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Strategies for Targeted Testing and Treatment for Latent Tuberculosis Infection: Applying ATS/CDC Guidelines to a Best Practice Evaluation

Background

CDC’s Division of Tuberculosis Elimination (DTBE) funded 17 grantees in 2000 to conduct 5-year projects on targeted testing and treatment of LTBI (TTTLTBI). These 17 grantees fielded 84 interventions with varying target populations and activities. In 2003, CDC commissioned RTI International to conduct an evaluation of the CDC-funded TTTLTBI projects. The objectives of the evaluation were to (1) identify effective programmatic strategies, (2) promulgate lessons learned, and (3) enhance efforts to provide appropriate TTTLTBI.

Figure 1. CDC’s Evaluation Framework

Source: Centers for Disease Control and Prevention. Framework for Program Evaluation in Public Health. MMWR 1999;48 (No. RR-11).

Methods

DTBE and RTI invited six intervention programs to participate in the evaluation, which was conducted in accordance with the CDC Framework for Program Evaluation in Public Health (CDC 1999) (see Figure 1). Table 1 presents the six best practice evaluation sites, the target populations, and brief program descriptions.

Table 1. Description of Best Practice Evaluation Sites

Site Name	Target Population	Program Description
Sussex County Health Unit, DE	Foreign-born poultry plant workers	Management and staff of local poultry plants institute pre-employment TB testing for all employees
Harrison County Correctional Facility, MS	Jail inmates	County jail clinic staff provide TB tests and treatment for LTBI for all inmates and ensure treatment follow-up in the community
University of Missouri–Columbia Student Health Center, MO	Foreign-born students	University-based student health center, registrar, and athletic departments coordinate testing and treatment
Suffolk County Health Department, NY	Foreign-born migrant workers	ESL classes and a local diocese host a mobile TB clinic
Virginia Department of Health, VA	Children aged 4 years or younger from TB endemic countries and day-care workers	Pediatricians and day-care providers raise awareness of TB in this population
San Diego Department of Health, CA	Medically underserved	Community clinics serving the homeless and other hard-to-reach populations ensure continuity of care

Note: ESL=English as a second language; LTBI=latent tuberculosis infection; TB=tuberculosis

The data collection comprised 1- or 2-day site visits, semi-structured interviews with program staff and partners, and follow-up telephone interviews with program staff. To explore how the recommendations were being put into practice, evaluation data were mapped to the 2000 ATS/CDC guidance.

Results

The evaluation data show that the intervention sites followed the ATS/CDC guidelines. This report highlights the strategies used by the sites to identify high-risk groups, access these groups for targeted testing, foster adherence to LTBI treatment, and establish the role of the health department in targeted testing and treatment.

Identifying High-Risk Groups

The ATS/CDC guidelines recommend that state and local public health agencies use local epidemiological data from TB case reports and testing data to detect trends and high-risk groups. The guidelines also recommend targeting groups that are identified as being at increased risk for TB. The evaluation data from intervention programs show that sites followed this recommendation, using data to define at-risk populations and to target high-risk groups. For example, for Mississippi, data showed a high prevalence of TB in Harrison County; the Mississippi program targeted Harrison County Correctional Facility jail inmates, many of whom were from TB endemic countries, were marginally housed, or had a history of injection drug use. Similarly, in Delaware, data indicated that the majority of active TB cases were among foreign-born poultry plant workers, and the Delaware program targeted this population. In addition, Missouri and New York programs targeted foreign-born populations; the Virginia program targeted children of foreign-born parents; and the San Diego program targeted medically underserved populations, such as homeless shelter residents (Table 1). Further evidence of the effectiveness of the programs at targeting high-risk groups is the fact that three of the sites identified cases of TB through these testing efforts.

St. Vincent de Paul Church, one of the TTTLTBI sites in San Diego

Accessing High-Risk Groups

To increase access to high-risk populations, the ATS/CDC guidelines recommend that intervention programs utilize nontraditional sites for targeted testing, rather than traditional sites such as the health department. All of the best practice programs conducted TTTLTBI in accordance with this recommendation. For example, the New York program collaborated with English as a Second Language (ESL) classes and local churches to reach high-risk populations for testing. This program also used a mobile chest radiography clinic to reduce barriers to testing (e.g., lack of transportation). In Delaware, the health department collaborated with local poultry plants to test and treat employees at their worksites.

Fostering Treatment Adherence

The ATS/CDC guidelines articulated several strategies for promoting adherence to treatment. The evaluation results indicated that programs successfully used several of these methods to increase treatment adherence:

• Patient education. Four programs explicitly noted the expansion of patient education efforts, to increase treatment adherence by improving treatment acceptance. For example, the Missouri program provided students with one-on-one counseling about the TB treatment process, and educational materials about LTBI and directly observed therapy (DOT). The New York program translated patient education materials, such as CDs and brochures, into 12 languages and distributed them to foreign-born patients to inform them about TB, LTBI, and the benefits of treatment.
   
• Reinforcement methods. Incentives and enablers tailored to the particular needs of the population were widely used as positive reinforcement methods. For example, the Virginia, Delaware, New York, and San Diego programs gave patients incentives such as grocery store or McDonald’s coupons or gift cards. The Missouri program provided students with gift cards to the university bookstore. In addition, the Virginia program gave children stickers to help with treatment adherence. The San Diego and New York programs provided bus tokens or taxi vouchers as enablers to improve access to care.
  
  Negative reinforcement was noted by two programs as specific strategies for promoting testing and treatment adherence. The Missouri program blocked students’ registration if they did not get tested. In the Delaware program, pre-employment testing for LTBI was a condition of employment.
   
• Directly observed preventive therapy. Available information suggests that DOT leads to higher treatment completion rates (Gourevitch et al, 1998). The Delaware and Missouri programs used DOT to help patients adhere to treatment. In the Delaware program, the poultry plant nurses administered the medication to patients, tracked treatment progress and completion, and communicated the treatment progress and completion information to the local health department. In the Missouri program, student athletes received DOT from their athletic trainers; all other students were strongly encouraged to participate in DOT, although it was not required. However, all patients were required to meet with the nurse program manager monthly to track treatment progress.

Role of the Health Department in Targeted Testing and Treatment

The ATS/CDC guidelines stressed that health departments can and should play an instrumental role in planning and coordinating TTTLTBI programs, setting performance standards, and monitoring service quality. These successful programs led efforts to:

• Establish linkages. All of these programs developed partnerships with community organizations to leverage resources and help reach high-risk groups for testing and to facilitate treatment adherence. Examples of these partner organizations include local employers, pediatricians, day-care facilities, community clinics, and churches (see Table 1). These partnerships expanded the reach and resources to provide TTTLTBI programs.
   
• Provide training. Five of the programs specifically noted providing some type of training to their community partners. For example, in Delaware, the health department trained poultry plant nurses on placing and reading tuberculin skin tests. In Virginia, program staff provided TB information and referral guidelines to pediatricians during grand rounds at local hospitals.
   
• Detect and manage barriers. Two essential components of an effective TTTLTBI program are (1) finding possible barriers to testing and treatment, and (2) subsequently addressing those barriers. The programs found interpersonal connections vital to identifying both barriers as well as unique ways to address these barriers to testing and treatment. For example, in Virginia, through discussions with parents of patients, the nurse discovered that transportation was a problem along with other work-related concerns. To address these, they offered later testing hours (after work), provided testing at schools and at work sites, and offered bus and taxi vouchers.

Discussion

The evaluation of these six TTTLTBI programs confirms that the strategies articulated in the ATS/CDC guidelines are critical components of an effective targeted testing program. Each of these programs identified a priority population and cultivated community-based partnerships to provide testing and treatment services. While stakeholders in the program sites recognized positive patient-level outcomes, a major limitation to this project was the lack of baseline data specific to the populations being targeted. Further efforts are needed to quantify and measure specific changes to time for potential TB transmission (coughing symptoms to TB case diagnosis) and adherence to treatment for LTBI due to these targeted testing strategies.

DTBE and RTI thank the six intervention programs that participated in the evaluation. For more information about this project, please contact Maureen Wilce at muw9@cdc.gov or Judy Gibson at jsgibson@cdc.gov.

References

CDC. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000;49(RR-06):1–54.

CDC. Controlling Tuberculosis in the United States: Recommendation from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR 2005;54(RR-12):40-42

CDC. Framework for Program Evaluation in Public Health. MMWR 1999;48(No. RR-11).

Gourevitch MN, Alcabes P, Wasserman WC, and Arno PS. 1998. Cost-effectiveness of directly observed chemoprophylaxis of tuberculosis among drug users at high risk for tuberculosis. Int J Tuberc Lung Dis 1998; 2:531–540.

—Submitted by Shelly Harris, MPH
and Amy Roussel, Ph.D.
RTI International*
*RTI International is a trade name of Research Triangle Institute