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TB Notes 2, 2003

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS

Significant Program and Outcome Improvements in the Miami-Dade County TB Control Program

In 1999, the Florida Bureau of TB and Refugee Health (BTBRH) invited a team from CDC’s Division of TB Elimination to conduct a program review of the Miami-Dade County TB Control Program. The main purposes of the review were to document areas in need of improvement, make recommendations for change, and influence key decision-makers that investment and changes in the TB program were needed. The review identified a number of areas of concern in all three high-priority activity areas: surveillance and completion of treatment for active TB cases, contact investigations, and targeted testing and treatment for latent TB infection (LTBI). Based on this review and a quality improvement review conducted by BTBRH in 2000, recommendations for improvement were made and an action plan with timeline was developed.

The Miami-Dade County TB Control Program has been reinvigorated over the past 2 years by following the recommendations and action steps outlined in the 1999 program review. Numerous personnel changes have been made; the nurse case management system has been fully implemented; additional office and clinic space have been acquired, which has had a positive effect on both staff morale and infection control; data systems have been developed; forms and record-keeping procedures have been streamlined and improved; clinical and operational procedures have been developed and implemented; and an increased emphasis has been placed on data quality and analysis. Another major change that impacted all three high-priority activity areas was the major reduction in low-risk tuberculin skin testing and treatment for LTBI. Screening for TB infection is now done by the immunization program using a risk assessment questionnaire, and only high-risk LTBI clients (e.g., contacts, HIV infected) are referred to the TB program for treatment and case management.

In addition, successful efforts have been made in securing additional local resources (both staff and funding), collaborating with the local lung association, and improving relationships and collaborating with the area hospitals and local jails. Perhaps most important has been the establishment of effective relationships between key program staff and the local health department administration staff. These relationships have significantly improved the credibility of the TB program and have led to additional local resources and support that had been absent for years.

Below is a chart comparing the key TB program indicators from the quality improvement review conducted in 2000 versus the follow-up review conducted in 2002. The chart shows Miami-Dade County results compared to the state of Florida as a whole and state goals. Active TB Cases

Indicator
Miami-Dade County
1998/99*
Miami-Dade County
2000/01**
State 2002
State Goal
Percent of TB cases completing a recommended course of therapy (calendar year 2000)
81% 90% 85% 90%
Percent of TB cases receiving DOT (calendar year 2000)
68% 82% 77% 80%
Percent of TB cases placed on currently recommended treatment regimen (calendar year 2001)
83% 80% 75% 100%
Percent of TB cases with documented HIV status (calendar year 2001)
83% 84% 71% 100%


* Program review conducted in calendar year 2000
** Program review conducted in calendar year 2002

Factors contributing to the improvements in the Miami-Dade Co. TB control program
The improvement of any program is not accomplished by one person or one strategy alone, but rather by many people who contribute many ideas and demonstrate an openness to change.

As was stated earlier in this article, the journey to success began several years ago when personnel changes occurred. The assignment of a new TB Director in July 2000, followed by the assignment of a Public Health Advisor and the recruitment and placement of a clinical director for the TB Program, were significant additions to the TB program and served to strengthen the managerial team that was in place. These assignments and a program reorganization improved communications throughout the TB program and the health department. Staff members soon felt comfortable with the new organization table, which clearly identified the person to consult when problems and issues came up. In addition, managers became more responsive to staff needs.

One of the early action steps that the management team undertook was to develop, revise, and implement TB program policies and procedures. Each policy and procedure was reviewed in its developmental stage with the key staff from the TB program. Prior to the implementation of any policy and procedure, a training session took place with all staff members so that each person understood what was required. Afterwards, each staff member was given a manual of all the program policies and procedures for reference.

Concurrently, the managerial staff was working on improving other administrative elements of its program. Personnel activities included identifying vacant positions and filling them with the best-qualified applicants that the program was able to recruit. Fiscal activities included improving the capability of the program to generate additional billings from Medicare and Medicaid, thereby increasing the revenue for the Miami-Dade County Health Department (MDCHD). This also provided the program with additional resources in its general revenue budget for TB activities.

Evaluation
In early 2001, the Miami-Dade County TB Control Program started to plan a strategy for strengthening its program evaluation component. The senior staff of the TB program held several meetings regarding the need to identify program activities that would enable the program to evaluate specific activities around its cases, suspects, and contacts. These activities included the following program areas: surveillance, case management, workload, refugees / immigrants, and contacts. Additionally, meetings were held to include other key program staff such as nurse case managers, surveillance analysts, health service representative supervisors, and data analysts.

During the next several months many reports were developed to assist the program in its evaluation process. All of these reports are completed and reviewed with key TB staff every month. During these meetings, staff make analyses, corrections, and updates. Each member of the managerial and supervisory staff has an opportunity to discuss each of the reports. Currently there are a total of 70 reports that are reviewed. The review session takes approximately 3 hours to complete. All involved feel that this is an extremely valuable session that provides timely input on the direction in which the program is headed. Several examples of these reports are as follows:

  • TB cases and suspects by medical facility (monthly and annually)
  • TB cases and suspects by zip codes
  • Key indicators - lists the TB cases caused by drug-resistant strains (MDR and monoresistant), TB among children (by age group), and HIV status, which reflects positive, negative, refused, not offered, test done but results unknown, and unknown
  • Basis of diagnosis - looks at culture positive, clinical diagnosis, and provider diagnosis
  • TB cases by country of origin - assists the program in identifying a patient profile

The CDC Aggregate Reports for Program Evaluation (ARPEs) are also updated and reviewed on a monthly basis. This process provides timely feedback into the evaluation of the program’s contact investigations. Several reports look at the case assignments by local region, by nurse case manager assignment, and by surveillance analyst by month and annual total. Other reports look at the number of cases open longer than 9 months and the number of cases that were closed by case manager per month. A Heath Service Representative Team report reflects the number of monthly assignments such as DOT, source investigations, interviews, and other types of field assignments by worker. These reports provide a very good picture of the workload and assist in making future staffing assignments.

The use of two data programs and of several clinic logs captures data for these reports. The two data systems are the Access-based TB Management Information System (TBMIS) developed by Miami-Dade County TB staff and the statewide Health Clinic Management System (HCMS). It should be noted that these reports are continuously reviewed and revised in order to meet the needs of the program. This will continue in order to meet the challenges of TB control in Miami-Dade County.

—Submitted by Harry Stern, Public Health Advisor and
TB Program Operations Management
Miami-Dade TB Control Program, and
Heather Duncan, Senior Public Health Advisor
Florida Bureau of TB and Refugee Health

Successful Tuberculosis Continuing Education Retreats Sponsored by the Virginia Division of Tuberculosis Control

In the fall of 2002, the Division of Tuberculosis Control (DTC) of Virginia sponsored two highly successful training retreats for public health outreach workers and nurses working in TB control. Both retreats were held at the rustic Massanetta Springs Conference Center near Harrisonburg, Virginia. The goal of both retreats was to enable the participants to become better able to facilitate the successful detection, treatment, and cure of persons with TB disease and their infected contacts. The conferences provided not only an opportunity for outreach workers and nurses to network with their colleagues, but also an orientation to TB control for newly hired outreach workers and nurses, and an update for those who have been working in the field for some time.

TB Outreach Worker Retreat

Image of three people enjoying lunch
Twenty-five TB outreach workers from across the Commonwealth of Virginia attended the retreat in September 2002. The previous outreach worker training was held in 1998.

Image of two Outreach workers with instructor
Two outreach workers with an instructor from
the Harrisonburg Police Department

The retreat curriculum included topics such as epidemiology of TB, a TB skin testing practicum, infection control, contact investigation, directly observed therapy (practical and legal issues), safety in the field, and documentation. The faculty included staff from DTC, the American Lung Association of Virginia, the Central Shenandoah Health District of Virginia, the City of Harrisonburg (VA) Police Department, and the Washington, DC, TB Control Program.

The outreach workers highly valued the didactic, practical, and professional development components of the program and commented as such in the program and course evaluations. Of the 23 outreach workers who completed the program evaluation form, the majority (78.3%) reported satisfaction with the retreat, all reported that the retreat provided information useful to their jobs, and 95.7% reported obtaining new skills as a result of their participation.

Image: Tuberculosis in Retreat. Approaching the 21st Century. October 28-31, 2002. Massanetta Springs, Harrisonburg, Virginia

In October 2002, 52 nurses working in TB control attended the TB nurse retreat, “TB in Retreat: Approaching the 5th Century,” which was the very first of its kind in Virginia. (Virginia has fought the spread of tuberculosis since the English colonists landed on its shores in 1607, and TB possibly took the life of one of its most famous early residents, Pocahontas). Many of the nurses, like the outreach workers, sincerely valued this opportunity to network with their colleagues. The nurses represented diverse professional experiences, years of employment in health care and/or the health department, and knowledge and skills in TB control.

Group photo of the nurses who attended the TB nurse retreat
Group photo of the nurses who attended the TB nurse retreat

DTC implemented a comprehensive didactic and hands-on TB nurse curriculum that included topics such as epidemiology of TB, diagnosis and management of TB infection and disease, the new immigrant and TB, program evaluation, contact investigation, case management, and the Virginia TB control laws. In addition to the didactic component of the retreat, the nurses were divided into seven work groups to allow broad input on DTC activities; these work groups indeed yielded products useful to TB control efforts statewide. (Two groups developed process and outcome evaluation indicators, one group reviewed the Virginia Standards of Care for TB patients, another group reviewed patient education materials, and three groups developed new patient records for TB control.) In fact, the TB educational materials reviewed by one of these work groups are now complete and posted on the DTC Web site http://www.vdh.state.va.us/epi/tb/patinfo.htm.

Image: Four TB nurses with Dr. John Marr (Director of the Office of Epidemiology)
Four TB nurses with Dr. John Marr (center), Director of the Office of Epidemiology

Instructors at the TB nurse retreat included Karen Connelly, RN, MSN, Virginia Director of Public Health Nursing, who delivered the keynote address; John Marr, MD, MPH, Director of the Office of Epidemiology; Karen Galanowsky, RN, MPH, Nurse Consultant, New Jersey State Department of Health and Senior Services; Margaret Tipple, MD, Director of the Washington, DC, TB Control program; and staff members from DTC, the Virginia Refugee Health Program, the American Lung Association of Virginia, and Virginia local health departments.

The TB nurses reported overwhelming satisfaction with the retreat content and activities. Of the 48 nurses who completed the retreat evaluation, 93.8% reported satisfaction with the retreat, 97.9% stated the retreat provided information useful to their jobs, and 91.7% reported obtaining new skills as a result of their retreat participation. As one nurse commented, the aspects of the retreat most useful to her were “meeting and talking with other nurses and VDH (Virginia Department of Health) staff and other speakers, information about labs…and contact (investigations).” Several participants expressed that the retreat was “wonderful, excellent…” and that they would like DTC to “do it again.”

Participant feedback from the outreach worker and nurse retreats indicates the need for and potential success of future training programs for these two audiences. The Division of TB Control remains strongly committed to continually training its physicians, nurses, and outreach workers to ensure that public health professionals remain prepared to address the changing epidemiology of TB in the Commonwealth of Virginia.

—Reported by Vipra Ghimire, MPH, CHES
Health Education Coordinator
Division of TB Control
Virginia Department of Health

A High TB Case-Fatality Rate in the Setting of Effective TB Control:
Implications for Acceptable Treatment Success Rates

The following is abstracted from a previously published article (Int J Tuberc Lung Dis 2002;6:1114-7).

Directly observed therapy (DOT) has been implemented in Baltimore for over 20 years, resulting in declining case rates, high sputum conversion rates, and high rates of treatment completion, all consistent with effective TB control. However, we noted upon standard programmatic review that the TB case-fatality rate was high, so further investigation was undertaken. We conducted a retrospective cohort study to assess the case-fatality rate among smear-positive pulmonary TB patients in Baltimore between January 1993 and June 1998. During this time period, the TB incidence rate was less than 17/100,000 population, rates of multidrug-resistant TB were less than 1%, and 99% of patients received DOT. Of the 174 study patients, 42 (24%) died on treatment. Patients who died were older (mean age: 62 vs. 47 years; P<0.001) and more likely to have underlying medical conditions. In multivariate analyses, older age, diabetes mellitus, and renal failure were independently associated with an increased risk of death.

In contrast, in 1998, the global case-fatality rate of newly-diagnosed smear-positive pulmonary TB among persons on treatment was substantially lower at 3.8%.1 Although age and comorbid illness data are not available for global case-fatality rates, a study of 5,905 Peruvian patients treated with DOT revealed a case-fatality rate of 2.2%; the average age of persons in the cohort was 27 years, suggesting that the low case-fatality rate could be related to the younger patient population.2 A study by the British Medical Research Council found a 15% fatality rate among patients from England and Wales, compared to 2% among patients from the Indian subcontinent; this difference was attributed in part to the older age of the patients from England and Wales.3

The high case-fatality rate in Baltimore in the setting of low tuberculosis incidence, compared to the global incidence rate of 141 per 100,000 population,1 suggests that as incidence rates decline, TB will become concentrated in older persons with chronic debilitating conditions, which will be associated with higher case-fatality rates.

These results have implications for the World Health Organization (WHO) goal of successfully treating at least 85% of detected cases.1 Treatment success is defined by WHO as the sum of cases that were either cured or completed treatment (two mutually exclusive categories).1 The rate of treatment success is inversely related to the case-fatality rate, and in areas where TB patients have high median age and frequency of comorbid illness, either the formula for treatment success needs to be modified, or the goals for treatment success should be lowered. However, if the latter approach is taken, it must be clear that other indicators of program effectiveness must be present, such as high rates of treatment adherence and sputum conversion, and low rates of TB incidence and drug resistance.

—Submitted by Timothy R. Sterling, MD
Medical Director, Baltimore City Health Department Eastern Chest Clinic
Center for Tuberculosis Research
Johns Hopkins University School of Medicine

References

1. World Health Organization. Global Tuberculosis Control: WHO Report, 2001 (Publication no. WHO/TB/2001.287). Geneva, Switzerland: World Health Organization; 2001.
2. Accinelli RA, Hernandez K, Alvarez LM, Pantoja C, Vidal L, Ibanez R, et al. Risk factors for failing, dying, and defaulting among TB patients treated with DOTS. Am J Resp Crit Care Med 2002; 165: A438.
3. Humphries MJ, Byfield SP, Darbyshire JH, Davies PDO, Nunn AJ, Citron KM et al. Deaths occurring in newly notified patients with pulmonary tuberculosis in England and Wales. Br J Dis Chest 1984; 78:149-158.

 


Released October 2008
Centers for Disease Control and Prevention
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