population health division protecting and promoting health and equity san francisco department of...
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POPULATION HEALTH DIVISIONPROTECTING AND PROMOTING HEALTH AND EQUITY
POPULATION HEALTH DIVISIONPROTECTING AND PROMOTING HEALTH AND EQUITY
San Francisco Department of Health Population Health Division
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Diagnosis and Treatment of TB Infection in the Homeless Population: San Francisco TB Program
ExperienceJulie Higashi, MD PhD, TB Controller
San Francisco Department of Public HealthPopulation Health Division
Disease Prevention and Control BranchAugust 14, 2014
San Francisco Department of Health Population Health Division
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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
San Francisco Department of Health Population Health Division
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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
San Francisco Department of Health Population Health Division
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TB & Homeless Task Force Developed in 2000 to Produce Guidelines
San Francisco Department of Health Population Health Division
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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
San Francisco Department of Health Population Health Division
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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
San Francisco Department of Health Population Health Division
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Strategies
• Keep It Simple, Stupid (K.I.S.S. method)• Make it funny/eye catching• Make it sustainable• Create guides for every level
• Directors - Guidelines/Policies• Supervisors -Flow Charts• Line staff -Easy to read accessible messages • Clients -Handouts/Posters
• Revisit shelter frequently and review a few topics at a time
• Be available for ongoing support and advise
San Francisco Department of Health Population Health Division
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BUGS YOU SHOULD KNOW
TBTUBERCULOSIS
THE ILLNESSES:TUBERCULOSIS (TB)
THE SYMPTOMS:Coughing, fevers, feeling tired, losingweight, soaking sweats at night
THE GERM:A bacteria that can infect any part ofthe 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 yearAnd... cover coughs!
MEDICATION:Specially prescribed antibiotics takenover 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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CHANGES System
• Tracking system using fingerprint imagesContains:– Demographics with a photo– Where you are (what shelter, what bed)– History in the system– Some Narrative information– Annual Tb clearance information
• Marked in RED on profile that pops up each time accessed• Clients have a 10 day window to get clearance (at entry
or if expires)– Critical alerts
Flowchart: Evaluation to Treatment of LTBI
Evaluate for active TB
At-risk person
TB test + symptom review
Negative Positive
Chest x-ray
Normal Abnormal
Treatmentnot indicated
Candidate for Rx of latent TB
San Francisco Department of Health Population Health Division
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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
San Francisco Department of Health Population Health Division
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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 Follow-up Data Entry
TST or QFT negative and asymptomatic
• None (until following year)
• Provide green TB clearance card
Enter shelter clearance date in the LCR
TST or QFT+ and asymptomatic
• Chest x-ray • Medical evaluation at
TB Clinic (refer with TB47 form)
TB Control enters shelter clearance date or clinical alert in the LCR
Symptomatic • New chest x-ray • Urgent medical
evaluation • TST or QFT
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
San Francisco Department of Health Population Health Division
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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, end-stage renal disease and HIV
• If new risk present, repeat chest x-ray annually if patient remains untreated
HIV+/ TST or QFT+ Completed preventive treatment
• Annual symptom review • Low threshold to repeat CXR
HIV+/ TST or QFT+ 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)
San Francisco Department of Health Population Health Division
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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)
San Francisco Department of Health Population Health Division
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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 from unpublished cost effectiveness analysis of QFT in San Francisco.3San 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
San Francisco Department of Health Population Health Division
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Homeless Cases, 2005-2013
Year Shelter SRO Street/Other
City Private
2005 (n=17) 3 (18%) 0 7 (41%) 7 (41%)
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
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Characteristics SF City Shelter Cases, 2005-2012 (1)
City Shelter
SRO
Pulm. Smear + 47% 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)
CityShelter
SRO
Converters 1 8
Clustered Cases1 0 92
1Clustered to another case in the same shelter or SRO at any time, 2005-2012.
2Two clusters.
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Collaboration is key
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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
San Francisco Department of Health Population Health Division
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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
San Francisco Department of Health Population Health Division
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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?
San Francisco Department of Health Population Health Division
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CDC guidelines: IGRA testing
• IGRA (Tspot or QFT) preferred test for BCG vaccinated or unlikely to return for TST reading
• TST preferred test in children < 5 yo• No preference for HCW screening, contact
investigations, other populations
San Francisco Department of Health Population Health Division
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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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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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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
San Francisco Department of Health Population Health Division
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Strategies: Directly observed preventive therapy (DOPT)
• Directly observed therapy regimens:– Biweekly INH 900 mg (mon-thurs, tues-fri) x 6-
9 months– Weekly INH/rifapentine 900mg/900mg x 12
weeks– Daily dosing at opiate replacement clinic
San Francisco Department of Health Population Health Division
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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
San Francisco Department of Health Population Health Division
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Treatment Regimens for Latent TB Infection
Drug(s) Duration Interval Minimum Doses
Isoniazid 9 months Daily 270
Twice weekly 76
6 months Daily 180
Twice weekly 52
Isoniazid & Rifapentine
3 months Once weekly 12
Rifampin 4 months Daily 120
San Francisco Department of Health Population Health Division
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Drug drug interactions with rifamycins
• ARVs (antiretroviral agents)• Oral contraception• Narcotics• Antipsychotics• Chemotherapeutic agents• Immune suppression for organ transplant
San Francisco Department of Health Population Health Division
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LTBI regimens: SF 2012-2013Cohort: All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason.
3HP* % INH %INH + RIF % RIF %
Started Treatment 71 295 50 180
Completed 60 85% 213 72% 44 88% 154 86% Adverse Reaction 3 4% 2 1% 0 0% 2 1%Chose to Stop/Lost/Refused 8 11% 64 22% 5 10% 19 11%Moved 0 0% 6 2% 0 0% 2 1%Provider Decision 0 0% 2 1% 0 0% 1 1%Other 0 0% 8 3% 1 2% 2 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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•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
Monitoring LTBI treatment
San Francisco Department of Health Population Health Division
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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
San Francisco Department of Health Population Health Division
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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.
San Francisco Department of Health Population Health Division
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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/
San Francisco Department of Health Population Health Division
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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
POPULATION HEALTH DIVISIONPROTECTING AND PROMOTING HEALTH AND EQUITY
POPULATION HEALTH DIVISIONPROTECTING AND PROMOTING HEALTH AND EQUITY
San Francisco Department of Health Population Health Division
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Practical Issues
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San Francisco Department of Health Population Health Division
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Aerosol Transmissible Disease Guidelines
San Francisco Department of Health Population Health Division
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San Francisco Department of Health Population Health Division
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Aerosol Transmissible Disease Guidelines
San Francisco Department of Health Population Health Division
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San Francisco Department of Health Population Health Division
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Add easy to follow flow sheets to policies
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Screen clients at check-in time:• Do you have a sore throator a cough and fevers?• Do you have any spots ora rash on your body?• Shortness of breath?• Severe vomiting?
If a client’s behavior or health doesnot seem ‘normal’ to you, that’sa good enough reason to look formedical care for that person.
Help arrange for clients to seea Medical Provider as soon aspossible 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 guttells you to. Clients may refuse togo in the ambulance, but they can’trefuse your decision make the call.
KNOWSICKWHEN YOUSEE IT,AND ACTIF IT DOESN’T SEEM RIGHT,IT PROBABLY ISN’T
WHEN IN DOUBT, TRANSFER OUT
San Francisco Department of Health Population Health Division
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COVERYOURCOUGHSANDSNEEZESWITH YOUR ARMOR ELBOW
REMINDOTHERSTO DOTHE SAME
Get in the habit of coughing andsneezing into your arm or elbow.It’s like wearing a seat belt; you willsoon do it naturally.
Coughing or sneezing into your handsis grosser than spitting on them.
“Airborne Illnesses” are germs thatspray into the air. If they hit a hardsurface like your arm they willprobably die.
San Francisco Department of Health Population Health Division
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Resources
• Tb and ATD Guidelines for Shelters can be found at:http://www.sfcdcp.org type in ATD in the search field
• For more information on SF Shelter Health and Wellness contact:
Kathleen Murphy Shuton, RN, PHNSan Francisco Department of Public HealthHomeless Family Team CoordinatorShelter Health Program Coordinator101 Grove, Room 118San Francisco, CA 94102415 355-7511 phone
• Email: [email protected]