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Monitoring Tuberculosis Programs --- National Tuberculosis Indicator Project, United States, 2002--2008

The National Tuberculosis Indicators Project (NTIP) is a secure, web-based monitoring system that uses routinely collected surveillance data on individual tuberculosis (TB) cases to measure the performance of state and local TB control programs, help programs to prioritize improvement efforts and focus on key TB control activities, and track progress toward national program objectives. Data are reported on a yearly basis and with frequent updates. This report summarizes NTIP results from the most recent 5 years for which data are available. Program performance was mixed, with general improvement for indicators related to TB case management (e.g., recommended initial therapy, genotyping data reported, human immunodeficiency virus [HIV] status reported, sputum culture reporting, and culture conversion documentation), but lower performance for indicators related to contact investigations of patients with infectious TB (e.g., contact elicitation, medical evaluation of contacts to infectious TB patients, and treatment initiation rate for persons diagnosed with latent TB infection [LTBI]). All performance indicators remained below the national performance targets for 2015. Starting in 2010, programs receiving CDC cooperative agreement funds for TB prevention and control will be required to use NTIP indicator data to describe their performance and formulate plans for improvement.

In 2006, representatives of state and local health departments, the National TB Controllers Association (NTCA), public health laboratories, and CDC's Division of Tuberculosis Elimination and the Division of Global Migration and Quarantine selected 15 national program objectives* highlighting priority activities and outcomes and set performance targets for 2015 (1). NTIP was established in 2009 to be the monitoring component of program evaluation for TB control in the United States. NTIP draws from current data collection systems and consists of a standard set of indicators within the established national objectives. Officials at all TB control programs receiving federal tuberculosis cooperative agreement funds have online access to their own NTIP reports and the national summary. The algorithms for calculating the indicators for these objectives were standardized through consensus among stakeholder representatives. Targets for 2015 were derived from recent results of programs ranked at the 90th percentile for the respective performance indicators.

Each of the 15 national objectives is associated with one to four indicators. Data for indicators in 12 of the 15 national objectives come from three national surveillance systems: the National Tuberculosis Surveillance System (case reports, diagnosis, and management), the Aggregate Reports for Program Evaluation (contact investigations), and the Electronic Disease Notification System (immigrant and refugee health screening after U.S. arrival). Other indicators are derived from the cooperative agreement application and other reporting documents; these variables are reported as "successful" or "not successful."

Indicators are calculated using standardized algorithms. The cohort is defined as those cases reported in the year of interest that are eligible to meet the performance objective for the indicator. For each indicator, inclusion and exclusion criteria are defined for the cohort. NTIP reports performance on a yearly basis with trend graphs describing performance for the last 5-year period, even though it contains data dating back to 2000. This report reviews national progress toward objectives by comparing the performance of the most recent year with data from the previous 4 years. Treatment for active disease takes about 9--12 months to complete; thus, data for some cases might not be available until 2 years after the initial case report date. Indicators associated with treatment completion and contact investigation are most complete for those cases reported in 2006 and earlier. Data elements for the remaining indicators are complete for cases reported in 2008.

In March 2009, NTIP was launched with reports for 11 indicators addressing eight national objectives, calculated using retrospective surveillance data collected since 2000. CDC has provided technical assistance to 43 programs in interpreting their NTIP reports and developing evaluation approaches to address problems; 38 programs have updated or corrected their surveillance data after reviewing their NTIP reports and discovering errors in their initial surveillance reporting.

Indicators related to TB case management include completion of treatment, drug-susceptibility results, recommended initial therapy, genotyping, HIV status, sputum-culture reporting, and culture conversion. Six of seven of these indicators improved during 2004--2008, the most recent assessment years available (Table 1), and the rate for reporting of initial drug-susceptibility test results decreased from 98.0% (2004) to 96.0% (2008).

For contact investigations in 2006, a total of 75,416 persons were reported to have been exposed to patients who had tested positive for TB by AFB-positive sputum-smear microscopy, and 79.6% were evaluated medically. Of these TB contacts, 22.6% were diagnosed with LTBI, among whom 71.9% started treatment. Among those contacts starting treatment, 65.6% completed treatment. The LTBI treatment completion rate increased by 6.5 percentage points from 2002 to 2006 (the most recent years with complete data for these indicators) (Table 2). However, the indicator for medical evaluation of persons exposed to TB cases with AFB-positive sputum-smear microscopy decreased by 2.6 percentage points during that period.

Reported by

S Hughes, New York State Dept of Health, National Tuberculosis Controllers Assoc. D Sodt, Minnesota Dept of Health, National Tuberculosis Controllers Assoc. K Young, J Jereb, R Pratt, T Navin, K Ijaz, A Khan, Div of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Editorial Note

From 2004 to 2008, most of the NTIP indicators for TB case management showed improvement. However, only one of the four indicators improved for contact investigations related to infectious cases reported from 2002 to 2006, the most recent years for which data are available. So far, no indicator has met the 2015 national performance target. For case management of patients with TB, drug-susceptibility results for patients with a positive culture is especially important and the 2015 national target calls for 100% reporting of drug susceptibility in culture-positive TB cases. In 2008, 96% of cases had drug-susceptibility results reported, indicating that TB programs were close to achieving this important national goal, but progress toward the goal has stalled in recent years. For indicators related to contact investigations, although some improvement was being made for treatment completion, progress on contact identification, evaluation, and treatment initiation remained unchanged. TB programs need to strengthen efforts to medically evaluate and provide appropriate treatment to all contacts of infectious patients. In programs where achieving high levels of performance has been challenging, CDC has recommended formal program evaluation, in collaboration with program partners, to better understand the obstacles. CDC TB program consultants and members of program evaluation team also are working with programs to assist them with meeting the target performance goals.

The findings in this report are subject to at least two limitations. First, the data used to calculate the indicators come from the surveillance system, which is an indirect data source. For example, a patient might have a drug-susceptibility test result in his or her medical record that was not entered into the surveillance system. Second, a delay of several years can result before certain data are available for NTIP; consequently, some data might not reflect current program performance.

NTIP was developed in collaboration with partners to build and institutionalize program evaluation capacity for ensuring continuous progress toward TB elimination goals (2). One of the basic elements of the World Health Organization global Stop TB initiative is to monitor and evaluate performance and impact (3), which is a responsibility of public health agencies working on TB control in the United States (4). In 2010, NTIP reports will become an integral component of the annual progress reports and assessments for recipients of CDC TB control cooperative agreements. Also in 2010, NTIP will expand its capability to monitor progress at the county level, for counties reporting at least 15 cases per year, and reporting will be streamlined to provide users with reports that are more up to date.

Acknowledgments

This report is based, in part, on contributions by state and local health departments and TB control officials, public health laboratories, and the National Tuberculosis Controllers Association.

References

  1. CDC. National TB program objectives and performance targets 2015. Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at http://www.cdc.gov/tb/programs/evaluation/indicators/default.htm. Accessed March 10, 2010.
  2. Institute of Medicine. Ending neglect: the elimination of tuberculosis in the United States. Washington, DC: National Academy Press; 2000.
  3. World Health Organization, Stop TB Partnership. The Stop TB strategy. World Health Organization; 2006. Available at http://www.tbtoolkit.org/assets/0/184/280/0d7f1d11-9c5b-46eb-9152-594e045deebe.pdf. Accessed March 11, 2010.
  4. CDC. Controlling tuberculosis in the United States: recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR 2005;54(No. RR-12).

* The complete list of 15 objectives, targets for 2015, and additional information are available at http://www.cdc.gov/tb/programs/evaluation/default.htm.

Includes the 50 states, the District of Columbia, nine cities (Baltimore, Chicago, Detroit, Houston, Los Angeles, New York, Philadelphia, San Diego, and San Francisco), and eight territories (American Samoa, Federated States of Micronesia, Guam, Puerto Rico, Northern Mariana Islands, Republic of Marshall Islands, Republic of Palau, and the U.S. Virgin Islands).

What is already known on this topic?

The National Tuberculosis Indicators Project (NTIP) is an indicator monitoring system that uses routine surveillance data to measure TB program performance.

What is added by this report?

According to NTIP results, TB program performance was mixed for the most recent 5 years, with general improvement for indicators related to TB case management, but lower performance for indicators related to contact investigations of patients with infectious TB.

What are the implications for public health practice?

Program should ensure that all patients with TB promptly begin and then complete a full course of treatment, and that contacts to infectious patients are identified, evaluated, and if infected, given a full course of treatment; progress should be monitored using NTIP, and effort invested to identify opportunities and to better understanding and overcome barriers and challenges.


TABLE 1. Percentage of eligible tuberculosis (TB) cases reported during the most recent 5-year period that met specified case management performance indicators --- National Tuberculosis Indicators Project (NTIP), United States, 2004--2008

National objective*

Case management indicators

2015 national performance target

(%)

Case reporting year

2004--2008 change

(percentage

points)

2004

(%)

2005

(%)

2006

(%)

2007

(%)

2008

(%)

Completion of treatment

Patients with newly diagnosed TB for whom ≤12 mos of treatment is indicated who complete treatment within 12 mos

93.0

82.9

83.1

83.7

N/A§

N/A

(+1.6)

Laboratory reporting

Culture-positive TB cases with initial drug-susceptibility test results reported

100.0

98.0

97.1

97.4

97.9

96.0

(-2.0)

Sputum culture conversion

TB patients with positive sputum culture results who have documented conversion to sputum culture-negative within 60 days of treatment initiation

61.5

50.8

50.9

53.8

N/A

N/A

(+6.0)**

Recommended initial therapy

Patients who are started on the recommended initial four-drug regimen when suspected of having TB disease

93.4

85.4

86.6

87.3

87.9

89.0

(+3.6)

Universal genotyping††

Culture-positive TB cases with genotyping data reported

94.0

N/A

59.2

60.6

65.6

66.4

(+7.2)

Known human immunodeficiency virus (HIV) status

TB cases with positive or negative HIV test result reported

88.7

72.7

73.5

75.4

78.6

79.8

(+7.1)

Sputum culture reported

TB cases with a pleural or respiratory site of disease in patients aged ≥12 yrs that have a sputum-culture result reported

95.7

90.9

90.8

91.8

91.7

92.2

(+1.3)

* The complete list of 15 objectives, targets for 2015, and additional information are available at http://www.cdc.gov/tb/programs/evaluation/default.htm.

Additional stratification is provided to users in NTIP reports.

§ Not available.

Calculated from data for the 5-year period beginning 2002, in which 82.1% of cases met performance indicators; for 2003, 82.8% of cases met performance indicators.

** Calculated from data for the 5-year period beginning 2002, in which 47.8% of cases met performance indicators; for 2003, 49.8% of cases met performance indicators.

†† Universal genotyping indicator does not yet have 100% coverage across the United States.

§§ TB cases reported in California are excluded from this calculation.


TABLE 2. Percentage of eligible tuberculosis (TB) cases reported during the most recent 5-year period that met specified case investigation performance indicators --- National Tuberculosis Indicators Project (NTIP), United States, 2002--2006

National objective*

Case investigation indicators

2015 national performance target

(%)

Case reporting year

2002--2006 change

(percentage points)

2002

(%)

2003

(%)

2004

(%)

2005

(%)

2006

(%)

Contact investigation

TB patients with positive acid-fast bacillus (AFB) sputum-smear results who have contacts elicited

100.0

92.4

92.7

91.9

92.4

92.2

(-0.2)

Contacts to sputum AFB smear-positive TB patients who are evaluated for infection and disease

93.0

82.2

80.3

81.8

79.8

79.6

(-2.6)

Contacts to sputum AFB smear-positive TB patients with newly diagnosed latent TB infection (LTBI) who start treatment

88.0

72.2

72.9

70.8

68.8

71.9

(-0.3)

Contacts to sputum AFB smear-positive TB patients who start treatment for newly diagnosed LTBI who complete treatment§

79.0

59.1

59.2

61.2

63.0

65.6

(+6.5)

* The complete list of 15 objectives, targets for 2015, and additional information are available at http://www.cdc.gov/tb/programs/evaluation/default.htm.

Contact investigation indicators do not yet have 100% coverage across the United States.

§ Additional stratification is provided to users in NTIP reports.


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