitigate the crisis?

1. Resilience: Immigrants are tremendously resilient. It takes incredible courage to make the journey that many immigrants (particularly undocumented immigrants) make.
2. Stoicism:  coping, "it's alright, I am fine", challenging for healthcare professionals to care for someone who says they are fine (when they clearly aren't). Dr. Flores' rec: Bring in partner if there is one/
3. Religious faith: "Si Dios quiere" God willing. Can be frustrating because seems fatalistic but is also protective. How can we leverage this?
4. Networks of support:  Overcrowded and/or Multi-generational households, which make them more vulnerable are also the very support structures that allow people to survive. How do we mobilize the 
5. Positive ethnic, racial and gender identity: reaffirm their identification (whatever they may be). Call them what they want us to call them. 

Remember that mediational factors may ADD to minority stress

• Internalized racism
• Controlling images (often propagated in the media-- more serious and perverse than stereotypes), many are gender specific (angry black woman, loud Latino, Latino male as criminal or rapist). How does this affect internalized perception of people of color?  How are people in power speaking about these controlling images?
• We must uphold the identities of the people with whom we work: we need to counter these controlling images (mental health workers)

And finally, on coping: how to potentiate coping, so we can be better healthcare providers and caretakers. 

Dr. Flores called this digging into our ancestral well: we have all learned lessons from our family that can help us to serve our patients. In times of crises, we can draw from the stories/legacies that the elders and ancestors have shared with us (and with each of our patients), which can help transform our fears into opportunities

Where do you draw your strength to continue to care for your patients?

Self care is essential during COVID-19:

It is important for us to promote self-care and resilience as we do this work.

Gendered expectations (nurture ourselves in order to refill the well)

Remember to check out and disconnect in order to connect to ourselves 

Cultural traditions can offer balancing and healing: including prayers, smudging, meditation, mindfulness, exercise, baking, cooking

An Epidemic of Loneliness (Naderi, 4/29/2020)

Such an important topic this week from Dr. Tahereh Naderi: An Epidemic of Loneliness. While she focused her talk on loneliness in elders, her presentation certainly has me pondering a loneliness in my own life-- especially in pandemic times.

What is loneliness? It's subjective: it's your own perception of the lack of interaction
What is social isolation? An objective lack of meaningful and sustaining communication and/or interaction.

Risk factors for loneliness include: older age (esp >80), poor subjective health and self-reported functioning, large number of chronic illnesses, impaired hearing, functional disability, lack of mobility or motor decline, hopelessness, depressed mood, psychiatric morbidity (e.g. depression), quality and quantity of social interactions, living arrangements, low SES, and race.

2 in 5 Americans report they sometimes or always feel their social relationships are not meaningful.
1 in 5 Americans feel lonely or socially isolated
In the past decade, average household size has decreased leading to 10% increase in people living alone, 28% of older adults live alone
Over the past 2-3 decades, the average size of our social networks has declined

The impact of loneliness is real:

• greater risk of cognitive decline and dementia
• lower self esteem and limited use of coping mechanisms
• increase in personality disorders, schizophrenia
• increase in risk for depression
• predictive of suicidal ideation and behavior
• increased substance use (especially alcoholism)

And what about quarantining?

Data following the SARS health crisis in China in 2003, found that quarantining had particular impact on healthcare workers even after restrictions were lifting including:

• low social contact
• avoiding enclosed public spaces
• not returning to work
• long term behavioral changes such as excessive hand washing

Isolation can exacerbate feelings of anxiety, anger, and pre-existing symptoms, can increase one's risk of developing PTSD, and interrupt treatment for substance use disorders. 

Dr. Naderi reminded us (we need to keep hearing this) that social distancing DOES NOT equal social isolation.

Also, guess what? There is an antidote to loneliness: social connection. Social connection actually makes people healthier!

• A meta-analysis including >300K people concluded that greater social connection is associated with a 50% reduced risk of early death
• In studies of the "blue zones" (regions in the world with the greatest concentration of centenarians), social connection is a component of 4 of the 9 of the power principles. The power principles are the 9 lifestyle habits that seem to be associated with longer, healthier, happier lives. 

Believe it our note, we can work on increasing or firming up our social connections in several different ways-- through mindfulness and acceptance, increased use of technology (yep, it's true, even for seniors) and intentionally reaching out to others to form community.

• A randomized controlled trial using mindfulness-based techniques was able to reduce loneliness by 22% and increased social interactions in daily life by 2 more interactions per day and one additional person per day!
• The use of technology-- even in seniors-- can effectively decrease loneliness (multiple modalities including email, video conferencing and computer training). 
• Shared activities were effective: gardening, physical activity, visual arts discssion, even animal therapy!!

Dr. Naderi introduced us to the concept of  Moais (模合, Mo-ai):social support groups that form in order to provide varying support from social, financial, health, or spiritual interests. Moai means "meeting for a common purpose" in Japanese and originated from the social support groups in Okinawa, Japan. These have been studies as part of the blue zone studies.

While Okinawan Moais are inherently built in to society, we may have to be more proactive about reaching out and creating ours. If you don't have one, consider taking steps toward forming a Moias. Or identify and strengthen the one you have. 

Dr. Naderi concluded with an quote by Vivek Murthy, internal medicine physician, 19th Surgeon General of the US, who took a particular interest in loneliness as surgeon general:

"The irony is that the antidote to loneliness, human connection, is also a universal condition. In fact, we are hardwired for connection-- as we demonstrate every time we come together around a common purpose or crisis- and even now as we face the global COVID-19 pandemic and resort to physical distancing to reduce the spread of the virus, we are recognizing that we cannot make it through fear, dager, and uncertainty of the current moment without supporting one another. "

Go ahead, close this browser, call that person you've been meaning to call. You won't regret it.

Structural Violence and Mayan People in Guatemala (Schirmer, 2/5/2020)

Muchas gracias to Dr. Billy Schirmer who gave a compelling (and dense) Grand Rounds this week on Structural Violence and Mayan People in Guatemala—spanning from 1492 to the present. While some of us may be surprised to see such a topic at a hospital grand rounds, it was an excellent reminder that we are not caring for patients on an island in Santa Rosa—but rather in a complicated global, sociopolitical context. And that context matters.

Dr. Schirmer reminded us right up front that current immigration from Guatemala (and really all of Central America) are directly related to a long and sordid history of structural violence**—violence that has been perpetrated continuously by the United States toward indigenous people as long as there has been foreign policy. 


Dr. Schirmer challenged us to take the long view—Guatemalan people are not coming to the US simply because coffee prices have dropped or opium fields are being destroyed or gang violence is endemic. While all these individual things are true, the story is much more layered—full of centuries of war, classism, fear, racism and persecution.

**structural violence: the imposition of unequal risk for disease, injury, and death by social, political, institutional and economic configurations and policies on identifiable population groups . This violence is structural because it results from durable systemic inequality produced by large scale social forces, including racism, gender inequality, poverty and harmful public policies rather than from isolated individual actions or serendipity (-definition from Dr. Paul Farmer, physician and medical anthropologist)



Some stats:

• There are 21 unique Mayan languages in Guatemala
• 41% of Guatemalans identify as Mayan/indigenous
• 79% of indigenous Guatemalans live in poverty
• 40% live on less than $1.90/day
• 90% of poor kids never graduate from high school

• 33% of indigenous Guatemalans cannot read or write
• Average educational attainment for indigenous women is 2 years
• The number of Guatemalan people seeking asylum at the US-Mexico border continues to rise—surpassing Mexican nationals

• 33% of those that apply for asylum without medical evaluation are granted asylum; 88% are granted asylum with a medical evaluation

And some history (I cannot possibly cover it all here, check out the recording of his GR here if you want to hear in its entirety)

• 1500s Pedro de Alvarado leads the Mayan conquest
• After the Spanish conquest all of the land in Guatemala is divided amongst ruling class “encomienda system”--legal slavery of the indigenous people by the ruling class.
• 1821 Guatemalan independence from Spain (not for the indigenous, who continue to be oppressed)
• 1877 remaining land on which indigenous people are living is stolen and sold to private coffee growers, leaving most Mayans without land
• Early 1900s, the United Fruit Company (a US company) establishes the banana industry. United Fruit owns (and controls) much of Guatemalan infrastructure (roads, trains, ports, radio, land) in the name of the banana industry. All supported by dictatorships who were supported by the US.
• 1940s: Guatemalan spring: attempt at unionization of the United Fruit workers
• Early 1950s, democratically elected President Arbenz implements Agrarian reform to reacquire land for the people of Guatemala
• Soon thereafter (1954), President Eisenhower and other high level US officials (the Dulles brothers) create an uprising against Arbenz and force the democratically elected president out of office in the name of “anti-communism”
• Over the next 40 years—during the Cold War—fear of communism drives horrible human rights abuses. Land is burned and taken from indigenous people, people in power abused people without power, and thousands of indigenous people were systematically murdered
• The US supplied training and weapons to corrupt Guatemalan governments in the name of democracy. This training and weaponry has left footprints everywhere
• 1970s and 80s: era of La Violencia under President Rios Montt: “scorched earth campaign”, 70-90% of indigenous communities are burnt to the ground by the Guatemalan government. President Reagan continues to send money and weapons to support Pres. Rios Montt
• Rigoberta Menchu, Nobel Peace Prize 1992
• 1999 Historical clarification commission: investigation of human rights abuses, “Memoria de Silencio”, highlights endemic racism contributing to violence and war in Guatemala

And now fast forward to current reality:

• International commission against Impunity under former President Jimmy Morales: In 2013, Guatemalan president Rios Montt was convicted in Guatemala of genocide, a week later that ruling was overturned on a technicality. He was never retried, and ultimately died in 2018 without punishment.
• Ongoing rampant sexual violence in Guatemala: 50-80% have experienced intimate partner violence, a culture of silence
• President Trump’s 2019 “Safe Third Party Agreement” with Guatemala, Honduras and El Salvador requires that any asylum seekers passing through Guatemala on the way to the US (from Honduras, El Salvador, etc) MUST apply for asylum in Guatemala before applying in the US. Though international experts agree that Guatemala has neither the infrastructure nor the resources to support such people, Trump threatened tariffs if Guatemala didn’t cooperate

And SO what can we do as health care providers?

• Create safe spaces in clinics and hospitals (be aware of chronic institutional distrust)
• Know that trauma is ongoing; it doesn’t end when people arrive in the US. It has negative effects on people’s health and should be addressed sensitively
• Don’t make assumptions about patients’ history or language of choice. Ask, humbly.
• Don’t blame the victims.
• And last, but not least, get trained to do asylum evaluations