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An outbreak of TB on an Indian reservation in a low-incidence state spurred TB controllers to make several crucial changes in their program, thanks to collaboration and teamwork with experts from the Centers for Disease Control and Prevention.
A case cluster among a group of alcoholics who lived and socialized together on an Indian reservation posed some tough medical and management-related problems, says Denise Ingman, TB control coordinator for the Montana Department of Public Health and Human Services. "As a low-incidence state, we’re finding that we’re having fewer easy cases, and that with the easy cases we do have, we do just fine. But we’re also finding that our remaining cases are very difficult."
As soon as the CDC got word of the outbreak, officials there offered to lend a hand, says Ingman. Renee Ridzon, MD, an epidemiologist with the Surveillance and Epidemiology Branch of the Division of TB Elimination, got especially high marks from Ingman: "Renee has so much energy and expertise," Ingman says. "By the time it was all over, we wanted her to just stay on and work with us."
The CDC, for its part, was eager to try implementing some of the mandates conveyed in the recent Institute of Medicine report on fighting TB in low-incidence areas, says Ingman. Stuck at a plateau of about 20 cases per year for the past decade, Montana made for a good test of what happens when a low-incidence state must grapple with a sudden surge in cases, she adds.
The index case, a 42-year-old alcoholic male living on an Indian reservation, was diagnosed in May 2000, Ingman says. Because he’d delayed seeking treatment, he was very infectious by the time of his diagnosis. Then, just as the contact investigation was getting under way, an unexpected death occurred. The patient who died was part of the same social network, a group of middle-aged men and women who lived in the same house and who all drank together. Apparently, she died not from TB (which wasn’t even diagnosed until results came back from biopsy) but, more likely, from problems related to her alcoholism.
Ultimately, three more cases in the social group were diagnosed, bringing the total to five cases diagnosed within nine months. Molecular epidemiological tests confirmed the cases were linked. Several of the Indian Health Services (IHS) physicians assigned to treat the cases had never seen a single case of TB in the three to four years they’d worked on the reservation, Ingman says — much less a cluster of five cases. Luckily, the tribe’s heath care system consists of an effective collaboration between public health nurses (hired with tribal funds on a contractual basis) and clinic nurses and physicians who work for the IHS.
State TB controllers and tribal health care providers made several alterations that helped the system cope better, Ingman says. First, an elderly public health nurse with a keen understanding of social networks on the reservation was convinced to come back to work the outbreak. TB experts from the CDC "spent three days just picking her brain on contacts," says Ingman. "She’d look at the list of contacts and say something like, Well, I don’t see Johnny’s brother here. Why is that?’" The health care team also began holding weekly case conferences, Ingman says. Meanwhile, Ridzon and other CDC experts provided ongoing education for staff, assisted in setting up better record-keeping services, and conducted chart reviews, Ingman says.
The fact that all the cases were alcoholics made obtaining compliance a continuous challenge, Ingman reports. Many patients would wander off to party for several days, in one instance to a neighboring town. Among contacts, the sheer numbers — 126 in all — made delivery of preventive therapy difficult at best. Public health nurses pulled out all the stops, including direct observation, enablers, and incentives, says Ingman. The participation of the formerly retired public-health nurse was a tremendous help, because she was known and trusted by everyone in the community.
TB controllers also decided to expand directly observed therapy to all contacts. For teens, that meant providing gift certificates to a nearby K-Mart; for adults, food coupons and other incentives were liberally applied. Even so, one contact who repeatedly disappeared was finally placed under house arrest and equipped with a wristband monitor — the first time such sanctions had ever been imposed, Ingman says. In the end, all surviving cases completed treatment without incident, and 90% of contacts have also completed preventive therapy, Ingman says. "We’re still trying with the rest of them," she adds.
In hindsight, Ingman says getting extra help from the CDC made a big difference. "We certainly welcomed the extra manpower and expertise," she says. "We liked the idea of having an expert to conduct chart reviews. And we wanted input on whether our contact investigations had been thorough."
The outbreak lent extra incentive to implementation of other important changes that TB controllers had already planned to pilot in several sites, says Ingman. They include:
• Contract with a TB physician. "We’ll start that with this particular reservation and maybe one more, and then expand," says Ingman. Duties of contractual experts will be to provide help at baseline and then on a monthly basis (or as needed). "We know there are model centers and so on, but we want consistency — the same person every time," Ingman notes. A supplemental grant the state program applied for and received will cover the costs.
• Provide additional, ongoing TB training. The state has already sent some staff for training to National Jewish Hospital in Denver, Ingman says. Other training will be conducted on-site.
• Beef up communication with weekly case conferences. "Our [IHS] physicians have huge workloads, sometimes with as many as 25 to 30 patients a day," notes Ingman. "So it’s very important for them to stay on top of each case."
• Begin targeting more high-risk contacts, and expand the use of directly observed preventive therapy to all contacts. Once the current outbreak work is over, Ingman’s plan is to devise a pilot program that will provide treatment for latent TB infection to diabetics who are skin-test positive. Diabetics’ risk for TB is four times higher than that for regular TST positives, she adds.
• Continue with careful, rigorous documentation of cases and contacts.
• Draw on community resources when possible. Hiring the retired nurse certainly paid off, and Ingman says she’d readily turn to similar community resources again.