Approaches to Build TB Capacity in Low-Incidence Areas

1. 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

2. 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

5. For Progress TowardTB Elimination • Regionalizing TB elimination activities • Using a combination of federal and multistate initiatives Source: Institute of Medicine Report: Ending Neglect Improve access to and efficiency in using clinical, epidemiological, and other technical services by

6. 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

7. The Task Order 6 Goal: Identify best practice models for regional capacity-building in low-incidence areas Task Order 6 Methods: • Assess needs • Develop interventions • Implement interventions • Evaluate interventions

8. 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

9. TB Cases and Rates

10. Trends: TB Rate 1994-2005

11. TB Rate in Vulnerable Populations 1994-2005

12. TB Cases in Vulnerable Populations

13. 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

14. 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 TB Control Program Structures

15. Identified Needs • Clinical consultation • Comprehensive guide to TB control for field and program staff • Laboratory services assessment • Training and education • Outbreak surveillance

16. Address Needs Develop and implement interventions

17. Advisory Group Process • Collaboration with state, local TB programs, public health laboratories, expert clinicians, CDC, FJ Curry National Tuberculosis Center

18. Intervention Areas • Intervention Areas: Outcomes: • 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

19. Intervention Areas • Intervention Areas: Outcomes: • 5. Training and Education Training needs assessment • Conduct regional trainings • 6. Advocacy/Collaboration Regional TB Elimination Plan • Program Evaluation Idaho case management teleconferences • Evaluation of interventions

20. TB Control Manual Template Create a TB control manual template that translates national guidelines into “how-to guide” for field and program staff • 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

21. 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

22. 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

23. 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

24. 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

25. Outbreak Response Plan Template • Outbreak response definitions • Roles and responsibilities • Communication and education • Checklists for all activities http://www.nationaltbcenter.edu/resources/tb_orp_lia.cfm

26. 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

27. Lessons • Building capacity and sustaining improved TB control practices requires dedicated resources and infrastructure • Selective application of regional approach • Not applicable for all TB activities • TB elimination requires not only maintenance; enhancement of TB control required • TB in foreign-born • Cultural competence • Further prevention planning and activities • TB in American Indians- a racial disparity

28. 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

29. Acknowledgments Chris 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