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TB Notes 3, 2000

Focus on Correctional Facilities

Project to Evaluate Short-Course Treatment of TB Infection Among Jail Inmates and Homeless Persons

New CDC/ATS guidelines for the treatment of latent TB infection (LTBI) include a regimen consisting of 2 months of rifampin and pyrazinamide (2RZ). Staff of DTBE initiated a project to evaluate the program implementation of these new recommendations as standard of care for the treatment of LTBI. The primary objective is to demonstrate improved adherence and thus an improved completion rate of treatment for LTBI using the 2-month regimen. Secondly, we will evaluate the tolerance and acceptability of this regimen. Ideal populations for short-course treatment of LTBI are those at high risk for progression to disease, e.g., persons infected with the human immunodeficiency virus (HIV) and recently infected with TB, persons difficult to reach by standard public health approaches, and persons in whom adherence and completion of therapy are unacceptably low. Prison and jail inmates undergo extensive tuberculin skin testing and have high rates of positive tuberculin reactivity, with very low rates of completion of LTBI therapy. Several studies have shown that the rate of completion among prisoners released to the community while receiving treatment is less than 20%. The use of a short-course regimen could be well suited to this population. In mid-1999 we initiated a demonstration project with six large jails around the country. To ensure high rates of completion, the project sites are using directly observed therapy, incentives to improve adherence, and outreach workers (ORWs) to motivate and facilitate patients' treatment. To date, we have enrolled patients at seven jails and three homeless shelters.

On September 20, 2000, 11 ORWs from 9 sites participating in the 2RZ demonstration project attended a one-day meeting in Atlanta. The purpose of the meeting was to allow the ORWs an opportunity to learn from one another by discussing issues and situations they confront daily. Project sites have a wide range of resources, from a single ORW assigned to cover an entire county, to a health department's entire staff of ORWs. The format of the meeting was a 2.5-hour focus group (see the following summary) followed by discussion around several topics. In addition, Khalil Sabu Rashidi from the Newark National TB Model Center gave a presentation that drew from his personal experiences regarding the challenges of working with difficult-to-access populations. Participants went away with a sense of sharing and a feeling of ownership for the project. Again we learned that outreach is a work of dedication and thoroughness. Outreach workers are essential team members for the project's success. The project staff held a conference call in October to discuss data collection issues, rate of completion of therapy, and drug toxicity, and will conduct additional conference calls on a regular basis.

óReported by Mark Lobato, MD
Medical Officer
Division of TB Elimination


Sharing Experiences, Insights, and Findings from a Discussion Among TB Outreach Workers

Introduction

Traditional regimens used to treat latent TB infection (LTBI) take at least 6 months to complete, and many patients have difficulty adhering to their treatments. To improve adherence rates, TB programs often use outreach workers to bring services into the patientís environment. Patients in temporary or transitory locations, such as jail inmates and homeless persons, often have very low adherence rates, but create special challenges for outreach.

Recently, CDC recommended a new short-course regimen for treating LTBI: 60 daily doses (approximately 2 months) of rifampin and pyrazinamide (2RZ). As described in the preceding article, a new CDC project focusing on prisoners in jails and homeless persons is evaluating the new recommendations to determine the completion rates and examine the tolerance and acceptability of short-course therapy. Outreach workers at each of the project sites provide patients with the personalized support needed to complete therapy.

CDC brought together the outreach workers from the project sites to discuss their experiences in working with patients on the 2RZ regimen. The outreach workers shared the techniques and strategies they use to help their patients adhere to treatment. Their insights provided valuable information for TB program staff, especially those working with challenging patients.

The CDC staff would like to thank Mathew Nwozuzu (New York City, NY), Khalil Rashidi (Newark, NJ), Ozzie Renwick (Jacksonville, FL), Dora Cotrim (San Francisco, CA), Antonio Torres (Chicago, IL), Joann Maniscalco and Pat Kubis (Nassau County, NY) Grace Sanchez (Denver, CO), Christopher Evans (Gulfport, MS), Tara Rogers and Howard Pope (Fulton County, GA), and Eric Morgan (Mobile, AL) for their participation in this focus group.

Findings

When asked to describe their job activities, all reported delivering LTBI medicines to patients in the patientís own environment: jails, shelters, or the community after release from jail or when leaving a shelter. Most outreach workers watch patients swallow their pills daily during the week, and allow the patient to self-administer the medicines on weekends. In addition to delivering medicine, outreach workers may place and read tuberculin skin tests, remind patients of health care appointments, and provide transportation to attend clinic. Further, they maintain records on patients and serve as liaisons, coordinating with TB control staff, other health providers, and staff at the prison facility or shelter.

All outreach workers see their primary role as helping patients adhere to and complete LTBI treatment, which requires building trust and establishing effective communication. Because patients may suspect that the outreach worker is a law enforcement official, the workers are always direct with patients in informing them that they work for the TB control program and not the facility. Dressing casually and "using the patientís language" reinforce the message that the patient can trust the outreach worker. The workers stress confidentiality and repeatedly tell patients that they will not share information with legal authorities. The workers arrange in advance for a separate, private room to meet with patients. In community settings, outreach workers scan their environment for less public settings, and act discreetly, greeting their patients as friends rather than in an official capacity.

Continually, the outreach workers emphasized the need to "show the patient that you respect and care about them." Given that these patients, prisoners, and homeless people often receive little respect, the outreach workersí respect establishes a core for the relationship. Outreach workers show their concern by listening to them patiently and calming fears by tying in the benefit of completing treatment. To help patients overcome the stigma associated with TB, personal stories are shared, such as those about the workerís family.

Communicating with patients who are not native English speakers can be a challenge. One outreach worker is bilingual, and other outreach workers have fellow staff members who can serve as translators when needed. Learning several key phrases in the patientís language was suggested as a way to help build trust. AT&T telephone translation services are also a resource for overcoming language differences (for information on this service, call 1-800-752-0093, extension 196, or visit the Web site www.att.com/languageline).

Once communication challenges have been solved, the outreach workers continually educate the patients about TB and LTBI. Several outreach workers noted that citing "worst-case scenarios" of people who developed TB served to emphasize the need for treatment. To explain the complexity of LTBI, one worker explains to patients that the germ is "sleeping." Given the status of these patients, the workers educate the patients that they are not "guinea pigs," and will be respected throughout the study.

After rapport is built, outreach workers maintain regular contact; "just being there for the patient, and taking time with them" is essential. Showing concern for the patientís overall well-being by assisting patients access additional health and social services reinforces trust. Helping patients enroll in substance abuse treatment programs is critical to increasing adherence. In addition, to help motivate patients, outreach workers report using incentives, such as food coupons, and enablers (e.g., transportation vouchers or bus tokens).

Maintaining contact requires knowing the patientís location throughout the treatment period. While the outreach workers in this project initially meet and enroll their patients in correctional facilities or in shelters, many patients will leave or be released before treatment is complete. At the start, some patients give false names and incorrect addresses, not trusting the outreach worker. Recognizing this challenge, outreach workers regularly review contact information with patients to learn possible aliases and alternate addresses, and over time, as trust builds, more accurate names and addresses are given. When patients cannot be located from the outreach workersí information, coordination with law enforcement staff, parole officers, or INS officials may help locate the patients. One worker reported having great success by involving younger patientsí parents in maintaining contact. Only when a patient cannot be located for over a month will most outreach workers close a case as "lost," although one worker noted her program closes cases in 2 wks.

While the outreach workers shared their techniques and tips on how to promote patient adherence, they cautioned that every patient is different and strategies had to be individualized to work. Underlying each success is perseverance and hard work, but not every case can be a success. The outreach workers often have high caseloads and competing priorities and often do not have enough time to devote to the most challenging situations. Some patients will not communicate honestly, some are lost to follow-up, and some refuse treatment. Data and records on patients are often missing or incorrect, and occasionally the cooperation of other professionals, such as certain jail personnel, is missing. But, despite these challenges, the outreach workers remain enthusiastic about their jobs. Armed with a sense of humor, patience, and compassion, each worker is committed to helping their patients complete their LTBI short-course treatment.

óReported by Maureen Wilce, MS
Division of TB Elimination


Florida Corrections TB Program Workshop

On July 27 and 28, 2000, I had the opportunity to participate in the Florida Corrections TB Program Workshop, which was held in Fort Pierce, Florida. The workshop brought together approximately 85 individuals from health departments, jails, and the Department of Corrections in Florida to increase their awareness of issues surrounding TB prevention and control among the incarcerated population.

The Florida Corrections TB Program is currently cosponsored by the Florida Department of Health (DOH) and the Florida Department of Corrections, the Florida Sheriff's Association, and the American Lung Association. The group members currently hold quarterly meetings, and use one meeting a year for a 2-day workshop; the meeting I attended was their annual workshop. The meeting was hosted by the St. Lucie County Sheriff's Office and the Indian River Community College.

Graydon Sheperd, Chief of the Florida DOH Bureau of TB and Refugee Health, was part of a DOH panel. The title of his presentation was "The State of the State - TB." A TB skin test certification course, for which trainers included Jo-Ann Arnold and Ellen Murray (nurses with the DOH), was among the break-out sessions.

Other speakers included Max Salfinger, the Director of Laboratories for the New York State Department of Health; representatives from the Florida Department of Corrections; staff from other DOH bureaus (HIV/AIDS and STD); staff from A.G. Holley Hospital; private physicians; and a representative from the social services division of the Salvation Army.

Presenting the key note address, I outlined the CDC recommendations for correctional facilities emphasizing screening, containment, assessment, and continuity of care.This proved to be a good introduction of the key points to consider. In the address, I stressed the barriers and facilitators to effective TB prevention and control in correctional settings. In my talk, I also provided national statistics on TB in correctional facilities and reviewed the reasons why correctional facilities and incarcerated populations are at high risk for TB. The discussion which followed focused on how to overcome barriers and develop specific strategies. Heather Duncan, a DTBE field staff public health advisor, also attended the meeting and gave a presentation entitled "TB: What Is My Risk?"

CDCís participation demonstrated our support for Florida's efforts. The Florida Corrections TB Program, and this workshop specifically, are good examples of the collaboration necessary to best address TB in the incarcerated population. In addition to general sessions presenting medical, legal, psychosocial, administrative, and programmatic issues regarding TB and HIV in corrections in Florida, breakout sessions provided the opportunity for the medical directors, nurses, correctional administrators, security staff, and program managers in attendance to have more detailed discussion and training on tuberculin skin testing, personal respiratory protection, and development of TB control plans including risk assessments.

óReported by Lauri B. Bazerman, MS
ASPH Fellow
Division of TB Elimination


TB Training Videos for Correctional and Health Department Personnel

The Texas Department of Health, with a grant from the U.S. Department of Justice, has developed five training videos based on the edited presentations from the satellite broadcast "TB Control in Correctional Facilities." The titles and running times are as follows:

  • Preventing TB in Correctional Facilities (22:00 minutes)

  • TB Screening and Diagnosis (28:50 minutes)

  • Safely Transporting Inmates with TB (14:00 minutes)

  • Creating a Plan to Control TB (21:30 minutes)

  • Ins & Outs of Contact Investigation (32:21 minutes)

You can purchase videos either singly for $7 or as a set of five for $30. These prices include shipping. To order, you will need to obtain an order form by calling the Texas Department of Health TB Elimination Division at (512) 458-7447 or by sending an e-mail to ray.silva@tdh.state.tx.us. No orders can be processed without an order form.

óReported by Phyllis Cruise
Texas TB Control Program

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

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