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The Making of a Documentary:

Tuberculosis on the Navajo Nation

Sarah Yazzie; NN TB Program Manager Diana Fortune RN BSN; NM TB Program

ManagerETN/PEN Conference September 2012

GEOGRAPHY LESSONWHERE IS THE “FOUR CORNERS”?

Navajo Nation

MAP OF NAVAJO NATION

662008 2009 2010 2011

0

50

100

150

200

250

300

0.0

2.0

4.0

6.0

8.0

10.0

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14.0

103

85 7170

6048 51 49

227 232283

256

2737

2034

8.87.9

1212.5

4.2 3.8 3.83.4

TB: Navajo Nation and Four Corners

CO NM AZ UT NN US**

Num

ber

of c

ases

Case

s Pe

r 10

0,00

0

Epidemiology of TBFour Corner States and

Navajo Nation

• 2008 Navajo Nation population estimate was used for 2009 and 2010.; • 2010 Navajo Nation population estimate was used for 2011. ** 2010 US TB case rate was estimated.

HOW IT STARTED?

Sept 2010: TB Presentation Northern Navajo Medical Center: Shiprock,

NM

A germ of an idea…………..was planted!

TB MORTALITY RATE IN NEW MEXICO: JAN 1, 2007 – DEC 31, 2009

Year Total TB cases Patients who died with TB

Mortality rate (%)

2007 51 8 162008 60 8 132009 48 11* 23

• Out of 159 patients diagnosed with TB from 2007-2009, 25 (15.7%) patients who died with confirmed TB were included in the final study group

TB MORTALITY STUDY CONCLUSIONS

A high TB-related mortality in a low-incidence state. Approximately 2/3 of deaths due to TB-associated

disease.

Disease often presents in the elderly is difficult to diagnose.

Foreign-born and Native Americans most affected.

Patient and provider delays in recognition of disease.

NEXT STEPS…..NOVEMBER 2010 Meeting of the minds…..in Gallup

NM TB Program Navajo Nation TB Program Indian Health Services

“What can we do”?

Ideas were watered & fertilized…….

TOOK ROOT AND BLOOMED….. Billboard designs:

Billboard_hyperlink.pptx

Posters :

Movie Ads – (run finishes October 2012) Gallup (2) Theatres 510,000 annual attendance Movie Theater Ads_hyperlink.pptx

Public Service Announcements: Navajo Nation

Documentary: Tuberculosis on the Navajo Nation

MEDIA CAMPAIGN March 2011

Press Conference held in Gallup Article in Navajo Times & Indian Country

NAVAJO NATION: TB & ANNIE WAUNEAKA“I’LL GO AND DO MORE”

First woman elected to the Navajo Tribal Council, 1951 -1978

Primary concern was to eradicate tuberculosis among Navajos.

She traveled across the huge reservation visiting the ill and encouraging those with tuberculosis to see physicians.

Traditional healers and medical doctors

Awarded the Presidential Medal of Freedom from John F. Kennedy in 1963.

NAVAJO NATION: PRESENT DAY TB EFFORTS

Sarah Yazzie: 40 Years as TB

Program Manager

Dramatically decreased the rates of TB

Continues to work diligently with TB patients/staff

FOUR DIRECTIONS STUDIO (SHIPROCK) Tremendous undertaking

Many months to produce Ideas transformed/changed during

production Patient personal perspective

This made ALL the difference Very courageous to tell his story

Joann King – Nurse that did the interview Connected well with patient

Navajo Nation TB Control Program

NAVAJO NATION COMMUNITY HEALTH REPRESENTATIVE & OUTREACH PROGRAM FISCAL YEAR 2006

Office Specialist Office Specialist Senior Accountant

Administrative Service Officer Property Clerk

Office Assistant Training Instructor

CHW Supervisor CHWs (15) Office Assis-

CHW Supervisor CHWs (17) Office Assistant *(19 staff)

CHW Supervisor CHWs (13) Office Assistant *(15 Staff)

CHW Supervisor CHWs (17) Office Assistant Office Specialist

Public Health Specialist Supervisor CHWs (8) Office Assistant *(10 Staff)

CHW Supervisor CHWs (22) Office Assistant *(2 nnn4Staff)



Program Supervisor I TB Technicians (10)

Program Supervisor I STD Technicians * NOTE: Total Number of staff at each

Revised: 7/16/06cm

Health & Social Services Committee

Health Educator (AIDS) *(5 Staff)

Program s & Project Specialist Health Education Techni-cian

Evaluation Contractor

Screening Contrac-

I.H.S

C.D.C

1-Chief TB Medical Officer 10-TB Medical Officer 9-PHN/TB Coordinator

Atlanta National Jewish Hospital

STATE

Arizona New Mexico Colorado Utah

COUNTY

McKinley Navajo Apache Cocooning San Juan

LABORATORY

New Mexico Arizona

Chinle

16-Chapters 1-Hospital 4-Clinics 1-Nursing Home 50-Pre Schools 2-Colleges 4-BIA Schools 11-Public Schools 1-AIDS Coalition 1-Dialysis 4-Chest Clinic 7-Contract Schools 2-Detention Centers 12-Senior Centers

16-Chapters 1-Hospital 2-Clinics 9 BIA Schools 4-Pre Schools 9-Public Schools 6-Private Schools 1-Chest Clinic 1-Dialysis 1-Youth Home 2-Detention Centers 1-Elderly Group Home 12-Senior Centers

Crownpoint

17-Chapters 2-Hospital 5-Clinics 2-County Health 3-Nursing Homes 5-BIA Schools 34-Pre Schools 2-Detox Center 1-Dialysis 2-Rehabs 4-Chest Clinic

Gallup

9-Chapters 1-Dialysis 1-Chest Clinic 1-Day Care 12-Senior Centers 1-Health Center 2-Clinics 5-Pre Schools 1-Public School 3-BIA Schools

14-Chapters 2-Hospital 1-Nursing Home 1-P&M Coalmine 1-Day Care Center 1-Detention Center 2-Chest Clinic 1-Clinic 12-Pre Schools 9-Public Schools 3-BIA Schools

8-Chapters 1-Hospital 1-Clinics 16-Pre Schools 4-BIA Schools 1-Dialysis 1-Chest Clinic

21-Chapters 2-Hospital 5-Clinics 3-County Health 2-Nursing Homes 3-Detention/Detox 16-Pre Schools 7-BIA Schools 2-Private Schools 2-Dialysis 2-Chest Clinic

Shiprock Tuba City Kayenta Ft. Defiance Winslow

8-Chapters 1-Health Center 2-Clinics 11-Pre Schools 3-BIA Schools 1-Contract School 1-Private School 1-Chest Clinic 4-Public Schools 1-Dialysis 2-Border Towns 6-Senior Centers

OTHER RESOURCES: HOSPITALS: University of New Mexico Albuquerque: VA Hospital Phoenix Indian Medical Center Tucson Medical Center American Lung Association Infection Control Safety Officer Diabetes Mellitus Navajo Nation/State Courts Police Departments (Navajo Nation/State/State Court) Hospital Employee Health

Navajo Nation TB Control Program

Revised 7/16/06 zzs

NAVAJO NATION TB CONTROL PROGRAM The Navajo Nation is the largest Indian Reservation

and the largest federally recognized Indian Tribe in the United States.

Its diverse geographic, cultural and historic context makes it uniquely attractive to a variety of people.

The Navajo Nation is a Sovereign Nation located in the Southwest region of the United States.

The Navajo Nation (about the size of the state of West Virginia) encompasses a total area of about 27,000 square miles.

The population on the Navajo Nation is increasing. In 1998, the census population was 234,792 and per Navajo Area IHS active user population now is at approximately 300,000.

The Navajo Nation is

located within three states, New Mexico, Arizona and Utah. With about two

thirds of the nation located in the state of

Arizona.

• The Navajo Nation TB Program consists of Ten TB Technicians and is Coordinated by Sarah Yazzie.

• Each TB Tech. covers different service unit which consists of several communities.

Dorothy

Chee

Sarah Yazzie TB Control

Coordinator

Jay Nez

Zena Ario

Zena Arviso

Due to the extensive tuberculosis history of the Four Corners area, the health care community has responded by establishing a high standard of care for TB patients.

The Navajo Nation TB Control Program collaborates with the Navajo Area Indian Health Services which includes a TB Medical Officer, a PHN/TB Coordinator and a DPHN/Nurse Consultant.

The TB Program serves 110 chapters, satellite clinics, border-towns/cities, preschools, nursing homes, detention centers, public, parochial, BIA and charter schools.

The Navajo Nation TB Control Program has a strong quality assurance in place so that TB patients receive the best care possible.

The Navajo Nation TB Control Program has Policies and Procedures, Plan of Operation, a Strategic Plan, and a Memorandum of Agreements with all Navajo Area IHS Service Units as well as PL93-638 Programs.

The Health and Social Services Committee of the Navajo Nation Council serves as an Oversight Committee for the TB Control Program.

• Due to the high standards of care provided, there have been no reported cases of multi-drug resistance to Tuberculosis on the Navajo Nation.

• The Navajo Nation TB Control Program mandates 100% Direct Observed Therapy (DOT) for all TB Cases.

NEW NAIHS TUBERCULOSIS CASES IN 2011 BY SERVICE UNIT

Chinle

Crownp

oint

Ft Defi

ance

Gallup

Kaye

nta

Shipr

ock

Tuba

City

Winslow

01234567

New TB Cases

FIGURE 2- 2011 NAIHS TB CASE SEX DISTRIBUTION

Male62%

Female38%

NAIHS 2011TB CASE AGE DISTRIBUTION

<5 years 5-14 years

15-24 years

25-44 years

45-65 years

>65 years

02468

101214

2011 NAIHS TUBERCULOSIS CASESBY SITE OF DISEASE

Pulm

onary

Renal

Pleura

l

Mening

eal

Miliary

Lymph

atic

Perito

neal

Dissem

inated

Bone

/Joint

Other

02468

101214

0

5

10

15

20

25

30

U.S. RATES NAVAJO RATES

NAVAJO VS. US TB INCIDENCE RATES: 1990-2011

2011 LATENT TB INDICATIONS FOR TREATMENT

Diabete

s

Dialysi

s

Alcoh

ol

Immun

osupp

ressiv

e Rx

Abno

rmal

CXR

TB Con

tact

Nursing

Home P

t

Nursing

Home E

mploye

e

Hospita

l Emplo

yee

Schoo

l Emplo

yee

PPD Con

verte

r

No Risk

Facto

r0

20406080

NAVAJO NATION TB CONTROL PROGRAM

Since the inception of the Navajo Nation TB Control Program in 1972 the high number of Tuberculosis cases has decreased dramatically.

Barriers to Achieving Objectives: Distances between communities and homes are

great on the Navajo Nation. It is not at all unusual for a Navajo Family to

live 50 to 100 miles from the nearest health care facility, and often, much of that distance may be a dirt road

impassible in times of bad weather

COMMUNICATION May also be a barrier

TB Technician has to be fluent in both Navajo and English for the patient to understand their care.

Occasionally, a very traditional Navajo patient is reluctant to accept the use of western medicine to combat their TB illness.

Some IHS Hospitals within the Navajo Nation now employs Navajo Medicine Men as staff members for the purpose of counseling and promoting health for patients by combining traditional and western medicine.

• GOAL:TUBERCULOSIS CONTROL : Reduce the rate of incidence/prevalence of Tuberculosis among our Navajo people.

• OBJECTIVE:Design and implement tuberculosis control activities on the Navajo Nation through case finding, case prevention, case follow-up, monthly and/or bi-monthly TB clinic services, screening of high risk groups, contact investigations and community education.

TASKS: I. Case Management:

A. Manage and provide Direct Observe Therapy (DOT) two to three times a week to patients with or suspected of having TB disease.

B. Manage and provide Direct Observed Preventive Therapy (DOPT) to selected patients who are at risk for developing active TB (e.g. Diabetics, substance abusers, close contacts, dialysis patients, nursing home patients, etc.)

C. Collection of TB specimens are submitted to

the State Laboratories for testing.

II. Surveillance A. Tuberculin Skin Testing: Screen and identify close contacts of Active TB Cases and also

target screening for high risk population.

III. TB/ Chest Clinics A. Develop each TB Patient’s Plan of

Treatment and monthly reviews with the TB

Medical Officer at the service unit TB/Chest Clinics.

∙ IV. Court OrdersA. Protecting the health of the public State and Tribal Court Orders may be used to detain patients who are infectious, unwilling to receive treatment or who are at risk for becoming infectious again and acquiring drug-resistant TB.

V. ReferralsA. Initiate and accept referrals of

TB clients for evaluation and possible treatment for TB.

VI. Health EducationA. TB Control Program provides

education about Tuberculosis to health care

providers, school health, and over-all

communities.

VII. Guidelines A. Observe the National CDC

guidelines, State, and Navajo Area IHS

Laws and Regulations.1. Treatment

recommendations2. HIPPA- Privacy, Confidentiality 3. Contact Investigations4. Reporting of TB Cases

• The TB program has come a long way.• Before the TB program, there was a high

number of TB cases.• Since the program was established in 1972

the number of TB cases has declined.• The last TB Sanatorium was closed 5 and

7 years after the program was started.• The high standard of care has made a

positive impact, therefore the Navajo Nation does not have any reported MDR.

• The Navajo Nation continues to collaborated with other National, State and Local entities to the rate of incident/prevalence of TB among our Navajo People.

DOCUMENTARY: TB ON THE NAVAJO NATION

For your Viewing Pleasure……..

QUESTIONS??

“Cat Corner”Canyon de Chelly

“I will go and do more……..”Annie Wauneka

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