Transcript Document

POPULATION HEALTH DIVISION
PROTECTING AND PROMOTING HEALTH AND EQUITY
Diagnosis and Treatment of TB Infection in the
Homeless Population: San Francisco TB Program
Experience
Julie Higashi, MD PhD, TB Controller
San Francisco Department of Public Health
Population Health Division
Disease Prevention and Control Branch
August 14, 2014
1
San Francisco Department of Health Population Health Division
Outline
• Overview of TB screening of homeless shelter
residents in San Francisco
• TB program-associated costs of homeless
screening
• Benefits of the homeless TB screening program in
San Francisco
• Treatment of TB infection in the Homeless
Population in San Francisco
• Questions for the future
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San Francisco Department of Health Population Health Division
Homeless TB Screening in
San Francisco
• Mandatory TB screening for residents of
City-operated shelters began in 2005
• Coincided with –
– Widespread adoption of QFT-Gold in SFDPH
clinics
– Implementation of the CHANGES shelter
registration system
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San Francisco Department of Health Population Health Division
TB & Homeless Task Force Developed
in 2000 to Produce Guidelines
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San Francisco Department of Health Population Health Division
TB Screening Policy
• All clients receiving San Francisco shelter services for more
than 3 days (cumulative within a 30-day period) are
required to complete TB screening and evaluation within
10 working days of entering the shelter system
• Includes city-operated emergency shelters and resource
centers but not private or faith-based shelters
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San Francisco Department of Health Population Health Division
Aerosol Transmissible Disease Guidelines:
Translating Policy to Practice
• All shelters are required to comply with
California’s Occupational Safety and Health
Administration (Cal-OSHA) Aerosol Transmissible
Disease Guidelines
• A user friendly manual specific for shelters and
residential facilities.
– Distribute manuals to all sites
– Work with shelter directors individually to make sure
each shelter understands how to comply with the
OSHA ATD guidelines
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San Francisco Department of Health Population Health Division
Strategies
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San Francisco Department of Health Population Health Division
BUGS YOU SHOULD KNOW
TB
TUBERCULOSIS
THE ILLNESSES:
TUBERCULOSIS (TB)
THE SYMPTOMS:
Coughing, fevers, feeling tired, losing
weight, soaking sweats at night
THE GERM:
A bacteria that can infect any part of
the body, but usually likes the lungs
SPREAD:
Cough
HOW TO PREVENT SPREAD:
Keep client’s TB clearance up to date
(that’s yearly)
Get a TB test for yourself every year
And... cover coughs!
MEDICATION:
Specially prescribed antibiotics taken
over months
San Francisco Department of Health Population Health Division
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Screening Sites
• For TB tests
– Shelter associated clinics
– SFDPH urgent care and primary care clinics
– City affiliated urgent care and primary care clinics (e.g.
consortium clinics)
– TB clinic (walk in - three mornings a week)
• For chest x ray
– TB clinic (six half day clinics per week)
– If has medical home, can get through PMD
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San Francisco Department of Health Population Health Division
CHANGES System
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San Francisco Department of Health Population Health Division
Flowchart: Evaluation to
Treatment of LTBI
At-risk person
TB test + symptom review
Negative
Positive
Chest x-ray
Normal
Treatment
not indicated
Candidate for
Rx of latent TB
Abnormal
Evaluate for
active TB
TB Screening and Evaluation
Process
• Client referred to DPH clinic/affiliated clinic for
TST/QFT
• If QFT/TST+ or prior positive or symptomatic,
client is referred to TB clinic for chest x-ray and
MD evaluation
• Clearance card given to client –
– At DPH/affiliated clinic if TST/QFT negative (select sites)
– At TB clinic if TST/QFT+, prior positive, or symptomatic
• Temporary clearance given as needed
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San Francisco Department of Health Population Health Division
TB Infection Prevalence By Test
and Clinic Type
Homeless
TB Clinic
Methadone
Immigrant
TST
(2001-2003)
26%
~50%
10%
37%
QFT-1
(11/03-2/05)
17 %
n=1848
48 %
n=292
18 %
n=346
37 %
n=344
QFT-G
(3/05-11/08)
7%
n=9166
23 %
n=4042
4%
n=1261
14 %
n=2505
QFT-IT
(4/08-2/09)
6%
n=1625
22 %
n=1555
___
20%
n=323
Decline in positive
rate from TST
↓ 73%
↓ 54%
↓ 60%
↓ 62%
San Francisco Department of Health Population Health Division
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Initial Screening
Screening Results
TST or QFT negative
and asymptomatic
TST or QFT+ and
asymptomatic
Symptomatic
Follow-up
 None (until following
year)
 Provide green TB
clearance card
 Chest x-ray
 Medical evaluation at
TB Clinic (refer with
TB47 form)
 New chest x-ray
 Urgent medical
evaluation
 TST or QFT
Data Entry
Enter shelter clearance date in the
LCR
TB Control enters shelter clearance
date or clinical alert in the LCR
All TB suspects should be sent to TB
Clinic for evaluation. If work-up by
provider is negative, enter clearance
in the LCR
LCR = Lifetime Clinical Record, DPH EHR
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San Francisco Department of Health Population Health Division
Annual Follow-up Screening
Client Type
Treatment History
Evaluation Required
HIV– or HIV+ /
TST or QFT–
No prior treatment
 Annual TST/QFT
 Annual symptom review
HIV– or HIV unknown/
TST or QFT+
Completed LTBI treatment
 Annual symptom review
HIV– or HIV unknown/
TST or QFT+
No prior or incomplete
treatment
 Annual symptom review and
medical risk assessment for
diabetes, cancer, immune
modulating medication intake, endstage renal disease and HIV
 If new risk present, repeat chest xray annually if patient remains
untreated
HIV+/ TST or QFT+
Completed preventive
treatment
 Annual symptom review
 Low threshold to repeat CXR
No prior or incomplete
treatment
 Minimum annual symptom review
and repeat CXR
 Should be followed by SF TB
Control (please refer to TB clinic
if necessary)
HIV+/ TST or QFT+
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San Francisco Department of Health Population Health Division
Clearance
• Shelter client issued a TB clearance card upon
completion of screening
• Expiration date is entered into the DPH Lifetime
Clinical Record (LCR)
• Client presents card to shelter/resource center
staff at check-in
• Expiration date is entered into the CHANGES
registration system
– Date color-coded based on whether clearance is about
to expire (orange) or has expired (red)
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San Francisco Department of Health Population Health Division
TB Program Costs – Assumptions
and Estimates (1)
• 2005-2012
– Annual average of 1,729 homeless needing
screening1
• QFT-Gold In-tube cost2: $32.86 (includes
labor and supplies)
• QFT-Gold In-tube positive rate3: 7%
• Chest X-ray and MD visit cost2: $82.50
1San
Francisco Human Services Agency. San Francisco Sheltered and Unsheltered Homeless Count. (2009 & 2011)
2Estimates
3San
from unpublished cost effectiveness analysis of QFT in San Francisco.
Francisco LTBI rate among homeless persons, 2005-2011.
San Francisco Department of Health Population Health Division
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TB Program Costs – Assumptions
and Estimates (2)
• TB Clinic staff time per patient needing
chest x-ray and MD evaluation1
– Clerical (registration) – 15 minutes
– Health Worker (registration) – 7 min
– Nurse (provide clearance) – 5 min
1Based
on TB Clinic time survey data collected February-March 2012. Time estimates do not include time to draw
QFT or refer patient to TB clinic for chest x-ray and evaluation.
San Francisco Department of Health Population Health Division
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Annual TB Program Cost
QFT-Gold In-tube Test:
1,729 x $32.86 =
$56,827
# needing chest x-ray and MD evaluation:
0.07 x 1,729 = 121
Chest X-ray and MD evaluation:
121 x $82.50 =
$9,987
TB Clinic staff time:
Clerical: 30.26 hours x $28.59 = $865
Health Worker: 14.12 hours x $27.69 = $392
Nurse: 18.23 min. x 10.09 hours = $665
$1,922
TOTAL ANNUAL COST
$68,736
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San Francisco Department of Health Population Health Division
Homeless Cases, 2005-2013
Year
Shelter
SRO
Street/Other
7 (41%)
7 (41%)
City
Private
2005 (n=17)
3 (18%)
0
2006 (n=22)
2
(9%)
1
(5%)
11 (50%)
8 (36%)
2007 (n=25)
3 (12%)
1
(4%)
12 (48%)
9 (36%)
2008 (n=15)
3 (20%)
0
5 (33%)
7 (47%)
2009 (n=15)
0
0
6 (40%)
9 (60%)
2010 (n=7)
1 (14%)
1 (14%)
2 (29%)
3 (43%)
2011 (n=11)
4 (36%)
0
5 (46%)
2 (18%)
2012 (n=12)
0
0
8 (67%)
4 ( 33%)
2013 (n=18)
2
0
4
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Total (n=142)
18 (13%)
3 (2%)
60 (42%)
61 (43%)
San Francisco Department of Health Population Health Division
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Characteristics SF City Shelter
Cases, 2005-2012 (1)
Pulm. Smear +
City
Shelter
47%
SRO
45%
Pulm. Culture +
80%
73%
Pulm. Cavitary
0
36%
HIV +
36%
33%
Died
6%
14%
San Francisco Department of Health Population Health Division
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Characteristics SF HSA Shelter
Cases, 2005-2012 (2)
Converters
Clustered Cases1
1Clustered
2Two
City
Shelter
1
SRO
0
92
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to another case in the same shelter or SRO at any time, 2005-2012.
clusters.
San Francisco
Department of Health Population Health Division
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Collaboration is key
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San Francisco Department of Health Population Health Division
Other Benefits (1)
• Developed close working relationship with homeless
providers and shelter staff
– Facilitates timely response to exposures
– Opportunities for education and training for shelter staff
• Brings TB awareness to shelter staff
• Use CHANGES to target contact investigations
• Overlapping mechanisms to track screening and clearance
– TB Control, CHANGES (shelters), LCR (EHR)
• Addresses the disparity in TB rates among the homeless
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San Francisco Department of Health Population Health Division
Other Benefits (2)
• Screening provides opportunity to link patients to
other services
– HIV, cancer, viral hepatitis, diabetes, mental health
services, primary care
• Indirectly provides screening for clients being
transferred from shelters to SRO housing
• QFT allows for LTBI surveillance in this population
• Green card is powerful motivation for getting TST
read
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San Francisco Department of Health Population Health Division
Questions for the future…
• With established relationships and tracking systems…
– Are there opportunities to reduce costs?
• Reduce frequency of annual screening?
– How can we expand treatment for LTBI in this population?
• Use new 12 dose weekly regimen?
– Is it cost effective?
• ?
– Does screening program have an impact on health outcomes?
• TB? Overall health of the population?
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San Francisco Department of Health Population Health Division
CDC guidelines: IGRA testing
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San Francisco Department of Health Population Health Division
TST vs. IGRA - What to do with
Discordant Results
•
•
•
•
•
Avoid using two tests for TB screening
TST(+)/IGRA(-)
– Foreign born with BCG and no severe immunocompromising condition - attribute to
BCG
• Caveat - abnormal CXR confirmed old TB and with risk factor for progression to
disease, consider treatment
– U.S. born - with no risk factors for exposure or risk factors for progression - may be
NTM colonization, unreliable TST result
TST(-)/IGRA(+)
– U.S. born with no risk factors for exposure or progression - repeat IGRA in 3-6 months
If discordant TST/IGRA and severe immunocompromising condition, offer LTBI
If severe immunocompromising condition and if TST-/IGRA- and abnormal CXR confirmed
old TB, offer LTBI treatment
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San Francisco Department of Health Population Health Division
New LTBI Testing and Treatment
Guidelines for SF
•
•
Eliminate recent arriver criteria for testing and treatment
High Priority: Focus on risk factors for progression
•
•
•
•
Foreign born with diabetes
Foreign born with active tobacco use
Foreign born/US born with immune suppression
• Medications (biologics, organ transplant)
• Cancer
• HIV (universal testing)
•
Converters
•
Contacts
Medium Priority: Foreign Born < 50
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San Francisco Department of Health Population Health Division
New LTBI Testing and Treatment
Guidelines for SF
• Eliminate recent arriver criteria for testing and treatment
• High Priority: Focus on risk factors for progression
•
•
•
•
Foreign born with diabetes -> risk for progression 1/3
Foreign born with active tobacco use -> risk for progression
1/4
Foreign born/US born with immune suppression
• Medications (biologics, organ transplant) ->
• Cancer -> variable
• HIV (universal testing)-> 10% per year risk of progression
• Converters
• Contacts
Medium Priority: Foreign Born < 50
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San Francisco Department of Health Population Health Division
Strategies: Directly observed
preventive therapy (DOPT)
• Directly observed therapy regimens:
– Biweekly INH 900 mg (mon-thurs, tues-fri) x 69 months
– Weekly INH/rifapentine 900mg/900mg x 12
weeks
– Daily dosing at opiate replacement clinic
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San Francisco Department of Health Population Health Division
Strategies:Incentives/Enablers
• Incentives for TB infection treatment
– halfway through treatment and at end of
treatment: movie tickets x 2
– Subway coupon at each clinic visit for a meal
later, sandwiches at the clinic
• Enablers
– Bus tokens to defray cost of trip to clinic
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San Francisco Department of Health Population Health Division
Treatment Regimens for Latent TB Infection
Drug(s)
Isoniazid
Duration
Interval
Minimum
Doses
9 months
Daily
270
Twice weekly
76
Daily
180
Twice weekly
52
6 months
Isoniazid &
Rifapentine
3 months
Once weekly
12
Rifampin
4 months
Daily
120
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San Francisco Department of Health Population Health Division
Drug drug interactions with
rifamycins
•
•
•
•
•
•
ARVs (antiretroviral agents)
Oral contraception
Narcotics
Antipsychotics
Chemotherapeutic agents
Immune suppression for organ transplant
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San Francisco Department of Health Population Health Division
LTBI regimens: SF 2012-2013
Cohort: All TB clinic patients starting LTBI treatment from 9/1/12 to present with known
treatment end reason.
3HP*
%
INH
%
295
INH +
RIF
% RIF %
50
180
Started Treatment
71
Completed
60
85%
213
72%
44
88% 154 86%
Adverse Reaction
Chose to
Stop/Lost/Refused
Moved
Provider Decision
Other
3
4%
2
1%
0
0%
2
1%
8
0
0
0
11%
0%
0%
0%
64
6
2
8
22%
2%
1%
3%
5
0
0
1
10%
0%
0%
2%
19
2
1
2
11%
1%
1%
1%
*Includes both TB Clinic and Study 33 patients
San Francisco Department of Health Population Health Division
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Monitoring LTBI treatment
•
monthly review with patient (nurse or pharmacist)
•
Initial face to face -> transition to phone calls if patient doing
well
•
assessment of compliance - e.g. pill count, pharmacy refill dispense medication only one month at a time
•
assessment of side effects
•
assessment for hepatotoxicity
•
anorexia, fatigue earliest signs
•
abdominal pain, jaundice late signs
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San Francisco Department of Health Population Health Division
Monitoring LTBI treatment
laboratory LFTs (INH or RIF), CBC (RIF)
•baseline and monthly if risk for hepatotoxicity
•underlying liver disease
•ETOH
•medications (statins, ARVs, chemo)
•> 50 years old
•Lower risk (younger), may start with LFTs on
treatment x 1 month
•If WNL x 2 months, will d/c lab monitoring and just
do symptom review
•
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San Francisco Department of Health Population Health Division
Summary
• Implementation of a shelter screening program is
a collaborative endeavor.
– Health department must be an active partner in
serving both the homeless and the homeless service
providers
• Early signs suggest that shelter screening is
effective at limiting transmission of TB within the
shelter
– Earlier diagnosis
– More effective and manageable contact investigations
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San Francisco Department of Health Population Health Division
Summary
• SF program experience with IGRA screening in the
shelter population has:
– Quantified the rate of TB infection in this population
– Likely contributed to the earlier diagnosis of TB disease
in the shelters relative to SROs and homeless living on
the streets
• Effective strategies for TB infection treatment in
the homeless include DOPT and the use of
incentive/enablers.
39
San Francisco Department of Health Population Health Division
Resources
• San Francisco TB Prevention and Control
website: www.sftbc.org
• Curry International Tuberculosis Center
– TB and Shelter videos - > here today!
– http://www.currytbcenter.ucsf.edu/
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San Francisco Department of Health Population Health Division
Acknowledgements
• Jennifer Grinsdale, MPH, Public Health
Informatics Officer, SFDPH
• Masae Kawamura, MD
• Christine Ho, MD
• Sheila Davis-Jackson, TB Clinic Manager
• Kate Shuton, RN, PHN
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San Francisco Department of Health Population Health Division
POPULATION HEALTH DIVISION
PROTECTING AND PROMOTING HEALTH AND EQUITY
Practical Issues
42
San Francisco Department of Health Population Health Division
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San Francisco Department of Health Population Health Division
Aerosol Transmissible Disease Guidelines
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San Francisco Department of Health Population Health Division
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San Francisco Department of Health Population Health Division
Aerosol Transmissible Disease Guidelines
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San Francisco Department of Health Population Health Division
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San Francisco Department of Health Population Health Division
Add easy to follow flow sheets to
policies
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San Francisco Department of Health Population Health Division
WHEN IN DOUBT, TRANSFER OUT
KNOW
SICK
WHEN YOU
SEE IT,
AND ACT
IF IT DOESN’T SEEM RIGHT,
IT PROBABLY ISN’T
Screen clients at check-in time:
• Do you have a sore throat
or a cough and fevers?
• Do you have any spots or
a rash on your body?
• Shortness of breath?
• Severe vomiting?
If a client’s behavior or health does
not seem ‘normal’ to you, that’s
a good enough reason to look for
medical care for that person.
Help arrange for clients to see
a Medical Provider as soon as
possible if you think they are sick.
There are many Urgent Care clinics in
San Francisco where clients can
be seen the same day.
Don’t hesitate to call 911 if your gut
tells you to. Clients may refuse to
go in the ambulance, but they can’t
refuse your decision make the call.
San Francisco Department of Health Population Health Division
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COVER
YOUR
COUGHS
AND
SNEEZES
WITH YOUR ARM
OR ELBOW
Get in the habit of coughing and
sneezing into your arm or elbow.
It’s like wearing a seat belt; you will
soon do it naturally.
Coughing or sneezing into your hands
is grosser than spitting on them.
“Airborne Illnesses” are germs that
spray into the air. If they hit a hard
surface like your arm they will
probably die.
REMIND
OTHERS
TO DO
THE SAME
San Francisco Department of Health Population Health Division
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Resources
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San Francisco Department of Health Population Health Division