Evaluating Tuberculosis Surveillance and Action in an Urban and Rural Setting Kristine Lykens, Ph.D. In collaboration with Anita Kurian, MPH, MBBS Patrick Moonan, MPH Stephen E. Weis, D.O Date: June 27, 2005

Project A collaborative effort between  Center for Disease Control and Prevention, Division of Tuberculosis Elimination  University of North Texas Health Science Center - Fort worth  Texas Department of Health  American Lung Association  Florida Department of Health

Draft of Performance Indicators CDC State Department of Health M/E Practices Stakeholder Focus Groups Program Staff County Health Department TB 400 A, TB 400 B TB 340, TB 341 State database (TIMS, State lab) Local database (HIV database, PNS screenings) Selected program Staff Interviews Initial set of 144 indicators selected Matrix of 34 indicators finalized Performance Analysis Methods Evaluation Staff

FOCUS GROUP I FOCUS GROUP II FOCUS GROUP III FOCUS GROUP IV Number of Participants 1286 Professional Level Medical Directors Project managers Clinicians Mid-level supervisors Clinic/ Outreach Nurses Contact investigators Outreach workers Clerks Medical records staff Nurses (TDH 2/3) Contact Investigators (TDH 2/3)

Conceptual Framework to Evaluate TB Surveillance and Action 1 Training Supervision Resource provision Communications Support Activity Feedback Analysis Confirmation Reporting Registration Detection Public Health Surveillance Public Health Action Acute (Epidemic-Type) Response Planned (Management- Type) Response Data-Information-Messages

Data Sources  Registered Public Health Records – TB 400 A, TB 400 B, TB 340, TB 341.  Selected staff interviews – Medical Director, Program Manager, Outreach supervisor, Medical records clerk, Billing clerk.  Local and State level databases  Local database – HIV database maintained by Medical records clerk, and the PNS roster maintained by the contact investigators.  State databases – TIMS, and state laboratory database.

Tarrant County Fort Worth is Central City County population over 1.5 million Tuberculosis program –Central Clinic –DOT and Contact Investigation centralized –Growing immigrant population –Site for several TB research projects

DHHS Region 2/3 37 rural counties without Public Health Departments. Central office in Arlington, TX Sub-Offices staffed by PH nurses TB program case-managed by nurses Contact investigation by nurses DOT by PH and contracted nurses

Selected Results – Tarrant Co. TB suspects who received visit within 3 working days – 65% TB suspects with completed evaluation within two weeks – 91% TB cases receiving Directly Observed Therapy (DOT) – 100% TB cases who completed DOT – 99%

Tarrant Co. Results (continued) TB cases with documented HIV status – 94% TB cases without any identified contacts – 4% Contacts with completed TB skin tests –With night shelter cases – 86% –Without night shelter cases – 57%

Selected Region 2/3 Preliminary Results TB suspects who received visit within 3 working days – 63% TB suspects with completed evaluation within two weeks – 78% TB cases receiving Directly Observed Therapy (DOT) – 90% TB cases who completed DOT – 89%

Selected Region 2/3 Preliminary Results (continued) TB cases with documented HIV status – 50% (4/10 refused test) TB cases without identified contacts – 0% TB contacts with completed TB skin tests – 55%

Conclusions  Few of the national TB goals were not only met but exceeded.  National TB goal 4 - The national TB goal of at least 75% of all newly reported TB cases will have the HIV status reported (TC).  National TB goal 5 - At least 90% of patients with newly diagnosed TB, for whom therapy for one year or less is indicated, will complete therapy within 12 months (TC). 89% in R2/3.  National TB goal 7 - At least 90% of newly reported sputum AFB-smear positive TB cases will have contacts identified.

 One activity amenable for intervention was the activity of ‘contact investigation’. An audit of 280 TB 341 forms revealed that only 25 (8.9%) of the TB 341 forms had all the data fields completed/updated.  One of the national TB goals that was not achieved pertained to the activity of contact investigation –  National goal 8 - At least 95% of contacts to sputum AFB- smear positive TB cases will be evaluated for infection and disease (TC).  National goal 4 – At least 75% of cases will have HIV status known. In Reg 2/3 four out of 10 refused test.

Recommendations  Have an Integrated data base**  Designate a separate ‘medical records clerk’ to update the TB 340s and TB 341s. (TC)  Cross train staff for contact info update (TC).  Improve communication between the contact investigators and the clinic staff (TC).  Conduct either a patient satisfaction survey or focus group involving patients to obtain feedback regarding the services provided by the program.

Recommendations (cont’d)  Educate the contacts of the cases regarding the importance of preventive therapy.  Streamline the process so that intake process and clinical evaluation can occur on the same day.  Review process for patients visiting the medical clinic for different services to reduce wait time for the patients (TC).  Increase follow-up for 2 nd TST (R2/3).  More field staff for Region 2/3 – nurses, administrative, and contact investigators.