Tuberculosis (TB) Control and Prevention Program Program Purpose PHD/CHPB Evelyn Poppell, x5600 Rachel Kidanne, x5605 Prevent the transmission of tuberculosis (TB) and cure individuals with active TB disease Program Information Tuberculosis is spread when a person with active pulmonary 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 a TB burden. This mandated program serves two populations: 1. Active TB disease: those infected with TB bacteria with symptoms of TB disease. Those with pulmonary TB can 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 of active TB disease 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 Centers for Disease Control and Prevention s (CDC) standard of care for active TB to assure completion. Staff observe the client in the home or workplace taking their medication. DOT is provided in 2 phases: - Initial phase (5 days/week for up to 2 months) when the risk of transmission is the highest - 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 reciprocate. The TB program s services are based on the Virginia Department of Health (VDH) and 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 o services to ensure compliance with isolation and treatment until cure. 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 private medical providers. TB Control and Prevention Program Page 1
PM1: How much did we do? Staff Total 8.25 FTEs: o 1 FTE Supervisor o 1 FTE Senior Public Health Nurse o 2.5 FTE Public Health Nurses o 2 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 Clients (unduplicated, all services)* 1,273 914 862 Total Active TB Cases on Treatment (includes all confirmed and suspected cases that received treatment) New Active TB Cases (diagnosed in Arlington or transferred from other jurisdictions) 19 22 20 12 14 14 With Latent TB on treatment 280 200 204 Visits (all settings) 5,245 3,754 3,730 DOT Visits 1,289 1,376 1,524** X-ray services 542 431 509 *Clients who do not have active or latent TB are also served in the Chest Clinic. Services include and are influenced by the number of contacts to active TB cases, tuberculin skin tests, chest x- rays, and letters certifying that individuals are free of active TB. In, there was a large contact investigation, affecting the number of clients and visits for that year. ** Increase in DOT visits attributed to an increase in complex TB cases on extended treatment (DOT 5 days a week from 9-12 months) 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
Measure 2.1 Clients with active TB disease who were started on the recommended treatment regimen and initiated DOT Percent of clients with suspected active TB disease who were started on the recommended treatment regimen and initiated DOT Goal = 6 4 2 15/15 Clients 12/12 Clients 14/14 Clients for and from the Active TB base. for were obtained via medical record review. All Arlington residents with clinically suspected or confirmed active pulmonary or extrapulmonary TB disease, who were recommended to begin treatment during the fiscal year, are included in the data. Clients transferred to Arlington already on treatment are not included. All clients with active TB disease were successfully started on treatment and DOT. Challenges to meeting this goal include: o Client cannot be located. In such cases, staff notify VDH and work diligently to locate clients and get them on treatment. o Client has underlying medical conditions that delay treatment start (e.g. advanced cancer, HIV). o Clients with non-infectious TB may refuse treatment. Treatment is not mandatory unless infectious. Stay the course Treatment start and DOT rates are expected to remain the same in FY 2018. TB Control and Prevention Program Page 3
Measure 2.2 6 4 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 9% 29% 24% 24% 91% 286/313 Contacts Assessed 71% 76% 76% 47/66 Contacts Assessed Goal =93% 92/121 Contacts Assessed Fully Assessed Not Fully Assessed CDC s 2020 National TB Indicator target for complete evaluation of contacts to infectious TB cases is 93%. for and were obtained from the Active TB base for cases of pulmonary and laryngeal tuberculosis. for were obtained via review of contact investigation forms (TB-502) submitted to VDH. NOTE: VDH s target in was 78%. VDH deleted this State target; now follows CDC targets. In, 76% identified contacts were fully assessed. Of the remaining 24%, more than half received at least baseline TB screening. The greatest challenge to assessing contacts is the lack of a legal mandate compelling TB screening (compared to clients with suspected TB disease). Staff utilize a range of strategies (e.g. phone calls, letters, home visits) to encourage contacts to be screened Researched best practices with VDH and no new strategies were identified. The 91% success rate in was an anomaly. One of the cases involved contact with students at an Arlington high school, where parents ensured their children were screened, which occurred during the school day. This investigation included 200 contacts. Stay the course Contact assessment rate in FY 2018 is expected to be in line with rate. TB Control and Prevention Program Page 4
Measure 2.3 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 =9 25% 6 4 75% 2 7/7 Clients 1/1 Clients 3/4 Clients for and was obtained from Active TB database. for was 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. Criteria to ensure a safe discharge from a hospital to the community include: 1) Client has an approved treatment plan that is signed off by the PHD director. 2) The case manager visits the client in hospital to discuss PHD role in providing care to client, 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 In, one client was hospitalized out-ofstate and case manager was unable to visit. Stay the course. Continue to review cases where all the criteria for safe hospital discharge have not been met to find the reasons for any delay or unsafe discharge. Safe hospital discharge rate for FY 2018 is expected to be in line with and FY 2016. TB Control and Prevention Program Page 5
Measure 3.1 6 4 2 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 63% 47% 37% 19/19 Clients 5% 6% 6% 47% 18/19 Clients 59% 59% 35% 35% 16/17 Clients Completed On schedule Did not complete for and was obtained from the Active TB base for was obtained via medical record review Includes confirmed cases of active TB who received treatment during the fiscal year. Does not include cases suspected of active TB on treatment 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. One extrapulmonary (non-infectious) client in FY 2017 refused to complete treatment despite numerous efforts (e.g. multiple home visits, phone calls, letters) by ACPHD and VDH. Under Virginia Code, only infectious TB clients can be court ordered to take TB treatment. Stay the course. Treatment completion rates are expected to remain the same in FY 2018. TB Control and Prevention Program Page 6
Measure 3.2 6 4 2 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 14% 18% 15% 15% 22% 64% N=280 3 35% 35% 53% 5 5 N=200 N=204 Goal =85% 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 6 81% 126/155 91% 114/125 98/123 86% 67/78 84% 109/130 86% 64/74 Goal =85% 84% 86% 4 2 N=280 N=200 N=204 (proj) 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. TB Control and Prevention Program Page 7
CDC has a goal of 83% for LTBI treatment completion. Because data includes clients who completed or are on schedule to complete, a higher goal of 85% has been set. Overall, the percent of clients who completed or are on schedule to complete LTBI treatment is 85%. There are multiple LTBI treatment options: o 3-month (3HP) o 4 to 6-month (Rif) o 9-month (INH) Compliance is highest for the 3-month option. VDH is currently providing all three preventative medications free of charge. Stay the course. Completion rates are expected to remain approximately the same in FY 2018. TB Control and Prevention Program Page 8