TB Notes Newsletter
No. 2, 2006
HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS
TB Education and Targeted Testing of Garfield County, Colorado,
The Garfield County, Colorado, Public Health Nursing Service
received a community health grant in 2002 to conduct a two-pronged
demonstration project designed to educate a vulnerable population
about tuberculosis (TB) and to identify and treat latent TB infection
(LTBI) in this same group. Using literature review findings, Colorado
TB surveillance data, and input from TB stakeholders, the project
team identified clients of the Garfield County Women, Infants, and
Children (WIC) program as its target population. Garfield
County’s WIC clients are low income and
75 percent are Hispanic; many come from Mexico
or Latin America. The project included the
prenatal and postpartum women and their 1- to 5-year-old children
who participate in the agency’s WIC program. In Garfield
County, the WIC agency operates as part
of the public health department, and its staff work closely with
other programs, including prenatal, immunizations, the Health Care
Program for Children with Special Needs, and the Early and Periodic
Screening, Diagnosis, and Treatment program. WIC clients often know,
and are known by, other public health staff. Hence a level of trust
and rapport was already established prior to implementation of the
project. Based upon our knowledge of WIC clients, we also considered
them likely to become TB prevention advocates by sharing with family
and friends the information they learned about TB risk factors,
symptoms, testing, and treatment options.
WIC clients were invited to participate in the project during a
routine WIC appointment. A bilingual WIC health educator presented
TB information and testing options to the clients. Those who chose
to participate were given a pretest on TB. The following true/false
statements were given:
- TB is caused by a germ.
- Someone who has TB can pass it on when they cough, sneeze, or
- A person can have TB and not know it.
- A skin test is the best way to tell if someone has M. tuberculosis
- There is vaccination that will protect you from ever getting
- Tuberculosis infection is different from tuberculosis disease.
- Some people are at greater risk for getting TB than others.
- A chest x-ray is a way to know if someone has TB in the lungs.
- A symptom of TB is a cough that lasts longer than a cold.
- There are other ways to cure TB besides taking medicine.
Participants were then given an illustrated booklet published by
the Channing L. Bete Company, “About Tuberculosis,” and viewed a
10-minute video, “You Can Prevent TB,” produced by the Bureau of
Tuberculosis Control, Education, and Training at the New York City
Department of Health. Both were in the client’s preferred language.
Effectiveness of education was measured by giving the same true/false
test at least 3 months later.
Participants were screened for TB risk, as were any children enrolled
in WIC. Risk was determined by being born in a high TB prevalence
country and living in the United States for less than 5 years; a
history of living or working in homeless shelters, jails, migrant
workers’ camps, hospitals, or nursing homes; living in a multifamily
home; or a history of possible TB in a household member or close
relative. Those identified as being at high risk were offered a
tuberculin skin test (TST). Participants who tested positive for
TB infection were medically evaluated and offered treatment based
upon the recommendations of the Colorado Department of Public Health
and Environment (CDPHE).
CDPHE TB program staff provided technical assistance and developed
an MS Access database for risk and test information. Data were compiled
and analyzed using Excel and SAS.
The project began with 713 participants, 430 women and 283 children.
Of the women who agreed to participate, 90 percent were Hispanic
and 82 percent reported Mexico
as their country of origin. The most common risks were recent immigration
from Mexico and living in a multiple-family
household. Based upon risk, 224 (52%) of 430 women and 22 (8%) of
283 children were given a TST. Sixty-three (28%) of 224 women and
two (9%) of 22 children had new positive TST results (9.1 percent
of the total study population). All were evaluated and diagnosed
with LTBI. No cases of active TB were detected.
Treatment was recommended for all but three LTBI cases. Thirty-nine
women (62%) and both children (100%) completed the full treatment
course. Of the 21 women initiating but not completing treatment,
five experienced real or perceived adverse side effects from the
medication, and the remaining moved away or were otherwise lost
Of the 430 women taking the pretest, 48 percent chose correct responses
(range 13.7 to 79.5). In comparison, 226 women took the posttest,
and 74 percent of them gave correct responses (range 46.9 to 95.1).
Encouragingly, among the 226 participants completing both a pretest
and posttest, 110 (48%) who answered question 6 incorrectly on pretest
(Tuberculosis infection is different than tuberculosis disease)
answered correctly on posttest. Questions 5 (There is vaccination
that will protect you from ever getting tuberculosis) and 10 (There
are other ways to cure tuberculosis besides taking medicine) remained
problematic, with less than half the participants answering correctly.
The success of this project depended on collaboration. During
the course of this project, we were presented with numerous opportunities
for educating our partners, not only about TB, but about the role
of public health in general; in other words, what we do. This has
led to a broader understanding in the community of how we provide
prevention education as well as monitor the health of our community.
Health care providers seek our public health expertise and are more
likely to refer patients to us as a result of these strengthened
partnerships. In many cases, a client’s participation in this project
led to advocacy and educational outreach to friends and family.
One of the objectives of this project was to identify cultural
barriers to accepting diagnosis and treatment for TB. The most obvious
factor we observed was the belief of many participants that prior
vaccination with BCG made tuberculin skin testing unnecessary for
them. They felt they were protected for their lifetime. They also
believed a positive TST result was due to BCG vaccination, based
on what health care providers in Mexico
had told them. The prevalence of this perception lends support to
recommendations for the use of blood assays for M. tuberculosis
(e.g., QuantiFERON®-TB Gold).
This project can serve as a model for many areas in our state and
others. It proved to be a successful means of identifying and treating
LTBI, thus preventing future disease. Just as importantly, it allowed
many families to become educated about TB, thus empowering them
to recognize risk factors and symptoms and to seek care. The demographics
of Garfield County’s
WIC clients provide an ideal population for targeted testing, a
scenario common to many counties. We believe this project demonstrates
the benefits of targeted testing, supporting the need for funding
allocated for this purpose.
—Submitted by Sandra Barnett, RNC
Laurel Little, MS
Brisa Chavez, TB Educator
Garfield County Public Health Nursing Service
Barbara Stone, MSPH
Colorado Department of Public Health and Environment TB Program