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
Feb 22, 2016
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 initiativesSource: 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 2005Year
TB c
ases
per
100
,000
pop
ulat
ion
ID MT UT WY Region
Trends: TB Rate 1994-2005
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
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 activitieshttp://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
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