Well, hello and welcome to the NICs Series-Breaking the Cycle, Tuberculosis Prevention and Management Behind Bars. My name is Chat Garrett and I am the health programs manager with the National Institute of Corrections. We are thrilled to have you join us for this informative series.

Exploring TB in the setting and highlighting proven approaches for carsonal TB medicine. Before we begin today's session, I need to cover just a few important housekeeping rules. This webinar is scheduled to last approximately 1 h. The session will be recorded in once captioned and made five oh eight compliant.

We will be posting it on our NIC website. Anyone who's registered should get a notification once it's been posted. This is a listen only event, meaning that your microphones have been muted. However, we had strongly like to encourage your engagement with our Webex chat feature, which we've already practiced. For those of you who have not practiced, please go to your chat feature to be at your bottom there.

Out of your screen and tell me what state you are from. We will also be using polling software during the presentation called Slido. And in order to participate in polling, I need everyone to find the Slido function which has been cleverly hidden from everybody. What I need you to do is go to the bottom right of your screen and on the very far right, you're gonna find three.

Little dots. I need you to click on those three little dots, and then I need you to click on Slido. Some of your institutions may have this feature blocked. I have found that just a few institutions do have it blocked. If it does, please use the chat to participate in our polls. I am gonna put up a test poll question.

Right now that you can answer. So for those of you that can pull up Slido, go ahead and answer our test poll question right now. If you experience any audio difficulties, we recommend connecting to the webinar via.

The telephone using the number provided in your registration confirmation email. There will be a post course survey to complete. There will be a QR code and a link, which is the easiest way, but we will also be sharing the link in the chat. Completing this post course survey is very, very important. As remember, this is your program and.

This is your chance to be heard. Before we get started, I want to hand the mic over to one of our exceptional NIC librarians, Mary Coffman. Mary, Mike is yours.

Thank you Chad. I am Mary Koffman. I'm one of the information specialists at NIC. We're a staff of four librarians and we are here to help you. If you have a corrections related question, by all means the NIC help desk is where you need to send it. I put it into the chat how you can reach us at support@NICIC.gov.

We welcome your questions. We're open Monday through Friday from eight to four mountain time, but you can send us a message anytime. We'll take about one business day to get back to you. If you have any questions about the field, let us know. We also have free of trainings and webinars on our website nIC.gov. That might be how you find out about this webinar, but please check.

For our website for more trainings and webinars as you'd like to take them. We also have free books and audio books through Overdrive and the Liby Apps on the website. All you need to do is get a username and password, and then we can help you do that if it's right as it's supported@NICIC.gov. Thank you Chad.

As always, thank you so very much. So tuberculosis has always had a flare for the dramatic. Its name comes from a Latin tubriculum, which means smallest swelling, but history has given it some far more memorable and fun titles like.

The white plague, the grave yard cough, and my favorite, the captain of all these men of death. At one point tuberculosis even inspired a fashioned trend called the consumption cheek because apparently looking dangerously ill was once considered fashionable.

Fortunately, our understanding has continues to evolve. TB remains a disease that thrives where people live in close closed quarters where detection is delayed and where prevention is inconsistent. TB maybe ancient, but the conditions that allow it to spread are decidedly modern and familiar.

Incorrectional inherit health care quality is rarely an accident. It is a product of preparation, persistence, and people who refuse to accept good enough. Today's presenter is one of those people, which in the commander Cassidy Burget serves as the regional quality improvement coordinator for the South central region of the federal.

Year of prisons where she helps transform data into decisions, challenges into opportunities and quality initiatives into measurable improvements because in correctional medicine doing it right the 1st time is always less expensive than doing it twice. A commissioned officer in the United States Public Health service within a commander Birchart earned her bachelor's science in nursing from southwestern Oklama State University.

And her MBA in healthcare from southern Nazarine University. She beyond her correctional health care career more than 14 years ago as a staff nurse at FCI Elino and has since served in leadership roles spanning quality improvement, infection prevention, health service administration, and executive healthcare operation.

Her experience literally stretches from the bedside to the boardroom, leading initiatives in patient safety, emergency preparedness, infectious disease management, and system wide performance improvement. She is known for bringing practical solutions to complex operational challenges and for my.

Why quality improvement is not about finding faults. It is about finding a better way forward. Today, she is gonna share some of those lessons from her years of improving health care and one of the nation's most complex practice environments. Please, everybody, welcome with me, Lieutenant commander Cassie Burchett. Commander, Mike is yours.

All right, good morning to some of you. Good afternoon to others. I am Lieutinet Commander Cassie Brechette and I'm very excited to be able to speak with you guys today on this series that Captain Roads has started with you. So in your last session with Captain Roads, you guys discussed latent TB or LTBI and today we're gonna move into active TB disease in the correctional setting. So tuberculosis are formerly known as consumption, as we can see from our slides here, has been around for about.

Thousands of years and and was once one of the world's leading causes of death, and even today it remains a serious disease especially in places like our work setting where people live in close quarters. The good news is TB obviously now is highly treatable with modern medication. Early detection is critical in the correctional setting.

And when we identify symptoms quickly and we follow screening protocols, we greatly reduce transmission inside our facilities. Our support and monitoring play a major role in keeping everyone safe. Correctional providers are at the center of TB control. We screen, educate.

Monitor symptoms and ensure treatment adherence, and our vigilance directly protects both staff and residents and even our surrounding communities. So in short, TV has a long history, but today is very treatable. Early detection, full adherence to therapy, and strong health care staff involvement are.

The foundation for TV prevention and our correctional health care setting.

So just very quickly, here are our objectives for this today that we're hoping that you guys take with you and back into your practice. And moving forward, if you get nothing else out of this presentation, please remember these.

Six take home points that we're gonna hit very heavily on. So TB screening is gonna be our 1st line of defense in their correctional setting. Every intake screening, every symptom check, every periodic test helps us catch cases early and prevent the spread within our facility. And remembering the signs and symptoms of TV.

That should prompt us to initiate that immediate evaluation. Our TB risk factors and understanding how these risk factors work in the disease process and why they make correctional populations particularly vulnerable, knowing the steps for a timely workup so we can ensure that we identify active disease quickly, knowing kind of our basic TV treatments.

And then TB partners that we're going to be working very closely with are public health partners, people that are gonna help us with community continuity of care, and collaboration with these folks is going to ensure safe management inside the facility and beyond our facilities.

1 s here, my screen froze a little bit from me Okay, so our 1st step towards identifying TB typically begins with screening our patients. So who can our.

Do you remember from Captain Rose's 1st presentation what the two FDA approved tests are for part of this screening?

I have opened that poll right now, so if you guys wanna go to that Slido and open it up.

And I will apologize to the audience. I'm not able to see your responses in Slido at the moment, but Chad will be monitoring those for me.

So the question is, for those of you who are in chat and can't open Slido, which of the two following tests are approved by the FDA for initial screening of tuberculosis? The adver blood tests, the TST, sputum smear, are the zeal need Nelson acid smear.

And it could be A, it could be A B, could be ABC, could be CD, BD, none of the above. I'm getting some great answers in chat, and it looks like so far we have people that are answering A and B and A NC.

Okay, so the correct answer is going to be A and B R igress, and R tsts. Okay, so why is screening for TB so important for us?

Or again, early detection is going to be our biggest thing that we're gonna be trying to strive for here because with early detection, again, we're going to slow down that potential spread and keep everyone safe. And in settings like ours, these things have the potential to spread very quickly. So stopping the spread, again, we're keeping everyone safe.

On that note, we will talk about those two FDA approved screening tests that you guys discussed in your previous presentation. So our TSD and our iggraph. Now, these two tests depending on the setup of your jail or your prison, the TSD or the blood test, one or the other may work.

Look better for you. So be aware that to administer the TST, the nurse that's providing it must be trained properly. And the inmate will also have to return in 48 to 72 h to have that TST read. So keep that in mind because if that person is gonna be moved.

Within that 48 to 72 h time frame, then the TST is not gonna be the right option for you. You may want to look at something different. We're not gonna be able to read it. The nurse that's gonna be reading the TST must also have proper training on how to measure the TST to ensure that we're putting an accurate result and documenting that in the medical record. Remember from Tara's last presentation that whenever she was talking about readings being conducted.

We want to make sure that the staff is measuring the induration and not just the redness that you can see in positive results sometimes. So we have another question for you. From your last presentation, do you guys remember what induration is? And you should be able to just freely type this in the chat. So if you remember, please let us know.

Yes, so I've opened the poll for those of us that can get into the Slido poll, you can go ahead and enter that there.

You can also enter in chat. So the question again is, how would you identify in duration? If you want to add your free text in there, I've got feeling of thickness, raised area.

Ah, you do not measure irothema. I like that. The hardening area, the hardened area under the skin? A 5 mm mountain. Okay, that's cute.

Alright, if the answers have kind of slowed, I will go ahead and let you know that as a reminder, enduration is going to be that firm raised powpable swelling that you're gonna be noting on that TST reading. So to continue on, the TST is cost effective, so this is.

It's gonna be nice for places that are smaller and have smaller budgets that they have to work with. It's very cheap to administer. But inaccurate writings that miss a potential TV diagnosis could lead to a much, much more costly outcome than just moving over to a different type of testing. So a lot of our small budgets can't handle that. So we need to ensure that, again, the nurses are trained in planting and reading the tsts. And one final side.

Important note that we wanna make about these is that the TST can be positively influenced in patients who have had the BCG vaccine in their history, which can skew your results, so you need to be aware of that when you're conducting your patient histories.

Okay, so now on the other hand, we have our blood tests, and they have the advantage of taking this user error that I'm describing kind of out of the out of the equation. The misinterpretation during the reading or incorrectly planting is removed whenever we're using this type of a test. It does cost more.

More. And it does require the facility to have the ability to draw the blood, process the sample, send it out to a lab that can give you your results, and this might not be a feasible option for some smaller units or some very remotely isolated units. So the use of these is going to greatly depend on your facilities capability.

Abilities. And one final thing that we'll mention again as a side note for the Igra is that unlike the TST, it is not affected. Its results are not affected by patients who have a history of having that BCG vaccine.

So our TB symptoms are very common symptoms that we're all kind of thinking of is that persistent cough, blood tinge disputum, fever, night sweats, weight loss, and especially very recent unexplained weight loss. Fatigue and.

Horses can also be seen that horsesness is particularly common in lorengial TV, which is a very concerning contagious form of TB. Weakness can also be noted. So for most of us, whenever we're thinking about TB symptoms, this is kind of what we're thinking, and I might be.

Dating myself a little bit here by using this reference, but if you can recall the movie Tombstone.holiday has TV in this movie and the very classic kind of gory presentation that we think of is just someone who will experiry that. I mean coughing up blood visibly, very clammy, looking to shoveled. That's kind of where the majority of our minds go, but that's going to flow into my next slide.

So now that we've covered our classic TV symptoms, again, my tumbstone reference and my picture there. We need to also mention that there are instances where patients may not note symptoms. There are cases where a patient had maybe just a positive TST reading. They had a follow up chest x ray that was completed.

And through the chest x ray, we were able to note findings consistent with TB. So these cases are referred to as subclinical TB. They represent a stage on the spectrum of TB disease that lies between the latent infection and active symptomatic disease.

They maybe infectious, but yet they do not report any of our typical classic TV symptoms. They may report to you that they feel fine. I have NO symptoms, I don't know what you're talking about. So we really need to be mindful of the possibility of these cases. And with these cases we want to.

Be sure that we're educating our patients on what we're doing and why we're doing it and keeping them looped in in their plan of care. Because this can be very confusing and frustrating for them because to them they feel fine in their own minds. So we have another question for you here. What is the 1st thing that you think someone, that you should do if someone presents with TB symptoms or you're trying to rule out a case of TB, what is the 1st thing that you should do?

So I've opened up that poll for y'all or you can answer in the chat if you like. Again, that question is, what's the 1st thing you should do if someone presents with symptoms of TB or you're trying to rule out TB?

I'm seeing a trend.

What trend do you see, sir?

I am seeing isolate, isolate, isolate, isolate negative pressure, bask and isolate, isolate. Don't worry about it, it's the end of your shift. I'm not sure that's right.

I do appreciate the humor. Okay, the trend is good. The trend is good because yes, we are going to mask the patient and we're going to isolate them. So if you're suspecting this, like I.

Said we're gonna mask and isolate them and if airborne isolation is available at your facility, they should be placed in one of these rooms. If NO airborne isolation is available, consider do you guys possibly have an agreement with a local hospital to house them in airborne isolation for you and assist you in conducting this workup? If neither of these is an option, either A, you don't have your own.

Own room where you don't have an agreement to be able to utilize another one at a bare minimum, so at the very least, we want to make sure that they are separated from all of the other inmates and everyone else that lives there. We want to put them in a separate room with a closeable door. That is very important. We want to be able to shut that door off. And we also want any healthcare staff.

For correctional staff, anybody that's gonna be involved with this patient in any way, those people need to be wearing at least an N 95 mask on themselves when interacting with them. So our TV risk factors.

During our workup of potential TV cases, we need to think about the following risk factors and if our patients have any of these whenever we're doing our assessments. So are they a close contact or a prolonged close contact to a known infectious TV case?

Are they foreignborn from a high instance country? Are they an injectable drug user? Those people are more at risk. Are they an HIV patient? Due to the compromised immune state of this disease? They're more at risk?

Are they a TST converter? Your TST converters are going to be most at risk of developing active TB in that 1st two years after their conversion. So you might look back and see when their last TB test was. Was it a conversion? Was it in this timeframe?

Residents or employees of presence in jail, so population. Anybody that is residing in something like that or long term care facilities, hospitals, homeless shelters, just really anywhere where people are living in a very close quarter environment.

Another question. What are some comorbidities? Like some other risk factors, other comorbidities that might place our patients at risk of developing active TB disease that would be in their history?

So I've opened that up in our poll. For those of you in chat, you can go ahead and enter in chat. What are some comorbidities our patients could have that might also be a risk factor? So in chat we're getting HIV smoking.

Diabetes, immunocompromised, ah sharing needles.

Yes?

And in our poll so far, we've got most people saying, all of the above, which would be silicasis, diabetes, renal failure, gastric bypass, and we have about 11 % that are have said diabetes, homelessness. Oh, that's excellent. Excellent.

So definitely a, a trend that there are a whole lot of comorbit.

There are, and while this is an all inclusive list, if you are answering within the multiple choice question, the answer is all of the above. So histories of silicosis, diabetes, chronic renal failure.

Bypass. Those are all going to be items that are gonna place our patients more at risk. These all have the potential to affect your immune system and how your body responds to infectious agents. And a few more that we're gonna list out here are gonna be leukemia or lymphomas, carcinomas of the head and neck.

And in the lung, if they're underweight or severely underweight, these are all also going to have effectsonomy and systems and play a role. So where in your body can you get TV?

We have some pictures that we're gonna go through with you here in a moment that are some actual images of places that you're gonna note it. But whenever we think about TV, we pretty much go straight to thinking about the lungs. And while this is the most common site that TV can occur, it can happen in other places of the body as well.

These cases are known as extrapulmonary TV. Some examples of extra pulmonary TV, again, I'm gonna show you some pictures here shortly, but we also have Lyrinix or the lorengial TV that I was mentioning in some previous slides that is very worrisome, very contagious, can happen in your lymph nodes, the plural space.

In your brain, kidneys, bones and joints, and it can even happen in the eurogenital tract. So Captain Roads was telling me a story of a case that happened very early in her career, where a patient presented with a chief complaint of grossly swollen testicles, which eventually.

Really led to a extremely painful non healing wound. And after a very long and extensive workup, this case actually ended up being TB of the testicles. That was the whole cause of this person's problem. It's pretty rare, but be aware that strange things like this can happen. TB can happen anywhere in your body.

So some types of extra pulmonary TB are not infectious. We wanna make a note of that. So places like your brain, your kidneys and bones and joints are not going to be infectious to other people. However, we must be certain in the early.

The Stages of diagnosis that we rule out any pulmonary earlinegial involvement because these things can be happening simultaneously. You can have extra pulmonary TV and pulmonary at the same time. We wanna make sure that we're rolling the infectious parts of the body out completely.

Before we say this person isn't going to infect others. So a complete workup is extremely important. And if you completely work them up and there is absolutely NO pulmonary or lorengial involvement, isolation can be discontinued and contact tracing will not be indicated for this particular case, which is good news to any of my IPNC folks out there. Contact tracing can be a very time consuming thing, so.

If there is any silver lining, at least you don't have to do that part of it. They will, however, still need a complete and very specific course of treatment. So let's review some of our photos that we have as examples of this. I can get my mouse to toggle correctly.

Okay, so some lorngial TV here, and then this is going to be like within our life notes that you're seeing, the neck, kind of the same part, but we're looking kind of up here, that growth swelling, and the.

Lymphodomopathy can actually also happen within the chest cavity and it's a little bit difficult to see it on this picture, but you have lymph nodes all in here, and those are kind of showing on this particular slide in the brain right here and then we can have this in our kidneys as we were saying. Bones and joints.

It's right in here and right in here. This picture is a little bit grainy and then in the spine, you can see it in all aspects, it's eating away at this right here.

Okay, for our TB workup, some of our baseline labs that we're going to need whenever we're working up our patients, HIV testing, untreated, latent tuberculosis infection is actually likely to advance to TB disease and people with HIV.

More so in people that don't have HIV. And TV is often more severe in people with HIV and weekend immune systems as we were mentioning heavily mentioning heavily earlier. So we want to get that baseline HIV testing or if they are a known HIV patient, we want to know where their CDA CD four viral loads are sitting at.

We want to get a CBC with platelets. We also want to get some lfts in Billy Ruben. We want to know if we are working with an already compromised deliver because our treatment regimens, our drugs are gonna be very, very liver heavy hitting drugs. So we want to know what kind of a liver we're working with from the get go.

We also want to check euric acid for patients with a known diagnosis of Galt or maybe they have an undiagnosed case of Galt. PCA, which is part of our treatment regimen, that can actually make out significantly worse, so we want to be looking for that whenever we're working with our patients. And.

And some other baseline considerations that might be a little bit more patient specific. We want to have a recent A1C on our diabetic patients. We want to know where their blood sugar levels are running or could they be potentially an undiagnosed case of diabetes that we need to be considering?

We might also want to get a baseline hepatitis C and B, to see, based on their history, are there risk factors that are indicating that they could have an undiagnosed case of this liver compromising disease state that we need to be aware of?

And things that we want to address during the history and physical. So we want to know, again, have they had a known exposure to an active TV case? Did they have that positive TST or Igra in their past?

Do they have any past LTBI treatment? Do they have any past active TB treatment? Because reactivation TV can happen. We wanna gather background info such as what country are they from?

Were they incarcerated while they were in this other country and do they have any immune compromising conditions? We want to be sure and get some baseline eye exams, so we want a baseline vision test and we also want to do baseline color vision screening, because in our treatment regimen we have a ambustall.

The Ambital can affect your vision and cause optic neuritis. So before starting these things, we want to know what their baseline is, and then we want to be monitoring that while they're on treatment as well to see if we're noticing that there's any deterioration. And our really key thing that everyone's probably already thinking about when we're talking about a TV workup is gonna be that chest X, right? So we want to get that.

And we want to make sure that it is two views, both both PA and left.

As we stated earlier, we want the patient isolated in airborne isolation room. If not, patients should either be moved to another facility with airborne isolation or a local hospital with airborne isolation. So we've moved out of the workup process. Let's say that we have.

Actual TV, like we know that we have that. This person absolutely needs to be in airborne isolation, to protect others. So we're gonna be getting sputum samples as part of this treatment workup. We want to obtain three sputum samples that include orders for AFB smears.

For acid fast basili smears, and cultures. And on at least one of these three samples, we want to also include an order for a PCR or a NAT, NAT standing for the nucleic acid amplification test. The PCR and NAT tests are looking for TBDNA that is gonna help us discern.

We're working with. Our three samples should be collected at least 8 h apart, and your best samples are going to be collected in the early morning right after the patient wakes up. In the samples and the actual specimen container itself.

We need to get at least six mils in each specimen container at a minimum. Ten mils is preferred, but if you can get at least six, then you're gonna be in good shape. And you need to please make sure that this is sputum and not just spit.

We really want to be working with our patients to make sure that they're really diving deep into those lungs and copping out the best gunk that they can give us. Some places you might want to institute a hub cough method if patients are having trouble getting that really deep lung sample. The hub cough method is.

Is actually on several YouTube videos, so if you're not familiar with that, YouTube has a wealth of knowledge or documentation depiction of what this is going to look like, so it can help you get the samples with those patients. So I have just a very general question for.

For you, what do you think whenever we're putting a patient in isolation because we've confirmed that they've likely have TV or we're rolling it out. What's the 1st thing that you think that you're going to get asked? What are they going to probably inundate you with the most?

So I have that poll question open if you guys wanna go ahead and type that in or if you have a thought, you can put that right in the chat When can I get out? How long will I be in?

ISO. When can I get out of isolation? How long will I be in here?

So I die from this? Yeah. Yes, you guys are spot on. If you haven't had to work up a patient before, they are going to be very noisy and they want to know when am I getting out of this room. Let me what is going on? When can you let me out of here? So for release criteria, here's how they're going to get out of here. In order to release our patients, we need to have the following in place.

So we need to have three consecutive negative smears and five days of medication if that chest x ray result said that they had NO cavity. So, we want to keep our chest x ray results in mind whenever we're making these decisions. If NO cavity was noted.

On this patient, you want three negative smears and five days of medication. Now let's say that a cavity was noted on that chest x ray report. That is still going to be three consecutive negative smears, and 14 days.

Of treatment medication for those cases. And I want to really hone in on this three consecutive negative smears for a moment. These have to all come from the same week and the same set of samples. So you cannot take a negative result like one negative result.

From your 1st week combine it with the negative result in your second week and then combine further with a negative result in the 3rd week. They all three, all three samples have to come negative at the exact same time for this to be the your consecutive negative criteria.

So our treatment. Ripe, as you're gonna hear me say a lot or just in general in TV community, ripe is going to be our standard treatment regimen that we're going to talk about today. There are red other regimens out there, but for the sake of this presentation, this is what we are gonna be primarily honing in on because.

It is the most common. It is standard if there is NO resistance to these medications. Resistance testing will be done. Should they find TBDNA in there and that's going to lead you on into what your regimen needs to be.

But let's say it's a simple case and there is NO resistance noted. This treatment is going to be six months, so you're going to have an initial phase of two months with a continuation phase of four months. Extrapulmonary TV that we mentioned earlier will have a longer continuation phase or res.

Or regimen. And for these extrapulmonary TV cases depending on the site that is involved, you're gonna be want, you're gonna wanna work closely with your health department partners or your TV experts, to help you determine the appropriate length.

Depending on the site. And while they're on this treatment, we're going to be doing a lot of monitoring during it. So things that we're gonna wanna monitor is we wanna get monthly sputums, those three samples like I was talking about earlier, we're going to get that monthly until full culture.

Conversion. We want to get a follow up chests x ray after they have completed 56 doses of this right treatment. So that 1st initial phase is 56 doses, and once that is complete, we're gonna wanna do another follow up chest x ray to see.

Where we're at in this progress. We want to be getting weights monthly, so again we want to be monitoring for any weight loss or weight improvement if they had significant weight loss. We want monthly vision screens like I was discussing because of this ethambiatol, so checking both just their general vision and their color.

And we want to be monitoring for any signs of hepatitis or acute hepatitis. I've mentioned that this is a very liver heavy regimen, so we want to be monitoring our lfts. And we might want to repeat lfts if we know that we're working.

With an already compromised liver liver so we can see if that is deteriorating any further. So I have another poll question for you on this note about lfts. How many times the upper limit of normal for our ALT and AST values would indicate a need to potentially hold this treatment regimen if we see this in our patients?

So that is open, right.

We are getting, little bit of a minazure, we've got anything above normal, three times the upper limit of normal. We've got both B and C, which is three times if they have symptoms and five times if they have NO symptoms.

So we have a pretty good mix.

We have a pretty good mix right this time.

Okay, well it was a little bit of a trick question, but the answer is D So what we are looking for when we're monitoring our ALT and AST values when we're looking at our liver function, we want to know if they reach three times the upper limit of a normal.

And they are symptomatic. They are experiencing symptoms of acute hepatitis. Then that is going to prompt us to stop or if they are five times the upper limit of normal, but they are experiencing NO symptoms of acute hepatitis. Both of these instances are going to.

To prompt us to possibly hold treatment and consult with our providers and our TV experts on what we need to do to be able to resolve this, but still keep that treatment going. Maybe adding drugs, subtracting drugs, waiting, we need to be working with our experts to make sure that we're one taking care of this patient's liver, but two, treating the infectious disease state.

So I've talked a lot about consulting your TB health partners and your TB experts. These are gonna be our local and state health departments. TB, even if it's just a suspected case of TB is still a reportable disease in the vast majority of states and the timeline for reporting is gonna depend on your local state guidance.

So making sure that you're following that guidance and you're reporting these cases to them timely so they can also give you timely advice is gonna be very important. We also have the TV centers of excellence, and we have your TV, and I'm gonna attempt to click and share what these websites.

Look like. So TV Centers of excellence, the link is here. I'm gonna try and drag and drop over. Hopefully everyone can see this.

Perfect.

Going to take you to their main page. And based on where you reside is going to depend on the center that you could reach out to. So here's your map.

And then here are your centers within these color coded regions. And then if you continue to scroll within this page right here, this is going to give you a direct link to their website and the way that you're going to access contacting them.

So this is something that you want to kind of keep in your pocket if you're needing advice on some very specific cases. And I will close out of this. Now cure TV, this is a partner that we have available to us that is gonna help us with that community continuity of care that I refer.

Earlier in the slides. If you have a patient that has TB or they are moving into a continuation phase of treatment and they are not finished, but they are gonna be releasing from your facility and either going back into the community or in some cases even going to another country, maybe for some of our ICE image.

Who might be deported to another country. QRTB is who can help them get set up with treatment providers in the community and those local health departments to make sure that this case is continued to be properly treated, resolved, and they get the follow up here that they need. So I'm gonna try and get the.

Your TV link up here for you as well and drag and drop.

Here we go. So when you're reaching out to QRTB, and this is their website, there are some forms that they want filled out and sent to them prior to working with you guys, and they are all on the website. So if you're requesting referrals.

There's the form, history request, contact investigation support, everything is all within the website, and then there's also information and instructions within this website on how you can reach out and get involved with them.

Alright, so our take home summary from all of this, is gonna be that we want to make sure that we are.

We're screening early, we're identifying early, we're assessing our patients, and we're treating our patients. Because if we do this, then we are all contributing to the world TB goal of ending TB disease.

Alright, whoop, I went a little too fast, and I apologize.

No, you are perfect. You are absolutely perfect on time.

If you have questions, feel free to drop them in the chat. We may follow up with you if your question is very case specific or Tara may have also follow up with this question in her next session, if I don't have the immediate answer right now, but drop this in the chat. The chat that I unfortunately can't see.

That's fine. I am watching it over like a hawk. If you want to go ahead and click forward, there you go. 1st of all, I want to thank our speakers so much for your your time and you can go ahead and continue to put a question in if you have any questions. That was an amazing presentation. I really, really, really appreciated it. Great, great job.

Yeah, thank you guys for the invitation and opportunity to talk to you today.

Ah, here we do. We had a question. Can you please go over your recommendations on weight based dosing for those borderline patients? Such as the use of LBW for patients with a BMI of 30.1?

So, I will, if you can provide me with your contact information, I can email that to you directly. That's alright because Dosages are going to be based upon weight milligrams per kilogram can be very specific to the patient.

Okay, well, we'll wait, but if everyone can give you a big round of applause again, thank you so very much for joining us. I really, really appreciate it. There is NO continued education for this course. You will get an email that will confirm that you've been here. So there's the survey to our link.

If you can't use our QR code, again, I really, really, really appreciate you all for joining us. I know how busy you are. Hopefully this was very informative. Remember we have one more session in this series. So make sure that you're signed up. I wouldn't miss it.

Yeah, Captain Rose will be joining you for your final session. She is our BOP TV expert and I mean, for all intents and purposes for us, the holder of all the knowledge.