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L.A. County Public Health
Partnering with the Private
Community to Control TB
Myrna Mesrobian, MD, MPH
LA County Department of PH
• Population of LA County: 9.8 million people
(2008 estimate)
• Number of Service Planning Areas (SPA): 8
• Number of Health Centers treating
Tuberculosis: 11
Reported TB Cases, 2008-2009
Los Angeles
County
California
United States
Cases: 2009
Total: 706
2,472
11,540
Cases: 2008
Total:792
2,695
12,905
TB Cases by Supervision
Los Angeles County, 2008-2009
Supervision*
2008
2009
Cases
%
Cases
%
Private
145
18.3%
178
25.2%
Public
647
81.7%
528
74.8%
Total
792
100.0%
706
100.0%
*TB cases managed in the County Public Health Centers, County hospitals, County jails or TB Control Program are classified as
Public; all other cases are classified as Private.
Strengthen the TB Link
• Effective treatment and preventing the
transmission of TB requires a sustained
partnership between:
– health care providers
– local and state public health practitioners
– patients infected with the disease
– public health and private laboratories
Public-Private Collaboration for
TB Management
• TB Physician Specialists and Private
Physicians can work as a team to:
– Enhance the understanding of TB
– Collaborate in developing and managing
TB treatment and prevention of
transmission
TB Patients Treated by the
Public Sector
• County Public Health Centers
• County hospitals
• County jails
• TB Control Program
TB Patients Treated by the
Private Sector
• Private patients
• Hospitalized patients
• Patients residing in skilled nursing facilities
(SNF) or convalescent hospitals
The Role of the
TB Physician Specialist
at the Health Center
9
Why a TB Physician Specialist ?
• Most doctors will not see a single case of active
TB in any given year
• Los Angeles County Service Planning Area
(SPA) TB Specialists may see up to 100 cases in
a year and three times as many TB Suspects
TB Control Program 2008
TB Physician Specialist Role in
the District Health Centers
• TB Clinical Care and Management
• TB Contact Investigations with PHNs
• Directly Observed Therapy
TB Physician Specialist Role in the
District Health Centers (cont.)
• B Referrals (new immigrants)
• Consultation to PMDs
• Legal Orders of the Health Officer
Private Sector Services Provided
by the TB Physician Specialist
• Consultation and case management of TB
cases
• Clinical care and follow-up if not feasible in
clinics and private MD’s offices
• In-services & education to the medical
community regarding TB care and evaluation
Oversight of Private Sector
TB Treatment
• Physician specialist reviews the case when first
reported to the district and then monthly
• Monitors TB medications prescribed by the
Private Medical Doctor (PMD)
• Ensures adequate public health measures are
taken when necessary
• Discusses contact investigation with the PHN
• Discusses the case with the PMD if needed
The Role of
Public Health
Nursing
in TB Follow-Up
Public Health Nursing Functions
•
•
•
•
•
TB Case Investigation
TB Contact Investigation
Health Education/Counseling
Referral and Follow-up
Case Management
Case Management
• Monitors client status
• Ensures confirmed TB
clients complete required
treatment
• Makes monthly home
visits
• Ensures adherence to
treatment
Case Management (cont.)
• Monitors adherence to home isolation, when
applicable
• Monitors client for complications at least
monthly until closed
• Requests monthly TB medical update if
followed by PMD
Request for
Monthly
TB Medical
Update
Summary of DPHN TB Case
Management
•
•
•
•
Monthly patient visits
Contact investigation
Patient and contact education
Monthly update requests from PMD until
completion of treatment
• Serves as liaison between PMD and Public
Health TB Physician Specialist
Directly Observed Therapy
(DOT)
• Delivery of every dose of TB medication (except
weekend dose and holidays) by a trained health
care worker who observes and documents that
the patient actually ingests the medication.
Absolute Indicators for DOT
•
•
•
•
•
HIV seropositive
History of previous tuberculosis
Homelessness
History of incarceration
Psychiatric disorder/cognitive dysfunction
Absolute Indicators for DOT (cont.)
• Current or past history of substance abuse
• Past history of non-adherence to medical
regimen
• Failure to respond to therapy
• Resistance to one or more drugs
Relative Indicators for DOT
• Age:
•
•
•
•
under 18 years
elderly
Non acceptance of TB diagnosis
Lack of understanding of TB dx
Congregate living
Recent immigration
Case 1
• 70 year old male
• Country of origin: Born in the US
• MRI lumbar spine (03/09): psoas muscle
abscess
• He had history of severe low back pain for 1
year before he was hospitalized on 03/18/09,
and had a psoas muscle abscess drained on
03/21/09
Case 1 (cont.)
• No CXR and sputum for AFB smear and
culture were done at the hospital, however his
physician accepted to schedule him to collect
sputum in April
• Since the patient was already started on therapy,
DPHN asked him to come to MHC on
03/30/09 for CXR and sputum testing
Case 1 (cont.)
CXR
03/30/09
Left pleural
effusion
Case 1 (cont.)
• Psoas tissue: AFB smear positive (4+)
• Final culture result: positive MTB, pansensitive
• He was started on RIPE treatment on 03/24/09
Case 1 (cont.)
• Sputae collected at MHC on 03/30/09,
04/08/09 and 04/09/09: AFB smear negative,
culture positive for MTB
• Sputae collected at the hospital in April could
not be located
Case 1 (cont.)
• He was treated by his PMD and was followed
up by the DPHN with monthly home visits and
pill counts for the duration of the treatment
• He had no side effects from the TB medications
• Contact investigation was done by the DPHN
Treatment Monitoring
Recommendations
• Baseline blood tests: LFT, CBC, BUN, Cr,
Glucose
• HIV
• Sputum for AFB smear and culture
• Home isolation until sputum AFB smears 3x
negative
• Avoid discontinuing any medication before
susceptibility results are available
Treatment Monitoring
Recommendations (cont.)
• Monthly LFTs
• CXR at 2-3 months and at the end of the
treatment at a minimum in case of pulmonary
TB
• Sputum for AFB smear and culture monthly
at the beginning of the treatment, for a few
months, and at its completion
Lessons Learned from Public-Private
Sector Collaboration
• Establish good communication channels with
the private provider and staff
• Be respectful of working habits and demands of
the private sector
• Communicate responsibly and in a timely
manner with both the patient and the private
physician
Lessons Learned from Public-Private
Sector Collaboration ( cont.)
• Show knowledge of the subject when discussing
cases with the private provider
• Guide the private provider (whenever requested)
in the treatment of TB
• Provide information material about TB if
necessary or if requested
Lessons Learned from Public-Private
Sector Collaboration ( cont.)
• Provide guidance, education and support to the
public health nurse
• Review all cases treated by the private sector at
least monthly ensuring close monitoring of TB
treatment
Treatment Monitoring
Ultimate goal of the public-private
collaboration is to ensure adequate TB
treatment completion within the desired
time period
American Thoracic Society
Guidelines
“…Regardless of the means by which treatment is
provided, the ultimate legal authority for
assuring that patients complete therapy rests
with the public health system.”