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TB Notes Newsletter
This is an archived document. The links
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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
- 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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References
- 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. (PDF)
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 2005.
- California Department of Health Services, Tuberculosis
Control Branch, Tuberculosis
Indicator Project Indicator Reports. June 2006.
Accessed 06/09/2006.
-
California AIDS surveillance report cumulative cases
as of March 31, 20066, (PDF) Office of AIDS.
Accessed 6/9/2006.
- 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.
Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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