New Concepts in TB Control Regionalization The New

New Concepts in TB Control Regionalization The New England Experience Mark N. Lobato, MD CDR U. S. Public Health Service Division of TB Elimination Brown Bag 2006

Partners n n n n Connecticut: James Hadler, George Raiselis, Tom Condren, Mukhtar Mohamed, Maureen Williams Maine: Kathy Gensheimer, Suzanne Gunston Massachusetts: Sue Etkind, Kathy Hursen, Sharon Sharnprapai, Janice Boutette, Marilyn Delvalle New Hampshire: Judy Proctor, Lisa Roy, Jose Montero Rhode Island: Utpala Bandy, Richard Missaghian, Jane Carter Vermont: Susan Schoenfeld RTMCC: Erin Howe, Rajita Bhavaraju CDC: Zachary Taylor, Dan Ruggiero, Maureen Wilce Subroto Banerjee, Bob Pratt, Sandy Price

Regionalization “CDC can facilitate regionalization by conducting pilot programs in conjunction with states, as well as by maintaining experienced personnel who can provide back-up during outbreak situations and complex investigations. ” Institute of Medicine, Ending Neglect, 2000

Purpose of Regionalization n n Purpose To mobilize and coordinate broad collaborative actions Method Create a new system Plan through existing structures

What can regionalization do for TB control? n n n Expand experts Build on diversity of experiences and practices Increase ability to affect health Improve efficiencies Strengthen advocacy

New England

Racial Composition, 2000 Source: U. S. Census Bureau

Demographic Trends NE, 1990 -2000 Source: U. S. Census Bureau

Immigration Source: Federal Reserve Bank of Boston

Urban immigrants Source: Federal Reserve Bank of Boston

Massachusetts Immigration

Tuberculosis in New England A Historical Perspective

New England Skeptical Society Vampires From 1790 to 1890, over a dozen cases of vampirism took place in New England involving families infected by "consumption". After a family member died from TB, living members would open the deceased’s graves to look for signs that spirits were preying as vampires on living family members. The treatment was to cut out the heart, burn it to ashes, dissolve the ashes in water to be drunk by the living family members.

Sanitorium Movement: CT Dr. Charles W. Gaylord in Branford, CT developed the family farm into a tuberculosis sanitarium. This farm is now the site of the Gaylord Hospital in Wallingford, a hospital with about 120 beds devoted to spinal injury and rehabilitation.

Eugene O’Neill After panning for gold in Honduras and living in a “flop house” in NYC, Eugene O’Neill entered Gaylord Farm Tuberculosis Sanitorium in 1912. While there he wrote his first plays and determined his future as a playwright.

Sanitorium Movement: MA _______________ REPORT OF THE SANITARY COMMISSION OF MASSACHUSSETTS, 1850 _______________ BY LEMUEL SHATTUCK

TB Hospital Lemuel Shattuck (1793 -1859) The Father of American Public Health Lemuel Shattuck Hospital Jamaica Plain, MA

Dr. Moses Stone asked, “Where are those too poor to pay going to get care? " He instilled this passion in a group of local Boston women. Through their efforts the Jewish TB Sanatorium was established in 1927.

NEJM Weekly CME Program Exam Listing: Tuberculosis n n n Priorities for the Treatment of LTBI Forgotten but Not Gone Dexamethasone for the Treatment of TB Meningitis in Adolescents and Adults The New England Journal of Medicine is owned, published, and copyrighted© 2005 Massachusetts Medical Society

Tuberculosis in New England 21 st Century

TB Background, 2004 n TB cases Total cases = 486 n Rate = 3. 4/100, 000 (range 1. 2 -4. 3) n n TB trends n Cases increased in 3 states MA (9%) n RI (10%) n NH (59%) n

TB Case Rates, 2004 Source: MMWR 2005; 54: 245

We’re All in the Same Boat “Successful TB control in the U. S. …depends on the development of effective strategies to control and prevent disease among foreign -born persons. ” Source: CDC. Controlling TB in the United States, 2005

Percent Foreign-Born TB Patients

Percent Foreign Born by State and Year

Tuberculosis in New England New Methods, Old Problems

Morbidity and Mortality Weekly Report December 5, 2003 Public health dispatch: TB outbreak in a homeless population-- Portland, Maine, 2002 -2003 During June 2002 -July 2003, seven men with active pulmonary TB disease in Portland, Maine, were reported to the Maine Bureau of Health. Six were linked through residence at homeless shelters; four had matching genotypes. Prompt investigation and identification of approximately 1, 100 contacts likely prevented further spread of TB. This report summarizes preliminary results of the ongoing investigation and efforts to work with health-care providers statewide to improve early detection of TB among homeless persons.

TB Resources n No … n n money staff front-line authority Have…good will

Regionalization Process n Stakeholder collaboration Establish regular communication Define priorities n Maintain political will n n

Zen Lessons n n n Live with uncertainty Be sensitive to uncertainty Befriend uncertainty

Uncertainty Principle Central tenets of the uncertainty principle • Take action in the face of uncertainty (using credible evidence) • Accept burden of proof as the proponent of an activity • Explore a wide range of alternatives • Be prepared to alter course

Overcoming Challenges n Different experiences n n Variable resources n n Build on what exists Divergent opinions n n Find common ground Establish consensus Competing priorities n Stay focused

Regional Objectives n n n Develop a regional plan Promote regional education Provide consultation Create a genotyping database Use program evaluation consistently

Regional Plan Objective 1. Create a regional plan including action steps so that appropriate state and local TB control managers and staff will have the necessary awareness and venues of regional communication to create a shared vision by Fall 2005. Action Steps: 1. Engage TB program leadership 2. Use existing or new venues to discuss vision 3. Visit each program at least once annually 4. Incorporate plan into TB elimination plans

Stratification of Tasks Priority High Immediate Communication Short term Consensus plan Long term Genotyping database Time Moderate Low Education & training Medical consult Evaluation New funding Contact Research investigations

Accomplishments n n n Established a shared vision Undertook “needs assessments” Created TB regional plan Initiated education for providers Planned genotyping database Develop program evaluation plans

Building Capacity Through Partnerships n n n CDC: Applied for a PHPS fellow UCONN: MPH student to analyze supplemental surveillance Western NE College: Informatics intern to help on regional website

Products n Educational series “TB Case Series for Providers and Clinicians” n n n Regional website Genotyping database State-specific n n Advisory committees Talks at conferences (NE, TB Today)

Education Objective “Support and assist the Northeast Regional TB Model Center for the purpose of planning and promoting region-wide training and education of staff, providers, and patients using in -person or distance modalities by the Winter 2005. ”

Educational Case Series n n Defined need to reach private providers Created basis for distance learning n n webinar continuing education credit Held two successful presentations Need to build e-mail lists

Interactive Web Presentation April 11, 2006 8: 00 A. M. Eliminating TB Case by Case A Case Series for Providers and Clinicians Joseph Gadbaw, Jr. , MD Lawrence and Memorial Hospital New London, CT ·TThe New England TB control programs invite you to participate in a case presentations of a patient with tuberculous meningitis and HIV infection. Access the TB Case Series at: www. mymeetings. com/nc/join. php? i=PG 1678747&p=2006&t=c Toll free audio access: 888 -552 -9191 Password = 2006 # Accreditation: CME, CNE, CHES. This activity has been designated by CDC for 1 Category 1 hour toward the AMA physician's recognition award, 1. 2 hours toward the ANCCCA nurse’s recognition award and 1 hour accreditation by NCHEC for educators.

New. England. TB. com n n Developed a team with expertise Purposes of website are to n n n Increase cohesiveness and visibility Promote regional and state education Exchange materials

Regional Genotyping “Send all M. tuberculosis isolates for DNA genotyping and enter results into a shared database. ”

Genotyping Database n n Established work group Defined data management capacity and needs Collaboration around CT cluster Participated in national effort

State Accomplishments (1) n Connecticut n n Started enhanced TB surveillance Revised pediatric guidelines Updated BCG guidelines New Hampshire n Surveyed 400 providers on educational preferences

State Accomplishments (2) n Maine n n Rhode Island n n Developed a corrections toolkit Completed an investigation in a medical waste facility Massachusetts n Planning a ‘Clinicians Update Conference’

New Models “The traditional model of TB control, in which planning and execution reside almost exclusively with the public health sector, is no longer the optimal approach…” Controlling Tuberculosis in the United States, 2005

One shoe does not fit all n n Maine, NH, and VT do not have outreach staff Connecticut and Mass. are organized into health districts Type of Provider (%), 2004

Advisory Committees n n MA: Well-established, 1999 RI: Reconstituted, May 2005 CT: Revitalized, October 2005 Regional perspective n n Advocacy Legislation Stigma QFT/laboratory

Cohort Review n n n Cohort reviews - an independent priority area and supportive of evaluation efforts CT looked to MA model of regional and state-wide reviews RI establishing own approach

Special Challenges n n n Intrajurisdictional contact investigations Migratory workers Maintaining expertise and sufficient resources

Lessons Learned n n Regional efforts offer benefits to state programs and to DTBE Modern TB control requires cooperation, coordination, and collaboration across jurisdictions

Best Practices n n Communication must be open and ongoing Agenda is set by the stakeholders

What Next? Bringing clean air to schools, jails, hospitals, and shelters in New England. Protect your patients, clients, inmates, students, and yourself from n BACTERIA: Tuberculosis n MOLDS: molds n VIRUSES: chicken flu n ODORS: "dirty sock syndrome“ Click Here For A Breath Of Fresh Air www. New. England. TB. com