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able to contribute to all of the programs, that there are definitely similarities that run across all of the programs and that his ability to contribute will increase over time.

The final meeting was held back at the Bureau of Health with Kim Ware, Public Health Nursing, Augusta; Kathleen Gensheimer, M.D., M.P.H.; Osborne Coates, M.D., Chair, Tuberculosis Consultants; and Steven Sears, M.D., Vice President Medical Affairs, Maine General Medical Center. The focus of this discussion was on the role of the TB consultants. There are nine TB consultants retained by the state and paid $225 per month, plus an extra fee for each clinic session. The consultants meet four times per year and this usually provides adequate time to review all cases under care at that time. The consultants are a mixture of infectious disease and pulmonary specialists and in general feel that they have few problems managing the treatment of cases. The greatest problem was in maintaining adherence with preventive therapy. The largest group on preventive therapy are Bosnian refugees and adherence dropped as soon as they obtained jobs. DOPT has been tried in selective cases but proved not to be cost effective for their program since the number of patients in any single language/ethnic group was so small. Another difficult group to maintain adherence is seasonal agricultural workers. In general, the greatest need seemed to be to identify new strategies to deal with preventive therapy.

Before leaving Augusta, the site visit team had the opportunity to attend a portion of a meeting with the state society of the Association of Practitioners of Infection Control (APIC). There was a presentation of a complicated case that highlighted issues about skin testing, timing of discharge from isolation rooms, maintenance of negative pressure rooms, and other infection control issues. The discussion highlighted the problems faced in adhering to the proposed OSHA regulations for TB infection control. The outcome of an inappropriate patient discharge also highlighted the amount of resources consumed through skin testing and other follow-up when infection control guidelines are not followed.

The site visit team then went to Portland and met first with management of a local food processing plant and Kathleen Gensheimer, M.D., M.P.H. Two patients with active tuberculosis were identified among the workforce at this company located in Portland. The company management was very cooperative with public health in conducting screening, and later in offering work-site preventive therapy. However, company managers still felt they lacked a great deal of knowledge about tuberculosis and needed outside help to deal with the problem. Despite company cooperation with work-site preventive therapy, completion of therapy rates were very low. The major barriers included language (the employees speak a variety of languages) and the stigma the employees perceived in association with a diagnosis of tuberculosis or tuberculosis infection.



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