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TB Notes 4, 2006
Director's Letter
Highlights from State and Local Programs
  Los Angeles Presents "The Opera and Perspectives on TB"
  Arizona's and Sonora's Meet and Greet Program for Deportees with TB
  The Flex Power of Memoranda of Agreements (MOAs)
  HIV Status Not Routinely Determined for TB Cases: an Evaluation of Four California Local TB Programs
CDC/ATSDR Group Award for Minority Health Mentor/Champion of Excellence
Laboratory Update
  New Technologies Unveiled at the 2006 National TB Controllers' Workshop
Nursing Updates
  The Red Snappers of National Tuberculosis Nurses Coalition (NTNC)
  Pacific Island TB Controllers Association (PITCA) -  Workshop for Nurses
TB Education and Training Network Updates
  Member Highlight
  Sixth Annual Conference Highlights
  Cultural Competency Subcommittee Update
Communication, Education, and Behavioral Studies Branch Update
  New Communication Efforts to Stop TB in the African-American Community
Clinical and Health Systems Research Branch Update
  Using a Private Claims Database for TB Health Services Research, Evaluation, and Analysis
Surveillance, Epidemiology, and Outbreak Investigations Branch Updates
  9th Semiannual Meeting of the Tuberculosis Epidemiologic Studies Consortium
  TBESC Task Order #10: Monitoring Performance and Measuring Cost of TB Public Health Practice at County and State Health Departments: Are We Making a Health Impact?
New CDC Publications
Personnel Notes
Calendar of Events
 
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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 TB-HIV patients.

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

  1. HIV testing with follow-up of results,
  2. known HIV-positive status, or
  3. 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:

  1. 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;
  2. 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
  3. 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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References

  1. 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.
  2. California Department of Health Services/California Tuberculosis Controllers Association Joint Guidelines: Guidelines for the treatment of active tuberculosis disease. (PDF)
    2003: 2. Accessed 6/9/2006.
  3. CDC. Reported Tuberculosis in the United States, 2004. Atlanta, GA: U.S. Department of Health and Human Services, CDC: September 2005.
  4. California Department of Health Services, Tuberculosis Control Branch, Tuberculosis Indicator Project Indicator Reports. June 2006.
    Accessed 06/09/2006.
  5. California AIDS surveillance report cumulative cases as of March 31, 20066, (PDF) Office of AIDS.
    Accessed 6/9/2006.
  6. Unpublished data. California Department of Health Services, Tuberculosis Control Branch, TB Case Registry, May, 2006.
  7. 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.
  8. 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.

 


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination - http://www.cdc.gov/tb

Please send comments/suggestions/requests to: hsttbwebteam@cdc.gov, or to
CDC/Division of Tuberculosis Elimination
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