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Evaluating Tuberculosis Surveillance and Action in an Urban and Rural Setting
Kristine Lykens, Ph.D.In collaboration with
Anita Kurian, MPH, MBBS
Patrick Moonan, MPH
Stephen E. Weis, D.O
Date: June 27, 2005
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Project
A collaborative effort between
Center for Disease Control and Prevention,
Division of Tuberculosis Elimination University of North Texas Health Science Center -
Fort worth Texas Department of Health American Lung Association Florida Department of Health
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Draft of Performance
Indicators
Draft of Performance
Indicators
CDC CDC
State Department of Health
State Department of Health
M/E PracticesM/E Practices
Stakeholder Focus Groups
Stakeholder Focus Groups
Program StaffProgram Staff
County Health DepartmentCounty Health
Department
TB 400 A, TB 400 BTB 400 A, TB 400 B
TB 340, TB 341TB 340, TB 341
State database (TIMS, State lab)State database (TIMS, State lab)
Local database (HIV database, PNS
screenings)
Local database (HIV database, PNS
screenings)
Selected program Staff Interviews
Selected program Staff Interviews
Initial set of 144 indicators selected
Matrix of 34 indicators finalized
Performance Analysis Methods
Evaluation StaffEvaluation Staff
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FOCUS GROUP
I
FOCUS GROUP
II
FOCUS GROUP
III
FOCUS GROUP
IV
Number of Participants
12 8 6 12
Professional Level
Medical Directors Project managers
Clinicians
Mid-level supervisors Clinic/Outreach Nurses Contact investigators
Outreach workers Clerks
Medical records staff
Nurses(TDH 2/3)
Contact Investigators(TDH 2/3)
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Conceptual Framework to Evaluate TB Surveillance and Action1
TrainingTraining SupervisionSupervision
Resource provisionResource provisionCommunicationsCommunications
Support ActivitySupport ActivityFeedbackFeedback
AnalysisAnalysis
ConfirmationConfirmation
ReportingReporting
RegistrationRegistration
DetectionDetection
Public Health SurveillancePublic Health Surveillance Public Health ActionPublic Health Action
Acute (Epidemic-Type) Response
Acute (Epidemic-Type) Response
Planned (Management-Type) Response
Planned (Management-Type) Response
Data-Information-MessagesData-Information-Messages
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Data Sources
Registered Public Health Records – TB 400 A, TB 400 B,
TB 340, TB 341.
Selected staff interviews – Medical Director, Program
Manager, Outreach supervisor, Medical records clerk,
Billing clerk.
Local and State level databases Local database – HIV database maintained by Medical records
clerk, and the PNS roster maintained by the contact
investigators.
State databases – TIMS, and state laboratory database.
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Tarrant County
• Fort Worth is Central City
• County population over 1.5 million
• Tuberculosis program– Central Clinic– DOT and Contact Investigation centralized– Growing immigrant population– Site for several TB research projects
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DHHS Region 2/3
• 37 rural counties without Public Health Departments.
• Central office in Arlington, TX
• Sub-Offices staffed by PH nurses
• TB program case-managed by nurses
• Contact investigation by nurses
• DOT by PH and contracted nurses
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Selected Results – Tarrant Co.
• TB suspects who received visit within 3 working days – 65%
• TB suspects with completed evaluation within two weeks – 91%
• TB cases receiving Directly Observed Therapy (DOT) – 100%
• TB cases who completed DOT – 99%
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Tarrant Co. Results (continued)
• TB cases with documented HIV status – 94%
• TB cases without any identified contacts – 4%
• Contacts with completed TB skin tests– With night shelter cases – 86%– Without night shelter cases – 57%
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Selected Region 2/3 PreliminaryResults
• TB suspects who received visit within 3 working days – 63%
• TB suspects with completed evaluation within two weeks – 78%
• TB cases receiving Directly Observed Therapy (DOT) – 90%
• TB cases who completed DOT – 89%
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Selected Region 2/3 Preliminary Results (continued)
• TB cases with documented HIV status – 50% (4/10 refused test)
• TB cases without identified contacts – 0%
• TB contacts with completed TB skin tests – 55%
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Conclusions Few of the national TB goals were not only met but
exceeded.
National TB goal 4 - The national TB goal of at least 75% of all
newly reported TB cases will have the HIV status reported (TC).
National TB goal 5 - At least 90% of patients with newly
diagnosed TB, for whom therapy for one year or less is
indicated, will complete therapy within 12 months (TC). 89% in
R2/3.
National TB goal 7 - At least 90% of newly reported sputum
AFB-smear positive TB cases will have contacts identified.
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One activity amenable for intervention was the activity of ‘contact investigation’. An audit of 280 TB 341 forms revealed that only 25 (8.9%) of the TB 341 forms had all the data fields completed/updated.
One of the national TB goals that was not achieved pertained to the activity of contact investigation –
National goal 8 - At least 95% of contacts to sputum AFB-smear positive TB cases will be evaluated for infection and disease (TC).
National goal 4 – At least 75% of cases will have HIV status known. In Reg 2/3 four out of 10 refused test.
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Recommendations
Have an Integrated data base** Designate a separate ‘medical records clerk’ to
update the TB 340s and TB 341s. (TC) Cross train staff for contact info update (TC). Improve communication between the contact
investigators and the clinic staff (TC). Conduct either a patient satisfaction survey or
focus group involving patients to obtain feedback regarding the services provided by the program.
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Recommendations (cont’d)
Educate the contacts of the cases regarding the importance of preventive therapy.
Streamline the process so that intake process and clinical evaluation can occur on the same day.
Review process for patients visiting the medical clinic for different services to reduce wait time for the patients (TC).
Increase follow-up for 2nd TST (R2/3).More field staff for Region 2/3 – nurses,
administrative, and contact investigators.