Where Are They now?Where Are They now?A Comprehensive Approach to Achieving A Comprehensive Approach to Achieving a High Treatment Completion Rate in a a High Treatment Completion Rate in a Worksite TB Exposure in Washington Worksite TB Exposure in Washington

County, OregonCounty, Oregon

Jen Reuer, MPHJen Reuer, MPH

EpidemiologistEpidemiologist

Washington County Public HealthWashington County Public Health

The SettingThe Setting Washington CountyWashington County

Population ~530,000Population ~530,000

Average 17 active TB cases per yearAverage 17 active TB cases per year

The Call CenterThe Call Center Provide computer-related technical advice over the Provide computer-related technical advice over the

phone.phone.

Employs mostly male (65%), U.S.-born (92%), native Employs mostly male (65%), U.S.-born (92%), native English speakers.English speakers.

Monthly turnover rate of approximately 10%.Monthly turnover rate of approximately 10%.

Index Case and ExposureIndex Case and Exposure

August 2006 - Index case’s symptom August 2006 - Index case’s symptom onsetonset

October 2006 – March 2007: Index case October 2006 – March 2007: Index case worked at a call center worked at a call center

Identified a total of 1750 individuals as Identified a total of 1750 individuals as possible contactspossible contacts

The Investigation:The Investigation:March 2007 – June 2008March 2007 – June 2008

Outreach and education: Outreach and education: letters from the Health Officerletters from the Health Officer media advisoriesmedia advisories informational talksinformational talks sessions with the county’s TB nurses sessions with the county’s TB nurses web links and handoutsweb links and handouts

On-site screenings, using a Point of On-site screenings, using a Point of Dispensing (POD) structureDispensing (POD) structure

The Investigation:The Investigation:July 2008 – June 2009July 2008 – June 2009

LTBI case management at the worksite in LTBI case management at the worksite in July 2008.July 2008.

Additional funds received at the county in Additional funds received at the county in October 2008October 2008 Outreach workerOutreach worker IncentivesIncentives

The Investigation:The Investigation:July 2008 – June 2009July 2008 – June 2009

OutreachOutreach Social networking sites (Facebook, Myspace)Social networking sites (Facebook, Myspace) Text messagesText messages Individualized lettersIndividualized letters

TestingTesting ImmediateImmediate QuantiFERONQuantiFERON

The Investigation:The Investigation:July 2008 – June 2009July 2008 – June 2009

Case ManagementCase Management Rifampin Rifampin Text messages Text messages Worksite and home-based LTBI case Worksite and home-based LTBI case

managementmanagement

IncentivesIncentives Each step of testing and treatment Each step of testing and treatment Extra incentive for completing treatmentExtra incentive for completing treatment

ResultsResults

Test negative38660%

Test positive10817%

Not tested13521%

Unable to locate

9973%

Did not need follow up2

1410%

Refused22

16%

LTBI10294%

No treatment8

8%

Completed Treatment

6100%

Tx not completed

2122%

Active TB6

6%

Treatment94

92%

Tx completed

7377%

Total1

1750

Low risk/volunteers

110963%

High risk64237%

1. Total includes household and social contacts of 2 clinical cases.2. Includes individuals who were determined to have had previous TB treatment, entered the military, deceased from another cause, and did not work during exposure time.

ChallengesChallenges Number of people requiring some form of follow-up was Number of people requiring some form of follow-up was

more than county staff had ever dealt with before.more than county staff had ever dealt with before.

Young, mobile population made finding contacts difficult.Young, mobile population made finding contacts difficult.

Data management- scale and available expertiseData management- scale and available expertise

Large geographic area- outreach worker worked across Large geographic area- outreach worker worked across Clackamas, Multnomah, and Washington counties.Clackamas, Multnomah, and Washington counties.

Call center employee’s initial mistrust of health Call center employee’s initial mistrust of health department staff- not differentiated from employerdepartment staff- not differentiated from employer

ConclusionsConclusions Intense investigation and follow up was Intense investigation and follow up was

necessary in reaching this young and highly necessary in reaching this young and highly mobile population.mobile population.

New, in addition to traditional, methods were key New, in addition to traditional, methods were key to reaching the exposed population.to reaching the exposed population.

Implementing a comprehensive strategy to Implementing a comprehensive strategy to educate, locate, test, and treat contacts was vital educate, locate, test, and treat contacts was vital to achieving a high rate of testing and treatment to achieving a high rate of testing and treatment completion.completion.

AcknowledgmentsAcknowledgments Washington CountyWashington County

Trevor Hostetler, RNTrevor Hostetler, RN Sharon Hofer, RNSharon Hofer, RN Mandy AndersonMandy Anderson Paul Lewis, MDPaul Lewis, MD Cathy Vickers, RNCathy Vickers, RN Gloria MatthewsGloria Matthews Amanda NewellAmanda Newell Sue Mohnkern, RNSue Mohnkern, RN Kathleen O’Leary, RNKathleen O’Leary, RN Monica SilvasMonica Silvas All the other staff who were involved in All the other staff who were involved in

the investigationthe investigation

Multnomah CountyMultnomah County Mary Ann Ware, MDMary Ann Ware, MD Gary Oxman, MDGary Oxman, MD TB program staffTB program staff

Clackamas County TB program staffClackamas County TB program staff

State of OregonState of Oregon Heidi Behm, RNHeidi Behm, RN Lindsey Lane, MPHLindsey Lane, MPH

CDCCDC Paul TribblePaul Tribble Maryam HaddadMaryam Haddad Kiren MitrukaKiren Mitruka Lauren LambertLauren Lambert

Volunteers who worked at the call Volunteers who worked at the call center during the PODscenter during the PODs

The call center for their cooperationThe call center for their cooperation