TB Notes Newsletter
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No. 1, 2006
HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS
On August 29, 2005, Hurricane Katrina slammed into the Northern Gulf of Mexico, causing devastation and destruction that severely crippled social and medical institutions in Louisiana, Mississippi, and Alabama. At the urgent request of Louisiana Governor Kathleen Babineaux Blanco, Texas Governor Rick Perry agreed to allow hurricane victims taking shelter in the New Orleans Superdome to be moved to the Houston Astrodome, which is located in Harris County, Texas. Texas officials agreed to allow the Astrodome to be used as a shelter for the evacuees. The Astrodome was soon filled to capacity with 23,000 displaced hurricane evacuees. An additional 120,000 displaced evacuees were housed in 97 shelters in other cities in Texas including Houston, Dallas, San Antonio, and dozens of smaller cities across the state as far north as Midland and as far west as El Paso. Another 100,000 persons were housed in hotels and motels around the state. It is estimated that a total of 250,000 displaced residents from Louisiana are now in Texas.
On August 31, 2005, Mr. Charles DeGraw, Louisiana State TB Controller, called the Texas Department of State Health Services TB Program to inform the program that approximately 100 TB patients could be among the displaced residents. Mr. DeGraw noted that the Louisiana TB Program had been significantly impacted by the flood waters coming from Hurricane Katrina. Working with Mr. DeGraw, the Texas TB Program immediately began putting in place support systems for those areas in the state receiving displaced residents from Louisiana. Local and regional health departments in Texas were notified to be on the lookout for persons with TB. Local and regional health departments were told to "Think TB" at all times because many of the persons diagnosed in Louisiana might not communicate their condition to the medical teams working in the shelters. Shelter workers were told to be alert to the signs and symptoms of TB. If shelter residents were identified as having TB, those persons were to be taken to the shelter medical triage stations for evaluation and isolation, if indicated. Mr. DeGraw also indicated that his medication supply was under water and thus his program would need TB medications. Mr. DeGraw asked the State of Texas to "loan" the Louisiana TB Program the necessary TB drugs to continue providing treatment to persons staying in Louisiana. The state agreed to provide the necessary medications for Louisiana. The Texas TB Program also worked with VersaPharm to arrange for medications to be sent to Louisiana. Mr. Joe Ware, President of VersaPharm, responded by shipping all the needed medications to the Louisiana TB Program at no cost to the State of Louisiana. The Texas Department of State Health Service TB Program organized a team comprised of staff from public health regions, local health departments, the data analysis unit at the Texas Department of State Health Services, and the Louisiana State Health Department TB Program to address the issues surrounding the management of persons in shelters who are found to have TB. Mr. DeGraw also requested laboratory support from the Texas Department of State Health Services. The Texas TB program arranged for the Texas State Laboratory to provide laboratory assistance. The Texas State Laboratory agreed to receive and process TB specimens submitted by the State of Louisiana for evaluation.
The Texas Laboratory provided the Louisiana TB Program with the containers needed to ship specimens to the Texas State Laboratory. As of October 31, there had been 307 specimens submitted to the Texas State Laboratory for processing.
In an effort to determine if any of the displaced Louisiana residents living in the shelters had been diagnosed, the Texas TB Program worked with the Texas Emergency Command Center, the Incident Command Center in Houston, the City of Houston and Harris County government officials, the Texas State Health Service Regions, local health departments throughout the state of Texas, local hospitals, the American Red Cross, and countless shelters across the state to match known tuberculosis patients with the listing of shelter residents. TB program staff confidentially worked with shelter administrators to match the lists. Persons identified were then evaluated and placed on medication and in some cases hospitalized for treatment. The Texas Tuberculosis Program worked with the Texas State Pharmacy to ensure tuberculosis medications were stocked on the mobile pharmacies deployed to shelters.
On September 7, 2005, Ms. Phyllis Cruise, Senior CDC Public Health Advisor assigned to Texas, was deployed to work at the Incident Command Center at the Houston Astrodome. Ms. Cruise assisted in the medical follow-up of persons residing in the shelters. She worked primarily in the three large shelters located in Reliant Park, which is located in Houston–Harris County, Texas. Reliant Park includes the Reliant Dome (i.e., the Astrodome), the Reliant Arena, and the Reliant Center. All together this complex housed 25,000 displaced persons. Houston also had another large shelter in the downtown area of the city, the George R. Brown Center, which housed 2,800 persons. Ms. Cruise assisted the city and county TB programs in their efforts to develop and deliver to shelter staff and residents educational messages and materials on TB, including the development of posters detailing the signs and symptoms of TB. Ms. Cruise also assisted city and county staff in planning activities for locating the persons who were on the patient list from Louisiana. This included using contacts from other agencies, both public and private and traditional as well as nontraditional sources such as the Federal Emergency Management Agency (FEMA). Ms. Cruise worked with FEMA to secure current addresses and telephone numbers for registered evacuees who had been diagnosed with TB and started on treatment in Louisiana. By mid- October, TB control officials were very happy to report that all TB patients who had been evacuated from the affected areas as a result of the hurricane had been accounted for.
—Reported by Charles Wallace, Ph.D., M.P.H.,
Phyllis Cruise, CDC Public Health Advisor
Texas Department of State Health Services
Following Hurricane Katrina’s landfall on August 29, 2005, staff of DTBE worked with the National TB Controllers Association (NTCA) to provide technical and logistical support and to facilitate communication for the TB programs affected by the sudden displacement of thousands of Gulf Coast residents.
At the request of the CDC Director’s Emergency Operations Center, DTBE developed resource materials to provide TB-related guidance to staff of approximately 750 shelters and evacuation centers in at least 18 states. Resources included an up-to-date list of TB program contacts, guidance for identifying persons in evacuation centers who may have TB, and a list of relevant TB educational resources. These were posted on the CDC hurricane website. These resources emphasized the importance of immediately consulting the local or state TB program if evacuees were or had been taking anti-TB medications or had symptoms suggestive of TB disease. Katrina-related heightened public health surveillance resulted in the reporting of at least 10 evacuees as potentially having TB. Although most were subsequently diagnosed with other conditions (e.g., lung cancer and infection with nontuberculous mycobacteria), two new cases of confirmed TB were found and reported.
Along with many others throughout CDC and the U.S. Public Health Service, 18 DTBE staff were deployed to various locations to provide on-site support to areas affected by Katrina. For example, Ted Misselbeck and Dawn Tuckey were deployed to Louisiana. Other staff already assigned to the field, like Phyllis Cruise with the Texas TB Program, found that Katrina-related work soon demanded their full attention (see related article, “Hurricane Katrina’s Impact on TB Control in the Gulf States”). Back in Atlanta, at least 10 others shifted their work priorities to focus on support for Katrina-related activities.
On September 2, DTBE established a Katrina Help Desk, with a team led by Gail Burns-Grant, to provide a 24/7 on-call system to respond to TB inquiries and to coordinate efforts by NTCA and the TB programs in Alabama, Louisiana, and Mississippi to account for all persons known by local public health authorities to be undergoing treatment for TB disease when the hurricane struck. Although most of the 180 TB patients in the most directly affected regions remained in their home states, others relocated to Arkansas, California, Colorado, Florida, Georgia, Illinois, Maryland, Massachusetts, Missouri, Ohio, South Carolina, Tennessee, Texas, and Washington State. Accounting for all these persons involved a great deal of collaboration and assistance from many state and local TB partners, as well as new partnerships with relief agencies and private companies to cross-match names for the purposes of locating displaced patients. As of October 13, all 180 had been located and were receiving follow-up attention and treatment continuity.
—Submitted by DTBE Atlanta and field staff:
Gaby Benenson, Gail Burns-Grant,
Phyllis Cruise (TX), Maryam Haddad,
Michael Iademarco, Ted Misselbeck (TN),
Patrick Moonan, Phil Talboy, and Dawn Tuckey
During Hurricane Katrina and its aftermath, a new secure, online service became available to help hurricane-affected individuals work with their health professionals to gain access to their own electronic prescription medication records. The new site allows authorized physicians and pharmacies to get records of medications evacuees were using before the storm hit, including the specific dosages. Having this information will help evacuees refill their medication prescriptions; it will also help health care professionals coordinate care and avoid harmful errors when prescribing new medications. Evacuees are spread out across the country; therefore, this information can be accessed from anywhere in the United States through www.KatrinaHealth.org. The urgent effort to make www.KatrinaHealth.org available to health care professionals was facilitated by the Office of the National Coordinator for Health Information Technology (ONC), within the U.S. Department of Health and Human Services.
This project has been supported by more than 150 organizations that have participated in the planning, testing, and launching of the site. Important data and resources were contributed by the American Medical Association (AMA), Gold Standard, the Markle Foundation, RxHub, SureScripts, and the Louisiana and Mississippi departments of health. More information including a press release and frequently asked questions (FAQs) can be found at www.KatrinaHealth.org.
—Reported by Mark D. Fussell
CDC Senior Management Official - Texas
Purpose and Goal of the TB Case Series. In an effort to reach several key partners using an educational venue, the six New England tuberculosis (TB) control programs organized a Web-based interactive “TB Case Series.” The TB Case Series is designed to allow providers to present cases that illustrate public health principles and practices. The goal of the TB Case Series is to offer a forum for
- Discussing the public health importance of infectious TB
- Describing the clinical management of TB, and increasing awareness of national recommendations for TB diagnosis and treatment, and
- Discussing options for ongoing patient care.
The course will promote standard diagnostic procedures and national guidelines through analysis and discussion of TB cases. Additionally, the course offers continuing education credit for physicians, nurses, health educators, and other participants.
First Two Presentations a Big Success. On October 26, 2005, more than 80 persons participated in the first case presentation. The inaugural presentation featured C. Robert Horsburgh, MD, a local and national expert in TB and HIV treatment. Dr. Horsburgh, formerly with CDC, is now the Chair of the Department of Epidemiology and the Director of the Prevention Research Center at the Boston University School of Public Health and the Boston University Medical Center. Dr. Horsburgh laid the groundwork for future case presentations and skillfully led the discussion, drawing participants into an active dialogue around the case. The second presentation was given in October by C. Fordham von Reyn, MD, Chair, Infectious Diseases and International Health at Dartmouth-Hitchcock Medical Center. The presentation skillfully combined a case and review of TB-related lymphadenopathy. About 45 participants from New England called in to listen and discuss the case and other cases.
Evidence of the Need for Educational Activities Targeting TB Providers. Several sources of evidence indicate that TB care providers have ongoing educational needs. These sources include 1) a regional education needs assessment, 2) studies documenting nonadherence to national standards and guidelines by private providers, and 3) a CDC study documenting that 40% of private providers do not use a recommended treatment regimen (Sumartojo EM, Geiter LJ, Miller B, Hale BE. Can physicians treat tuberculosis? Report on a national survey of physician practices. Am J Public Health 1997;87:2008-11). In addition, in 2004 DTBE and the three Model TB Centers developed a national strategic plan for TB training and education in conjunction with experts in TB and education, health care providers, and other partners. The plan states that private providers who serve high-risk populations need to learn about TB diagnosis, treatment, and management (www.nationaltbcenter.edu/ strategicplan/strategic_plan.html).
Thanks to the Organizers. A coordinating group representing the New England TB programs, the Regional Training and Medical Consultation Centers (RTMCCs), and DTBE organized the course. These contributors to the New England TB Case Series included Kathy Hursen (Massachusetts TB Program), Judy Proctor (New Hampshire TB Program), Rajita Bhavaraju (Northeast RTMCC), and Mark Lobato, Subroto Banerji, Regina Bess, and Judy Gibson (DTBE).
—Reported by Erin Howe
Regional TB Medical Consultation Consortium – New England
Kathy Hursen, RN, MS
Massachusetts Div of TB Prevention and Control
Mark Lobato, MD, New England TB Consultant
Div of TB Elimination
Lisa Roy, TB Educator
New Hampshire TB Program Div of Public Health Services
Standardized Nursing Case Management Interventions Described in the Evaluation of a TB Targeted Testing/Treatment Project
The evaluation of the CDC-funded Targeted Testing and Treatment of Latent TB Infection (TT TLTBI) Program in Arlington County, Virginia, provided an opportunity to capture best practices and develop lessons learned that could benefit state and local TB programs. In describing the program for the purpose of evaluation, the role of the Pediatric TB Public Health Nurse (PHN) case manager was described. This description was used to develop a nursing practice logic model.
Public health nursing activities traditionally play a prominent role in TB control efforts. However, the process and the standards for those activities must be described before they can be evaluated. The TB Patient-Level Care Model 2002, developed by the National TB Nurse Consultant Coalition, links TB-specific recommendations (statement and guidelines) associated with theory-based multiple determinants of behavior (from the patient’s perspective) with the NANDA taxonomy of nursing practice, the Nursing Intervention Classification, and the Nursing Outcome Classification. The model serves to describe case management, what it is expected to achieve, and what activities it includes.
In a collaborative effort to describe the TT TLTBI project in Virginia for evaluation, TB PHNs at the local, state, and national levels applied the TB Patient-Level Care Model to the case manager’s role description and developed a nursing practice logic model. From this model, the team described process and outcome indicators for evaluation. Next steps include developing the tools to gather credible evidence, justifying conclusions based on this evidence, and using the lessons learned.
During the NTNCC meeting held June 27, 2005, in Atlanta, Georgia, a partial description of the evaluation for the CDC-funded TT TLTBI program in Arlington County, Virginia, was presented. Virginia Thackery, Pediatric TB PHN case manager, presented an overview of the Arlington TT TLTBI Project and her role as the Pediatric TB PHN case manager. Judy Gibson, Nursing Consultant, Field Services and Evaluation Branch, DTBE, presented the methods used in developing the nursing practice logic model and an overview of the team-developed model. Jane Moore, Nursing Consultant, Virginia Department of Health, presented the TB Service Plan, developed in Virginia, that lists nursing actions tailored to patient needs. The TB Service Plan was also used in reviewing the role description of the Pediatric TB PHN case manager.
—Reported by Jane Moore, RN
Virginia Department of Health,
and Judy Gibson, RN
Div of TB Elimination