1. Lab Results + RVCT Notification=
All Together Now
Lab Results + RVCT Notification=
Linking
PLEASE NOTE THAT I’M PLANNING TO CREATE SOME VISUAL FLOW CHARTS OF THE INFORMATION/DATA FLOW

2. Objectives Summarize laboratory process for genotyping
Review surveillance reporting elements in relation to genotyping
Explain how both systems integrate to link demographic and genotype information
Discuss measures of timeliness

3. Laboratory Summary
It takes approximately 6-8 weeks for a M. tuberculosis culture to grow
Cultures/isolates must flow through DSHS lab
Ensure specimens (cultures/isolates) sent to DSHS
Provide education and follow-up with private providers/labs when needed
DSHS ships weekly batches for genotyping
It takes approximately 10 days once shipped from DSHS to obtain genotyping results
In total, it can take a minimum of 2 months to obtain genotyping results
During these two months the contact investigation should be well on its way, which is one reason genotyping does not drive our epidemiologic investigations.

4. CDC Contracted Genotyping Laboratory
Michigan

5. Laboratory Summary
If no culture or isolate is sent to DSHS, there will be no GENType
Only positive cultures are submitted for genotyping
True clinical cases will not have a culture to submit
Private providers may not submit initial specimen:
Possible solutions?
Regional/local health department should seek to obtain a specimen from private laboratory
Obtain specimen at regional or local health department
Training of private providers when not complying
- Best Practice #1: ensure each patient with a positive m tb culture has a genotyped isolate.
- Ask jurisdictions for examples of when they’ve needed to do this

6. Surveillance Summary Cases must be reported to DSHS Surveillance
RVCT forms must contain the following minimum data elements:
Name
Date of birth
Race and ethnicity
Country of origin
If non U.S., date of entry into the U.S.
Address, city, county, zip-code with 4 digit code, and if in or outside the city limits
If diagnosed while in a facility or shelter, the name of the facility or shelter
Once notified as a verified case it can take up to 9 days to link in TB GIMS, due to system processes
If we are first aware of the case through genotyping shipments, we have lost valuable time.

7. “Happy Birthday Laura”
Surveillance Summary
Minimum RVCT information entered into TBPAM and transmitted to CDC (notified)
Notification flows from TBPAM  NTSS
De-identified information loaded from NTSS to TBGIMS
Every Wednesday it feels like TBGIMS is shouting,
“Happy Birthday Laura”
Notifications upload daily
NTSS  TBGIMS occurs on Tuesday nights
Information linked in TBGIMS on Wednesday morning

8. Statistic: Log Likelihood Ratio (LLR) High (3-year LLR≥10)
TB GIMS Dashboard
High level overview
Alert Changes
Surveillance coverage
Timeliness (next slide)
Isolate linking
Pending Isolates
Alert levels in TB GIMS are based on geospatial concentration
Statistic: Log Likelihood Ratio (LLR)
On the county level
High (3-year LLR≥10)
Medium (3-year LLR = 5.0 to 9.99)
None (3-year LLR ≤ 4.99)

9. Timeliness
We must all work together to ensure we perform these steps in a timely manner both for the health of Texans to support our programs.
Specimen collection date: date the source specimen for the isolate was initially collected. (time starts ticking)
Date genotyping results were first completed. (out of our control)
Date State Case Number Entered: Date a State Case Number is first entered into an isolate record in TBGIMS. This might be prior to the genotype create date, in which case the days would be reported as 0! (very much in our control)
Date the isolate record is linked to a surveillance record (RVCT).

10. Linkage Complete
An individual GENType does not hold meaning until it is linked to:
Demographic data
Geographic data
Clinical data
Risk Factor data

11. If genotyping does not drive contact investigations then why is timely linking important?
We will not be able to view individual results
TBGIMS will not be able to issue a cluster alert
We will not be able to use other features in GIMS:
Mapping
Cluster snapshots
This addresses Best Practice #2.
If we cannot view individual results then we can’t confirm our epi links. Could this be a cluster of concern? We will see more later the power and support that TBGIMS can offer. One of those great features is cluster alerts. These strengthen our capacity to detect increases in cases that are above what is expected.
The applications in TBGIMS will not include cases that have not been linked therefore this limits our ability to use and interpret genotyping results

12. Genotyped but not Reported
On average, 70% of Texas cases have state case numbers (RVCT #s) at time of shipment to Michigan.
What’s going on with the other 30%?
Out of state specimens
Bi-national cases
Conflicting/missing demographic information
Entry to U.S. (awaiting 90 days to report, RVCT criteria)
Correctional facilities
- This average has only been calculated/tracked since May 2014
Demographic information: we need help from local jurisdictions to clarify this when not clear

13. Genotyped but not Reported
Unreported “true” Texas cases These need to be addressed and can affect performance measures * Remember: there is a minimum of 2 months to obtain RVCT information.
-These need to be addressed. Given the 2 months of time it takes for growth, shipments, etc of a culture this should be completed when these are shipped for genotyping.

14. Quiz:
Minimum requirements for reporting a verified case of tuberculosis include all of the following, except:
Race and ethnicity
Country of origin
Address, city, county, zip-code with 4 digit code and if in our outside the city limits
If non U.S., date of entry into the U.S.
HIV status
If diagnosed while in a facility or shelter, the name of the facility or shelter
Name
Date of birth
Correct answer is E

15. Quiz:
You have worked with a family in which three individuals have culture-confirmed TB results. All specimens have been submitted to DSHS lab for genotyping. You are awaiting the GENType results to support your hard work in this investigation and to confirm your epidemiologic links.
You have submitted a completed RVCT for two of the family members but the information for the third individual is sitting on someone’s desk, therefore no state case number has been assigned.
The GENType results for this unreported TB case will be viewable through your TBGIMS account?
True or False
Answer: false

16. Quiz: True or False Genotype Results are available for ALL TB cases?
False - Genotype results are only available for cases with a positive culture AND have been submitted to our DSHS lab for testing.

17. Objectives Summarize laboratory process for genotyping
Review surveillance reporting elements in relation to genotyping
Explain how both systems integrate to link demographic and genotype information
Discuss measures of timeliness

18. Questions for lab or surveillance?