Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Public health genomics wikipedia , lookup
Fetal origins hypothesis wikipedia , lookup
Social determinants of health wikipedia , lookup
Health system wikipedia , lookup
Race and health wikipedia , lookup
Rhetoric of health and medicine wikipedia , lookup
Health equity wikipedia , lookup
Reproductive health wikipedia , lookup
International Association of National Public Health Institutes wikipedia , lookup
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 2 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 3 San Francisco Department of Health Population Health Division TB & Homeless Task Force Developed in 2000 to Produce Guidelines 4 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 5 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 6 San Francisco Department of Health Population Health Division Strategies 7 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 8 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 9 San Francisco Department of Health Population Health Division CHANGES System 10 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 12 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 13 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 14 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+ 15 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) 16 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 17 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 18 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 19 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 12 Total (n=142) 18 (13%) 3 (2%) 60 (42%) 61 (43%) San Francisco Department of Health Population Health Division 20 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 21 Characteristics SF HSA Shelter Cases, 2005-2012 (2) Converters Clustered Cases1 1Clustered 2Two City Shelter 1 SRO 0 92 8 to another case in the same shelter or SRO at any time, 2005-2012. clusters. San Francisco Department of Health Population Health Division 22 Collaboration is key 23 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 24 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 25 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? 26 San Francisco Department of Health Population Health Division CDC guidelines: IGRA testing 27 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 28 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 29 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 30 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 31 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 32 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 33 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 34 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 35 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 36 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 • 37 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 38 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/ 40 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 41 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 43 San Francisco Department of Health Population Health Division Aerosol Transmissible Disease Guidelines 44 San Francisco Department of Health Population Health Division 45 San Francisco Department of Health Population Health Division Aerosol Transmissible Disease Guidelines 46 San Francisco Department of Health Population Health Division 47 San Francisco Department of Health Population Health Division Add easy to follow flow sheets to policies 48 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 49 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 50 Resources 51 San Francisco Department of Health Population Health Division