Diagnosis and Treatment of TB Infection in the Homeless Population: San Francisco TB Program Experience

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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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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

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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

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TB Homeless Task Force Developed in 2000 to
Produce Guidelines
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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

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Aerosol Transmissible Disease Guidelines
Translating Policy to Practice

• All shelters are required to comply with
  Californias 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

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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

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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 clients TB clearance
up to date (thats 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
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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 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

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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
Evaluate for active TB
Treatment not indicated
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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

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TB Infection Prevalence By Test and Clinic Type
Homeless TB Clinic Methadone Methadone Immigrant
TST (2001-2003) 26 50 50 10 37
QFT-1 (11/03-2/05) 17 n1848 48 n292 48 n292 18 n346 37 n344
QFT-G (3/05-11/08) 7 n9166 23 n4042 23 n4042 4 n1261 14 n2505
QFT-IT (4/08-2/09) 6 n1625 22 n1555 22 n1555 ___ 20 n323
Decline in positive rate from TST ? 73 ? 54 ? 54 ? 60 ? 62
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Initial Screening
LCR Lifetime Clinical Record, DPH EHR
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Annual Follow-up Screening
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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)

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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.
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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.
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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
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Homeless Cases, 2005-2013
Year Shelter Shelter SRO Street/Other
City Private
2005 (n17) 3 (18) 0 7 (41) 7 (41)
2006 (n22) 2 (9) 1 (5) 11 (50) 8 (36)
2007 (n25) 3 (12) 1 (4) 12 (48) 9 (36)
2008 (n15) 3 (20) 0 5 (33) 7 (47)
2009 (n15) 0 0 6 (40) 9 (60)
2010 (n7) 1 (14) 1 (14) 2 (29) 3 (43)
2011 (n11) 4 (36) 0 5 (46) 2 (18)
2012 (n12) 0 0 8 (67) 4 ( 33)
2013 (n18) 2 0 4 12
Total (n142) 18 (13) 3 (2) 60 (42) 61 (43)

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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
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Characteristics SF HSA Shelter Cases, 2005-2012
(2)
City Shelter 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

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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

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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?

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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 lt 5 yo
• No preference for HCW screening, contact
  investigations, other populations

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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 lt 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 -gt risk for
  progression 1/3
• Foreign born with active tobacco use -gt risk for
  progression 1/4
• Foreign born/US born with immune suppression
• Medications (biologics, organ transplant) -gt
• Cancer -gt variable
• HIV (universal testing)-gt 10 per year risk of
  progression
• Converters
• Contacts
• Medium Priority Foreign Born lt 50

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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

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StrategiesIncentives/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

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Treatment Regimens for Latent TB Infection
Drug(s) Duration Interval Minimum Doses
Isoniazid 9 months Daily 270
Isoniazid 9 months Twice weekly 76
Isoniazid 6 months Daily 180
Isoniazid 6 months Twice weekly 52

Isoniazid Rifapentine 3 months Once weekly 12

Rifampin 4 months Daily 120
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Drug drug interactions with rifamycins

• ARVs (antiretroviral agents)
• Oral contraception
• Narcotics
• Antipsychotics
• Chemotherapeutic agents
• Immune suppression for organ transplant

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LTBI regimens SF 2012-2013
Cohort All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. Cohort All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. Cohort All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. Cohort All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. Cohort All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. Cohort All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. Cohort All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. Cohort All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. Cohort All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. Cohort All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. Cohort 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
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Monitoring LTBI treatment

• monthly review with patient (nurse or pharmacist)
• Initial face to face -gt 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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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)
• gt 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

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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

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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.

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Resources

• San Francisco TB Prevention and Control website
  www.sftbc.org
• Curry International Tuberculosis Center
• TB and Shelter videos - gt here today!
• http//www.currytbcenter.ucsf.edu/

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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

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Practical Issues
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Aerosol Transmissible Disease Guidelines
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Aerosol Transmissible Disease Guidelines
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Add easy to follow flow sheets to policies
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WHEN IN DOUBT, TRANSFER OUT
KNOW SICK WHEN YOU SEE IT, AND ACT IF IT DOESNT
SEEM RIGHT, IT PROBABLY ISNT
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 clients
behavior or health does not seem normal to you,
thats 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. Dont hesitate to call
911 if your gut tells you to. Clients may refuse
to go in the ambulance, but they cant refuse
your decision make the call.
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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. Its 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.
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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 kathleen.shuton_at_sfdph.org