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TB Notes 4, 2004
No. 4, 2004
HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS
San Diego County Implements Video DOT Program
The San Diego County TB Control Program has implemented a program
that uses videophones to provide directly observed therapy (DOT)
for selected patients currently receiving TB treatment. This program
is being tested to determine its effectiveness as a safe and reliable
method to supplement the existing in-person DOT program.
San Diego County reported 316 cases of active TB during 2003. Fifteen
public health nurse (PHN) case managers working out of six regional
offices provide case management for all patients with active TB.
DOT is the initial adherence strategy for virtually all patients.
The PHN case managers, in association with eight outreach workers,
are responsible for providing all DOT visits. Traffic delays, travel
distances, patient availability, and language barriers are only
some of the challenges faced by staff members who provide DOT in
San Diego County, which covers more than 4,200 square miles with
a population of over 2.9 million.
The first videophone was installed in a patient’s home in San Diego
County on March 23, 2004. The program served a total of 12 patients
during the first 3 months of operation.
Each patient begins treatment with standard in-person DOT provided
by a PHN or outreach worker. Patients are selected for participation
in the video DOT program based upon the PHN case manager’s assessment
using the following criteria:
- Patient has successfully completed at least 2 weeks of in-person
DOT with 100% adherence;
- Patient has a stable residence with an appropriate place for
- Patient is motivated and has family or other social support;
- Patient understands the need for TB treatment;
- Patient has the ability to accurately identify each medication
and pour his or her own medications;
- Patient speaks a language that can be accommodated by video
DOT personnel; and
- Either travel distance or time of patient’s availability makes
video DOT a good option.
The patient signs a consent form prior to participating in the
program. The consent clarifies that participation is voluntary and
the patient may opt to return to in-person DOT at any time during
treatment. The patient agrees to return the equipment to the health
department upon completion of treatment or discontinuation of video
The videophones purchased by the program have a 4-inch screen and
connect directly to a standard telephone line. The PHN sets up the
videophone in the patient’s home and instructs the patient in the
use of the videophone and in video DOT procedures. The PHN observes
the first video DOT session in the patient’s home. After video DOT
is established, the PHN visits the patient at least monthly for
routine visits and as needed to address any problems that arise.
Video DOT is observed and documented centrally at the TB control
program office. A staff person who has also been introduced to the
patient calls the patient at a mutually agreed-upon time. While
one staff person is primarily responsible for observing the video
DOT, other staff members who speak a variety of languages are available
to provide assistance with interpretation as needed. There have
been few technical problems in observing video DOT. On rare occasions
there may be some difficulty in establishing the video connection.
Redialing to establish a better connection has solved this problem.
During the first 3 months of the program, 282 video DOT observations
were completed for 12 patients. Travel savings calculated for this
implementation phase are summarized in the table below. The average
distance of 19.1 miles per visit results in a saving of nearly $7.00
per visit in mileage expenses. Salary savings listed in the table
are for typical outreach worker staff and account for an average
of $10.40 per visit. These salary savings are even greater when
visits are observed by a PHN. These calculations cover only travel
time and personnel expenses during travel, and do not include the
actual amount of time spent during the visit. Typical video DOT
visits last 2 to 3 minutes, while in-person DOT visits may last
10 to 15 minutes.
Travel time and mileage saved in the 3-month implementation phase
of the video DOT program:
Total # Video
visit @ $.365 per mile
time/ visit @ $20/hr (salary + benefits)
Total miles @
$.365 per mile
Total travel time
@ $20/hr (salary + benefits)
19.1 miles @ $.365 = $6.97
31 minutes @ $20/hr = $10.40
5378 miles @ $.365 = $1963
146 hours @ $20/hr = $2,920
The cost benefits of the program are evident after only 3 months
of experience using video DOT. The minimum estimate of nearly $5,000
in savings on travel expenses and staff time is impressive and is
anticipated to increase as more patients participate in the program.
Patients are enthusiastic about the convenience and flexibility
that video DOT provides. There were no DOT failures during the 3-month
implementation phase, and all patients chose to continue with the
program once it was established.
The program purchased 40 videophones at a cost of less than $200
per unit ($8,000 total). Savings realized in operating the program
will soon cover this initial expense. If the videophones prove to
be reliable, they will be used multiple times with no need to incur
additional equipment costs. With the possibility of as many as 35
participants in the video DOT program at any one time, this program
has the potential for significant cost savings while providing safe,
convenient, and reliable DOT services for patients. In addition,
staff can be shifted to other priority activities, such as contact
investigation, while still providing excellent patient adherence
services for the community.
—Submitted by Linda Bethel, PHN IV
San Diego County TB Control Program
TB Strain with Strong Persistence and with Highly
Efficient and Rapid Transmission to HIV-Infected Patients, Louisiana,
The Louisiana Office of Public Health TB Control Program detected
a cluster of TB cases caused by the same organism, identified through
restriction fragment length polymorphism (RFLP) fingerprinting.
These cases were highly infectious, with multiple failures of directly
observed therapy (DOT) for latent TB infection (LTBI) with isoniazid
(INH, sometimes abbreviated as H), and with extremely virulent and
rapidly transmissible organisms.
The source patient, Patient A, identified in November 1998, was
diagnosed with sputum smear–positive TB and started on a standard
adult treatment regimen of isoniazid, rifampin, pyrazinamide, and
ethambutol (HRZE). Treatment compliance was adequate, recovery was
satisfactory, sputum-smear conversion occurred within the first
2 months, and the patient was considered cured upon completion of
6 months of DOT. Six household contacts and five nonhousehold contacts
of Patient A were evaluated, using Mantoux tuberculin testing, with
infection rates of 100% (6/6) and 60% (3/5) respectively. In Louisiana,
two different regimens for the treatment of LTBI are used. For children
and HIV-infected persons, the recommended duration of LTBI treatment
is 9 months. For all others, the recommended treatment duration
is 6 months. All contacts with LTBI were treated with either the
6-month or the 9-month INH regimen, as appropriate.
In July 1999, Patient B, one of Patient A’s children and a member
of the household, was diagnosed with sputum smear–positive TB, with
the same organism. A standard adult treatment regimen (HRZE) was
used. Again, treatment compliance was adequate, recovery was satisfactory,
sputum-smear conversion occurred within the first 2 months, and
the patient was considered cured upon completion of 6 months of
In November 1999, Patient A was rediagnosed with sputum smear–positive
TB, once more with the same TB organism. It is not clear whether
the relapse was due to reactivation of previous disease or reinfection
from Patient B. Patient A was re-treated with PAS (A) and ciprofloxacin
(C) in addition to the standard drugs (HRZE). Once again, treatment
compliance was adequate, recovery was satisfactory, sputum-smear
conversion occurred within the first 2 months, and the patient was
considered cured upon completion of 8 months of DOT. Six additional
nonhousehold contacts of Patient A were investigated, with an infection
rate of 88% (5/6). All contacts with LTBI were treated with INH
for either 6 or 9 months.
In February 2004, Patient C, one of Patient A’s grandchildren living
in the same household, was diagnosed with sputum smear–positive
TB. The same organism was identified. Patient C is currently on
a directly observed regimen of INH, rifampin, pyrazinamide, and
streptomycin (HRZS), is recovering well, and had sputum smear conversion
within the first 2 months. Of the five household contacts of Patient
C who were investigated, all were infected (infection rate of 100%).
In addition, an infection rate of 55% (31/55) was found in high-risk
nonhousehold contacts. In low-risk nonhousehold contacts, however,
the infection rate was as low as 2% (1/52). Once again, all contacts
with LTBI were treated with INH for either 6 or 9 months.
Recently, three more cases were diagnosed with sputum smear–positive
or culture-positive TB, due to the same organism. They are summarized
- In February 2004, Patient D, a step-grandparent and household
contact of Patient C, was diagnosed with culture-positive TB.
- In May 2004, Patient E was diagnosed with sputum smear–positive
TB. Patient E was never named as a contact of Patient C. However,
after RFLP matching, both cases were linked, with less than 3
hours’ exposure. Patient E is known to be HIV infected.
- Also in May 2004, Patient F was diagnosed with culture-positive
TB. Again, Patient F was not named as a contact of Patient C.
After RFLP matching, however, Patient F was also linked to Patient
C, having had occasional exposures totaling less than 4 hours
per month. Patient F is also known to be HIV infected.
This case review shows that, in spite of prompt diagnosis and appropriate
treatment of the cases, thorough contact identification and investigation,
and adequate treatment for LTBI with INH, transmission of infection
and occurrence of disease persisted. Infection rates for Patients
A and C were 100% among high-risk household contacts, and were consistently
high, even among high-risk nonhousehold contacts. The failure of
INH treatment for LTBI to prevent disease, at least in Patient C,
and possibly in Patient B, is an unusual finding. INH treatment
for LTBI has been proven highly (at least 85%) effective at preventing
Of note, documented transmission to Patients E and F, both HIV
infected, was the result of very limited and short contact with
Patient C. Even with an extremely timely and thorough TB contact
investigation, this type of almost casual exposure usually will
be missed. A high index of suspicion for HIV-infected contacts is
obviously warranted, but in reality, the HIV status of contacts
is often not known or not disclosed. As a result, it is advisable
that all known HIV-infected persons, being highly susceptible to
TB infection, have routine and regular tests for LTBI and TB disease.
Treatment for LTBI is recommended for all coinfected persons. Timely
assessment of risk and adequate prevention of TB will unquestionably
improve the health and prolong the lives of HIV-infected persons.
—Reported by Peter Vranken, RN, DPH, MBA
EIS Officer, Office of Workforce and Career Development
Assigned to the Infectious Disease Epidemiology Section,
Louisiana Office of Public Health
and Carol Williams
Regional TB Manager, TB Control Section
Louisiana Office of Public Health
Southeastern TB Nurse Consultants’ Meeting
On September 30, 2004, nurses representing Florida, Kentucky, Louisiana,
North Carolina, South Carolina, Virginia, and CDC convened during
the Annual Southeastern TB Controllers’ Meeting held at the Ritz
Carlton in New Orleans. Presentation and discussion topics
included state reports; safety syringes, with information on retractable
technology, by Kathryn Duesman; an NTNCC update, a correctional
facility needs assessment, and staffing standards activities by
Ellen Murray of Florida; and the Goal Attainment Scaling Project
by Judy Gibson.
All the presentations were excellent, but those on safety syringes
and retractable technology stood out, since "standard precautions"
are recommended in every arena of health care, including TB skin
testing. Nurses are among the greatest number of users of syringes
and needles in patient care, and are at risk for needlestick injuries
from the "old-fashioned" syringes and needles with which
many nurses are familiar. The presentation and demonstration provided
by Kathryn Duesman of Retractable Technology, Inc., reinforced the
need for TB nurses to have access to a safety syringe that is practical
and easy to use, and that also provides the precision required when
administering a skin test. Thus, the information about the
new safety devices, how they work, and why they are necessary to
the health and safety of nurses and other health care workers was
of extreme interest to the group.
It had been several years since this group of nurses joined forces.
All participants agreed that being familiar with their counterparts
is beneficial not only to facilitating county and state TB program
operations, but more importantly to improving the quality of patient
services and care as public health nursing is challenged to maintain
expertise during the 21st century. We look forward
to the meeting next year in Kentucky, and challenge our TB controllers
to have travel funds available.
—Reported by Roma Oliveri, RN, MSN
Nurse Consultant, Louisiana TB Control Program
Nurses attending the meeting, by state:
Front row, from left: David DeBiasi-VA-ALA, Donna Perkins-KY, Ellen
Murray - FL, Judy Gibson-CDC, JoAnn Arnold-FL, Julie Luffman-NC
Back row, from left: Jane Moore-VA, Elizabeth Zeringue-NC, Debra
Ray-SC, Myra Allen-NC, Roma Oliveri-LA