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No. 3, 2008

Highlights From State and Local Programs

Florida TB and Corrections Team Wins 2008 Prudential-Davis Productivity Award!

In 2008, the Department of Health (DOH) TB staff in Florida were recognized with a group award for their work with the Lowell Correctional Institution TB Deployment Team. The contribution being recognized involved a case-finding investigation in a women's correctional facility. The group award was one of the Prudential Financial–Davis Productivity Awards given each year in Florida.

The awards were created by the late J.E. Davis and A.D. Davis (co-founders of Winn-Dixie Stores, Inc.) and are sponsored by Prudential Financial. Since 1989, the Davis Productivity Award program has publicly recognized and rewarded Florida state employees and agencies whose work significantly increases productivity and promotes innovations that improve the delivery of services, while saving money for Florida taxpayers and businesses. This year’s competition attracted 489 nominations from all over the state for innovation and productivity improvements worth $322 million in cost savings, cost avoidances, and increased revenue for state government. Since 1989, award winners have produced more than $5.9 billion worth of added value. The official award winners.

The accomplishment

The 34-member statewide team combined the resources of two agencies, the Department of Health and the Department of Corrections, to find an undiagnosed inmate with highly contagious TB. The previous year, this correctional facility had experienced a TB outbreak. The contact investigation done at the time was considered to have been not as extensive as it should have been. Therefore, the decision was made to do active case finding as opposed to contact investigation. Working almost around the clock for 3 weeks, the team screened 2,729 inmates and prison employees.

The team's first priority was to conduct symptom screening with individuals who might have active TB. To do this, the team developed an interagency electronic data-sharing system and database with specific inmate and officer medical information. This new system allowed the nurses to view the documented medical history of each inmate prior to assessing the inmate's physical signs and symptoms; this allowed for greater efficiency for the active case-finding investigation. The team combined their expertise to design a system for extracting protected health information from the Offender Based Information System (OBIS), a very antiquated system. Obtaining this needed information was the major obstacle this team encountered. However, through the creativity and expertise of the medical and information staff, they accomplished what was originally thought to be almost impossible. This innovation eliminated the need to review approximately 3,000 paper medical records, thus materializing savings of approximately 500 person-hours, for an estimated cost savings of $5,000.

As a result of efforts, the team found an undiagnosed case and prevented further TB spread. Individuals with TB who do not receive treatment can infect as many as 20–30 individuals. The cost of treating one uncomplicated case of TB in Florida is estimated at $21,000 (2003 dollars). By finding this active case of TB, we estimate that at least 20 other people were saved from developing this disease, resulting in a cost avoidance of $420,000 (20 x $21,000=$420,000). After deducting the $92,209 spent on labor and consumables, the team realized a cost savings of $327,791 (annually). The interagency electronic data-sharing system saved an additional $5,000, for a total cost avoidance of $332,791.

This was the first active case-finding investigation conducted within a prison in Florida. The collaborative effort between the two departments added significant value to the active case-finding mission by capitalizing on the abilities and advantages of each agency. Critical factors that ensured the success of the mission included the agencies’ sharing information, providing access to the facility, and maintaining ongoing communication. In addition, this investigation was accomplished in a very short period of time. It was a truly successful collaborative venture!

Recognition

This team was recognized at the Florida Department of Health/Bureau of Tuberculosis and Refugee Health Fourth Annual Statewide Meeting in Tampa. The group members were praised by the director of Disease Control for their “noble commitment and outstanding hard work, which far exceeded Department, Division and Bureau expectations."

This innovative project demonstrated best practices to reduce the spread of a potentially deadly respiratory disease, and improved outcomes for all Floridians. Infectious diseases within a prison can spread to local communities through inmates who return home after completing their sentences, as well as through the exposed workforce.

Employee tuberculin skin testing was identified as an area for improvement during this investigation. A Department of Corrections process map was developed and a quality management approach utilized to improve institutional employee testing compliance. The process of improvement is on going, but the initial results indicate incremental improvement.

—Nomination developed by Mary Hackney
Florida Department of Corrections
Submitted to TB Notes by Jimmy Keller, DHSc
Div of TB Elimination

Program Collaboration and Integration Activities in Connecticut

In January 2007, the program manager of Connecticut’s Sexually Transmitted Diseases (STD) Control Program also became the manager of the TB Control Program. The integration of these two programs has presented a great opportunity for staff from these programs to collaborate, offering a variety of services to clients seen for STDs or TB.

In the STD program, Disease Intervention Specialists (DIS) interview clients with certain STDs and follow up with notification, examination, and treatment of exposed sex partners. These staff are also responsible for counseling and interviewing clients infected with HIV and locating their needle-sharing and sex partners for appropriate testing and referral. The DIS staff are able to draw blood, collect urine samples, and collect a swab for HIV testing in the field setting.

In 2007, with the integration of these two programs, Connecticut initiated a cross-training program that is helping the TB program nursing supervisor and the TB case managers become certified HIV counselors. The training, which can take several months to complete, is provided by staff of the Connecticut HIV/AIDS prevention program. To meet the requirements of this training, the TB staff observe the counseling sessions and practice in a variety of settings. For example, they have worked with STD staff in high school settings where students are being screened for STDs and HIV. The TB case managers are able to conduct HIV pretest counseling sessions with students to hone the skills needed for this certification. Once trained and certified, TB staff will be able to conduct HIV counseling and testing for TB patients who have not already been tested for HIV through their medical provider, and can also complete HIV testing on contacts, if there is a need to determine HIV status. This testing can be completed in a nonmedical setting,* which will facilitate the completion of the test and help ensure appropriate management of the TB patient.

*Note: In revised recommendations from 2006, CDC recommends HIV screening for all TB patients after the patient is notified that testing will be performed unless the patient declines (i.e., opt-out screening); however, these recommendations only address health care settings. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006; 55 (No. RR-14). Fact sheet

The TB case managers and nursing supervisor also had training in phlebotomy in order to draw blood for QuantiFERON tests (QFTs), which will be performed at the state laboratory. QFTs will be available later in 2008. Protocols will be established on the eligibility requirements for QFTs, but it is expected that the majority of eligible clients will be those seen and managed by the TB staff. The ability to draw blood and deliver the specimens to the state lab promptly is crucial to the processing of the test. Case managers can facilitate this process to ensure accurate results.

Further collaboration is occurring with the STD program. DIS staff are now more familiar with TB and the need for TB testing of high-risk clients (e.g., those who are also HIV infected). They are aware of TB clinics in their area and of the staff in the TB program who can assist to ensure TB testing occurs. Clinicians in STD clinics will also be introduced to the nursing supervisor and case managers in the TB program. Once they are familiar with staff and clinics in the area, there will be a heightened awareness of the need for high-risk STD patients to be referred for TB testing.

Recently, additional collaboration has taken place between the AIDS division and the STD and TB programs. In selected community health centers, anyone receiving a positive HIV test is referred for STD services. This includes comprehensive STD screening, hepatitis A/B vaccination, hepatitis C screening, partner notification services, and referral to care for HIV infection. These clients are also referred for TB testing services. This integrative effort has provided a very comprehensive approach to anyone receiving a positive HIV test.

In the area of integrated epidemiologic and surveillance capacity, the Connecticut Department of Public Health recently hired Dr. Lynn Sosa, former CDC EIS officer, to serve as the medical epidemiologist for the TB and STD programs. The additional capacity has strengthened the programs’ ability to implement collaborations in the areas of epidemiologic analysis, outbreak investigations, and collaborations in screenings.

Looking to the future, preliminary discussions are underway regarding routine HIV screening in TB clinics and other settings serving patients with TB and their contacts. Recommendations will be reviewed, and collaboration with the HIV/AIDS prevention program will again be an integral part of this initiative.

Integration has been effective and productive for these programs. Staff members from the TB and the STD programs are much more aware of the need for comprehensive screening, as well as the availability of appropriate testing and referral sources for follow-up, particularly for the high-risk clients with whom all staff come into contact on a daily basis. Hepatitis C screening and hepatitis A/B vaccinations are available at most STD clinics, another area that CDC is targeting for program collaboration and service integration (PCSI). Through staff training and collaboration on a regular basis, this initiative has been extremely successful in keeping all staff aware of how they can easily and effectively work together and serve the needs of their clients.

—Submitted by Heidi Jenkins
TB/STD Program Director
Connecticut Department of Public Health

Los Angeles County TB Control Program Collaborates with Community Groups to Organize and Present a Successful World TB Day Symposium

For several years, the Los Angeles County (LAC) Tuberculosis Control Program (TBCP) has been forging partnerships with community-based organizations serving populations at high risk for tuberculosis (TB), such as African Americans, HIV/AIDS patients, homeless persons, immigrants, and substance-abusing populations. These partnerships led to the establishment of the TB Coalition of LAC in 2006. The World TB Day planning committee, carved out of this Coalition, planned a half-day symposium to commemorate World TB Day this year. The LAC TBCP and the TB Coalition engaged in extensive outreach to involve participants who would most benefit from increased education and awareness about TB in LAC. Owing to the increasing proportion of foreign-born TB patients in Los Angeles, a concerted effort was made to target organizations and community leaders working with recent immigrant populations, especially those from parts of the world with high TB prevalence.

On March 15, the LAC TBCP, in collaboration with several local community-based organizations such as Breathe California of Los Angeles County (BREATHE LA) and the American Lung Association of California, presented the 2008 World TB Day Forum, which took place from 9 am to 12 noon at the California African American Museum in Los Angeles, CA. The theme for the forum was “I Am Stopping TB – A Disease without Borders.” The purpose of the forum was to educate community leaders about TB so they could take an active role in TB education and prevention within their communities. Community leaders included those from cultural, educational, health care, political, and religious organizations.

Over 115 people representing 55 organizations attended the forum, which began with a keynote address by CA State Senator Mark Ridley-Thomas. Sen. Ridley-Thomas, who sits on the State Health and Appropriations committees, recognized the potential negative effects of budget cuts on the ability to control TB in LAC, promising, “We will not sit idly by as the TB budget continues to be slashed… I will take your message to the Governor.”

The program also included an educational presentation on TB, as well as a TB patient testimonial. A panel of experts discussed cultural myths surrounding TB among the following high-risk groups in LAC: African Americans, Latinos, South Asians, and Southeast Asians. Myths that were discussed included “TB is not a Latino disease, it’s an Asian disease,” “BCG is a vaccine that protects you against getting TB for the rest of your life,” and “Smoking causes TB.” A panel of providers later discussed services available to those with TB in LAC. The program concluded with a discussion on advocacy and what each participant could do to help in the fight against TB. As a follow-up to the forum, the director and a nurse consultant, both representing the LAC TBCP, appeared on a television show entitled Pacesetters which aired on channel KTLA on April 6.

The LAC World TB Day Forum was successful in employing a community-based participatory approach to informing and galvanizing communities about TB. Specifically, leaders in high-risk communities were educated about the continuing importance of TB and the need to take an assertive approach in fighting the disease. Many participants, by signing letters drafted by a key community partner, were mobilized to educate decision-makers about the potentially devastating impact of funding cuts and the disruption of the TB control public health infrastructure.

—Submitted by Chhandasi P. Bagchi, MPH, Robert Miodovski,MPH, and Annette T. Nitta, MD,
Los Angeles County Department of Public Health, TB Control Program; and
Romesh Anketell, MPH, Breathe California of Los Angeles County (BREATHE LA)
 

Arizona TB Nurse Case Management Course

The Arizona Department of Health Services (ADHS) TB Control Program, in collaboration with the Heartland National TB Center (HNTC), developed a TB Nurse Case Management Course which was held February 2008 in Phoenix, Arizona.

The course included presentations given by experts in the field including Drs. Barbara Seaworth and Adriana Vasquez from HNTC, and Dr. Karen Lewis from ADHS. The presenters allowed time for questions and were available after their presentations to address individual concerns.

Some of the topics included Principles of TB Nurse Case Management Techniques, TB Epidemiology, Diagnosis and Medical Management of LTBI and TB Disease, Infection Control, TB/HIV Coinfection, TB Medications and Adverse Effects, the Laboratory’s Role in TB Diagnosis and Treatment, Cultural Considerations, and Border and Interjurisdictional Issues.

The training seemed to have been very well received by the participants. To determine if this training was in fact successful, and why, the participants were asked to complete an evaluation form at the end of the conference. In addition, some of the individuals’ evaluation responses needed clarification; these attendees were contacted after the training and asked for more specific feedback about the conference.

The responses indicated that the course was a success. Some of the comments were as follows:

• “I’ve learned more in these couple days than I had working in TB for 8 years.”
• “I will immediately re-evaluate my current case load to ensure they [patients] are receiving optimal treatment with the information offered at this workshop. I will be in a better situation to make informed decisions and choices. I will be better able to identify problems or issues.”
• “It was not the information as much as the staff/instructors answering our questions and getting back to us in a timely manner.”

Other comments included a thank you for not making them play games, role play, or break into groups.

If you are interested in more information or the PowerPoint handouts, please contact Millie Blackstone, RN, MPH, at blacksm@azdhs.gov

Resources:

Case Management Conference
Heartland and the Arizona Department of Health Tuberculosis Control

Tuberculosis Case Management for Nurses: Self-Study Modules

These four self-study modules provide an overview of public health nursing and discuss the fundamentals of TB case management, leadership skills of the nurse case manager and management of the pediatric patient.

Tuberculosis Case Management for Nurses Workshop: The Facilitator's Guide

This resource outlines the process of planning and conducting a two-day, interactive workshop for TB nurse case managers and is available as an online product.

Planning & Implementing the TB Case Management Conference: A unique opportunity for networking, peer support and ongoing training

This manual is a step-by-step guide for developing and conducting the case management conference.

—Submitted by Millie Blackstone, RN, MPH
Arizona Dept of Health Services