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U.S. Department of Health and Human Services

  

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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 videophone equipment;
  • 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 DOT.

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 DOT observed

Average miles/ visit @ $.365 per mile

Average travel time/ visit @ $20/hr (salary + benefits)

Total miles @ $.365 per mile

Total travel time @ $20/hr (salary + benefits)

282

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, 2004

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 DOT.

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 as follows:

  • 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 disease.

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:

Image of Nurses attending the meeting, categorized 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

 


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