Transcript Document

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
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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 backup during outbreak situations and
complex investigations.”
Institute of Medicine, Ending Neglect, 2000
Purpose of Regionalization
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Purpose
To mobilize and coordinate
broad collaborative actions
Method
Create a new system
Plan through existing structures
What can regionalization
do for TB control?
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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
120%
100%
80%
60%
40%
20%
0%
Source: U.S. Census Bureau
Asian
SE Asian
Hispanic
African-American
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
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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
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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
21st Century
TB Background, 2004
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TB cases
Total cases = 486
 Rate = 3.4/100,000 (range 1.2-4.3)
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TB trends
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Cases increased in 3 states
MA (9%)
 RI (10%)
 NH (59%)
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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
80
70
60
50
NE
40
U.S.
30
20
10
0
1997-99 2000-02 2003-04
Percent Foreign Born
by State and Year
90
80
70
60
2002
50
2003
2004
40
30
20
10
0
CT
ME
MA
NH
RI
VT
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
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No …
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money
staff
front-line authority
Have…good will
Regionalization Process
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Stakeholder collaboration
Establish regular communication
Define priorities
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Maintain political will
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Zen Lessons
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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
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Different experiences
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Variable resources
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Build on what exists
Divergent opinions
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Find common ground
Establish consensus
Competing priorities
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Stay focused
Regional Objectives
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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.
2.
3.
4.
Engage TB program leadership
Use existing or new venues to discuss vision
Visit each program at least once annually
Incorporate plan into TB elimination plans
Stratification of Tasks
Priority
Time
High
Immediate Commun-
Moderate
Education &
training
Low
Medical
consult
ication
Short term Consensus Evaluation
New
funding
plan
Long term Genotyping Contact
Research
database
investigations
Accomplishments
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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
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CDC: Applied for a PHPS fellow
UCONN: MPH student to analyze
supplemental surveillance
Western NE College: Informatics
intern to help on regional website
Products
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Educational series
“TB Case Series for Providers and Clinicians”
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Regional website
Genotyping database
State-specific
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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
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Defined need to reach private
providers
Created basis for distance learning
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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
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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=PG1678747&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.
NewEnglandTB.com
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Developed a team with expertise
Purposes of website are to
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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
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Established work group
Defined data management
capacity and needs
Collaboration around CT cluster
Participated in national effort
State Accomplishments (1)
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Connecticut
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Started enhanced TB surveillance
Revised pediatric guidelines
Updated BCG guidelines
New Hampshire
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Surveyed 400 providers on
educational preferences
State Accomplishments (2)
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Maine
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Rhode Island
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Developed a corrections toolkit
Completed an investigation in a
medical waste facility
Massachusetts
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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
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Maine, NH, and
VT do not have
outreach staff
Connecticut
and Mass. are
organized into
health districts
Type of Provider (%), 2004
90
80
70
CT
MA
ME
NH
RI
VT
60
50
40
30
20
10
0
HD
Pvt
Both
Advisory Committees
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MA: Well-established, 1999
RI: Reconstituted, May 2005
CT: Revitalized, October 2005
Regional perspective
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Advocacy
Legislation
Stigma
QFT/laboratory
Cohort Review
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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
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Intrajurisdictional contact
investigations
Migratory workers
Maintaining expertise and
sufficient resources
Lessons Learned
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Regional efforts offer benefits to
state programs and to DTBE
Modern TB control requires
cooperation, coordination, and
collaboration across jurisdictions
Best Practices
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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
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BACTERIA: Tuberculosis
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MOLDS:
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VIRUSES: chicken flu
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ODORS:
molds
"dirty sock syndrome“
Click Here For A Breath Of Fresh Air
www.NewEnglandTB.com