Centers for Disease Control and Prevention (CDC) Atlanta GA TB Notes No. 4, 2005

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1 DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention (CDC) Atlanta GA TB Notes No. 4, 2005 Dear Colleague: We continue to make progress in reducing the incidence of tuberculosis (TB) in this country, but concerns we have noted in recent years remain. For 2004, CDC received reports of 14,517 confirmed TB cases and a rate of 4.9/100,000, making these the lowest number and rate since the initiation of national reporting. As these trends continue, we remain concerned that the observed decreases for 2003 and 2004 are the smallest since In addition, foreign-born patients now represent 54% of the TB burden in the United States, and racial and ethnic minority groups continue to have TB rates that greatly exceed the rates of the nation overall. Please see DTBE s latest surveillance report, Reported Tuberculosis in the United States, 2004, for the latest TB updates and trends. We have recently experienced new challenges for the control of TB and other diseases as a result of the flooding and damage from hurricanes Katrina and Rita. Many persons were displaced from their homes, requiring novel efforts to ensure continuity of care and to prevent relapses. These disasters and our response to them have disrupted the normal flow of CDC and DTBE activities by causing many CDC and other staff to be deployed to the Gulf region. It has been heartening to observe the close network of TB programs come together with CDC to help state and local health departments identify and find persons with infectious diseases, including TB disease. These prompt efforts have ensured treatment continuation and have prevented disease transmission. DTBE staff members worked with the National TB Controllers Association to develop guidance documents for hurricane workers and evacuees, including one on identifying persons in evacuation centers who may have TB, and another on recommendations for tuberculin skin testing at evacuation centers. Those documents have been posted on DTBE s Internet website, which is Staff members have posted a document detailing TB educational resources, and CDC s Emergency Preparedness and Response website, also links to the documents. In addition, we have agreed with all TB Controllers to keep a record of TB patients who have been affected by the hurricanes and to report to DTBE their knowledge of any hurricane-related TB patients. In addition to those patient populations whom we serve, many of our employees and colleagues have been affected either directly or indirectly by these disasters. We extend our thoughts and prayers to colleagues who suffered losses and damage to their homes. And we salute them for their selfless efforts to remain focused on trying to find displaced TB patients in the aftermath of the evacuations.

2 2 This year marks the fifth year of the TB Education and Training Network (TB ETN); the background and accomplishments of TB ETN are reviewed in an article in this issue. Also, the members of TB ETN held their fifth annual conference in Atlanta this past August. The 2005 conference, entitled Stepping Up Education and Training to Eliminate TB, was held August at the Westin Buckhead Atlanta and attracted over 100 participants this year. Attendees benefited from a variety of session topics. The participants favorable comments reflected on the success and hard work of TB ETN members in planning and carrying out this conference. The 36 th IUATLD World Conference on Lung Health was held in Paris October 18 22, DTBE will request conference participants to submit updates for publication in the next newsletter. In addition, staff members of DTBE have partnered with other experts to conduct the Program Managers Course here in Atlanta October 24 28, We will provide information on the proceedings of this course in a later issue. Kenneth G. Castro, MD

3 3 In This Issue Highlights from State and Local Programs... 4 New Mexico DOH Collaborates to Ensure Case Management of Multidrug-Resistant TB... 4 New York City s Interjurisdictional Referral Program... 6 TB Contact Investigations and Contact Case Management in Washington State: A Comparison Between 1994 and What s on Your TB Program Holiday Wish List? Knight Public Health Journalism Fellowship TB Education and Training Network Updates Member Highlight TB ETN Welcomes its 500 th Member Summary of Fifth Annual Conference Cultural Competency Subcommittee Update TB Education and Training Resources Submission Form Available Online Tuberculosis Education and Training Network: Celebrating 5 years of Bringing Together TB Education and Training Professionals TB Epidemiologic Studies Consortium Update Use of Network Analysis to Characterize M. tuberculosis Transmission Patterns Among Women and Other High-Risk Populations TB Trials Consortium Update Introducing the TB Trials Network Enhancing the U.S. Public Health System s Willingness and Capacity to Engage in Clinical Research Information Technology Update International Update Binational Referral System for Migrating TB Patients: Pilot Project (Binational Card Project) New CDC Publications Personnel Notes Calendar of Events Note: The use of trade names in this issue is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

4 4 TB Notes Centers for Disease Control and Prevention Atlanta, Georgia Division of TB Elimination National Center for HIV, STD, and TB Prevention Number 4, 2005 HIGHLIGHTS FROM STATE AND LOCAL PROGRAMS New Mexico DOH Collaborates to Ensure Case Management of Multidrug-Resistant TB A 26-year-old undocumented immigrant from Mexico was taken into the custody of the U.S. Marshals Service in southern New Mexico (NM) in August His subsequent medical work-up in Doña Ana County, NM, Detention Center revealed that he had active pulmonary TB resistant to isoniazid, rifampin, and streptomycin (multidrug-resistant TB, or MDR TB). The patient had been symptomatic for approximately 3 weeks prior to diagnosis. Second-line therapy was initiated in September 2004 by medical staff of the detention center, under close supervision by the New Mexico Department of Health (NM DOH) TB Program. A subsequent contact investigation within the detention center detected 23 contacts, 19 of whom were TST positive, and all were started on a regimen of pyrazinamide and ethambutol for treatment of latent TB infection (LTBI). The patient successfully completed 4 months of treatment, but then refused further treatment. Federal criminal charges were dropped in January 2005 and the patient was transferred to Immigration and Customs Enforcement (ICE) custody, at which time he was physically transferred to the ICE Service Processing Center in El Paso, Texas, to await an immigration hearing. While in El Paso ICE custody, the patient was placed under strict isolation; he continued to refuse treatment. Upon the patient s arrival in El Paso, public health authorities from New Mexico, Texas, and Mexico collaborated extensively with officials from the Mexican Consulate, the US/Mexico Border Health Commission, the Binational Project Juntos, the Migrant Clinician s Network (MCN)/TB Net, the Immigration Health Services, ICE, and the El Paso Quarantine Station (EPQS) to ensure coordinated case management pending the patient s hearing and possible deportation to Mexico. The plan was for ICE officials and an MCN/TB Net representative to escort the patient to the international port of entry between El Paso, Texas, and Ciudad Juarez, Chihuahua, and for public health officials from Mexico to receive the patient and transport him to an in-patient treatment facility in Mexico. On February 23, 2005, the patient received a hearing, and a court order deportation ruling was issued. On February 24, public health officials learned that the patient had been deported after hours to Mexico. His deportation was not in accordance with prearranged case management plans, and he was lost to follow-up for approximately 24 hours. Officials from the Mexican Consulate, staff from Binational Project Juntos, and the binational case management project (MCN/TB NET) subsequently located the patient in a distant farming community in Mexico. NM TB control staff have been communicating on an ongoing basis with the Secretariat of Health in Chihuahua, Mexico, and with Mexican TB control officials in an effort to reinstate case management for the patient and his family contacts. Dr. Muñoz, director of the health jurisdiction for Casas Grandes, invited interested individuals from the United States to come to Mexico to discuss potential collaborative efforts,

5 NUMBER 4, TB Notes is a quarterly publication of the Division of TB Elimination (DTBE), National Center for HIV, STD, and TB Prevention (NCHSTP), Centers for Disease Control and Prevention (CDC). This material is in the public domain, and duplication is encouraged. For information, contact TB Notes Editor CDC/NCHSTP/DTBE, Mailstop E Clifton Road, NE Atlanta, GA Fax: (404) DIRECTOR, DTBE Kenneth G. Castro, MD EDITORIAL REVIEW BOARD Ann Lanner, Managing Editor Jack Crawford, PhD Gloria Gambale Michael Iademarco, MD, MPH Mary Naughton, MD, MPH Scott McCombs, MPH Scott McCoy, MEd Rita Varga Elsa Villarino, MD, MPH Erika Vitek, MD Sherry Brown, Mailing List Manager Visit DTBE s Internet home page, for other publications, information, and resources available from DTBE. not only to put the patient back on anti-tb medications (possibly through using incentives), but to potentially pool resources to address what appears to be a cluster of MDR TB cases in the border area. On June 6, 2005, representatives from the New Mexico TB Program District III Public Health Office and the Border Environmental and Epidemiology Center drove to Casas Grandes to meet with health officials from the Chihuahua Department of Health. Dr. Muñoz and Dr. Magaña, Medical Epidemiologist, met with them to discuss the binational case of MDR TB and the contact investigation of this case. The NM DOH TB program staff discussed a number of ways in which the NM DOH may be able to assist the Chihuahua Department of Health with the management of this case and the contacts, including provision of chest x-rays for the patient and appropriate contacts. On June 7, 2005, two physicians and two nurses from New Mexico s DOH staff accompanied Dr. Magaña and Dr. Acosta (a physician from Janos, the closest town to the patient s home) to meet with the MDR TB patient and his close family members. The DOH medical team included Dr. Simpson, the NM DOH Infectious Disease Medical Director; Dr. Pastrana, NM DOH District III Public Health Physician; Ms. Tapia, District III TB Nurse Coordinator; and Ms. Luna, District III Nurse Practitioner. Unfortunately the patient had been sent by his employer to work in a neighboring town and was not available to be seen by the DOH staff. However, approximately 10 close family members were located and evaluated. Plans were made by Drs. Magaña and Acosta to perform PPD skin tests and chest x- rays, and to take sputum samples on the appropriate family members. The sputum samples would be sent to both the NM state lab as well as the Mexican lab facility in Chihuahua. As a result of the trip, a number of follow-up activities were carried out: Trip activities were communicated by Dr. Vilchis, Director, Border Environmental and Epidemiology Center, NM DOH, to Mr. Dan Reyna, Director, Office of Border Health. Dr. Vilchis and Mr. Reyna updated the Chihuahua Secretary of Health on this visit and on progress regarding collaborative activities. Dr. Vilchis is developing policies and procedures on communication regarding binational TB cases and other infectious diseases. Velia Luna, CNP, delivered tuberculin skin test supplies to Dr. Magaña at the Palomas/Columbus Binational Health Council Meeting in Palomas on June 10, 2005, and will continue to collect sputum samples from Mexican health authorities and submit to the NM state laboratory. NMDOH TB control program staff will continue to assist Dr. Muñoz, Dr. Magaña, and Dr. Acosta in the treatment of the MDR TB case as requested. This may include assistance with obtaining the second-line TB medications, if

6 6 NUMBER 4, 2005 unavailable in Chihuahua, for treatment of the case and the contacts. Chris Jameson, NM TB Program Manager, is working on developing a binational provider agreement with a radiologist in Janos for chest x-rays of the patient and contacts. The NMDOH TB control program established an group of all participants for future communications. The New Mexico group is following up with internal conference calls on an ongoing basis as well as binational conference calls and e- mail correspondence with Drs. Magaña, Muñoz, and Acosta. Reported by Christine Jameson, MA New Mexico TB/Refugee Health Program Manager New York City s Interjurisdictional Referral Program New York City (NYC) has a large number of major hospitals where residents from neighboring counties and states often seek care. In addition, NYC provides work to many who live elsewhere. Therefore, many patients evaluated or undergoing treatment for TB may not live in NYC, while others move to or leave NYC at some period during their evaluation and treatment. Because of this high level of population movement to and from NYC, the New York City Bureau of TB Control (BTBC) deemed it a priority to have an efficient patient interjurisdictional referral process, and in 2000 an Interstate Desk was created. Prior to the creation of the Interstate Desk, BTBC case managers were individually responsible for referring patients who moved from NYC and for obtaining follow-up information. The Office of Surveillance received referrals from other jurisdictions and forwarded the information to the unit responsible for patient management. Case managers had to ensure that patients moving to NYC were located and evaluated, provided follow-up information to the referring jurisdiction, and requested similar information for patients who left NYC. As a result of the large number of staff responsible for patients referral and followup, the notification process was frequently inefficient. This nonstandardized notification procedure led to an excessive number of BTBC staff calling other health departments for followup information, complaints from other health departments, and often inadequate follow-up and incomplete treatment completion information for patients who moved from NYC to other parts of the country. To facilitate the referral of and communication about TB patients and their contacts who move to or from NYC and to ensure continuity of care and evaluation of contacts who may be in another jurisdiction, the BTBC created the Interstate Desk, which is handled by Interstate Coordinators. The Interstate Desk is organizationally located within the Office of Surveillance in the BTBC. In addition, the BTBC wrote and implemented two protocols specifying the interjurisdictional notification process within the United States and internationally, available at The Interstate Coordinator was given the responsibility for transferring all TB patients (confirmed cases, TB suspects, their contacts, and patients with latent TB infection [LTBI]) to or from NYC. A database was also created, using Microsoft Access, to collect information on all transfers and ensure timely and complete follow-up. The database includes demographics, clinical information, and data on patients location, transfer, and follow-up. The role of the Interstate Desk is to 1) coordinate the flow of information for TB patients; 2) contact the patients new jurisdiction to request timely feedback; 3) provide periodic updates to NYC case managers on NYC patients who had moved; 4) give follow-up information to other jurisdictions; and 5) maintain the interstate database. In the initial stages of implementation of the Interstate Desk, there was limited staff

7 NUMBER 4, cooperation: case managers continued to refer patients directly to other jurisdictions, while receiving staff could not understand why the Interstate Coordinator was requesting follow-up information, and often did not cooperate owing to conflicts with other priorities. To resolve these issues, both BTBC and other health department staff were educated on the new procedure and its benefits. Over time, both NYC BTBC staff and out-of-nyc health department staff understood the benefits of the new procedure and have supported the Interstate Coordinator. The interstate database was designed to track interjurisdictional patient referrals and facilitate timely notifications and follow-up requests. The database also provides summary data on notifications to and from NYC. During , outgoing notifications were made for 741 NYC patients, including 89 notifications for NYC residents confirmed with TB who moved within the United States (55) or internationally (34), and 80 for confirmed TB patients from other jurisdictions diagnosed by NYC health care providers (71 cases from out of NYC and living in the United States, eight cases diagnosed in NYC in foreign visitors or temporary residents who moved internationally, and one worksite contact investigation request); 141 referrals for follow-up on patients suspected of TB (136 within the United States, three international notifications, and two worksite contact investigation requests); 339 notifications for contacts of NYC cases and 66 for high-risk LTBI patients and 21 requests for contact investigations outside of NYC related to an NYC index case and five airline exposure notifications. The Interstate Desk received 378 incoming notifications from out-of-nyc jurisdictions for TB patients, including 20 notifications for NYC patients confirmed with TB diagnosed outside of NYC (16 notifications for patients diagnosed in the United States, one international notification, three requests for contact investigations) and 58 notifications for persons confirmed with TB elsewhere and moving to NYC (56 from within the United States and two notifications from other countries); 37 notifications for patients suspected of TB and 61 for evaluations of contacts, 188 referrals for high-risk LTBI patients, and 14 requests for contact investigations. The centralization of interjurisdictional notifications achieved its goal of streamlining referrals, ultimately improving communication with other jurisdictions, increasing data completeness of final outcomes for patients who left NYC, and reducing the workload of BTBC case managers. Other benefits of centralized interjurisdictional referrals include 1) unique expertise at the interstate desk; 2) standardized procedures and data collection, ensuring timely notifications and follow-up; 3) simplification of the process, allowing other jurisdictions to contact only one BTBC staff; and 4) closer relationship between the Interstate Coordinator and staff of other jurisdictions, and thus improved ability to obtain information quickly. The streamlined process ultimately helped ensure the proper and timely follow-up of TB patients, clarified confusion, improved the assessment of the final outcome of TB patients who moved to or out of NYC, and likely contributed to more complete national data. For more information, contact Muriel Silin at msilin@health.nyc.gov. To make a patient referral, the Interstate Desk at TBIntDesk@health.nyc.gov. Please guard against including patient identifiers (names) in e- mail communications to protect confidentiality. If an NYC Patient Number is known, that number and the patient's initials can be used. Otherwise

8 8 NUMBER 4, 2005 please fax the interjurisdictional notification form to NYC s confidential number: (212) Submitted by Fabienne Laraque, MD, MPH, Director, Surveillance Office Dawn Cummins, Interstate Coordinator Muriel Silin, MPH, Asst Director, Surveillance Office Sonal Munsiff, MD, Asst Commissioner Bureau of Tuberculosis Control, NYC Department of Health & Mental Hygiene TB Contact Investigations and Contact Case Management in Washington State: A Comparison Between 1994 and 2004 Contact investigations are critically important in the prevention and control of TB. At the Washington (WA) State Department of Health, contact summaries are completed each quarter; however, activities and results have never been compared over time to determine if improvements have been made in the contact management process. To refine the process of contact investigation, it is necessary to proactively seek opportunities for improvement. Bailey et al. emphasize this point in a study designed to test a predictive model for identifying positive tuberculin skin test (TST) results in contact investigations. 1 The model was specifically designed to help health workers conserve resources by reducing the number of contact investigations performed. Mohle-Boetani and Flood also stress the need for improving the focus of contact investigations in order to increase efficiency when public financial resources run low. 2 Through the introduction of the California State guidelines and cohort review process, WA State has made significant efforts in improving TB contact investigations and case management, therefore increasing efficiency. In 1997, the WA State TB program introduced the California State contact investigation guidelines as a reference tool for contact investigations and case management of TB. Six years later, the program implemented the cohort review process as a model for quality assurance and quality improvement. 3 The California State guidelines serve as a reference tool for quality assurance in contact investigations, and offer protocols for activities such as interviewing infectious TB patients, establishing contact investigation priorities, interviewing and assessing contacts, and ensuring the timely and appropriate medical management of TB contacts. 4 With this essential tool, TB case managers are able to evaluate their efficiency and aim to meet set standards, as opposed to solely estimating the quality of their performance. Cohort review is another means of quality assurance and quality improvement, through the systematic review of TB patients and their contacts. Each quarter, expert clinicians, TB program managers, local health jurisdiction health workers, and epidemiologists convene to review TB cases according to standard case management criteria in order to assess individual patient outcomes. Cohort review and the accompanying analysis are tools for increasing general TB knowledge, holding case managers accountable, identifying strengths and weaknesses of current strategies, pinpointing areas for targeted improvement, and offering opportunities for TB program staff to interact. It is similar to clinical and programmatic "grand rounds" in the TB field. The reviewers observe and ask questions as local TB program staff present their TB case summaries and describe the disposition of each case. It is an opportunity for both learning and accountability. In addition, the review process has led to increased consciousness in regard to benchmarking, or creating targets based on the top performance standards for the industry, and therefore, greater excellence in tracking and managing TB cases is produced. For example, WA State DOH has put forth the goal of ensuring that 95% of TB patients complete their course of treatment within 12 months, with 85% of those patients participating in directly observed therapy (DOT). 3 The

9 NUMBER 4, achievement of this goal can be directly tracked through the process of cohort review, resulting in the greater likelihood of success. As a result of this detailed accountability and case management, overall incidence of TB cases will likely decrease and outcomes will improve. Presently, Washington may be the only state that has implemented cohort review statewide. However, the method was pioneered by the International Union Against Tuberculosis and Lung Diseases and first implemented in the United States by New York City. To date, several other program areas have received training in the method, although we have not surveyed them to assess their progress. A few program areas have adapted the method to fit their own needs, including Georgia, Utah, and Nassau County and Rockland County in New York. Additionally, cohort review training has been provided to staff in the states of Florida, Hawaii, Illinois, Massachusetts, Missouri, and New York, and in the cities Chicago, IL; Detroit, MI; Hartford, CT; Philadelphia, PA; and Washington, DC. As a result of these efforts, we in the TB Program of WA State believe that improvements in contact investigations and contact case management have been made since the introduction of the guidelines and the cohort review process in In order to evaluate this possibility, we compared data from 1994, prior to any formal guidelines or cohort review, with data for 2004, following the adoption of the guidelines and review process. The primary question was, How well were TB contacts managed in 1994 and 2004 as demonstrated by selected summary indicators? The results of our analysis offer a glimpse into the improvements made as a result of both aforementioned tools and suggest opportunities for continued improvement. The following is a summary of the findings, taking into consideration the fact that the completeness of data of the two time periods is not comparable. In 1994, though the TB Program used the same contact database it uses today, it did not collect and analyze the data concurrently. Collected data were reported, but data not submitted were not proactively retrieved and entered into the database at that time. The following data were retrieved from the WA State TB contact database 5 and CDC s Tuberculosis Information Management System. 6 The results are divided into two areas: those that show improvement and those that reveal a need for improvement. Areas demonstrating improvement: There was a decrease in total infectious TB cases from 1994 to 2004, with 260 cases in 1994 and 244 in In 1994, we found 3,144 contacts of infectious TB cases, with a mean of 19.4 and a median of 6.5 contacts per case showed a marked difference, with only 973 contacts found for infectious cases (mean of 7.37 and a median of 4.0 per case). The fact that the median is closer to the mean in 2004 indicates it is a more accurate picture of contacts per case. The number of infectious patients with no contacts found remained essentially the same: 110 (42%) in 1994 and 112 (46%) in The reason for this plateau is unclear and warrants further analysis. In 1994 there were no contacts reported as lost to follow-up (not started on treatment). However, this is probably the result of incomplete data. In 2004, six (1%) were reported as lost to treatment. In 1994, we tested and evaluated 701 (22%) contacts for infectious TB. However, in 2004, the proportion more than doubled, with 505 (52%) tested and 506 (52%) evaluated out of the total number of contacts, revealing improvement. Of those who were evaluated in 1994, 381 (54%) were found to be infected and therefore eligible for treatment, with only one (0%) found to be diseased. Of those evaluated in 2004, 256 (51%) were found to be infected and eligible for treatment, with 14 (3%) found to be diseased. Though the national average of infectivity to contacts is less than 0.1% 7, this large yield of infected

10 10 NUMBER 4, 2005 contacts seems to imply that targeting has been honed through guidelines and regular review. Analysis of future data is warranted in conjunction with close attention to the overall incidence of TB statewide. Vast improvement was revealed with respect to the treatment of contacts. In 1994, only 85 out of 381 (22%) eligible contacts started treatment, while in 2004, 190 of 256 (74%) eligible contacts started treatment. Areas revealing a need for improvement: Of those who started treatment, 42 (33%) were not infected in 1994, while 53 (22%) were not infected in It is unclear why these individuals were started on treatment when they were not infected. According to the 1994 contact summary data, none of the 127 contacts who started treatment completed it in 365 days. This reveals an incomplete 1994 database. Data are not yet complete for 2004 to date, as only 34 (14%) are recorded as having completed treatment, leaving 156 (64%) currently on treatment. Given the length of LTBI treatment regimes, analysis will need to be completed closer to the end of In 1994, no contact was reported as refused treatment, lost to follow-up, deceased, or moved, giving further reason to believe the data are incomplete, making it impossible to know what degree of improvement was achieved in 10 years. In 2004, 13 (5%) discontinued treatment, 11 (5%) were lost to follow-up, 2 (1%) died, and 1 (0%) moved. These findings reveal the differences in contact investigation procedures between 1994 and Overall, this comparison shows current better prioritization of contacts: even though significantly fewer contacts were found, a greater proportion were tested and evaluated, resulting in our detecting an expected number of diseased contacts with less effort. Also, the proportion of eligible contacts starting treatment greatly increased from 1994 to 2004, while the proportion of eligible ones with no treatment greatly decreased. Therefore, time and energy are now being spent more efficiently on a reasonable number of contacts, allowing for greater quality of case management. One obvious problem noted was the gap in data regarding the number of contacts who are currently on treatment or have completed treatment. It must be acknowledged that the means by which the TB Program collected and recorded data in 1994 were not adequate, therefore resulting in missing data data are more dependable because of the use of an improved contact database. Though contact information needs to be reviewed yearly, it would be beneficial to continue use of the California guidelines, cohort review, and contact database, and perform another assessment in 2014, offering a more reliable 10-yr comparison. A future analysis would more accurately reveal the degree of valid improvement if the process of data collection remains the same, What have we learned in 10 years? We are much better at prioritizing contacts and therefore more efficiently managing resources to find secondary disease. As a result, we uncovered a greater number of diseased contacts in 2004 than in We are better at ensuring that eligible contacts receive treatment and minimizing the number of eligible contacts not receiving treatment. We are better at tracking those who are completing treatment by regularly updating the database. We have improved by not starting as many uninfected contacts on treatment, thus saving resources. Improvement needs to continue in this direction. There is a need for improvement in identifying contacts for TB cases. We continue to have a high proportion of cases with no contacts identified. Overall, it can be concluded that the California contact investigation guidelines and the process of cohort review have been beneficial to the TB

11 NUMBER 4, program of Washington State with reference to contact investigations, though this analysis does not reveal which has had the greatest effect. The comparison of summary indicators between 1994 and 2004 reveals that improved contact investigation methods together with the accountability of cohort review have increased efficiency and likely saved resources. With continued use of the California guidelines and cohort review, the process of contact investigation will probably be more sharply honed and produce even greater results. (Editor s note: Cohort review educational materials (including videotape and guide) have been developed and will be available in late 2005.) Submitted by Jana Glessner, RN,, BSN Washington State TB Control Program Acknowledgments I would like to acknowledge the following individuals who significantly contributed to this project by offering time, support, guidance, and knowledge in their fields of expertise: Kim Field, RN, MSN, TB Program Coordinator, WA State Dept of Health; Alexia Exarchos, MPH, Epidemiologist, WA State Dept of Health; Bill Bower, MPH, Director of Education and Training, Charles P. Felton National TB Center, Harlem Hospital, New York City; and Erin Piskura, MPH, TB Surveillance Coordinator, WA State Dept of Health. References 1. Bailey W, Gerald L, Kimerling M, Redden D, Brook N, Bruce F, et al. Predictive model to identify positive tuberculosis skin test results during contact investigations. JAMA 2002; 287(8): Mohle-Boetani JC and Flood J. Contact investigations and the continued commitment to control tuberculosis. JAMA 2002; 287(8): Field K. Quality Assurance in Tuberculosis Control Programs. PowerPoint slides presented at Case Management and Contact Investigation Intensive Course, San Francisco, CA, March CDHS/CTCA. Contact Investigation Guidelines. California Department of Health Services, Tuberculosis Control Branch, DOH. WA Tuberculosis Contact Database. Washington State Department of Health, CDC, Atlanta, GA: U.S. Department of Health and Human Services. Tuberculosis Information Management System (TIMS); version Licensed to Washington State Department of Health, Jereb J, Albalak R, & Castro K. The Arden House Conference on Tuberculosis, revisited: perspectives for tuberculosis elimination in the United States. [Electronic version]. Seminars in Respiratory and Critical Care Medicine 2004; 25(3): What s on Your TB Program Holiday Wish List? Fall is in the air, and before you know it, the holidays will be here. More importantly, December 16 th will be here! Do you have your TB program wish list ready? Do you have the evidence to support your wish list? Most importantly, do you have an Evaluation Plan for your program so you can have this wish list and the evidence to support it? The DTBE deadline for submitting a TB Program Evaluation Plan is December 16. By now all program managers and staff should have heard the news about TB program evaluations from their Program Consultant as well as other sources. DTBE, along with many other CDC programs, is requiring all state programs to formalize program evaluation following the CDC Program Evaluation Framework. DTBE s Evaluation Working Group (EWG) has been working to educate TB Controllers on the purpose, process, and products of evaluation. There have been several opportunities for staff to familiarize themselves with program evaluation, including NTCA workshops, webinars, and other in-person trainings. A Guide to Developing a TB Program Evaluation Plan is currently available at

12 12 NUMBER 4, ation/default.htm and will help you meet that December 16 deadline. Other materials that comprise the TB Program Evaluation Toolkit will be available soon; stay tuned! What s that you say? You know all this. You ve read the materials (or at least browsed through them) and you ve attended at least one training session. But maybe you still don t know where or how to begin evaluating or planning to evaluate. Exactly what is it that DTBE and the EWG want you to do? For those conducting their first program evaluation, the materials, terminology, and methods can be overwhelming. For those accustomed to program evaluation, it can be frustrating to change an existing practice to a different standardized, systematic process. Although change can be daunting or stressful, we want to reassure you that evaluations are going to help all of us in TB control do our jobs better. Planning for evaluations is going to make the evaluation process that much easier. Remember, we are all focused on the same goal: TB elimination. Evaluations will help us get closer to that goal. Where do I start with my Evaluation Plan? Here are some ideas to get you started: 1. Set a time for PE. We are not talking about prevention effectiveness or physical education. Set an hour or so of your week to dedicate to Program Evaluation. During this time, you can follow the steps below to get you started on writing a Program Evaluation Plan. New activities, including evaluation, take time to integrate. Once the system is in place, the process becomes cyclical. 2. Review your CoAg, Progress Reports and other data sources. Believe it or not, a good chunk of the information required for your Program Evaluation Plan will come from your CoAg and your Progress Reports. Flip through these documents with program evaluation in mind. Along with the CoAg and Progress Reports, look at other data that monitor your program performance like ARPEs and RVCTs. In what area does your program consistently struggle to meet objectives? In which areas does your program seem to be doing well, despite resource limitations? 3. Pick an activity. For first-time evaluation planners, trying to determine programs or objectives to evaluate can be overwhelming. Try to focus on an activity within a program area that aims to meet an objective. Think about geographic areas in your state increasingly susceptible to TB outbreaks. Once you ve reviewed your program s existing information, you should have a good idea about which program activities work well and which ones need improvement. Think about your program s priorities and select an activity or small group of related activities to evaluate. New activities can be evaluated to see that they are implemented as planned; ongoing activities can be evaluated to ensure they are producing the results intended. You have most of the information needed for a Program Evaluation Plan. Pick an area or activity and go for it! 4. Read the samples. Go through the materials provided by DTBE s Evaluation Working Group and first look at the examples. Keep your activity in mind as you read them. How are the examples similar to your activity? What areas are different? How can your activity fit in these samples? Again, the best place to start looking at examples, models, and table shells for your Evaluation Plan is valuation/default.htm

13 NUMBER 4, Use trial and error. Now, give it a go! Once you have the process on paper, it will be easier to rethink and edit. Start writing and create a draft. 6. Ask Us! The Evaluation Working Group is here to serve you. We know this is a new process for many of you, and we want to help. We re happy to look at drafts, help you pick an activity to evaluate, or simply provide moral support. Just let us know! We want you to get all you wished for this holiday season or at least have a good plan to make a great case for it! us at TBEWG@cdc.gov or call Maureen Wilce ( ) or Kai Young ( ). Questions, Questions, Questions! Many of you are moving along with your evaluation plans or at least thinking about it. You have submitted wonderful questions and have identified areas of confusion to EWG. Here are some frequently asked questions to help. Q. What period of time does the Evaluation Plan cover? A. The time frame for an evaluation plan depends on the program activity you choose to evaluate. Time frames can vary, but should be realistic, practical, and meaningful for the program. Evaluation Plans become an integrated part of your program process. Q. Doesn t the Annual Progress Report already provide sufficient evaluation information? A. The Annual Progress Report states whether the program is meeting its objectives or not. It does not provide formal evidence for how those objectives were successfully met or why they were not met. The Evaluation Plan will help you map out a systematic process to gather this information and provide evidence-based findings as a useful decision-making tool for future program planning and continuation. Your Program Evaluation will feed back into your CoAg and become an iterative process. Q. My program has no resources to devote to evaluation; how can I meet this requirement? A. Program evaluation is a necessary part of program management. It is a systematic process to clarify and make explicit why a program is successful or not. According to the Cooperative Agreement, you should already be actively evaluating your program. We are now asking you to systematize the process and regularly report your progress. Q. Do we have to evaluate all of our goals and objectives at our state TB program and all local programs? A. No, it is rarely feasible to conduct an evaluation of that scale. Instead, you should work with your stakeholders to identify what information is most needed about the TB program and its activities. A Guide to Developing a TB Program Evaluation Plan can provide you with ideas about focusing your evaluation. Q. Do we have to evaluate all components of our program? A. No. Although the evaluation process asks you to consider how all components of a program interrelate, it also asks you to focus on priority issues and activities. Q. Do we have to use the Guide and Template? A. No. The Guide and Template are tools designed to assist you in the process. In addition, your following the Guide will help us provide technical assistance to you if you require it. However, to be considered complete, your plan should address all of the elements listed in the guide. Q. The sample plan in the Guide is quite long. Do we have to develop plans that are that extensive? A. No. The sample plan, as a teaching tool, provides context and explanations that would not

14 14 NUMBER 4, 2005 be required in your plans. Your evaluation plan need not be more than a few pages long, but needs to address the items requested in the template and tables. Remember to focus on your goal: an evidencebased TB program wish list! Submitted by Anupa Deshpande, MPH, and Linda Leary, BBA Div of TB Elimination Knight Public Health Journalism Fellowship As a journalist selected for a Knight Journalism fellowship, Rachel Cohen worked this summer alongside scientists in a project designed to raise the quality of health reporting. She was based with CDC in Atlanta, in DTBE. This fellowship is funded by the John S. and James L. Knight Foundation in partnership with the CDC Foundation. The goals of the Knight Journalism fellowships at CDC are to raise the quality of medical and public health reporting in the United States and abroad and to fill critical gaps in training for journalists by helping them develop the skills needed to analyze and report on public health problems, policies, and practices. The need for journalists to understand public health has increased with the advent of outbreaks of illnesses such as SARS, avian flu, and mad cow disease. These subjects require not just the ability to write about complex ideas in an understandable format, but the ability to interpret complex scientific data. That is exactly what the Knight Journalism Program at CDC provides training, coursework, and field experiences in public health that help journalists better understand and translate these complex issues for the public. This year s fellows all worked in different focus areas, including malaria, air pollution, HIV prevention, and breast cancer screening. The group members had diverse journalistic backgrounds, and two were from overseas. Prior to starting the fellowship, this year s five Knight fellows and a dozen other journalists with health reporting careers convened for a weeklong public health boot camp in Decatur, close to Atlanta. They learned from daily epidemiology and biostatistics lectures and met experts from several CDC divisions, including DTBE s Dolly Katz, an epidemiologist. She presented the history of TB, discussed today s affected populations, and distributed tuberculin skin test (TST) rulers to demonstrate the challenges in reading and interpreting test results. Inspired, Rachel chose to work in DTBE. Rachel is an award-winning magazine news writer, and she has also worked in broadcast journalism. In the course of her career, she has reported for the biweekly newspaper of the American Speech-Language-Hearing Association and has held positions at the Discovery Networks and the Travel Channel. She currently resides in San Francisco. Funding from the California Wellness Foundation supported her participation in the 5-day boot camp and the ensuing 3-month fellowship. As an introduction to the unit, DTBE s scientific and program administration staff invited Rachel to attend two conferences in Atlanta to immerse her in current scientific knowledge and practices surrounding tuberculosis. She attended the 2005 National TB Controllers Workshop in June and the QuantiFERON-TB Gold conference in July. In August, Rachel traveled to South Georgia to work with a local clinic that was testing new research and outreach efforts for Hispanic persons under the auspices of the CDC. She shadowed DOT workers at Atlanta s Fulton County TB clinic. She also chose to focus on and study the development of TB prevention programs and new diagnostic tools. In September, she was able to spend 9 days in Botswana, in southern Africa, where TB clinics are testing a TB therapy and new diagnostic tool. Visiting Botswana enabled Rachel to observe the clinical trial process with the team of nurses, data

15 NUMBER 4, managers, lab technicians, and study supervisors. These experts generously explained established models for running clinical trials as well as common systematic and behavioral obstacles to the success of clinical trials, such as data management, patient confidentiality, recruitment, and adherence. Having the time to study these issues in depth increased Rachel s understanding of the scientific facts and practicalities involved. She also came to realize how factors such as drought, HIV infection, Botswana s high unemployment rate, and the unstable leadership in neighboring countries can affect daily life and health. Rachel seized the opportunity to absorb these facts and details that will allow her as a journalist to educate and inform the nonscientific community. She has learned from this fellowship how to prepare in order to understand and write about science issues, such as where and of whom in the CDC community to ask questions, and she has a team of supportive co-fellows to call on for advice. Rachel ended the program in September with several ideas for stories and with support from DTBE to write them. She greatly appreciates the support of DTBE in providing this eye-opening experience that allowed her to further develop her reporting skills and learn to better engage the public in health matters. Reported by Rachel Cohen Knight Public Health Journalism Fellow TB EDUCATION AND TRAINING NETWORK UPDATES Member Highlight Jerry Cyr, BSN, is a TB Coordinator for the British Columbia, Canada, Center for Disease Control. He graduated with a BS degree in nursing from the University of British Columbia. Jerry s job responsibilities consist of coordinating all activities pertaining to tuberculosis in a large marginalized population in the downtown east side of Vancouver, British Columbia. He provides DOT to all persons within the area with active TB, conducts contact tracing, and provides ongoing screening and in-services to all health care workers in the area. He also serves as a resource for all physicians and health care providers by promoting active case findings and taking referrals from various professionals. At the last North American IUATLD meeting in Vancouver, Jerry was introduced to TB ETN. His primary reason for joining TB ETN was the fact that it is a very resource-rich organization through which he can access current relevant information and educational material. It also provides an avenue to collaborate with other health professionals in the area, said Jerry. He is continually updating and modifying his TB teaching materials, which are primarily presented in PowerPoint. He provides in-services and education to a wide variety of audiences; these include physicians, nurses, and home support staff, as well as a network of intravenous drug users. He is continually modifying his presentations to provide relevant, useful information in the particular settings in which they are given. In addition, along with other nurses in his organization, Jerry has developed a teaching program for skin testing and tuberculosis designed for public health nurses who provide care to TB patients in the field. In his spare time he enjoys music primarily guitar as well as hiking, and also enjoys literature. Jerry is also involved with Amnesty International and various ecology groups that operate near him in the Northwest. I work with a lot of HIV-infected clients who are coinfected. I would like to travel and volunteer some time in South Africa with some of the clinics there where coinfection rates are high. I also plan to do some work in the fall on the Burmese/Thai border with Burmese refugees, doing some TB work, Jerry explained.

16 16 NUMBER 4, 2005 If you d like to join Jerry as a TB ETN member and take advantage of all TB ETN has to offer, please send an requesting a TB ETN registration form to tbetn@cdc.gov. You can also send a request by fax at (404) or by mail at TB ETN, CEBSB, Division of Tuberculosis Elimination, CDC, 1600 Clifton Rd., N.E., MS E10, Atlanta, Georgia If you would like additional information about the TB Education and Training Network, visit Reported by Regina Bess Div of TB Elimination TB ETN Welcomes its 500 th Member The TB Education and Training Network (TB ETN) has been growing since it was first established in In August, TB ETN received the membership application of its 500 th member, Judith E. Beison. Judith s title is Director of TB Programs for the American Lung Association (ALA) of Metropolitan Chicago. Her primary duty in this position is serving as the Project Coordinator for the TB Epidemiologic Studies Consortium (TBESC) Chicago site. In addition, she coordinates activities for the Metropolitan Chicago TB Coalition (MCTC), which is an affiliated subsidiary of the ALA of Chicago. The TBESC and the MCTC are related in that the MCTC oversees and administers the TBESC contract for Chicago. The mission of the MCTC is to create, coordinate, and mobilize a variety of resources to focus on the elimination of TB; its members provide education and advocacy about TB awareness and work with HIV groups. Judith is a member of the ALA Chicago planning committee for World AIDS Day and World AIDS Testing Day. She coordinates and plans Chicago s World TB Day activities with a committee of other MCTC members. She is also responsible for informing the public about the research that MCTC is doing for TBESC. Her educational background is in the areas of urban development and human services. Judith became familiar with TB ETN at the 2005 IUATLD conference where TB ETN members were exhibiting. She later did further research on TB ETN through the TB ETN website and found that several of her colleagues were already members. Dr. Wanda Walton, who was a speaker at Chicago s World TB Day, also spoke about the TB ETN in her remarks. Judith liked what she heard and concluded that her joining would benefit MCTC, and that MCTC could probably be of benefit to TB ETN. I think MCTC and TB ETN could become well established partners by working together, said Judith. Judith is also a member of the TB ETN Cultural Competency subcommittee. I joined this subcommittee because I have always believed that we as a people need to understand as much as we can about all cultures we may encounter. If we can help in someway, I think we will make a difference across the board in our efforts to live and work and become a healthier world. There are too many myths about different cultures that become barriers. Hopefully, I can be a resource, Judith explained. Judith hopes that in the next couple of years TB ETN will multiply its membership significantly and continue to help build resources that can assist with education and awareness of TB. Although TB is an airborne disease, it plays second fiddle to many things, she stated. Judith has assisted in the development of a number of training and education products and programs: The Senior Citizen Education TB/HIV Coinfection Education Program. This consists of a train-the-trainer component, a pretest and a posttest, a vignette related to educating an elderly person, a PowerPoint

17 NUMBER 4, presentation, Qs and As, and an evaluation. The MCTC members are presenting this program to residents of senior citizen housing in higher-risk areas. The MCTC is currently seeking funds to sustain this program and to expand it to church or senior community centers. Along with other members of MCTC, she designed a TB Jeopardy! palm card to be mailed and passed out at meetings and workshops. Based on the television game show, the card contains three simple facts about TB, along with questions that match the statements. The card also lists the telephone number of the ALA for those wanting more information about TB. In addition, recipients are given an incentive to keep the cards. A code is printed on the back of each card, and recipients are told that they may be eligible to win a prize if they are asked (by mail or other means) for the code printed on the back of their card and they are able to give it. The MCTC members are planning the sites and venues where winners will be announced and prizes handed out. Judith, her staff, and members of MCTC have developed an educational panel discussion video. It was produced for cable and can be used as an awareness tool. It was released on cable television channel 21 prior to World TB Day 2005 as a promotional event on TB and HIV, and focuses on why the community should be involved. The title is The Community: A Resource in TB Elimination. Some other training and education products and programs in which Judith has been involved are as follows: In 2002 the MCTC engaged a local high school to write a play about TB as part of its health education class. The play s title is Love Gone Airborne, and it was presented at Chicago s DuSable Museum. MCTC staff educated the students about TB and asked them to write a play relating to community issues. Students, neighborhood residents, and a local physician made up the cast. Since the project was operating on a shoestring budget, the Southside Community Planning Group stepped in to assist. It was videotaped (although for financial reasons it could not be done professionally) and is being used by some organizations that have found it useful. The local Northside Community Planning Group developed a TB knowledge assessment to be used to assess the need for education among those joining community groups. The purpose is to correct any misinformation and prepare information resources. The Westside Community Planning Group hosts annual education meetings for the MCTC membership and for shelter providers. The group developed a workshop on how to read Mantoux tuberculin skin test results. In Judith s free time she enjoys sewing, crafts, and acting. Her interests are community service and advocacy. Judith is also the grandmother of three wonderful girls: Faith, 7; Saasha, 6; and Olivia, 11 months. If you would like more information about the TB Education and Training Network, visit the website Reported by Regina Bess Div of TB Elimination Summary of Fifth Annual Conference TB Education and Training Network (TB ETN) members gathered in Atlanta for the fifth annual TB ETN conference in August. The title of this year s conference, Stepping Up Education and Training to Eliminate TB, was based on a dance theme. Participants had the opportunity to build knowledge and skills while also having a bit of dancing fun!

18 18 NUMBER 4, 2005 Participants attended both plenary lectures and breakout sessions designed to enhance skillbuilding. Highlights of the conference included an engaging presentation by Rhajita Bhavaraju, Program Director of Education and Training at the Northeastern National Tuberculosis Center. Ms. Bhavaraju s session, based on her own experiences in the field, focused on the systematic process of developing education and training materials and programs. Another highlight was a plenary session by Helen Osborne, a passionate health literacy advocate. One participant stated after the session, I will use what I learned from her in my writing, teaching, and patient communication. She's a wonderful, thoughtful, and inspiring speaker. Participants of the conference received a copy of Ms. Osborne s book, Health Literacy from A to Z. Ms. Osborne also presented a breakout session entitled Using Visuals, Stories, and Other Methods to Enhance Health Communication. months leading up to the conference, 27 abstracts were accepted. Abstracts from Georgia, Massachusetts, and New York were selected for oral presentation based on their correlation with the conference sessions. Participants from California, Florida, Georgia, Illinois, Kansas, Maine, Minnesota, New York, Virginia, and Canada shared materials developed in their programs at the educational materials display. Conference participants enjoyed the opportunity to network at an evening social sponsored by Translation Plus. During the social, participants were treated to a special dance performance. The cha-cha, the merengue, the rumba, and salsa dancing were performed by young dancers years old from a local dance school in Atlanta. After the performance, conference participants had the opportunity to strut their stuff during a salsa lesson instructed by the young dancers and their dance teacher. Participants came away from the conference rejuvenated and equipped with new knowledge and creative ideas to practice and share in their work. Evaluations of the conference show that participants thought the conference was very informative and even entertaining! One To showcase projects from the state and local areas, the conference featured a poster session and an educational materials display. In the

19 NUMBER 4, participant stated, This creative atmosphere has spilled over into other areas of my work. I've found myself having all these creative thoughts and ideas and I think it's been the conference that has done this. For more information about the TB Education and Training Network, visit the website at Reported by Betsy Carter Marchant, MPH, CHES Div of TB Elimination Cultural Competency Subcommittee Update The Cultural Competency subcommittee focuses its efforts on providing resources for members of TB ETN to promote cultural competency in TB control activities. Recent projects include an update of the Cultural Competency Resource List that was originally developed in This was made available to all participants at the TB ETN conference and was included on the TB Education and Training Resources website Each listing includes a brief description of the resource and the name and contact information of the organization for further information. Several new resources were identified by members of the subcommittee and are included in the updated version. To identify additional needs of TB ETN members in the area of cultural competency, the subcommittee initiated a process to contact other subcommittee members by telephone to develop a dialogue and elicit suggestions for future projects. Ideas for projects were developed during these personal interviews, and this information became the basis for presenting specific suggestions to the general membership. Those attending the conference will be asked to evaluate the proposed activities to determine which ones would be most beneficial. Based on these results, the subcommittee will determine the future direction of its efforts to provide additional resources for members of TB ETN. Members of the subcommittee participated in piloting the use of a WebBoard to facilitate communication, particularly among international members. Scott McCoy of DTBE s Communications, Education, and Behavioral Studies Branch joined in on one of the conference calls and reviewed the online features of the system. The WebBoard includes an area for updating tasks and posting information as well as communicating with other members. Other guest speakers were invited to participate in the monthly conference calls to describe the development of new resources. John Scott, Director of the Refugee Health Information Network (RHIN) at the Center for Public Service Communications, Arlington, Virginia, described the RHIN website ( that is under development. Julie Coxdale from the Virginia Newcomer Health Program ( shared her state clearinghouse for cultural information. After her return from a temporary assignment in Southeast Asia, CDC subcommittee staff liaison Gabrielle Benenson described her cross-cultural experiences and insights. Members of this subcommittee are always looking for new resources to share with each other and with the general membership of TB ETN. Cultural Competency Quote Cultural competence education and training broadly describes a vast array of educational activities aimed at enhancing the capacity of the individuals and the service delivery system to meet the needs of different racial and ethnic populations. The literature suggests that cultural competency training can include educational activities aimed at increasing sensitivity and awareness; skills building in bicultural and bilingual interviewing and patient assessment; enhancing the use of race or ethnic-specific epidemiological data in diagnosis and treatment; and increasing cultural knowledge and understanding. It is believed that the knowledge and skills gained through training will enable providers and institutions to work more effectively

20 20 NUMBER 4, 2005 in cross-cultural situations by developing new approaches to communication, patient care, and services planning that are based on cultural and linguistic needs. From Setting the Agenda on Research on Cultural Competence in Health Care. Office of Minority Health, US Department of Health and Human Services, August Submitted by Margaret Rohter, MPH Suburban Cook County TB Sanitarium District Co-chair, TB ETN Cultural Competency Subcommittee TB Education and Training Resources Submission Form Now Available Online Photo: Filling out the TB Education and Training Resources online submission form Follow three easy steps to share your TB education and training resources: 1. Visit 2. Fill out the online submission form 3. Upload your materials electronically Tuberculosis Education and Training Network: Celebrating 5 years of Bringing Together TB Education and Training Professionals This year marks the fifth anniversary of the Tuberculosis Education and Training Network (TB ETN). TB ETN has come a long way since it was started, and I d like to provide a summary of the activities and accomplishments of TB ETN. For those of you who are not yet members, I hope that this overview serves as an incentive to become an active member so that you can take advantage of all TB ETN has to offer. Background. In 1998, a strategic planning process for TB-related training and education was undertaken by the three National TB Model Centers, CDC, and numerous state and local partners, and resulted in the Strategic Plan for Tuberculosis Training and Education, which was published in To meet the plan s recommendation of establishing a network of persons involved in TB education and training, the TB ETN was established in early The Plan has since been updated ( ). The updated plan continues to endorse TB ETN, and can be found online at In addition to TB ETN, other outcomes of the first strategic plan were The TB-Educate listserv (currently over 1600 subscribers) ( e.asp) The TB Education and Training Resources Website ( Recognition and support for TB education and training (national attention) Goals. TB ETN strives to build capacity by ensuring that members become familiar with and use the systematic health education process when developing education and training products and courses. The goals of TB ETN include furthering TB education and training by Building, strengthening, and maintaining collaboration Providing a mechanism for sharing resources to avoid duplication Developing, improving, and maintaining access to resources Providing updated information about TB courses and training initiatives Assisting members in skill building

21 NUMBER 4, Primarily through capacity building, TB ETN has facilitated the development of a cadre of TB educators and trainers with improved skills and abilities, knowledge of available resources, and the ability to serve as a resource for high-priority needs such as outbreaks and implementation of new guidelines. The ability to network and share successes is invaluable. Membership also allows me to keep up to date with new guidelines, materials, and what s happening in the battle to eliminate TB. Teri Lee Dyke Michigan Dept. of Community Health Membership. As of September 2005, there were 504 members in TB ETN (369 Active and 135 Information Only members). When TB ETN was first established, members consisted of primary and secondary members from state, big city, and territorial TB programs (about 70 members). At the first TB ETN conference in 2001, participants suggested that membership be open to all interested in TB education and training issues. To make it easier to join, the TB ETN steering committee set up two categories of membership, Active and Information Only. Persons interested in joining TB ETN can choose which type of membership they prefer. Active members Have lead role for TB education and training in their agencies Participate in TB ETNrelated activities Receive priority registration for TB ETN activities Have voting privileges May serve on subcommittees Information only members Do not have lead role for TB education and training or do not wish to actively participate in TB ETN activities Receive information on TB ETN meetings, activities, etc., via e- mail postings to the membership No voting privileges Cannot serve on subcommittees TB ETN has a diverse membership, providing members with great networking opportunities. Members include representatives from U.S. state, local, and territory TB programs Regional Training and Medical Consultation Centers (RTMCCs) Local American Lung Association affiliates International agencies Correctional institutions Managed care organizations Universities Each of the 50 states and over 30 countries are represented in the Network. International members make up about 20% of the membership. TB ETN is truly an international organization. Steering Committee and Subcommittees. The guiding forces behind TB ETN are the steering committee and three subcommittees. Each of these helps guide TB ETN activities. The steering committee is chosen by TB ETN members and reflects the make-up of the membership. Steering committee members serve 2-year terms, with the exception of the Regional Training and Medical Consultation Center (RTMCC) representative, who serves a 1-year term. Steering Committee, Suzy Peters FL Edith Sampson Cochise Co., AZ Joanne Maniscalco Nassau Co., NY Nfornuh Alenwi Cameroon, Africa Rajita Bhavaraju RTMCC Representative D.J. McCabe RTMCC Representative Bill Bower RTMCC Representative Maria Fraire, Betsy Carter Marchant, Gabrielle Benenson CDC Past Steering Committee, Judy Bulmer NY Kathy Hursen MA Debbie McIntosh CA Bill Bower Model Center Representative David Berger Model Center Representative 2001 Conference Planning Committee Genevieve Greeley UT

22 22 NUMBER 4, 2005 Kathleen Hursen MA Kathleen Perez-Hureaux NY Barbara Seaworth TX Candice Zimmerman CA Debra Kantor Model Center Representative Subcommittee Co-chairs and Activities Communications and Membership Current co-chairs: Teri Lee Dyke MI, Linette McElroy Canada Past co-chairs: Vipra Ghimire VA, Suzy Peters - FL Goal: To recruit members for TB ETN by promoting benefits of membership and encourage communication and sharing of information and activities among network members Activities: Conducted a membership database analysis Wrote TB Notes articles Developed TB ETN lapel pin for members Developed TB ETN brochure and poster Displayed TB ETN poster at local, state, national, and international TB-related events Provided suggestions for TB ETN website Cultural Competency Current co-chairs: Margaret Rohter IL, Savitri Tsering WI Past co-chairs: Genevieve Greeley UT, Serge Chicoye - NY Goal: Promote cultural competency among members of TB ETN Activities: Wrote TB Notes articles Developed a cultural competency resource list Conducted a needs assessment and follow-up Solicited case scenarios for the Northeastern National TB Center s Cultural Competency Newsletter Provided suggestions for cultural competency sessions at the annual conference Invited guest speakers on conference calls Conference Planning Current chair: Gail Denkins MI Past co-chairs: Jean Montgomery TX, Kathleen Hursen MA, Karen Farrell FL, Ann Tyree TX, D.J. McCabe Model Center Representative Goal: To plan the annual conference Activities: Planned each of the five annual conferences I have seen tremendous growth and excitement among TB educators over the last 4 years. The annual meetings are a great avenue for networking, and I have made many new professional contacts all over the U.S. and Canada. Suzy Peters Health Education Consultant, Florida Annual Conferences. TB ETN s most important event is the annual conference. These conferences focus on the systematic health education process: planning; development, including formative evaluation; implementation; and evaluation. Persons who have attended these conferences in the past can attest to the benefits of participating in the conferences and implementing what they have learned. Participant evaluations of these conferences are used to help guide TB ETN activities and future conferences. Highlights from past conferences include plenary sessions with distinguished speakers, breakout sessions with skill-building activities, educational materials displays, learning games, networking activities, poster sessions, and presentations from TB programs about education and training projects. Following are the titles of past conferences: 2001 Culture, Language, and Literacy in TB Education and Training

23 NUMBER 4, Reaching Key Audiences Through Innovative TB Education and Training Methods 2003 Oh, the Places TB Education Can Go 2004 TB Education and Training Survivor: Improving skills, building alliances, meeting challenges 2005 Stepping Up Education and Training to Eliminate TB Bylaws. Another accomplishment was the development of bylaws to formalize procedures, such as voting procedures. The Steering Committee drafted the bylaws, which were then approved by the membership. The bylaws are accessible on the TB ETN website. Marketing materials. TB ETN uses various materials for marketing. Posters and pamphlets are distributed by the Steering Committee at conferences and training sessions. In addition, TB ETN shares news, education-related articles, and cultural competency tips with subscribers in each issue of TB Notes newsletter. TB ETN has also developed a website that provides information about the network and how to join. A Members Only section was recently added to provide additional information to the membership. This section includes Steering Committee and subcommittee minutes, a membership directory, bylaws, and detailed information about each of the subcommittees (e.g., goal, objectives, and activities). To assist with marketing efforts, a link to the TB ETN website is now located on the Find TB Resources website. Awards. TB ETN was awarded the Horizon Health Education Program Award by CDC's Public Health Education and Promotion Network. As part of the 2004 Excellence in Health Education Awards, the Horizon Award is given to a program that was developed by CDC or in collaboration with CDC partners, has been in existence for 2 4 years, and exhibits significant potential to substantially and positively affect the practice of health education. The award was presented at Health Education Day on October 22, Cooperative Agreements. TB ETN has raised awareness about the importance of education and training as an essential part of a TB program. As a result, TB ETN has influenced the creation of new funding for education and training. In the 2005 cooperative agreements, DTBE included provisions for funds for human resource development (i.e., education and training) as a core component of TB control programs. As part of this component, each TB program must have at least one designated training focal point who is a member of TB ETN. Summary. In the 5 years since the network s inception, TB ETN has grown significantly and has become progressively more active. How far we ve come in 5 years: There are now 504 members in the network representing all 50 states within the United States and growing international representation. TB ETN has developed a cadre of TB educators and trainers across the United States and internationally with improved skills and abilities, knowledge of available resources, and the ability to serve as a resource for high-priority needs. Collaborative efforts between TB programs and other organizations conducting TB education and training have increased the visibility, momentum, and impact of TB education and training efforts. TB ETN has raised awareness about the importance of education and training as an essential part of a TB program and as a result, has influenced the creation of new funding for education and training. TB ETN is maximizing the effectiveness and efficiency of groups and individuals interested in TB education and training, and will continue to for years to come. Reported by Maria Fraire, MPH, CHES Div of TB Elimination Thank you, TB ETN, for this valuable resource. Being new to the world of tuberculosis, it is a great relief to know I am never too far away from someone who says, Been there, done that; now how can I help you? Gail Denkins, RN, BS Regional TB Nurse Consultant, Michigan

24 24 NUMBER 4, 2005 that contacts prioritized with network analysis were more likely to have LTBI than nonprioritized contacts. TB ETN: Bringing Together TB Education and Training Professionals TB EPIDEMIOLOGIC STUDIES CONSORTIUM UPDATES Use of Network Analysis to Characterize M. tuberculosis Transmission Patterns Among Women and Other High-Risk Populations The science of network analysis (NA) includes mathematical and visual strategies for examining nodes (people and places) and the connections (relationships) among the nodes. For TB, a respiratory infection spread via droplet nuclei, NA aims to identify the most critical nodes responsible for transmission and predict the contacts most likely infected. In the presence of ongoing M. tuberculosis transmission, networks of individual TB patients and contacts will begin to converge over time and provide early evidence of an outbreak. Many of the data collected in a routine TB contact investigation provide the fundamental basis for NA. Many investigators believe network analysis can be used to complement local health departments current contact investigation practices, not supplant these practices. TBESC task order 7 had the following objectives: 1) to determine whether routine contact investigation data could be abstracted from local health department records on an ongoing basis and analyzed by commercially available network analysis software, and 2) to test the hypothesis Task order 7 included three consortium sites (California Dept of Health, Emory University, and University of British Columbia), three local TB control program collaborators (Contra Costa County TB Control, CA; DeKalb County TB Control, GA; and Downtown Eastside Chest Clinic, Vancouver), two independent network analysis experts, plus extensive collaboration with DTBE staff. Over a 6-month period, each site abstracted routine demographic and clinical data from TB case records and contact investigation records and entered these data into a Microsoft Access database. Each site also employed a 1-page form to collect data from patients and contacts regarding places of frequent social aggregation during the 6-month period preceding TB diagnosis or evaluation as a contact. The database was designed to flag repeatedly-named patients and repeatedlynamed places of social aggregation. Over the 6-month data collection period, the three sites enrolled 42, 36, and 9 TB cases and 179, 218, and 56 contacts, respectively. NA did not detect any clustering of TB cases (no overlapping or repeatedly-named contacts or places of social aggregation) in Contra Costa despite the presence of three 2-case PCR genotype clusters (RFLP pending). However, NA did detect clustering in both DeKalb County and Vancouver. Repeatedly-named places helped connect TB cases in both DeKalb and Vancouver, which were later confirmed through genotyping. In Vancouver, contacts linked to multiple repeatedly-named places of social aggregation were more likely to be diagnosed with LTBI than contacts linked to TB cases only. Despite very different demographic composition of cases and contacts across the three sites, there was remarkable consistency in the distribution of reported daytime, evening, and night places of social aggregation. The number of repeatedly-named places was inversely related