TB Notes Newsletter
No. 4, 2006
Surveillance, Epidemiology, and Outbreak Investigations Branch
9th Semiannual Meeting of the Tuberculosis Epidemiologic Studies
The 9th Semiannual Meeting of the Tuberculosis
Epidemiologic Studies Consortium (TBESC) convened July 12–13,
2006, in Atlanta, Georgia. The primary purpose of the TBESC is to
conduct epidemiologic, behavioral, economic, laboratory, and operational
research in TB prevention and control.
The goal of the meeting was to update consortium members on the
status of research projects, discuss and refine the process by which
research proposals are submitted and reviewed, and discuss the latest
study on new diagnostic tests for detecting latent TB infection.
Over 90 persons participated in the meeting. Attendees included
CDC staff, consortium principal investigators, project coordinators,
and project specific personnel.
Participants heard presentations from CDC, TBESC members, and invited
guests on a broad array of topics that included-
- Scientific updates from TBESC studies with new research results
- Administrative and fiscal updates on consortium-related activities
- Updates from the Bylaws and External Relations Committees, and
the Translating Research into Practice Workgroup
- The epidemiologic basis of TB control
Participants discussed modifying the process by which consortium
research proposals are submitted, reviewed, and awarded, and reexamined
the research agenda focus, goals, and research questions. The meeting
was productive and responsive to the mission of the TBESC.
—Reported by Christopher J. Kissler, MPH
Div of TB Elimination and
TBESC External Relations Committee
TBESC Task Order #10: Monitoring Performance and Measuring Cost
of Tuberculosis Public Health Practice at County and State Health
Departments: Are We Making a Health Impact?
In the past, TB public health evaluation focused on two questions:
- Are we headed in the right direction (objectives)? and
- Are we making efficient progress (performance)?
These two questions are usually asked of TB case management, contact
investigation, targeted testing, and outbreak investigation (action).
However, for the most part, these questions ignore TB case detection,
registration, and analysis (surveillance). Further, the question
of effectiveness is unasked, and often, local and state TB programs
remain unaware of missed opportunities to improve both efficiency
and effectiveness. Further, the limited evaluation efforts that
currently exist focus mainly on monitoring, with little to no in-depth
evaluation, which is required to know where and how to intervene
in response to poor performance. While objectives are established,
programs have few tools to monitor and evaluate progress toward
them in a user-friendly, Web-based, real-time manner.
Other evaluation areas remain problematic for TB managers. Program
costs come to the manager in the form of line items (e.g., personnel,
travel, or equipment). This does not allow costs to be translated
into specific public health activities. For example, a program manager
cannot answer the simple question, how much does it cost to perform
case management or outbreak investigation? This is because cost
data are not passed through what might be called an “interpretive
grid” into specific public health activities. Often intuitive
rather than data-driven decisions are made by program managers.
Cost is important to program, but is not generally considered for
evaluation. In recent years, TB budgets have shrunk, challenging
programs to do the same or more with less money. Knowing the cost
involved in running a successful TB program that achieves health
impacts is crucial, especially in the face of shrinking budgets.
Programs should and must be able to ask and answer questions such
as, what is the cost of each program activity, such as case finding
or case management? In what areas of my program is the most money
Task Order #10’s vision was to develop tools that will facilitate
quick, user-friendly monitoring and evaluation as a way to help
TB programs target interventions toward cost efficiency and improved
performance. The goal was to develop and implement simple, standardized,
Internet-based tools for TB programs that can be used to monitor
performance and measure costs. Task Order #10 achieved this goal.
The Florida Department of Health (FL DOH) and the University of
North Texas Health Science Center conducted this operational research
and developed two tools. These two simple, standardized, yet customizable
tools are based on an action-led conceptual framework that includes
eight core activities (detection, registration, reporting, confirmation,
analysis, feedback, acute response, and planned response) and four
support activities (communication, training, supervision, and resource
In phase I, we collected program indicators from a variety of national,
state, and local programs. We compiled these indicators in a database
totaling over 150 indicators mapped to the conceptual framework.
Task Order #10 sites held focus groups at multiple locations with
various levels of public health professionals ranging from nurses
to program managers, to determine which indicators were the most
useful. Group participants evaluated the indicators based on importance,
understandability, utility, availability, measurability, and cost
effectiveness. In phase II, we continued to collect and analyze
evaluation data from additional counties or regions at the two project
sites. In addition, the Task Order #10 teams began the process of
costing TB activities using the conceptual framework. In phase III,
we developed and refined the two tools.
The Florida Public Health Impact Tool (PHIT) assists TB control
programs in monitoring performance, evaluating established objectives,
examining related costs, and measuring the health impact of their
interventions. PHIT uses data readily available to TB programs to
calculate the costs associated with performance measures. These
calculations can focus on specific program areas such as surveillance
or contact investigation, look at program areas over time, and compare
across programs. By linking the cost to performance outcomes, PHIT
provides meaningful information that will help managers highlight
program accomplishments or investigate areas that need attention.
These evaluation findings provide useful data for improving TB programs
and advocating for resources.
Texas’ Tuberculosis Program Economic Decision Support tool
(TB EDS) can be used to assist TB control programs in modeling the
effect of changes in local conditions. TB EDS can be used to estimate
the resources required to achieve a level of performance and predict
the additional resources needed to meet changing conditions. The
ability to model the effect of changing conditions on performance
enables managers to maximize resources and increase program efficiency.
TB EDS can also be used to guide program staff in budget preparation,
contingency planning, and comparisons of alternative program components
|The Task Order # 10 team at the University of
North Texas Health Science Center campus during the Second Annual
Health Economic conference, October 2005.
The funding for Task Order #10 ends on September 30, 2006, but
our work will continue. Three peer-reviewed manuscripts have been
published, and five manuscripts are in preparation. Over our 3-year
project, 28 abstracts have been presented at various meetings, including
the National TB Controllers Association and American Evaluation
Association. We have given numerous oral presentations including
seven Division Brown Bag seminars. Two Economic Health Forums supported
by Task Order #10 were held on the campus of the University of North
Texas Health Science Center in 2004 and 2005. For a copy of our
bibliography, a description of Task Order #10 tools, or copies of
the tools themselves, please contact Bridget Young at firstname.lastname@example.org.
—Submitted by Bridget Young
Div of TB Elimination