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No. 1, 2006
HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS
Hurricane Katrina’s
Impact on TB Control in the Gulf States
On August 29, 2005, Hurricane Katrina slammed into the Northern
Gulf of Mexico, causing devastation and destruction that severely
crippled social and medical institutions in Louisiana, Mississippi,
and Alabama. At the urgent request of Louisiana Governor Kathleen
Babineaux Blanco, Texas Governor Rick Perry agreed to allow hurricane
victims taking shelter in the New Orleans Superdome to be moved
to the Houston Astrodome, which is located in Harris County, Texas.
Texas officials agreed to allow the Astrodome to be used as a shelter
for the evacuees. The Astrodome was soon filled to capacity with
23,000 displaced hurricane evacuees. An additional 120,000 displaced
evacuees were housed in 97 shelters in other cities in Texas including
Houston, Dallas, San Antonio, and dozens of smaller cities across
the state as far north as Midland and as far west as El Paso. Another
100,000 persons were housed in hotels and motels around the state.
It is estimated that a total of 250,000 displaced residents from
Louisiana are now in Texas.
On August 31, 2005, Mr. Charles DeGraw, Louisiana State TB Controller,
called the Texas Department of State Health Services TB Program
to inform the program that approximately 100 TB patients could be
among the displaced residents. Mr. DeGraw noted that the Louisiana
TB Program had been significantly impacted by the flood waters coming
from Hurricane Katrina. Working with Mr. DeGraw, the Texas TB Program
immediately began putting in place support systems for those areas
in the state receiving displaced residents from Louisiana. Local
and regional health departments in Texas were notified to be on
the lookout for persons with TB. Local and regional health departments
were told to "Think TB" at all times because many of the
persons diagnosed in Louisiana might not communicate their condition
to the medical teams working in the shelters. Shelter workers were
told to be alert to the signs and symptoms of TB. If shelter residents
were identified as having TB, those persons were to be taken to
the shelter medical triage stations for evaluation and isolation,
if indicated. Mr. DeGraw also indicated that his medication supply
was under water and thus his program would need TB medications.
Mr. DeGraw asked the State of Texas to "loan" the Louisiana
TB Program the necessary TB drugs to continue providing treatment
to persons staying in Louisiana. The state agreed to provide the
necessary medications for Louisiana. The Texas TB Program also worked
with VersaPharm to arrange for medications to be sent to Louisiana.
Mr. Joe Ware, President of VersaPharm, responded by shipping all
the needed medications to the Louisiana TB Program at no cost to
the State of Louisiana. The Texas Department of State Health Service
TB Program organized a team comprised of staff from public health
regions, local health departments, the data analysis unit at the
Texas Department of State Health Services, and the Louisiana State
Health Department TB Program to address the issues surrounding the
management of persons in shelters who are found to have TB. Mr.
DeGraw also requested laboratory support from the Texas Department
of State Health Services. The Texas TB program arranged for the
Texas State Laboratory to provide laboratory assistance. The Texas
State Laboratory agreed to receive and process TB specimens submitted
by the State of Louisiana for evaluation.
The Texas Laboratory provided the Louisiana TB Program with the
containers needed to ship specimens to the Texas State Laboratory.
As of October 31, there had been 307 specimens submitted to the
Texas State Laboratory for processing.
In an effort to determine if any of the displaced Louisiana residents
living in the shelters had been diagnosed, the Texas TB Program
worked with the Texas Emergency Command Center, the Incident Command
Center in Houston, the City of Houston and Harris County government
officials, the Texas State Health Service Regions, local health
departments throughout the state of Texas, local hospitals, the
American Red Cross, and countless shelters across the state to match
known tuberculosis patients with the listing of shelter residents.
TB program staff confidentially worked with shelter administrators
to match the lists. Persons identified were then evaluated and placed
on medication and in some cases hospitalized for treatment. The
Texas Tuberculosis Program worked with the Texas State Pharmacy
to ensure tuberculosis medications were stocked on the mobile pharmacies
deployed to shelters.
On September 7, 2005, Ms. Phyllis Cruise, Senior CDC Public Health
Advisor assigned to Texas, was deployed to work at the Incident
Command Center at the Houston Astrodome. Ms. Cruise assisted in
the medical follow-up of persons residing in the shelters. She worked
primarily in the three large shelters located in Reliant Park, which
is located in Houston–Harris County, Texas. Reliant Park includes
the Reliant Dome (i.e., the Astrodome), the Reliant Arena, and the
Reliant Center. All together this complex housed 25,000 displaced
persons. Houston also had another large shelter in the downtown
area of the city, the George R. Brown Center, which housed 2,800
persons. Ms. Cruise assisted the city and county TB programs in
their efforts to develop and deliver to shelter staff and residents
educational messages and materials on TB, including the development
of posters detailing the signs and symptoms of TB. Ms. Cruise also
assisted city and county staff in planning activities for locating
the persons who were on the patient list from Louisiana. This included
using contacts from other agencies, both public and private and
traditional as well as nontraditional sources such as the Federal
Emergency Management Agency (FEMA). Ms. Cruise worked with FEMA
to secure current addresses and telephone numbers for registered
evacuees who had been diagnosed with TB and started on treatment
in Louisiana. By mid- October, TB control officials were very happy
to report that all TB patients who had been evacuated from the affected
areas as a result of the hurricane had been accounted for.
—Reported by Charles Wallace, Ph.D., M.P.H.,
and
Phyllis Cruise, CDC Public Health Advisor
Texas Department of State Health Services
DTBE Responds to Hurricane Katrina
Following Hurricane Katrina’s landfall on August 29, 2005,
staff of DTBE worked with the National TB Controllers Association
(NTCA) to provide technical and logistical support and to facilitate
communication for the TB programs affected by the sudden displacement
of thousands of Gulf Coast residents.
At the request of the CDC Director’s Emergency Operations
Center, DTBE developed resource materials to provide TB-related
guidance to staff of approximately 750 shelters and evacuation
centers in at least 18 states. Resources included an up-to-date list
of TB program contacts, guidance for identifying persons in
evacuation centers who may have TB, and a list of relevant TB
educational resources. These were posted on the CDC hurricane
website.
These resources emphasized the importance of immediately consulting
the local or state TB program if evacuees were or had been taking
anti-TB medications or had symptoms suggestive of TB disease. Katrina-related
heightened public health surveillance resulted in the reporting
of at least 10 evacuees as potentially having TB. Although most
were subsequently diagnosed with other conditions (e.g., lung cancer
and infection with nontuberculous mycobacteria), two new cases of
confirmed TB were found and reported.
Along with many others throughout CDC and the U.S. Public Health
Service, 18 DTBE staff were deployed to various locations to provide
on-site support to areas affected by Katrina. For example, Ted Misselbeck
and Dawn Tuckey were deployed to Louisiana. Other staff already
assigned to the field, like Phyllis Cruise with the Texas TB Program,
found that Katrina-related work soon demanded their full attention
(see related article, “Hurricane Katrina’s Impact on
TB Control in the Gulf States”). Back in Atlanta, at least
10 others shifted their work priorities to focus on support for
Katrina-related activities.
On September 2, DTBE established a Katrina Help Desk, with a team
led by Gail Burns-Grant, to provide a 24/7 on-call system to respond
to TB inquiries and to coordinate efforts by NTCA and the TB programs
in Alabama, Louisiana, and Mississippi to account for all persons
known by local public health authorities to be undergoing treatment
for TB disease when the hurricane struck. Although most of the 180
TB patients in the most directly affected regions remained in their
home states, others relocated to Arkansas, California, Colorado,
Florida, Georgia, Illinois, Maryland, Massachusetts, Missouri, Ohio,
South Carolina, Tennessee, Texas, and Washington State. Accounting
for all these persons involved a great deal of collaboration and
assistance from many state and local TB partners, as well as new
partnerships with relief agencies and private companies to cross-match
names for the purposes of locating displaced patients. As of October
13, all 180 had been located and were receiving follow-up attention
and treatment continuity.
—Submitted by DTBE Atlanta and field staff:
Gaby Benenson, Gail Burns-Grant,
Phyllis Cruise (TX), Maryam Haddad,
Michael Iademarco, Ted Misselbeck (TN),
Patrick Moonan, Phil Talboy, and Dawn Tuckey
KatrinaHealth.org
During Hurricane Katrina and its aftermath, a new secure, online
service became available to help hurricane-affected individuals
work with their health professionals to gain access to their own
electronic prescription medication records. The new site allows
authorized physicians and pharmacies to get records of medications
evacuees were using before the storm hit, including the specific
dosages. Having this information will help evacuees refill their
medication prescriptions; it will also help health care professionals
coordinate care and avoid harmful errors when prescribing new medications.
Evacuees are spread out across the country; therefore, this information
can be accessed from anywhere in the United States through www.KatrinaHealth.org.
The urgent effort to make www.KatrinaHealth.org
available to health care professionals was facilitated by the Office
of the National Coordinator for Health Information Technology (ONC),
within the U.S. Department of Health and Human Services.
This project has been supported by more than 150 organizations
that have participated in the planning, testing, and launching of
the site. Important data and resources were contributed by the American
Medical Association (AMA), Gold Standard, the Markle Foundation,
RxHub, SureScripts, and the Louisiana and Mississippi departments
of health. More information including a press release and frequently
asked questions (FAQs) can be found at www.KatrinaHealth.org.
—Reported by Mark D. Fussell
CDC Senior Management Official - Texas
Austin, Texas
Eliminating Tuberculosis Case by Case:
An Educational Initiative by New England TB Programs
Purpose and Goal of the TB Case Series. In an effort to reach several
key partners using an educational venue, the six New England tuberculosis
(TB) control programs organized a Web-based interactive “TB
Case Series.” The TB Case Series is designed to allow providers
to present cases that illustrate public health principles and practices.
The goal of the TB Case Series is to offer a forum for
- Discussing the public health importance of infectious TB
- Describing the clinical management of TB, and increasing awareness
of national recommendations for TB diagnosis and treatment, and
- Discussing options for ongoing patient care.
The course will promote standard diagnostic procedures and national
guidelines through analysis and discussion of TB cases. Additionally,
the course offers continuing education credit for physicians, nurses,
health educators, and other participants.
First Two Presentations a Big Success. On October 26,
2005, more than 80 persons participated in the first case presentation.
The inaugural presentation featured C. Robert Horsburgh, MD, a local
and national expert in TB and HIV treatment. Dr. Horsburgh, formerly
with CDC, is now the Chair of the Department of Epidemiology and
the Director of the Prevention Research Center at the Boston University
School of Public Health and the Boston University Medical Center.
Dr. Horsburgh laid the groundwork for future case presentations
and skillfully led the discussion, drawing participants into an
active dialogue around the case. The second presentation was given
in October by C. Fordham von Reyn, MD, Chair, Infectious Diseases
and International Health at Dartmouth-Hitchcock Medical Center.
The presentation skillfully combined a case and review of TB-related
lymphadenopathy. About 45 participants from New England called in
to listen and discuss the case and other cases.
Evidence of the Need for Educational Activities Targeting
TB Providers. Several sources of evidence indicate that TB
care providers have ongoing educational needs. These sources include
1) a regional education needs assessment, 2) studies documenting
nonadherence to national standards and guidelines by private providers,
and 3) a CDC study documenting that 40% of private providers do
not use a recommended treatment regimen (Sumartojo EM, Geiter LJ,
Miller B, Hale BE. Can physicians treat tuberculosis? Report on
a national survey of physician practices. Am J Public Health 1997;87:2008-11).
In addition, in 2004 DTBE and the three Model TB Centers developed
a national strategic plan for TB training and education in conjunction
with experts in TB and education, health care providers, and other
partners. The plan states that private providers who serve high-risk
populations need to learn about TB diagnosis, treatment, and management
(www.nationaltbcenter.edu/
strategicplan/strategic_plan.html).
Thanks to the Organizers. A coordinating group representing
the New England TB programs, the Regional Training and Medical Consultation
Centers (RTMCCs), and DTBE organized the course. These contributors
to the New England TB Case Series included Kathy Hursen (Massachusetts
TB Program), Judy Proctor (New Hampshire TB Program), Rajita Bhavaraju
(Northeast RTMCC), and Mark Lobato, Subroto Banerji, Regina Bess,
and Judy Gibson (DTBE).
—Reported by Erin Howe
Regional TB Medical Consultation Consortium – New England
Kathy Hursen, RN, MS
Massachusetts Div of TB Prevention and Control
Mark Lobato, MD, New England TB Consultant
Div of TB Elimination
Lisa Roy, TB Educator
New Hampshire TB Program Div of Public Health Services
Standardized Nursing Case Management Interventions
Described in the Evaluation of a TB Targeted Testing/Treatment Project
The evaluation of the CDC-funded Targeted Testing
and Treatment of Latent TB Infection (TT TLTBI) Program in Arlington
County, Virginia, provided an opportunity to capture best practices
and develop lessons learned that could benefit state and local TB
programs. In describing the program for the purpose of evaluation,
the role of the Pediatric TB Public Health Nurse (PHN) case manager
was described. This description was used to develop a nursing practice
logic model.
Public health nursing activities traditionally play
a prominent role in TB control efforts. However, the process and
the standards for those activities must be described before they
can be evaluated. The TB Patient-Level Care Model 2002, developed
by the National TB Nurse Consultant Coalition, links TB-specific
recommendations (statement and guidelines) associated with theory-based
multiple determinants of behavior (from the patient’s perspective)
with the NANDA taxonomy of nursing practice, the Nursing Intervention
Classification, and the Nursing Outcome Classification. The model
serves to describe case management, what it is expected to achieve,
and what activities it includes.
In a collaborative effort to describe the TT TLTBI
project in Virginia for evaluation, TB PHNs at the local, state,
and national levels applied the TB Patient-Level Care Model to the
case manager’s role description and developed a nursing practice
logic model. From this model, the team described process and outcome
indicators for evaluation. Next steps include developing the tools
to gather credible evidence, justifying conclusions based on this
evidence, and using the lessons learned.
During the NTNCC meeting held June 27, 2005, in Atlanta,
Georgia, a partial description of the evaluation for the CDC-funded
TT TLTBI program in Arlington County, Virginia, was presented. Virginia
Thackery, Pediatric TB PHN case manager, presented an overview of
the Arlington TT TLTBI Project and her role as the Pediatric TB
PHN case manager. Judy Gibson, Nursing Consultant, Field Services
and Evaluation Branch, DTBE, presented the methods used in developing
the nursing practice logic model and an overview of the team-developed
model. Jane Moore, Nursing Consultant, Virginia Department of Health,
presented the TB Service Plan, developed in Virginia, that lists
nursing actions tailored to patient needs. The TB Service Plan was
also used in reviewing the role description of the Pediatric TB
PHN case manager.
—Reported by Jane Moore, RN
Virginia Department of Health,
and Judy Gibson, RN
Div of TB Elimination
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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