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

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

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

  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)

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

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.

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

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

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%

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%

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%

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%

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.

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.

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.

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.