How to stay sharp with falling caseloads

Supervision and consultants are needed

It may seem like looking a gift horse in the mouth, but TB programs that are seeing falling caseloads are finding success has its price. As if declining funds weren’t enough, many programs are coping with the additional challenge of how to keep clinicians’ skills up, even in the face of declining prevalence.

"Frontline providers may be seeing only a handful of cases," says Naomi Bock, MD, MS, medical officer for research and evaluation in the Division of TB Elimination at the Centers for Disease Control and Prevention in Atlanta. "But someone with a tremendous amount of skills needs to be available to them to provide back-up and expertise."

That’s especially true in rural states or places where TB cases are few and far between, says Bock. The tendency in such places is to look at falling morbidity rates and conclude that funding support can be cut at the same speed. To the contrary, "running in place" still takes a minimal support crew, and that means the per-capita can be much higher than in crowded, high-prevalence settings.

One problem Bock’s been looking at lately is how much training, and what kind of training, is appropriate for TB workers on the front line and for those who provide supervision and support.

"What’s the appropriate level of training for a TB nurse in a county that doesn’t see much TB? Does she get the same training as the TB clinic nurse? Clearly," Bock says, "the skills it takes to know every patient in your clinic are a different set of skills from what it takes to know all the patients in a 15-county area."

Rural frontline nurses need more training

The level of training is another issue deserving more study. Clearly, Bock points out, the nurse in the far-flung rural county needs some TB training, but without a substantial TB caseload, she may not get enough day-to-day experience to reinforce what she’s learned. At the very least, the frontline nurse needs to know it’s time to call for help; the same goes for those further up in the hierarchy, she adds. "It’s like asking yourself, Do I know what I don’t know? And do I know who to call?’"

It may look simple on paper, but it’s not. Bock, who’s also the medical consultant to the Georgia TB program, says she makes conference calls weekly to the state districts, but at one conference a week and 19 districts, it takes four months to get back around to each place. That means responsibility for staying on top of cases rests on the next layer down, the district supervisors.

Keeping skills sharp and not letting situations get out of hand aren’t the only challenges in a low-prevalence setting. As TB becomes increasingly less familiar, stigma against TB patients may grow, Bock speculates. At a recent presentation in Vancouver at the conference for the International Union Against Tuberculosis and Lung Diseases, Bock listed a number of instances in which patients reported having been harassed on the job, hounded off the job site, besieged by threatening phone calls, forced to change high schools, or barred from receiving preventive therapy on the premises of a private social service agency.

Part of what fuels such behavior, Bock is convinced, is lack of knowledge about an increasingly rare disease. "I’m always shocked," she adds, "at how many times people ask me, Is there a cure for TB?’"