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TB Notes 4, 2003


Missed Opportunity and Diagnostic Delays Lead to Multiple Secondary Cases

On July 11, 1994, a 34-year-old African-American female presented to the local health department with a complaint of productive cough, chest pain, weight loss, fatigue, and difficulty breathing. She indicated that she was a contact of a previously reported TB case patient; however, the case patient had not named her as a contact. Her tuberculin skin test (TST) result was 28 mm with blistering. Her chest x-ray was read as "abnormal - not TB." Sputum specimens were collected and submitted for smear and culture, with all results negative for AFB. After she failed to return to the clinic for her final culture results, clinic staff attempted to contact her, by telephone and then by letter, to refer her to her private physician for further evaluation. She did not respond, and her file was closed to public health follow-up. In retrospect, we now realize that the health department's action in closing her case without consideration of preventive therapy constituted a missed opportunity.

Missed opportunities like the one detailed above have been observed in many areas of the United States, and represent some of the most painful lessons learned by field staff. However, another missed opportunity is the failure to diagnose TB in a timely manner, thus delaying initiation of field activities designed to interrupt transmission of TB. To illustrate this point, please consider the rest of the story, which involves the same patient 8 years later.

On August 27, 2002, the patient (by then 42 years old) reported to the emergency room of Hospital A, a moderately sized regional medical center. The patient complained of headache and a severe cough, stating that she had experienced these symptoms before. The physical exam revealed pharyngeal erythema, lymphadenopathy, and a purulent nasal discharge.The patient was diagnosed as having sinusitis, and was sent home with Bactrim (sulfamethoxazole-trimethoprim), prednisolone, and a cough suppressant. Total time for the visit was 2 hours and 24 minutes.

Three months later (on November 21, 2002), the patient returned to the emergency room of Hospital A. She complained of a 4-month cough, fever, chills, nausea, and vomiting. The physical exam revealed wheezing and pharyngeal erythema. A nursing note also documents that the patient reported having a sore throat. A chest x-ray was done at this visit, and the report reveals "Extensive infiltrates throughout the left lung. An area of cavitation is seen in the left upper lung field … there has been a significant change compared with the older study of 8/31/01.” 1 The patient was diagnosed with bronchitis and sent to the respiratory therapy department for breathing treatment with a bronchodilator. A note from the respiratory therapist states that "the patient tolerated treatment with no complications." The patient was then sent home with a cough suppressant. Total time for this visit was 5 hours and 38 minutes.

Shortly after her second emergency room visit in Alabama, the patient traveled to Texas with her adult son, his wife, and their four children. Patient and family made this 12-hour road trip in a passenger van. Approximately 1 month later (on January 9, 2003) the patient reported to Hospital B in Texas. According to the patient, the emergency room staff released her with a presumptive diagnosis of the flu. Two weeks later, the patient returned to the emergency room at Hospital B and was diagnosed with pulmonary tuberculosis. The local health department was notified, and TST results were positive for the adult son, his wife, and their four children. All six were placed on preventive therapy by TB control staff in Texas.

Information regarding the index case's diagnosis followed two separate tracks. The adult son in Texas notified the two adult daughters (residents of Alabama), and urged them to report to the health department. The State of Texas also reported the identification of this index case via the Interstate Reciprocal Notification process. Upon notification of their mother's TB diagnosis in Texas, the two adult daughters in Alabama reported to the local health department for evaluation. A contact investigation was initiated, resulting in the identification of eight secondary cases of TB, seven of which were found in children ranging in age from 1 to 11 years. Two of the child contacts were confirmed as cases via gastric aspirate, and the remaining five all met the clinical case definition for TB. The eighth secondary case was identified as the son-in-law of the index case, and was confirmed by culture. All cases in this cluster are pansensitive. An additional 11 contacts in Alabama were identified with latent TB infection: six adults and five children who were 4 years of age and younger. All of these contacts were placed on preventive therapy.

Missed opportunities and diagnostic delays facilitate transmission of tuberculosis and the development of secondary cases. This is not a new phenomenon, yet discussion of this problem generally focuses on failures in the contact investigation. As evidenced by the public and private response in Texas, contact investigations are more likely to be successful in preventing disease when TB is suspected and diagnosed early. Public and private providers must “think TB.”

This case study reinforces a proposal made by Alabama's Division of Tuberculosis Control in December of 2002. At that time, the Division's first Annual Training Plan was prepared and submitted for review. While Alabama has long supported training for TB field staff, the Annual Training Plan includes two new goals: provider education and expansion of the basic training (e.g., TB 101) to include community partners such as emergency room staff, infection control practitioners, and others.

We are pleased to report that one of these goals (expansion of basic training) will be achieved this year. Our TB 101 class has been opened to community partners from the Alabama Sheriffs Association, the Alabama Department of Corrections, and infection control practitioners. We continue to work toward our second goal of "provider education," and are confident that these training efforts are both achievable and sustainable.

—Submitted by Racine Waddell, RN, Nancy Keenon, MPH, and Scott Jones, Sr. PHA
Alabama Div of TB Control

Implementing Cohort Review in Washington State

The cohort review method has been synonymous with New York City and its successful increase in TB treatment completion rates, which over time has contributed to a sustained reduction in the number of TB cases. Starting in 2002, the Washington (WA) State Department of Health TB Program explored the feasibility of implementing cohort review at the state level. Foremost in the minds of program staff was the question: Why should we take on this challenge when we are already swamped with other work and are already doing a pretty good job with oversight of our cases? The methods, including staff motivation, that were used to take on this challenge will be described in this article. In a subsequent article, lessons learned and the outcomes stemming from implementation of cohort review in WA State will be discussed.

General Information about the Cohort Review Process in New York City
Cohort review is a systematic review of patients with tuberculosis (TB) disease and their contacts. A “cohort” of patients from a specific period of time (usually 3 months) is reviewed in terms of individual patient outcomes and program performance. Thus it is a management process used to motivate staff, identify program strengths and weaknesses, determine staff training and professional education needs, and hold staff accountable for completion of treatment for both TB disease and latent TB infection (LTBI).

Case managers know that their day-to-day efforts will be reflected in the cohort review several months later and that they are accountable for the services they provide. The review also allows clinical staff to ask expert clinicians and managers about patient care. Most important, when cohort reviews are being conducted, patients are less likely to “fall through the cracks” and receive inadequate care. Since cohort reviews began in New York City, the treatment completion rate there has increased from less than 50% to 93%. The components of the cohort review process are highlighted below.

  • Case management – Every patient reported as a TB case is assigned to a case manager, whether he or she is seen at a health department clinic or in the private sector. Case managers are responsible for ensuring that patients adhere to treatment, comply with medical visits, and complete treatment. Case managers are also responsible for making sure that contacts are identified and evaluated, and complete treatment for LTBI, if appropriate.

  • TB registry – Each patient’s case is documented in a computerized database of information about all persons with suspected or confirmed TB disease and their contacts. This could be the TB Information Management System (TIMS) or a locally developed database, which gives the “universe” or cohort of patients to be reviewed.

  • Supervision and teamwork – Supervisors provide timely review and assistance to the health team. Through periodic reviews, they make sure there are no loose ends in managing each case. Case managers coordinate efforts of the clinical team and the outreach workers who identify contacts, do skin testing in the field, refer infected contacts to clinics, and return missing patients to service.

  • Preparation – Supervisors and case managers prepare the case reviews to be presented by participating in biweekly reviews and a 2-month review by the medical manager. These periodic reviews ensure that all the case details are in place, from initial interview to compliance with and completion of treatment to contact investigation. Staff also get a chance to develop their presentation skills.

  • Presentation – Case managers follow a specific format in presenting detailed information about each case (demographics, site of disease, bacteriology, radiology, treatment, adherence, completion, contact investigation). The director and medical manager have an opportunity to ask pertinent questions, which are clarified by the case manager, supervisors, or colleagues.

  • Review – Based on the case reviews, data about outcomes and programmatic indicators are tallied manually or by spreadsheet. The results are summarized to provide a “report card” for that quarter’s TB control efforts.

  • Follow-up – After the cohort review session, staff update the registry, address problems that were identified, prepare a summary report for managers, provide medical consultation as needed, and develop staff training if such needs were indicated.

Why Cohort Review in WA State
Cohort review has been successful in New York City, but are there enough compelling reasons for implementing it in Washington State? Would it make a difference in a medium-morbidity setting that is geographically much larger than one metropolitan jurisdiction? Would it be a huge effort to undertake -- and for what gain? All of these questions were discussed and debated before the decision was made to begin implementation of this process.

In 2002, WA State reported 252 cases with a case rate of 4.1 per 100,000 persons, representing a 5% decrease in the state case rate as compared with 2001 (4.3 per 100,000). In addition to the WA State TB Program Manager, there are two Nursing Consultants who are responsible for oversight of cases in the northern and southern regions of the state. The Nursing Consultants provide oversight of TB cases and technical consultation to the local health jurisdiction staff who provide direct management of TB cases. Oversight is not provided by the Nursing Consultants for the TB Program in Seattle & King County, which has a large separate program with a TB Program Director, TB Program Manager, Nurse Supervisor, and six nurse case managers. Seattle & King County by itself has approximately 160 cases a year.

The WA State TB Program Manager and one of the Nursing Consultants had attended cohort review presentations and observed cohort review in action. Both were very interested in using this method at the state level with the goal of eventually involving local health jurisdiction nurses who provide direct TB case management. Their excitement and enthusiasm was helpful in convincing other staff that this process would confer benefits, even if it might be time consuming.

We concluded that there were many positive reasons for implementing cohort review in WA State. Adopting this method would assist in improving treatment completion; Washington State’s completion of therapy rate had been 95% in 1997 but dropped to 89% in 2001. Our goal is to maintain or exceed the national objective of 90% completion of therapy in WA State.

Only 68% of infected contacts 15 years of age and older initiated treatment for LTBI in 2001 and 67% completed treatment in 2000 in WA State. Thus, another compelling reason to implement cohort review was to improve rates of initiation and completion of treatment of LTBI, especially for infected contacts 15 years of age and older, in order to meet national TB program objectives.

With planning and discussions about the 2005 CDC Cooperative Agreements starting in 2002, we thought cohort review would be imperative for ensuring that cases and contacts are appropriately and effectively followed from initiation of screening to completion of therapy. State programs will be evaluated based on performance and achievement of national and state objectives. Implementing cohort review in WA State, in addition to improving case management, will be very useful for program evaluation.

After numerous discussions, staff agreed that this was a worthwhile effort for improving case management, ensuring completion of therapy, and meeting or exceeding national objectives.

Many meetings were held with the WA State TB Program Manager, the Nursing Consultants, the epidemiologist, the surveillance coordinator, the data entry compiler, and our CDC Consultant to ensure that everyone understood the purpose and process of cohort review. Information was gathered from the Bureau of TB Control, New York City Department of Health and Mental Hygiene, and the Charles P. Felton National Tuberculosis Center on their process, methods, and tools.

We adapted the cohort review process for WA State and decided which cohort of TB cases to review at which point in time. A timeline was developed and decisions were made about appropriate outcome measures to evaluate, such as timeliness of lab collection and of receipt at the lab, and starting therapy after TB disease is suspected. The cohort review form was obtained from New York City and modified to meet WA State’s needs and to add timeliness measurements that were felt to be of value in conducting programmatic evaluation.

Roles and responsibilities were clarified. The role of the epidemiologist was to analyze case and contact data based upon outcome measures that the TB program determined to be of importance to evaluate. For instance, in WA State, timeliness of reporting, adherence to medication, and HIV testing were added to the analysis as outcome measures. In addition, a data dictionary was created so that everyone involved in the cohort review would be familiar with the outcome measures. The TIMS and the WA State TB Contacts Database were analyzed to provide case and contact summaries.

Cohort reviews were initiated at the beginning of May 2003 and another session was conducted at the end of May with state staff including the TB Program Manager, two TB Nursing Consultants, and the state TB epidemiologist. Bill Bower from the Charles P. Felton National TB Center and Judy Gibson, CDC Consultant, also participated in this first cohort review. Cases counted between April and June 2002 and those counted between July and September 2002 were reviewed in May. Cases counted between October and December 2002 were reviewed at the end of July. In addition, nurse case managers as well as the TB Program Director and other staff from Seattle & King County participated in cohort review for the first time in July 2003. We wanted to become more accustomed to the cohort review process initially, so we conducted them more frequently than the quarterly New York City model. Beginning in November 2003, cohort review sessions now occur on a quarterly basis with a review of cases counted about 8-10 months prior (for example, in November, cases counted January to March 2003 were reviewed).

The TB Nursing Consultants prepared for and presented the cases while the Program Manager served as the facilitator. Preliminary analyses of cases and contacts were provided at the beginning of the cohort review. After the cohort review sessions, the Nursing Consultants worked with the local health jurisdiction nurses to follow up on questions raised during the case presentations. Final analyses of cases and contacts were provided for the previous cohort at the following cohort review session.

The implementation of cohort review in WA State has been a team effort. Extra time was required to adapt the New York City model to the needs of WA State. In addition, all staff had to be clear about the process, methods, and roles and responsibilities. It was worth the effort to have many discussions with staff. The methods and process have been altered periodically, with everyone recognizing and accepting that cohort review is a work in progress.

At the time of this writing, four cohort review sessions have taken place. Staff from Seattle & King County have collaborated with state staff to make the cohort review process comprehensive and successful. The TB Nursing Consultants have found these reviews to be helpful with state-level case oversight, especially as the cases are being reviewed and feedback is provided on treatment completion rates for cases and contacts. We will be sharing this method with local health jurisdiction (LHJ) staff in order to conduct future cohort review sessions with the LHJ case managers who provide direct care of the cases.

For further questions about cohort review in WA State, please contact Trang Kuss by telephone at (360) 236-3465 or by e-mail at For additional questions about the cohort review method, please contact Bill Bower at the Charles P. Felton National Tuberculosis Center by telephone at (212) 939-8258 or by e-mail at

—Submitted by Trang Kuss, RN, MN, MPH, Nursing Consultant
and Kim Field, RN, MSN, Program Manager,
Washington State Dept of Health TB Program,
and Bill Bower, MPH, Director of Education and Training,
Charles P. Felton National TB Center,
with Dr. Masa Narita and staff, Public Health–Seattle & King County TB Program

New Training Initiatives by the TB Education Center, Texas

The Tuberculosis Education Center (TBEC), an affiliate of the Texas Department of Health (TDH)/Texas Center for Infectious Disease, is pleased to announce the launch of three new training initiatives dealing with binational TB control along the Texas/Mexico border, the newly released TB treatment guidelines, and TB/bioterrorism (BT) linkages. As is the case with all TBEC courses, our goal is to ensure that health professionals participating receive up-to-date information and the highest quality training, so that at the completion of training they will have the enhanced skills needed for dealing with the problems they face on the front lines in the battle against TB.

Binational Programs: The Director of the TB Education Center, Barbara Seaworth, MD, has long been involved with the treatment of TB in the state of Texas and is recognized nationally as an expert on drug-resistant TB and MDR TB. In addition to treating patients at the Texas Center for Infectious Disease, Dr. Seaworth is the TB Consultant for the State of Texas and the Binational Project, and provides consultation services nationwide. Her experience with TB patients along the US-Mexico border resulted in the formation of the TB Education Center, with the assistance of the Health Education Training Center Alliance of Texas (HETCAT), developing cross-border training events in conjunction with the US-Mexico Border Health Association, the Ten Against TB (TATB) technical committee, the El Paso Health Department, the TDH Region 9 Office, and the TDH Region 8 Office in Del Rio. Training courses were held on September 10 and 11, 2003, in Juarez, Mexico, and on September 12 in El Paso, Texas, to address the issues of TB in correctional facilities on both sides of the border and the complications caused by the transient nature of correctional populations and the free movement of individuals across the US-Mexico border. Attendees and presenters came from both sides of the border during the 3 days of training; it is hoped that the exchange of information will lead to a higher level of cooperation and result in greater success rates in the treatment of TB in the Juarez/El Paso metropolitan area. Training also took place in Ciudad Acuna, Mexico, on September 4, and was designed primarily for area doctors and nurses, with US as well as Mexican presenters and participants. As a result of these cross-border efforts, the TBEC hopes to include similar training events in 2004 as part of our goal of providing comprehensive TB training to health care professionals in the Texas area and Mexican communities along the US-Mexico border.

TB Treatment Guidelines: After serving on the TB Committee of the Infectious Diseases Society of America, which reviewed and provided input for the development of the new TB treatment guidelines, Dr. Barbara Seaworth recognized the immediate need to disseminate the information in the guidelines to public health practitioners. The first step TBEC took in this direction was to create a poster for distribution to clinicians, hospitals, and other providers. The poster presents in a concise, “quick-reference” format, the new treatment guidelines.

Step two was TBEC’s course, “New Approaches to TB Treatment,” first presented on May 23, 2003, at the TDH Region 7 Headquarters in Temple, TX. Participants included public health technicians, administrative support staff, nurses and doctors from the public and private sectors, and staff of civilian as well as military facilities. The participants were not only eager to learn about the new approaches to TB treatment, but were also open about sharing their own experiences in treating difficult TB cases. Following the enthusiastic response to training in Temple, the course was offered in San Antonio July 14, 2003, and the course is scheduled for presentation of the next 18 months to ensure coverage for the remainder of the state. The “New Approaches” curriculum includes an overview of the new TB treatment guidelines geared for licensed TB clinicians. The presentation is enhanced by review and discussion of how the guidelines were used by Dr. Seaworth in her recommendations for management of cases on which she has consulted. The course also includes case studies that are selected and presented in order to specifically illustrate pertinent points in the guidelines. Course participants are guided in working through the case and determining the proper management approach required. Each exercise concludes with a facilitated discussion of the case, the recommended course of treatment, and a question and answer period. Future dates for this course will be posted on the TBEC Web site.

Two conferences entitled “Exploring TB/BT Linkages” were held in Dallas and San Antonio, Texas, in December 2003. These programs were developed to show the experiences of TB programs and the applications to bioterrorism preparedness against airborne pathogens. Using the TB module, the presentations underscored the role of public health protection as practiced by TB programs throughout the state. Linkages between TB and BT were described in terms of signs and symptoms, index of suspicion, physician and nurse public health expertise, diagnosis, case finding, contact investigation, infection control practices (including isolation and administrative, environmental, and personal protection programs), existing communicable disease laws designed to protect the public health, the dual use of resources such as those that provide for Level II Laboratory capabilities, and the communication of epidemiology data and analysis in outbreak situations.

For further information about the TB Education Center and its courses please visit the TBEC Web site:

—Submitted by Faye McCarthy, RN, and
Stephanie Ott, TB Education Center
Texas Dept. of Health

1 A search for records associated with an emergency room visit or hospitalization on 8/31/01 was initiated. Only the chest x-ray report was available for review. This report revealed left lung abnormalities as well, and that a "CT scan is suggested for evaluation of a possible nodule." No CT scan was obtained.


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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