1. L.A. County Public Health Partnering with the Private Community to Control TB Myrna Mesrobian, MD, MPH

2. LA County Department of PH Population of LA County: 9.8 million people (2008 estimate) Number of Service Planning Areas (SPA): 8 Number of Health Centers treating Tuberculosis: 11

3. Reported TB Cases, 2008-2009 Los Angeles County CaliforniaUnited States Cases: 2009 Total: 706 2,472 11,540 Cases: 2008 Total:792 2,695 12,905

4. TB Cases by Supervision Los Angeles County, 2008-2009 Supervision* 20082009 Cases% % Private 145 18.3%17825.2% Public 64781.7%52874.8% Total 792100.0%706100.0% *TB cases managed in the County Public Health Centers, County hospitals, County jails or TB Control Program are classified as Public; all other cases are classified as Private.

5. Strengthen the TB Link Effective treatment and preventing the transmission of TB requires a sustained partnership between: –health care providers –local and state public health practitioners –patients infected with the disease –public health and private laboratories

6. Public-Private Collaboration for TB Management TB Physician Specialists and Private Physicians can work as a team to: –Enhance the understanding of TB –Collaborate in developing and managing TB treatment and prevention of transmission

7. TB Patients Treated by the Public Sector County Public Health Centers County hospitals County jails TB Control Program

8. TB Patients Treated by the Private Sector Private patients Hospitalized patients Patients residing in skilled nursing facilities (SNF) or convalescent hospitals

9. 9 The Role of the TB Physician Specialist at the Health Center

10. Why a TB Physician Specialist ? Most doctors will not see a single case of active TB in any given year Los Angeles County Service Planning Area (SPA) TB Specialists may see up to 100 cases in a year and three times as many TB Suspects TB Control Program 2008

11. TB Physician Specialist Role in the District Health Centers TB Clinical Care and Management TB Contact Investigations with PHNs Directly Observed Therapy

12. TB Physician Specialist Role in the District Health Centers (cont.) B Referrals (new immigrants) Consultation to PMDs Legal Orders of the Health Officer

13. Private Sector Services Provided by the TB Physician Specialist Consultation and case management of TB cases Clinical care and follow-up if not feasible in clinics and private MD’s offices In-services & education to the medical community regarding TB care and evaluation

14. Oversight of Private Sector TB Treatment Physician specialist reviews the case when first reported to the district and then monthly Monitors TB medications prescribed by the Private Medical Doctor (PMD) Ensures adequate public health measures are taken when necessary Discusses contact investigation with the PHN Discusses the case with the PMD if needed

15. The Role of Public Health Nursing in TB Follow-Up

16. Public Health Nursing Functions TB Case Investigation TB Contact Investigation Health Education/Counseling Referral and Follow-up Case Management

17. Monitors client status Ensures confirmed TB clients complete required treatment Makes monthly home visits Ensures adherence to treatment

18. Case Management (cont.) Monitors adherence to home isolation, when applicable Monitors client for complications at least monthly until closed Requests monthly TB medical update if followed by PMD

19. Request for Monthly TB Medical Update

20. Summary of DPHN TB Case Management Monthly patient visits Contact investigation Patient and contact education Monthly update requests from PMD until completion of treatment Serves as liaison between PMD and Public Health TB Physician Specialist

21. Directly Observed Therapy (DOT) Delivery of every dose of TB medication (except weekend dose and holidays) by a trained health care worker who observes and documents that the patient actually ingests the medication.

22. Absolute Indicators for DOT HIV seropositive History of previous tuberculosis Homelessness History of incarceration Psychiatric disorder/cognitive dysfunction

23. Absolute Indicators for DOT (cont.) Current or past history of substance abuse Past history of non-adherence to medical regimen Failure to respond to therapy Resistance to one or more drugs

24. Relative Indicators for DOT Age:under 18 years elderly Non acceptance of TB diagnosis Lack of understanding of TB dx Congregate living Recent immigration

25. Case 1 70 year old male Country of origin: Born in the US MRI lumbar spine (03/09): psoas muscle abscess He had history of severe low back pain for 1 year before he was hospitalized on 03/18/09, and had a psoas muscle abscess drained on 03/21/09

26. Case 1 (cont.) No CXR and sputum for AFB smear and culture were done at the hospital, however his physician accepted to schedule him to collect sputum in April Since the patient was already started on therapy, DPHN asked him to come to MHC on 03/30/09 for CXR and sputum testing

27. Case 1 (cont.) CXR 03/30/09 Left pleural effusion

28. Case 1 (cont.) Psoas tissue: AFB smear positive (4+) Final culture result: positive MTB, pansensitive He was started on RIPE treatment on 03/24/09

29. Case 1 (cont.) Sputae collected at MHC on 03/30/09, 04/08/09 and 04/09/09: AFB smear negative, culture positive for MTB Sputae collected at the hospital in April could not be located

30. Case 1 (cont.) He was treated by his PMD and was followed up by the DPHN with monthly home visits and pill counts for the duration of the treatment He had no side effects from the TB medications Contact investigation was done by the DPHN

31. Treatment Monitoring Recommendations Baseline blood tests: LFT, CBC, BUN, Cr, Glucose HIV Sputum for AFB smear and culture Home isolation until sputum AFB smears 3x negative Avoid discontinuing any medication before susceptibility results are available

32. Treatment Monitoring Recommendations (cont.) Monthly LFTs CXR at 2-3 months and at the end of the treatment at a minimum in case of pulmonary TB Sputum for AFB smear and culture monthly at the beginning of the treatment, for a few months, and at its completion

33. Lessons Learned from Public-Private Sector Collaboration Establish good communication channels with the private provider and staff Be respectful of working habits and demands of the private sector Communicate responsibly and in a timely manner with both the patient and the private physician

34. Lessons Learned from Public-Private Sector Collaboration ( cont.) Show knowledge of the subject when discussing cases with the private provider Guide the private provider (whenever requested) in the treatment of TB Provide information material about TB if necessary or if requested

35. Lessons Learned from Public-Private Sector Collaboration ( cont.) Provide guidance, education and support to the public health nurse Review all cases treated by the private sector at least monthly ensuring close monitoring of TB treatment

36. Treatment Monitoring Ultimate goal of the public-private collaboration is to ensure adequate TB treatment completion within the desired time period

37. American Thoracic Society Guidelines “…Regardless of the means by which treatment is provided, the ultimate legal authority for assuring that patients complete therapy rests with the public health system.”