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*261. The Department of Veterans Affairs (DVA): Breaking the Barriers between Clinical and Facilities-based Services to Combat Mycobacterium Tuberculosis (TB) in the Veterans health Administration (VHA)

GA Roselle, Department of Veterans Affairs; SM Kralovic, Department of Veterans Affairs; LH Danko, Department of Veterans Affairs; LA Simbartl, Department of Veterans Affairs; ML Render, Department of Veterans Affairs

Objectives: With the resurgence of TB in the late 80s and early 90s, the VHA needed to be proactive to combat the epidemic on a national level.

Methods: To reduce TB in VHA facilities, the VAHQ Infectious Diseases Program Office formed a task force with facilities-based services (FBS); (e.g., Engineering, Safety/Industrial Hygiene, Plant management, Construction and Planning) in 1992. VHA sites were surveyed to determine the facility capacity (TB patient rooms) of the VHA system to care for patients with TB. These data combined with TB incidence rates for each (172) VHA facility were used to prioritize facility TB construction projects annually for FYs 94, 95, and 96 for a total of 152 projects (135 sites) costing $60 million. National VHA TB guidelines designed to reduce the risk of exposure to persons with infectious TB (including the use of respirators in compliance with CDC performance requirements, OSHA, and American National Standards Institute [ANSI] standards) were published in 1993 and revised in 1995. National directives addressing reporting TB cases to health departments, an Employee Health tuberculin skin testing program, and aerosolized pentamidine administration were developed. National TB educational programs from 1994 1997 emphasized the need for local communication between clinical and FBS.

Results: From 1992 to 1998, the number of TB cases in the VHA dropped 53.4% (p<0.0001, chi square). From 1991 to 1998, the number of cases of multidrug resistant (resistant to isoniazid and rifampin) TB (MDRTB), TB in the HIV coinfected, and MDRTB in HIV coinfected persons all decreased significantly (p=0.02, 0.0002, and 0.05 respectively). Nationally, the rate of TB in the VHA (cases/105 persons served) decreased at a greater rate than TB in the nation as a whole (cases/105 U.S. population); p = 0.0001, linear regression model.

Conclusions: By breaking clinical/FBS barriers, an effective program to combat TB was implemented. Assessing clinical outcome over time, program effectiveness was documented.

Impact: Future initiatives for similar problems should benefit from this lesson learned.