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TB Notes 3, 2004

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS

Daily Accountability and Innovative Methods That Push Performance and Achieve Higher Outcomes

In many areas, the demand for TB control services outweighs available resources. Such is the case in Houston, Texas. Teamwork simplifies the processes, but how can a team of 6 to 10 supervisory and administrative staff direct, plan, evaluate, and provide daily supervision to achieve the program objectives of a large metropolitan TB program covering 617 square miles? Houston TB staff consistently deliver and supervise between 1,200 and 2,000 directly observed therapy (DOT) doses per week.

The answer: increase accountability to ensure daily achievement of objectives through daily administrative and supervisory staff meetings, and implement innovative methodologies.

Accountability, Accountability, Accountability

Accountability drives improvement. Accountability enables changes that impact outcome. How do we achieve it? Push daily accountability and conduct daily administrative and supervisory staff meetings. Staff come prepared to share yesterday’s outcomes, issues, and concerns, and are ready to assess situations and offer solutions.

The Meeting

“You want what? DAILY staff meetings? You've got to be kidding!” Staff were reluctant when it was first suggested. "We're too busy."
"We don't have time to meet every day."
"Mornings are the busiest times.”
“How about meeting once a week?"
These were only a few of the many objections expressed by the administrative and supervisory staff.

Today we wouldn't change it! Daily staff meetings provide daily accountability for every area of the TB Bureau. This 30- to 60-minute period has become the most important part of the day. It is the fastest and most efficient way for staff to share pertinent information, discuss nonadherent patients and clinic issues, distribute assignments, brainstorm solutions to specific issues, propose new ideas, and implement new plans. This meeting also allows staff to triage and troubleshoot issues that impede achievement of objectives.

Meeting Scenario

How many patients missed DOT doses yesterday? Not last week, not last month! Who missed a DOT dose, why did they miss it, what are the plans to make up the missed doses today? Was a visit made on Saturday or Sunday to make up the missed dose? Which new suspects and cases were not started on DOT? Which new cases or suspects who were interviewed yesterday require expanded contact investigation at school or work sites? Which patients are nonadherent to TB services? All staff contribute ideas toward a comprehensive solution. Staff leave the meeting committed to the final negotiated group decision and ready to support it. This allows alternative plans to be implemented immediately and to impact outcomes. This is real-time case management.

The More, the Better

This daily meeting fosters more individual and collective accountability, more sharing of information, more collaboration, and more creative problem-solving, which result in more and improved services, using the same resources.

Take Care of Today, and Tomorrow Will Take Care of Itself

Daily accountability pushes higher daily achievement of objectives. The daily check-in by each field staff member provides daily verification that each DOT dose is successfully supervised, contacts are identified and examined, and nonadherent patients are located and returned to supervision. This results in no surprises. Monthly, quarterly, and annual outcomes are known.

Contact Investigation: Divide and Strengthen

Traditionally, contact investigation was initiated by assigning each new patient or suspect to a field staff member. The staff member would conduct an initial interview with the patient or suspect and proceed to locate each of the contacts identified. Tuberculin skin tests (TSTs) were administered and read in the field and referrals were given to those contacts in need of further medical evaluation. Staff traveled over large geographic areas in heavy traffic to locate all the named contacts. Caseloads exceeded 150 at any given time, and staff spent more than half their time in the office reviewing patient or suspect files to determine which contact needed what and to plan visits for the day. Interviews were not being initiated within 3 days of assignment because of conflicting priorities. When staff returned to read TSTs, they had to make additional visits later the same day if some of the contacts were not available for the reading, thus interrupting other visits planned for that day. How can you achieve objectives within specified time frames when the same staff provide activities that compete for priority: interviewing versus tuberculin testing and patient evaluation? The solution was to separate the responsibilities into an Interview Team and a Follow-up Team and dispatch assignments to the Follow-up Team.

Two public health investigators (PHIs) assigned to the Interview Team now ensure that all new patients and suspects are interviewed within 3 to 7 days of assignment. These PHIs are also responsible for reinterviewing patients whose contacts have a high rate of TST-positive reactions, whose bacteriology results remain positive more than 3 months, or who develop positive bacteriology results after initial conversion.

With the dispatch system, all named contacts are included in a master database file. The CI Coordinator prioritizes the need to evaluate each contact based on the date of contact interview, infectiousness of index case, age of contact, and positive reactor rate for the contact cohort of each index case. Individual contacts are assigned to the Follow-up Team by geographic location rather than by case cohort. This system increases productivity by reducing the number of miles and driving time. A computer-generated itinerary and the corresponding Contact Evaluation and Treatment forms are dispatched daily to each PHI. This system allows field staff to provide services to the highest priority contacts for the day. The supervisor conducts a daily review with each worker to assess the outcome of work dispatched. This process provides a high degree of accountability and facilitates rapid assessment and development of alternative plans for contacts not completing examination according to the recommended schedule.

The Computer Works for You

In addition to holding daily staff meetings and redesigning the way contact investigation services are provided, we have also recently redesigned the information-delivery system to provide integrated, real-time, accurate data on which to base daily patient-care decisions. A readily accessible computer team, knowledgeable about TB and the interrelation of program components, rapidly responds to changing needs by tailoring the information-delivery system. This dynamic system has become an essential tool used by all staff throughout the program. Supervisors and managers collaborate with the computer team to facilitate this process, which ensures a user-friendly system that requires minimal training. The electronic Case Register card, DOT adherence report, DOT medication card, and contact evaluation and treatment tracking form ensure accurate patient tracking and adherence. The use of computer-generated field staff itineraries assists in monitoring and ensuring daily individual staff accountability.

The Rewards

Accountability, daily staff meetings, separation of contact investigation interview and follow-up teams, and contact investigation dispatch, combined with a very usable information delivery system, have been instrumental in pushing staff performance and achievement to a higher level.

The Achievements

  • The percentage of patients started on DOT increased annually from 88.8% in 1998 to 97.6% in 2003.
  • The percentage of suspects started on DOT increased annually from 84.4% in 1998 to 99% in 2003.
  • A DOT success rate of 93% to 95% is consistently maintained annually.
  • The percentage of isolates with drug-susceptibility results was maintained at 93% to 98% annually during the last 5 years.
  • The percentage of patients and suspects interviewed within 3 days of assignment increased from 45% to 79% since division of the interview and follow-up teams in 2003.
  • The percentage of time spent in the field providing direct contact investigation services increased from 52% to 67% since implementation of the dispatch system in September 2001.

—Reported by J. Marcos Longoria, BAS, Bureau Chief
Mary Lou Hernandez, BS, Administration Manager
Kathy Penrose RN, MPH, Chief Nurse
Houston TB Control Program

LTBI Program Implementation in a Substance Abuse Treatment Facility

Background:  To accelerate the decline of TB in the United States, TB programs will need to strengthen targeted TB testing and treatment of latent TB infection (LTBI) efforts in high-incidence communities with high-risk populations. Substance abusers are at increased risk of developing TB, and in many poor, urban communities they contribute substantially to the annual incidence of disease. Staff of the New Jersey Medical School National TB Center (NTBC) reviewed the files of 357 persons reported with TB from 1999 to 2001 in Essex County, New Jersey. Their review revealed that 26% were HIV infected and 26% had a history of substance abuse in the past year. Using an expanded history intake form to ask TB patients about previous encounters with the health care system1, NTBC learned that many newly reported TB patients had been clients of substance abuse treatment facilities (SATFs) prior to TB diagnosis. Subsequently, NTBC sent a Facility TB Profilequestionnaire to health care facilities serving clients at high risk of developing TB disease. The responding methadone SATFs in Essex County reported that they (1) served clients with high levels of LTBI (24%), HIV infection (18%), and injection drug use (31%); (2) had physician and nursing staff on site; (3) referred clients with documented LTBI to the local health department for follow-up; and (4) were aware of neither the follow-up TB evaluation results nor of whether treatment for LTBI had been initiated. Applying a mathematical model to the Facility TB Profile data, NTBC determined that a large number of TB cases could potentially be prevented through strengthened TB testing and treatment of LTBI in Essex County methadone facilities.

As a result, NTBC collaborated with the New Jersey State TB Program in a project to develop and implement procedures for carrying out onsite TB testing and treatment for LTBI in a pilot SATF. The goal is to increase the numbers of high-risk clients who start and remain adherent with treatment for LTBI. This pilot project is ongoing, with some valuable lessons learned even from start-up.

Methods/Needs Assessment: Using Facility TB Profile data as an entry or discussion point, NTBC and state TB program staff held follow-up discussions with staff of selected SATFs and local health departments to determine barriers to the initiation and completion of therapy for LTBI among SATF clients. Subsequently, a detailed needs assessment was conducted in one SATF whose medical director was willing to explore innovative approaches without additional funding. The needs assessment included  reviews of client characteristics, of the initial medical screening, and of current TB follow-up procedures and problems. Following this, a collaborative plan was developed to (1) increase the number of clients who started and completed treatment among those infected with M. tuberculosis, (2) address the barriers found in the needs assessment, (3) collect data to document results, and (4) serve as a template that could be adapted by other health facilities.

The needs assessment determined that this SATF serves about 200 clients who receive daily methadone; about 45% have been in the program for at least one year. Most clients were of minority race or ethnicity (70% black and 20% Hispanic), 60% were medically indigent, and another 25% were Medicaid eligible. About 45% were injection drug users (IDUs), 15%-20% had LTBI, 10% had HIV infection, and 20%-30% had hepatitis C.

Upon admission to the SATF, the medical screening that a client would normally receive included (1) a physical examination, (2) blood chemistry work-up (including liver function tests [LFTs], complete blood count, urine analysis, RPR, and drug screening), (3) HIV counseling and testing, and (4) a Mantoux tuberculin skin test (TST), unless the client could produce written documentation of a prior positive TST result.  We learned that although many clients give a verbal history of a prior positive TST result, few can produce written documentation; hence the TST is repeated.

A client with a positive TST result would then be referred to one of four health departments, depending on the client’s place of residence. The local health department would refer the client to a local radiologist or hospital for a chest radiograph or x-ray (CXR).  When the client returned, the health department chest clinic physician would evaluate the client for TB disease and for treatment of LTBI, including LFTs, because of the risk for liver disease. If started on treatment for LTBI, the client would return monthly to the health department to pick up medication and to be monitored for toxicity. All medication was dispensed to clients for self-administration.

Several problems were found with these procedures:

  • Clients giving a verbal history of a prior positive TST result (but no documentation) had to be retested.
  • It was time-consuming and confusing for clients to be referred to different facilities for follow-up CXR, medical evaluation, and treatment.
  • There were often delays in clients getting an appointment at the health department after the CXR was taken.
  • Health departments were not consistent about starting treatment for LTBI.
  • Health departments repeated the LFTs, even though they had already been done by the SATF.
  • Patients often failed to keep their monthly LTBI treatment appointments at the health department.
  • Clients were often not adherent with their self-administered medication.
  • Medical information (especially treatment results) was not shared with SATF staff.

Intervention: To address these problems, NTBC and state TB program staff collaborated with the SATF and local health department staff to develop revised procedures, in an attempt to achieve the following objectives:

  • 95% of new clients will have a documented TST result.
  • 90% of persons with LTBI will be placed on treatment, unless contraindicated.
  • 90% of persons started on treatment will complete therapy.

In the revised procedure, all clients with a documented positive TST result are given a voucher for a CXR at a single nearby radiology facility. The local health department pays for the CXR, even if the client resides outside the local  jurisdiction. The radiologist faxes the CXR reading to the SATF medical director, who then evaluates the client for TB or LTBI without delay. If the CXR is abnormal or if TB symptoms are present, the client is referred to the NTBC chest clinic for further evaluation and treatment of TB disease. If TB disease is ruled out, the SATF physician immediately starts treatment for LTBI, unless contraindicated. Since the LFTs were done on admission, they do not have to be repeated before therapy is initiated. At the same time that the client receives methadone, the SATF nurse directly observes daily LTBI treatment onsite and monitors the client for adverse reactions. Consequently, adherence to the medication is ensured and treatment efficacy is maximized. SATF staff are encouraged to call specific NTBC Chest Clinic staff with any questions or problems. At the completion of therapy, SATF staff give the client a wallet-sized LTBI card, which reflects the TST, CXR, and treatment regimen and completion, so these will not be repeated by other health care providers. SATF staff record TB risk-factor data, as well as TST, CXR, and treatment results, on a Tuberculosis Testing, Follow-Up, and Treatment of LTBI Form (LTBI Form). This form provides a single document on which to record clinical and program evaluation data.

Conclusion and Lessons Learned: Persons with TB and their contacts remain the highest priorities for health department TB programs. With limited resources, health department LTBI efforts should focus on building capacity in other health care entities serving high-risk clients. We have demonstrated that this can be done, even without additional resources. Keys to the success of this effort included the following:

  • The facility served clients with a high prevalence of LTBI and risk factors for developing TB disease (i.e., HIV and IDU).
  • The facility had a medical staff to manage clients with LTBI.
  • The facility medical director was committed to the success of the program.
  • A needs assessment was conducted to determine problems and barriers to success.
  • A written plan was developed by all parties involved in its implementation. The plan included objectives, procedures (with clear delineation of responsibilities), and a method of evaluation.
  • The facility and health department each assigned a lead individual to oversee the project.
  • A single nearby location was selected to which all clients with LTBI were referred for CXR. The local health department was willing to pay for all the CXRs, regardless of the clients’ areas of residence.
  • Methods were implemented to ensure adherence with LTBI treatment (i.e., DOT when client receives methadone).
  • A single form was used for collecting clinical and program evaluation data.

These procedures were fully implemented in April 2004. Following 6 months’ experience, the NTBC will evaluate the project with regard to carrying out the procedures and achieving the objectives. Subsequently, we will more fully document the planning and implementation process, develop a detailed report of the experience and lessons learned, and post the report on NTBC’s website.

— Submitted by Chris Hayden, MPH, Consultant, LTBI Activities, NJMS National TB Center
Karen Galanowsky, RN, Nurse Consultant, TB Program, NJ Dept of Health and Senior Services
Eileen Napolitano, Deputy Director, NJMS National Tuberculosis Center

References

1. NJMS National Tuberculosis Center. Identifying missed opportunities for preventing TB: a resource for TB programs. 2003. (www.umdnj.edu/ntbcweb/tbsplash.html)

2. NJMS National Tuberculosis Center. Facility TB Profile for Targeted TB Testing and Treatment of Latent TB Infection. 2004 (www.umdnj.edu/ntbcweb/tbsplash.html)

Missouri’s TB Awareness Fortnight

For more than 15 years, the State of Missouri has declared the last 2 weeks in March TB Awareness Fortnight in honor of World TB Day. In March 2004, a coalition of Missouri health care organizations again sponsored an education blitz throughout the state to heighten public awareness about TB and to provide TB education opportunities for health care professionals.

Research continues to show that repeated efforts to educate health care professionals regarding TB protocols are needed: Rao, Iademarco, Fraser, and Kollef (1999) found delays in initial suspicion of TB and in initiation of treatment in St. Louis–area hospitals, illustrating a need for improved education of physicians about the benefits of early initiation of TB therapy.

A 2002 survey that assessed training needs of Missouri public health nurses found two areas of concern: knowledge of TB control and treatment, and state policies and procedures. Another finding was that 78% of survey participants devoted less than 25% of their nursing time to TB. As Missouri’ s TB incidence continues to drop, public health nurses will have even less experience with TB.  The study’s recommendation was to continue educational experiences for health care professionals so as to maintain TB nurse consulting and case management expertise at the state and district level (Libbus, Phillips, and Benjakul, 2003).

A preventable-case analysis conducted by the Missouri Department of Health and Senior Services showed that Missouri had 68 preventable cases of active TB in 2002 and 73 cases in 2003, nearly half the total number of cases in the state. The majority of preventable cases (85%) involved a missed opportunity to screen patients with risk factors, such as previous contact to TB cases, foreign-born persons, or those having other medical or social risks. Designers of the study concluded that physicians in Missouri need to be continually reminded of risk factors for TB and to screen and prescribe treatment for those at risk (Phillips and Tomlinson, 2003).

With 131 reported TB cases in Missouri for 2003 (down only 5 cases from 136 in 2002), it is evident that TB rates are not declining fast enough. History shows us that being lax in treatment efforts can easily promote a resurgence of the disease. Amid decreases in federal, state, and local public health funding, new and exotic diseases getting disproportionate publicity, and the public’s belief that TB is a disease of the past, Missouri struggles to keep TB on the minds of health care providers. One of the state’s strategies is to hold educational programs during TB Awareness Fortnight. During this 2-week period, health care professionals are updated on the latest TB data and treatment strategies and encouraged to continue their perseverance in pursuit of Missouri’s 2010 TB elimination goal. For 2004, the American Lung Association of Missouri (ALAM) and the Missouri Department of Health and Senior Services (MDHSS) set a goal of organizing three TB seminars around the state with at least 30 participants per location. The objectives for seminar attendees were as follows:

  • Increase knowledge of the most up-to-date information regarding TB infection, treatment, directly observed therapy (DOT), prevention, and statistics.
  • Be aware of programs and services available through ALAM and MDHSS to assist in the diagnosis and treatment of TB.
  • Be able to list risk factors for TB transmission, and gain basic knowledge of TB disease and infection.
  • Be able to describe TB trends in the United States, and list cultural considerations when working with foreign-born persons.
  • Meet present participation goals for seminars, as evidenced by posttest score means above 90%.

The 2004 goal of three seminars with at least 30 participants each eventually grew to six seminars averaging audiences of more than 50 participants, led by distinguished presenters with statewide and national reputations. Seminar topics and speakers included the following:

Missouri Rehabilitation Center (MRC), Mt. Vernon, March 17:
TB Infection, Diana Fortune, RN, BSN

History of TB, Dr. Ronald Williams (Chief Medical Officer, Missouri Rehabilitation Center)

Association for Professionals in Infection Control and Epidemiology (APIC) Meeting, St. Louis, March 18:
TB Outbreak - City of St. Louis Homeless Shelters, Lynelle Phillips, RN, MPH (CDC Public Health Advisor, MDHSS), and Ted Misselbeck (CDC Public Health Advisor, St. Louis City Department of Public Health)

St. Louis County, March 19:
TB Infections & Treatment with Emphasis on the Foreign-born and Homeless, Lynelle Phillips, RN, MPH (CDC PHA, MDHSS)

Managing TB in Homeless Shelters; St. Louis Area Statistics, Ted Misselbeck, MA (CDC PHA, St. Louis City Department of Health)

How DHSS Can Help You, David Oeser (Health Program Representative, MDHSS)

TB Screening & Testing for Pre-Employment, Jenelle Leighton, RN (St. Louis County Department of Health)

TB Disease, Risk Factors, and New Guidelines, Thomas Bailey, MD, FACP (Associate Professor of Medicine, Washington University School of Medicine, Medical Director of TB Control, St. Louis County Department of Health)

ALAM Programs & Services, Vicki Tomko, RN, BS (ALAM)

Cape Girardeau, March 23:
TB in Missouri—Disease Treatment Recommendations, Philip LoBue, MD (Team Leader, Medical Consultation Team, CDC Division of TB Elimination)

TB Transmission, Lynelle Phillips, RN, MPH (CDC PHA, MDHSS)

DHSS Services/ALAM Services & Programs, David Oeser (Health Program Representative, MDHSS)

TB Disease and Risk Factors, Theodore Grieshop, MD (Internal Medicine and Infectious Disease)

Pre-Employment Testing and Screening, Lynn Tennison, RN (TB Control Nurse, Missouri Pulmonary Medicine and Infectious Diseases, University of Colorado School of Medicine)

Grand Rounds, St. Louis, March 25:
Diagnosis and Treatment of Multidrug-Resistant TB, Dr. Michael Iseman (Girard and Madeline Beno Chair in Mycobacterial Diseases; Chief, Clinical Mycobacteriology Service in the Mycobacterial Disease Division, National Jewish Medical Research Center; Professor of Pulmonary Medicine and Infectious Disease, University of Colorado School of Medicine)

Kansas City Metro Coalition, March 26:
Prevalence of Incidence Trends; Special Consideration in Diagnosis and Treatment, Dr. Ram Koppaka (CDC Division of Global Migration and Quarantine, Atlanta, Georgia)

Cultural Considerations in the Foreign-born, Lynelle Phillips, RN, MPH (CDC PHA, MDHSS)

Identifying and Treating LTBI/INH Side Effects, Garold O. Minns, MD (Professor of Medicine, Department of Internal Medicine, University of Kansas School of Medicine, Wichita; Advisory Physician to Sedgwick County Health Department TB Program)

Identifying Active TB and Common Mistakes in Diagnosis, Dennis Pyszczynski, MD,  FCCP (University of Missouri School of Medicine, Kansas City; Advisory Physician to the KC Metro TB Coalition)

A total of 519 health care providers who work or have an interest in TB attended the six sessions presented during TB Awareness Fortnight. Nurses with RN degrees or credentials of advanced practice represented more than 52% of the participants, the majority coming from the public health field; physicians made up another 35%. Microbiologists, social workers, epidemiologists, LPNs, and students filled out the remaining participant lists. Evaluations from the Fortnight conference revealed that participants felt each seminar reached its objectives of heightening TB awareness and providing needed educational opportunities for health care professionals. Speaker presentation ratings averaged 4.7 out of 5.0. Participant comments ranged from praises for the excellent speakers to appreciation for the relevancy of the information. Participants cited TB screening, testing, and transmission as the most useful topics covered in the seminars. Topics requested for future TB Awareness Fortnight seminars centered around administration and reading of PPD skin tests, especially questionable readings. Pretest assessments of general TB knowledge among 2004 Fortnight participants had shown a mean correct score of 64.2%; particularly satisfying to organizers was the average posttest score of 93.3%. As Missouri lowers its reported TB case numbers for yet another year, plans begin for next year’s TB Awareness Fortnight to again re-educate the state’s health care professionals, as Missouri strives toward meeting its goal of TB elimination by 2010.

—Reported by Marilyn Martin, LPN
BSN Student
Sinclair School of Nursing
University of Missouri-Columbia
and Lynelle Phillips, RN, MPH
CDC Public Health Advisor
Disease Investigation Unit
Missouri Department of Health and Senior Services

References

1. Libbus MK, Phillips L, and Wunvimul B. Assessment of tuberculosis knowledge and practice among Missouri public health nurses. (Poster.) American Public Health Association Annual Meeting, Philadelphia, PA, November 2002.

2. Phillips L and Tomlinson V. Results of the preventable-case analysis of Missouri’s 2002 TB cases: how prevalent are our missed opportunities to prevent TB? (Abstract.) National TB Controllers Workshop, Washington, DC, June 2003.

3. Rao V, Iademarco E, Fraser V, Kollef M. Delays in the suspicion and treatment of tuberculosis among hospitalized patients. Annals of Internal Medicine 1999; 130(5): 404-411.

The Clinical Management and Outcome of Nail Salon–Acquired Mycobacterium Fortuitum Skin Infections

The following is a summary of a recently published article: Winthrop KL, Albridge K, South D, et al. The clinical management and outcome of nail salon–acquired Mycobacterium fortuitum skin infection. Clinical Infectious Diseases 2004;38:38-44.

Mycobacterium fortuitum is one of several rapidly growing, nontuberculous mycobacteria (NTM) that are ubiquitous in soil and water habitats [1-5]. These mycobacteria usually cause cutaneous infections in association with trauma or clinical procedures, but are also known to cause pulmonary or disseminated disease [6]. Recently, we documented a large outbreak of community-acquired infections at a nail salon in California, where over 115 patrons contracted severe, lower-extremity M. fortuitum furunculosis (skin boils) [7]. The infections were traced to a series of contaminated whirlpool footbaths used in the salon as part of the pedicure procedure. Since recognition of this outbreak, additional outbreaks and similar sporadic cases of disease have been reported from around the country [7-9]. Because these whirlpool footbath–associated infections have only recently been described, their optimal clinical management is unclear. To better understand the clinical and diagnostic features of these infections, we observed the clinical course of a subset (n=62) of patients found during the outbreak investigation.

We asked physicians of patients to complete a standardized questionnaire that gathered clinical details from each patient; details included medical history, treatment regimen, duration of clinically evident infection, and disease outcome. No attempt was made to modify or influence treatment length or choice among treating physicians, since the study was observational in nature.

Patients receiving antibiotics against mycobacteria for at least 2 weeks were considered treated. Patients receiving no antibiotic treatment, treatment with antibiotics typically not known to have in-vitro activity against mycobacteria, or treatment with antibiotics with activity against mycobacteria for less than 2 weeks were considered untreated. Univariate and multivariate analyses were conducted to detect relationships between disease duration and variables that could potentially influence that duration.

Follow-up information was available for 61 of 62 patients; 60 (98%) were female. Patient ages ranged from 13 to 53 years. No persons were immunocompromised; three were pregnant at the time of infection. Patients had a median of two boils each (range 1-20). All lesions were below the knee in a distribution pattern corresponding to water exposure from the whirlpool footbaths used during the pedicure procedure. The clinical appearance and progression of the lesions in this outbreak were strikingly uniform. Lesions typically first appeared as small papules (similar to spider bites in appearance) and later progressed to large fluctuant boils, with subsequent ulceration and scarring.

Of the 61 patients, 48 received antibiotic therapy and 13 were untreated. No persons required surgical resection of lesions. All treated and untreated persons eventually had resolution of disease. One initially untreated, HIV-negative person was given antibiotic therapy after lymphatic dissemination of infection and the development of a large intra-thigh abscess that required drainage and was later found culture-positive for M. fortuitum.

Overall, the mean disease duration was 170 days (range 41–336 days). Persons treated with antibiotics were treated for a mean of 4 months (range 1–6). Clinicians most frequently used doxycycline or minocycline alone, or in combination with ciprofloxacin. Isolates were generally susceptible to amikacin, cefoxitin, ciprofloxacin, doxycycline, gentamicin, and minocycline, and resistant to sulfa, clarithromycin, and azithromycin. Persons with culture-negative disease and those with fewer lesions had significantly shorter disease durations. A final, multivariable linear regression model controlling for these and other effects indicated that antibiotic treatment was associated with shorter disease duration only when initiated early in the disease course (in first 9 weeks after disease onset) in persons with extensive disease (multiple boils).

In summary, this was the first study to document the natural history of treated and untreated M. fortuitum furunculosis. Since this initial California outbreak, it has become apparent that such nail salon–associated NTM infections are more widespread than previously known. Importantly, while surgical resection of lesions has been reported by other authors in the treatment of cutaneous infections caused by rapidly growing NTM [8,10], our experience indicated that oral antibiotic therapy alone may be sufficient in treating these nail salon–acquired M. fortuitum infections and that surgical resection is not necessary. Our data suggested that persons with more extensive disease (more than one boil) who initiate antibiotic therapy early in their disease course benefit most from therapy. Although untreated infection may be self-limited, we found that dissemination of these infections can occur in healthy individuals, and we recommend that persons who go untreated should be followed closely to assess for such complications.

—Reported by Kevin Winthrop, MD
California Dept of Health Services PHA


References

1. Collins CH, Grange JM, Yates MD. A review: mycobacteria in water. J Appl Bacteriol 1984;57:193-211.

2. Fischeder R, Schulze-Robbecke R, Weber A. Occurrence of mycobacteria in drinking water samples. Zentralbl Hyg Umwelmed 1991;192:154-158.

3. Covert TC, Rodgers MR, Reyes AL, Stelma Jr GN. Occurrence of nontuberculous mycobacteria in environmental samples. Appl Environ Microbiol 1999;65: 2492-2496.

4. Wolinsky E, Rynearson TK. Mycobacteria in soil and their relation to disease-associated strains. Am Rev Respir Dis 1968; 97:1032-1037.

5. Jones RJ, Jenkins DE. Mycobacteria isolated from soil. Can J Microbiol 1965; 11:127-133.

6.  Brown BA, Wallace RJ Jr. Infection due to nontuberculous mycobacteria. In: Mandell GL, Bennett JE, Dolan R, eds. Principles and practice of infectious disease. 5th ed. Philadelphia, PA: Churchill Livingstone; 2000: 2630-2636.

7.  Winthrop KL, Abrams M, Yakrus M, Schwartz I, Ely J, Gillies D, Vugia DJ. An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon. N Engl J Med 2002; 346:1366-1371.

8. Sniezak PJ, Graham BS, Busch HB, et al. Rapidly growing mycobacterium infections following pedicures. Arch Dermatol 2003; 139:629-634.

9. Arizona Department of Health Services. Mycobacterium fortuitum furunculosis associated with salon footbaths. Prevention Bulletin 2001;15:3.

10. Rappaport W, Dunington G, Norton L, Ladin D, Peterson E, Ballard J.  The surgical management of atypical mycobacterial soft-tissue infections. Surgery 1990;108:36-39.

Foreign-Nation TB Information Packets Prove Useful for New Hampshire Patients and Staff Members

The proportion of U.S. TB cases occurring in foreign-born persons has steadily increased since the mid-1980s. The State of New Hampshire (NH) has shown a similar trend. In 2003, 85% (13/15) of the state’s active cases and 77% (606/786) of latent TB infections occurred in foreign-born persons.

The NH TB program is responsible for the detection and proper treatment of persons with TB. The program is staffed by a Program Coordinator, a Medical Secretary, a Latent TB Infection Coordinator, and a part-time TB Controller, with seven Disease Control Public Health Nurses (PHNs) available on an as-needed basis. TB services in the two largest NH cities, Manchester and Nashua, are provided through contractual arrangements with these cities’ health departments. In the past, TB staff members have expressed frustration with their lack of knowledge about specific countries, cultures, and health beliefs, as well as with the lack of patient-friendly education materials that could help them address patient concerns in the foreign-born populations they serve.

A series of focus groups were conducted among staff to determine cultural and linguistic barriers to effective TB prevention and treatment. A consistent theme was that staff members wanted to know about the foreign countries from which their clients came. In particular, they wanted to better understand health care practices, family and social values, religious beliefs, and languages spoken. Staff reported that their patients’ limited or nonexistent English language skills made it difficult to determine the patients’ understanding about what causes TB, how it is transmitted, and how it is treated. TB staff also believed they needed to better understand patients’ perceptions of the burden of TB and its risk potential, in their home countries as well as in the United States. As a result of these findings, NH TB program staff developed TB informational packets about frequently seen countries of origin, with information for staff as well as for patients. When a new foreign-born patient is reported to the TB program, a TB information packet on his or her country is made available to the PHN who will be managing the case. Patient information is tailored to meet an individual patient’s needs and assumes the patient has some command of the English language. The PHN can select specific pieces to give to a patient during visits, recognizing that not all patients require the same level of education.

In general, each packet contains the following information:

For patients-

  • TB news articles reported in the home-country newspaper

For staff-

  • CDC annual surveillance data, Reported Tuberculosis in the United States
  • TB cases in foreign-born persons by country of origin
  • TB case rates in U.S.-born vs. foreign-born persons
  • Length of U.S. residence prior to TB diagnosis
  • Countries of birth for foreign-born persons reported with TB
    www.cdc.gov/nchstp/tb/surv/surv2002/default.htm  

The packets can be duplicated by other TB control programs, and packet content is limited only by a TB program staff’s imagination. Needed material can be compiled from numerous sources. New Hampshire’s packets include CDC’s yearly surveillance publication, Reported Tuberculosis in the United States. This provides statistical information displayed in charts and graphs that clearly demonstrate U.S. TB cases in foreign-born persons by country of origin, the prevalence of TB in foreign-born persons over time, and the length of residence in the United States prior to diagnosis. Our packets also include translated educational materials to enhance patient comprehension and understanding. The CDC’s Tuberculosis Education and Training Resource Guide as well as various state public health department web sites are excellent resources for translated brochures and pamphlets on subjects such as the Mantoux skin test, TB infection and disease, TB and HIV coinfection, and medications. Information on cultural traditions, religious beliefs, and health care practices that empower TB programs to work more effectively in cross-cultural situations may be found online.

Acclimating to a new country and to what may seem to be strange health care practices can be frightening to newly arrived immigrants. News from home is always welcome. Articles about TB, as reported in home-country newspapers, may be the key to convincing foreign-born persons with TB disease or M. tuberculosis infection of the gravity of their diagnosis and the need for starting and finishing treatment. A simple Google search (www.google.com), entering “newspapers in (foreign country of interest)” will provide links to a variety of newspapers published in a particular country. Most newspapers have a search key. Typing in the word “tuberculosis” will display current articles on TB activities. If a TB program has an interpreter on staff who can verify article content, then articles written in different languages may be used. Otherwise, many of the newspapers published in other countries are in English and can be useful for those patients who do speak English.

As the proportion of TB in foreign-born persons increases, TB program staff in the United States are increasingly challenged to work with unfamiliar populations. Having readily available culturally-oriented TB education packets helps staff understand their patients and equips staff with the information they need to convince foreign-born patients about the seriousness of TB and to encourage them to start and complete treatment.

Submitted by Dianne Donovan
 New Hampshire TB Program

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

Please send comments/suggestions/requests to: hsttbwebteam@cdc.gov, or to
CDC/Division of Tuberculosis Elimination
Communications, Education, and Behavioral Studies Branch
1600 Clifton Rd., NE - Mailstop E-10, Atlanta, GA 30333