Regionalization : A New Strategy for TB Control & Elimination The New England Experience Mark Lobato, MD Division of Tuberculosis Elimination Centers for.

Regionalization:A New Strategy for

TB Control & EliminationThe New England Experience

Mark Lobato, MDDivision of Tuberculosis Elimination

Centers for Disease Control and Prevention

The last TB upsurge

• Loss of public health infrastructure

• HIV co-epidemic

• Outbreaks in congregate settings

• Increasing immigration

Response to TB resurgenceMDR-TB Action Plan

& New Resources

Improved Case Identification & Training

Updated DiagnosticLabs

New Infection Control& Rx Recommendations

DOT &Improved Completion

Rebuilt Research Capacity

HRZE

Enhanced TB control

Reported TB cases United States, 1982–2007

12,000

14,000

16,000

18,000

20,000

22,000

24,000

26,000

28,000

1982 1985 1990 1995 2000 2007

Year

No

. of

ca

ses

-4.9% per year

-2.6% per year

High incidence areaslead the decline in TB

05

10152025303540

1993

1995

1997

1999

2001

2003

2005

Year

Cas

e ra

te USNYCLAHouston

Actual and adjusted Federal funds for TB Control

1967-2007

0

20

40

60

80

100

120

140

160

180

'67 '69 '71 '73 '75 '77 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05

Year

$ x

Mil

lio

n

Actual $

BRDPI Adjusted $

The next TB upsurge

• Decreased funding

• Weakened public health infrastructure

• Loss of TB expertise

• High growth of immigration

• Outbreaks in hard-to-reach populations

• Lag in new diagnostics and drugs

The perfect storm

• Mass.– 37% staff loss– 21% budget cut

• CT– 33% staff loss– 1 of 3 outreach

• RI– Program

manager laid off

Erosion of infrastructure

Mississippi Tuberculosis Rate Surges PastNational Average - Clarion Ledger, March 24, 2008  

Mississippi health officials announced the state’s rate of the disease has … increased 12 percent since 2006. Several factors could explain Mississippi’s rate, including the loss of nurses who investigate TB cases and notify others suspected of being at risk. Between 2002 and 2007, the number of nurses at the state Department of Health fell from 412 to 366.

TB cases increase in 16California health jurisdictions

San Jose Mercury News, March 13, 2008

“All of the Bay Area’s large counties recorded substantial increases in new TB cases in 2007. In Santa Clara, San Francisco, Alameda, and San Mateo counties, TB cases spiked last year. San Francisco County experienced its first significant jump since an AIDS-related TB outbreak in the early 1990s. The county now has the highest TB rate in the state. …Over the past two years, TB cases in Santa Clara have increased 21%.”

National trends inTB case rates, 1992-1999

02468

1012141618

1992 93 94 95 96 97 98 99

Year

Cas

e ra

te U.S.

Top 131 cos

Other cos

County State 1997 2006 % Increase

Denver CO 37 40 8.1Marion IN 34 47 38.2Anchorage AK 27 38 40.7Guilford NC 19 38 100Franklin OH 21 85 304Tarrant TX 107 107 0.0Maricopa AZ 165 171 3.6Hennepin MN 88 95 8.0King WA 113 145 28.3

Trends in casesSelect counties, 1997–2006

County State 2000 2006 % Increase

Marion IN 4.3 5.4 32.6

Pima AZ 2.7 3.7 37.0

Guilford NC 4.7 8.4 78.7

Franklin OH 7.4 7.8 5.4

King WA 7.3 7.9 8.2

Dallas TX 9.0 10.4 15.6

Shelby TN 8.9 11.7 31.5

Trends in case ratesSelect counties, 2000–2006

TB complexity

Safety net

TB Cases in the US

Drug resistant co-m

orbidityUS Infrastructure

Existing regional TB collaborations

• Binational border projects

• Bay Area Coordinating Committee

• New England TB Consortium

• Capitol Region TB Council (MD-DC-VA)

• Low incidence region (TBESC TO #6)

• Genotyping laboratories

• RTMCC

BackgroundNew England TB Consortium

The 6 New England TB programs are collaborating in new ways as an approach to TB elimination.

• Identifying strategies for collective problem solving

• Building program capacity on a regional level

New England TB, 2007

•TB cases- 408 cases- 3.0 / 100,000

(range 0.5–4.3)

•Regional cases equivalent to state with 8th highest TB burden

Many cultures – one bug

0

20

40

60

80

100

CT ME MA NH RI VT

2004

2005

2006

State

% FB

“So, why did you do it?”

World TB Day, 2008

“This country’s progress in eliminating TB will not be sustainable without ongoing and strengthened collaborations with local, state, national, and international partners…”

Kevin Fenton, MD,

Director, NCHHSTP, CDC

What can regionalization do for TB control?

• Build a diverse and effective team

• Solve problems collectively

• Expand expertise

• Enhance state and local programs

• Involve stakeholders

• Strengthen advocacy

New England TB Action Plan

Five key strategies:

• Team building

• Education

• Capacity expansion

• Universal genotyping

• Medical and outbreak consultation

Resources

• State– TB programs– TB Advisory Committees

• Regional– RTMCC– Shattuck Hospital TB Unit

• CDC– DTBE– Fellows

Value added

New England TB.org

Eliminating TB Case by Case

• Presented by master clinicians

• Designed to reach private providers

• Created basis for distance learning– web-based– continuing education credit

• Held 10 successful presentations

• Need for ongoing marketing

Interactive Web PresentationApril 11, 2006

8:00 A.M.

Accreditation: CME, CNE, CHES..

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.org

Built a website to

• Increase cohesiveness and visibility

• Promote regional and state education

• Exchange tools and materials

Genotyping Work Group

• Defined data management capacity

• Identified only 1 instance of definite transmission with a cluster of 26 cases

• Highlighted missed opportunities to prevent disease

• Measured strain prevalence and dispersion across states

Lessons learned

• Modern TB control requires– Building a team leadership– Coordination and collaboration

across jurisdictions

• Regional efforts offer advantages to state programs and to CDC

Next steps

• Analyze project evaluation data– Improve collaborative efforts– Determine how to replicate model

• Created the New England TB Consortium

• Building a new case management series “TB Talk”

Future outlook

• Expand

collaboration

• Increase capacity for managing

MDR/XDR TB

• Initiate

evaluation

We need a doublehull infrastructure

New England TB ConsortiumConnecticutHeidi Jenkins, Tom Condren, Lynn Sosa, Maureen Williams, James Hadler,Gary Budnick

MaineKathy Gensheimer, AnneSites, Suzanne Gunston,Julie Crosby

MassachusettsSue Etkind, Kathy Hursen, Sharon Sharnprapai, Marilyn DelValle, John Bernardo, Alex Sloutsky

New HampshireJill Fournier, Lisa Roy,Jody Smith, Peggy Sweeny

Rhode IslandUtpala Bandy, Mike Gosciminski, Chris Goulette, Toby Bennett

VermontSusan Shoenfeld, Susan Cook,Becky Temple

RTMCCErin Howe, Nicolette Patrick

DTBEDan Ruggiero, Kashef Ijaz, BobPratt, Joe Scavotto, Ken Castro

Prepare,you’ll sleep better at night.