Improved Latent Tuberculosis Therapy Completion Rates in Refugee Patients Through Use of a Clinical Pharmacist Kimberly L. Carter, Pharm.D., BCACP Assistant Professor & Clinical Pharmacist Thomas Jefferson University, Jefferson College of Pharmacy Penn Center for Primary Care Philadelphia, PA

Data presented is from a retrospective chart review of all refugee patients who received medical screening at Penn Center for Primary Care (PCPC) in Philadelphia, PA between August 2011 and April 2016

UPenn Refugee Clinic Opened on October 15, 2010 Partnership between UPenn and HIAS 436 refugees screened since inception 20 Internal Medicine residents, all Global Health or Primary Care track, two “refugee clinic firm chiefs” 4 attending physicians (3 GIM, 1 ID) 1 clinical pharmacist and pharmacy students Specialty clinics: Women’s Health and Pharmacy (LTBI, smoking cessation, OCP)

LTBI Screening While active TB is relatively uncommon, LTBI is very common, present in up to 40% of new arrivals (though this depends on pre-travel risk) 1 For unexplained reasons, migration seems to trigger active disease, with the majority of pts with LTBI seeing their disease reactivate within 5y of migration, half of those within 2 years 2,3 30.9% of Penn Refugee Clinic patients have been QuantiFERON Gold positive (121 LTBI cases; 14 active TB cases) 1 Stauffer WM and Weinberg M. Clin Op in Inf Dis 2009. 22:436-442 2 Barnett ED. Clin Inf Dis. 2004. 39:833-41 3 Stauffer WM. Minn Med. 2007. 90(3):42-6

Creation of the LTBI Clinic By early 2012 clinic staff had identified that although 30.9% of patients screened positive for LTBI, 86% of those patients either did not initiate or did not complete treatment and were lost to follow-up. A quality improvement project was undertaken to improve these measures. A pharmacist-run LTBI clinic was initiated in March 2012 to ensure successful completion rates PharmD visits are free of charge to all refugee patients; visits are 30 to 40 minutes in duration and utilize a telephone interpreter

PharmD LTBI Clinic Standardized treatment: Rifampin 10 mg/kg (max 600mg) x 4 months Responsibilities of the pharmacist: Review diagnosis of LTBI; emphasize the importance of adherence Screen for signs / symptoms of active tuberculosis Provide thorough counseling on rifampin use; discuss benefits and risks of treatment Identify potential barriers to adherence; establish a plan to ensure adherence Counsel on HOW to refill a prescription Screen for adverse drug reactions; evaluate and manage drug-drug interactions Assess adherence via pill counts and refill dates Ensure all vaccinations and labs are up to date

LTBI Four Month Timeline Patients with a (+) QF Gold are sent for Chest X-ray screening Patients with a (-) CXR are sent to PharmD for scheduling Scheduled for treatment initiation within 2 weeks One month follow-up in LTBI Clinic Optional: Monthly follow-up for patients with questionable adherence Final 4 month follow-up in LTBI Clinic; Certificate of Completion Provided All refugee patients have baseline chemistries drawn at their initial screening visit QuantiFERON Gold (QF Gold) is a required lab 1 All patients who complete 4 months of rifampin therapy are reported to the Philadelphia Refugee Health Coordinator at the Department of Health for tracking and statistical purposes

Results: Countries of Origin Total Clinic Demographics since LTBI Clinic Initiation (N = 436) Tuberculosis* Demographics (N = 135) *Combined LTBI + Active

+QFGold Results per Geographic Area 35% 34% 48% 6.5% 11% Other: Afghanistan, Ukraine, Russia, Belarus, Tajikistan, Uzbekistan, El Salvador

LTBI Patient Demographics Int J Tuberc Lung Dis 2017;21(4):432-437

Profile of Study Population Int J Tuberc Lung Dis 2017;21(4):432-437

LTBI Data 2012 - 2016 85 out of 90 patients (94.4%) successfully completed LTBI therapy The remaining 13 completed treatment after the study period Int J Tuberc Lung Dis 2017;21(4):432-437

Interventions Per Geographic Region 36% 54% 36% 63% 71% 17% 67% Int J Tuberc Lung Dis 2017;21(4):432-437

Summary of Findings Prior to the establishment of a pharmacist-run LTBI clinic, less than 20% of patients completed treatment for LTBI; many patients were lost to follow-up Through the implementation of a pharmacist-run LTBI clinic, completion rates have more than tripled; 94% of patients have successfully completed therapy At least 40% of these patients would not have been adherent without PharmD intervention 100% of patients who completed therapy were reported to the Philadelphia Department of Health for tracking and statistical purposes PharmD visits allowed for patients to complete required vaccination series A pharmacist-managed LTBI clinic has substantial impact on improving treatment rates, reducing the transmission of disease, and improving overall public health outcomes Int J Tuberc Lung Dis 2017;21(4):432-437

11 are still actively receiving treatment LTBI Data May 2016 – April 2017 Region / Country Arrivals LTBI Cases % LTBI Middle East 84 6 7.1% Central Africa 44 5 11.4% Eastern Europe 47 ----- Bhutan 34 14.7% E. Africa 15 40% Burma 3 20% Afghanistan W. Africa 1 100% N. Africa 2 66.7% Pakistan 50% Total 251 29 11.6% 17 out of 18 patients completed therapy within the defined time period = 94.4% completion 11 are still actively receiving treatment

Questions? kimberly.carter@uphs.upenn.edu