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TB Notes 1, 2003

Highlights from State and Local Programs

The First MDRTB Patient in Los Angeles County
Detained at Home by Court Order

This article relates the interactions of a CDC public health advisor (PHA) with the first chronically contagious multidrug-resistant TB (MDRTB) patient detained at home in the County of Los Angeles. The experience gave the PHA not only an opportunity to learn about the complexities of providing for home detention, but also a chance to witness how the interactions between the TB Control Program and patients with TB affect disease prevention efforts.

The patient, a 72 year old Asian male, was first diagnosed with active TB in 1962 in Viet Nam. He came to the United States in 1978. He was nonadherent with multiple treatment attempts over the years, and in 1985 the patient was diagnosed with MDRTB by the County of Los Angeles Department of Health Services.

Numerous challenges subsequently evolved between the patient, the TB Control Program, and the County health center that was responsible for managing the case. The health center staff noted that the patient repeatedly and persistently asked the local health staff to perform his sputum and X ray tests, despite the fact that his strain of M. tuberculosis is resistant to all known TB drugs; because of this, health center staff thought the patient was trying to be difficult. More importantly, he was not willing or able to follow either the TB physician's advice or the conditions outlined in the containment agreement that he had signed, so that the TB Control Program had to try increasingly restrictive means of securing the patient’s adherence. A containment agreement is a contract between the patient and the County health center that sets forth certain patient behaviors or activities that are necessary to prevent transmission of TB to other persons. Containment is a less-restrictive alternative to civil detention. Two of the conditions set forth in the containment agreement were that the patient wear a mask whenever he is in public and that he notify the County health center of his activities and whereabouts. However, the TB Control Program learned that the patient was working at the garment factory that his son owned, entering a local restaurant, and entering a local market to purchase Chinese and Viet Namese language newspapers without either notifying the health center or wearing a surgical mask.

Another condition to which he had agreed was that no one outside the family could enter his home without authorization from the health center. On one occasion, a public health investigator from the local health center noted more shoes than usual on the front porch of the patient’s house (per Asian custom, shoes are not worn inside a house; thus, Asian family members typically leave their shoes on the front porch). The local health center staff counseled the patient, reminding him of the conditions of the containment agreement. Unfortunately, some of the County health center staff began to believe that this patient could not be trusted or reasoned with and that his flagrant disregard for the containment agreement indicated that he had no respect or consideration for himself, his friends and family members, or the community.

As a result of the problems noted above, the Los Angeles County TB Control Program served an Order of Civil Detention to this patient in June 1999. The patient was taken to a regional TB detention center in Lancaster, California, where he was detained for 4 months. After court hearings and negotiations between the TB Control Program, county counsel, and the patient’s attorney, a judge ordered the patient to be detained in his home. The order detaining the patient in his home contained many conditions, one of which was that the patient’s whereabouts be electronically monitored. The patient was required to wear an electronic ankle bracelet that allowed him only 150 feet of roaming space. The 150-foot boundary constituted the patient’s home and front and back yards. If he moved farther than the specified 150 feet, the monitor would send a signal to the monitoring company, and the monitoring company would then notify a designated TB Control Program staff member. A local health center staff member would then be notified that the patient had left his yard and a staff member would go to the patient’s home to investigate. County health center staff were to visit on a random basis to assess the patient’s compliance with home isolation.

In January 2000, the CDC PHA was asked to help coordinate the TB Control Program Detention Unit. One of his main duties was to work with this particular patient. As a liaison between the patient, the health center, and the TB Control Program, this PHA was responsible for the following tasks:

Determining why he was not willing or able to cooperate with the health department;

Determining if the patient understood his diagnosis of MDRTB;

Re-educating the patient on the contagiousness of his disease and the potential for transmitting his multidrug-resistant strain of TB;

Bridging the language barrier;

Learning more about the patient’s lifestyle; and

Attempting to assist the patient and his family during his confinement by taking the patient’s wife to the grocery store (she doesn’t drive), arranging for a Chinese-language newspaper to be delivered to the patient's home, and generally functioning as a liaison between the patient and the health department.

The PHA worked closely with this patient for many months and, after a period of time, developed a rapport with him. The patient and his wife were initially unsure of the PHA’s motives, but eventually they began to trust him. Over time, the patient also came to trust the County health department in general. One indicator of this trust was that the patient finally shared with the PHA that he had been taking Chinese herbal medicine in the hope that it would cure his TB. He confided that he was also eating specific exotic foods because he believed that these foods would strengthen his lungs and eventually help his body to get rid of the TB germs. He also gave his reason for asking the local health center staff to do the sputum and X ray tests so frequently: he was anxious to know if the Chinese herbs and the foods he had been eating were having any effect on his disease. Even though there was no medicine to treat his disease, he refused to give up hope. He had actively researched new information treatments for his disease and had also read many articles that claimed that TB can be cured through Chinese medicine.

Eventually, as mutual trust continued to develop between the County health department and the patient, alternatives to the electronic ankle bracelet were pursued. The court finally determined that the patient no longer had to wear the electronic ankle bracelet. As an alternative to that monitoring system, the TB Control Program decided to experiment with a computerized voice verification system. The voice verification system is a telephone based system designed to verify the patient's voice print. The computer at the monitoring company generates random calls to the patient's telephone. When the patient answers the telephone, he is required to recite a series of numbers. This voice sample is then compared to the patient’s original voice print that was created during the enrollment process so that the computer can determine that the voice it hears is in fact the patient's voice. After a short trial period, it was determined that the language barrier again was a problem; because of this patient's difficulty in following instructions in English and his accent, the voice verification system did not work for him.

After the failed attempt with the voice verification system, the TB Control Program briefly considered using the global positioning satellite system (GPS). The GPS is able to track a person’s movements via satellite. To be tracked, the person must carry a portable device wherever he goes. The portable device creates a record of every place the person travels, the length of time he visits each place, and the speed and direction of travel. "Hot zones" can be established if a person is forbidden from traveling to a specific area. Ultimately, GPS was rejected because the TB Control Program believed that it was impractical to require the patient to carry around a device the size of a shoebox whenever he left his home.

Since the patient’s whereabouts were no longer being electronically monitored, it became the responsibility of the local health center staff to randomly monitor the patient’s activities. The patient was still detained to his home, so the health center staff were responsible for ensuring that the patient remain in his home or on his property. The staff conducted the monitoring simply by knocking on the patient’s door at random periods throughout the day to determine if the patient was in his home and unauthorized visitors were not present.

With the passage of time, the patient has been granted more liberty. He takes walks 7 days a week on a designated route that is periodically monitored by the local health center staff, and the local health center staff are still conducting regular sputum and X ray tests. As a representative of the TB Control Program, the CDC PHA continues to assist the patient and his wife with their grocery shopping and anything else they may need. Currently, the director of the TB Control Program is consulting with CDC, the National Jewish Medical Center, and other agencies on a possible new treatment for this patient.

Several valuable lessons were learned through working with this patient. The foremost lesson is that patients must be approached with cultural sensitivity and that interactions with all patients must be in a language that is easily understood by the patient. The increasing numbers of MDRTB cases among foreign born persons highlight the need for effective communication between TB Control Program staff and patients. It cannot be assumed that because a person can engage in limited conversation in one language, the same language can be used to provide complex information and instruction. This patient can converse to a limited extent in English, but English was not the appropriate language in which to provide information about his disease, legal issues, or anything else binding or of importance. One solution to the problem of bridging a language barrier is for trained interpreters to be used whenever necessary. In addition, TB control programs throughout the country should follow the lead of Los Angeles County and seek creative ways to detain a person outside of a hospital or other restrictive setting should long-term isolation be required. Every patient is a unique individual, so we must not use a one-size-fits-all approach to detention. One day, new and potent drugs may become available to treat TB in the many patients who have multidrug-resistant TB. However, until that day comes, language and cultural barriers must be overcome so that we can provide care in a culturally competent manner.

-Reported by Kim Do
CDC Public Health Advisor
Los Angeles TB Control Program

Minnesota Holds Statewide Videoconference on
Conducting TB Contact Investigations


In October 2002, the Minnesota Department of Health (MDH) Tuberculosis (TB) Prevention and Control Program held a half-day interactive videoconference entitled “Controlling the Transmission of Tuberculosis (TB) in Your Community: Performing Effective TB Contact Investigations,” for local (county) public health department staff statewide. The purpose of the videoconference was to assist local public health personnel in strengthening their TB contact investigation skills and to introduce a new procedure manual and a revised MDH TB Contact Investigation Report form, which will be implemented for all TB contact investigations statewide in January 2003. MDH TB Program staff worked with our agency’s Distance Learning Coordinator to plan the logistics of the videoconference. Regional sites were reserved at 12 locations throughout the state to ensure that, despite the state’s large size, no participant would have to travel more than 100 miles to attend. The regional sites provided the added benefit of bringing public health nurses from adjoining counties together to discuss common issues and concerns about TB. Participants included 112 local public health professionals, representing 76 of Minnesota’s 87 counties and two of Minnesota’s 11 tribal governments. Presenters included epidemiology and nursing staff from the MDH TB Program and a public health nurse from the largest of Minnesota’s three public TB clinics.

Contrary to national trends, the incidence of TB in Minnesota is steadily increasing. A large proportion of TB cases in Minnesota occur among persons born in countries where TB is common, adding new challenges to traditional TB control activities. But despite an overall increasing incidence rate, TB disease is a rare occurrence in many counties in Minnesota. In 2001, 28 of the state’s 87 counties reported at least one TB case, with county-specific numbers ranging from 1-140. Clinicians may be unfamiliar with current recommendations for collaborating with public health professionals to facilitate adequate TB contact investigations. When a case of infectious TB occurs, it is critical that a contact investigation be conducted in a timely and thorough manner, using limited local public health resources in an effective manner and ensuring that the community is protected from further transmission of TB.

Data for infectious TB cases reported in Minnesota from 1998 to 2001 indicate that although 97% of sputum smear-positive cases had contacts identified, only 60% of those contacts were fully evaluated. In addition, among infected contacts of cases reported from 1998 to 2000, only 70% of those who started treatment for latent TB infection (LTBI) completed an adequate course of therapy. These findings do not meet national objectives for TB contact investigations, yet they are consistent with recent national studies that have indicated that the processes and outcomes of TB contact investigations conducted by health departments in the United States need improvement.

According to Minnesota’s “Common Activities Framework,” which defines the roles of state and local public health agencies statewide regarding communicable disease prevention and control activities, it is the responsibility of each local Community Health Service (CHS) agency to “designate staff within the CHS agency to have communicable disease responsibilities for TB” and to “assure (that) contacts of infectious TB patients in the CHS jurisdiction are identified, located, evaluated, and followed appropriately.” Similarly, the Common Activities Framework states that it is the responsibility of MDH to “provide local public health agencies with a list of minimum expectations for the local TB control nurse,” “provide technical assistance to CHS agencies to assure a thorough contact investigation is conducted for each infectious TB case,” and collect data on contact follow-up from CHS agencies.

A large portion of the conference was spent covering step-by-step procedures for TB contact investigations, as outlined in a new resource manual. The purpose of the manual is to provide information that will enable local public health professionals to conduct timely and complete contact investigations surrounding cases of infectious TB residing in their jurisdictions, to utilize the system of collaboration between local agencies and MDH to maximize the effectiveness of TB contact investigations, and to implement revised data collection procedures for reporting results of TB contact investigations to MDH. The manual includes follow-up algorithms and documentation forms, and discusses measures for maintaining confidentiality of private medical data. Also included are copies of pertinent CDC Self-Study Modules, the CDC Core Curriculum on Tuberculosis, ”TB Interviewing for Contact Investigation” materials from the New Jersey Medical School National Tuberculosis Center, a template letter for notifying health care facilities of infectious TB cases seen in their facilities, a suggested script for use during contact investigation interviews, national TB diagnostic standards, MDH recommendations for targeted testing and treatment of LTBI, and information regarding additional materials available from CDC, the national TB centers, and MDH.

The videoconference also included a review of the transmission and pathogenesis of TB; the rationale and responsibility for conducting TB contact investigations; recommended contact investigation procedures, documentation and reporting procedures, infection control measures, suggestions for using incentives and enablers in contact investigations, cultural considerations, and guidelines for making interjurisdictional referrals. A 45-minute segment of the videoconference was devoted to a discussion led by the head public health TB nurse in Hennepin County (Minneapolis) about the practical aspects of conducting a TB interview and field investigation, and cultural considerations for working with foreign-born persons. Three question-and-answer sessions were provided to encourage questions and comments from participants at all locations.

The costs of the videoconference were modest and consisted primarily of the photocopying and assembly of the manual and course materials, postage, courier services to deliver course materials to the regional sites, refreshments for participants, and the copying of a videotape of the conference for distribution to local agencies to train future staff. Most participating counties provide videoconferencing facilities free of charge for use by public health workers, and the public health nurse from Hennepin County TB control donated her time. CDC and New Jersey Medical School National TB Center materials were provided at no cost to MDH. There was no charge to participants, although their agencies were responsible for transportation costs incurred by their staff.

Participants completed pretests and posttests. Preliminary evaluation shows that scores improved significantly after completion of the course. The success of the videoconference will also be measured by indices such as the timeliness of future TB contact investigations, completeness of data reported, and evaluation measures reported on ARPE reports submitted to CDC. Evaluations completed by participants were overwhelmingly positive. Participants indicated after the videoconference that they better understood their role in conducting TB contact investigations, believed they would be more thorough in educating patients about TB, and would be more organized, confident, and persistent when conducting TB investigations in the future.

-Submitted by Deborah Sodt, PHN, MPH,
Nurse Consultant, TB Prevention and Control Program,
Minnesota Department of Health

Multilingual TB Education Hits Hawaii’s Airwaves

Since July 2002, the Hawaii Tuberculosis Control Program has been reaching out to the islands’ immigrant communities in an innovative way. Through a partnership with Honolulu-based KNDI-AM radio and a grant from the Chamber of Commerce of Hawaii, the TB Control Program has been given radio airtime to use for tuberculosis education.

KNDI prides itself in being one of Hawaii’s most diverse and well-established radio stations. Ethnic communities have been listening to the station for 42 years, and today it broadcasts in 13 different languages. Listeners can tune in to KNDI on all eight Hawaiian Islands, from urban Honolulu to isolated Niihau.

Providing TB information to Hawaii’s ethnic communities ranks as a top priority, since foreign-born people are at highest risk for TB in Hawaii. In 2001, 83% of the state’s TB cases were born outside of the United States. Over the past year, Hawaii’s Targeted Testing Program has screened 490 foreign-born persons living in Hawaii. Out of this group, 247 people (more than 50%) were found to have latent TB infection or TB disease. Out of the patients who started TB treatment in this group, 85% have completed, or are in the process of completing, their course of medicine.

Publicizing these free Targeted TB Testing services to the foreign-born community marked the beginning of the relationship between the Hawaii TB Control Program and KNDI radio. The station has a tradition of featuring social and community issues of interest to non-English speaking audiences. To make this possible, the station’s non-profit offshoot, the Ethnic Education Foundation, applies for grants that fund multi-lingual educational programs. When the TB Control Program expressed interest in increasing their presence on the station, the Ethnic Education Foundation helped to secure a grant from the Chamber of Commerce of Hawaii Public Health Fund to cover one year of bimonthly TB education radio programming.

With 24 half-hour time slots to fill, the station’s bilingual radio hosts and TB program staff have been busy developing radio shows. Planners are experimenting with interviews of TB doctors and outreach workers, patient “talk story” sessions, ethnic music, and other social and health topics affecting newly arrived immigrants.

Hawaii’s Marshall Islander community will be the target audience for a special month-long series of TB radio shows. This community was chosen for three main reasons. First, Marshallese are overrepresented in Hawaii's TB cases. From January 2001 through October 2002, 5.2% of the state’s TB cases were born in the Marshall Islands, yet only about 0.5% of Hawaii’s citizens are Marshallese. Second, since this is a relatively new ethnic community in the Islands, there have been limited health education materials developed for Marshall Islanders living in Hawaii. Requests for Marshallese health education materials far outweigh what currently exists. Finally, TB program staff have reported high levels of noncompliance among their Marshallese patients, and requested that an intervention be implemented.

The Republic of the Marshall Islands (RMI) is an independent nation of 34 atolls and islands located between Australia and Hawaii in the Pacific Ocean. RMI is signatory to the Compact of Free Association with the United States, a relationship rooted in U.S. defense interests in the islands. Owing to the free association status, people from the Marshall Islands can live and work in the United States without restriction, and Hawaii has become a popular destination for Marshallese seeking jobs, education, or medical care.

Josephine Hunter, a Honolulu college administrator originally from the Marshall Islands, along with her husband John Hunter, the program director for the American Lung Association of Hawaii, have agreed to host the radio shows in a mix of English and Marshallese. The series will feature special guests from Hawaii’s Marshallese community, staff from the American Lung Association and the TB Control Program, and music and news from the Marshall Islands. The TB messages in this program will emphasize the risk factors for TB, the signs and symptoms of TB, the importance of completing the full course of TB medicine, and the free services that are available from the Hawaii TB Control Program.

After these programs are aired, Hawaii’s TB health educator will make tapes and CDs of the TB shows to give to Marshallese patients who are on TB medication. It is hoped that the audio information will begin to fill the need for appropriate health education materials. Patients who listen to the program audios will be asked questions about the usefulness of the information so that the effectiveness of this initiative can be evaluated.

In addition to the Marshallese language, TB shows have already aired on KNDI’s Laotian, Vietnamese, Samoan, and Visayan (a Filipino dialect) programs. The station’s Spanish, Ilocano, Tagalog, and Cantonese shows will also focus on TB at some point in the year. Special programming is being planned for World TB Day 2003, and for the grand opening of Hawaii’s new TB clinic in early 2003.

Through a partnership with the State’s Bilingual Health Services Program, the TB Control Program has access to a pool of bilingual workers who speak all languages in which the TB radio shows will be aired. Therefore, the listeners of all shows will be able to receive services and educational materials from the TB clinic in their own language.

Overall, KNDI radio has been an ideal partner in the effort to raise TB awareness in Hawaii. The station’s radio personalities are respected community leaders, and have contributed greatly to the development of effective and culturally appropriate TB education programs for Hawaii.

In the near future, select TB radio programs will be available to download from the Hawaii Department of Health TB Program website, www.hawaii.gov/doh/resource/comm_dis/tb/educate.htm.

-Reported by Rachel Blair, MPH
Public Health Educator
and Jason Nehal
Public Health Advisor
TB Branch, Hawaii Dept of Health

Videophone Pilot Project in Washington State for TB Patients

With the focus on efficient use of resources in these budget-stressed times, Snohomish Health District in Washington State is completing a yearlong test of videophones to watch TB patients take their medications at home. Project manager Maggie Osborn believes the potential for savings could translate to more than 225 hours of driving time in home visits per patient in a year’s time. In a health district larger than Delaware, economizing on mileage benefits both the patient and the agency budget.

“Our virtual visits cut down to 3 minutes an encounter that would take 10 minutes plus travel time to do face-to-face,” said Osborn. Home visits have been reduced from 22 a month per patient to an average of two visits.

“Public health’s preventive services are always a good deal, because prevention saves the costs of future expensive-to-treat illness in addition to protecting health,” said M. Ward Hinds, MD, MPH, Health Officer for Snohomish County. “With the videophones we can treat and prevent disease from spreading in our community for even less than before, so the public gets an even better deal,” he said.

Snohomish Health District’s standard of care requires directly observed therapy (DOT) for all TB patients who have active disease. In 2001, the countywide TB program treated about 600 patients who have latent TB infection and 28 with active TB.

The health district purchased four videophones for less than $500 each, and installed three in the homes of three actively ill TB patients and four of their household contacts. The fourth unit resides in the TB program office.

“We took great care to select patients who were highly motivated to take their medications and who had strong family support,” Osborn said. Other selection criteria included lengthy distance between home and TB office, and multiple patients residing at the same household.

Patients sign a consent form and can withdraw from the voluntary program at any time. TB staff visit the patient’s home to set up the equipment, test it, and train the users. Osborn reports excellent compliance and satisfaction among her videophone clients, and attributes it to ease of use and convenience. Individuals call in, but can be flexible about the timing according to their schedules and the health agency’s business hours.

“The videophone is client-friendly,” she said. “If they can use a telephone, they can use this.” The “stand-alone” model her program uses has a 4-inch screen, is easily installed, and requires only an ordinary telephone line to operate. No computer or IP connections are necessary for it to work. The picture is sufficiently clear to discern the shape, color, and size of pills, and also to visually evaluate the patient’s tolerance to the medicines. Optionally, it can be hooked up to a TV screen for a larger picture.

“From a client’s point of view, using a videophone is far less intrusive than an in-home visit from staff,” said Osborn. “They don’t have to dress up, do dishes, or vacuum. Moreover, the virtual visit protects their privacy – there’s no health district car parked out front.” The clients set a call-in schedule tailored to their needs. Missed call-ins are rare, and usually due to traffic delays or conflicts with other appointments. Add to the list of advantages the improved behavior of one young patient. “When he’s on camera, he’s a ‘star’ and takes his pills like a champion,” said Osborn, “whereas on a home visit additional coaxing may be necessary.”

Challenges. Compared to the advantages of videophone DOT (VDOT), its downsides are thin. Clients could palm or hide their meds easily. Occasionally the video image stalls or goes blank, requiring a second call during peak telephone hours. As with computers, today’s VDOT equipment may become outmoded quickly by new developments. For example, wireless videophones are already in use in some Asian countries, and higher-quality IP units are available; however, clients need DSL or cable access to use them. Lastly, insurance billing for visits is not approved in Washington State, and may be 3 years away.

The bottom line. Although the savings in resources may get the spotlight, Snohomish Health District will measure the success of the videophone project in terms of patient compliance and satisfaction. Since the health agency adopted DOT in 1993, it has identified only two cases of relapsed disease and not one of its patients has developed multidrug-resistant TB. “Telemedicine opens a whole new way to provide patient care, not only for DOT in our TB program,” said Osborn, “but also for observing children with special care needs, HIV/AIDS work, and many other case management applications.” She noted videophones are a similar success in Tacoma-Pierce Health District, also in Washington State, but knows of no other public health jurisdictions using the technology.

At the conclusion of the test period, Osborn will submit her findings and clients’ evaluations to health district officials. She hopes they will consider expanding the VDOT program to more households.

“It’s high time to take a fresh look at our traditional methods of service delivery,” said Osborn. “Field and office visits used to be the only ways to get the job done, but now technology can help us work smarter,” she said. “We still interact with our patients as if we were in the same room, we save staff hours doing it, and we get healthier and happier patients.”
Video DOT: Potential Hours and Cost Savings

Type of encounter

# of visits 1/3/02 -1/31/03

Average encounter time

Total Mileage 1/3/02 -1/31/03

Mileage cost @ $0.365/mi

Staff salary plus benefits @ $25.71/hr

Approximate cost per encounter @ $25.71/hr

Value

VDOT

829

1.5 min/call

0

0

$533

$ 0.64

533

Comparable home visit to same households

829

25 min/HV

5,194 mi

$1,895

$8,880.70

$13.00

$10,776

To request a copy of the VDOT protocol and patient consent form, contact Maggie Osborn, mosborn@shd.snohomish.wa.gov.

For additional information:

  1. DeMaio J, Schwartz L, Cooley P, Tice A. The application of telemedicine technology to a directly observed therapy program for tuberculosis: a pilot project. Clinical Infectious Disease 2001 December 15:33(12): 2082-4.
  2. www.atmeda.org News and resources, links to telemedicine Web sites
  3. www.videophonesales.com (Vendor used by Snohomish Health District)

-Submitted by Suzanne M. Pate, MA
Public Information Officer
Snohomish Health District
Washington State

 


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

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