Approaches to Build TB Capacity in Low-Incidence Areas

1
Approaches to Build TB Capacity in Low-Incidence
Areas
FRANCIS J. CURRY NATIONAL TUBERCULOSIS CENT
ER

• Lisa Pascopella, PhD, MPH
• FJ Curry National Tuberculosis Center
• San Francisco, CA
• May 14, 2007

2
Objectives

• Describe background to the TB capacity-building
  project
• Describe project methods and relevance to TB
  control in other low-incidence areas
• Present challenges and lessons learned
• Task Order 6 of the TB Epidemiologic Studies
  Consortium

3
(No Transcript)
4
(No Transcript)
5
For Progress TowardTB Elimination

• Improve access to and efficiency in using
  clinical, epidemiological, and other technical
  services by

• Regionalizing TB elimination activities
• Using a combination of federal and multistate
  initiatives
• Source Institute of Medicine Report Ending
  Neglect

6
TB Control Challenges

• Maintenance of clinical, epidemiologic,
  laboratory and programmatic expertise
• Few resources
• Long distances/mountain passes/weather as
  barriers to specimen transport and DOT
  administration
• Delayed case finding and increased transmission
• Need for surge capacity
• Prevention is lower priority

7

• The Task Order 6 Goal
• Identify best practice models for regional
  capacity-building in low-incidence areas
• Task Order 6 Methods
• Assess needs
• Develop interventions
• Implement interventions
• Evaluate interventions

8
Needs Assessment

• Describe TB epidemiology in the region
• Describe infrastructure for TB control
• Identify challenges in each area of TB control
• Core TB program functions
• Private sector and partnerships
• Laboratory
• Training/Education

9
TB Cases and Rates
State (2006 population) Cases in 2006 2006 case rate
Idaho (1,466,465) 20 1.4
Montana (944,632) 13 1.4
Utah (2,550,063) 34 1.3
Wyoming (515,004) 4 0.8
10
Trends TB Rate 1994-2005
11
TB Rate in Vulnerable Populations 1994-2005
12
TB Cases in Vulnerable Populations
Cohort Foreign-born American Indian (AI) US-born, non AI Total
1994-1999 178 111 238 527
2000-2005 ( change) 201 (11) 62 (-79) 146 (-63) 409 (-29)
13
Foreign Born Cases2003-2005
Mexico 40 cases Somalia 9 cases 10
countries 2-7 cases 18 countries 1 case
SVG map created by Adam Filipowi
14
TB Control Program Structures

• IDAHO
• 0.5 FTE (2 persons) at State TB Control Program
• District Generalist PHNs and Epidemiologists
• State TB controller is M.D.
• MONTANA
• 1 TB dedicated FTE at State
• County Generalist PHNs
• No nurse nor M.D. consultants

• UTAH
• Adequate staff for State TB Control
  Program/Refugee Health
• County Generalist PHNs
• Nurse and M.D. consultants
• WYOMING
• 1 TB-dedicated FTE at State
• State and County Generalist PHNs
• No nurse nor M.D. consultants

15
Identified Needs

• Clinical consultation
• Comprehensive guide to TB control for field and
  program staff
• Laboratory services assessment
• Training and education
• Outbreak surveillance

16
Address Needs

• Develop and implement
• interventions

17
Advisory Group Process

• Collaboration with state, local TB programs,
  public health laboratories, expert clinicians,
  CDC, FJ Curry National Tuberculosis Center

18
Intervention Areas

• Intervention Areas Outcomes
• Policy Planning TB Control Manual Template
• 2. Clinical Consultation Regional Warmline
• 3. Laboratory Services Surveys of laboratory
  practice
• Regional laboratory trainings
• 4. Surveillance Regional use of genotyping
• Outbreak Response Plan Template

19
Intervention Areas

• Intervention Areas Outcomes
• 5. Training and Education Training needs
  assessment
• Conduct regional trainings
• 6. Advocacy/Collaboration Regional TB Elimination
  Plan
• Program Evaluation Idaho case management
  teleconferences
• Evaluation of interventions

20
TB Control Manual Template
Create a TB control manual template that
translates national guidelines into how-to
guide for field and program staff

• Applicable to low-incidence states
• Customizable to address each states unique
  epidemiologic and infrastructure circumstances
• Standardizes case management/CI and clinical
  practice
• Will be available at www.nationaltbcenter.edu

21
Clinical Consultation

• Four states have access to specific medical
  consultants (Charles Daley, Charlie Nolan,
  Randall Reves) through the FJ Curry National TB
  Center Warmline
• Advantage compared to usual operation Warmline
• Built relationships and continuity

22
Laboratory Services

• Assessed mycobacteriology laboratory practices
  across 4-state region
• Identified areas of concern
• Lab safety issues
• Turnaround times
• Reporting issues
• Held laboratory trainings (included those from
  public and private sector)
• Ongoing network to share problems and solutions

23
Surveillance

• Regional approach to using genotyping data
• Data sharing agreements
• Regional genotyping coordinator
• Routinely reviews genotyping data across region
• Provides expertise and consultation to region and
  states
• Facilitates communication between states
• Policies and procedures for reviewing and sharing
  cluster findings

24
Surveillance cont.

• Identified 7 inter-state PCR clusters
• 2 PCR clusters with isolates having different
  RFLP patterns
• Rv/Ra cluster
• Follow-up pending on 2 PCR clusters
• 1 regional outbreak among homeless
• Identified issues related to duplicate reporting
  of results in 2 different states
• Developed lab notification system to prevent
  duplicate reporting in future

25
Outbreak Response Plan Template

• Outbreak response definitions
• Roles and responsibilities
• Communication and education
• Checklists for all activities
• http//www.nationaltbcenter.edu/resources/tb_orp_l
  ia.cfm

26
Case Management Teleconferences

• Bi-monthly teleconferences in Idaho with state
  and local participation
• Local PHN presents case in standard format
• State TB controller guides discussion
• Include external TB experts (nurses and M.D.)
• Evaluation using CDC framework documented the
  usefulness of the ID case management
  teleconference format
• In New England, a regional case conference model
• http//www.nationaltbcenter.edu/resources/id_tb_cm
  .cfm

27
Lessons

• Building capacity and sustaining improved TB
  control practices requires dedicated resources
  and infrastructure
• Selective application of regional approach
• Not applicable for all TB activities
• TB elimination requires not only maintenance
  enhancement of TB control required
• TB in foreign-born
• Cultural competence
• Further prevention planning and activities
• TB in American Indians- a racial disparity

28
Conclusion and Next Steps

• Best-practice models
• TB Manual Template
• Outbreak Response Plan Template
• Regional Surveillance Approach
• Laboratory Advisory Group
• Idaho Case Management Teleconferences
• Complete evaluation of these models and present
  findings to national TB audience
• Post model tools at www.nationaltbcenter.edu

29
Acknowledgments

• Chris Hahn, Kathy Cohen, Ellen Zager, Cheryle
  Becker, Denise Ingman, Ruth Swenson, Carol Regel,
  Jackie Cushing, Carol Pozsik, Cristie Chesler,
  Jerry Carlile, June Oliverson, Genevieve Greeley,
  Alex Bowler, Colleen Greenwalt, Susie Zanto, Dan
  Andrews, Gale Stevens, Jim Walford, Ed Desmond,
  Laura Freimanis, Marguerite Oates, Karen
  Mulawski, Tania Tang, Shannon Cowlin, Chuck
  Daley, Randall Reves, Charlie Nolan, Phil
  Hopewell, Kim Field, Gayle Schack, Evelyn
  Lancaster, Brenda Ashkar, David Berger, John
  Seggerson, Carl Schieffelbein, Neil Abernethy,
  Jennifer Kanouse, Karen Steingart, Fernando del
  Rosario, Tom Stuebner, Paul Tribble, John Jereb,
  Zachary Taylor