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Genotype Cluster Investigation Within A Homeless Population

Genotype Cluster Investigation Within A Homeless Population. Lucinda Gardner, MSPH Epidemiologist Communicable Disease Control. Objectives. Overview of a LHD experience with a complex case/contact investigation

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Genotype Cluster Investigation Within A Homeless Population

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  1. Genotype Cluster Investigation Within A Homeless Population Lucinda Gardner, MSPH Epidemiologist Communicable Disease Control

  2. Objectives • Overview of a LHD experience with a complex case/contact investigation • Describe how to implement a novel referral strategy to improve contact investigations • Identify community partners that can help with contact investigation in hard-to-reach populations

  3. TB in Sonoma County

  4. TB in Sonoma County • Typically see 9-13 active TB cases per year (average 10) • In 2017, 7 cases; 1.4 cases per 100,000 • In 2016, 12 cases; 2.4 cases per 100,000 • Rank 33rd among CA Counties • Age range 23-87 (all but 3 aged 40 years or younger) • 71% non US-born

  5. Sonoma County TB Program • TB cases are managed within the Communicable Disease Program • 1 dedicated PHN • 1 part-time MD • 1 part-time CDI • 4 other PHNs available to support investigations • Epi support as needed

  6. Sonoma County TB Case Management • Sonoma follows the CDPH/CTCA Joint Guidelines for TB Case Management: Core Components. • Utilizes CDPH expertise and Francis Curry International Tuberculosis Center when necessary. • Relies on the collaboration with community partners to treat cases. • Providers refer suspect cases to Sonoma County Public Health (SCPH) • ~60 per year • Reviewed by PHN and MD • If criteria met, request sputum • Specimens tested by Sonoma County Public Health Laboratory • SCPH provides medical oversight for all cases and case management for most cases • Work with primary care for other health conditions • SCPH staff assigned for DOT • Contact investigations handled by Sonoma County Public Health

  7. Case Characteristics Case 1 • Aug 2015, incidental finding of cavitary pulmonary nodule on CT • TB follow up recommended but not done • Hospital did not notify PH • Sept/Oct 2017, +PPD, +CXR reported to PH • Jan 2018, LTFU/Non-compliant with TB treatment • May 2018, resurfaced with symptoms, 3+, hemoptysis weight loss • Currently on DOT set to complete in early spring 2019

  8. Case Characteristics Case 2 • Jan 2018 presented to clinic with COPD exacerbation and wheezing • Feb 2018, another visit for cough/resp. PPD placed (no reading) • Mar 2018, another visit for COPD exac. and LE swelling. QFT done (positive). CXR ordered. • Apr 2018, another visit for CHF, LE swelling • May 2018, CXR completed, abn (looked like CHF, blood work showed CHF, reported to PH) • July 2018, 4+ • On DOT set to complete in late spring 2019

  9. Cluster Investigation • Common factors: • Genetic match • Homeless • Smoke cigarettes • Use methamphetamines • Lived same region of the county • However: • No clear link • Could not identify overlapping social network • Named contacts are very difficult to track down • Complications: • Distrust of government • Important to stay in region (wooded area, rural) • Gang affiliation (1 case) • Resistance to western medical practices (chest x-rays, antibiotics)

  10. Timeline and CDPH Assistance

  11. Action Plan – Targeted Health Outreach • Offer screening for priority diseases • TB, HIV, Syphilis • Vaccination clinic • Influenza, Hepatitis A • Possible opportunity to enroll participants for Whole Person Care • Refer known contacts to events for screening

  12. Results – Health Screening Prior to Outreach • 20 contacts identified and tested • 8 reactors, 12 negative Screening Clinics 2 locations, 2 dates, 36 participants • 29 homeless • 29 screened for TB (25 homeless) • 21 gift cards issued • Several high risk contacts to Case#2 • 4 reactors • 7 screened for Syphilis (all negative) • 12 screened for HIV (all negative)

  13. Lessons Learned • Utilization of community partners • Natalie, RN homeless outreach nurse at RRHC • Cooperation with jail • Hospital relationship • CDPH assistance • Value of building relationships • Build trust, needed multiple encounters • Incentives • Meet people where they are • Flexible • Remember the larger goal

  14. Thank you and Disclosures This presentation reflects the hard work and dedication of the Sonoma County Communicable Disease Team, including the following: Rebecca Purcell, PHN Mary Miller, PHN Lindsey Totah, PHN Arcelia Reyes-Delgado, PHN Miranda Patrick, PHN Emely Hernandez, PHN Alan Powell, PHI Johanna Ruiz, PHN Bob Benjamin, MD MPH Karen Holbrook, MD MPH As well as our community partners and the extensive guidance and assistance from CDPH. I, the undersigned, declare that within the past 12 months neither I, nor any immediate member of my family, have had a financial relationship or any conflict of interest with any commercial interest that may have a direct bearing on the subject matter of the CME activity. In addition, I do not intend to include information or discuss investigational or off-label use of pharmaceutical products or medical devices. Lucinda Gardner, MSPH, Epidemiologist Sonoma County Department of Health Services (707) 565-4533 lucinda.gardner@sonoma-county.org

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