Prevent the transmission of tuberculosis (TB) and cure individuals with active TB disease

Transcription

1 Tuberculosis (TB) Control and Prevention Program Program Purpose Program Information PHD/CHPB Evelyn Poppell, x5600 Nga Nguyen, x5663 Prevent the transmission of tuberculosis (TB) and cure individuals with active TB disease PM1: How much did we do? Tuberculosis is spread when a person with active TB disease coughs. Risk factors include prolonged contact (~8 hours or more) with a person with TB disease, or travel to an area with high risk of TB. This mandated program serves two populations: 1. Active TB disease: those infected with TB bacteria with symptoms of TB disease including a bad cough that lasts 3+ weeks, coughing up blood or sputum, sweating at night, and weight loss. They are able to spread TB to others. 2. Latent TB infection (LTBI): those infected with TB bacteria who are without symptoms and cannot spread it to others. Progression from latent to active TB is most likely in children, those with chronic diseases such as diabetes, and those recently infected. The program treats all with active TB to prevent disease spread, and prioritizes LTBI treatment for those most at risk for progression to active TB. o Treatment typically takes 6 to 9 months. Treatment completion is critical to prevent bacteria in the person from becoming medication-resistant. Treatment of medication-resistant TB can take up to 2 years. o Directly Observed Therapy (DOT) is the CDC standard of care for active TB to assure completion. DOT staff observe the client in the home or workplace taking their medication. DOT is provided in 2 phases: the Initial phase (5 to 7 days/week for up to 2 months) when the risk of transmission is the highest and the Continuation phase (2 days/week for the remainder of treatment) when lab results indicate reduced risk. Arlington provides DOT for non-residents working in the County to ensure compliance; other jurisdictions do the same. The TB program s services are based on the Virginia Department of Health (VDH) and Centers for Disease Control and Prevention (CDC) guidelines: o Clinic services include laboratory testing, radiology, physician consultation, and referrals. Environmental and infection prevention controls are used to prevent disease transmission in the clinic. o Case management services for clients with active TB may include arranging temporary housing for isolation and referring to other DHS services to ensure compliance with isolation and treatment until cure. o Outbreak investigation and screening occurs at congregate settings such as schools, worksites and nursing homes to identify those exposed to clients with new, active TB disease. The program is partially funded by a grant from CDC. Partners: VDH, Division of Consolidated Laboratory Services (DCLS) and other labs, Virginia Hospital Center, and community medical providers. Staff Total 9 FTEs: o 1 FTE Supervisor o 1 FTE Senior Public Health Nurse TB Control and Prevention Program Page 1

2 o 2.75 FTE Public Health Nurses o 2.5 FTE Outreach Workers o 1 FTE Clinic Aide o 0.75 FTE Pharmacy Technician Contractors o X-ray Technician (8 hrs. per week) o Transcription services (varies) o TB Consultant (2-3 hrs. per week) Customers and Service FY 2013 FY 2014 Clients (unduplicated, all services)* 1,205 1,296 1,273 Total Active TB Cases on Treatment New Active TB Cases (diagnosed in Arlington or transferred from other jurisdictions) With Latent TB on treatment Not available Not available Not available Visits (all settings) 4,055 4,999 5,245 DOT Visits** 2,437 1,251 1,289 X-ray services *Clients who do not have active or latent TB are also served in the Chest Clinic with services including tuberculin skin tests, chest x-rays, and letters for employers certifying that they are free of active TB **Variation in numbers is due to reduced demand for DOT for residents from other jurisdictions PM2: How well did we do it? 2.1 Clients with active TB disease who were started on the recommended treatment regimen and initiated DOT 2.2 Identified contacts to an active TB case who were assessed to determine their infection status 2.3 Clients with active TB disease who met the criteria for a safe hospital discharge to the community PM3: Is anyone better off? 3.1 Clients with active TB who completed or are on schedule to complete treatment according to protocol 3.2 Clients with latent TB infection starting medications who completed or are on schedule to complete treatment according to protocol TB Control and Prevention Program Page 2

3 Measure Clients with active TB disease who were started on the recommended treatment regimen and initiated DOT Percent of clients with active TB disease who were started on the recommended treatment regimen and initiated DOT Goal = /15 Clients for were obtained via medical record review. All clients with clinically suspected or confirmed active TB disease who were recommended to begin treatment during the fiscal year are included in the figures for that year. What is the story behind the data? All clients with active TB disease were successfully started on treatment and DOT. Challenges to meeting this goal included: o TB disease diagnosed at sites other than the lungs has a low risk of spread, accounting on average for up to 3 of all TB cases. Treatment for these clients is not mandated. o When active cases cannot be found for DOT, staff notify VDH and work diligently to locate clients and get them back on treatment. o If clients have travel plans at time of diagnosis/treatment, staff work closely with the client, private providers, VDH, and the CDC Quarantine Station to monitor the situation and ensure that client is noncommunicable prior to flying. Continue case management. There is no national standard for time from suspicion/ confirmation to treatment start. In FY 2016, the program will review time to treatment data and identify a target timeframe. Construct Active TB Disease base to streamline data collection in future. Treatment start and DOT rates are expected to remain the same in FY TB Control and Prevention Program Page 3

4 Measure 2.2 Identified contacts to an active TB case who were assessed to determine their infection status Percent of identified contacts to an active TB case who were assessed to determine their infectious status % 26% Goal =93% Virginia=78% 6 91% 74% 286/313 Contacts Assessed Yes No for were obtained via review of contact investigation forms (TB-502) that are submitted to VDH. The Virginia average contact assessment rate is based on statewide performance for CY The National TB goal is 93%. What is the story behind the data? Staff utilize a range of strategies to encourage contacts to get tested, including education, placing calls, sending letters, and making home visits. The 91% success rate in is an anomaly. One of the cases investigated included 200 contacts, representing 2/3 of contacts assessed in. This investigation involved students at an Arlington high school, where parents ensured their children were tested and testing occurred during the school day. This is in contrast to other settings involving adult contacts. The challenge to a successful contact investigation is that there is no legal authority to compel testing of contacts. Continue to research and explore strategies to encourage contacts to get assessed/tested. Construct Active TB Disease base to streamline data collection in future. Contact assessment rate in FY 2016 is expected to be lower than and more in line with CY 2013 (74%) and VDH rates. TB Control and Prevention Program Page 4

5 Measure Clients with active TB disease who met the criteria for a safe hospital discharge to the community Percent of clients with active TB who met the criteria for a safe hospital discharge to the community Goal = /7 Clients were obtained via medical record review. All clients who met the following criteria are included: a) suspected or confirmed active TB disease, b) recommended to begin treatment during the fiscal year, c) were admitted to the hospital, and d) were Arlington residents. What is the story behind the data? All clients with active TB disease met the criteria for a safe discharge to the community. The program worked to establish a discharge checklist with VHC and other local hospitals and to ensure a safe discharge to the community. The principal criteria are: 1) Client has an approved treatment plan. 2) The case manager visits the client in hospital to discuss Public Health role in providing care to client as well as protecting the community, including the need for the client s isolation at home to prevent spread of disease. 3) The case manager visits the client s home to make sure it is appropriate for isolation. If home is unsuitable (e.g. young children living in the house), the case manager works with EID and VDH to find alternate housing. 4) The client s discharge treatment plan is signed off by the PHD medical director/designee. Delays in client discharge from hospital may occur due to non-tb related health conditions. Stay the course. There is no national standard for time from local health department notification of TB disease to discharge. Starting in FY 2016, the program will: o Collect data on time from notification by a hospital to time by which PHD has met discharge criteria o Identify and propose solutions to any PHD-related causes for delays to discharge o Identify a target timeframe Construct Active TB Disease base to streamline data collection in future. Safe hospital discharge rate is expected to remain the same in FY TB Control and Prevention Program Page 5

6 Measure Clients with active TB who completed or are on schedule to complete treatment according to protocol Percent of clients with active TB who completed or are on schedule to complete treatment according to protocol Goal =93% 63% 63% 37% 37% 19/19 Clients Completed On schedule Did not complete for was obtained via medical record review. All confirmed cases of active TB disease who received treatment during the fiscal year are included in the figures. Determination of treatment completed is made by TB physician based on treatment protocol and client condition, not on length of treatment. On schedule totals include clients who were on schedule to complete treatment at the time that they left Arlington or died. Three on-schedule clients died or departed Arlington in. 93% goal is set by VDH. What is the story behind the data? All clients on treatment in either already completed treatment or are on target to complete treatment. Stay the course. Construct Active TB Disease base to streamline data collection in future. Treatment completion rates are expected to remain the same in FY TB Control and Prevention Program Page 6

7 Measure Clients with latent TB infection starting medications who completed or are on schedule to complete treatment according to protocol Percent of clients with latent TB infection starting medications who completed or are on schedule to complete treatment 17% 14% 14% Goal =85% 22% 22% 43% 64% 64% FY /197 Clients 240/280 Clients Completed On schedule Not on schedule Percent of clients with latent TB infection starting medications who completed or are on schedule to complete treatment by treatment type 82% 89/109 84% 74/88 91% 81% 114/ /155 Goal =85% 81% 91% FY 2014 INH or Rif 3-HP on clients with latent TB infection is maintained in a separate database. Case managers update the database with treatment progress. LTBI treatment may cross fiscal years and as such, clients may be duplicated across fiscal years. CDC has a goal of 75% for LTBI treatment completion. Because data includes clients who completed or are on schedule to complete, a higher goal of 85% has been set. TB Control and Prevention Program Page 7

8 What is the story behind the data? PERFORMANCE PLAN Overall, the percent of clients who completed or are on schedule to complete LTBI treatment is 86%, exceeding the goal of 85%. There are 3-month (3HP), 4- to 6-month (Rif), and 9-month (INH) LTBI treatment options. Compliance is highest for the 3-month option. Those clients eligible for 3HP who opt to take INH instead may do so because 3HP requires clients to take 9 pills at once during DOT. VDH is currently providing 3HP free of charge. Stay the course. In FY 2016, the program will collect data on the number of clients that are eligible for 3HP but request INH instead and explore ways to encourage selection of 3HP. Completion rates are expected to remain approximately the same in FY TB Control and Prevention Program Page 8