January 25, 2 Improving LTBI Treatment by Telephone Monitoring: Kaiser Santa Clara s Program Ken Purdy, M.D. Pediatric Infectious Diseases Kaiser Santa Clara, California TB Case Rates by Reporting Jurisdictions in California Counties, 07 00,000 population Rate per 8 6 2 0 8 6 2 0 7.7 6.6 3..9 5 0.5 9.0 8. Santa Clara County had the third highest TB case rate in the California 7.9 7. 7.0 7.2 Reporting Jurisdictions Source: California Department of Health Services, California Department of Public Health, Division of Communicable Diseases, TB Control Branch, 07. California Department of Finance, Demographic Research Unit TB Case Counts in Santa Clara County, 07 A View from the Private Sector of 5
TB Case Counts in Santa Clara County, 07
January 25, 2 Santa Clara County s Foreign-Born TB Cases by Country of Birth, 07 Ethiopia (2%) Other* (%) N = 27 Peru (2%) China (7%) 5 5 5 23 Vietnam (29%) 62 Mexico (%) 23 India (5%) 32 5 Philippines (2%) Source: SCC Public Health Department, Epidemiology and Data Management, 07 * Other category includes countries with fewer than 5 TB cases POLL: What is the most common barrier parents express in refusing LTBI treatment?. Fears about the toxicity of INH 2. Disbelief that child has LTBI: their X-rays are normal and the child is asymptomatic 3. Perception that the positive PPD is a false positive (the child received BCG n years ago). Parent may lack understanding purpose of INH (to prevent active TB in the future) 5. Other Treating Pre-Adults for LTBI Are children and teens more likely to complete LTBI treatment than adults? Parents may perceive greater benefit to the same intervention if it involves their child Similar phenomenon appears to occur with recommended vaccines and with treatment for chronic diseases like diabetes A breakdown in compliance may occur with socioeconomic, cultural, or teen barriers A View from the Private Sector 2of 5
January 25, 2 Our LTBI Treatment Program Run by one MD and one RN Only children with positive PPDs and without exposures to active TB cases are eligible Enrolled when a new positive PPD is read The LVN who reads the positive PPD orders chest x-rays in my name and forwards results to me (MD) I review chest x-rays, then forward chart to primary care provider recommending (a) LTBI treatment, (b) repeating the films, or (c) referring the patient to me The provider orders INH based on a table from Ann Loeffler (a 3-month supply with 2 refills), then forwards chart to our TB nurse, Chris Rodriguez How Patients Are Followed Our nurse, Chris, provides her phone number for parents to call for suspected side effects She calls month after INH is picked up to ask the parents how things are going (perceived barriers, self-reported missed doses) Calls at months (time of first INH refill) Documents if patient has refilled the bottle (can see from electronic pharmacy record) Asks me to call some parents to encourage them Calls at 7 months (second refill) Calls at 0 months (completion) Outcomes Among Enrollees Most patients do not comply with the 9 months of INH preventive therapy Some openly refuse within the first 3 months, but most do not overtly refuse LTBI treatment Some patients move away or otherwise are lost to follow-up (some likely screen their calls) Rarely, some BCG recipients request a Quantiferon TB Gold and are found to be negative (likely have false positive PPDs) Even so, rates of completion have risen since we started the program A View from the Private Sector 3of 5
Outcomes of INH Completion Program by Year 60 0 00 0 08 80 60 0 8 0 5 9 2 22 9 Year of Program 3 Incomplete Refused False positives Complete Patients (n)
January 25, 2 Outcomes of INH Completion Program by Year ients (n) Pati 60 0 00 0 08 80 60 0 8 5 9 0 9 2 Year of Program 3 Incomplete Refused False positives Complete 22 Outcomes of 3 Patients, 5.% 6.3% 2.8% 75.5% Incomplete False positives Refused Complete Getting Buy-In From Our Doctors We had to teach our physicians that: Most patients with active TB are infected in childhood (especially the foreign-born) Time/costs of treating LTBI are less than time/costs of treating active TB cases and tracking down and treating contacts Time invested in explaining the benefits and risks of INH preventive therapy is well spent Treatment-resistant parents could be referred to me Program doesn t depend on MD referral The chest x-rays are referred to me and I learn about cases who have not been followed up from Chris A View from the Private Sector of 5
January 25, 2 Our Interaction with Public Health When I identify an LTBI case linked to an active TB case, I notify our county TB program to find out if we have susceptibilities on the index case Our TB nurse makes sure each LTBI case or exposure is reported (or that the patient s MD has documented reporting the case) Julie and her TB team refer many of the exposed children to us They let us know about drug-resistant TB cases We interact a lot about children who move to new counties or who have drug-resistant source case (or cavitary disease source case) Maintaining the Program What helps sustain our program? Interested physician and nurse Don t have to have an ID specialist or pulmonologist or a nurse with public health experience, but helpful We have attended CME programs on TB (Curry Center, IDSA): few days per year Our management supports our time Both Chris and myself spend relatively little of our work hours doing the initial enrollment and follow-up 50 patients per year (0 to 60 minutes per patient per treatment course) = 2 to 8 work days Having electronic records helps but is not required We want to see fewer active cases of TB A View from the Private Sector 5of 5