Blue Ribbon Project Outline 2 Marym Lakhani
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Transcript of Blue Ribbon Project Outline 2 Marym Lakhani
Project TypeDevelopment of TB Education
Materials for school Healthcare Staff
Project TitleA Comprehensive Desk- Guide
on TB Protocols and DOT Administration for School
Nurses
INTRODUCTION
Background
Academic InformationDes Moines University- College of Health
SciencesMaster of Public Health (MPH) Candidate 2016
DSHS PlacementDSHS TB Elimination Division
Health Service Region 4/5N- TB Prevention & Immunization Clinic
DSHS Supervisor- Suzanne Fisher, MPA-HCA, BSN-RN
Sub Office- Nacogdoches, TX
Texas TB statistics
A total 1,269 TB cases were reported in Texas in 2014
5 in 100,000 Texans had active TB last year compared to the national average of 3 in every 100,000
55% of reported TB cases in 2014 were among Hispanics, 18% were among African Americans, 9% percent were among Whites, and 18% were among Asians.
On average 57 cases have large contact investigations with more than 50 contacts identified.
TB rates are higher along the Texas-Mexico border and TB/HIV co-infection is more commonly found in urban areas of Texas
TB Demographics in Texas Counties
County Cases
Harris 320
Dallas 167
Bexar 89
Tarrant 77
Hidalgo 70
Cameron 67
El Paso 43
Travis 49
Collin 27
Webb 25
Highest incidence of TB Cases in Texas Counties, 2014
Regional TB statistics in Texas
Health Service Region
Number of Cases
Percentage of Cases (%)
1 52 4.09
2/3 305 24.03
4/5N 43 3.38
6/5S 387 30.5
7 82 6.46
8 132 10.4
9/10 56 4.41
11 189 14.9
Texas 1269 100
Why is there need for a TB Desk-Guide for school Nurses? Situation? Very little formal state literature that addresses the problem of TB on
school campuses and/or is catered towards school nurses
The Texas Health guide for schools has only allocated 2 pages on the topic of TB.
Most of the students diagnosed with TB take their medication on school campuses (DOT), hence a well trained nursing workforce is crucial to eradicate TB in school going children.
The Need!-A need for a state literature based on the CDC/DSHS
guidelines that goes into more detail about the TB Topics such as TST reading/interpretation and DOT administration.
.
What is the purpose of this?The purpose of this desk-guide is to
Educate and train the school nurses on the right protocol handling TB cases on school campuses.
Let’s Begin!!!
Borderline- High Risk Counties of Texas
The rate of tuberculosis in these counties is twice the average of the state
Brooks Calhoun Cameron Cherokee
Collingsworth Edwards Frio Garza
Hansford Jack La Salle Lipscomb
Martin Moore Nacogdoches Parmer
Reagan Terry Val Verde Webb
Zavala
Incidence Rate of TB with various Risk factors
What is Tuberculosis /Transmission and Pathogenesis
Tuberculosis is caused by the
Mycobacterium tuberculosis (M.
tuberculosis) and is spread by airborne
droplet nuclei
The transmission of TB is causes by the prolonged contact with the infected
individual.
Transmission occurs by coughing, sneezing, laughing
or singing
Any untreated person with active
pulmonary TB disease can infect
an estimated 10-14 people in a year
TB is categorized into two-related conditions: latent TB infection and active TB disease.
Latent TB Infection Active TB Disease
Inactive Tubercle Bacilli in the body Active Tubercle bacilli in the body
Tuberculin skin Test (TST) or Interferon-gamma release assay (IGRA) usually
positiveTST or IGRA usually positive
Chest radiograph usually negative/normal Chest Radiograph usually positive/abnormal
Sputum smear and culture negative/normal Sputum smear and culture positive
Lack of symptoms Symptoms such as cough, fever. Weight loss
Not infectious Often infectious before treatment
Difference between TB infection and TB Disease
Symptoms of TBThese symptoms are more common in adults and older children (American Academy of Pediatrics [AAP], 2000). Symptoms of TB include one or more of the following:
Fever
Persistent cough (3 weeks)
Weight loss/failure to gain weight
Lymphadenopathy (LAD)
Fatigue
Night Sweats Chest Pain
Hemoptysis
Chills
How to Test for TB (TB blood test) vs. Skin Test)
TB blood tests
Interferon-gamma release assays or IGRAs- measures how
the immune system reacts to the bacteria that cause TB.
Two IGRAs are approved by the U.S. Food and Drug
Administration (FDA) and are available in the United States
QuantiFERON®–TB Gold In-Tube test (QFT-GIT)
T-SPOT®.TB test (T-Spot)
How to Test for TB (TB Blood Test)
TB Skin Testing
The diagnostic tool for detection of TB infection is
the tuberculin skin test (TST) using the Mantoux
method.
“Target testing” is recommended, and
Routine testing should not be done in low prevalence
areas
As the school nurse, you may be asked to do the testing for a “high-risk
child”
High Risk for TBPeople at High Risk for an LTBI infection People at High Risk for active TB disease
Close contacts of people known or suspected to have TB
People living with HIV
People, including children, who have come to the United States (within the last 5 years) from areas of the worlds where TB is common (for example, Asia, Africa, Russia, Eastern Europe, or Latin America)
People recently infected with M. tuberculosis (within the past 2 years)
Low-income groups with poor access to health care, including homeless people
People with medical conditions known to increase the risk for TBo Silicosiso Diabetes mellituso Severe kidney disease and certain
intestinal conditionso Certain types of cancer & Organ transplanto Immunosuppressive therapy (prolonged
use of corticosteroids and (TNF-alpha)
People at High Risk for an LTBI infection People at High Risk for active TB disease
People who inject illegal drugs People who inject illegal drugs
People who live and work in high-risk residential settings (for example, nursing homes, homeless shelters, or correctional facilities)
Infants and children younger than 4 years
Healthcare workers who serve high risk clients
Low body weight
Healthcare or ethnic minority populations, as locally defined
Infants, children and adolescents exposed to adults in high-risk groups
High Risk for TB Cont’d
What constitutes as Target Testing TB Targeted testing is a TB control strategy that is used to identify and
treat persons who are at high risk for LTBI or at high risk for developing TB disease.
During patient evaluations, healthcare providers should identify and test persons who are at high risk for TB.
Testing activities should only done when there is a plan for follow-up care to evaluate and treat all individuals diagnosed with LTBI or TB disease. “The decision to test is the decision to treat”.
People who are not high risk for LTBI generally should not be tested.
Testing in low-risk populations can take resources away from other important activities.
How to determine if you repeat a TB Skin test on a child?How to perform a TB test? TST using the Mantoux method is the only skin testing method that should be used. Before administration, it is important to obtain the student/ patient’s TST history.
No
Has the child ever tested positive using the Mantoux TST method?
If No IF Yes
Yes No
Yes No
Does the documentation have the dr. signature, date, mm? ?reading?
Child is exempt Is there documented history of treatment?
Ask for written documentation Proceed with the TST
Proceed Wit the Test Child may be exempt; inquire with DSHS
Interpret the TST
TB Treatment Plan
Medicine Dosage and Timings
Isoniazid (INH)
9 months/ *2 every week= 76 dosesThese two doses must be 72 hours apart (at least alternative days). For instance,
(M & Th), (Tu & F) or (M & F)
Latent TB Infection Treatment Plan
Medicine Dosage and Timings
Isoniazid and Rifampin (INH/RIF)
7 days a wk. (14days)
2 days a wk. (60 days)
Total of 40 doses
Isoniazid and Pyrazinamide(INH/PZA)
7 days a wk. (14days)
2 days a wk. ( 6 months)
= Total of 76 doses
Active TB Disease Treatment Plan
Methods of the Project
Literature research on educational TB resources
Annotation of the previously written material for the project.
Proposed modifications to the DSHS and submitted work plan
for approval
Initiate and complete writing phase
References and appendix
Phase I- Project Research & Writing
Methods Continued
Submit for review to DSHS Supervisor
Create an anonymous feedback survey and administer to a sample of school nurses.
Gather the survey results and discuss feedback
Finalize the document.
Submission to DSHS for publication and usage as a future
resource
Phase II- Project Evaluation and Analysis
Results100% of the respondees found it to be a helpful
addition to TB training & related educational
materials.
For 100% of the respondees, it took less
than an hour to read
100% of the respondees indicated that the guide
addressed all the relevant TB related topics for school
nurses
100% of the respondees indicated the guide provides detailed
instructions on Direct Observed Therapy (DOT)
with visual aids
67% of the respondees found the guide “easy to
read” whereas 33% found the guide “very easy to
read”
Recommendations
Officially publish the desk- guide under as a DSHS
resource
Distribution of the guide to all
the school nurses and school
campus DOT providers
Continued Training and CE for school
nurses on TB related topics
ReferencesAdverse Reactions. (2008, April). Retrieved 11 05, 2015, from Curry International Tuberculosis Center: www.currytbcenter.ucsf.edu/drtbArbex, M. A., Varella, M. d., Siqueira, H. R., & Mello, F. A. (2010). Antituberculosis drugs: Drug interactions, adverse effects, and use in special situations. Part 1: First-line drugs. J Bras Pneumol, 626-640.Clinic Locations- Region 4/5 N. (2016, May). Retrieved November 5, 2015, from http://www.dshs.state.tx.us/region4-5/Clinic-Locations.pdfCDC | TB | Basic TB Facts. (2012). Retrieved from Centers of Disease Control and Prevention website: http://www.cdc.gov/tb/topic/basics Diagnostic Standards and Classification of Tuberculosis. (1990). American Review of Respiratory Disease, 142(3), 725-735. doi:10.1164/ajrccm/142.3.725 Direct Observed Therapy [Photograph]. (2014). Retrieved from https://results.usaid.gov/georgia/health/tuberculosis#fy2014 Graham, S. M. (2015). Desk-Guide For Diagnosis and Management of TB in Children. Retrieved from International Union against TB and Lung Disease (The Union) website: http://www.theunion.org/what-we-do/publications/technical/desk-guide-for-diagnosis-and-management-of-tb-in-childrenHealth Service Region 4/5N Tuberculosis Elimination Program. (2015, March). Retrieved from http://www.dshs.state.tx.us/region4-5/tuberculosis.shtmHow To Administer, Read and Interpret TB. (2014). Retrieved from http://www.parsterileproducts.com/products/products/aplisol/administer-read-interpret.phpMantoux- Tuberculin Skin Test [Poster]. (2012). Retrieved from http://www.cdc.gov/tb/publications/Posters/images/Mantoux_wallchart.pdf Self-Study Module on Tuberculosis: Transmission and Pathogenesis of Tuberculosis. (2008). Retrieved from US Department of Health and Human Services & Centers for Disease Control and Prevention- Division of Tuberculosis Elimination website: http://www.cdc.gov/tb/education/ssmodules/pdfs/module1.pdfSelf-Study Module on Tuberculosis: Treatment of Latent Tuberculosis Infection and Tuberculosis Disease. (2008). Retrieved from US Department of Health and Human Services & Centers for Disease Control and Prevention- Division of Tuberculosis Elimination website: http://www.cdc.gov/tb/education/ssmodules/pdfs/module4.pdfSelf-Study Modules on TB: Targeted Testing and the Diagnosis of Latent Tuberculosis Infection and Tuberculosis Disease. (2008). Retrieved from US Department of Health and Human Services & Centers for Disease Control and Prevention- Division of Tuberculosis Elimination website: http://www.cdc.gov/tb/education/ssmodules/pdfs/module3.pdfTexas Department of State Health Services- Health Service Region 4/5N: Tuberculosis Manual ( ). (2015). Tyler, TX: Texas Department of State Health Services.Tuberculosis Control Laws and Policies: A handbook for Public Health and Legal Practioners. (2009). Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov/tb/programs/TBLawPolicyHandbook.pdfTuberculosis Day. (2015). Retrieved from http://www.earthtimes.org/newsimage/world-tuberculosis-day_24-3-2013.jpgWorking towards a TB and HIV free community [Photograph]. (2013, February). Retrieved from http://emailblog.graphicmail.com/mobile-marketing-case-study-tbhiv-care-association/
Questions/ Comments?
Thank you very much for you time!