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TB Notes 3, 2001

Highlights from State and Local Programs

Farewell Note from Dr. Davidson of LA County

Dr. Davidson presented the following information and comments at a meeting of the California Public Health Commission prior to his retirement. He gave permission for his remarks to be reprinted in TB Notes.

I will be retiring from County service October 1, 2001, after completing 18 years as Director of Tuberculosis Control for Los Angeles County, California. These have been eventful years, full of twists and turns in the circumstances related to the control of TB as well as in the many changes in the California Department of Health Services and Public Health. I believe I can honestly say that I will leave the control of tuberculosis in a more favorable condition for the County then when I arrived. I regret to say that there is still a long way to go before this disease can be eliminated in Los Angeles. However, at the current level of disease, the possibility of elimination is at least in sight.

I would like to summarize some of the important trends in the incidence of TB in Los Angeles County and some of the outcome accomplishments related to program objectives. I will conclude by making a few general reflections as I begin to fade out of the picture.

During the year 2000 the number of cases of reported TB declined for the eighth year in a row at 1065. This is a 9% decline from the number in 1999 and outpaced both the State of California and the United States, which have also had 8 years of declining incidence. The incidence of TB is at a historical low for all these jurisdictions. 

There has also been a decline in the number of cases in all races and ethnic groups during the past 8 years. Persons of Asian and of black race continue to be overrepresented and whites underrepresented as compared to the overall population. Hispanics are equally represented.

The number of cases by age group has declined most dramatically in the 15 to 34 age group during the past 8 years. However, there has been a leveling in the number of cases in this age group during the past 4 years. The 65-and-older age group has remained level for many years and contributes the second largest number of cases. As TB is controlled and gradually eliminated, the 65-and-older age group will become the predominant group in terms of cases and incidence. The corollary to this is that the 0 to 14 age group should be the first age group to approach zero if TB is fully under control and moving toward elimination.

The number of cases of TB in both foreign-born and US-born persons has declined during the past 8 years. However, the percentage of cases in foreign-born persons has been steadily increasing from 62.6% in 1990 to 72.7% in 2000. Since TB continues to be out of control in many parts of the world, the foreign-born population may be the Achilles heel that will make elimination of TB in Los Angeles County very difficult.

The cases in persons infected with HIV and in the homeless have reached an all-time low in 2000 with 77 and 76 cases, respectively. A decline in the control of the spread of HIV or a serious downturn in the economy could adversely affect TB in these populations. The same would hold true with persons who have multiple risk factors such as being foreign-born, homeless, and HIV infected.

Considerable effort is being placed on setting objectives and measuring outcomes for all public health programs. Los Angeles Tuberculosis Control, in collaboration with the State of California and CDC, has been evaluating program effectiveness and documenting outcomes related to TB for many years. Our ability to participate in this process has been dramatically increasing with the availability of computerized data systems and the strengthening of the data management and epidemiology staff at Tuberculosis Control and in the Health Centers.  Directly observed therapy (DOT) is a highly effective program activity that ensures that patients receive their medications. The number of TB patients receiving DOT has steadily increased since 1995. Our objective is to reach 100% of all cases being managed with DOT.

The CDC national objective regarding the percentage of TB patients who should complete a prescribed course of therapy within 12 months is 85%. In 2000, Los Angeles County performed at the 65% level. There are a number of factors that inhibit our reaching this objective such as patients dying, moving, or taking longer to complete therapy. We have very little ability to control some of these factors. Overall a very high percentage of patients who are started on treatment in Los Angeles County eventually complete treatment if they do not die within the first 12 months. A very small percentage of patients (1.9%) are lost to follow-up.

Los Angeles County has exceeded the national objective of 92% in drug susceptibility testing for a number of years with 98.5% in 2000. This is a reflection on the excellent Public Health Laboratory support we have in Los Angeles County. 

New guidelines concerning preventive therapy were published by CDC/ATS this past year. The Tuberculosis Control Program for Los Angeles County recently approved and circulated the standards expected for Los Angeles County. These standards are based on the CDC/ATS and the State of California guidelines. Among the changes has been the terminology. “Treatment of latent tuberculosis infection” (LTBI) is now preferred to that of “preventive therapy.” One of the highest priorities for treatment of LTBI is for contacts of contagious cases of TB. The national objective for treating contacts is that 85% should complete treatment of LTBI. The 1999 cohort of contacts in Los Angeles County only completed therapy in 47.3%. The national objective for completing treatment of LTBI in other groups that are targeted because of increased risk is 75%. The results of completing treatment by the community-based organizations that had contracts with the County were 52.8%, significantly below the set objective. Testing those at high risk for tuberculosis infection and successfully treating those with LTBI will need to be a higher priority for the Tuberculosis Control Program in coming years as we move toward elimination of this disease.

In conclusion, a great deal of work must be done before we can declare victory over TB. I believe the following are some of the more important aspects for Los Angeles Public Health to address in coming years to ensure the decline and eventual elimination of this disease:

  • Every effort must be made to maintain the necessary infrastructure to get the job of eliminating TB done. This includes maintaining level and in some cases increased funding despite decreasing numbers of cases.
  • The treatment of TB is a specialty. It will be necessary to maintain specialty clinics staffed by appropriately trained and experienced physicians, nurses, and support personnel.
  • The availability of DOT is essential to the eventual elimination of TB. This includes availability to patients cared for by both the private and public sectors.
  • There should be continued efforts to establish TB specialty clinics in strategically located full-service outpatient facilities.
  • As TB declines it will be increasingly found in members of limited subsegments of the population, many of whom will be difficult to reach and serve. New programs will be necessary to successfully eliminate TB in these populations. Examples of such populations include the elderly, the homeless and the poor, the undocumented foreign-born, and the mentally ill.
  • Maintenance of incentives and enablers will remain an essential part of eliminating TB. New and innovative approaches will be necessary. Flexibility will be essential.
  • A highly skilled field services staff will be necessary to find cases as early as possible and test and find those at risk for developing disease. Supervision of treatment with DOT and other enablers is critical. Innovation is also necessary here. The roll of community workers and other nonlicensed persons should be expanded into testing, case finding, and providing treatment services for cases and those on treatment of LTBI.
  • Above all, the first priority is to prevent the transmission of TB. Only then will there be an emerging succession of generations free of infection, without risk of developing disease, vigorously marching toward the elimination of this amazingly persistent disease.

—Paul T. Davidson, M.D.
Director, Los Angeles TB Control

Childhood Screening for TB in Texas

As TB continues to decrease in Texas, the strategies to control and prevent its spread must change to target those populations most at risk. On January 18, 2001, the Texas Department of Health (TDH) convened a group of pediatric TB experts, which was designated the Blue Ribbon Committee on Childhood TB, to consider the best strategies for controlling TB disease and infection in children. In May and June, the Committee’s recommendations and a questionnaire developed by the committee to help in screening for risk of TB exposure were presented for review and comment to groups with an interest in child health. These included representatives from TDH programs that provide services to children and representatives from school districts and other state agencies.

In July, TDH sent a copy of the recommendations and the questionnaire to local and regional health departments and asked them to work with school districts to use the risk assessment questionnaire in place of universal TB skin testing, which some school districts were continuing to require for all children entering their schools. The questionnaire asks about exposure of children to adults with symptoms or risk factors for TB. Children for whom positive responses are given to the questions about risk factors should be evaluated for TB infection with a tuberculin skin test and followed appropriately.

Use of the questionnaire is recommended for school entry in seven counties in Texas where the 3-year average rate of TB is double the state rate. In six counties that have a 3-year average rate of TB that is 50% to 99% higher than the average rate for Texas, the decision to require TB screening with the questionnaire for school entry should be a joint decision of the local health department and the school district, as resources allow. 

The “Health Steps” program in Texas, which provides screening and health services for Medicaid-eligible children, plans to adopt the questionnaire for TB screening as the program revises its service delivery guide manual in 2002.

—Submitted by Phyllis Cruise
CDC Senior Public Health Advisor
and Ann Tyree
Communications Specialist
TB Elimination Division, Texas Dept of Health

Meeting of New TB Controllers Association

The Northern Rocky Mountain TB Controllers Association held its inaugural meeting on July 27, 2001. Mr. Alex Bowler, TB Control Officer for the State of Wyoming, invited participants to Jackson Hole, Wyoming, for the first annual meeting of this new regional conference.

Those accepting Alex's invitation were Dr. Christine Hahn (Idaho), Dr. Randall Reves (Denver), Ms. Denise Ingman (Montana), Ms. Kristin Rounds (South Dakota), Ms. Pat Infield (Nebraska), and Mr. Walt Page, Executive Director of the National TB Controllers Association (NTCA). Two DTBE Program Consultants, Andy Heetderks and Scott Jones, were in attendance as well; they presented a brief update on CDC activities and discussed the FY 2002 Cooperative Agreement. The TB Control Officers from Utah and North Dakota had been invited but were unable to attend.

The agenda for this meeting is similar in format to the Midwestern and Southeastern TB Controller Conferences. Each TB Controller presented a program overview with emphasis on a particular aspect. For example, the Nebraska and South Dakota TB controllers emphasized the impact of refugee resettlement on programs with limited resources, which prompted a helpful discussion of approaches and strategies from the other participants.

All attendees voiced their appreciation for the opportunity to meet as a region. Some stated that a regional focus was very helpful, in that suggestions and solutions were immediately transferable between states with similar challenges. A tentative agreement was reached to meet again next year; Ms. Ingman of Montana volunteered to act as host for the second annual Northern Rocky Mountain TB Controllers Association.

—Reported by Scott Jones
Division of TB Elimination


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