TB Notes 1, 2005
No. 1, 2005
Highlights from State and Local Programs
Immediate Cost Impact of Extended Treatment for
Patients at High Risk for Relapse of TB in North Carolina
Short-course (6 month) treatment regimens, where indicated, are
preferred and are highly effective for cure of TB. However, within
the population of patients for whom a short-course regimen is indicated,
there are those patients who have risk factors for treatment failure
or relapse. The latest TB treatment guidelines include a recommendation
to prolong the treatment for patients at high risk of treatment
failure or relapse. These recommendations were based in part on
US Public Health Service Study 22 of the TB Trials Consortium. Study
22 suggested that patients who had cavitation on initial chest radiograph,
plus positive sputum culture after 8 weeks of treatment, were at
higher risk for treatment failure and relapse. Pursuant to that
observation, the current recommendation is to extend treatment from
6 to 9 months for patients who have these two risk factors. We evaluated
past TB cases in North Carolina to determine how many would have
met the new criteria for extended therapy and their length of treatment,
and estimated the immediate cost of extending treatment for these
Methods: The cohort included reported cases of TB from 1993
to 2002, inclusive. Patients who had positive sputum cultures and
who had a documented culture conversion were included (n=2173).
We limited our cost considerations to the cost of medication for
the added length of the regimen and the time factor for a public
health worker to perform biweekly directly observed therapy (DOT)
using isoniazid (INH) at $2.80/month and rifampin (RIF) at $14.58/month.
For personnel costs, we determined that $30,000 was an approximate
average annual salary for those providing DOT in North Carolina,
resulting in a computed hourly rate of $15.63. We estimated 3 hours
per patient to perform DOT (1 hour to travel each direction to visit
the patient and 1 hour to give DOT and complete records). Based
on those two factors, we estimated the cost at $392.50 for 1 month
of treatment for one additional TB patient to receive the extended
regimen. We assumed that TB patients with risk factors for treatment
failure and relapse were evenly distributed for each year.
Results: Of the 2,173 patients who had documented culture
conversion, 469 met the high-risk definition (21.6%) of having a
cavitary lung lesion on chest radiograph plus delayed sputum conversion;
only 119 (25.4%) received 9 months or more of treatment. Of the
remaining 350 patients, 104 received 6 months of therapy (22.2%)
and 246 (52.5%) received between 6 and 9 months of therapy. Thus,
6 hrs/wk of DOT for 12 additional weeks per patient, plus the cost
of additional INH and RIF, amounts to $1,177.50/patient. Assuming
35 patients per year would need 3 months’ additional treatment to
comply with the new TB treatment guidelines, North Carolina TB Program
costs are expected to increase approximately $41,212.50/year.
Discussion: The cost to treat patients who have active TB
is generally borne by the public health system. In North Carolina,
the cost of medication for TB patients is funded by general revenue
funds allocated by the state legislature. Hence, the rise in costs
for treating this subset of TB patients presents a significant challenge
to the North Carolina TB Program when viewed along with budget cuts
in three major categories of state funding. Funding for TB medication
has been reduced three times within the past 4 years. General revenue
funds for TB aid to counties have been reduced, and funding for
TB medical services for the counties has also been reduced. Like
many other states, North Carolina is a “home rule” state (home rule
is a delegation of specific types of power from the state to its
subunits of government, including counties, municipalities, towns
or townships, or villages). Therefore, responsibility for TB control
rests with the county or regional health district. The North Carolina
TB Program works with these jurisdictions, providing limited funding
and program guidance, to achieve state and national TB program objectives.
The cost of extending treatment for those having risk factors for
relapse is an issue with which public health officials have to contend,
but it is balanced by the costs incurred when a patient relapses,
resulting in an additional 6 full months of therapy. TB Controllers
will need to provide the educational leadership to help their state
public health officials understand the longer-term benefits that
we hope will accrue with this approach.
As to the limitations of this study, for those patients receiving
6 to 9 months of therapy, we do not have a way of knowing exactly
how many doses they received.
Conclusion: Proactive intensification of TB treatment
for high-risk individuals will result in additional program costs.
A more formalized cost-benefit analysis is planned to consider the
costs of re-treatment, including contact investigations and possible
secondary cases, to better delineate the public health benefit of
the new treatment recommendations.
—Submitted by Carol D. Hamilton, MD, Jimmy Keller,
Ashley Ewing, BS, Dee Foster, RN, Elizabeth Zeringue, RN,
Myra Allen, RN, and Julie Luffman, RN
North Carolina TB Program
New and Old Ideas Blend Well at Harbor Light Shelter
In spring 2003, the St. Louis City Health Department TB control
program noted an increase in TB cases among the city’s homeless,
with a possible link to a shelter called Harbor Light. Owned and
managed by the Salvation Army, Harbor Light is the city’s largest
homeless shelter. The state and city TB staff had been noting this
trend through program assessments and case reviews. The city’s TB
nurse case manager requested a thorough investigation by the state
health department, which was completed on April 29, 2003. The goal
of the investigation was to confirm or rule out Harbor Light as
a significant site of transmission and to develop new strategies
for curbing this outbreak.
The investigation revealed that since February 2001, 16 homeless
persons with active TB had been diagnosed and epidemiologically
linked to stays at Harbor Light. Fourteen had AFB-positive smears
at time of diagnosis; two were HIV infected. Two died, one shortly
after diagnosis and one while hospitalized at the Missouri Rehabilitation
Center (Missouri’s inpatient TB facility). Isolates were available
for 13, allowing for confirmation of epidemiological links (identified
by chart review and shelter log records) through genotyping.
From analysis, two distinct outbreaks emerged. In the first, four
patients had epidemiological links to each other and to the shelter
and also had the same genotype pattern. These cases were diagnosed
between June 2001 and January 2002. In the second, nine others were
linked, having another distinct and matching genotype pattern, and
became the focus of the investigation. The first two cases in this
group were diagnosed in July 2001. One of these case patients was
found critically ill at the shelter and died shortly after hospitalization.
Both were deemed to have been highly infectious while staying at
the shelter between April and July 2001. Eight cases were linked
back to this exposure. Four out of five shelter workers also converted
their skin tests at this time. Two cases did not have culture isolates
available, but were also epidemiologically linked to this second
group. A second critical exposure period existed between January
and March 2003, when the second patient who died had stayed in the
shelter, and two additional infectious cases were diagnosed.
Eleven of these surviving patients were completely treated. One
reactivated and was treated twice; two were lost to follow-up. Compared
with the other TB patients in Missouri, patients in this outbreak
were four times more likely to be HIV infected, eight times more
likely to abuse alcohol, nine times more likely to use noninjected
drugs, and 25 times more likely to inject drugs.
The outbreak persisted and reached 19 cases by August 2003, despite
the city health department staff’s excellent efforts in contact
follow-up, targeted testing, and symptom reviews. With the prospect
of another cold Missouri winter and the likelihood that homeless
persons would crowd this large shelter for another season, several
unconventional recommendations were considered. Many of these included
primary prevention activities, such as environmental controls at
the shelter, to reduce the incidence of TB transmission at this
high-risk congregate setting. The following discussion will explain
what was done and why.
Managing TB in Homeless Shelters in the St. Louis Area
During May through June 2003, 250 clients, staff, and frequent
visitors (e.g., ministers) were given a TB skin test at the Harbor
Light shelter in response to two cases and a death that were reported
during the previous 2 months. A few positive skin tests were reported
and evaluated, but no active TB cases were identified.
In August 2003, the City of St. Louis Health Department TB control
program began to use a homeless shelter client tracking system called
ROSIE (Regional Online Service Information Exchange). This tracking
system keeps a current record of all movement of homeless clients
throughout the city’s shelter network. The value of this system
is that it allows the TB Control Program to identify contacts who
may have moved from one city shelter to another and be able to find,
evaluate, and provide treatment as necessary. Access to this system
resulted in identifying six homeless contacts from previous cases.
In September 2003, a TB outbreak containment meeting was held at
the Harbor Light Shelter and was attended by representatives of
the City of St. Louis Health Department TB Control Program; CDC’s
DTBE, including Dr. Paul Jensen, who has extensive engineering experience
working in shelters and prisons in countries such as Russia and
South Africa; CDC’s National Institute for Occupational Safety and
Health (NIOSH); the Missouri State Department of Health and Senior
Services (DHSS); the Salvation Army shelter management staff; and
the Salvation Army’s new facilities management company, Lenzy Hayes.
As a result of that meeting, a strategy was developed to conduct
a comprehensive evaluation of the entire heating, air conditioning,
and ventilation (HVAC) system in the shelter. Their recommendations
included cleaning and retrofitting all 23 air handlers, upgrading
the filters inside the air handlers to higher-rated, less porous
filters, and installing TB-killing ultraviolet germicidal irradiation
(UVGI) lights as funds were available.
In October 2003, funds were secured to conduct mobile, on-site
radiographs at the Harbor Light Shelter. This provided a baseline
evaluation of 250 clients, staff, and frequent visitors prior to
the implementation of the suggested engineering improvements. There
was a potential concern regarding how to proceed if large numbers
of clients were found with abnormal radiograph results. To address
this concern, in October the Florida Department of Health Laboratory
in Jacksonville agreed to a memorandum of understanding (MOU) with
the Missouri Department of Health and Senior Services and the City
of St. Louis Health Department TB Control Program to provide the
rapid, 1-day nucleic acid amplification (NAA) Mycobacteria Tuberculin
Direct (MTD) Test for any homeless clients. Eight clients were found
to have abnormal radiographs and referred to the TB control program
for further evaluation. All eight were determined to be negative
for TB disease. Abnormal results varied from old, healed gunshot
wounds to a referral for possible carcinoma.
On November 26, 2003, the state health department issued a Public
Health Advisory. The Advisory alerted the St. Louis–area medical
community to the outbreak, and recommended that providers 1) “think
TB” for homeless shelter users and workers with respiratory illness,
2) screen for TB disease risk factors and symptoms in area emergency
departments, 3) send all sputum specimens to the state TB lab, and
4) report all TB suspects within 24 hours. The state health department
issued an epi-X report shortly following the advisory, in an effort
to alert neighboring states. (Epi-X, or the Epidemic Information
Exchange, is a secure, moderated means of communication between
public health officials for reporting and discussing outbreaks and
other acute health events.)
During November-December 2003, the Salvation Army paid to have
the 23 air handlers, including two roof units, completely cleaned,
scrubbed, and retrofitted. This investment by the Salvation Army
division headquarters resulted in thorough air quality improvement
(versus a band-aid measure). The visiting nurses who see clients
a few hours a day reported seeing a significant reduction in complaints
for respiratory ailments (such as coughs, colds, and allergies).
During this 2-month period of time, the air filters were replaced
with higher-rated air filters a couple of times to capture residual
particles from the cleaning effort.
In April 2004, funds in the amount of $25,000 were secured through
the State of Missouri Department of Health and Senior Services to
purchase TB-killing ultraviolet lights. Lumalier Incorporated, located
in Memphis, Tennessee, was awarded the contract. Mr. Charley Dunn,
Chairman, has worked on a number of shelter and jail projects and
as a consultant with CDC on projects throughout the United
States, Eastern Europe, Africa, and South America.
A number of UVGI lights were purchased based upon the evaluation
of Dr. Paul Jensen (CDC/DTBE), Drs. Chris Coffey and Steve Martin
(CDC/NIOSH), and Mr. Charley Dunn. This type of UVGI lighting was
designed to provide the best type of application based on the size
of the room, the amount of airflow, and the client capacity.
In July 2004, a nine-member engineering team from CDC/NIOSH conducted
a week-long tracer gas study in the Harbor Light Shelter Annex unit
(the area where all TB cases were identified) in order to determine
the air flow patterns and the volume of air circulated and to measure
for static air locations. This is important in that some homeless
clients are permitted to remain in the shelter sleeping quarters
during the day because of illness or injury.
A member of the NIOSH team takes an air sample
in Harbor Light shelter (from the St. Louis Post-Dispatch,
July 15, 2004).
In July 2004, a second phase of UVGI light installation ($10,000)
was completed. Mr. Charley Dunn of Lumalier Incorporated designed
a new type of air circulation/UVGI light combination called a “Silent
Air Mover” (referred to as SAM). This new light helps to continually
circulate the air throughout the room (remains on 24 hours a day)
and into the attached UVGI TB-killing chamber.
Photo shows SAM units in bunk area.
In October 2004, another team from NIOSH returned to conduct a
tracer gas study in the Harbor Light Shelter main building. This
is where clients enrolled in long-term drug or work programs reside
and is also where the staff offices as well as the dining and meeting
rooms are located.
Other intervention measures
The installation of large, unusual lighting devices and of large
tanks releasing tracer gas, along with the other uncommon activities
being conducted in the shelter, were deemed potentially intimidating
to the residents, and we felt that the perceptions of the residents
and staff needed to be considered. Ongoing in-service meetings were
scheduled with clients to reassure them that the “strangers” in
their facility were there to improve the air quality and make it
safer. Educational TB literature, handouts, and posters were provided
and time was allotted for questions and answers. The fact that staff
and residents noted the improved air quality in their shelter helped
foster a positive reception.
Several key lessons were learned during the last year and a half
of this project.
- Persevere; it is important to keep sight of the goals of the
project strategy despite obstacles. Throughout this project there
were a number of delays. Some were expected, such as scheduling
members of the team so they could be at the shelter at the same
time. Other obstacles were more difficult to overcome. Obtaining
funding for the UVGI lights and getting approval through the various
levels of government and shelter management was time consuming,
but worth the effort.
- Provide education and outreach. The shelter working conditions
during the project were made easy in part by the ongoing information
sessions held with clients and staff. Once they realized that
different people would be coming into their facility to make improvements,
everyone was helpful.
- “Toot your own horn.” Members of the press, the television
and radio stations, and the St. Louis Science Center were invited
to two different media events held at the shelter. The TB Program,
CDC, the State of Missouri Health Department, and the Salvation
Army all received positive press (St. Louis Post-Dispatch)
and TV and radio network coverage (Fox, CBS, NBC, and Media Network
Radio). We coordinated the events through the St. Louis City Health
Department and Salvation Army public relations offices. The media
will come if there is news.
- Promote communication and teamwork. Keeping all parties informed
of even small accomplishments or obstacles helped to forge a team
atmosphere among the 11 different agencies and vendors. By doing
this, everyone came on-site more prepared and were able to order,
manufacture, or bring with them needed supplies or equipment.
There have been no TB cases reported from the shelters since August
2003. As we proceeded with installation of the engineering improvements
throughout the winter and spring, we remained focused on identifying
any other measures that we could implement. Although some of the
homeless clients only stay at the shelter for a few days, on any
given day a client with active TB could enter the shelter and put
the resident population at risk. Engineering improvements are one
part of the overall TB prevention strategy; TB education is another
important ongoing prevention element. Staff and visiting nurses
are provided with signs-and-symptoms checklists, and posters are
placed in sleeping quarters and shower hallways.
The feasibility of implementing some or all of the TB strategy
of this project within other homeless shelter networks in other
parts of the nation is greatly dependent upon the size of the shelters,
commitment of the participating shelter management, and availability
and negotiation posture of the parties involved. Above all, remaining
persistent and forging sincere partnerships were the keys to the
success of this project.
—Submitted by Ted Misselbeck
PHA, City of St. Louis Health Department
and Lynelle Phillips, RN, MPH
PHA, Missouri Department of Health and Senior Services
2004 Northeast TB Controllers’ Conference
The 2004 Northeast TB Controllers’ Conference was hosted by the
Rhode Island TB Program. Members of the Northeast TB Training Consortium,
including the Massachusetts Division of TB Prevention and Control
and the New Jersey Medical School National Tuberculosis Center,
played active roles in planning and sponsoring the conference. The
conference was held on October 18-19, 2004, at the Hyatt Regency
Hotel in Newport, RI. There were over 120 participants consisting
of TB control officers, nurses, physicians, managers, epidemiologists,
laboratorians, and public health professionals from states in the
Northeast TB region, as well as from Florida, Georgia,
and Hawaii. The conference addressed many identified needs and interests
of TB programs such as advocacy, regional approaches to TB control,
clinical case presentations, outbreak investigations, and partnerships
with TB laboratories. The University of Medicine and Dentistry of
New Jersey Center for Continuing and Outreach Education granted
approval for the following types of continuing education credits:
continuing medical education credits (CME), continuing education
units (CEU), and nursing contact hours.
A separate meeting for TB controllers addressed advocacy in state
government, strategies for achieving state initiatives in the face
of changes in funding, a report on training and education needs
in the Northeast, and a discussion on the purpose and format of
the annual meeting.
The 2005 Northeast TB Controllers’ Meeting will be hosted by the
New York State TB Control Program.
—Reported by Anita Khilall, BS, and
DJ Mccabe, RN, MSN
NJMS National Tuberculosis Center
Education and Training Department