Regionalization:A New Strategy for

TB Control & EliminationThe New England Experience

Mark Lobato, M.D.Division of Tuberculosis Elimination

Centers for Disease Control and Prevention

Advisory Committee for the Elimination of TB

Atlanta, GA March 3-4, 2009

New England TB ConsortiumConnecticutLynn Sosa, Heidi Jenkins,Tom Condren, MaureenWilliams, Gary Budnick,James Hadler, CACET

MaineDiane Brooks, Kathy Gensheimer, Joyce Roy,Julie Crosby

MassachusettsSue Etkind, Kathy Hursen,Sharon Sharnprapai, Marilyn DelValle, John Bernardo, Janice Boutotte, Alex Sloutsky, MACET

New HampshireJill Fournier, Lisa Roy,Jody Smith, Peggy Sweeny

Rhode IslandUtpala Bandy, Mike Gosciminski, Paula Pullano, Toby Bennett

VermontSusan Shoenfeld, Susan Cook,Becky Temple

RTMCCNicolette Patrick

DTBEDan Ruggiero, Kashef Ijaz, PatrickMoonan, Maria Fraire, Ken Castro

RegionalizationThe Time Has Come

• Orients to field-based interventions– Rapid response to problems– Increases program capacity– Promotes federal-state cooperation

• Attempts to improve program effectiveness

• Reflects a changing relationship between DTBE and the states

The Perfect Storm The Next TB Upsurge

• Flat funding• Weakened public

health infrastructure• Loss of TB expertise• Ongoing immigration• Continued outbreaks• Few new diagnostics

and drugs

“In the middle of difficulty, lies opportunity.” – Albert Einstein

New England TB, 2007

• TB cases- 408 cases- 3.0 / 100,000

(range 0.5–4.3)- 67% among FB

• Equivalent to state with 8th highest TB burden

Kent

Sharon

StaffordSalisbury

Lebanon

Newtown Lyme

Goshen

Norfolk

Litchfield

Killingly

Woodstock

Guilford

Granby

Haddam

Suffield

TollandPomfret

Danbury

Cornwall

Hebron

New Milford

Ashford

Ledyard

Union

Salem

Enfield

Colchester

Oxford

Groton

Thompson

Mansfield

Montville

Greenwich

Plainfield

Canaan

Avon

Berlin

Preston

East Haddam

Glastonbury

EastonMadison

Shelton

Stamford

Coventry

Wilton

Griswold

Bristol

Hamden

Hartland

Southbury

Somers

Torrington

Redding

Warren

Cheshire

Ellington

Windsor

Voluntown

Stonington

Simsbury

Canterbury

Fairfield

MiddletownWoodbury

Canton

Eastford

Waterford

Sterling

Wallingford

Norwich

Monroe

Ridgefield

Washington

North Stonington

Willington

Colebrook

Brooklyn

Roxbury

Winchester

Southington

Milford

Barkhamsted

Harwinton

Durham

Portland

Windham

Meriden

Burlington

Bozrah

Weston

Waterbury

Morris

Hampton

New Hartford

WatertownWolcott

Putnam

Sherman

Norwalk

Bethel

Bethany

Trumbull

Vernon

Chaplin

Old Lyme

Farmington

Branford

Lisbon

Manchester

Orange

Franklin

Bloomfield

Westport

Columbia

Chester

Clinton

BoltonHartford

Essex

East Windsor

South Windsor

Darien

Bethlehem Sprague

Prospect

Seymour

Naugatuck

Cromwell

East LymeKillingworth

East Hampton

Plymouth

Scotland

Stratford

BrookfieldNew Fairfield

Andover

Marlborough

New Canaan

North BranfordNorth Haven

New Haven

West Hartford

Woodbridge

Middlebury

Bridgeport

Westbrook

East Granby

Bridgewater

North Canaan

East Hartford

Rocky Hill

Deep River

Newington

Old Saybrook

Middlefield

East Haven

New BritainThomaston

Wethersfield

Plainville

West Haven

Derby

Beacon Falls

Ansonia

Windsor Locks

New London

TB CASE RATES,* CONNECTICUT, 2004

*Cases Per 100,000

NOTES:CT Tuberculosis Case Rate in 2004 = 3*

Case rates for centain towns (Easton, Burlington, Tolland, Cromwell, Winchester, Woodbury) may be higher due to low

population and cases.

CASE RATE*

0

< 2.8

2.9 - 4.9

5 - 8.8

8.9 - 11

>12

State of ConnecticutDepartment of Public Health

World TB Day, 2006

“So, why did you do it?”

Value Added

New England TB.org

New England TB Consortium Collaboration for Change

• Leadership• Education

– TB Talk– Eliminating TB Case by Case

• Communication• Genotyping• Public Health Law• Awards

Interactive Web PresentationJune 24, 2008

Noon

Accreditation: CME, CNE, CHES

“TB testing using QuantiFeron Gold:What the provider needs to know”

Eliminating TB Case by CaseA Case Series for Providers and Clinicians

Nira Pollock, MD, PhDDivision of Infectious Diseases,

Beth Israel Deaconess Medical Center, Boston

Access the TB Case Series atwww.mymeetings.com/nc/join.php?i=PG1678747&p=2006&t=c

Toll free audio access: 888 -552 -9191 Password = 2006 #

Eliminating TB Case by Case

• Presented by master clinicians• Designed to reach private providers• Created basis for distance learning

– web-based– continuing education credit

• Need for ongoing marketing“People love the case presentations.Since we are very rural, and we can’t goout of state for training, this is a greatopportunity.” - Consortium stakeholder

TB Talk – New England A case discussion by and for nurses, outreach

educators, and case management staff

January 13, 2009 12:00 – 1:00 pm John Bernardo, M.D., Boston University

“Ask the Expert”Lloyd Friedman, M.D. (Pulmonary), Milford Hospital, Yale

Joseph Gadbaw, Jr., M.D. (ID), Lawrence & Memorial HospitalRobert Husson, M.D. (Pediatrics), Childrens Hospital Boston

Phone: 866-774-8920 Passcode: 8612841#

New Engl andTB ConsortiumConnecticut M aine M assachusetts New Hampshire Rhode I sl and Vermont

NewEnglandTB.org

• Built a website– To increase cohesiveness and visibility– To promote regional and state education– To exchange tools and materials

• Partnered with HHS Region I (wiki)

Genotyping Work Group

• Defined data management capacity• Identified instances of interstate

transmission in 2 clusters• Highlighted missed opportunities• Measured strain dispersion across

states “The genotyping calls are an opportunity to exchange information and to feel we are not in a vacuum… It is hard when you are in a void.”- Consortium stakeholder

Consultation

• Early detection of an outbreak and need for a CDC investigative team

• Facilitated technical support for 3 large contact investigations

• Performed on average 7 consultations for CIs and 20 for complex cases per year

New England Public Health Law Project

• Call to Action sent to NTCA• Addresses gap in Model TB Act• Formed a broad partnership• Defining options for involuntary

isolation of patients from another state• Applied for CDC award “Innovations in

Public Health Policy”

TB Heroes Award

• To recognize exceptional contributions to TB control and the well-being of patients and the community

• First annual award presented at the 2008 northeast TB meeting

• Article in current TB Notes

Call for nominations

New

TBEngland

Heroes

New England TB Heroes Award

In recognition of an exceptional contribution to TB control and the well-being of patients and the community

Please send nominations to your TB program by April 1st  

Presented by the New England TB Consortium

PCSI• The best programs are the best

collaborators• Beginning collaboration between TB

and STD• TB Notes (2008)

Lab Collaboration

• 5 states using uniform lab survey• Questions regarding lab capacity and

practices• Marketing tool

Dissemination• Presentations

– NTCA (plenary): 2008– NTCA (posters): 2008 (“TB Talk” - D. Orcutt)

2007 (Regionalization), 2006 (Education)– ATS: 2007 (Genotyping)– IUTLD: 2008 (Isolation - Gensheimer; Regionalization)– TB ETN: 2009 (Education)– Northeast TB Conference: 2005, 2006, 2007– DTBE Brown Bag: 2006, 2009

• Publications– TB in the foreign born (Lobato, et al.)– Prison outbreak in CT (Sosa, et al.)– Community outbreak (Buff, et al.)– TB Notes:

• 2009 (TB Heroes – New England)• 2008 (PCSI)• 2007 (Regionalization)• 2006 (Education)

Evaluation of the NETC• Carried out by Maureen Wilce, DTBE• To determine the factors promoting or

hindering this regionalization effort• Results

– Created a formal framework with a consensus plan of action

– Provided a structure for all voices to be heard equally

– Facilitated the sharing of knowledge and resources– Found resource limitations that limit program staff

from optimizing involvement

Evaluation Conclusion

The New England TB Consortium “provides a model for building consensus through strategic planning [and] establishing formal agreements”

“Regional assignees can be effective to promote regionalization, providing skills and resources as incentives to promote collaborative efforts.”

Lessons Learned

• Modern TB control requires– Building a team leadership– Coordination and collaboration across

jurisdictions• Regional efforts enhance programs• Regionalization offers advantages CDC

“The conference calls are comfortable and supportive… I found we are all struggling with the same issues.”- Consortium stakeholder

Next Steps

• Hold a leadership retreat– Improve collaborative efforts– Update the strategic plan– Examine how to replicate model

• Extend the model to labs and refugee coordinators

• Enhance resources for treating complex or non-adherent patients

Future Outlook

• Extend the model nationally

• Strategic placement of TB staff

Prepare, you’ll sleep better…