Tuberculosis (TB) is responsible for nearly two million deaths worldwide each year. In 2012, the rate of TB in Nassau County (NC) was 2.7/100,000 versus 1.9/100,000 statewide. Active pulmonary TB is highly infectious and spreads through the air when an infected person coughs, sneezes, or speaks. Ensuring isolation of the index case, facilitating treatment adherence, and identifying and treating exposed contacts is essential in preventing the spread of TB. Consequently, the Nassau County Department of Health (NCDOH) conducts contact investigations for each index case to identify those potentially exposed and ensure that each contact receives medical evaluation, and if necessary, treatment.
Contact investigations are resource intensive, as hundreds of people can be exposed to an index case across numerous exposure locations. Field staff and nurse case managers must track identified contacts for as long as nine months, ensuring that everyone who needs treatment and evaluation receives it. All contact information, including demographics, evaluation status, and infection status, is reported in the NYS Health Commerce System (HCS). Nonetheless, the HCS is difficult to use for contact tracking, as contacts cannot be sorted by evaluation or infection status and no alert system exists to identify contacts that need follow up; thus, field staff rely on paper-based tracking methods and memory to coordinate follow up.
Consequently, NCDOH created an innovative tool for tracking and monitoring contacts. The goal was to develop a tool that would facilitate tracking contacts in large-scale contact investigations to control the spread of TB while still interfacing with the existing reporting system on the NYS Health Commerce System (HCS). There were three primary objectives for the project: 1) To develop and acquire the technology and capability to use Excel Macro Visual Basic for Applications (VBA) software in building this tool; 2) To implement the tool and use it for contact tracking and reporting for large contact investigations to reduce loss to follow up and promote evaluation and treatment completion; 3) To improve staff efficiency and timeliness of contact follow up and reporting.
TB Track was developed in September 2013 and successfully applied to a large-scale contact investigation of nearly 350 contacts from November 2013 to June 2014. Overall, 76% of contacts were evaluated, 78% of those needing treatment were treated, and only 24% were lost to follow up. Moreover, only one field staff was needed for the investigation. Prior to TB Track, investigations of such a size required two field staff, which is the total number of full-time TB field staff at NCDOH.
TB Track can be applied to contact investigations across a variety of communicable diseases. Moreover, Excel is an easy to use and widely available program. As local governments continue to cut back on health department funding, innovative program such as TB Track, which increase staff efficiency and effectiveness, have become increasingly important.
Nassau County Department of Health
Located on Long Island, Nassau County (NC) is home to some 1,339,532 residents. NC is bordered by New York City (NYC) to the west and Suffolk County to the east. NC has seen a significant increase in its Hispanic population, from 10% in 2000 to 14.6% in 2010. Compared to New York State (NYS), NC has a higher percentage of white residents (65.7% of NYS residents), a lower percentage of blacks (15.9% of NYS residents) and a slightly higher percentage of Asian/Pacific Islander residents (7.4% of NYS residents). NC is home to many immigrants, in part due to its proximity to NY’s largest international airport. Approximately 20% of NC’s population is foreign born (2010 US Census).TB is a disease caused by the bacterium Mycobacterium tuberculosis. Although it most commonly affects the lungs, TB can attack any part of the body. If not treated properly, TB disease can be fatal. NYS Department of Health (NYSDOH) reports that in 2012, nationally, NYS had the sixth highest incidence rate of TB (4.4/100,000), particularly because of the high rate of in TB in NYC. However, three metro area counties, Nassau, Suffolk and Westchester report almost half of the cases of TB in the state, exclusive of NYC. In 2012, the rate of TB in NC was 2.7/100,000 versus a rate of 1.9/100,000 in NYS overall excluding NYC. Nassau cases were 78% foreign born that year, compared to 72% in NYS excluding NYC. Asians, Hispanics, and blacks historically have higher rates of TB compared to whites, in NC as well as in NYC and NYS overall.
Pulmonary TB is highly infectious and spreads through the air when an infected person coughs, sneezes, speaks or sings. Ensuring isolation of the index case, facilitating treatment adherence, and identifying exposed contacts is necessary for proper prevention. As such, contact investigations are essential for any TB control program. Although resource intensive, each contact is on an individualized timeline to minimize loss to follow-up. Contacts are tracked and monitored through a multistep evaluation process, which takes months to complete. For those contacts that require treatment, follow up can take over 9 months. Contact investigations vary in size and scope, ranging from one to hundreds of individuals. Investigations occur in households, worksites, schools or any other congregate setting. Long-term monitoring is complicated in large-scale investigations of over 25 contacts due to the sheer number of contacts requiring tracking and the variety of sites in which the investigations take place.
Nassau County Department of Health (NCDOH) TB Control sought to create an innovative tool for tracking and monitoring contacts. The goal was to develop a tool that would facilitate tracking contacts in large-scale contact investigations to control the spread of TB while still interfacing with the existing reporting system on the NYS Health Commerce System (HCS). There were three primary objectives for the project: 1) To develop and acquire the technology and capability to use Excel Macro Visual Basic for Applications (VBA) software in building this tool; 2) To implement the tool and use it for contact tracking and reporting for large contact investigations to reduce loss to follow up and promote evaluation and treatment completion; 3) To improve staff efficiency and timeliness of contact follow up and reporting.
Objective 1 was met when the macro, TB Track was developed in September 2013 following numerous planning meetings among TB Control staff. TB Track interfaces with HCS, using the reporting fields which are downloaded from HCS into an Excel spreadsheet. The macro creates a new Excel workbook which categorizes contacts, indicating stage of evaluation and follow up needed. Objective 2 was met when TB Track was successfully implemented from November 2013 to June 2014 in a large-scale contact investigation of 345 people, with 76% evaluation success, 78% treatment success and only 24% lost to follow up. Objective 3 was met by using the tool in the large-scale contact investigation to increase staff efficiency in the TB Control program. Using TB Track, one staff member was able to manage all the reporting and tracking of contacts in the HCS and conduct prompt follow up with those needing testing and treatment.
TB Track impacts public health by facilitating contact investigations and decreasing TB transmission. Contact investigations prevent the spread of TB by identifying contacts with active or latent disease, promoting the treatment and isolation of those with active disease before they spread the disease to others, and connecting those with latent TB to treatment before they develop active disease. TB Track is a mechanism to efficiently track contacts throughout the evaluation and treatment process, which decreases lost to follow up and thus reduces the chance that infected contacts will spread the disease to others.
Essential components of a contact investigation include: 1) identifying persons exposed to a pulmonary case, 2) screening those contacts for infection, 3) ensuring that those with active or latent infection have access to treatment, 4) facilitating medical evaluation, treatment and follow-up of those contacts, and 5) reporting contact information on the NYS Health Commerce System (HCS). This is a very laborious process that requires careful documentation, consistent communication and timely follow up. Because of Nassau County’s high case rate, a large number of contacts are tracked. In 2013, Nassau County identified 584 contacts in 27 contact investigations, one of which had 345 contacts. To date in 2014, 171 contacts have been identified in 17 contact investigations, one with 109 individuals. With only two full-time field staff responsible for following contacts, timely follow up of such large numbers of contacts is arduous.
The first step in a contact investigation involves careful interview of the index case. Establishing rapport and trust between case and interviewer is critical in obtaining accurate exposure information and often requires investigative work over multiple visits. Cases are asked to retrace their steps over the three month period prior to placement in isolation (called the infectious period). They are asked about household, work, school, and social contacts and any history of travel. A prioritization category is assigned to each contact (high, medium, and low) depending on the type and duration of exposure, the age of the exposed, and the infectivity, symptomology, and resistance pattern of the index case. After contacts are identified and prioritized, field staff endeavor to track them down. This often requires extensive detective work, as the index case may not be able to provide specific contact information for each contact. Once contacts are tracked down, each individual must be interviewed and educated on TB disease and transmission. For those with a known history of TB disease, or prior positive skin test, a symptom review is performed and a chest x-ray recommended. The chest x-ray distinguishes between active disease and latent disease. For those with no known prior exposure or a history of negative skin test, a symptom review is performed and an initial skin test is planted as soon as possible. After two days the skin test is read. If negative, a repeat skin test is required 8 weeks after last known exposure, unless the initial skin test was planted eight weeks after last date of exposure to the index case. For those with a positive skin test, a chest x-ray is recommended. Those with active disease are often prescribed a 6-9 month treatment regimen consisting of four antibiotics, whereas those with latent disease are prescribed one antibiotic for nine months. Children five and under receive eight weeks of treatment even if the initial skin test is negative due to the potential for rapid progression of latent infection into active TB disease in small children. The exact treatment regimens for contacts can vary depending on if the index case is drug-resistant. For every step in the evaluation process, field staff facilitate scheduling of medical follow up and verify visit compliance, treatment initiation, and treatment completion.
Contacts to pulmonary cases of TB are entered by field staff into the Communicable Disease Electronic Surveillance System (CDESS) on the NYSDOH HCS once identified. Contact information and demographics are entered initially. As the individual goes through the multi-step evaluation process, the testing information is updated until the contact is fully evaluated. If during the evaluation process, it is determined that the contact is infected with latent TB, that contact is followed until they complete treatment; the patient’s treatment regimen and completion date must also be entered into CDESS. The CDESS interface, however, is not well-designed for daily tracking. Though the system can produce a summary report of the evaluation and infection status of all of a case’s contacts, it is very difficult to read and interpret; contacts are not listed in alphabetical order, by evaluation status, or by infection status. Moreover, there is no system which alerts users that certain contacts still need evaluation or treatment. Monitoring, therefore, takes place primarily on paper, and field staff must remember when to follow up with contacts. This system in large-scale investigations is cumbersome and often unreliable.
Streamlining the contact investigation process benefits TB Control staff, the TB Control program and the contacts themselves. Improving the process allows staff to better respond to contacts and ensures that contacts are educated, evaluated and, when applicable, treated in an efficient manner. Because contacts may be of any race, gender or age and investigations take place in a variety of environments, TB Track may benefit a broad portion of the population.
TB Track uses the line list function on CDESS. The line list function pulls fields from the contact reporting record in CDESS onto a downloadable Excel spreadsheet. The TB Track macro sorts the downloaded contact information and creates three distinct spreadsheets. The Masterlist spreadsheet lists all contacts from a specified case or time period. The Unevaluated sheet lists contacts that have not completed evaluation, highlighting in red those more than 60 days old. The LTBI sheet lists contacts who began treatment for latent tuberculosis infection but have not completed, highlighting in red those that started treatment more than 9 months ago. This quick, standardized method of tracking makes information readily available, categorized and prioritized, so that losses to follow up are minimized. A step by step instruction sheet was created for TB Track allowing all staff to use TB Track regardless of technological aptitude.
Although the concept of tracking contacts to TB cases is not new to public health, TB Track is novel in its approach. This tool provides an electronic, comprehensive system for contact tracking, monitoring and reporting and can replace traditional paper-based tracking systems. In a one-step process, TB track uses information already entered into CDESS and categorizes contacts based on their evaluation and treatment status to facilitate prompt follow up. In addition, this system is fairly low tech. Its use does not require high levels of technological or programming knowledge. Much of the programming language required to create the macro was found on the internet and users on online Excel forums provided extensive advice when difficulties arose. Moreover, to use TB Track, one does not need to purchase an expensive database system or a contract with information technologists to provide maintenance. Excel is a widely used, user-friendly and readily available program and TB Track can interface with any reporting system that has download capability.
TB Track is modeled after well-known evidence-based practices. The contact investigation is a well-established method for stopping the transmission of tuberculosis (http://www.cdc.gov/tb/). Furthermore, a recently commissioned meta-analysis by the World Health Organization Expert Panel said that thorough investigation, evaluation and treatment of contacts was a priority in high income and resource limited settings, and that innovative strategies should be incorporated into investigation protocols (Eur Respir J. 2013 Jan;41(1):140-56. doi: 10.1183/09031936.00070812. Epub 2012 Aug 30.). An additional report indicated that contact investigations were “paramount to the success of TB control in high risk communities and low prevalence countries.” Furthermore, this report discussed that “Further investigation should focus on questionnaire development and adaptation, electronic data management and infrastructure….” (Int J Tuberc Lung Dis. 2012;16(3):297-305. doi: 10.5588/ijtld.11.0350. Epub 2011 Dec 2).
Electronic data management, in particular Excel macro, has been used for administrative purposes (http://www.mc.vanderbilt.edu/crc/workshop_files/2008-02-22.pdf) and financial modeling (Sengupta, C., Financial Modeling Using Excel and VBA 2004: NJ, John Wiley and Sons, Publishing). However, after much research using the PubMed database, permutations and combinations of the key words: tracking, algorithms, monitoring, excel, VBA, contacts, investigation and tuberculosis, no tracking mechanism using macro language has been developed for health outcomes, let alone tuberculosis contact tracking. Therefore, though the principles for contact tracking have been well documented and VBA data management is used in administrative functions in other fields, the application of VBA to streamline contact tracking is innovative.
Nassau County Department of Health (NCDOH) TB Control Program sought to create a tool that would facilitate tracking contacts in large-scale contact investigations to control the spread of TB while still interfacing with the existing reporting system on the NYS Health Commerce System (HCS). There were three primary objectives for the project: 1) To develop and acquire the technology and capability to use Excel Macro Visual Basic for Applications (VBA) software in building this tool; 2) To implement the tool and use it for contact tracking and reporting for large contact investigations to reduce loss to follow up and promote evaluation and treatment completion; 3) To improve staff efficiency and timeliness of contact follow up and reporting.
As part of NCDOH’s accreditation initiative, it was awarded a master’s fellow from Stony Brook University’s Program in Public Health through the New York City Long Island Lower Tri-County Public Health Training Center to assist with the effort from June to August 2013. This individual was assigned to the division of Quality Improvement, Epidemiology and Research (QIER). As part of the fellowship, this student assisted division staff with orienting the Health Department on Quality Improvement and Performance Management, Domain 9 of Accreditation. The fellow, in conjunction with staff from the division of QIER created a power point presentation which served as an orientation to the concepts of performance management and quality improvement. This presentation was presented to divisions within the health department. Upon completion, staff were asked to brainstorm ideas for Quality Improvement within their division. This conversation sparked the division of STD to initiate a quality improvement project with the assistance of the QIER staff. In an effort to improve performance, the fellow developed a tracking database using Excel Macro VBA for the division of STD Control. This precipitated, collaboration between the division of QIER and the division of TB Control in considering using the similar Excel macro to track TB contacts. Concurrently, in late July 2013, the division of TB Control was awarded a CDC Public Health Associate.
The TB and QIER staff met with the Stony Brook master’s fellow and the CDC Associate to discuss the idea of creating a macro for tracking TB contacts. The Stony Brook student oriented the CDC Associate to the macro and VBA language. The CDC Associate then met with TB epidemiologist and the Director of TB to discuss what functions were needed in the macro. For example, it needed to use the already existing CDESS fields so that staff were not duplicating efforts by entering information into CDESS and a database. Also important was a means to identify time-sensitive information quickly, for example highlighting in red those individuals with overdue evaluation. In addition, the macro needed to be able to sort individuals into different stages of evaluation and treatment to expedite follow up. The tool, TB Track, went through development, testing and staging between July 2013 and October 2013. It was developed and tested in collaboration between the divisions of QIER and TB; the epidemiologist, the Director and CDC Associate. It was also presented to other TB Control staff, who had the opportunity to provide input and test the tool. Comprehensive instructions were created and a live demonstration ensued.
Overall, TB Track’s development was a collaboration between many stakeholders from a variety of backgrounds, including academia, funded grantees, and health department staff. It was originally envisioned as a quality improvement tool used in the Division of STD. In that context, the macro was proposed to track timely case treatment. In this effort, the QIER partnered with Stony Brook University and received funding to support a student fellow through the Columbia University: NYC, Long Island, Lower Tri-County Public Health Training Center. The Training Center, together with Stony Brook University, provides public health support to local health departments. The outcome of this project was an elementary-level macro to support STD case monitoring. This initial collaboration facilitated peer-to-peer training between the Stony Brook fellow and the CDC Associate and gave the CDC Associate a framework upon which to base the technical development of TB Track. Within the local health department, QIER collaborated with the Division of TB to identify its needs for monitoring. Important information such as reporting fields, contact investigation elements and design were highlighted. Staff from both divisions worked together and were engaged on a regular basis to provide feedback in the development process. Staff included nurses, social health investigators, epidemiologist and the TB director. The CDC Associate also provided input throughout the process and served as technical support.
Objective 1, to develop and acquire the technology and capability to use Excel Macro Visual Basic for Applications (VBA) software in building this tool was met when the macro, TB Track was developed in September 2013 following numerous planning meetings among TB Control staff. TB Track interfaces with HCS, using the reporting fields which are downloaded into an Excel spreadsheet. The macro creates a new Excel workbook which categorizes contacts, indicating stage of evaluation and follow up needed. Objective 2, using the tool for contact tracking and reporting for large contact investigations to reduce loss to follow up and promote evaluation and treatment, was met between November 2013 and June of 2014. During this time, TB Track was used in a large scale contact investigation of 345 people exposed to a multi-drug resistant case of TB in multiple community and healthcare settings. Timely evaluation was imperative due to the high-risk exposure of immunocompromised individuals. In addition, proper treatment of contacts with latent tuberculosis infections was important to prevent drug-resistant disease development. Under the direction of a nurse case manager, the CDC Associate entered contact information on CDESS, downloaded CDESS data, and ran TB Track weekly to facilitate timely follow up. With the help of TB Track, the contact investigation was successful; 76% of contacts completed evaluation, 78% of those with latent infection began treatment, and only 24% of contacts were lost to follow up.
Objective 3 was met by using TB Track to increase staff efficiency in the large-scale contact investigation. Because it is not possible to sort contacts by evaluation and treatment status directly in CDESS, prior to TB Track, staff members used a paper-based system to keep track of contact follow up. This paper-based system required duplicative data entry in CDESS and on the paper chart, wasting staff resources and increasing the chance of human error. Staff depended largely on memory to remember with who and when to conduct follow up. TB Track, however, facilitates contact monitoring by reducing the staffing needed for timely contact tracking and improving data accuracy. Only one staff is needed to enter the data, perform the download into Excel, follow up with contacts based on TB Track alerts, and communicate findings to the nurse case manager or director.
The success of TB Track in the large-scale contact investigation is due in large part to collaboration with contact exposure sites and local healthcare partners, who have a vested interested in effectively evaluating and treating exposed contacts. Throughout the investigation, TB Control worked with these entities to identify those exposed to the TB patient; at some sites, over 100 patients and staff members were exposed to the index case. To aid contact identification, evaluation, and treatment, TB Control communicated daily with exposure sites throughout the six-month investigation to educate infection control nurses, physicians, and administrators about TB evaluation and treatment. TB Track facilitated this education by identifying patients with specific evaluation and treatment needs. Start-up costs for TB Track are minimal. To develop and run TB Track, one needs a computer with Microsoft Office Excel and a technologically-savvy staff member to create and use the macro. Because most county governments have a dedicated IT staff, health departments can depend on IT staff to develop and maintain the TB Track system.
Nassau County Department of Health (NCDOH) TB Control Program sought to create an innovative tool for tracking and monitoring contacts. The goal was to develop a tool that would facilitate tracking contacts in large-scale contact investigations to control the spread of TB while still interfacing with the existing reporting system on the NYS Health Commerce System (HCS). There were three primary objectives for the project: 1) To develop and acquire the technology and capability to use Excel Macro Visual Basic for Applications (VBA) software in building this tool; 2) To implement the tool and use it for contact tracking and reporting for large contact investigations to reduce loss to follow up and promote evaluation and treatment completion; 3) To improve staff efficiency and timeliness of contact follow up and reporting. In assessing the value of TB Track, it is important to consider each objective, its performance measures, the relevant data and evaluation results.
Objective 1). To develop and acquire the technology and capability to use Excel Macro Visual Basic for Applications (VBA) software in building this tool
Outcome performance measures for this objective:• Final written Excel Macro VBA program code for TB Track• Final written detailed instructions on querying fields from CDESS, downloading data into Excel and running TB Track• Final protocol for TB Track use: use regularly when conducting large scale investigations of over 25 contacts• Trained staff fluently using TB Track
Process performance measures for this objective include:• 3 planning/brainstorming meetings to decide on fields needed from CDESS and what information the macro will provide• 2 meetings with health department staff to get feedback and make modifications• 1 training/demonstration by CDC Associate for epidemiologist and TB director• 1 training for TB staff by CDC Associate• TB staff practice using TB Track• 1 program meeting to discuss when and how TB track would be used (creating protocol)
Data for objective one outcome performance measures was collected by TB Control staff. Data sources included the following final documents:• TB Track Excel Program• TB Track instructions• 6 staff trained to use TB Track• TB Track Protocol
Data for process performance measures were also collected. Data sources included email correspondence, meeting minutes and agendas, draft instructions and protocols, previous versions of macro program code and staff tutorials on TB Track.
Through this evaluative process, we learned that to use TB Track one must have a stable internet connection and CDESS must be functioning properly. If CDESS is not interfacing properly with the local network, data cannot be downloaded and TB Track will not run. We also learned that TB Track could be enhanced with greater programming knowledge. It would be ideal if TB Track were integrated directly into CDESS, eliminating the need to download the data into Excel before running the macro. Finally, we realized that comfort with TB Track varies considerably between individuals; hands-on training, practice and demonstration of understanding is essential for successful staff use. Overall, all process and outcome measures were achieved and the objective was met.
Objective 2). To implement the tool and use it for contact tracking and reporting for large contact investigations to reduce loss to follow up and promote evaluation and treatment completion
Outcome performance measures for this objective:• Number of large scale contact investigations for which TB Track has been used since its inception 2 • Number of contacts elicited in contact investigations 345 109• Percent of elicited contacts followed through TB Track 100% (345/345) 100% (109/109)• Number and percent of contacts evaluated 76% (262/345) 7% (8/109) investigation ongoing• Number and percent of eligible contacts treated for latent TB infection 78% (7/9) 0% (0/0) None eligible• Number and percent of contacts completing treatment for latent infection Ongoing, no one due to complete None eligible• Number and percent lost to follow up 24% (83/345) 0% (0/109) investigation ongoing
TB Track was initially implemented in November 2013, when it was used for a large scale investigation of 345 people, which mostly concluded in June 2014. Treatment of contacts with latent TB infection is ongoing. TB Track was used again in July 2014 for another large scale investigation of 109 contacts, which is ongoing.
Data for objective two performance measures was collected by TB Control staff. Primary data sources were contact interviews, clinic visit records and conversations with health care providers. This data was entered into CDESS, downloaded and run through TB Track. Through this evaluation process, we learned that timely entry of data into CDESS is imperative because the usefulness of TB Track is dependent on the integrity of the data it sorts through. Therefore, frequent CDESS updating throughout the investigation must be part of the TB Track protocol. Nonetheless, while the validity of TB track depends on the accuracy of information in CDESS, TB Track helps ensure that CDESS information is up-to-date by identifying which contacts need evaluation and treatment.
Objective 3). To improve staff efficiency and timeliness of contact follow up and reporting
In most contact investigations, one nurse case manager and one field staff are primarily responsible for follow up. The nurse case manager directs the investigation, providing recommendations and guidance to doctors and contacts as required and ensuring proper follow up of contacts. The field staff, meanwhile, is responsible for identifying contacts, scheduling testing, performing skin tests, facilitating clinic appointments, following up with contacts prescribed treatment and updating CDESS. In the case of a large scale investigation, it is often necessary to draw in additional field staff. Due to the elevated workload, updating CDESS becomes less of a priority, occurring once a month. Follow up timing is left to paper and recall. Thus, using TB Tack improves staff efficiency, follow up timing and reporting, and reduces data errors.
Outcome performance measures for this objective:• Savings in staff time 50% savings in staff time by using 1 field staff for follow up instead of 2• Reduced follow up and reporting time Increased follow up frequency 4-fold by running TB Track 1/week to direct outreach efforts rather than only reviewing CDESS 1/month Increased CDESS reporting 4 fold by updating CDESS 1/week instead of 1/month
The primary data source for the outcome performance measures was collected by TB Control staff during the implementation of TB Track. We learned through this evaluation that TB Track greatly enhanced program function. With limited staff resources, large scale investigations have the potential to impede other TB Control duties, especially smaller scale contact investigations.
In summary, we successfully met all three of the project objectives described above, creating a CDESS-based tool which facilitated contact tracking in large-scale contact investigations to control the spread of TB. The CDC Associate involved in the development and implementation of TB Track was selected to present the contact investigation and TB Track at the annual Public Health Associate Program meeting in July 2014. At NCDOH’s annual NYSDOH TB site visit, TB Track was demonstrated and discussed. The program was very well received by NYSDOH, as they expressed interest in using it statewide to facilitate contact investigations in other counties.
A key feature of TB Track is its sustainability. Its sustainability stems from the collaborative way in which it was developed, its minimal costs, its stakeholder investment, and its significant benefits. By improving the contact investigation process, TB Track aligns with the Bureau of TB Control’s mission of controlling the spread of TB. QIER has worked closely with TB Control to identify challenges to this mission and implement new initiatives. Nassau County TB Control is always updating its training and methods. The division is engaged regularly with the Learning Management Tool provided by the NYSDOH.
TB Track benefits from a number of resources which will contribute to its sustainability. Excel macros are available to Nassau County through its Microsoft Office programs. Moreover, TB Track does not require an elaborate or costly system to install and maintain and County Information Technology (IT) can provide necessary support for Excel glitches. In addition, there is no additional cost for the system itself or its support, as both are provided to county health staff as part of the administration budget of the county. It should be noted that Nassau County is particularly resource limited and has been under the Nassau County Interim Finance Advisory Board for several years. Nonetheless, this innovative system was relatively easy to develop, implement and sustain. The system saves costs through increased staffing efficiency and benefits TB Control’s activities.
Stakeholder investment speaks to the collaborative aspect of TB Track. Within the division, there is a strong commitment to TB Track among the field staff, nurse case managers, epidemiologist and director because it is an effective and efficient way to improve large-scale contact investigations. It is also easy to implement, even for those less skilled with technology. In addition to internal collective support for the program, NCDOH has received interest from outside the department. NYSDOH is anxious and interested to learn more about the system. Because TB Track interfaces with the NYS reporting system, CDESS, it is imperative that NYS Department of Health remain invested in the county’s operations. Non-governmental organizations are also invested in TB Track; work-sites that are the target of TB Control’s contact investigations benefit from the local health department’s ability to keep good track of exposed contacts. Communication with these institutions occurs regularly and they are eager to participate in contact investigations to mitigate TB transmission.
Sustainable programs are also adaptable. Because this system is relatively simple to create and maintain, the biggest challenge to its ongoing use is the code behind the macro. Nonetheless, should the program need modification, coding methods are available in the public domain and the health department IT can further support recoding efforts. NCDOH also maintains Memoranda of Understandings with local universities who can also provide technologically-savvy interns and IT support. Finally, the epidemiologist is well versed with computer language and can troubleshoot issues if they arise. A second challenge to this system is its ability to interface with the NYS reporting program, CDESS. Connective and functional that arise with CDESS may interfere with the ability to download usable data into the macro. Therefore, to prepare for these issues, close communication with NYSDOH is necessary. Because of a long standing relationship, NYS TB Control is a partner with the local health department in this effort.
Sustainability plans include the regular evaluation of the program so that it meets its objectives of streamlining contact investigations and controlling TB in the county. It is a results-oriented program that is well supported by both QIER and TB Control. The plan calls for the continuous identification of strategies that improve contact investigations and modifications to TB Track’s downloadable CDESS fields. Internal staff and outside stakeholders, such as healthcare facilities and academic institutions, are regularly engaged for their feedback about ways to improve the county’s contact investigation efforts. The plan also designates key champions of the system. This includes the epidemiologist and director who can leverage interest within the department for support and encourage its use among staff members. The epidemiologist and director also promote an environment that encourages input and investment from other staff members. This internal system of infrastructure is necessary for the use and sustainability of TB Track. Finally, the plan includes avenues for adaptation of the system if necessary. NYSDOH, academic partners, and County IT can provide TB Control with technical assistance, while our non-governmental healthcare partners can provide recommendations for overall system improvements.
TB Track is sustainable because it simple, low-tech, cost-free and an important and useful tool for tracking TB contacts and ultimately controlling TB within the county. This innovative and comprehensive system can be used outside of TB for other communicable diseases facing large contact investigations. Disease control remains a public health challenge in the 21st Century, and this 21st Century tool can improve its success.