Model center for South urged by Alabamans
Endemicity, distances lend region distinction
TB in the southeastern part of the United States is different from TB in other parts of the country. So why doesn’t the South have its own TB model center?
So argue TB experts at the University of Alabama in Birmingham (UAB), which has longed served as an informal focus for research activities and technical expertise. Now, UAB TB experts say they’d like to go a step further by formalizing and expanding their operations. With support and encouragement from sister states in the region, UAB researchers have submitted a formal proposal to the Centers for Disease Control and Prevention in Atlanta, says Nancy Dunlap, MD, PhD, medical adviser to the state’s division of TB control.
"The kind of TB we have here in the Southeast presents some challenges that are unique to our region and requires approaches and skills that also are unique," Dunlap says. "It’s not like TB that’s associated with HIV infection or with being foreign-born."
Long distances, patients who share in common a set of demographic characteristics, and endemicity also set apart TB control in the South, she adds. Plus, there are the sheer numbers: "Thirty-six percent of native-born TB cases occur in the Southeast," she says. "That’s significant, but traditionally, there’s been very little focus on this part of the country."
She and her colleagues at UAB envision a center that corrals regional expertise, serves as a focal point for sharing resources, and develops new courses and materials that will be especially useful to the region. That’s not to say such a center would serve only the South — Alabama, after all, has large migrant communities, too. It also would focus on problems associated with endemic disease among poor, American-born populations across the nation.
So far, Dunlap says she’s had more luck convincing other TB controllers in the region than the feds. "TB down South just isn’t as sexy as it is some other places," she concedes. "It’s kind of boring down here. When you come visit, often you wind up going to lots of counties where there isn’t a whole lot of infrastructure."
Far from being discouraged, UAB researchers say they’re going ahead on their own, trying to offer more of the kinds of services that extra funding would help them expand. As the designated Southeastern genotyping laboratory, the university already types strains from Maryland, which is its surveillance site. "We try to find spare time to help other states with genotyping in situations where there’s a question of whether they’ve got ongoing transmission," Dunlap says. North Carolina, South Carolina, and Mississippi have all turned to UAB for such help in the past, she adds.
In an attempt to make it easier to share expertise and expedite communication, Dunlap also has managed on her own to get the states in the region connected by the Internet.
Expertise is one resource already present in the region and waiting to be mined, Dunlap says. Historically, southeastern states are poorer than states in other parts of the country, but the result is that they’ve had to be creative, she notes. For example, researchers at UAB have been working on ways to streamline contact investigations. "You don’t always have the money to do everything you like, so we’ve tried to isolate the factors that put people at highest risk [for infection following exposure], so we’ll know who to focus on," she says.
Expertise needs to be shared
Not all the expertise has been written down, she adds, but that doesn’t mean it’s not there. "There’s a lot of regional know-how we need to draw on so we can pass it along to the younger people in training now," she says. "For example, what’s the best way to get preventive medicine into someone who lives a three-hour drive away? How do you gain the trust of an elderly black man?"
She’d also like to be able to provide more technical assistance for tasks such as fingerprinting and testing drug levels. Molecular fingerprinting technology in particular is important in the region, Dunlap says. "The disease here has a smoldering, slow-moving quality that makes it hard to tease out from the typically high background rates," she explains. In some settings, molecular epidemiology is the only way investigators have of deciding where to focus, she adds.
"We might know, for example, that we have high rates of TB in homeless shelters. But we can’t go to every single shelter, and this gives us a way to see whether we’ve got ongoing transmission or not, and where."
In Birmingham/Jefferson County, for example, the annual tally of shelter-based TB cases stood at about 30 for as long as anyone could remember, Dunlap recounts. Using molecular epidemiology, investigators finally were able to determine that transmission was ongoing and to pinpoint the source. Now, cases from shelters in the city have plummeted, with just two cases last year.
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