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U.S. Department of Health and Human Services

  

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TB Notes 3, 1999

Hightlights from State and Local Programs

California | Georgia | New York

Survey of Local Tuberculosis Case Registry Practices and Capacities in California

Introduction

The tuberculosis (TB) surveillance system in the United States can provide a wealth of information for public health officials to use in developing and evaluating TB prevention and control programs and policies. Before TB programs can utilize their surveillance data, such data must be accurately collected and the capacity to analyze the data must exist. Although the TB Control Branch of the California Department of Health Services has the ultimate responsibility in California for collecting and reporting quality TB data to CDC, it relies on local health departments to actually collect the data. In turn, the TB Control Branch has been encouraging local health departments to analyze and use their data for program planning and evaluation. To better assist local health departments in their collection and use of surveillance data, the TB Control Branch undertook a survey of practices and capacities of local TB registries in the state.

Methods

In June-September 1998, staff from the TB Control Branch visited the 19 largest local health departments (out of 61 local health departments) in California to review their TB case registry practices. These local health departments reported 92% of the state’s cases in 1998. Using a standardized survey, relevant staff in each local health department were interviewed in person. The survey covered staffing for key TB registry functions, reporting policies, databases, and data analysis.

Results

Reporting of TB data

Staffing. With regard to staffing for activities such as confirmation of TB cases, completion of the Report of Verified Case of TB (RVCT), data entry into TIMS, and quality control of RVCT data, 15 local health departments (79%) reported that, in the past 2 years, there was staff turnover in one or more of these areas. Seven local health departments (37%) had a vacancy in one or more of these positions at the time of the survey.

Quality control of TB data. Sixteen local health departments (84%) performed some quality control check on each RVCT before submission to the TB Control Branch. This was most commonly performed by the Program Manager or Public Health Nurse (eight sites), followed by clerical staff (six sites), epidemiologist (two sites), and TB Controller (one site); one local health department had two staff performing quality control checks. Fifteen sites (79%) checked for internal consistency and missing data, 11 (58%) compared the RVCT to medical records, and four (21%) reviewed the "Facsimile" RVCT printout from SURVS/TIMS.

Selected problematic issues in reporting

In the assessment of reporting policies, we found inconsistencies in the way local programs reported on certain issues. We provide four examples of the more problematic issues below.

Directly observed therapy (DOT). Eight local programs (42%) report a patient to be on "DOT only" if most doses of therapy are observed; 13 (68%) consider TB patients to be on DOT when they are hospitalized; 16 (84%) consider all incarcerated TB patients to be on DOT.

Healthcare provider type. When the health department is providing DOT to a "private" patient, nine programs (47%) report this patient as being cared for by the private provider only; but another nine (47%) would report this as receiving care from both the health department and private provider.

HIV testing of TB patients. In 1997, the TB Control Branch asked local health departments to collect information on whether HIV testing was offered to each TB patient. More than one year later, only nine local health departments (47%) have a written policy on HIV testing of TB patients. Six (32%) could not answer the question "Was HIV testing offered?" for all TB cases cared for by private providers.

Movement of TB cases. Patients who move during TB treatment require referral to ensure continuity of treatment in the new local health departments. Only five local health departments (26%) follow up on patients to confirm that they have arrived in the next local health departments. Only three (16%) schedule an appointment for patients in the destination local health departments.

Data analysis

Availability of epidemiological expertise. In seven local health departments (37%), the TB program had no access to an epidemiologist (defined by having at least a master’s degree in epidemiology). Seven other sites (37%) shared an epidemiologist with other disease programs. Several epidemiologists reported that since their funding did not come from the TB program, analysis of TB data was not a priority for them. In three local health departments (16%) the epidemiologists had other major responsibilities such as being the Program Manager. Only two sites (13%) had a full-time TB epidemiologist. An epidemiologist actually performed routine analysis of case data in only eight local health departments (42%).

Data systems and analysis. Aside from having SURVS-TB/TIMS, 15 local health departments (79%) also had their case data computerized in another database. Contacts to cases were computerized in only four local health departments (21%). Fifteen (79%) reported routinely analyzing their TB case data, but only one analyzed contact data for purposes other than the Program Management Report.

Discussion

The results of this survey have permitted the TB Control Branch to determine how we can better assist local health departments in their collection and use of surveillance data. The high turnover and vacancy rate in staff responsible for TB reporting means that local expertise in reporting is often lost. Both the timeliness and the quality of reporting frequently suffer whenever changes in TB registry staff occur. Our survey revealed problems in several reporting issues. Although guidelines clarifying many reporting issues have been disseminated in California, problems continue to occur, perhaps due in part to staff turnover.

Based on these results, the TB Control Branch is increasing the technical assistance to and training for local TB registry staff. We hope to establish closer communication with staff of local registries so that staffing changes and local problems can be quickly identified and more timely assistance provided. The TB Control Branch is in the process of providing local health departments with guidelines on reporting that will help to clarify national guidelines, e.g., administrative closure. In addition, we are distributing all current reporting guidelines and protocols in a single binder; this will make it easier for local staff to refer to them when the need arises and for updating or adding guidelines.

The TB Control Branch has been encouraging local TB programs in California to analyze and use their own TB data. The Francis J. Curry National TB Center, in collaboration with the TB Control Branch, has developed a user-friendly software program (titled TB-Info) to analyze TIMS data. The TB Control Branch has distributed TB-Info to local programs with the hope that these programs can more easily analyze their own epidemiologic and treatment data. We found that most local health departments are analyzing their TB case data. However, only one routinely analyzes contact data for purposes other than meeting the current reporting requirement. One reason for this is that most local health departments do not have a computerized database on contacts. But a more important issue may be the lack of an available epidemiologist in most TB programs to perform the data analysis and help interpret the results.

To improve the use of contact data, more local health departments in California will need to establish a contact database. In addition, the TB Control Branch is working with local health departments to develop a standard methodology for evaluating contact investigations. This will be tied to the implementation of the new CDC Aggregate Reports on Program Evaluation. Finally, improving the local use of TB data will require the availability of an epidemiologist in local programs; specific funding should be provided for this purpose.

For more information, contact Janice L. Westenhouse, MPH, TB Registry Coordinator, Tuberculosis Control Branch, 2151 Berkeley Way, Room 608, Berkeley, CA 94704, phone: (510) 883-6076, fax: (510) 540-3535, e-mail: jwestenh@dhs.ca.gov

—Reported by Janice L. Westenhouse, M.P.H.,
and Daniel P. Chin, M.D, M.P.H.
TB Control Branch, California Department of Health
Services

 


 

California | Georgia | New York

 New Facility for Involuntary Confinement of Georgia TB Patients

In June 1995, Georgia closed the doors of its TB inpatient hospital, one of the few remaining TB sanatoriums in the United States. The closing of the 41-bed facility occurred for several reasons. The advances made in the treatment of TB have resulted in more patients being treated in outpatient settings. Consequently, the hospital admitted only a few patients annually. Maintaining a facility with an annual budget of over $1 million was economically unfeasible, given the minimal need for this type of facility. In addition, the building was not a secured, locked facility; although patients were sent there under court order, many patients left against medical advice. Patients needing intensive medical care for adverse medical reactions or complications resulting from coinfection with HIV had to be transferred to other hospitals for medical care. Finally, most patients were there owing to homelessness or alcohol or drug abuse, but the hospital provided no interventions for these problems.

Since 1995, various alternatives have been developed to provide TB treatment to patients who were court ordered to receive care. A collaboration with the Georgia Chapter of the American Lung Association provides housing, meals, and directly observed therapy (DOT) to infectious TB patients who are homeless or have unstable home environments. In addition, the Georgia TB Program collaborates with Antioch Urban Ministries, a local community-based organization, to provide similar services to noninfectious homeless patients. Additional sites utilized have included personal care homes, motels, and substance abuse facilities. However, none of these facilities provided a secured facility, and if patients were determined to leave, they could not be held. The need continued to exist for a secured facility for the hard-core, involuntarily committed TB patient who required a more structured environment to ensure completion of therapy.

During the Annual Southeastern TB Controllers’ Conference of 1997, Carol Pozsik, RN, (TB Controller, South Carolina) briefed the Georgia TB Controller on a new privately managed prison hospital, Columbia Care Center, that was available to care for TB patients in the Southeast. In October 1998, a team from the Georgia TB Control Program met with Columbia Care Center’s administration. The team toured the facility and discussed a possible arrangement to admit TB patients from Georgia. Several issues were of concern for the TB Program. Most important was the safety of Georgia’s TB patients. These patients are detained under a civil court action; as such they are not criminals and should not have encounters with persons incarcerated on criminal charges. After discussions and assurances by the warden of Columbia Care Center, we were confident of the safety and treatment of Georgia’s TB patients.

Columbia Care Center, located in Columbia, South Carolina, is a 326-bed, private prison hospital. The facility provides medical care and treatment for a variety of conditions, including TB. The Columbia Care Center offers a cost-effective alternative to the traditional hospital setting, providing medical care and treatment to patients who have been involuntarily committed and require a secured facility to complete TB treatment. The basic rate for uncomplicated TB (e.g., HIV-seronegative, pansensitive) is $135 per day. For dually infected patients, i.e., TB/HIV, the cost is $250 per day. The facility has a complete medical staff including physicians, registered nurses, licensed practical nurses and certified nursing assistants, as well as correctional officers on each floor. The facility is equipped with 10 isolation rooms with negative air pressure in addition to rooms that will accommodate 2 or 4 individuals. All medications are administered by DOT. Bacteriology tests for patients admitted to the facility are processed at the South Carolina State Laboratory under a mutual agreement between Columbia Care physicians and the South Carolina TB Control Program.

Since January 1999, six patients from Georgia have been admitted to the facility. Four are still under care and one has completed treatment. One patient was transferred to an acute care hospital, due to complications from AIDS, and later died. The average cost per patient is $141 per day.

How successful this collaboration will be has yet to be determined. What is known is that the cost per day is substantially less than at area acute care hospitals (approximately $500 per day); the patients cannot leave the facility against medical advice, which ensures their completion of treatment; and patients are satisfied with the care they receive. The staff at Columbia Care Center demonstrate caring and concern for every patient. They provide exceptional medical care in a safe and secure setting. The Columbia Care Center is available for admitting patients from across the Southeast.

Inquiries about the facility can be directed to Dr. Kevin McLaughlin at the Columbia Care Center at (803) 935-0505.

—Submitted by Beverly DeVoe, MSH
TB Program Manager
Georgia TB Control Program

 


 

California | Georgia | New York

Improving B1/B2 Tuberculosis Follow-up in New York State

Introduction

Foreign-born persons comprise an increasing proportion of TB cases in New York State. Final numbers for 1998 reveal 50% of all cases reported in New York State exclusive of New York City (the project area) were among individuals born outside of the United States. In both 1996 and 1997, 46% of the cases reported in the project area were in foreign-born persons. Traditional methods of community-based TB control efforts are becoming less effective, considering half of today’s cases (i.e., recent, foreign-born arrivals) did not reside in the community 5 years ago. Therefore, newly arrived refugees and immigrants must become a priority for assessment, case identification, and prevention programs.

Immigrants and refugees are the only groups of foreign-born persons routinely required to have a TB screening prior to obtaining a visa to enter the United States. This screening is done as part of the Overseas Medical Examination, which is conducted by panel physicians to identify individuals with excludable medical conditions such as HIV infection, serious psychological disorders, and untreated communicable diseases such as leprosy, sexually transmitted diseases, or TB.

Persons whose smears are found to be positive for acid-fast bacilli (AFB) are designated as having Class A TB, a condition that makes individuals inadmissible into the United States. These individuals have two options: (1) they may choose to successfully complete a recommended course of therapy overseas with documented smear negativity at the end of treatment, after which they are reclassified as having old, healed TB (Class B2), or (2) they may elect to be treated overseas until their smears become negative, and apply for a waiver that will permit immigration, with therapy to be completed here. For an individual to receive a waiver, a document must be signed by a U.S. health care provider and countersigned by the appropriate local health department official (or signed only by the local health department official if he or she is the provider) in the individual’s intended U.S. destination, thus ensuring that the provider will assume responsibility for the completion of TB treatment after arrival. Persons with Class B1 TB (suspect active TB, smear negative) or Class B2 TB (suspect TB, inactive, smears not required) are allowed to immigrate with no restrictions. At the port of entry, the Division of Quarantine generates a CDC 75.17 form, "Notice of Arrival of Alien with Tuberculosis" for these individuals. This form identifies a new arrival as someone with Class B1/B2 TB. The CDC 75.17 form has two sections: one for the state health department, and one for the local health department. Both sections are sent to the state health department, which in turn forwards the appropriate part to the local jurisdiction. Class B1/B2 arrivals are requested to have a follow-up evaluation within 30 days of entry. The date by which the examination should be done is in bold print on each portion of the CDC 75.17 form. There are six questions on the form relative to the patient evaluation: (1) U.S. smear results; (2) U.S. x-ray results; (3) x-ray results (overseas); (4) U.S. presumptive diagnosis; (5) previous chemotherapy or prophylaxis; and (6) prescription of chemotherapy or prophylaxis as a result of this exam.

After completing the form, the local health authority returns it to the state health department to be forwarded to the Division of Quarantine. If the individual does not report for an evaluation, that information is also sent to Division of Quarantine via the state health department.

Background

Persons with Class B1/B2 TB are a high priority for follow-up because of the significant number in this group who subsequently progress to and are reported with active TB disease. Studies have shown 10%-14% of B1 arrivals and 2%-3% of B2 arrivals were later diagnosed with active TB. Project area data from 1994 show 323 notifications of Class B1/B2 arrivals settling in New York State (exclusive of New York City). Of the 323 notifications, county health departments returned 217 (68%) CDC 75.17 forms to the state health department. A TB evaluation was completed on 138 individuals, or 43% of the known B1/B2 arrivals. Active TB was identified in 4 of the 103 B1 arrivals and in 2 of the 220 B2 arrivals, a yield of 4% and 1%, respectively. In early 1995, a match between the TB registry and the B1/B2 arrivals over the 3-year period 1992-1994 identified 29 reported TB cases among the 934 B1/B2 arrivals in that period. Of these 29 cases, 11 (38%) were identified on the CDC 75.17 form with active TB during their initial evaluation, 7 (24%) were presumptively diagnosed with inactive TB, 1 (3%) was reported to not have TB, and 10 (35%) were never evaluated. Active disease was reported in 25 of the 29 within 6 months of arrival in the United States.

Methods

Given the relatively high proportion of active TB cases identified in the population classified as B1/B2, and the low proportion of the B1/B2 group receiving an evaluation in the project area, the New York State Department of Health Bureau of Tuberculosis Control (BTBC) launched a project in 1995 to assist counties in evaluating B1/B2 arrivals. BTBC staff met with county health department staff to discuss the increased risk of TB in this group and the importance of providing TB assessment and follow-up care. At the same time, protocols for TB evaluation were distributed. Regional BTBC staff began monitoring and assisting the county health departments in efforts to improve follow-up. A training program was developed which included a TB program assessment, instructions on completing the CDC 75.17 form, TB evaluation protocols, and sputum analysis protocols. Each county with a Class B1/B2 arrival was visited by a BTBC staff person. An open-ended, structured interview was conducted with county staff to determine the evaluation strategy employed in each locale. Questions of interest included how the B1/B2 population (refugees, immigrants, or both) was identified and what protocols were utilized by each county to complete and return the CDC 75.17 form to BTBC. Bureau staff analyzed the results, identified areas for improvement, made suggestions and modifications, and worked directly with the county health departments over subsequent years.

Results

State and county staff identified a number of key problem areas: (1) lack of staff to provide direct outreach to locate persons and get them in for evaluations; (2) lack of communication among various service providers within counties; (3) incomplete TB evaluation procedures; (4) language and cultural barriers; and (5) misunderstandings about paperwork and time frame requirements. Solutions developed jointly by BTBC staff and county staff included interventions such as (1) BTBC field visits at the county’s request to locate patients; (2) meetings between local health department staff and other service providers to improve communication, referrals, and feedback; (3) the education of county health department staff about evaluation guidelines and time lines; and (4) the creation of log books to track arrivals and each individual's progress through the TB evaluation process.

Graph I shows the proportion of B1/B2 arrivals for whom the CDC 75.17 form was not returned by the county health department. Prior to implementation of the intensive follow-up initiative in 1995, almost 40% of the forms were not returned to the State. Since 1996, forms have been returned for more than 95% of the notified arrivals. Graph 2 demonstrates that the percentage of returned forms documenting a completed TB evaluation has also increased steadily since 1995.

Table I shows the number of B1/B2 arrivals by year and the number of active TB cases detected as the result of county health department follow-up. Prior to implementation of the project, 1.85 % of the total number of B1/B2 arrivals were found to have active TB on evaluation. In the years 1995 through 1997, 841 persons with Class B1 or B2 TB settled in the project area. Over 80% had a TB screening and 40 active cases of TB were identified, nearly 5% of the B1/B2 arrivals.

Conclusions

With almost 5 of every 100 B1/B2 arrivals found to have TB disease during their initial evaluation, it is evident that within this high-risk population, targeted screening of a comparatively small population can be an effective public health intervention. Continued success requires the combined vigilance of federal, state, and local health authorities. Prompt notification of arrivals coupled with quick, comprehensive follow-up and treatment can lead to reduced periods of infectivity due to quick case finding, a decrease in the number of infections transmitted, and the identification of potential candidates for preventive therapy.

—Reported by John C. Grabau, Ph.D., M.P.H., Noelle E.
Howland, R.N, MS. and Colleen Flynn, R.N., B.S.N.,
Bureau of TB Control, New York State Department of Health

 

 

Table 1

Number of Active TB Cases Detected Among B1/B2 Arrivals 1994 - 1997

Year

B1/B2 Arrivals

(N)

Active TB Cases

(n)         (%)

1994

323

6       (1.85)

1995

281

15      (5.33)

1996

302

15      (4.97)

1997

258

10      (3.88)

Total (1995-1997)

841

40     (4.76)

 


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