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No. 3, 2009

Highlights From State and Local Programs

Implementing and Revising Louisiana’s Guideline for Disaster Preparedness for TB Control

In August 2005, Hurricane Katrina caused wide disruption of tuberculosis (TB) services, TB infrastructure, and loss of patient records within the Louisiana Office of Public Health (OPH). Owing to these experiences and the coastal nature of much of the state, the OPH’s TB Control Program developed a guideline entitled Disaster Preparedness for TB Control for use by state, regional, and parish TB staff.  The guideline was designed to provide continuity of TB medications, lessen the disruption of TB services, and retain medical records located in at-risk areas.  Several strategies in this document were implemented and shown to be successful 3 weeks after Hurricane Katrina, during Hurricane Rita.  Other strategies were subsequently developed and refined over the past 2 years in response to Hurricanes Gustav and Ike.

Key elements in the guideline allow for continuity of patient care, including the provision of TB medications and a follow-up plan for displaced patients. A 30-day supply of self-administered medications requiring physician authorization was issued to all patients in areas under evacuation. Medication regimen and dosage changes were required on all TB patients on intermittent therapy to change them to daily self-administered therapy.  Patients received medications from Disease Intervention Specialists (DIS) and were instructed to notify shelter staff of their TB status if they sought housing at a shelter.  Patients were asked to contact their case manager as soon as they were able to return home; those who could not immediately return home were told to contact the local health department in whatever area they temporarily settled. During Hurricane Gustav, TB program staff reviewed 111 case and suspect patient records, wrote prescriptions, and delivered medications within 48 hours. After the storm, all 111 patients were located and returned to supervised therapy.  The plan for record retention worked well during the evacuation and no historical or current patient information was lost, even though two health units were destroyed. 

There were several other key elements to a successful plan that were not included in the guideline.  Louisiana TB Program staff collaborated with the National TB Controllers Association (NTCA) to share information on those patients who relocated to another state.  Similarly, a referral center was established within CDC’s Division of Tuberculosis Elimination to facilitate locating patients and reporting on the return of patients to supervised TB care. Successful strategies not included in the first version will be included in the revised guideline.  Before each hurricane season, regional TB managers are instructed by TB Program staff to request additional medications from the state pharmacy to increase the stock supply in each region.  The Louisiana TB Program was pleased with how the guideline was activated and implemented, and how successful the regional TB staff were in providing medications to TB patients under evacuation orders in Louisiana.  The guideline is currently under revision to incorporate the lessons learned and to make it a more effective and efficient tool.

—Reported by Kathryn Guillen
Div of TB Elimination

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Addressing the Control of Tuberculosis with Diminishing Resources

The implementation, coordination, and maintenance of TB prevention and control activities are resource-intensive endeavors. The recommendations for diagnosis, treatment, containment, investigation, and prevention were drafted and published before the current economic downturn, and were likely based upon the assumption that resources from state and federal entities would be commensurate with demand.

Unfortunately, this is not the case. Reductions in funding due to state budget cuts and federal rescissions have seriously degraded the operational capabilities of TB control programs across the country. Against this backdrop, the individual states seek ways to “work smarter” and identify innovative approaches to control a condition that kills millions each year around the globe. Please note the following example of how Alabama is attempting to address this issue. 

Public-private partnerships in TB control
In the past 2 years, staff members from the Alabama Department of Public Health (ADPH) Division of TB Control have conducted three separate contact investigations in a poultry processing plant in the area of Decatur, AL. All seven cases detected in the plant investigation were in persons from the same South American country, and an eighth case from another plant matches one of the two genotypes associated with these cases. A total of 721 tuberculin skin tests (TSTs) were placed and read by TB program field staff, and 235 contacts with latent TB infection (LTBI) were identified.  Of the workers identified as contacts, 216 were started on treatment for LTBI.  Fully one third (33%) of the workers tested were TST positive. Secondary cases of TB were found in each of the three investigations.

On January 18, 2008, ADPH staff met with poultry plant corporate officials and asked them to consider pre-employment screening of workers, in the hope that implementation of such a voluntary program would prevent the introduction of new TB cases into the workforce and reduce the frequency of large-scale investigations. The ADPH staff felt that successful implementation of a sustainable screening program that included treatment for LTBI would yield benefits beyond the workplace.

As the ADPH staff negotiated with their new corporate partner, the following complicating factors were encountered. First, an aggressive media market (print and television) began distributing xenophobic pieces that upset a number of people in the community, and a significant amount of staff time was required to respond to individual callers to the health department. Second, local politics became involved, and one individual spoke out against the corporate partner—suggesting that the current hiring practices put the public at risk.

The State Health Officer intervened and facilitated a discussion that ended in a “win-win” agreement that shared credit for the solution and avoided burdensome legislation. A “memorandum of understanding” between the new corporate partner and ADPH was signed on April 15, 2008.  The agreement formalized the relationship and enables ADPH to initiate treatment for those employees found to be latently infected through employment screening, and then to delegate monitoring and ongoing treatment of LTBI. Any employee found to have disease was to be followed up by ADPH staff.

This partnership enables the ADPH to stretch limited public health resources. Once the partnership was in place, the corporate partner became a valued colleague and was included in programmatic and clinical updates.  A message to take away from this is that successful partnerships require routine maintenance. After initiating a partnership, stay involved; develop and maintain the relationship to ensure its sustainability. Otherwise, you risk losing all the efforts and gains you had made to that point.

—Reported by J. Scott Jones
Div of TB Elimination

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John Doe #213: An Example of Effective Collaboration at Multiple Levels

On April 25, 2008, paramedics responded to a call from a local motel in Jersey City, NJ. When they arrived, they found an emaciated and unidentified 31-year-old Asian-Indian male who was incoherent and could not move. He was admitted to the ICU as John Doe #213.  Neurological, cardiology, and infectious disease evaluations were performed. A computed tomography (CT) scan of the brain showed changes compatible with a stroke.  A chest x-ray showed bilateral upper-lobe nodular infiltrates and bilateral pleural effusions.  Three sputum smears were positive for acid-fast bacilli (AFB).  Mr. Doe was moved to respiratory isolation on April 28 and started on an initial four-drug treatment regimen as a TB suspect. The result of an HIV antibody test was negative. M. tuberculosis was subsequently identified on culture, susceptible to all first-line drugs.          

The hospital reported the newly identified TB suspect to the Hudson County Chest Clinic upon initiation of anti-TB therapy.  Upon initial visit, Mr. Doe was belligerent towards chest clinic staff stating, he was “not sick and did not need to deal with the health department.”  As early as April 30, John Doe was threatening to leave the hospital against medical advice, and on May 6 the local health officer issued an isolation order.  Health department staff eventually established rapport by paying for television privileges in 5-day increments in exchange for information about himself and his potential contacts. This approach, however, did slow down the acquisition of essential information. During this time it was learned that John Doe had been in the U.S. illegally since 1996. He reported that he had been working in various liquor stores in Newark. He had been sick with a cough since January 2008 and had lost 85 pounds, and had been taken to the Jersey City motel by “friends” from Essex County.  Eventually, the address of his residence prior to being taken to the motel was disclosed; it was in Belleville (Essex County). 

The contacts at John Doe’s prior residence were evaluated by the Lattimore Practice at the New Jersey Medical School Global Tuberculosis Institute in Newark.  This clinic provides TB prevention and control services to the residents of Essex County.  Six people lived in his previous residence in Belleville, including children; five had latent TB infection and one had active TB disease upon evaluation.  These contacts refused to allow John Doe to return to the residence after hospital discharge, despite assurances that he presented no danger to them or to others who might enter the residence.  The head of the household, however, did provide the health authorities with John Doe’s passport, which showed no evidence of legal entry into the United States.

John Doe’s TB disease continued to improve clinically with consistently negative smears after 1 week and consistently negative cultures within 1 month of initiation of therapy.  His concurrent conditions seriously complicated discharge planning, particularly the residual effects of the stroke.  Mr. Doe had no health insurance, and his illegal status made him ineligible to access essential services that would be required post-discharge.  Mr. Doe required a leg brace, but could not put it on or stand without assistance, and could not ambulate without the use of a walker.  Further complicating matters was his consistently professed unwillingness to adhere to a regimen of DOT upon discharge.  He repeatedly stated that upon discharge, “No one will be able to find me.”  Both of these factors made him ineligible for the American Lung Association’s housing program used by the state TB program to provide room and board to homeless patients with active TB disease throughout their course of treatment. 

The hospital informed the chest clinic on May 15 of its intention to discharge the patient to the clinic’s care.  The state TB program intervened to prevent this inappropriate discharge, pending a meeting between all parties on May 29. The aim was to develop a discharge plan that would protect the public health and provide the patient with an opportunity for success in overcoming or coping with his other health issues.  During the meeting, it was agreed that the most prudent course of action was to return the patient to the care of his family in India. At this point adversaries became allies, as all parties agreed to their roles in the execution of this plan.           

The hospital agreed to pay for the airline ticket to return the patient to his family in India.  The Hudson County Chest Clinic staff agreed to attempt to convince him that returning home was his best course of action, since they had been successful in establishing rapport with the patient.  The state TB program agreed to work with the Indian Consulate in New York City to secure the documents necessary for the patient to legally leave the U.S. and return to India.  The TB program agreed to transport the patient to Newark Liberty International Airport for his flight and coordinate with the quarantine station at the airport to streamline the boarding process.  The TB program advised Indian health authorities of the patient’s condition and treatment history, his arrival date, and his family’s residence address to facilitate continuity of therapy.

All parties followed through with their respective responsibilities as agreed above.  The patient was provided clothing, money for travel, a copy of his medical record, and a 1-month supply of Rifamate, and boarded his flight for India on July 23, 2008.

Lessons Learned

If you are deathly ill and your “friends” want to drop you off at a motel in a different city from where you reside, they might not be your “friends.”

Even if your patient is initially resistant to interview or rapport-building efforts, be persistent until you find an incentive that provides the patient a reward sufficient to foster disclosure and cooperation.

Never allow a hospital to inappropriately discharge a TB patient to the street, but do not abandon the hospital to deal with the issue alone.  Stay engaged and become a partner to assist in resolving patient management and discharge issues.  Such an approach will minimize discharge surprises in the future.

As illegal immigration increases and access to social services and health care decreases for this high TB incidence population group, situations like the one described above will increase in number and complexity.  Remain open-minded, explore all options, develop a feasible plan, and assign mutual responsibilities to achieve a favorable outcome for all parties, including the patient.

All interested parties working collaboratively can achieve more than public health working alone — collaborate whenever possible to achieve your objectives.

 —Reported by Thomas D. Privett
Div of TB Elimination

 

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