Approaches to Build TB Capacity in Low-

Incidence AreasLisa Pascopella, PhD, MPH

FJ Curry National Tuberculosis CenterSan Francisco, CA

May 14, 2007

FRANCIS J. CURRYNATIONALTUBERCULOSISCENTER

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

For Progress TowardTB Elimination

Regionalizing TB elimination activities Using a combination of federal and

multistate initiatives

Source: Institute of Medicine Report: Ending Neglect

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

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

The Task Order 6 Goal: Identify best practice models for regional capacity-building in low-incidence areas

Task Order 6 Methods:Assess needsDevelop interventionsImplement interventionsEvaluate interventions

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

TB Cases and RatesState(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

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

TB

ca

se

s p

er

10

0,0

00

po

pu

lati

on

ID MT UT WY Region

Trends: TB Rate 1994-2005

0

5

10

15

20

25

30

1994 1996 1998 2000 2002 2004

TB

Ca

se

s p

er

10

0,0

00

.

United States

US-born non AI

American Indian

Foreign Born

TB Rate in Vulnerable Populations 1994-2005

TB Cases in Vulnerable TB Cases in Vulnerable PopulationsPopulations

CohortCohort Foreign-Foreign-born born

American American Indian (AI)Indian (AI)

US-born, US-born, non AInon AI

TotalTotal

1994-19991994-1999 178178 111111 238238 527527

2000-20052000-2005

(% change)(% change)201201

(+11)(+11)6262

(-79)(-79)146146

(-63)(-63)409409

(-29)(-29)

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

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

Identified Needs

Clinical consultation Comprehensive guide to TB

control for field and program staff Laboratory services assessment Training and education Outbreak surveillance

Address Needs

Develop and implement interventions

Advisory Group Process Collaboration with state, local TB

programs, public health laboratories, expert clinicians, CDC, FJ Curry National Tuberculosis Center

Intervention Areas: Outcomes:

1. 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

Intervention Areas

Intervention Areas: Outcomes:

5. Training and Education Training needs assessment

Conduct regional trainings

6. Advocacy/Collaboration Regional TB Elimination Plan

7. Program Evaluation Idaho case management teleconferences

Evaluation of interventions

Intervention Areas

TB Control Manual Template

Applicable to low-incidence states Customizable to address each state’s unique

epidemiologic and infrastructure circumstances Standardizes case management/CI and clinical

practice

Will be available at www.nationaltbcenter.edu

Create a TB control manual template that translates national guidelines into “how-to guide” for field and program staff

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

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

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

Surveillance cont.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

Outbreak Response Plan Template

Outbreak response definitions Roles and responsibilities Communication and education Checklists for all activities

http://www.nationaltbcenter.edu/resources/tb_orp_lia.cfm

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

LessonsLessons Building capacity and sustaining improved Building capacity and sustaining improved

TB control practices requires dedicated TB control practices requires dedicated resources and infrastructureresources and infrastructure

Selective application of regional approachSelective application of regional approach Not applicable for all TB activitiesNot applicable for all TB activities

TB elimination requires not only TB elimination requires not only maintenance; maintenance; enhancementenhancement of TB control of TB control requiredrequired TB in foreign-born TB in foreign-born

Cultural competenceCultural competence Further prevention planning and activitiesFurther prevention planning and activities

TB in American Indians- a racial disparityTB in American Indians- a racial disparity

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

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