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POPULATION HEALTH DIVISION PROTECTING AND PROMOTING HEALTH AND EQUITY San Francisco Department of Health Population Health Division 1 Diagnosis and Treatment of TB Infection in the Homeless Population: San Francisco TB Program Experience Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health Population Health Division Disease Prevention and Control Branch August 14, 2014

Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

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Diagnosis and Treatment of TB Infection in the Homeless Population: San Francisco TB Program Experience. Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health Population Health Division Disease Prevention and Control Branch August 14, 2014. - PowerPoint PPT Presentation

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Page 1: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

POPULATION HEALTH DIVISIONPROTECTING AND PROMOTING HEALTH AND EQUITY

POPULATION HEALTH DIVISIONPROTECTING AND PROMOTING HEALTH AND EQUITY

San Francisco Department of Health Population Health Division

1

Diagnosis and Treatment of TB Infection in the Homeless Population: San Francisco TB Program

ExperienceJulie Higashi, MD PhD, TB Controller

San Francisco Department of Public HealthPopulation Health Division

Disease Prevention and Control BranchAugust 14, 2014

Page 2: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

2

Outline

• Overview of TB screening of homeless shelter residents in San Francisco

• TB program-associated costs of homeless screening

• Benefits of the homeless TB screening program in San Francisco

• Treatment of TB infection in the Homeless Population in San Francisco

• Questions for the future

Page 3: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

3

Homeless TB Screening in San Francisco

• Mandatory TB screening for residents of City-operated shelters began in 2005

• Coincided with –– Widespread adoption of QFT-Gold in SFDPH

clinics– Implementation of the CHANGES shelter

registration system

Page 4: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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TB & Homeless Task Force Developed in 2000 to Produce Guidelines

Page 5: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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TB Screening Policy

• All clients receiving San Francisco shelter services for more than 3 days (cumulative within a 30-day period) are required to complete TB screening and evaluation within 10 working days of entering the shelter system

• Includes city-operated emergency shelters and resource centers but not private or faith-based shelters

Page 6: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Aerosol Transmissible Disease Guidelines: Translating Policy to Practice

• All shelters are required to comply with California’s Occupational Safety and Health Administration (Cal-OSHA) Aerosol Transmissible Disease Guidelines

• A user friendly manual specific for shelters and residential facilities.– Distribute manuals to all sites – Work with shelter directors individually to make sure

each shelter understands how to comply with the OSHA ATD guidelines

Page 7: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Strategies

• Keep It Simple, Stupid (K.I.S.S. method)• Make it funny/eye catching• Make it sustainable• Create guides for every level

• Directors - Guidelines/Policies• Supervisors -Flow Charts• Line staff -Easy to read accessible messages • Clients -Handouts/Posters

• Revisit shelter frequently and review a few topics at a time

• Be available for ongoing support and advise

Page 8: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

8

BUGS YOU SHOULD KNOW

TBTUBERCULOSIS

THE ILLNESSES:TUBERCULOSIS (TB)

THE SYMPTOMS:Coughing, fevers, feeling tired, losingweight, soaking sweats at night

THE GERM:A bacteria that can infect any part ofthe body, but usually likes the lungs

SPREAD:Cough

HOW TO PREVENT SPREAD:Keep client’s TB clearance up to date(that’s yearly)Get a TB test for yourself every yearAnd... cover coughs!

MEDICATION:Specially prescribed antibiotics takenover months

Page 9: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Screening Sites

• For TB tests– Shelter associated clinics– SFDPH urgent care and primary care clinics– City affiliated urgent care and primary care clinics (e.g.

consortium clinics)– TB clinic (walk in - three mornings a week)

• For chest x ray– TB clinic (six half day clinics per week)– If has medical home, can get through PMD

Page 10: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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CHANGES System

• Tracking system using fingerprint imagesContains:– Demographics with a photo– Where you are (what shelter, what bed)– History in the system– Some Narrative information– Annual Tb clearance information

• Marked in RED on profile that pops up each time accessed• Clients have a 10 day window to get clearance (at entry

or if expires)– Critical alerts

Page 11: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

Flowchart: Evaluation to Treatment of LTBI

Evaluate for active TB

At-risk person

TB test + symptom review

Negative Positive

Chest x-ray

Normal Abnormal

Treatmentnot indicated

Candidate for Rx of latent TB

Page 12: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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TB Screening and Evaluation Process

• Client referred to DPH clinic/affiliated clinic for TST/QFT

• If QFT/TST+ or prior positive or symptomatic, client is referred to TB clinic for chest x-ray and MD evaluation

• Clearance card given to client –– At DPH/affiliated clinic if TST/QFT negative (select

sites)– At TB clinic if TST/QFT+, prior positive, or symptomatic

• Temporary clearance given as needed

Page 13: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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TB Infection Prevalence By Test and Clinic Type

Homeless TB Clinic Methadone Immigrant

TST(2001-2003)

26% ~50% 10% 37%

QFT-1(11/03-2/05)

17 %n=1848

48 %n=292

18 %n=346

37 % n=344

QFT-G (3/05-11/08)

7 %n=9166

23 %n=4042

4 %n=1261

14 %n=2505

QFT-IT(4/08-2/09)

6 %n=1625

22 %n=1555

___20%

n=323

Decline in positive rate from TST ↓ 73% ↓ 54% ↓ 60% ↓ 62%

Page 14: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Initial Screening

Screening Results Follow-up Data Entry

TST or QFT negative and asymptomatic

• None (until following year)

• Provide green TB clearance card

Enter shelter clearance date in the LCR

TST or QFT+ and asymptomatic

• Chest x-ray • Medical evaluation at

TB Clinic (refer with TB47 form)

TB Control enters shelter clearance date or clinical alert in the LCR

Symptomatic • New chest x-ray • Urgent medical

evaluation • TST or QFT

All TB suspects should be sent to TB Clinic for evaluation. If work-up by provider is negative, enter clearance in the LCR

LCR = Lifetime Clinical Record, DPH EHR

Page 15: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Annual Follow-up Screening

Client Type Treatment History Evaluation Required

HIV– or HIV+ / TST or QFT–

No prior treatment • Annual TST/QFT • Annual symptom review

HIV– or HIV unknown/ TST or QFT+ Completed LTBI treatment • Annual symptom review

HIV– or HIV unknown/ TST or QFT+

No prior or incomplete treatment

• Annual symptom review and medical risk assessment for diabetes, cancer, immune modulating medication intake, end-stage renal disease and HIV

• If new risk present, repeat chest x-ray annually if patient remains untreated

HIV+/ TST or QFT+ Completed preventive treatment

• Annual symptom review • Low threshold to repeat CXR

HIV+/ TST or QFT+ No prior or incomplete treatment

• Minimum annual symptom review and repeat CXR

• Should be followed by SF TB Control (please refer to TB clinic if necessary)

Page 16: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Clearance

• Shelter client issued a TB clearance card upon completion of screening

• Expiration date is entered into the DPH Lifetime Clinical Record (LCR)

• Client presents card to shelter/resource center staff at check-in

• Expiration date is entered into the CHANGES registration system– Date color-coded based on whether clearance is about

to expire (orange) or has expired (red)

Page 17: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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TB Program Costs – Assumptions and Estimates (1)

• 2005-2012– Annual average of 1,729 homeless needing

screening1

• QFT-Gold In-tube cost2: $32.86 (includes labor and supplies)

• QFT-Gold In-tube positive rate3: 7%• Chest X-ray and MD visit cost2: $82.50

1San Francisco Human Services Agency. San Francisco Sheltered and Unsheltered Homeless Count. (2009 & 2011)2Estimates from unpublished cost effectiveness analysis of QFT in San Francisco.3San Francisco LTBI rate among homeless persons, 2005-2011.

Page 18: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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TB Program Costs – Assumptions and Estimates (2)

• TB Clinic staff time per patient needing chest x-ray and MD evaluation1

– Clerical (registration) – 15 minutes– Health Worker (registration) – 7 min– Nurse (provide clearance) – 5 min

1Based on TB Clinic time survey data collected February-March 2012. Time estimates do not include time to draw QFT or refer patient to TB clinic for chest x-ray and evaluation.

Page 19: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Annual TB Program Cost

QFT-Gold In-tube Test: 1,729 x $32.86 =

$56,827

# needing chest x-ray and MD evaluation: 0.07 x 1,729 = 121

Chest X-ray and MD evaluation: 121 x $82.50 =

$9,987

TB Clinic staff time: Clerical: 30.26 hours x $28.59 = $865 Health Worker: 14.12 hours x $27.69 = $392 Nurse: 18.23 min. x 10.09 hours = $665

$1,922

TOTAL ANNUAL COST $68,736

Page 20: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Homeless Cases, 2005-2013

Year Shelter SRO Street/Other

City Private

2005 (n=17) 3 (18%) 0 7 (41%) 7 (41%)

2006 (n=22) 2 (9%) 1 (5%) 11 (50%) 8 (36%)

2007 (n=25) 3 (12%) 1 (4%) 12 (48%) 9 (36%)

2008 (n=15) 3 (20%) 0 5 (33%) 7 (47%)

2009 (n=15) 0 0 6 (40%) 9 (60%)

2010 (n=7) 1 (14%) 1 (14%) 2 (29%) 3 (43%)

2011 (n=11) 4 (36%) 0 5 (46%) 2 (18%)

2012 (n=12) 0 0 8 (67%) 4 ( 33%)

2013 (n=18) 2 0 4 12

Total (n=142)

18 (13%) 3 (2%) 60 (42%) 61 (43%)

Page 21: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Characteristics SF City Shelter Cases, 2005-2012 (1)

City Shelter

SRO

Pulm. Smear + 47% 45%

Pulm. Culture + 80% 73%

Pulm. Cavitary 0 36%

HIV + 36% 33%

Died 6% 14%

Page 22: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Characteristics SF HSA Shelter Cases, 2005-2012 (2)

CityShelter

SRO

Converters 1 8

Clustered Cases1 0 92

1Clustered to another case in the same shelter or SRO at any time, 2005-2012.

2Two clusters.

Page 23: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Collaboration is key

Page 24: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Other Benefits (1)

• Developed close working relationship with homeless providers and shelter staff– Facilitates timely response to exposures– Opportunities for education and training for shelter staff

• Brings TB awareness to shelter staff• Use CHANGES to target contact investigations• Overlapping mechanisms to track screening and clearance

– TB Control, CHANGES (shelters), LCR (EHR)• Addresses the disparity in TB rates among the homeless

Page 25: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Other Benefits (2)

• Screening provides opportunity to link patients to other services– HIV, cancer, viral hepatitis, diabetes, mental health

services, primary care• Indirectly provides screening for clients being

transferred from shelters to SRO housing• QFT allows for LTBI surveillance in this population• Green card is powerful motivation for getting TST

read

Page 26: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Questions for the future…

• With established relationships and tracking systems…– Are there opportunities to reduce costs?

• Reduce frequency of annual screening?– How can we expand treatment for LTBI in this population?

• Use new 12 dose weekly regimen?– Is it cost effective?

• ?– Does screening program have an impact on health outcomes?

• TB? Overall health of the population?

Page 27: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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CDC guidelines: IGRA testing

• IGRA (Tspot or QFT) preferred test for BCG vaccinated or unlikely to return for TST reading

• TST preferred test in children < 5 yo• No preference for HCW screening, contact

investigations, other populations

Page 28: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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TST vs. IGRA - What to do with Discordant Results

• Avoid using two tests for TB screening• TST(+)/IGRA(-)

– Foreign born with BCG and no severe immunocompromising condition - attribute to BCG

• Caveat - abnormal CXR confirmed old TB and with risk factor for progression to disease, consider treatment

– U.S. born - with no risk factors for exposure or risk factors for progression - may be NTM colonization, unreliable TST result

• TST(-)/IGRA(+)– U.S. born with no risk factors for exposure or progression - repeat IGRA in 3-6 months

• If discordant TST/IGRA and severe immunocompromising condition, offer LTBI• If severe immunocompromising condition and if TST-/IGRA- and abnormal CXR confirmed

old TB, offer LTBI treatment

Page 29: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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New LTBI Testing and Treatment Guidelines for SF

• Eliminate recent arriver criteria for testing and treatment

• High Priority: Focus on risk factors for progression• Foreign born with diabetes

• Foreign born with active tobacco use

• Foreign born/US born with immune suppression• Medications (biologics, organ transplant)• Cancer• HIV (universal testing)

• Converters• Contacts

• Medium Priority: Foreign Born < 50

Page 30: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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New LTBI Testing and Treatment Guidelines for SF

• Eliminate recent arriver criteria for testing and treatment• High Priority: Focus on risk factors for progression

• Foreign born with diabetes -> risk for progression 1/3• Foreign born with active tobacco use -> risk for progression

1/4• Foreign born/US born with immune suppression

• Medications (biologics, organ transplant) ->• Cancer -> variable• HIV (universal testing)-> 10% per year risk of progression

• Converters• Contacts

• Medium Priority: Foreign Born < 50

Page 31: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Strategies: Directly observed preventive therapy (DOPT)

• Directly observed therapy regimens:– Biweekly INH 900 mg (mon-thurs, tues-fri) x 6-

9 months– Weekly INH/rifapentine 900mg/900mg x 12

weeks– Daily dosing at opiate replacement clinic

Page 32: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Strategies:Incentives/Enablers

• Incentives for TB infection treatment– halfway through treatment and at end of

treatment: movie tickets x 2– Subway coupon at each clinic visit for a meal

later, sandwiches at the clinic

• Enablers– Bus tokens to defray cost of trip to clinic

Page 33: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Treatment Regimens for Latent TB Infection

Drug(s) Duration Interval Minimum Doses

Isoniazid 9 months Daily 270

Twice weekly 76

6 months Daily 180

Twice weekly 52

Isoniazid & Rifapentine

3 months Once weekly 12

Rifampin 4 months Daily 120

Page 34: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Drug drug interactions with rifamycins

• ARVs (antiretroviral agents)• Oral contraception• Narcotics• Antipsychotics• Chemotherapeutic agents• Immune suppression for organ transplant

Page 35: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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LTBI regimens: SF 2012-2013Cohort: All TB clinic patients starting LTBI treatment from 9/1/12 to present with known treatment end reason. 

  3HP* % INH %INH + RIF % RIF %

 Started Treatment 71 295 50 180 

Completed 60 85% 213 72% 44 88% 154 86% Adverse Reaction 3 4% 2 1% 0 0% 2 1%Chose to Stop/Lost/Refused 8 11% 64 22% 5 10% 19 11%Moved 0 0% 6 2% 0 0% 2 1%Provider Decision 0 0% 2 1% 0 0% 1 1%Other 0 0% 8 3% 1 2% 2 1% 

*Includes both TB Clinic and Study 33 patients

Page 36: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

36

Monitoring LTBI treatment

• monthly review with patient (nurse or pharmacist)• Initial face to face -> transition to phone calls if patient doing

well• assessment of compliance - e.g. pill count, pharmacy refill -

dispense medication only one month at a time• assessment of side effects• assessment for hepatotoxicity

• anorexia, fatigue earliest signs• abdominal pain, jaundice late signs

Page 37: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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•laboratory LFTs (INH or RIF), CBC (RIF)•baseline and monthly if risk for hepatotoxicity

•underlying liver disease•ETOH•medications (statins, ARVs, chemo)•> 50 years old

•Lower risk (younger), may start with LFTs on treatment x 1 month•If WNL x 2 months, will d/c lab monitoring and just do symptom review

Monitoring LTBI treatment

Page 38: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Summary

• Implementation of a shelter screening program is a collaborative endeavor. – Health department must be an active partner in

serving both the homeless and the homeless service providers

• Early signs suggest that shelter screening is effective at limiting transmission of TB within the shelter– Earlier diagnosis– More effective and manageable contact investigations

Page 39: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

39

Summary

• SF program experience with IGRA screening in the shelter population has:– Quantified the rate of TB infection in this population– Likely contributed to the earlier diagnosis of TB disease

in the shelters relative to SROs and homeless living on the streets

• Effective strategies for TB infection treatment in the homeless include DOPT and the use of incentive/enablers.

Page 40: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

40

Resources

• San Francisco TB Prevention and Control website: www.sftbc.org

• Curry International Tuberculosis Center– TB and Shelter videos - > here today!– http://www.currytbcenter.ucsf.edu/

Page 41: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Acknowledgements

• Jennifer Grinsdale, MPH, Public Health Informatics Officer, SFDPH

• Masae Kawamura, MD• Christine Ho, MD• Sheila Davis-Jackson, TB Clinic Manager• Kate Shuton, RN, PHN

Page 42: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

POPULATION HEALTH DIVISIONPROTECTING AND PROMOTING HEALTH AND EQUITY

POPULATION HEALTH DIVISIONPROTECTING AND PROMOTING HEALTH AND EQUITY

San Francisco Department of Health Population Health Division

42

Practical Issues

Page 43: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Page 44: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Aerosol Transmissible Disease Guidelines

Page 45: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Page 46: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

46

Aerosol Transmissible Disease Guidelines

Page 47: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Page 48: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Add easy to follow flow sheets to policies

Page 49: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Screen clients at check-in time:• Do you have a sore throator a cough and fevers?• Do you have any spots ora rash on your body?• Shortness of breath?• Severe vomiting?

If a client’s behavior or health doesnot seem ‘normal’ to you, that’sa good enough reason to look formedical care for that person.

Help arrange for clients to seea Medical Provider as soon aspossible if you think they are sick. There are many Urgent Care clinics in San Francisco where clients can be seen the same day.

Don’t hesitate to call 911 if your guttells you to. Clients may refuse togo in the ambulance, but they can’trefuse your decision make the call.

KNOWSICKWHEN YOUSEE IT,AND ACTIF IT DOESN’T SEEM RIGHT,IT PROBABLY ISN’T

WHEN IN DOUBT, TRANSFER OUT

Page 50: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

50

COVERYOURCOUGHSANDSNEEZESWITH YOUR ARMOR ELBOW

REMINDOTHERSTO DOTHE SAME

Get in the habit of coughing andsneezing into your arm or elbow.It’s like wearing a seat belt; you willsoon do it naturally.

Coughing or sneezing into your handsis grosser than spitting on them.

“Airborne Illnesses” are germs thatspray into the air. If they hit a hardsurface like your arm they willprobably die.

Page 51: Julie Higashi, MD PhD, TB Controller San Francisco Department of Public Health

San Francisco Department of Health Population Health Division

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Resources

• Tb and ATD Guidelines for Shelters can be found at:http://www.sfcdcp.org type in ATD in the search field

• For more information on SF Shelter Health and Wellness contact:

Kathleen Murphy Shuton, RN, PHNSan Francisco Department of Public HealthHomeless Family Team CoordinatorShelter Health Program Coordinator101 Grove, Room 118San Francisco, CA 94102415 355-7511 phone

• Email: [email protected]