California TB Elimination Heroes, 2023
Margo Sidener has led the fight to prevent TB for 40 years in Santa Clara County with Breathe California. Breathe California with the Asian Americans for Community Action created and sustained the TB Prevention Partnership (TPP) from 1996-2015, almost 20 years, including the Santa Clara County Tuberculosis Control Program as a partner and funding agency. This community-based effort, with a small grant, $40K from the United Way and other supporting funds from the Santa Clara County Public Health Department, created outreach materials for high risk populations and also anchored annual World TB Day events at community hospitals, corporate offices, and the health department. They were everywhere and received a lot of media attention, which helped spread the word about TB and TB services.
They trained community providers. Working with the TPP occupational nurses wrote a TB guide about how to work with public health on the TB problem in Santa Clara County. CBOs and schools were also involved. They drew 40 people quarterly to coalition meetings. They reached about 4,000 high risk community members through strategic group and agency outreach per year. Through tabling at health fairs and community events they reached 20,000 community members. The community became aware of the problem and that TB is preventable and curable.
Santa Clara County awarded the coalition a grant to do more provider trainings. Outcomes from this investment, training community providers, including 152 nurses, there were fewer poor outcomes, and increased use of appropriate regimens, improved contact investigations, improved occupational medicine interventions improved. As a new TB controller in Santa Clara County, Margo helped me plan and execute World TB Day events, always the reliable passionate voice for the call to action to fund TB infrastructure. With her sunny personality and trademark laugh, she makes everything thing possible. I was lucky to have been part of her gravitational pull in those years where she helped our TB program roll out a new risk based TB testing strategy to K-12 schools.
For the past two years Margo has shared her experience, her success with the TB Prevention Partnership, with new partners in the Coalition for a TB-free California and members of the legislature, telling her stories of what success can be had with a small investment in TB prevention. Thank you for your leadership and your partnership, Margo.
Sonia Lira, Project Specialist, San Diego County Office of Education, Innovation Division, Project-based Learning
Sonia has worked with the San Diego County TB Control Branch’s Outreach and Education Team for the past seven years to provide access to high schools in high-risk TB communities. Over this period, starting with promoting our TB 101s to high schools with health academies and now expanding our outreach with the TB Peer Educator Project, we have been able to present to more than 11 schools (some with previous TB cases) and have reached more than 1000 students. In addition, because of Sonia’s commitment to our TB elimination cause, we have presented or done outreach to three conferences attended by teachers and students from programs in San Diego and neighboring Imperial counties.
- Sustaining 7-year partnership with the San Diego County TB Control and Refugee Health Branch and their Outreach and Education Team (OET).
- During this partnership, Ms. Lira has been responsible for connecting the OET with more than 10 high schools throughout San Diego County, including in high-risk TB communities, presenting TB 101s to 1500 individual students.
- While implementing the TB 101 presentations, the OET saw the opportunity to expand its education outreach into a multi-week, project-based curriculum entitled, The TB Peer Educator Project (TB PEP). The project focuses on high schools in high-risk TB communities. Since February 2021, because of Ms. Lira’s committed effort, the OET has implemented the TB PEP curriculum at three high schools and is completing additional rounds at two more (one high school is participating in its second implementation). Due to Ms. Lira’s endless energy on our behalf, the OET has been able to do a more in-depth TB education, promoting students to create TB prevention messaging products for young adults ages 15 – 24. So far, more than 190 students have participated in the TB PEP since the start of its implementation. As a result, students have developed TB prevention TikTok and school announcement videos, Instagram accounts, t-shirt and sticker designs. One of the high schools even created a TB prevention t-shirt shop as a class fundraising project. The San Diego County TBCRHB and the OET cannot thank Ms. Lira for her belief and support of our TB prevention outreach efforts.
During her tenure as Director of Immigrant Health at North East Medical Service (NEMS), where she has served since 2019, Dr. Tang has been a persistent and impassioned champion for TB prevention. In addition to her clinical duties, providing primary care during a pandemic to a population at risk for TB infection, she has trained fellow providers on evidence-based practices for LTBI care, developed protocols and quality improvement measures to increase LTBI testing and treatment, and led the analysis of NEMS data over a ten-year period to understand their LTBI care cascade. Over the analysis period, coinciding with unfunded QI interventions intended to reduce barriers to LTBI care, there was a significant increase in the proportion of patients receiving LTBI testing as well as a significant increase in the proportion of patients receiving prescriptions for LTBI treatment. DR. Tang has helped build evidence that primary care interventions can reduce barriers to LTBI testing and treatment and drive TB elimination. Her work has led to a TB Epidemiology Studies Consortium Grant to measure the impact of specific clinic interventions on LTBI testing and treatment. She is a thoughtful and generous collaborator, frequently sharing her experience with colleagues looking to do similar TB prevention work. Her efforts benefit not only her patients, but also have broader impacts on clinics and patients across California.
Suzanne Khambata has been a strong advocate for TB prevention in schools. When San Diego County’s TB Elimination Initiative (TBEI) was launched in January 2020 to create a public-private partnership and framework for TB elimination in San Diego County, Suzanne assumed the role of Co-chair for the TBEI Schools Committee, focused on promoting awareness of TB and LTBI among County schools and taking action to prevent TB cases on K-12 and higher education campuses in San Diego County. In this role, Suzanne created an assessment of current TB practices among all institutions of higher education community colleges in San Diego County, engaged stakeholders to participate in the TBEI Schools Committee and provided strategic input to the overall TBEI program as part of the TBEI Advisory Committee. Since 2020, Suzanne has been a strategic partner in promoting TB prevention among schools in San Diego County and implementing TB prevention strategies at Mesa Community College. TB prevention practices she has implemented include:
- Incorporating the LTBI care cascade into the Mesa College Student Health EHR.
- Hosting a combined COVID and flu vaccination clinic with TB risk assessment and testing event on the Mesa College Campus with Champions for Health.
- Engaging a Nursing Ph.D. graduate student to develop and implement a successful student-teacher led COVID and TB/LTBI peer education program in a class for ESL students at risk for TB. This class can serve as a model for other colleges.
Dr. Fayette Truax has been an exemplary leader in engaging in tuberculosis (TB) prevention projects throughout Orange County in the past few years. In addition to her many commitments as an Assistant Professor at Loma Linda University, Pediatric Nurse Practitioner at Inscriptions Children’s Clinic, and a Vice President of the Doctors Abroad Foundation, she has led impactful projects that focus on serving the Vietnamese population, who comprise over a third of TB disease cases in the county each year.
In 2017-2018, Dr. Truax worked closely with Nhan Hoa, a federally qualified health center serving primarily Vietnamese patients, to improve latent tuberculosis infection (LTBI) care and TB disease prevention. In this quality improvement (QI) project, LTBI testing and treatment-focused provider training sessions, phone consultations with providers, new risk assessment materials for providers, educational materials for patients, poster advertisements in waiting rooms, a part time LTBI care coordinator role, and a new LTBI screening process were incorporated as interventions. There is compelling evidence of the impact and success of this project, published in the Journal of Nursing Care Quality (Truax et al 2022). Before this project, only 7% of the center’s patients with LTBI were started on treatment, however, after 4 months following the interventions, 72% of patients diagnosed with LTBI were started on treatment. Not only was she successful in achieving a significant increase in the number of patients with LTBI being treated, but her work has also led to considerable improvement in prescription of the preferred short-course treatment regimens and the use of recommended interferon gamma release assay (IGRA) blood test in lieu of Tuberculin skin test (TST) within the clinic. Half of the clinic providers expressed discomfort with prescribing short course treatment regimens before the intervention, however, this increase in the use of shorter regimens 4 months post-intervention illustrates how provider trainings and consultations can help build confidence in adopting new approaches to treatment. This underscores significant progress in TB prevention efforts among some of the most high-risk populations in the county.
At present, Dr. Truax is leading another QI project that focuses on improving the LTBI care cascade for elderly Vietnamese patients at Southland, another federally qualified health center in the county. She was awarded the TB Elimination Alliance (TEA) mini-grant for this project and is currently in process of collecting the baseline data. This project builds upon her work at Nhan Hoa and incorporates patient education of high-risk patients through a culturally relevant Vietnamese video that discusses LTBI and LTBI testing and treatment capacity-building for in-house IGRA blood draws, a patient navigator role, and provider training on LTBI testing and treatment.
Dr. Truax is a true hero in the realm of TB prevention and is a genuinely wonderful person who inspires those around her into action and service. I have the privilege of collaborating with her on this recent project and can attest to her determination and commitment to improving the futures of Vietnamese community members both locally and internationally who are at risk of TB disease.
Truax FN, Low J, Mochizuki T, Asfaha S, Nguyen TN, Carson M, Katrak S, Shah N, Nguyen D. Latent Tuberculosis Infection Testing and Treatment at a Federally Qualified Health Center in Southern California: A Quality Improvement Project. J Nurs Care Qual. 2022 Apr-Jun 01;37(2):155-161. doi: 10.1097/NCQ.0000000000000579. PMID: 34261089.
Dr. Devan Jaganath has demonstrated through his work over the years that he is a TB Elimination Hero. First, he has worked to improve LTBI testing and treatment among pediatric patients in the East Bay through an initiative with Children’s Hospital Oakland and UCSF. Second, he has worked closely to improve our understanding of TB-HBV and LTBI-HBV and has worked with me on several projects related to this, and also has published a paper on diagnosis and treatment of LTBI for gastroenterologists/hepatologists. Third, he has also helped analyze TB surveillance data and has provided co-mentorship with me to an MD-MPH student at UC Berkeley that has led to two publications on TB in the elderly. Fourth, he has been available to our Public Health Program and colleagues at Children’s Oakland to answer any questions on TB/LTBI in the pediatric population. On a personal note, I have worked closely with Devan since he was a fellow at UCSF and he has remained committed to TB prevention and research over the past 5 years, and he has provided excellent mentorship to various individuals including students, nurses, and physicians.
The San Diego County TB Elimination Initiative Community of Practice (TBEI CoP) was created in October 2021 to encourage the development and use of a LTBI care cascade by healthcare organizations in the County. Members meet quarterly and have committed to promoting LTBI care improvement within their organizations. At each quarterly meeting, members share LTBI improvement projects, best practices, lessons learned and data measuring their LTBI care cascade. TBEI CoP members are recognized as TB elimination heroes by engaging colleagues and initiating changes within their own practices, including presentations to decision-makers, measurement of their LTBI care cascades, EHR enhancements supporting the LTBI care cascade, adding LTBI coordinator positions, LTBI workflow changes, creating workgroups to focus on LTBI improvements, incorporating telehealth for LTBI care, and implementing provider education that supports LTBI care. Since beginning the TBEI CoP in October 2021, the following healthcare organizations have participated in the quarterly meetings and most participants have initiated TB prevention efforts within their practices:
- Asian Pacific Health Foundation
- County of San Diego TB Clinic
- Family Health Centers of San Diego
- Indian Health Council
- Healthy San Diego Health Plan Representatives
- Kaiser Permanente
- La Maestra Community Health Centers
- Neighborhood Healthcare
- RADY Children’s Primary Care Medical Group
- San Diego Family Care
- San Ysidro Health
- Southern Indian Health Council
- Sun Health Medical Clinic
- University of California at San Diego (UCSD)
- Vista Community Clinic
We would also like to recognize the TBEI CoP Chairs: Dr. Richard Garfein (UCSD), Dr. Sujana Gunta (Vista Community Clinic), Dr. Jeffrey Percak (County of San Diego TB Control and Refugee Health Branch) for their strategic input and leadership for the CoP, as well as the leadership of Dr. Jeannette Aldous (San Ysidro Health) who both co-Chairs the TBEI Advisory Task Force and is a member of the Community of Practice.
There’s just no “I” in TEA. The San Diego TB Elimination Alliance (TEA) Coalition, recently united, comprises the three national TEA mini-grant recipient agencies in San Diego county. Together they collaborated at a recent health fair hosted by the UCSD Medical Education Mission Outreach (MEMO) student organization in City Heights, a high-risk TB community. At this event on February 18, 2023, there was a designated “TB Elimination Area.” Led by the Asian Pacific Health Foundation and their TB education program, a two-year TEA recipient, CARE TB/Champions for Health, a three-year TEA recipient, provided TB screening, and testing, along with COVID vaccinations and other immunizations, and La Maestra, a first-year TEA recipient, promoted their new program, located at their City Heights clinic. San Diego County TB Control screened and tested 8 participants that CARE TB will follow through the LTBI cascade of care. In addition to the health fair participation, the three agencies are participating in the San Diego County TB Elimination Initiative’s World TB Day (WTBD) promotion subcommittee. As subcommittee members, these agencies and others will contribute to a calendar of WTBD events in San Diego county, including a coordinated social media communication plan. Continuing with their collective outreach, the group focuses on another health fair activity in National City in the late spring, providing TB education, screening, testing, and linkage to care. As a result, the goals of the TB Elimination Alliance and its mini-grant program have been heightened and expanded in San Diego county, benefiting a more extensive scope of diverse community members.
Champions for Health – 3 Rounds of TEA Mini-grants: 2020 – Present
- Conducted outreach to 10 non-profit organizations that serve Filipino, Vietnamese, and Latinx communities.
- Performed a total of 171 community needs assessments in these same communities to identify pertinent TB prevention messaging and input on how to promote these messages.
- Conducted more than 5 TB risk assessment events yielding more than 100 unique educational opportunities with high-risk TB community members.
- Coordinated three TB screening and testing events that yielded 51 risk assessments and unique educational opportunities, leading to 24 tests with a 25% positivity rate.
- Expanded collaboration and outreach with one San Diego City high school and the Asian Pacific Health Foundation during these three events.
Asian Pacific Health Foundation – 2 Rounds of TEA Mini-grants: 2021 – Present
- Collected 201 participant responses to our educational surveys across 12 educational sessions across the North Coastal, Central, and Southern regions of San Diego.
- Here are some demographics of our respondents:
- Age: ~53% of respondents have identified as being 16-19, with ~38% of the remaining respondents identifying in the age range of 20-30.
- Ethnicity: ~56% of respondents have identified their race/ethnicity as API or mixed, ~37.5% of respondents have identified as Hispanic/Latino or mixed. ~12.5% of respondents have identified as Black or African American or mixed.
- LTBI risk factors: ~62.5% of respondents have met at least one risk factor, as set forth by the County of SD TB Risk factor screening criteria and have been advised by our peer educators to seek testing if they have not already done so with their regional county clinics.
- Content Knowledge of TB: The average score increase of the knowledge assessments increased by 3.6 points out of 10 points total. The average respondent score during their post-educational knowledge assessment was 9/10.
- Common Initial Misconceptions: Based on our pre-educational knowledge assessments, we’ve noted that the most frequent misconception is the countries that are considered to have a high level of TB (according to County of SD TB Risk factor screening criteria). The second greatest misconception pertains to the efficacy of the TB skin test vs the TB blood test for individuals who have received the BCG vaccine.
La Maestra – First round of TEA Mini-Grant-2023 As a new partner of the SD TEA Coalition, La Maestra will contribute its linkage to care expertise, connecting participants at the Coalition’s outreach events to their services throughout their healthcare clinics in San Diego’s high-risk TB communities. As a TEA mini-grant recipient, La Maestra will focus on culturally and linguistically appropriate health education visits and materials to Hispanic/Latino and African American individuals to encourage TB clinical evaluation follow-up. In addition, La Maestra plans to host provider-to-provider TB elimination education opportunities across their multi-clinic system. With these added activities that La Maestra has committed on behalf of the communities and individuals they serve; they will also expand the reach of the San Diego TEA Coalition.