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TB Notes 2, 2006
Highlights from State and Local Programs
  An Outbreak Response in a Rural, Southwest Missouri County Jail
  No Reported TB Cases in Wyoming in 2005
  Suffolk County (New York) Targeted TB Testing and Treatment Program Among the Foreign-born, 2000–2004
  The Changing Epidemiology of TB in Connecticut, 2000-2004
  Molecular Genotyping of Mycobacterium tuberculosis in Connecticut
  Third Annual Conference on TB in the U.S. Pacific Islands: Meeting Highlights, Challenges, and Solutions for Addressing the Disparities
  "Update: Tuberculosis Nursing" Workshop in Hawaii
  Lessons Learned in the Process of Evaluation – Illinois
  TB Education and Targeted Testing of Garfield County, Colorado, WIC Clients
Laboratory Updates
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Communications, Education, and Behavioral Studies Branch Updates
Information Technology and Statistics Branch Update
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TB Notes Newsletter

No. 2, 2006


Suffolk County (New York) Targeted Tuberculosis Testing and Treatment Program Among the Foreign-born, 2000–2004

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 the county.

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 pattern.

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 activities.

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 Health Center 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 control activities.

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.

Flow chart/graph of TTP

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


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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