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No. 4, 2009


Addressing the Challenges of Missed Opportunities for Finding TB in Arkansas, 2008

Editor’s note: The following abstract was presented by Dr. Leonard Mukasa at the first TB PEN conference in July 2009.


In December 2005, in response to a DTBE request for program evaluation focus areas, the Arkansas Department of Health (ADH) TB control program submitted a proposal to focus on treatment of latent tuberculosis infection (LTBI). In the initial study covering the years 2004–2007, ADH reported that 37% of its cases were considered missed opportunities. A missed opportunity was defined as a case of TB in a person

  • With a previous documented diagnosis of LTBI,
  • In a population group included in an established targeted testing program,
  • Under age 5, or
  • Whose TB was not reported until after death.

We have now adopted the strategy of evaluating each TB case as a missed opportunity. The value and importance of this approach has been reinforced to TB control staff through cohort reviews, workshops, and tailored trainings for TB nurses in their local communities. The purpose of this study is to assess any change in the profile of TB missed opportunities in 2008 as compared to our previous report, and to estimate the impact of the missed opportunities on the incidence of TB in Arkansas.

Surveillance and genotyping data for 2004–2008 were obtained from the TB Registry. Study variables included demographics and clinical parameters. We reviewed each clinical record to identify information pertaining to missed opportunities. When data were not available in the clinical record, we sought clarification from the counties. A missed opportunity group was constructed using a dummy variable 1, 0 on study subjects. Analysis using frequencies and cross-tabulation was done in SAS.

Missed opportunities were associated with 42.2% of the cases in 2008 compared to 37% in 2007. In the missed opportunity group, there was an increase in the proportion contributed by patients having had prior known LTBI, by healthcare workers, or by nursing home patients and employees, whereas there was a decrease in the cases contributed by international students. Of the 21 cases with prior known LTBI, 13 (62%) had been detected at least 5 years before TB diagnosis. In the non–missed opportunity group, all the factors assessed in the 2004–2007 study (including having diabetes or cancer) remained at similar levels in 2008. More importantly, there were new findings among the non–missed opportunity group: 12 of 16 (75%) had a history of exposure to TB in the past but were not given a tuberculin skin test (TST) at the time; and the remaining 4 of 16 (25%) had a history of TB exposure but had a negative TST. Clustering by genotype was at 48% for years 2004–2008.


Although TB incidence is on the decline, the potential of using current strategies and tools to advance TB elimination in Arkansas remains as important as ever, but the tools and strategies are underutilized. Treatment of known LTBI cases will lead to a substantial reduction in TB morbidity. The exposed group, identified through family history of TB or documented TST, highlights three areas in need of improvement: (a) failure of the TST to detect LTBI with greater accuracy, (b) failure of the TB program workers to perform follow-up TSTs, and (c) the need of the TB program workers to evaluate and treat a sub-population who have a history of LTBI who can be reached and reevaluated with an intent to treat them when shorter and cost-effective regimens for treating LTBI become available. Tuberculosis screening in diabetics and cancer patients born before 1950 must be strengthened. Also, an effective intervention policy to screen and successfully treat foreign-born persons who have LTBI, but are not international students, is urgently needed.

—Reported by Leonard Mukasa MD, Joe Bates MD, Rosalind Abernathy MD,
James Phillips MD, Elizabeth Karpoff BSN RNP, Iram Bakhtawar, MD
Arkansas Department of Health

Increasing HIV Testing in the Hawaii TB Control Program


Increasing the proportion of tuberculosis (TB) patients aged 25–44 who have been tested for human immunodeficiency virus (HIV) is a performance measure of the CDC Cooperative Agreement for TB Elimination and Laboratories. Historically, Hawaii had not met the national TB program objective of 75% for this performance measure. In 2000 and 2002, the Hawaii TB Control Program collaborated with the Hawaii Sexually Transmitted Disease (STD)/AIDS Prevention Branch, and developed a plan to increase HIV testing of TB cases and suspects. However, it wasn’t until 2005 that these plans were implemented and policies and procedures developed. Since 2005, the Hawaii TB Control Program has made progress towards meeting the national TB program objective, and finally surpassed 75% in 2007. This report will review the factors that contributed to this achievement and identify programmatic improvements needed to continue success.


In February 2006, the Hawaii TB Control Program conducted its first TB cohort review, which is a systematic review of patients with TB disease and their contacts.  During the case presentations, a high number of patients had unknown HIV status despite the development of policies and procedures intended to improve this outcome.  Because cohort review is a retrospective review of patients who have completed or are close to completing TB treatment, this process was ineffective in ensuring that HIV testing was performed. Missed opportunities needed to be identified and corrected earlier in the course of a patient’s TB treatment. Therefore, starting October 2006, the program conducted monthly TB case conferences in lieu of quarterly cohort reviews. 

At case conferences, summaries of TB cases and suspects were presented at 1 and 3 month intervals after the start of TB treatment.  HIV testing outcomes were reported; if testing was not completed, the Nurse Case Manager reported when testing would be offered or completed. Additionally, line-list reports of cases with unknown HIV status were printed and distributed to Chest Clinic Physicians and Nurse Case Managers on a quarterly basis to call attention to cases that needed follow-up. Both processes motivated staff to become accountable for offering HIV testing. Despite the development of policies and procedures in 2005 to conduct HIV testing of TB patients, it wasn’t until outcomes were routinely measured during case conference and staff were provided reports of delinquent HIV results that the Hawaii TB Control Program surpassed the national TB program objective for HIV testing of TB cases.

HIV Status of TB Cases 25-44 years old - Hawaii, 2004-2008. Year 2004. 0. n=32. Year 2005. 29% Know HIV status; 8% test offered, patient refused. n=24. Year 2006. 39% Know HIV status; 9% test offered, patient refused. n=33. Year 2007. 79% Know HIV status; n=24. Year 2008. 60% Know HIV status; 12% test offered, patient refused. n=25. National TB Program Objective - 75%.Case conference also provided a forum for discussing challenges to obtaining HIV tests.  Staff needed clarification on the ages of TB patients who needed to be offered HIV testing. At the time of these discussions, the national TB program objective only measured HIV outcomes of TB in persons aged 25–44 years. However, during case conference, HIV results for cases outside this age group were requested, causing confusion among staff. Interim policies were developed as a result of this discussion, and HIV testing was offered to all cases 18 years of age or older. Additionally, HIV testing was included in the baseline laboratory tests ordered when all patients started on treatment for active TB disease. Making this a routine test ensured that a patient’s HIV status was known shortly after the initial clinic visit. Prior to that, testing was only offered after a patient was diagnosed with active TB disease (i.e., after culture confirmation was received or after clinical diagnosis was made). This meant TB suspects were on treatment for months without being tested for HIV. The delay conflicted with the message to patients and staff about the importance of knowing a patient’s HIV status because of the impact HIV infection can have on the effectiveness of TB treatment and the potential for delayed diagnosis and management of HIV infection.

Results. After the interim policies and procedures were in place, statewide data on the HIV status of TB cases were analyzed.  During 2004–2006, the Hawaii TB Control Program showed progress toward meeting the 75% national TB program objective for known HIV status of TB cases, and finally surpassed the objective in 2007; however, the program fell short of meeting the objective in 2008 (Attachment A). To identify areas that needed improvement and identify missed opportunities, we analyzed 2007 and 2008 data on the HIV status of TB in persons 18 years of age and older (Attachment B).  In 2007 and 2008, the Honolulu Chest Clinic provided TB treatment and case management to the majority of the TB patients at least 18 years of age in the state of Hawaii, 72.0% (85/118) and 60.8% (73/120), respectively.  Because all of the activities and changes described above were implemented at the Honolulu Chest Clinic, it had the highest percentage of TB patients with known HIV status: 77.6% (66/85) and 69.9% (51/73), respectively.  The percentage of known HIV status was lowest among patients who received TB treatment at the Chest Clinics on the Neighbor Islands, and patients who received all TB treatment through their private medical doctor (PMD). The low rates on the Neighbor Islands were attributed to a lack of standardized policies, procedures, training, and accountability for HIV testing of TB patients. The low rates among PMD cases were attributed to a lack of oversight and case management of PMD cases by the Hawaii TB Control Program.

HIV Status of TB Cases greater than or equal to 18 years old. Hawaii, 2007-2008. Honolulu CC - 2007: 78% Known HIV Status; 12% test offered, patient refused; n=85. 2008: 70% Known HIV status; 23% test offered, patient refused; n=73. Honolulu CC + other - 2007: 67% Known HIV Status; n=3. 2008: 60% Known HIV status; n=5. Hawaii CC - 2007: 0%. n=2. 2008: 25% test offered, patient refused; n=4. Kauai CC - 2007: 0. n=0. 2008: 0. n=3. Maui CC - 2007: 13% Known HIV Status; n=8. 2008: 13% Known HIV status; n=15. PMD only - 2007: 10% Known HIV Status; n=20. 2008: 25% Known HIV status; n=20. National TB Program Objective - 75%. Future Plans

The interim policies and procedures were revised and were scheduled to be finalized and officially approved before the end of 2009. They require HIV testing of TB patients of all ages in accordance with the new national TB program objective and include principles of opt-out screening as outlined in the 2006 CDC MMWR, “Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings.”  We expect to see a decrease in the number of TB patients who refuse HIV testing once opt-out procedures are implemented.  Before the end of the first quarter of 2010, statewide training will be conducted to ensure that there is a standardized approach for conducting HIV testing of TB cases.  To increase HIV testing among PMD cases, the TB Nurse Consultant of the Hawaii TB Control Program plans to meet in person with the physicians in the private sector who treat persons with TB, stress the importance of HIV testing, discuss the new national TB program objective, and identify potential barriers to accomplishing this goal.

Lessons learned:

  • Holding staff accountable for HIV testing outcomes during case conference and through the distribution of line listing reports proved to be an effective method of improving rates for this performance measure.
  • Discussing with staff the national TB program objective for HIV testing and the importance of knowing the HIV status of TB patients at the beginning of this initiative helped gain the buy-in needed to implement change.
  • Initiating open dialogue with staff provided them the opportunity to recommend revisions to policies and procedures that facilitated progress toward our goal of increasing HIV testing of TB patients.
  • Collaborating with the Hawaii STD/AIDS Prevention Branch was critical to ensure that the revised policies and procedures were both practical and legal.
  • Analyzing statewide HIV testing data allowed us to identify the areas where improvement was needed.

—Reported by Derrick D. Felix
Div of TB Elimination
PHA, Hawaii TB Control Program


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