TB Notes Newsletter
No. 4, 2006
Highlights From State and Local Programs
Los Angeles Presents "The Opera
and Perspectives on TB”
La Traviata by Giuseppe Verdi is considered by many to be the most
beautiful opera ever written. The opera was the first of three that
describe and depict cultural and societal perceptions about tuberculosis
(TB). Violetta Valéry, the heroine of Verdi's La Traviata, suffers
from consumption, or tuberculosis, and dies at the end of the opera.
In spring 2006, hundreds of Los Angeles Unified School District
teachers (K-12th grade) were attending the Opera for Educators series
and were scheduled to attend a performance of La Traviata at the
Los Angeles Opera in April. (Editor’s note: Los Angeles Opera’s
award-winning Opera for Educators series teaches about opera from
an interdisciplinary approach. It helps educators learn about opera
and the context in which it was created through discussions of opera
as history, as art, and as language and social documentary.) The
Los Angeles Opera Education Coordinator contacted the Los Angeles
County Tuberculosis Control Program and requested a lesson on TB.
As a result of this request, and with short notice, Los Angeles
County Tuberculosis Program Nurse Manager April King-Todd, RN, BSN,
MPH, prepared a 1-hour presentation entitled, "The Opera and
Perspectives on TB in the 1800s.” She gave the TB presentation
about 2 weeks before the date of the actual opera performance, in
the Los Angeles Opera rehearsal room.
The TB presentation interwove the historical significance of TB
with scenes from the opera, which is set in a time when the causal
organism and effective treatment regimens were unknown. The presentation
also included some very important TB educational messages for today.
The presentation stirred a tremendous interest in TB among the
participants, was well received, and was followed by very positive
written comments. Some of the teachers planned to incorporate the
TB information into their classroom lesson plans.
—Reported by Paul D. Moffat, MPA, MPH
Los Angeles County TB Control Program and
Div of TB Elimination
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Arizona’s and Sonora’s “Meet and Greet”
Program for Deportees with TB
The Arizona Department of Health Services (ADHS) and public health
officials in Sonora, Mexico, have conducted a collaborative “Meet
and Greet” program since 2002. The program addresses the problems
created when people with active pulmonary TB are deported before
their TB treatment is completed.
The “Meet and Greet” program involves the complex coordination
of binational public health organizations and US law enforcement
staff. Medical personnel from the Hospital General in Nogales, Sonora,
meet the deportees at the border and offer the TB patients an opportunity
to complete their treatment in Sonora. The coordination of this
process involves many different organizations and jurisdictions.
Communication and timing problems can impede the successful linkage
of the TB patient to the Sonoran medical officials. Some examples
of challenges include the following:
- Public health officials are not always notified in a timely
manner as to when the TB patient is going to be deported.
- Prisoners are often moved between correctional facilities, making
continuity of medical care difficult.
- Local health departments are not always aware of TB cases in
correctional facilities in their jurisdiction.
- Communication between Arizona public health, Sonoran public
health, and US law enforcement is not always adequate to properly
time the deportation and ensure the presence of Sonoran public
health officials at the border.
To improve the program, ADHS sponsored a Meet and Greet workshop
on June 18, 2006. A number of organizations and representatives
participated: an epidemiologist from the Hospital General of Nogales,
the TB Control Officer of the State of Sonora, US Immigration and
Customs Enforcement (ICE), US Quarantine Division, US Border Patrol,
US Marshal Service, Border County Health Departments, TBNet, Arizona
county jails, ADHS Border Health Office, ADHS TB Control Section,
Mexican National Institute of Immigration, and the Mexican Consulate.
Simultaneous translation into English and Spanish allowed all attendees
to be actively involved in the discussions.
The workshop began with an explanation of the steps involved in
the “Meet and Greet” program, including use of the
Binational Card (PDF). Communication, coordination, legal, immigration,
and public health issues were discussed, agencies’ roles were
identified, and a more detailed program protocol was agreed upon.
Multiple steps were recognized as necessary for program improvement.
Correctional facilities agreed to work on providing more advance
notice of deportation to public health officials. Local health departments
identified ways to improve coordination with local jails, prisons,
and ICE. ADHS consented to assist with TB education in correctional
facilities. ICE will continue to work on implementing the enhanced
protocol, including ways to place a medical alert in their databases
to ensure that prisoners will not be discharged without proper continuity
of care, and people who are re-apprehended will be rapidly identified
as needing evaluation for TB. ADHS will distribute an updated program
protocol to the participants. Having an accepted protocol will help
in identifying which steps of the process need improvement, as well
as assisting in measuring TB program indicators.
The Arizona Department of Health Services will continue fostering
collaborative efforts between the Meet and Greet partners by hosting
biannual conference calls and facilitating ongoing work groups to
continue addressing areas for improvement.
It is difficult to ensure continuity of TB care in people who are
being deported. However, in 2005 the “Meet and Greet”
program initiated continuity-of-TB-care arrangements for eight people,
and seven of these were successfully carried out (it is not yet
known if these patients completed therapy). The “Meet and
Greet” program is helping Arizona bring together the law enforcement
and public health community in a way that is increasing collaboration
between multiple agencies. This is expected to improve TB treatment
and TB control and to protect the public’s health, not only
in Arizona but in other states and in other countries as well.
—Submitted by Karen Lewis, M.D.
Arizona Tuberculosis Control Officer
Arizona Department of Health Services
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The Flex Power of MOAs
As the needs and challenges of TB control continue to evolve, programs
must adapt and find creative ways to deliver direct patient services
at the local level. One example of this need for flexibility is
in the area of agreements for TB services. As morbidity shifts and
changes, the Virginia Division of Disease Prevention-TB (DDP-TB)
has recognized the need to redirect resources to areas of demonstrated
need. DDP-TB has been exploring options for providing surge capacity
and response at the local level.
In the past, the DDP-TB had established Memoranda of Agreement
(MOA) with the local health districts solely to provide funds for
individuals hired as outreach workers (ORWs). These individuals
primarily deliver directly observed therapy (DOT) to TB patients
in a defined geographic area. These ORWs were dedicated to providing
TB services; funding for them generally covered salary, fringe benefits,
and travel. While this arrangement worked well in the past, TB morbidity
has shifted over time, and the personnel assignments did not follow
the shift. By moving toward an MOA for broadly defined TB services,
DDP-TB was able to easily shift funds to address the particular
needs of individual health districts. The new MOA also allows the
district to provide TB services that are language- and culture-specific
at the local level.
Under the new MOAs, the health district agrees to provide associated
administrative functions if the decision is made to hire an individual
to fulfill the functions of the MOA. These duties include recruiting,
interviewing, and hiring the individual. The district also agrees
to furnish the tools necessary to provide the TB services described
in the MOA such as training and supervision.
As part of monitoring the MOA, the district provides monthly activity
reports to document the services that were provided and the number
of patients seen. DDP-TB reviews these reports to ensure compliance
with the agreed-upon activities. DDP-TB provides technical support
and consultation, as well as training for individuals hired to provide
the services. DDP-TB also monitors the provision of services to
ensure that the standards of care are met, regardless of the individual
who provides the service.
We have learned several lessons from this experience. First, hiring
full-time, permanent employees to provide TB outreach services does
not allow the state program to easily redirect resources. Because
they are hired for very specific work activities, the employees
cannot be easily reassigned to other districts when morbidity changes.
Second, under the new MOAs, the health districts enjoy greater flexibility
in determining the best means of providing the TB outreach activities
in their jurisdiction. They are free to determine the most appropriate
personnel for the job based on factors such as the community, culture,
and language spoken. Lastly, having flexibility in how MOAs are
written with regard to services and timeframes allows DDP-TB to
use a statewide approach to TB prevention and control activities.
This approach leads to more efficient use of diminishing resources.
Submitted by Wendy Heirendt, MPA
CDC Public Health Advisor
Formerly with the Virginia Div of Disease Prevention;
Now with the CDC Div of Diabetes Translation
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HIV Status Not Routinely Determined for TB Cases: an Evaluation
of Four California Local TB Programs
Background. Many patients with active TB disease are also
at risk for coinfection with HIV. Timely detection of HIV coinfection
in TB patients has significant implications for diagnosis, treatment,
and contact tracing of both diseases. National and California guidelines
state that counseling and voluntary testing for HIV should be offered
to all patients with suspected or confirmed active TB, regardless
of risk factors (1, 2). However, national data show only
54 percent of all TB patients and 67 percent in the 25- to 44-year-old
age group in the United States had known HIV results in 2003 (3).
California has the highest TB caseload in the United States; 2,903
new TB cases (7.9 per 100,000) were reported in California in 2005
(4). The state also has a significant population of individuals
with AIDS; 140,435 AIDS cases were reported in California as of
March 2006 (5). A yearly match of the California Department
of Health Services (CDHS) Office of AIDS (OA) case registry with
the CDHS Tuberculosis Control Branch (TBCB) case registry found
AIDS matches for 4.1 to 5.7 percent of new TB cases per year for
the years 2000 to 2004 (6). HIV reporting has only recently
been implemented in California; thus, it is unknown if the proportion
of HIV-infected TB patients is actually higher. At present, very
little is known about HIV counseling and testing practices in TB
clinics in California. We set out to determine the HIV counseling
and testing practices that are in place at the local level, potential
barriers to providing HIV testing, and the degree to which the HIV
status of TB cases is identified.
Methods. We retrospectively evaluated local TB programs’
HIV counseling and testing practices for persons newly diagnosed
with active TB disease using a qualitative and a quantitative assessment.
Four local TB programs were selected based on their desire for inclusion
in the evaluation, their managing at least 50 TB cases in 2002,
and their having reported at least one patient with TB and AIDS
during 2001 to 2002. For the qualitative assessment, TB program
staff members were interviewed to determine the HIV counseling and
testing policies and procedures in place during the study period.
In the quantitative assessment, we reviewed the public health records
of a random sample of TB patients reported to CDHS TBCB in 2002
to evaluate the extent to which TB patients’ HIV status was
determined. This included information on whether TB patients had
received HIV counseling, whether they had HIV testing performed,
and the results of any HIV tests. A weighted sample of TB cases
were reviewed based on patient characteristics reported in the Report
of Verified Case of Tuberculosis (RVCT) by the four local TB programs
and results of the 2004 registry match between TBCB and OA case
registries. TB cases for chart review were prioritized to include
the evaluation of all reported TB/AIDS cases, all TB patients with
HIV risk factors reported on the RVCT (injection drug use, noninjection
drug use, and history of homelessness), all US-born TB patients
over 15 years of age, and a random sample of all remaining TB cases.
Analyses were performed using SAS version 8.2, SAS Institute, Inc,
Cary, North Carolina.
Results. The qualitative assessment showed that two (50%)
of the local TB programs had a written policy for HIV counseling
and testing. Three out of four (75%) had an explicit question regarding
HIV status included on the TB history or intake form. Perceived
barriers to HIV testing and documentation indicated by the four
local TB programs included lack of formal training or certification
of staff in providing HIV counseling (n=1); lack of standardization
in how HIV risk is assessed (n=1); no system to track the results
of patients who have been tested, especially for patients tested
outside of the TB program (n=1); lack of a formal process for requesting
HIV test results from patients managed outside the health department
(n=1); lack of privacy in assessing HIV risk if the assessment takes
place during a home visit (n=2); and cross-cultural and language
barriers associated with the subject of HIV (n=2).
Of the 252 TB patient charts reviewed, 29 patients (11.5%) entered
TB evaluation and care with a known positive HIV status. Of the
223 patients with an unknown HIV status, 193 (86.5%) had documentation
of HIV counseling and 128 (57.4%) had HIV testing performed. Of
the 128 patients tested with previously unknown HIV status, 106
(82.8%) were tested in the two local TB programs that had written
HIV counseling and testing policies in place. This represents 58.2%
(106/182) of TB patients in the two TB programs with implemented
written policies, compared to 31.4% (22/70) of TB patients in programs
without written policies. Of the tested TB patients, 84 (65.6%)
had documentation of the patient’s test results. Of patients
offered testing, 14 (9.7%) refused testing. Other reasons documented
for why TB patients did not receive HIV testing included lack of
risk factors, known positive HIV status, and a previous negative
HIV test result.
A total of 32 TB patients were found to be coinfected with TB and
HIV, and the HIV-positive status for three (9.4%) of those cases
was newly detected during TB evaluation and treatment. HIV status
was determined for a total of 138 TB patients (55%); 106 patients
had documented negative HIV test results in addition to the 32 coinfected
Discussion. Despite state and national policies for universal
HIV testing for TB patients, nearly half of the TB patients in the
participating four local TB programs had no HIV status documented,
representing missed opportunities for the identification of HIV
status among TB patients. Reasons for the missed opportunities included
a lack of HIV testing (because of patient refusal, lack of risk
factors, known positive status, or previous negative result), a
lack of documentation and follow-up of HIV test results, and lack
of a written HIV counseling and testing policy.
In this evaluation, TB clinics with a written policy were more
likely to test for HIV and also more likely to diagnose HIV infection.
However, it was not possible to determine the exact reasons for
this association. A written policy may directly influence the number
of TB patients tested, and could also be the result of knowledgeable
TB clinic staff who are already inclined to conduct HIV testing.
Regardless, such a policy is likely to raise awareness in TB clinic
staff, provide specific guidance surrounding testing, and thus lead
to increased HIV testing. A recent study of testing for latent TB
infection (LTBI) in HIV patients showed that attendance at a facility
with a written policy for LTBI testing was significantly associated
with increased testing (7). Such findings further support
the association of written policies for HIV counseling and testing
among TB patients with an increased likelihood of HIV testing.
“Testing for HIV” has been a measure frequently used
to assess practices of TB clinics, but this may not be the optimal
measure to reflect best practices. A better measure may be “identification
of HIV status” that is determined by either
- HIV testing with follow-up of results,
- known HIV-positive status, or
- documented negative HIV test result within last 6 months in
the absence of a recent possible HIV exposure.
The effectiveness of HIV detection in TB patients is further supported
by national guidelines stating that, in “…high [HIV]
prevalence settings (e.g., ≥1%), all clients should be routinely
recommended HIV testing...” (8). The statewide
TB/AIDS match already confirms that 4.1% to 5.7% of TB patients
had AIDS, and this evaluation showed that HIV testing increased
HIV/AIDS case finding in four local TB programs. In the chart review,
2.8% of TB patients whose HIV status was not previously known had
newly detected HIV infection identified during TB diagnosis and
evaluation. While these results come from a small sample of California
TB programs, it highlights that TB patients present an important
opportunity for detecting new HIV infections.
The results of this evaluation have been shared with the participating
local TB programs in order to improve local HIV testing practices.
In addition, subsequent collaboration with the California Office
of AIDS has identified the following ways to improve HIV testing:
- improve collaboration of HIV/AIDS and TB programs at both the
state and local level in order to increase the awareness and skills
of TB clinic staff;
- implement written policies for HIV testing of all new TB patients
in TB clinics; implementation can be facilitated by providing
local health jurisdictions with templates for HIV counseling and
testing guidelines; and
- consider the use of HIV rapid testing to increase the likelihood
that HIV results are known and documented.
Several factors may limit the generalization of these findings.
The results may not be applicable to TB patients residing in regions
with low TB or HIV/AIDS incidence or those outside of California.
Data presented may not account for instances where HIV testing information
was known to key staff, but not recorded in the TB public health
charts because of the confidentiality policies surrounding HIV information.
Also, if a 2002 coinfected TB or AIDS case was reported after the
registry match had been conducted in 2003, the case may not have
been included in this study. Nonetheless, the analysis indicates
that in mid- to high-TB morbidity counties in California, key HIV
counseling and testing practices are not in place.
Conclusions. Despite the fact that many TB patients are
at risk for HIV coinfection, HIV testing was not routinely taking
place in four California local TB programs. Improvements in HIV
testing policies and practices would lead to improved care and outcomes
for patients found to be coinfected with TB and HIV.
—Submitted by Elizabeth S. Lawton, M.H.S.
and Deborah M. Miller, M.B., Ch.B., M.P.H.
California Department of Health Services
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- CDC. Controlling tuberculosis in the United States: recommendations
from the American Thoracic Society, CDC, and the Infectious Diseases
Society of America.
MMWR 2005; 54 (No. RR-12):23.
- California Department of Health Services/California Tuberculosis
Controllers Association Joint Guidelines:
Guidelines for the treatment of active tuberculosis disease.
2003: 2. Accessed 6/9/2006.
- CDC. Reported Tuberculosis in the United States, 2004. Atlanta,
GA: U.S. Department of Health and Human Services, CDC: September
- California Department of Health Services, Tuberculosis Control
Indicator Project Indicator Reports. June 2006.
California AIDS surveillance report cumulative cases as of March
31, 20066, (PDF) Office of AIDS.
- Unpublished data. California Department of Health Services,
Tuberculosis Control Branch, TB Case Registry, May, 2006.
- Lee LM, Lobato MN, Buskin SE, Morse A, Costa S. Low adherence
to guidelines for preventing TB among persons with newly diagnosed
HIV infection, United States.
Int J Tuberc Lung Dis 2006; 10(2): 209-214.
- CDC. Revised guidelines for HIV counseling, testing, and referral
and revised recommendations for HIV screening of pregnant women.
MMWR 2001; 50 (No. RR-19):11.