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Approaches to Build TB Capacity in Low- Incidence Areas Lisa Pascopella, PhD, MPH FJ Curry National Tuberculosis Center San Francisco, CA May 14, 2007 FRANCIS J. CURRY NATIONAL TUBERCULOSIS CENTER
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Approaches to Build TB Capacity in Low-Incidence Areas

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FRANCIS J. CURRY NATIONAL TUBERCULOSIS CENTER. Approaches to Build TB Capacity in Low-Incidence Areas. Lisa Pascopella, PhD, MPH FJ Curry National Tuberculosis Center San Francisco, CA May 14, 2007. Objectives. Describe background to the TB capacity-building project* - PowerPoint PPT Presentation
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Page 1: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 2: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 3: Approaches to Build TB Capacity in Low-Incidence Areas
Page 4: Approaches to Build TB Capacity in Low-Incidence Areas
Page 5: Approaches to Build TB Capacity in Low-Incidence Areas

For Progress TowardTB Elimination

Regionalizing TB elimination activities Using a combination of federal and

multistate initiativesSource: Institute of Medicine Report: Ending Neglect

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

Page 6: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 7: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 8: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 9: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 10: Approaches to Build TB Capacity in Low-Incidence Areas

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 2005Year

TB c

ases

per

100

,000

pop

ulat

ion

ID MT UT WY Region

Trends: TB Rate 1994-2005

Page 11: Approaches to Build TB Capacity in Low-Incidence Areas

0

5

10

15

20

25

30

1994 1996 1998 2000 2002 2004

TB C

ases

per

100

,000

.

United States

US-born non AI

American Indian

Foreign Born

TB Rate in Vulnerable Populations 1994-2005

Page 12: Approaches to Build TB Capacity in Low-Incidence Areas

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)

Page 13: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 14: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 15: Approaches to Build TB Capacity in Low-Incidence Areas

Identified Needs Clinical consultation Comprehensive guide to TB

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

Page 16: Approaches to Build TB Capacity in Low-Incidence Areas

Address Needs

Develop and implement interventions

Page 17: Approaches to Build TB Capacity in Low-Incidence Areas

Advisory Group Process Collaboration with state, local TB

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

Page 18: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 19: Approaches to Build TB Capacity in Low-Incidence 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

Page 20: Approaches to Build TB Capacity in Low-Incidence 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

Page 21: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 22: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 23: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 24: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 25: Approaches to Build TB Capacity in Low-Incidence Areas

Outbreak Response Plan Template

Outbreak response definitions Roles and responsibilities Communication and education Checklists for all activitieshttp://www.nationaltbcenter.edu/resources/tb_orp_lia.cfm

Page 26: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 27: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 28: Approaches to Build TB Capacity in Low-Incidence Areas

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

Page 29: Approaches to Build TB Capacity in Low-Incidence Areas

AcknowledgmentsChris 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