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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 treatment. 

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 Chihuahua.

As a result of the trip, a number of follow-up activities were carried out:

  • 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 laboratory.
  • 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 Referral Program

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 requests);
  • 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 notifications.

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 msilin@health.nyc.gov. 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, Surveillance Office
Dawn Cummins, Interstate Coordinator
Muriel Silin, MPH, Assistant Director, Surveillance Office
Sonal Munsiff, MD, Assistant Commissioner
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 for improvement.

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 treatment.
  • 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 started treatment.

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 not infected.
  • 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 greater results.

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

Acknowledgments

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.

References

  1. 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; 287(8): 996-1002.
  2. Mohle-Boetani JC and Flood J. Contact investigations and the continued commitment to control tuberculosis. JAMA 2002; 287(8):1040-1042.
  3. Field K. Quality Assurance in Tuberculosis Control Programs. PowerPoint slides presented at Case Management and Contact Investigation Intensive Course, San Francisco, CA, March 2005.
  4. CDHS/CTCA. Contact Investigation Guidelines. California Department of Health Services, Tuberculosis Control Branch, 1998.
  5. DOH. WA Tuberculosis Contact Database. Washington State Department of Health, 1994-2004.
  6. 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.
  7. 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.

 


Released October 2008
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