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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.
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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
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 Outline
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 Homeless TB Screening in San Francisco
TB & Homeless Task Force Developed in 2000 to Produce Guidelines
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 TB Screening Policy
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
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
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 BUGS YOU SHOULD KNOW TB TUBERCULOSIS
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 Screening Sites
CHANGES System • Tracking system using fingerprint images Contains: • 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 At-risk person TB test + symptom review Negative Positive Chest x-ray Normal Abnormal Candidate for Rx of latent TB Treatment not indicated Evaluate for active TB
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 TB Screening and Evaluation Process
Initial Screening LCR = Lifetime Clinical Record, DPH EHR
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) Clearance
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 TB Program Costs – Assumptions and Estimates (1) 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.
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 TB Program Costs – Assumptions and Estimates (2) 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.
Characteristics SF HSA Shelter Cases, 2005-2012 (2) 1Clustered to another case in the same shelter or SRO at any time, 2005-2012. 2Two clusters.
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 Other Benefits (1)
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 Other Benefits (2)
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? Questions for the future…
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
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
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
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
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 Strategies: Directly observed preventive therapy (DOPT)
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 Strategies:Incentives/Enablers
ARVs (antiretroviral agents) Oral contraception Narcotics Antipsychotics Chemotherapeutic agents Immune suppression for organ transplant Drug drug interactions with rifamycins
LTBI regimens: SF 2012-2013 *Includes both TB Clinic and Study 33 patients
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
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
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 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. Summary
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/ Resources
Jennifer Grinsdale, MPH, Public Health Informatics Officer, SFDPH Masae Kawamura, MD Christine Ho, MD Sheila Davis-Jackson, TB Clinic Manager Kate Shuton, RN, PHN Acknowledgements
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.
COVER YOUR COUGHS AND SNEEZES WITH YOUR ARM OR ELBOW REMIND OTHERS TO DO THE SAME 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.
