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October 2003, Vol 93, No. 10 | American Journal of Public Health 1637-1639
© 2003 American Public Health Association

FIELD ACTION REPORT

A No-Name Tuberculosis Tracking System

Dennis Y. Kim, MD, MPH, Renee Ridzon, MD, Beverly Giles, RN, BSN, Teresa Mireles, MSN, APRN, BC, Kelli Garrity, MSN, A. Leroy Hathcock, PhD, David Crowder, MPH, Robert Jackson, MD and Zachary Taylor, MD, MS

At the time of the study, Dennis Y. Kim was with the Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Ga. Renee Ridzon was with, and David Crowder and Zachary Taylor are with the Division of Tuberculosis Elimination, Centers for Disease Control and Prevention. Beverly Giles and Teresa Mireles are with the Sussex County Health Unit, Delaware Health and Social Services, Georgetown. Kelli Garrity, A. Leroy Hathcock, and Robert Jackson are with the Division of Public Health, Delaware Health and Social Services, Dover.

Correspondence: Requests for reprints should be sent to Zachary Taylor, MD, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail Stop E-10, Atlanta, GA 30333 (e-mail: zxt0{at}cdc.gov).


   ABSTRACT
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 THE SUSSEX COUNTY TRACKING...
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Foreign-born persons from countries where tuberculosis (TB) is endemic make up a significant percentage of poultry industry workers in Delaware, a leading poultry-producing state. Many of these workers enter the United States without documentation and assume multiple identities, making it difficult for public health staff to investigate TB contacts who work in the poultry plants.

The Sussex County Health Unit of the Delaware Division of Public Health developed a no-name TB tracking system to facilitate identification and treatment of poultry plant workers with TB infection and disease in a high-risk population whose members assume one or more aliases. Completion rates for treatment of latent TB infection in this group increased from 48% to 64% 2 years after the program’s implementation.


   INTRODUCTION
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IN DELAWARE, A LEADING poultry-producing state, a large part of the poultry workforce is composed of people from countries with high rates of tuberculosis (TB). In Sussex County, 70% of the estimated 6000 poultry workers are foreign born; 50% come from Mexico and Guatemala, where TB is endemic.1 Many workers enter the United States without documentation and obtain falsified identification cards to work. A single individual may assume many identities, or a single identity may be used by many people.

These practices make it difficult for public health staff to investigate the contacts of TB patients who are plant workers. In 1998, the TB case rate in Sussex County was 7.6 cases per 100 000, whereas the estimated rate for poultry plant workers ranged from 83.3 cases per 100 000 to 150.0 cases per 100 000 (Delaware TB Elimination Program, unpublished data). From 1993 to 1998, 35 of 78 of Sussex County TB cases (44%) were associated with a poultry plant; of these, 34 were in foreign-born persons.


   THE SUSSEX COUNTY TRACKING SYSTEM
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The Sussex County Health Unit of the Delaware Division of Public Health has collaborated with the poultry-processing industry in the development of a no-name TB tracking system that facilitates identification and treatment completion rates of persons with TB infection and disease in a high-risk population whose members may assume aliases.

Five of the 6 poultry plants in Sussex County participate in the joint program between the Sussex County Health Unit and the industry. At these plants, all newly hired personnel are required to be screened for TB. Workers with a prior positive tuberculin skin test and appropriate medical evaluation, documented by an original letter from the Sussex County Health Unit, are not retested and are hired the same as those with a negative tuberculin skin test. Those who test positive require a physical examination and chest radiograph at the expense of the state.

Because employees often use aliases, the Sussex County Health Unit issues each tuberculin skin test–positive person a photo identification card that has a unique number but includes no name. The card identifies a person, regardless of the name used, through this unique number, which can be cross-referenced with a database at the Health Unit that contains demographic, contact, and medical information, including history of treatment of TB or latent tuberculosis infection (LTBI) and if treatment was completed.

In order for a tuberculin skin test–positive new employee to be cleared, he or she needs to present a work letter issued by the Sussex County Health Unit stating that the person either (1) does not have TB disease and should receive directly observed treatment for LTBI at the worksite or (2) has TB disease but is not infectious, and should receive anti-TB treatment in a directly observed manner at the worksite. If he or she has TB disease and is potentially infectious, a work clearance letter will not be issued until medications have rendered him or her noninfectious.

The cooperative arrangement between the Sussex County Health Unit and poultry plant management facilitates employee access to TB diagnostic and treatment services. The Sussex County Health Unit supplies medications to the poultry plant, where the employee health staff supervises directly observed therapy. The staff of the Sussex County Health Unit confirms completion of treatment after reviewing worksite records.

Because this industry has high employee turnover, many individuals leave before completing treatment. When an employee on medication is terminated or resigns, the Sussex County Health Unit is notified and its staff members attempt to contact the employee to ensure completion of treatment. If treatment has not been completed, this is noted in the Sussex County Health Unit record. If the worker seeks employment at another poultry company under another name, a new clearance letter is required.

Both management and workers accept the program. The workers feel that the company is taking an interest in their health, while the plants benefit from cost sharing and the participation of the Sussex County Health Unit.


   DISCUSSION AND EVALUATION
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The numbers of persons identified and treated from 1997, when the tracking system was initiated, through 1999 are listed in Table 1Go. The proportion of those who completed treatment modestly increased each year, reaching 64% in 1999, compared with 62% for persons treated for LTBI in both Delaware and the United States (Centers for Disease Control and Prevention, unpublished data).


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  		TABLE 1—— Results of Tuberculin Skin Test (TST) Among Poultry Plant Workers: Sussex County, Delaware, 1997–1999
 
We performed a cost evaluation of the tracking system (Table 2Go). The annual program cost is approximately $150 000. Treatment of LTBI is the highest cost component and tuberculin skin test screening is the lowest. For each activity, the labor costs, including lost wages for workers and salaries for medical staff, exceeded the material costs.


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  		TABLE 2—— Annual Screening and Evaluation Volume and Costs of Tuberculosis Tracking System for Poultry Plant Workers: Sussex County, Delaware
 
Foreign-born persons from countries where TB is endemic constitute a high-risk population for TB infection and disease.2 Limited access to health care facilities, crowded living conditions, and low income also contribute to the higher rates of TB in this population.3–6 The use of aliases creates challenges for public health staff attempting to identify, screen, and treat people for LTBI and TB disease. In spite of the transient nature of this population, the no-name tracking system developed by the Sussex County Health Unit has been associated with higher completion rates for LTBI treatment. A system such as this, which protects the identity and immigration status of the worker, may be useful for other TB programs that encounter patients who share identities and assume aliases.

Five of the 6 local poultry plants participate in the no-name tracking system, exemplifying how industry and public health departments can collaborate to improve the health of a community, especially in a setting with a relatively low incidence of TB and limited resources for TB control. The strengths of the program include cooperation and cost sharing between the TB control program and industry. Efforts to eliminate TB in the United States will require a clear understanding of the local epidemiology of TB and innovative solutions such as this to address the special needs of certain populations.


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Further evaluation is necessary to determine the acceptance of the tracking system among workers and its cost-effectiveness. Tracking systems such as the one described here have potential for adoption by other TB programs, especially since tracking undocumented workers is a problem for TB programs. Furthermore, it should be determined if this tracking system is applicable to other health fields in which the use of multiple identities presents a challenge to public health workers.


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   Footnotes
 
Contributors
D. Y. Kim and R. Ridzon led the investigation and wrote the first draft of the report. B. Giles, T. Mireles, K. Garrity, A. L. Hathcock, and R. Jackson participated in the creation and continued management of the no-name tracking system. D. Crowder was the project officer supporting the Sussex County Health Unit. Z. Taylor contributed to the planning of the cost study. All authors participated in the editing of this report.

Peer Reviewed

Accepted for publication May 16, 2003.


   References
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 INTRODUCTION
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1. Global Tuberculosis Control. WHO Report 2001. Geneva, Switzerland: World Health Organization; 2001. Publication WHO/CDS/TB/2001.287.

2. Jacobson ML, Mercer MA, Miller LK, Simpson TW. Tuberculosis risk among migrant farm workers on the Delmarva Peninsula. Am J Public Health. 1987;77:29–32.[Abstract/Free Full Text]

3. Talbot EA, Moore M, McCray E, Binkin NJ. Tuberculosis among foreign-born persons in the United States, 1993–1998. JAMA. 2000;284:2894–9001.[Abstract/Free Full Text]

4. Wells CD, Ocana M, Moser K, Bergmire-Sweat D, Mohle-Boetani JC, Binkin NJ. A study of tuberculosis among foreign-born Hispanic persons in the US states bordering Mexico. Am J Respir Crit Care Med. 1999;159:834–837.[Abstract/Free Full Text]

5. Zuber PL, McKenna MT, Binkin NJ, Onorato IM, Castro KG. Long-term risk of tuberculosis among foreign-born persons in the United States. JAMA. 1997;278:304–307.[Abstract]

6. Zuber PL, Knowles LS, Binkin NJ, Tipple MA, Davidson PT. Tuberculosis among foreign-born persons in Los Angeles County, 1992–1994. Tuberc Lung Dis. 1996;77:524–530.[ISI][Medline]




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