1. Tuberculosis Services Branch Adolfo Valadez, MD, MPH Assistant Commissioner Division for Prevention and Preparedness Services

2. Tuberculosis (TB) in Texas In 2010,there were 1385 cases of tuberculosis (TB) reported in Texas In 2010, the rates of TB (overall, by race/ethnicity, border): Overall rate of 6 per 100,000 population Rates are higher along the border In 2010, among the reported TB cases: 51.3% were among Hispanics, 18.4% were among African Americans, 14.8% were among Whites, 14.85 were among Asians, and 0.7% were among persons of unknown ethnicity.

3. * Cases per 100,000 population. Population estimates from the Texas State Data Center, Office of the State Demographer as of July 1, 2011 The number of reported TB cases declined 7% from 2000 to 2010. TB Cases and Incidence Rates Texas, 2000-2010

4. Collin Harris Dallas Tarrant Travis Bexar El Paso Cameron Hidalgo Webb State Rate: 5.5/100,000 TB Incidence Rates, Texas 2010

5. * Cases per 100,000 population. Population estimates from Texas Vital Web Population Data: www.ehdp.com/vn/ro/txu1/pt1/dgw/en_US/index.htm as of July 1, 2011 * Excludes TDCJ cases TB Incidence Rate: Border vs. Non-Border Texas, 2001-2010

6. Program Mission and Goal Mission: Prevent, treat and control the spread of tuberculosis in Texas. Goal: Reduce the number of new tuberculosis infections, and assure access to care and treatment for persons infected with tuberculosis and others diagnosed with active tuberculosis disease.

7. Program Responsibilities Provide funding to health service regions and local health departments to support TB prevention and control activities. Provide TB medications to public health clinics that treat patients with TB disease and persons with latent TB Infection (LTBI). Provide TB testing supplies for public health use.

8. Program Responsibilities Assure persons diagnosed with TB disease including contacts to a known case are successfully evaluated and complete appropriate treatment. Contact investigation and outbreak response. Support public health laboratory testing within available resources. TB/HIV/STD/Viral Hepatitis Unit

9. TB Program Activities TB Prevention & Control Medication and Testing Supplies Laboratory Services Case Management Standards of Care Contract Administration Services delivered primarily by local health departments Program Evaluation Data Analysis Site Reviews

10. Provide TB prevention and Control Activities in Areas without Local Health Departments (LHDs) Conduct Case Investigations Administer Medications via Directly Observed Therapy (DOT) Provide Case Management Provide Oversight and Technical Assistance to LHDs Conduct Site Reviews Conduct Data Analysis DSHS Health Service Region TB Activities

11. Partners The DSHS Tuberculosis Services Branch works with many external partners to prevent and control tuberculosis in Texas. These partners include: U.S.-Mexico Border Health Commission Centers for Disease Control and Prevention (CDC) Texas Association of Local Health Officials (TALHO) American Thoracic Society (ATS) Pan American Health Organization (PAHO) Texas Center for Infectious Disease (TCID) RESULTS Rotary International International Union Against TB and Lung Disease (IUATLD) Texas Medical Association (TMA) National TB Controllers Association (NTCA)

12. TB Surveillance TB Surveillance and Case Reporting are done by the TB/HIV/STD Epidemiology and Surveillance Branch that is in the same Unit as the TB Services Branch.

13. TB Appropriations

14. TB Services Branch Budget

15. Successes

16. TB morbidity in Texas is at its lowest level since record keeping began over 40 years ago. Texas participated in the Tuberculosis Epidemiologic Research Consortium, a CDC funded 10-year initiative that translated the following research into practice: Implementing blood assay testing, (i.e. QuantiFERON or T-Spot TB) to efficiently screen for the presence of TB. Identifying genetically linked cases through DNA genotyping. TB Prevention & Control in Texas

17. The Heartland National Tuberculosis Training Center in San Antonio serves as one of four regional training medical and consultation centers in the US. Since 2006 through mid-2011, it has provided more than 4,500 Texas consults. The Texas Center for Infectious Disease is the only TB hospital in the United States. Patients requiring court-ordered management are sequestered to this hospital for TB treatment.

18. Other Successes Ongoing bi-national collaboration with Mexico on the treatment of TB with a focus on complicated multi-drug resistant TB. Specialized pediatric TB consultations through Texas Childrens Hospital. Texas maintains a national and international presence in TB prevention and control efforts by holding leadership positions in TB committees and associations.

19. Challenges

20. Current Funding Issues Federal funding rescission (reduction in CDC funds) Loss of TB research consortium funds Reduction in state General Revenue funds Some local health departments discontinuing or reducing TB services because of inadequate funding

21. Uncertainties The future of federal funding Potential changes related to the Patient Protection and Affordable Care Act and its impact on public health delivery systems Sustainable general revenue funding A sustained competent workforce in light of an aging workforce

22. Outbreak & Large Scale TB Investigations - 2011 One large TB outbreak with multiple cases traceable to a single index case. Health Service Region 2/3 (Dallas-Ft. Worth area) currently has 3 investigations related to this outbreak in Ennis, Red Oak and Tarleton State University. There are 11 cases of confirmed TB and 1 suspected case 13 other large scale contact investigations in congregate settings (workplace, school, etc.) involving more than 100 contacts. To date about 4,500 persons tested in the outbreak and contact investigations with almost 500 (11%) infected with TB (mostly latent TB infections).

23. Outbreak & Large Scale TB Investigations Within these investigations, the percentage of contacts found to be infected varies by location and duration of exposure. Estimated cost for Ennis outbreak: $1,062,247 (staff time & travel, testing & diagnostics, treatment) Social media (Facebook) used to reach out to possible contacts who left the school. Average cost per large scale investigation: $14,500 or $188,500 total for the 13 investigations

24. Role Provide strategic direction and oversight Provide input and advice throughout project life cycle Monitor progress and milestone achievement Members Dr. Adolfo Valadez (Chair) Dr. James Morgan (Regional / Local) Ms. Janna Zumbrun (Infectious Disease Prev.) Mr. Felipe Rocha (TB Branch) Input Opportunities Stakeholder Input Sessions 1 1 1.San Antonio 2.Dallas 3.Houston 4.Harlingen 5.Austin Blue Ribbon Expert Panel 2 2 1.Clinical decision- making 2.Treatment 3.Testing 4.Screening Start: February 23 End: March 30 Convene: No later than week of April 2 – 6 TB Focused Work Groups 3 3 1.Outbreak response 2.Funding 3.Data 4.Internally facing activities Varies by work group Output Texas TB Strategic Plan 2012 to 2017 Texas TB Strategic Plan 2012 to 2017 Due: June 1, 2012 Completed and Ongoing Action Plan Due: Varies by goal and objective Texas TB Strategic Planning Process

25. Questions? Contact: Adolfo Valadez, M.D., M.P.H. Assistant Commissioner Division for Prevention and Preparedness Services 512/458-7729 adolfo.valadez@dshs.state.tx.us