Jen Reuer, MPH Epidemiologist Washington County Public Health

1. Where Are They now?A Comprehensive Approach to Achieving a High Treatment Completion Rate in a Worksite TB Exposure in Washington County, Oregon Jen Reuer, MPH Epidemiologist Washington County Public Health

2. The Setting • Washington County • Population ~530,000 • Average 17 active TB cases per year • The Call Center • Provide computer-related technical advice over the phone. • Employs mostly male (65%), U.S.-born (92%), native English speakers. • Monthly turnover rate of approximately 10%.

3. Index Case and Exposure • August 2006 - Index case’s symptom onset • October 2006 – March 2007: Index case worked at a call center • Identified a total of 1750 individuals as possible contacts

4. The Investigation:March 2007 – June 2008 • Outreach and education: • letters from the Health Officer • media advisories • informational talks • sessions with the county’s TB nurses • web links and handouts • On-site screenings, using a Point of Dispensing (POD) structure

5. The Investigation:July 2008 – June 2009 • LTBI case management at the worksite in July 2008. • Additional funds received at the county in October 2008 • Outreach worker • Incentives

6. The Investigation:July 2008 – June 2009 • Outreach • Social networking sites (Facebook, Myspace) • Text messages • Individualized letters • Testing • Immediate • QuantiFERON

7. The Investigation:July 2008 – June 2009 • Case Management • Rifampin • Text messages • Worksite and home-based LTBI case management • Incentives • Each step of testing and treatment • Extra incentive for completing treatment

8. Results 1. Total includes household and social contacts of 2 clinical cases. 2. Includes individuals who were determined to have had previous TB treatment, entered the military, deceased from another cause, and did not work during exposure time.

9. Challenges • Number of people requiring some form of follow-up was more than county staff had ever dealt with before. • Young, mobile population made finding contacts difficult. • Data management- scale and available expertise • Large geographic area- outreach worker worked across Clackamas, Multnomah, and Washington counties. • Call center employee’s initial mistrust of health department staff- not differentiated from employer

10. Conclusions • Intense investigation and follow up was necessary in reaching this young and highly mobile population. • New, in addition to traditional, methods were key to reaching the exposed population. • Implementing a comprehensive strategy to educate, locate, test, and treat contacts was vital to achieving a high rate of testing and treatment completion.

11. Washington County Trevor Hostetler, RN Sharon Hofer, RN Mandy Anderson Paul Lewis, MD Cathy Vickers, RN Gloria Matthews Amanda Newell Sue Mohnkern, RN Kathleen O’Leary, RN Monica Silvas All the other staff who were involved in the investigation Multnomah County Mary Ann Ware, MD Gary Oxman, MD TB program staff Clackamas County TB program staff State of Oregon Heidi Behm, RN Lindsey Lane, MPH CDC Paul Tribble Maryam Haddad Kiren Mitruka Lauren Lambert Volunteers who worked at the call center during the PODs The call center for their cooperation Acknowledgments