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taining training levels and competence as tuberculosis laboratory services are more often provided in the private sector. One challenge for working with the private laboratories has been developing reimbursement models so that rapid smear results can be provided on site before referring the specimen to a full service laboratory. The division is also providing assistance internationally through the development of training materials and providing consultation to selected national laboratories (Mexico) through WHO and PAHO. The laboratory provides reference laboratory services and a national genotyping surveillance network through seven laboratories. The surveillance project currently covers about 15% of isolates in 15 states. The laboratory also provides consultation in the evaluation of new laboratory technology for operational use.

The site visit on July 20 continued with a review of the tuberculosis program in Atlanta and the State of Georgia by Don Hopkins and the IOM staff.

Fulton County Health Department of Health and Wellness serves the largest county in the state of Georgia, covering a 535 contiguous square mile area and encompassing approximately 88 percent of the city of Atlanta. 187 cases were reported 1998. The vast majority were U.S.-born African-Americans with a smaller proportion of foreign-born cases than the average of the United States. Public services are provided through a central tuberculosis clinic staffed by clinic and outreach staff. Major challenges to the program include a reorganization of staffing and cost-recovery efforts. The county HIV/AIDS, STD, and TB programs are being merged in an attempt to reduce costs and enhance service delivery. The merger has just begun and management staff expressed optimism that outreach workers would be able to provide multiple services to the patients and families they work with. Outreach staff expressed some concern about cross training. No one is denied services due to an inability to pay but, after receiving services, everyone must complete an interview about their ability to pay and receive a bill. Third-parties are billed when there is insurance. Outreach and clinic staff expressed concern that, even though patients will not be required to pay, charging for services and the eligibility interview will serve as a barrier for the patients. Grady Hospital

Grady Hospital is a large public hospital located across the street from the health department. The tuberculosis services are provided by staff from Emory University. During our meeting it was pointed out that about 25% of all cases in the State are first encountered and treated at Grady Hospital. While Grady Hospital receives about $350,000 annually in combined state and federal funding for tuberculosis activities, staff

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