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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
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TB Notes Newsletter

No. 2, 2006


TB Education and Targeted Testing of Garfield County, Colorado, WIC Clients

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:

  1. TB is caused by a germ.
  2. Someone who has TB can pass it on when they cough, sneeze, or speak.
  3. A person can have TB and not know it.
  4. A skin test is the best way to tell if someone has M. tuberculosis infection.
  5. There is vaccination that will protect you from ever getting TB.
  6. Tuberculosis infection is different from tuberculosis disease.
  7. Some people are at greater risk for getting TB than others.
  8. A chest x-ray is a way to know if someone has TB in the lungs.
  9. A symptom of TB is a cough that lasts longer than a cold.
  10. 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 to follow-up.

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


Released October 2008
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