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Regionalization:A New Strategy for
TB Control & EliminationThe New England Experience
Mark Lobato, MDDivision of Tuberculosis Elimination
Centers for Disease Control and Prevention
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The last TB upsurge
• Loss of public health infrastructure
• HIV co-epidemic
• Outbreaks in congregate settings
• Increasing immigration
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Response to TB resurgenceMDR-TB Action Plan
& New Resources
Improved Case Identification & Training
Updated DiagnosticLabs
New Infection Control& Rx Recommendations
DOT &Improved Completion
Rebuilt Research Capacity
HRZE
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Enhanced TB control
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Reported TB cases United States, 1982–2007
12,000
14,000
16,000
18,000
20,000
22,000
24,000
26,000
28,000
1982 1985 1990 1995 2000 2007
Year
No
. of
ca
ses
-4.9% per year
-2.6% per year
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High incidence areaslead the decline in TB
05
10152025303540
1993
1995
1997
1999
2001
2003
2005
Year
Cas
e ra
te USNYCLAHouston
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Actual and adjusted Federal funds for TB Control
1967-2007
0
20
40
60
80
100
120
140
160
180
'67 '69 '71 '73 '75 '77 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01 '03 '05
Year
$ x
Mil
lio
n
Actual $
BRDPI Adjusted $
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The next TB upsurge
• Decreased funding
• Weakened public health infrastructure
• Loss of TB expertise
• High growth of immigration
• Outbreaks in hard-to-reach populations
• Lag in new diagnostics and drugs
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The perfect storm
• Mass.– 37% staff loss– 21% budget cut
• CT– 33% staff loss– 1 of 3 outreach
• RI– Program
manager laid off
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Erosion of infrastructure
Mississippi Tuberculosis Rate Surges PastNational Average - Clarion Ledger, March 24, 2008
Mississippi health officials announced the state’s rate of the disease has … increased 12 percent since 2006. Several factors could explain Mississippi’s rate, including the loss of nurses who investigate TB cases and notify others suspected of being at risk. Between 2002 and 2007, the number of nurses at the state Department of Health fell from 412 to 366.
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TB cases increase in 16California health jurisdictions
San Jose Mercury News, March 13, 2008
“All of the Bay Area’s large counties recorded substantial increases in new TB cases in 2007. In Santa Clara, San Francisco, Alameda, and San Mateo counties, TB cases spiked last year. San Francisco County experienced its first significant jump since an AIDS-related TB outbreak in the early 1990s. The county now has the highest TB rate in the state. …Over the past two years, TB cases in Santa Clara have increased 21%.”
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National trends inTB case rates, 1992-1999
02468
1012141618
1992 93 94 95 96 97 98 99
Year
Cas
e ra
te U.S.
Top 131 cos
Other cos
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County State 1997 2006 % Increase
Denver CO 37 40 8.1Marion IN 34 47 38.2Anchorage AK 27 38 40.7Guilford NC 19 38 100Franklin OH 21 85 304Tarrant TX 107 107 0.0Maricopa AZ 165 171 3.6Hennepin MN 88 95 8.0King WA 113 145 28.3
Trends in casesSelect counties, 1997–2006
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County State 2000 2006 % Increase
Marion IN 4.3 5.4 32.6
Pima AZ 2.7 3.7 37.0
Guilford NC 4.7 8.4 78.7
Franklin OH 7.4 7.8 5.4
King WA 7.3 7.9 8.2
Dallas TX 9.0 10.4 15.6
Shelby TN 8.9 11.7 31.5
Trends in case ratesSelect counties, 2000–2006
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TB complexity
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Safety net
TB Cases in the US
Drug resistant co-m
orbidityUS Infrastructure
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Existing regional TB collaborations
• Binational border projects
• Bay Area Coordinating Committee
• New England TB Consortium
• Capitol Region TB Council (MD-DC-VA)
• Low incidence region (TBESC TO #6)
• Genotyping laboratories
• RTMCC
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BackgroundNew England TB Consortium
The 6 New England TB programs are collaborating in new ways as an approach to TB elimination.
• Identifying strategies for collective problem solving
• Building program capacity on a regional level
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New England TB, 2007
•TB cases- 408 cases- 3.0 / 100,000
(range 0.5–4.3)
•Regional cases equivalent to state with 8th highest TB burden
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Many cultures – one bug
0
20
40
60
80
100
CT ME MA NH RI VT
2004
2005
2006
State
% FB
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“So, why did you do it?”
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World TB Day, 2008
“This country’s progress in eliminating TB will not be sustainable without ongoing and strengthened collaborations with local, state, national, and international partners…”
Kevin Fenton, MD,
Director, NCHHSTP, CDC
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What can regionalization do for TB control?
• Build a diverse and effective team
• Solve problems collectively
• Expand expertise
• Enhance state and local programs
• Involve stakeholders
• Strengthen advocacy
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New England TB Action Plan
Five key strategies:
• Team building
• Education
• Capacity expansion
• Universal genotyping
• Medical and outbreak consultation
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Resources
• State– TB programs– TB Advisory Committees
• Regional– RTMCC– Shattuck Hospital TB Unit
• CDC– DTBE– Fellows
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Value added
New England TB.org
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Eliminating TB Case by Case
• Presented by master clinicians
• Designed to reach private providers
• Created basis for distance learning– web-based– continuing education credit
• Held 10 successful presentations
• Need for ongoing marketing
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Interactive Web PresentationApril 11, 2006
8:00 A.M.
Accreditation: CME, CNE, CHES..
TThe New England TB control programs invite you to participate in a case presentations of a patient with tuberculous meningitis and HIV infection.
Eliminating TB Case by CaseA Case Series for Providers and Clinicians
Joseph Gadbaw, Jr., MDLawrence and Memorial Hospital
New London, CT
Access the TB Case Series at:www.mymeetings.com/nc/join.php?i=PG1678747&p=2006&t=c
Toll free audio access: 888-552-9191 Password = 2006 #
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NewEnglandTB.org
Built a website to
• Increase cohesiveness and visibility
• Promote regional and state education
• Exchange tools and materials
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Genotyping Work Group
• Defined data management capacity
• Identified only 1 instance of definite transmission with a cluster of 26 cases
• Highlighted missed opportunities to prevent disease
• Measured strain prevalence and dispersion across states
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Lessons learned
• Modern TB control requires– Building a team leadership– Coordination and collaboration
across jurisdictions
• Regional efforts offer advantages to state programs and to CDC
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Next steps
• Analyze project evaluation data– Improve collaborative efforts– Determine how to replicate model
• Created the New England TB Consortium
• Building a new case management series “TB Talk”
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Future outlook
• Expand
collaboration
• Increase capacity for managing
MDR/XDR TB
• Initiate
evaluation
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We need a doublehull infrastructure
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New England TB ConsortiumConnecticutHeidi Jenkins, Tom Condren, Lynn Sosa, Maureen Williams, James Hadler,Gary Budnick
MaineKathy Gensheimer, AnneSites, Suzanne Gunston,Julie Crosby
MassachusettsSue Etkind, Kathy Hursen, Sharon Sharnprapai, Marilyn DelValle, John Bernardo, Alex Sloutsky
New HampshireJill Fournier, Lisa Roy,Jody Smith, Peggy Sweeny
Rhode IslandUtpala Bandy, Mike Gosciminski, Chris Goulette, Toby Bennett
VermontSusan Shoenfeld, Susan Cook,Becky Temple
RTMCCErin Howe, Nicolette Patrick
DTBEDan Ruggiero, Kashef Ijaz, BobPratt, Joe Scavotto, Ken Castro
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Prepare,you’ll sleep better at night.