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No. 3, 2008

Surveillance, Epidemiology, and Outbreak Investigations Branch Updates

TBESC Task Order 12 Update:
Primary Care Management of LTBI and TB Disease among Foreign-born Populations: A Study of Barriers and Facilitators

Project Overview:

CDC, Seattle and King County Public Health Department, and the University of Washington have completed a 3-year study about the facilitators and barriers associated with the primary-care management of latent and active TB among immigrant populations. National surveillance data indicate that the highest incidence of TB disease within the United States occurs in recent immigrants from Mexico, the Philippines, and Vietnam. Effective TB control strategies require that primary care providers be adept at identifying active TB as well as managing persons with latent TB infection (LTBI).

The objectives of this study were to-

• Conduct formative research to describe the factors influencing the efficient management of latent and active TB among primary care providers caring for immigrants from Mexico, the Philippines, and Vietnam;
   
• Design, implement, and assess the impact of an educational intervention to improve LTBI management in primary care; and
   
• Assess the effectiveness of this intervention on altering knowledge and attitude of primary care providers regarding LTBI testing and treatment.

Methods:

This study was implemented in two phases. In Phase I, qualitative interviews were conducted, including focus groups and individual interviews with health care providers to elucidate aspects of primary care practice that impact TB testing and treatment management. Participants had to have practiced in primary care medicine (e.g., internal medicine, family practice, pediatrics, women’s health), have 3 or more years of medical experience, have practiced in their current setting at least 1 year, and have a patient population of at least 25% foreign-born individuals.

A total of 80 health care providers were interviewed. Major themes were identified by three reviewers and used to shape Phase II of this study. For the second phase (i.e., the intervention phase), a 1-hour didactic session was developed that integrated national and local TB epidemiology and reviewed the nuances of LTBI testing and treatment. A pre-intervention assessment composed of knowledge questions on the epidemiology of TB within the United States, risk groups for LTBI, interpretation of the tuberculin skin test, and LTBI treatment was administered to a group of primary care providers who did not participate in Phase I of this study.

The didactic session was presented by a local TB control expert to these primary care providers. A post-intervention assessment was administered to each participant 2 to 4 weeks after the didactic session. A comparison of pre- and post-intervention responses was used to assess the effectiveness of this intervention on changing the knowledge and attitudes of primary care physicians with regard to LTBI testing and treatment. The assessment tool and the didactic session materials can be found at www.ethnomed.org.

Preliminary Results:

A total of 92 primary care providers participated in Phase II (intervention phase) of this study. The mean age of participants was 47 years, of whom 52% were male and 64% were foreign born. Eighty percent of participants were either medical doctors (MDs) or doctors of osteopathic medicine (DOs), and 55% practiced in a federally qualified health center. Only 55% reported having some form of TB training in the past.

Responses to the knowledge questions showed that the intervention increased the provider’s knowledge about patients who are at added risk for LTBI, particularly those who are HIV infected, and those who have the co-morbid conditions of renal failure, diabetes, and silicosis. The providers showed increased knowledge in the interpretation of the tuberculin skin test, especially in the settings of HIV, previous BCG vaccination, and recent exposure to an individual with active TB. Clinicians were updated to the fact that isoniazid, the mainstay for LTBI treatment, can be offered to all age groups who have latent infection if they have no other contraindications to the treatment.

In the pre-intervention assessment, over 70% agreed that provision of free isoniazid for LTBI treatment, a reliable treatment tracking system, better co-management of patients with the local TB clinic, and a public health effort to educate their patients were “very important.”

Private practice physicians were more concerned about reimbursement for LTBI care, more likely to agree that insurance reimbursement impacted the care they delivered for LTBI, and more likely to be concerned about the financial implications of LTBI. In federally qualified health centers and public hospitals, physicians encouraged persons with LTBI to take treatment, even though LTBI conceptually was difficult to explain to their patients. Resources for billing and nursing support were more available to federally qualified health center clinicians and public sector clinicians than for private physicians.

Conclusions:

An intervention to improve primary care providers’ knowledge about LTBI testing and treatment among primary care providers for high-risk foreign-born groups was shown to increase key measures of knowledge. Measures of attitude generally endorsed the importance of LTBI, and indicated that LTBI was difficult to manage and required additional resources. A subgroup analysis of practice type revealed that private practice physicians worried more about finances and that reimbursement issues affected their care as compared to community-based clinicians. The intervention did not alter these attitudes, nor was it designed to do so. Future interventions to change attitudes toward LTBI testing and treatment should address these unique concerns of clinicians based on their practice settings.

—Submitted by Jenny Pang, MD, MPH,
Seattle and King County Public Health Prevention,
and Carey Jackson, MD, MPH, MA
University of Washington School of Medicine, Dept of General Internal Medicine 

13th Semiannual Meeting of the Tuberculosis Epidemiologic StudiesConsortium (TBESC)

The 13th Semiannual Meeting of the Tuberculosis Epidemiologic Studies Consortium (TBESC) convened July 16–17, 2008, in Seattle, Washington. The primary purpose of the TBESC is to conduct epidemiologic, behavioral, economic, laboratory, and operational research in TB prevention and control.

Over 80 persons participated in the meeting; attendees included CDC staff, TBESC principal investigators, project coordinators, and project-specific personnel. TBESC members and CDC staff presented results and gave updates on the status of ongoing research projects and activities.

Presentations included the following:

• Research gaps related to TB transmission
• Modeling of TB rates and implications for future research
• The draft Strategic Plan and ideas for new research
• Administrative updates on consortium-related activities
• Update on the Semiannual Tuberculosis Advisory Review (STAR) process
• Updates from the Publication and Presentations and External Relations Committees
• Update from the Translating Research into Practice (TRiP) Workgroup

In addition, spirited discussions were held at the meeting regarding the focus of future TBESC research; TBESC will undergo a recompetition in 2010. Ideas are currently being generated as to the scope and direction of TBESC projects. At the meeting, members also discussed the Strategic Planning Workgroup, whose purpose is to select a research concept that will provide a unifying focus for TB research in the next several years.

When not attending the meeting, TBESC attendees enjoyed Seattle’s scenery, blue skies, and mild weather. Planning for the 14th semiannual meeting, scheduled for February 4–5, 2009, in Atlanta, is currently underway.

For more information on the TBESC.

—Reported by Brian Sizemore, MBA
TBESC Project Manager
Div of TB Elimination

Last Updated: 10/7/2008