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TB Notes Newsletter
No. 4, 2005
Hightlights from State and Local Programs
New Mexico DOH Collaborates to
Ensure Case Management of Multidrug-Resistant TB
A 26-year-old undocumented immigrant from Mexico
was taken into the custody of the U.S.
Marshals Service in southern New Mexico (NM) in August 2004. His
subsequent medical work-up in Doña Ana County, NM, Detention Center
revealed that he had active pulmonary TB resistant to isoniazid,
rifampin, and streptomycin (multidrug-resistant TB, or MDR TB).
The patient had been symptomatic for approximately 3 weeks prior
to diagnosis. Second-line therapy was initiated in September 2004
by medical staff of the detention center, under close supervision
by the New Mexico Department of Health (NM DOH) TB Program. A subsequent
contact investigation within the detention center detected 23 contacts,
19 of whom were TST positive, and all were started on a regimen
of pyrazinamide and ethambutol for treatment of latent TB infection
(LTBI). The patient successfully completed 4 months of treatment,
but then refused further treatment. Federal criminal charges were
dropped in January 2005 and the patient was transferred to Immigration
and Customs Enforcement (ICE) custody, at which time he was physically
transferred to the ICE Service Processing Center in El Paso, Texas,
to await an immigration hearing. While in El Paso ICE custody, the
patient was placed under strict isolation; he continued to refuse
Upon the patient’s arrival in El Paso, public health authorities
from New Mexico, Texas, and Mexico collaborated extensively with
officials from the Mexican Consulate, the US/Mexico Border Health
Commission, the Binational Project Juntos, the Migrant Clinician’s
Network (MCN)/TB Net, the Immigration Health Services, ICE, and
the El Paso Quarantine Station (EPQS) to ensure coordinated case
management pending the patient’s hearing and possible deportation
to Mexico. The plan was for ICE officials and an MCN/TB Net representative
to escort the patient to the international port of entry between
El Paso, Texas, and Ciudad Juarez, Chihuahua, and for public health
officials from Mexico to
receive the patient and transport him to an in-patient treatment
facility in Mexico. On
February 23, 2005, the patient received a hearing, and a court order
deportation ruling was issued. On February 24, public health officials
learned that the patient had been deported “after hours” to Mexico.
His deportation was not in accordance with prearranged case management
plans, and he was lost to follow-up for approximately 24 hours.
Officials from the Mexican Consulate, staff from Binational Project
Juntos, and the binational case management project (MCN/TB NET)
subsequently located the patient in a distant farming community
in Mexico. NM TB control
staff have been communicating on an ongoing basis with the Secretariat
of Health in Chihuahua, Mexico,
and with Mexican TB control officials in an effort to reinstate
case management for the patient and his family contacts. Dr. Muñoz,
director of the health jurisdiction for Casas Grandes, invited interested
individuals from the United States to come to Mexico to discuss
potential collaborative efforts, not only to put the patient back
on antituberculosis medications (possibly through the use of incentives),
but to potentially pool resources to address what appears to be
a cluster of MDR TB cases in the border area.
On June 6, 2005, representatives from the New Mexico TB Program
District III Public Health Office and the Border Environmental and
Epidemiology Center drove to Casas Grandes to meet with health officials
from the Chihuahua Department of Health. Dr. Muñoz and Dr. Magaña,
Medical Epidemiologist, met with them to discuss the binational
case of MDR TB and the contact investigation of this case. The NM
DOH TB program staff discussed a number of ways in which the NM
DOH may be able to assist the Chihuahua Department of Health with
the management of this case and the contacts, including provision
of chest x-rays for the patient and appropriate contacts.
On June 7, 2005, two physicians and two nurses from New Mexico’s
DOH staff accompanied Dr. Magaña and Dr. Acosta (a physician from
Janos, the closest town to the patient’s home) to meet with the
MDR TB patient and his close family members. The DOH medical team
included Dr. Simpson, the NM DOH Infectious Disease Medical Director;
Dr. Pastrana, NM DOH District III Public Health Physician; Ms. Tapia,
District III TB Nurse Coordinator; and Ms. Luna, District III Nurse
Practitioner. Unfortunately the patient had been sent by his employer
to work in a neighboring town and was not available to be seen by
the DOH staff. However, approximately 10 close family members were
located and evaluated. Plans were made by Drs. Magaña and Acosta
to perform PPD skin tests and chest x-rays, and to take sputum samples
on the appropriate family members. The sputum samples would be sent
to both the NM state lab as well as the Mexican lab facility in
As a result of the trip, a number of follow-up activities were
- Trip activities were communicated by Dr. Vilchis, Director,
Border Environmental and Epidemiology Center, NM DOH, to Mr. Dan
Reyna, Director, Office of Border Health. Dr. Vilchis and Mr.
Reyna updated the Chihuahua Secretary of Health on this visit
and on progress regarding collaborative activities.
- Dr. Vilchis is developing policies and procedures on communication
regarding binational TB cases and other infectious diseases.
- Velia Luna, CNP, delivered tuberculin skin test supplies to
Dr. Magaña at the Palomas/Columbus Binational Health Council Meeting
in Palomas on June 10, 2005, and will continue to collect sputum
samples from Mexican health authorities and submit to the NM state
- NMDOH TB control program staff will continue to assist Dr. Muñoz,
Dr. Magaña, and Dr. Acosta in the treatment of the MDR TB case
as requested. This may include assistance with obtaining the second-line
TB medications, if unavailable in Chihuahua, for treatment of
the case and the contacts.
- Chris Jameson, NM TB Program Manager, is working on developing
a binational provider agreement with a radiologist in Janos for
chest x-rays of the patient and contacts.
- The NMDOH TB control program established an e-mail group of
all participants for future communications.
- The New Mexico group is following up with internal conference
calls on an ongoing basis as well as binational conference calls
and e-mail correspondence with Drs. Magaña, Muñoz, and Acosta.
—Reported by Christine Jameson, MA
New Mexico TB/Refugee Health Program Manager
New York City’s Interjurisdictional
New York City (NYC) has a large number of major hospitals where
residents from neighboring counties and states often seek care.
In addition, NYC provides work to many who live elsewhere. Therefore,
many patients evaluated or undergoing treatment for TB may not live
in NYC, while others move to or leave NYC at some period during
their evaluation and treatment. Because of this high level of population
movement to and from NYC, the New York City Bureau of TB Control
(BTBC) deemed it a priority to have an efficient patient interjurisdictional
referral process, and in 2000 an Interstate Desk was created.
Prior to the creation of the Interstate Desk, BTBC case managers
were individually responsible for referring patients who moved from
NYC and for obtaining follow-up information. The Office of Surveillance
received referrals from other jurisdictions and forwarded the information
to the unit responsible for patient management. Case managers had
to ensure that patients moving to NYC were located and evaluated,
provided follow-up information to the referring jurisdiction, and
requested similar information for patients who left NYC. As a result
of the large number of staff responsible for patients’ referral
and follow-up, the notification process was frequently inefficient.
This nonstandardized notification procedure led to an excessive
number of BTBC staff calling other health departments for follow-up
information, complaints from other health departments, and often
inadequate follow-up and incomplete treatment completion information
for patients who moved from NYC to other parts of the country.
To facilitate the referral of and communication about TB patients
and their contacts who move to or from NYC and to ensure continuity
of care and evaluation of contacts who may be in another jurisdiction,
the BTBC created the Interstate Desk, which is handled by Interstate
Coordinators. The Interstate Desk is organizationally located within
the Office of Surveillance in the BTBC. In addition, the BTBC wrote
and implemented two protocols specifying the interjurisdictional
notification process within the United States
and internationally, available at www.nyc.gov/html/doh/html/tb/tb-controllers.shtml.
The Interstate Coordinator was given the responsibility for transferring
all TB patients (confirmed cases, TB suspects, their contacts, and
patients with latent TB infection [LTBI]) to or from NYC. A database
was also created, using Microsoft Access, to collect information
on all transfers and ensure timely and complete follow-up. The database
includes demographics, clinical information, and data on patients’
location, transfer, and follow-up.
The role of the Interstate Desk is to 1) coordinate the flow of
information for TB patients; 2) contact the patients’ new jurisdiction
to request timely feedback; 3) provide periodic updates to NYC case
managers on NYC patients who moved; 4) give follow-up information
to other jurisdictions; and 5) maintain the interstate database.
In the initial stages of implementation of the Interstate Desk,
there was limited staff cooperation: case managers continued to
refer patients directly to other jurisdictions, while receiving
staff could not understand why the Interstate Coordinator was requesting
follow-up information, and often did not cooperate owing to conflicts
with other priorities. To resolve these issues, both BTBC and other
health department staff were educated on the new procedure and its
benefits. Over time, both NYC BTBC staff and out-of-NYC health department
staff understood the benefits of the new procedure and have supported
the Interstate Coordinator.
The interstate database was designed to track interjurisdictional
patient referrals and facilitate timely notifications and follow-up
requests. The database also provides summary data on notifications
to and from NYC. During 2003–2004, outgoing notifications were made
for 741 NYC patients, including
- 89 notifications for NYC residents confirmed with TB who moved
within the United States (55) or internationally (34), and 80
for confirmed TB patients from other jurisdictions diagnosed by
NYC health care providers (71 cases from out of NYC and living
in the United States, eight cases diagnosed in NYC in foreign
visitors or temporary residents who moved internationally, and
one worksite contact investigation request);
- 141 referrals for follow-up on patients suspected of TB (136
within the United States,
three international notifications, and two worksite contact investigation
- 339 notifications for contacts of NYC cases and 66 for high-risk
LTBI patients and 21 requests for contact investigations outside
of NYC related to an NYC index case and five airline exposure
The Interstate Desk received 378 incoming notifications from out-of-NYC
jurisdictions for TB patients, including
- 20 notifications for NYC patients confirmed with TB diagnosed
outside of NYC (16 notifications for patients diagnosed in the
United States, one international notification, three requests
for contact investigations) and 58 notifications for persons confirmed
with TB elsewhere and moving to NYC (56 from within the United
States and two notifications from other countries);
- 37 notifications for patients suspected of TB and 61 for evaluations
of contacts, 188 referrals for high-risk LTBI patients, and 14
requests for contact investigations.
The centralization of interjurisdictional notifications achieved
its goal of streamlining referrals, ultimately improving communication
with other jurisdictions, increasing data completeness of final
outcomes for patients who left NYC, and reducing the workload of
BTBC case managers. Other benefits of centralized interjurisdictional
referrals include 1) unique expertise at the interstate desk; 2)
standardized procedures and data collection, ensuring timely notifications
and follow-up; 3) simplification of the process, allowing other
jurisdictions to contact only one BTBC staff; and 4) closer relationship
between the Interstate Coordinator and staff of other jurisdictions,
and thus improved ability to obtain information quickly. The streamlined
process ultimately helped ensure the proper and timely follow-up
of TB patients, clarified confusion, improved the assessment of
the final outcome of TB patients who moved to or out of NYC, and
likely contributed to more complete national data.
For more information, contact Muriel Silin at firstname.lastname@example.org. To make a patient
referral, e-mail the Interstate Desk at TBIntDesk@health.nyc.gov. Please guard
against including patient identifiers (names) in e-mail communications
to protect confidentiality. If an NYC Patient Number is known, that
number and the patient's initials can be used. Otherwise please
fax the interjurisdictional notification form to NYC’s confidential
fax number at (212) 788-4179.
—Submitted by Fabienne Laraque, MD, MPH, Director,
Dawn Cummins, Interstate Coordinator
Muriel Silin, MPH, Assistant Director, Surveillance Office
Sonal Munsiff, MD, Assistant
Bureau of Tuberculosis Control, New York City Department
of Health & Mental Hygiene
TB Contact Investigations and
Contact Case Management in Washington State: A Comparison Between
1994 and 2004
Contact investigations are critically important in the prevention
and control of TB. At the Washington (WA) State Department of Health,
contact summaries are completed each quarter; however, activities
and results have never been compared over time to determine if improvements
have been made in the contact management process. To refine the
process of contact investigation, it is necessary to proactively
seek opportunities for improvement. Bailey et al. emphasize this
point in a study designed to test a predictive model for identifying
positive tuberculin skin test (TST) results in contact investigations.1
The model was specifically designed to help health workers conserve
resources by reducing the number of contact investigations performed.
Mohle-Boetani and Flood also stress the need for improving the focus
of contact investigations in order to increase efficiency when public
financial resources run low.2
Through the introduction of the California State guidelines and
cohort review process, WA State has made significant efforts in
improving TB contact investigations and case management, therefore
increasing efficiency. In 1997, the WA State TB program introduced
the California State contact investigation guidelines as a reference
tool for contact investigations and case management of TB. Six
years later, the program implemented the cohort review process as
a model for quality assurance and quality improvement.3
The California State guidelines serve as a reference tool for quality
assurance in contact investigations, and offer protocols for activities
such as interviewing infectious TB patients, establishing contact
investigation priorities, interviewing and assessing contacts, and
ensuring the timely and appropriate medical management of TB contacts.4
With this essential tool, TB case managers are able to evaluate
their efficiency and aim to meet set standards, as opposed to solely
estimating the quality of their performance.
Cohort review is another means of quality assurance and quality
improvement, through the systematic review of TB patients and their
contacts. Each quarter, expert clinicians, TB program managers,
local health jurisdiction health workers, and epidemiologists convene
to review TB cases according to standard case management criteria
in order to assess individual patient outcomes. Cohort review
and the accompanying analysis are tools for increasing general TB
knowledge, holding case managers accountable, identifying strengths
and weaknesses of current strategies, pinpointing areas for targeted
improvement, and offering opportunities for TB program staff to
interact. It is similar to clinical and programmatic "grand
rounds" in the TB field. The reviewers observe and
ask questions as local TB program staff present their TB case
summaries and describe the disposition of each case. It is
an opportunity for both learning and accountability. In addition,
the review process has led to increased consciousness in regard
to benchmarking, or creating targets based on the top
performance standards for the industry, and therefore, greater excellence
in tracking and managing TB cases is produced. For example,
WA State DOH has put forth the goal of ensuring that 95% of TB patients
complete their course of treatment within 12 months, with 85% of
those patients participating in directly observed therapy (DOT).3 Achievement
of this goal can be directly tracked through the process of cohort
review, resulting in the greater likelihood of success. As a result
of this detailed accountability and case management, overall incidence
of TB cases will likely decrease and outcomes will improve.
Presently, Washington may be the only state that has implemented
cohort review statewide. However, the method was pioneered by the
International Union Against Tuberculosis and Lung Diseases and first
implemented in the United States
by New York City. To date, several other program areas have received
training in the method, although we have not surveyed them to assess
their progress. A few program areas have adapted the method to fit
their own needs, including Georgia,
Utah, and Nassau County and Rockland County in New York. Additionally,
cohort review training has been provided to staff in the states
of Florida, Hawaii, Illinois, Massachusetts, Missouri, and New York,
and in the cities Chicago, IL; Detroit, MI; Hartford, CT; Philadelphia,
PA; and Washington, DC.
As a result of these efforts, we in the TB Program of WA State
believe that improvements in contact investigations and contact
case management have been made since the introduction of the guidelines
and the cohort review process in 2003. In order to evaluate this
possibility, we compared data from 1994, prior to any formal guidelines
or cohort review, with data for 2004, following the adoption of
the guidelines and review process. The primary question was, How
well were TB contacts managed in 1994 and 2004 as demonstrated by
selected summary indicators? The results of our analysis offer a
glimpse into the improvements made as a result of both aforementioned
tools and suggest opportunities for continued improvement.
The following is a summary of the findings, taking into consideration
the fact that the completeness of data of the two time periods is
not comparable. In 1994, though the TB Program used the same contact
database it uses today, it did not collect and analyze the data
concurrently. Collected data were reported, but data not submitted
were not proactively retrieved and entered into the database at
that time. The following data were retrieved from the WA State TB
contact database5 and CDC’s Tuberculosis Information
Management System.6 The results are divided into two
areas: those that show improvement and those that reveal a need
Areas demonstrating improvement
- There was a decrease in total infectious TB cases from 1994
to 2004, with 260 cases in 1994 and 244 cases in 2004.
- In 1994, we found 3,144 contacts of infectious TB cases, with
a mean of 19.4 and a median of 6.5 contacts per case. 2004 showed
a marked difference, with only 973 contacts found for infectious
cases (mean of 7.37 and a median of 4.0 per case). The fact that
the median is closer to the mean in 2004 indicates it is a more
accurate picture of contacts per case.
- The number of infectious patients with no contacts found remained
essentially the same: 110 (42%) in 1994 and 112 (46%) in 2004.
The reason for this plateau is unclear and warrants further analysis.
- In 1994 there were no contacts reported as lost to follow-up
(not started on treatment). However, this is probably the result
of incomplete data. In 2004, six (1%) were reported as lost to
- In 1994, we tested and evaluated 701 (22%) contacts for infectious
TB. However, in 2004, the proportion more than doubled, with 505
(52%) tested and 506 (52%) evaluated out of the total number of
contacts, revealing improvement.
- Of those who were evaluated in 1994, 381 (54%) were found to
be infected and therefore eligible for treatment, with only one
(0%) found to be diseased. Of those evaluated in 2004, 256 (51%)
were found to be infected and eligible for treatment, with 14
(3%) found to be diseased. Though the national average of infectivity
to contacts is less than 0.1%7, this large yield of
infected contacts seems to imply that targeting has been honed
through guidelines and regular review. Analysis of future data
is warranted in conjunction with close attention to the overall
incidence of TB statewide.
- Vast improvement was revealed with respect to the treatment
of contacts. In 1994, only 85 out of 381 (22%) eligible contacts
started treatment, while in 2004, 190 of 256 (74%) eligible contacts
Areas revealing a need for improvement
- Of those who started treatment, 42 (33%) were not infected
in 1994, while 53 (22%) were not infected in 2004. It is unclear
why these individuals were started on treatment when they were
- According to the contact summary data in 1994, none of the 127
contacts who started treatment are recorded as having completed
it in 365 days. This reveals an incomplete 1994 database. Data
are not yet complete for 2004 to date, as only 34 (14%) are recorded
as having completed treatment, leaving 156 (64%) currently on
treatment. Given the length of LTBI treatment regimes, analysis
will need to be completed closer to the end of 2005.
- In 1994, no contact was reported as refused treatment, lost
to follow-up, deceased, or moved, giving further reason to believe
the data are incomplete, making it impossible to know what degree
of improvement was achieved in 10 years. In 2004, 13 (5%) refused
to continue treatment, 11 (5%) were lost to follow-up, 2 (1%)
died, and 1 (0%) moved.
These findings reveal the differences in contact investigation
procedures between 1994 and 2004. Overall, this comparison shows
current better prioritization of contacts: even though significantly
fewer contacts were found, a greater proportion were tested and
evaluated, resulting in our detecting an expected number of diseased
contacts with less effort. In addition, the proportion of eligible
contacts starting treatment greatly increased from 1994 to 2004,
while the proportion of eligible ones with no treatment greatly
decreased. Therefore, time and energy are now being spent more efficiently
on a reasonable number of contacts, allowing for greater quality
of case management. One obvious problem noted was the gap in data
regarding the number of contacts who are currently on treatment
or have completed treatment. It must be acknowledged that the means
by which the TB Program collected and recorded data in 1994 was
not adequate, therefore resulting in missing data. Data in 2004
are more dependable because of the use of an improved contact database.
Though contact information needs to be reviewed yearly, it would
be beneficial to continue use of the California guidelines, cohort
review, and contact database, and perform another assessment in
2014, offering a more reliable 10-year comparison. A future analysis
would more accurately reveal the degree of valid improvement if
the process of data collection remained the same from 2004 to 2014.
What have we learned in 10 years?
- We are much better at prioritizing contacts and therefore more
efficiently managing resources to find secondary disease. As a
result, we uncovered a greater number of diseased contacts in
2004 than in 1994.
- We are better at ensuring that eligible contacts receive treatment
and minimizing the number of eligible contacts not receiving treatment.
- We are better at tracking those who are completing treatment
by regularly updating the database.
- We have improved by not starting as many uninfected contacts
on treatment, thus saving resources. Improvement needs to continue
in this direction.
- There is a need for improvement in identifying contacts for
TB cases. We continue to have a high proportion of cases with
no contacts identified.
Overall, it can be concluded that the California contact investigation
guidelines and the process of cohort review have been beneficial
to the TB program of Washington State with reference to contact
investigations, though this analysis does not reveal which has had
the greatest effect. The comparison of summary indicators between
1994 and 2004 reveals that improved contact investigation methods
together with the accountability of cohort review have increased
efficiency and likely saved resources. With continued use of the
California guidelines and cohort review, the process of contact
investigation will probably be more sharply honed and produce even
Editor’s note: Cohort review educational materials (including videotape
and guide) have been developed and will be available in late 2005.
—Submitted by Jana Glessner, RN, BSN
Washington State TB Control Program
I would like to acknowledge the following individuals who significantly
contributed to this project by offering time, support, guidance,
and knowledge in their fields of expertise: Kim Field, RN, MSN,
TB Program Coordinator, WA State Dept of Health; Alexia Exarchos,
MPH, Epidemiologist, WA State Dept of Health; Bill Bower, MPH, Director
of Education and Training, Charles P. Felton National TB Center,
Harlem Hospital, New York City; and Erin Piskura, MPH, TB Surveillance
Coordinator, WA State Dept of Health.
- Bailey W, Gerald L, Kimerling M, Redden D, Brook N, Bruce F,
et al. Predictive model to identify positive tuberculosis skin
test results during contact investigations. JAMA 2002;
- Mohle-Boetani JC and Flood J. Contact investigations and the
continued commitment to control tuberculosis. JAMA 2002;
- Field K. Quality Assurance in Tuberculosis Control Programs.
PowerPoint slides presented at Case Management and Contact Investigation
Intensive Course, San Francisco, CA, March 2005.
- CDHS/CTCA. Contact Investigation Guidelines. California
Department of Health Services, Tuberculosis Control Branch, 1998.
- DOH. WA Tuberculosis Contact Database. Washington State Department
of Health, 1994-2004.
- CDC, Atlanta, GA: U.S.
Department of Health and Human Services. Tuberculosis Information
Management System (TIMS); version 1.20.42. Licensed to Washington
State Department of Health, 1994-2004.
- Jereb J, Albalak R, & Castro K. The Arden House Conference
on Tuberculosis, revisited: perspectives for tuberculosis elimination
in the United States.
[Electronic version]. Seminars in Respiratory and Critical
Care Medicine 2004; 25(3): 255-269.