1. 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

2. 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

3. 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)

4. 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 :
2 Barnett ED. Clin Inf Dis :833-41
3 Stauffer WM. Minn Med (3):42-6

5. 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

6. 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

7. 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

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

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

10. LTBI Patient Demographics
Int J Tuberc Lung Dis 2017;21(4):

11. Profile of Study Population
Int J Tuberc Lung Dis 2017;21(4):

12. LTBI Data
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):

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

14. 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):

15. 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

16. Questions?