TB Notes Newsletter
No. 2, 2006
HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS
Suffolk County (New York) Targeted
Tuberculosis Testing and Treatment Program Among the Foreign-born,
Introduction: Suffolk County, New York, occupies the eastern
two thirds of Long Island,
New York. The county covers an area of 912
square miles consisting of rural, suburban, and small urban areas.
The 2000 US Census estimates the population to be 1,468,000 (84.6%
white, 6.9% black, 10.5% Hispanic or Latino, and 11.2% foreign-born
persons). High concentrations of foreign-born persons exist throughout
In the 3-year period covering 2002 through 2004, approximately
75% of the county’s reported tuberculosis (TB) cases occurred in
foreign-born persons from high TB prevalence countries. The majority
of these cases were in persons who originated from Latin America
and South America. The Targeted Testing and
Treatment Program (TTP) was developed to address this epidemiologic
TTP Description: The initial task of the TTP team was to identify
community leaders of the social networks (e.g., churches, adult
education centers, English-as-a-second-language [ESL] classes, food
and clothing pantries, and health care organizations) that serve
our target population of foreign-born persons. These community network
leaders were educated about TB and the TTP and how the TTP could
benefit the members of their community. If the community leaders
thought the TTP would benefit their groups, they invited TTP staff
to give a TB education presentation. To improve communication with
the TTP’s population, Spanish-speaking personnel were used for these
education sessions and for all targeted outreach and translation
In consultation with an advertising agency, the TTP team developed
an English- and Spanish-language TB education and awareness package
consisting of a TB awareness and education poster, two TB awareness
and education pamphlets, and a TB awareness and education multilanguage
CD. Both the English- and Spanish-language versions of these materials
were used at the TB education sessions. Information on TB infection
and TB disease was provided by a graphics-intensive, low-literacy
poster entitled “Do you need a TB test? Yes, be sure! GET TESTED!!”
(“Necesita usted una Prueba de TB?…Si! Asegureses! Hagase la Prueba!”).
A pamphlet with the same title as the poster was given to all TTP
participants. This pamphlet summarized the material discussed in
the education session. A second pamphlet covered the medical evaluation
that results from a positive TB test and the adverse drug effects
of the medications used to treat latent TB infection (LTBI); the
pamphlet is entitled ”Your TB test is POSITIVE! You will need a
chest x-ray, TB medical exam, and TB medicine to prevent TB infection
from becoming TB disease” (“Su Prueba de TB Es Positiva! Usted va
a necesitar un(a) radiografia del pecho, examen medico de TB, y medicina para TB para prevenir la
infeccion de la TB de desarrollarse en la enfermedad de TB”). This
pamphlet was given to those with positive TB test reactions.
A multilanguage CD was also produced. The CD had two tracks that
covered the same material as the pamphlets: “Do you need a TB test..?”
and “Your TB test was positive..!” Each track on the CD was in English,
Spanish, Mandarin, French, Creole, Hindi, Polish, Russian, Turkish,
Urdu, Vietnamese, and Cantonese. The multilanguage CD improved communication
with persons not speaking English or Spanish and proved especially
useful in the setting of ESL classes.
After the TB education presentation, a TB test was performed (either
a tuberculin skin test [TST] or a QuantiFERON® TB
[QFT] assay) on those interested in participating in the TTP. By
using the QFT assay, results were obtained in 100% of those tested.
This saved the time and effort that would have been expended in
locating those who fail to return for a TST reading, and since it
was a controlled laboratory test, it was not affected by subjective
interpretation, incorrect placement, or reader bias. Adverse reactions
associated with the TST such as blistering or necrotic reactions
that may occur in hypersensitive persons or positive reactors (post-TST
scar) were also avoided. Positive results with QFT occurred at the
same rate as with the TST.
The TTP staff returned to the TB testing site within 48 to 72 hours
to either interpret the TST reaction or to inform participants of
their QFT results. At that time, those with positive reactions received
a chest radiograph (CXR) on site using a portable x-ray machine.
The use of on-site chest radiography at time of TB test reading
on positive reactors resulted in 97% of newly positive reactors
receiving a CXR. The TTP team contracted with the same firm that
provided portable x-rays at the county jail to perform CXRs for
the TTP. The contractor brought the x-ray machine, which ran on
standard household AC current, to the site of TB test reading in
a small van that also contained a generator-operated automated dry
CXR processor. The x-ray machine was set up in a room at the TB
test reading site and directed towards an outside wall. The CXRs
were then developed in the van. Thus, CXRs could be taken and developed
on-site at the time of the TB test reading and were available for
immediate viewing. This allowed the diagnosis of LTBI to be made
and therapy initiated within 72 hours of TB test placement.
Large groups of positive reactors were seen on-site at the time
of TB test reading by the TTP staff for CXR interpretation, medical
evaluation, venipuncture, and initiation of treatment for LTBI in
a mobile clinic. All follow-up clinics were held at a conveniently
located Suffolk County
in the evening and usually ran until at least 8:30 pm. The TTP staff
completed all clinical assessments using a custom designed flow-sheet,
performed venipunctures, and directly dispensed LTBI medications.
The custom-designed flow-sheet improved the uniformity of TTP participant
encounters by standardizing questions about the presence or absence
of symptoms of TB disease and adverse drug effects. The symptom
screen was written in both English and Spanish in a check-list format.
This enabled the clinical assessment to be rapidly and accurately
completed by nursing personnel.
At all TTP clinics, targeted outreach was used with Spanish-speaking
staff which included telephone contact with TTP participants to
remind participants of their clinic appointments; using incentives
(e.g., pre-paid telephone calling cards) and enablers (e.g., transportation
vouchers) to encourage clinic attendance; and introducing TTP participants
and their families to other health department programs and services.
These efforts contributed to the high completion of therapy rates
by building trust with TTP participants.
Since many TTP participants had seasonal jobs (e.g., landscaping,
construction, agriculture) and were thus deemed unlikely to complete
the CDC preferred 9-month isoniazid regimen (9-INH) to treat LTBI,
a shorter course regimen to treat LTBI was initiated to help improve
completion of therapy. The TTP team began using a 4-month course
of rifampin (4-RIF) administered daily to treat LTBI after reports
of fatal and severe liver injuries associated with the use of a
2-month course of rifampin and pyrazinamide (2-RZ). TTP participants
who were not suitable candidates for rifampin-containing drug regimens
(e.g., those using oral contraceptive medication and participants
using medications with potential for interaction with RIF)
were placed on 9-INH.
Conclusion: The TTP successfully identified social networks serving
foreign-born populations from Latin America and South America, a
population that accounted for approximately 75% of the TB cases
reported by Suffolk
County between 2000 and 2004. The TTP offered
this population free, comprehensive LTBI diagnostic and treatment
services, and achieved a completion of LTBI therapy rate of 78.2%.
The TTP successfully reached a large medically underserved population
and developed innovations that have broad application to other TB
TTP Results: TTP staff provided educational programs to 3,310 individuals
(see figure). Of the target population, 1473 members participated
in a TB evaluation. Of those evaluated, 132 (9.0%) had previously
TST positive results and 124 (93.9%) were evaluated with a chest
x-ray; 24 of those with a previously positive TST were started on
treatment for LTBI and 20 completed LTBI therapy (83.3%).
Of those not known to have had a previously positive TST, 1341
received either a TST or QFT assay. TST readings or QFT assays were
completed in 1303 (97.2%) of those tested. A total of 460 new positives
reactors were found; 447 (97.2%) of new positives reactors received
a CXR with 385 (86.1%) starting treatment for LTBI. Of the new positives
who started, 300 (77.9%) completed treatment.
Overall, 409 TTP participants started treatment for LTBI and 320
completed treatment, for a rate of 78.2%. The TTP found five cases
of TB disease.
Funding support for the TTP came from the New York State Department
of Health, Bureau of Tuberculosis Control, through the NYS TB Cooperative
Agreement with CDC.
—Submitted by Lewis Mooney, MD, FCCP
Medical Program Administrator
Suffolk County, New York
Department of Health Services,
Bureau of Chest Diseases