1. Improving Initial Evaluation for Persons with Class A/B TB Conditions Massachusetts Department of Public Health, Bureau of Infectious Disease Division of Tuberculosis Prevention and Control Refugee Immigrant Health Program Sharon Sharnprapai

2. Background   Newly arrived persons with class A/B TB condition with abnormal chest x-ray are at increased risk for progression to active TB.   It is essential that the persons are evaluated for TB soon after entry into the US.

3. National TB Program Objectives and Performance Target for 2015 Evaluation of Immigrants and Refugees CDC - not yet determined the “N%” for these indicators MA goal – 75% MA goal – 85% MA goal – 75%

4. Working Definition When medical evaluation is considered initiated? When medical evaluation is considered completed? Working definitions developed : Medical evaluation initiated -> If Initial tuberculosis skin test (TST) was done or nursing assessment was done to determine that a TST was not needed. Medical evaluation completed -> American Thoracic Society (ATS) classification was assigned to the newly arrived either by the TB clinic staff or another medical provider.

5. 2009 Massachusetts Data Total Notifications ReceivedN=242 Medical evaluation initiated180 (74%) Not evaluated N=62 (26%) Within 30 days (Goal 75%)121 (67%) Within 60 days147 (82%) Within 90 days158 (88%) Medical evaluation completed175 (97% of initiated) Within 90 days92 (51% of initiated) Appropriate for Rx InitiationN=91 Treatment Initiated60 (66%) Treatment Completed41 (68%)

6. Goal of Evaluation To increase the rate of initial medical evaluation How ? Need to understand why the newly arrived persons did not receive initial medical evaluation Develop plans to address issues

7. Survey - Why not receive initial evaluation Total New Arrival 2009 N=242 Medical evaluation initiated N=180 (74%) Not evaluated N=62 (26%) Survey Methods - Phone call to nurse case managers at the local health departments (LHD) for each of 62 newly arrived persons Questions to nurses:  Did you receive notification about the arrivals from the TB Division &  Were you able to contact the newly arrived; if not, why?

8. Survey Results Of the 62 newly arrived; Nurses able to provide information for 49 persons (79%) ________________________________ Of the 49 persons,   Nurses not able to locate 15 persons (31%)   14 persons (29%), follow-up may have been initiated by the nurses, however, records of follow- up were not found; and 5 persons (10%) moved soon after arrival in MA.

9. Survey - Identified Issues 1. Home address of the newly arrived persons supplied through the CDC’s Electronic Disease Notification System (EDN) can be incorrect. This can led to the LHD nurses not being able to locate some persons, and caused delays when the notification had to be re-routed to a different jurisdiction. Example – address given 123 Summit street Brookline but actually home in Brighton.

10. Survey - Identified Issues (continued) 2. If the LHD nurses are unable to locate the newly arrived persons, they often held the “follow-up worksheet”. TB Division is then unaware of the disposition and unable to help LHD nurses to locate the person in a timely manner.

11. Action Plans 1. Verify the address of the newly arrived persons using Google before the notification is sent to the LHD nurses. If the address is invalid, we will contact the sponsor by phone to obtain the new address. Confirming the validity of address may help LHD nurses locate the newly arrived and reduce delay of notification.

12. Action Plans (continued)   Institute active follow-up by calling the LHD nurses to obtain updated status reports about the newly arrived persons and answer questions regarding follow-up procedures if the “TB follow-up worksheet” has not been returned within 30 days after the notification is sent to the LHD nurses.   A check-list was developed to help guide the LHD nurses in the medical evaluation process.

13. Check list

14. Limitations Because 2009 data were used, LHD nurses had difficulties recalling why initial medical evaluation was not initiated or the nurses assigned to provide case management to the newly arrived had left the health department.

15. Next Steps Verification of addresses has initiated. The number of notifications with invalid addresses will be tracked. The implementation of active follow-up will start in October. The rate of initial medical evaluation persons arriving in 2013 will be compared to those who arrived in 2009-2011 to evaluate the extent to which our initiatives have increased the initial medical evaluation rate. For 2013, focus on increasing the rate of treatment initiation and treatment completion.

16. Acknowledgements Marisa Chiang Jennifer Cochran Pat Iyer Maura McGarty Kate Penrose Andrew Tibbs

17. Questions