New Concepts in TB Control Regionalization The New England Experience Mark N. Lobato, MD CDR U.S. Public Health Service Division of TB Elimination Brown.

New Concepts in TB Control

RegionalizationThe New England

ExperienceMark N. Lobato, MD

CDR U.S. Public Health ServiceDivision of TB Elimination Brown Bag

2006

Partners Connecticut: James Hadler, George Raiselis, Tom

Condren, Mukhtar Mohamed, Maureen Williams Maine: Kathy Gensheimer, Suzanne Gunston Massachusetts: Sue Etkind, Kathy Hursen, Sharon

Sharnprapai, Janice Boutette, Marilyn Delvalle New Hampshire: Judy Proctor, Lisa Roy, Jose

Montero Rhode Island: Utpala Bandy, Richard Missaghian,

Jane Carter Vermont: Susan Schoenfeld RTMCC: Erin Howe, Rajita Bhavaraju CDC: Zachary Taylor, Dan Ruggiero, Maureen

Wilce Subroto Banerjee, Bob Pratt, Sandy Price

Regionalization

“CDC can facilitate regionalization by conducting pilot programs in conjunction with states, as well as by maintaining experienced personnel who can provide back-up during outbreak situations and complex investigations.”

Institute of Medicine, Ending Neglect, 2000

Purpose of Regionalization

PurposeTo mobilize and coordinate

broad collaborative actions Method

Create a new systemPlan through existing

structures

What can regionalization do for

TB control? Expand experts Build on diversity of

experiences and practices Increase ability to affect health Improve efficiencies Strengthen advocacy

New England

Racial Composition, 2000

Source: U.S. Census Bureau

Demographic TrendsNE, 1990-2000

0%

20%

40%

60%

80%

100%

120%

AsianSE AsianHispanicAfrican-American

Source: U.S. Census Bureau

Immigration

Source: Federal Reserve Bank of Boston

Urban immigrants

Source: Federal Reserve Bank of Boston

Massachusetts Immigration

Tuberculosis inNew England

A Historical Perspective

New England Skeptical Society

VampiresFrom 1790 to 1890, over a dozen cases of vampirism took place in New England involving families infected by "consumption". After a family member died from TB, living members would open the deceased’s graves to look for signs that spirits were preying as vampires on living family members. The treatment was to cut out the heart, burn it to ashes, dissolve the ashes in water to be drunk by the living family members.

Sanitorium Movement: CT

Dr. Charles W. Gaylord in Branford, CT developed the family farm into a tuberculosis sanitarium. This farm is now the site of the Gaylord Hospital in Wallingford, a hospital with about 120 beds devoted to spinal injury and rehabilitation.

Eugene O’Neill

After panning for gold in Honduras and living in a “flop house” in NYC, Eugene O’Neill entered Gaylord Farm Tuberculosis Sanitorium in 1912. While there he wrote his first plays and determined his future as a playwright.

Sanitorium Movement: MA

_____________________________

REPORT OF THESANITARY COMMISSIONOF MASSACHUSSETTS, 1850_____________________________BY

LEMUEL SHATTUCK

TB Hospital

Lemuel Shattuck (1793-1859)The Father of

American Public Health

Lemuel ShattuckHospital

Jamaica Plain, MA

Dr. Moses Stone asked, “Where are those too poor to pay going to get care?" He instilled this passion in a group of local Boston women. Through their efforts the JewishTB Sanatorium was established in 1927.

NEJM Weekly CME ProgramExam Listing: Tuberculosis

Priorities for the Treatment of LTBI Forgotten but Not Gone Dexamethasone for the Treatment of TB Me

ningitis in Adolescents and Adults

The New England Journal of Medicine is owned, published, and

copyrighted© 2005 Massachusetts Medical Society 

Tuberculosis inNew England

21st Century

TB Background, 2004 TB cases

Total cases = 486 Rate = 3.4/100,000 (range 1.2-

4.3) TB trends

Cases increased in 3 states MA (9%) RI (10%) NH (59%)

TB Case Rates, 2004

Source: MMWR 2005;54:245

We’re All in the Same Boat

“Successful TB control in the U.S. …depends on the development of effective strategies to control and prevent disease among foreign-born persons.”Source: CDC. Controlling TB in the United States, 2005

Percent Foreign-BornTB Patients

0

10

20

30

40

50

60

70

80

1997-99 2000-02 2003-04

NE

U.S.

Percent Foreign Bornby State and Year

0

10

20

30

40

50

60

70

80

90

CT ME MA NH RI VT

2002

2003

2004

Tuberculosis inNew England

New Methods, Old Problems

Morbidity and Mortality Weekly Report

December 5, 2003

Public health dispatch: TB outbreak in a homeless population-- Portland, Maine, 2002-2003

During June 2002-July 2003, seven men with active pulmonary TB disease in Portland, Maine, were reported to the Maine Bureau of Health. Six were linked through residence at homeless shelters; four had matching genotypes. Prompt investigation and identification of approximately 1,100 contacts likely prevented further spread of TB. This report summarizes preliminary results of the ongoing investigation and efforts to work with health-care providers statewide to improve early detection of TB among homeless persons.

TB Resources No …

money staff front-line authority

Have…good will

Regionalization Process Stakeholder collaboration Establish regular communication Define priorities

Maintain political will

Zen Lessons Live with uncertainty Be sensitive to uncertainty Befriend uncertainty

Uncertainty Principle

Central tenets of the uncertainty principle

• Take action in the face of uncertainty (using credible evidence) 

• Accept burden of proof as the proponent of an activity

• Explore a wide range of alternatives• Be prepared to alter course

Overcoming Challenges Different experiences

Find common ground Variable resources

Build on what exists Divergent opinions

Establish consensus Competing priorities

Stay focused

Regional Objectives

Develop a regional plan Promote regional education Provide consultation Create a genotyping database Use program evaluation

consistently

Regional PlanObjective 1. Create a regional plan

including action steps so that appropriate state and local TB control managers and staff will have the necessary awareness and venues of regional communication to create a shared vision by Fall 2005.

Action Steps:1. Engage TB program leadership2. Use existing or new venues to discuss vision3. Visit each program at least once annually4. Incorporate plan into TB elimination plans

Stratification of Tasks

TimePriority

High Moderate Low

Immediate

Commun-ication

Education & training

Medical consult

Short term

Consensusplan

Evaluation New funding

Long term

Genotyping database

Contact investigations

Research

Accomplishments Established a shared vision Undertook “needs assessments” Created TB regional plan Initiated education for providers Planned genotyping database Develop program evaluation plans

Building CapacityThrough Partnerships

CDC: Applied for a PHPS fellow UCONN: MPH student to

analyze supplemental surveillance

Western NE College: Informatics intern to help on regional website

Products Educational series“TB Case Series for Providers and

Clinicians” Regional website Genotyping database State-specific

Advisory committees Talks at conferences (NE, TB Today)

Education Objective

“Support and assist the Northeast Regional TB Model Center for the purpose of planning and promoting region-wide training and education of staff, providers, and patients using in-person or distance modalities by the Winter 2005.”

Educational Case Series Defined need to reach private

providers Created basis for distance

learning webinar continuing education credit

Held two successful presentations Need to build e-mail lists

Interactive Web PresentationApril 11, 2006

8:00 A.M.

Accreditation: CME, CNE, CHES. This activity has been designated by CDC for 1Category 1 hour toward the AMA physician's recognition award, 1.2 hours toward theANCCCA nurse’s recognition award and 1 hour accreditation by NCHEC for educators.

TThe New England TB control programs invite you to participate in a case presentations of a patient with tuberculous meningitis and HIV

infection.

Eliminating TB Case by CaseA Case Series for Providers and Clinicians

Joseph Gadbaw, Jr., MDLawrence and Memorial Hospital

New London, CT

Access the TB Case Series at:www.mymeetings.com/nc/join.php?i=PG1678747&p=2006&t=c Toll free audio access: 888-552-9191 Password = 2006 # 

NewEnglandTB.com Developed a team with

expertise Purposes of website are to

Increase cohesiveness and visibility

Promote regional and state education

Exchange materials

Regional Genotyping

“Send all M. tuberculosis isolates for DNA genotyping and enter results into a shared database.”

Genotyping Database Established work group Defined data management

capacity and needs Collaboration around CT

cluster Participated in national effort

State Accomplishments (1)

Connecticut Started enhanced TB surveillance Revised pediatric guidelines Updated BCG guidelines

New Hampshire Surveyed 400 providers on

educational preferences

State Accomplishments (2)

Maine Developed a corrections toolkit

Rhode Island Completed an investigation in a

medical waste facility Massachusetts

Planning a ‘Clinicians Update Conference’

New Models

“The traditional model of TB control, in which planning and execution reside almost exclusively with the public health sector, is no longer the optimal approach…”

Controlling Tuberculosis in the United States, 2005

One shoe does not fit all

Maine, NH, and VT do not have outreach staff

Connecticut and Mass. are organized into health districts 0

10

20

30

40

50

60

70

80

90

HD Pvt Both

CTMAMENHRIVT

Type of Provider (%), 2004

Advisory Committees MA: Well-established, 1999 RI: Reconstituted, May 2005 CT: Revitalized, October 2005 Regional perspective

Advocacy Legislation Stigma QFT/laboratory

Cohort Review Cohort reviews - an

independent priority area and supportive of evaluation efforts

CT looked to MA model of regional and state-wide reviews

RI establishing own approach

Special Challenges Intrajurisdictional contact

investigations Migratory workers Maintaining expertise and

sufficient resources

Lessons Learned Regional efforts offer benefits

to state programs and to DTBE Modern TB control requires

cooperation, coordination, and collaboration across jurisdictions

Best Practices Communication must be open

and ongoing Agenda is set by the

stakeholders

Bringing clean air to schools, jails,

hospitals, and shelters in New England.

Protect your patients, clients,inmates, students, and yourself from

BACTERIA: Tuberculosis

MOLDS:  molds

VIRUSES:  chicken flu

ODORS:  "dirty sock syndrome“

Click Here For A Breath Of Fresh Air

www.NewEnglandTB.com

What Next?