TB Notes Newsletter

No. 2, 2010

HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS

Los Angeles County Collaborates with Private Medical Community on Symposium on Public-Private Partnerships to Control TB

In honor of World TB Day 2010, on March 24 the Tuberculosis Control Program (TBCP) and Community Health Services (CHS)¹ of the Los Angeles County (LAC) Department of Public Health (DPH) collaborated with a consortium of private hospitals in a high tuberculosis (TB) incidence area of LAC known as the San Gabriel Valley. Together they presented an educational symposium targeting the private medical community, entitled “Public Health and the Private Medical Community: Partnering Together to Control TB in LAC.”

Dr. Kuei and Dr. Alvarez

In the photo are two of the symposium attendees: Dr. Joseph Kuei, Pulmonologist, Garfield Medical Center, Monterey Park, and Dr. Frank Alvarez, Director, TB Control Program, Los Angeles.

In 2008, the San Gabriel Valley, also known as service planning area (SPA) 3, reported the second highest number of TB cases compared to the other seven SPAs that make up LAC.  The main purpose of the event was to strengthen the ongoing relationship with private medical doctors (PMDs) in the co-management of TB patients.  The symposium covered TB epidemiology, the reporting and discharging of TB patients, the partnership between the private and public sectors in controlling TB, and updates on TB diagnosis and treatment. Attendees were offered 2 hours of continuing education credits.

The symposium was held at Garfield Medical Center, a private hospital within SPA 3 that reported 13 TB cases in 2008, which made it the second highest TB-reporting private facility in SPA 3 for 2008. Of the six speakers at the conference, there were two physicians and one nurse manager from the TBCP, one physician and one public health nurse from CHS, and one PMD from Garfield Medical Center.

The event attracted 54 participants, including 18 physicians and 30 nurses, most of whom responded very positively about the event on their evaluations.  In fact, over 90% of the participants felt that all objectives were fully met.  There was also a 13.4% increase in provider knowledge based on the completion of pretests and posttests. The anticipated outcome is that participation in this event, and the resultant increase in private provider knowledge and understanding, will translate into greater collaboration between the public and private sectors in the co-management of TB patients, as well as an improvement in TB treatment completion rates.

In addition to the World TB Day symposium, Dr. Frank Alvarez, the TBCP Director and LAC TB Controller, wrote an article that appeared in various publications, including the Hospital Association of Southern California (HASC) newsletter² and the LAC DPH’s Rx for Prevention.³  The target audience and main readership for these newsletters is the private medical community.

In order to spread the message of the importance of public-private partnerships to an even wider audience, Dr. Alvarez participated in a statewide media call on March 23, which also included a representative from the World Health Organization, the TB Controller for the state of California, and a former TB patient who has become a patient advocate.  This media call was organized and sponsored by the California TB Controllers Association (CTCA) and Breathe California.

Along with the media call, the TBCP Assistant Medical Director, Dr. Steven Hwang, was interviewed and quoted in an article that focused on drug-resistant TB.  This article appeared in The Sun.⁴

Finally, press releases were issued and distributed by the LAC DPH and key community partner, the American Lung Association in California (ALAC). Articles that resulted from these press releases appeared online in USA Today,⁵ India Times,⁶ The Medical News,⁷ and Earth Times.

—Reported by Chhandasi Pamina Bagchi, MPH, Health Educator
and Robert Miodovski, MPH, Senior Health Educator
Los Angeles County Tuberculosis Control Program

References

1. Community Health Services is the direct provider of public health services via 15 public health centers throughout Los Angeles County.
2. http://www.hasc.org/briefsarchive.cfm?resID=255218
3. https://admin.publichealth.lacounty.gov/wwwfiles/ph/media/media/rxmar10.pdf
4. Dunavan, Claire Panosian. “Infection Files: Tuberculosis Is a Complex but Treatable Disease.” The Sun (newspaper for San Bernardino and the Inland Empire in Southern California). March 25, 2010. http://www.sbsun.com/search/ci_14749372. Accessed March 26, 2010.
5. “American Lung Association in California Supports Efforts for Quality TB Care.” USA Today. March 25, 2010.   http://content.usatoday.com/topics/article/Places,+Geography/Towns,+Cities,+Counties/Los+Angeles/03GEeOl6YReld/1. Accessed April 13, 2010.
6. “American Lung Association in California Supports Efforts for Quality TB Care.” India Times. March 25, 2010 http://oneclick.indiatimes.com/article/03GEeOl6YReld?q=Los+Angeles. Accessed April 13, 2010.
7. “American Lung Association in California Supports Efforts for Quality TB Care.” The Medical News. March 25, 2010. http://www.news-medical.net/news/20100325/American-Lung-Association-in-California-supports-efforts-for-quality-TB-care.aspx. Accessed April 13, 2010.

Philadelphia TB Control
Program Collaboration and Service Integration

Program Collaboration and Service Integration (PCSI) is an important initiative of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).  As defined by CDC, PCSI is a mechanism of organizing and blending interrelated health issues, separate activities, and services in order to maximize public health impact through new and established linkages between programs to facilitate the delivery of services. Since 2006, CDC has assessed the amount and types of PCSI activities occurring among funded programs in the United States and monitored internal progress on commitments and activities, and the effect these activities have had in the field. 

This report assesses the existing structure of the Philadelphia Department of Public Health (PDPH) TB Control Program (TBC) to support PCSI activities; describes strategies used to increase the participation in PCSI activities; inventories efforts to increase these activities within the TB Control Program; and reviews the overall progress of PDPH toward CDC goals for PCSI.

The PCSI activities described in this field report are important aspects of TB Control Program Services and Evaluation activities.  These activities support and strengthen core components described in the “Essential Components of Tuberculosis Prevention and Control Programs”.  The TB control program components deriving the greatest benefits from PCSI activities include the management of persons who have or are suspected to have TB disease, the identification of persons infected with M. tuberculosis through the expansion of TB skin testing of high-risk groups, increased laboratory and diagnostic services including HIV testing and counseling, data collection and analysis through the sharing of information, program evaluation, and training and education of health-care providers and members of the public health community.

The existing structure of PDPH supports PCSI activities in many ways. The PDPH TB Control Program Manager also serves as the overall administrative manager for PDPH Division of Disease Control (DDC). In addition to the TB Control Program, the DDC also manages the city’s STD, Viral Hepatitis, Public Health Emergency Preparedness, and Public Health Epidemiology Programs, among others. As a result, there are already a number of interrelated activities between TB Control and other DDC units. This organizational structure provides coordinated management and removes some barriers to service integration. This is important in that it allows programmatic decisions among DDC units to be made internally, avoiding delays encountered by the need to coordinate policies at the Division level within PDPH.

An early DDC strategy was the formation of the HIV/TB/Hepatitis/STD Integration Workgroup. The Integration Workgroup was convened by the PDPH/DDC in response to CDC’s July 2007 green paper, “Program Collaboration and Service Integration: Enhancing the prevention and control of HIV/AIDS, Viral Hepatitis, STD, and TB in the United States.” The Integration Workgroup is coordinated by the Pennsylvania/Mid-Atlantic AIDS Education and Training Center; the TB Control Program has been an active part of the workgroup since its inception in May 2008.  Early on, the Integration Workgroup performed an assessment of the four programs to gauge the degree to which prevention services between them met CDC guidelines.  Following the assessment, the workgroup developed an initial inventory of collaboration and service integration and has begun efforts to expand prevention services across the four programs. The Integration Workgroup also tracks program-related activities and monitors progress toward CDC’s PCSI goals and objectives.

The TB Control Program has recently inventoried its own efforts to increase PCSI activities within the program services and evaluation units.  This inventory of activities is provided below.

What are the common target populations? Along with the AIDS Activities Coordinating Office (AACO) and Hepatitis Program, we target homeless persons, correctional facility inmates, residents of long term care (LTC) facilities, recent immigrants and refugees, and persons with chemical and substance abuse issues. TB Control outreach and targeted testing programs in LTC facilities, in correctional facilities, and throughout the homeless shelter network have led to early detection and prevention of TB cases in these populations.  The Integration Workgroup has brought together PDPH programs serving these vulnerable populations to share strategies for providing population-based services and intervention programs.

What are your current collaborative efforts/activities? In terms of the provision of integrated services, we currently provide HIV rapid screening and hepatitis B/C screening for all TB patients at the Flick Clinic. Our goal is to ensure that all newly diagnosed TB cases and patients with LTBI are counseled and tested for HIV and referred for HIV services if found to be HIV infected. TBC also supports HIV providers’ efforts to test HIV-infected patients for TB.

The TB Control Program has worked through the Integration Workgroup to strengthen and maintain an ongoing relationship with AACO. We currently conduct at least annual TB and AIDS registry matches to ensure completeness of reporting of HIV and TB coinfected patients to both surveillance systems.  For example, TB Control is able to obtain current HIV status on TB cases and suspects and share information related to AIDS-defining conditions identified through our clinical assessments.

What trainings have taken place so far? The PDPH TB Control Program has provided TB in-service and updates to the Inventory Workgroup, AACO HIV service providers, and Philadelphia's Office of Addiction Services addiction counselors during the past year.

Are there any issues, restrictions or barriers related to funding, surveillance, or training that hinder integration? During our TB Cooperative Agreement (CoAg) application process, we received guidance memoranda from CDC's Procurement and Grants Office (PGO) advising programs on the limitations of redirecting TB CoAg funds and supported personnel to other activities. PDPH TB Control assumes many of these restrictions may also apply to PCSI activities in Philadelphia. There are also state and local regulations and restrictions on the use of program funds.

Are any funds shared or used to support other related prevention programs for HIV, STD, TB, and Hepatitis (i.e., personnel, testing, and training)? This is limited to the administrative and structural integration that DDC provides to each of the programs and the PCSI initiatives that DDC funds.

What reporting systems are being utilized? There are no common reporting systems currently being utilized by PDPH programs. Pennsylvania's version of the National Electronic Disease Surveillance System (PA-NEDSS) may have potential as a common reporting system.

How are partner services delivered? Partner services continue to be program-specific activities and are not conducted in an integrated fashion. Referrals for HIV and hepatitis services are made at the point of service for TB program patients.

During the past year, PDPH TB Control has achieved an expanded level of TB program collaboration and service integration as defined by CDC.  Service integration across CDC-funded programs based on risk assessment has been met, and there are few program-specific opportunities for collaboration that haven't been identified and explored by TB Control and the Integration Workgroup, thus far.  

In the future, it may be a bit more difficult to achieve comprehensive integration, which is defined as a single package of prevention, diagnosis, and treatment activities integrating HIV, STD, viral hepatitis, and TB services, with linkage and/or referral to a specialist or other prevention services. With the continued support of PDPH/DDC, the Integration Workgroup will continue to meet and work to expand these activities in the coming years.

—Reported by Daniel P. Dohony, MPH
Div of TB Elimination
PHA, Philadelphia TB Control Program

Adoption of the Cohort Review in Miami

Overview
The staff of the Miami-Dade County TB Control and Prevention Program (hereafter referred to as the Miami TB program) provide medical, clinical, diagnostic, and treatment services at three sites: the Downtown Family Medical Center, the Little Haiti Medical Center, and the West Perrine Health Center. Each staff member of the Miami TB program plays an important role, with all working together to control TB. The senior public health advisor (PHA) in Miami was concerned that the program was not running as efficiently as it could be. He was familiar with the cohort review process and believed it could help bridge the gaps needed to overcome programmatic barriers.

The senior PHA was dedicated to the idea of adopting the cohort review process. He knew that if he could also gain the full support and commitment of TB program management, it would smooth the way for implementation of this process. After about a year of continuously reinforcing the goals and objectives of the program, he was able to show the need for cohort review, and thereby gained their commitment.

While serving as a TB PHA in Philadelphia, I had developed the skills and abilities needed to facilitate the cohort review. In August of 2009, I transferred from the Philadelphia TB control program to the Miami TB program. The Miami senior PHA and I partnered together to conduct the first cohort review in Miami, Florida.

Process
Cohort review is an evaluation method used by TB control programs to monitor and evaluate program performance. This method is an organized review of patients with TB disease and their contacts. The senior public health advisor at the Miami TB program wanted to implement this method as a way of ensuring accountability and improving case management and prevention. The process would also allow staff to see both weaknesses and strengths in the program.

My role in the Miami cohort review process began with a clear list of objectives and goals outlined by the program manager. The program manager reviewed actual CDC national objectives and Florida state objectives to be sure that Miami-Dade county objectives were realistic. He was committed to the process and ensured that all staff in the program were aware of the reasons for adopting and implementing the cohort review. 

Our next step was to compile the list of cohort TB cases that were counted in the first quarter of 2009 (all TB cases in January, February, and March 2009). This list of 39 cases was generated from the data collected in the Health Management System (HMS) used by the TB program.

In order to ensure that consistent information is presented on each case, a standardized cohort review form was needed.  During the presentation, demographic information, sites of disease, treatment regimen, status of treatment completion, and contact investigation information on each case would be presented by staff.  I modified a cohort review form provided by the Philadelphia TB control program to ensure that all pertinent information of the Miami TB program would be available and addressed at the cohort review presentation.

Preparation also included weekly meetings between me, the senior public health advisor, and field staff supervisors. During the meetings, we practiced by discussing specific data elements for each case and ensuring that all information on the cohort form was complete and correct. Since this was a completely new process for the staff, we wanted to be sure that supervisors were familiar with the cohort review presentation process. This would allow them to confidently practice with field staff members and to help those presenting cases to be prepared. Additionally, meetings were arranged with nurse case managers and the surveillance team to ensure that all team members played an integral role in the cohort review process.

Outcomes
The analysis of cohort review outcomes was presented at the end of the cohort review session. Below are some of the results as they relate to program objectives:

1. Index of treatment completion at the time of cohort review: 50%
2. Index of completion: 93.8%
3. Overall contact index: 6
4. Percent of smear-positive cases with contacts identified: 100%
5. Percent of contacts of smear-positive cases evaluated: 97.5%
6. Percent of contacts of smear-positive cases started on treatment for LTBI: 61.2%
7. Demographic and medical data were also collected, including patient HIV test status: Positive – 6; negative – 17; unknown – 1; not offered – 8; refused – 7.

Conclusions
The cohort review process is a tool that can be used to help ensure that a TB control program is working at its highest performance level possible. The outcomes may reveal that strategies and practices that have been the norm are no longer in place or are in need of modification. During this cohort process it was evident that follow-up was needed on some issues.

Increasing the number of TB patients offered HIV testing is a top priority. The cohort data showed eight individuals were not offered the HIV test and all were between the ages of 19 and 45. In 2005, CDC reported that approximately 9% of all TB cases, and nearly 16% of TB cases among persons aged 25 to 44, were occurring in HIV-infected persons.1 In 2007, approximately 20% of TB patients in Miami-Dade County were co-infected with HIV. TB continues to be the leading cause of disease for those infected with HIV. TB program staff must consistently provide information and education about HIV and, most importantly, offer testing to all individuals.

Contact investigations are a key part of the program’s goal to eliminate TB.  By improving interview skills and conducting re-interviews, our overall contact index can increase. The field staff members who interview patients should remember to build rapport with the patient and ensure privacy when soliciting contact information. Follow-up interviews should be conducted by the medical staff in all clinics as an extension of the original interview to facilitate identification of additional contacts. 

The surveillance team expressed a need for increasing partnerships and communication with private physicians and hospitals that manage TB cases in the Miami area. Many health professionals in the community have little understanding of patient risk factors and of screening and treatment protocols. Cultural competency is extremely important in a city as diverse as Miami. In the future, we may see an increase in the early diagnosis of TB and treatment completion rates if we can successfully gain support and raise the awareness of private physicians and hospitals in the community.

Overall, the Miami-Dade County TB Control and Prevention Program has reached a significant milestone with the adoption of the cohort review. We have an ongoing commitment to the process. The 2nd quarter 2009 Cohort Review was held on January 22, 2010.

—Reported by Cindy Castaneda
Div of TB Elimination
PHA, Miami-Dade TB Control Program

Reference

• CDC. Reported HIV status of tuberculosis patients—United States, 1993–2005. MMWR 2007; 56:1103-1106.