Tuberculosis Control

State: NY Type: Model Practice Year: 2003

In Nassau County, New York, in the last decade, the percentage of patients with tuberculosis (TB) who were foreign born increased from 39 percent to 78 percent. To minimize the occurrence of tuberculosis, the Nassau County Department of Health (DOH) provides a program of targeted testing and case management for high-risk populations. Providing tuberculin skin testing (TST) to this group, identifying latent TB infection (LTBI), and treatment should lead to a decrease in the incidence of TB. Dedicated staff is able to monitor patients through completion of therapy, either with directly observed therapy (DOT) or weekly or biweekly home visits. The new immigrant population is reached at community-based organizations (CBOs), especially those that provide English as a Second Language (ESL) classes. Since August of 2001, of 1,251 immigrants attending those classes, 48 percent (597) completed testing, and 39 percent (233) of those tested were positive and were referred for medical evaluation.
This program responds to the identified high TB morbidity in the new immigrant population by seeking to identify and treat those with LTBI. In Nassau County, many of the new immigrants are undocumented, poor, and uninsured. They may not know how to access the health care system, they may not trust the public health system, and they may not understand English. By providing them with the initial TB evaluation in a setting that they trust, the DOH is able to access individuals at high risk for developing TB disease and is able to provide therapy for LTBI in order to eliminate TB. This program is innovative because the services are being provided to the high-risk population in settings in which they are already receiving services. ESL classes are an excellent venue for this purpose for the following two reasons: 1) classes attract new immigrants and 2) classes are held two to three times per week and the immigrants are accessible for the two-step TST (implanting and then "reading" the test in 48 to 72 hours).
The community based organizations (CBOs) agreed to schedule times either at the beginning or end of the ESL classes to test their clients. Many sent out flyers to notify their clients about the program. The organizations also spoke to their clients and informed them of the importance of this initiative. Teachers and the administrators were willing to be tested, acting as the leaders in this initiative and fostering trust in the populations they served. Competitive grant funding from New York State Department of Health supports the costs of the program, which is approximately $200,000. This supports two public health nurses, two licensed practical nurses, and seven community outreach workers, as well as funding for incentives and mileage. The staff provides patient education, testing, referrals to the community health centers for further medical evaluation and treatment, intensive case management, and directly observed therapy (DOT) of the patients accepted to ensure they complete their treatment. The incentives that are used and have proven to be effective are phone cards, bus passes to the clinics, food, and notebooks and pens for use in the classrooms.
Program staff look at process and outcome data, specifically, the number of sites at which testing is requested, the number of sites that agree to DOH education and testing, the number of immigrants at each program who are educated, the number who accepted TST and who completed TST, the number of immigrants with positive TSTs, the number referred for medical evaluation, the number placed on treatment, the number who completed an appropriate course of treatment and the number that received case management.Prior to case management, only 20% completed an appropriate course of treatment. Following the addition of evening and weekend case management, (which includes education about the disease, follow-up, patient contact weekly/biweekly) completion rates almost doubled to 37%. The long-term outcome, after many years should be a decrease in morbidity.
CBOs are a good venue to access the new immigrant population, as 1) the immigrants are already in a classroom situation and 2) they are available for the follow-up reading of the TST, since classes are held two to three evenings a week. Education is needed on BCG for private providers and patients. Weekend and evening case management assignments are necessary to access this population for intense follow-up, education and compliance with treatment. Key elements needed to replicate the practice include: Dedicated supervisors. CBO collaboration for accessing hard-to-reach populations. Case management to ensure evaluation and treatment is appropriate. Culturally sensitive/appropriate staff. Evening and weekend case management assignments. Use of incentives and enablers. The core program could be conducted by one person on a small scale and expanded, based upon the size of the county, the TB morbidity and the new immigrant population. The advantage of this program is that it is adaptable and useful to small and large counties.