Using the CDC framework for program evaluation in public health to assess tuberculosis contact investigation programs.

SETTING: In Massachusetts, despite the efforts of state and local health department tuberculosis (TB) programs, the rates of contact testing and follow-up remain below the state and national objectives. Changes in contact investigation practices are therefore needed to achieve these objectives. OBJECTIVE: To develop contact investigation self-evaluation tools in accordance with the Centers for Disease Control and Prevention's (CDC) Framework for Program Evaluation in Public Health. These tools will be used to assess state and local level contact investigation practices. DESIGN: The self-evaluation tools were developed using the CDC's framework and pilot-tested by public health nurse case managers in five city health departments. The tools were revised according to feedback received from the nurses. RESULTS: The Massachusetts TB Division conducted three of the six steps of the CDC's framework. Stakeholders of the evaluation were identified and engaged, logic models were created describing state and local TB program components, and self-evaluation tools were developed. CONCLUSION: The CDC's framework provided a useful methodology for beginning the assessment process for evaluating TB contact investigation programs. When the contact investigation self-evaluation tools are implemented statewide, the findings will be used to target areas in need of improvement and develop strategies to make noteworthy changes.

Clonal relationships in a shelter-associated outbreak of drug-resistant tuberculosis: 1983-1997.

SETTING: An outbreak of tuberculosis caused by Mycobacterium tuberculosis resistant to isoniazid and streptomycin (HS-resistant) was documented in Boston's homeless population in 1984. Isolate relatedness was confirmed at the time by phage typing. In the late 1990s, cases of HS-resistant tuberculosis in the homeless were also documented, confirmed by RFLP typing using IS6110. None of the phage typed isolates from the 1980s were viable for performing RFLP analysis. We attempted to determine, using mixed-linker PCR (M-L PCR) finger-printing, whether or not these cases were all due to the same strain of M. tuberculosis. DESIGN: Isolates from 10 HS-resistant patients-four non-viable isolates from the 1980s and six viable isolates from 1996-1997-were sent to the Centers for Disease Control and Prevention for M-L PCR fingerprinting. These results were combined with record reviews of older cases and an ongoing epidemiologic investigation. RESULTS: Eight of 10 of the isolates were clonal, and the other two were strongly suspected matches. Epidemiologic investigation determined that transmission continued to occur after the initial outbreak in 1984-1985, and that a streptomycin-monoresistant variant of the strain was also circulating. CONCLUSION: M-L PCR fingerprinting combined with epidemiology was able to document links between cases across 15 years.

Treating hard-to-treat tuberculosis patients in Massachusetts.

For most patients with tuberculosis (TB), treatment has never been shorter or cure more certain than with current drug regimens. However, in Massachusetts and elsewhere in the United States there is a growing minority of patients who are not easily cured with the best available outpatient regimens. Close treatment supervision through culturally appropriate outreach workers has been successful for some foreign-born TB patients in whom therapy might otherwise fail. Full supervision of outpatient therapy, sometimes with incentives, has also been used successfully to treat selected homeless patients. However, a growing number of hard-to-treat homeless patients are addicted to illicit drugs, human immunodeficiency virus (HIV) infected, or have major behavioral problems. These patients often do not cooperate with fully supervised therapy and acquire drug resistance as a result of erratic drug taking. They can then transmit these dangerous organisms to others, especially to other HIV-infected persons within shelters, jails, prisons, detoxification centers, clinics, and hospitals, infecting institutional workers at the same time. In Massachusetts these hard-to-treat TB patients are increasingly being legally committed to involuntary, long-term, inpatient therapy. Although long-term inpatient TB treatment is expensive, it is likely to be cost effective when it successfully breaks the chain of transmission within institutions, and achieves cures not otherwise possible. A new model of lower-cost inpatient care that incorporates psychosocial rehabilitation techniques to modify the behavior of the hardest-to-treat patients is briefly described. Ultimately, however, the reversal of the current upsurge in hard-to-treat TB cases in Massachusetts and elsewhere depends not on inpatient care but on substantial changes in the socioeconomic order that perpetuates homelessness, substance abuse, crime, and the transmission of both TB and HIV infections.