tuberculosis reporting and referrals in los angeles county · 2019-12-18 · tuberculosis reporting...
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Tuberculosis Reporting and Referrals
in Los Angeles County
Alicia H. Chang, MD MSActing Director
Tuberculosis Control ProgramLos Angeles County Department of Public Health
Los Angeles County2015 Estimated Population:10,347,437
1st in 2015 population
Land Area, including Santa Catalina & San Clemente Islands: 4,084 Square Miles
No. of cities: 88
No. of unincorporated areas:140
One of 4 major immigrant ports of entry
Organization of Los Angeles County TB Services
Health Agency
Dept. of Health Services
County Hospitalsand Clinics
Dept. of Public Health
Communicable Disease Control Program
Community HealthServices
Tuberculosis ControlProgram
Public HealthCenters
Private MDsPrivate Hospitals
Tuberculosis Control Program
TB Control Program
Mission: To prevent the transmission of TBwithin Los Angeles County throughearly detection and treatment ofactive disease & latent infection
Vision: To eliminate TB from Los AngelesCounty
TB Program Priorities
1. Identify and treat active cases
2. Identify and treat contacts to active cases
3. Targeted testing and treatment of high-risk populations
TB Control Program Services• TB surveillance• Analysis and reporting of data• Policy development• Education for patients, health care providers,
and community• Disease Control and Case Management
TB Control Program ServicesDisease Control and Case Management
• Medical consultation for providers within Public Health and in Community
• Discharge approvals from hospitals “Gotch Law”• Oversee the clinical management of every MDR
and XDR TB patient• Consultation during large or high profile contact
investigations• Issue Legal Orders for noncompliant patients
Other CountyTB Service Providers
• 12 Public Health Centers, 2 satellite clinics– 10 with TB services
• 3 County Hospitals– LAC-USC– Harbor-UCLA– Oliveview Med Center
• 1 County Jail
Los Angeles County 8 Service Planning Areas
Reporting• Why Report?• Who Must Report?• When Do You Report?• How Do You Report?• Delay or Failure to Report!
Case #1
• 21 yo man born in Turkey• TST = 8mm• CXR Findings/Impression
– patchy density right infrahilar region and right lower lobe
– early or mild RLL infiltrate• QFT = negative
Why Report ?• Mandated by State Health And Safety Code
Sections 120130& 121362, and
• California Code of Regulations, Title 17, Sections 2500 (a) (4), (11), (18), and (23), (b), (c) and (j) (1).
• Requires reporting within one working day of diagnosis.
Who Must Report?
• All health care providers in attendance of a patient suspected or confirmed with active TB disease.
• The director of any clinical lab when the lab finds evidence suggestive of TB in a clinical specimen.
When Do You Report• When the following conditions are present
– Signs and symptoms of TB and/or,– Abnormal CXR consistent with TB or,– The patient is placed on two or more anti-TB
drugs
• When bacteriology smears or cultures are positive for acid fast bacilli (AFB)
When Do You Report (cont.)
• When the patient has a positive culture for M. tuberculosis or M. bovis
• When a PCR test is positive for M. tuberculosis• When a pathology report is consistent with
tuberculosis
• If in doubt: call TBCP 213-745-0800• If in doubt, report!
Delay or Failure to Report
• Has contributed to serious consequences in the past
• Is a misdemeanor punishable by a fine or by imprisonment
• Is a citable offense under the California Business and Professions Code (Section 2234), “Unprofessional Conduct”
Case #1
• 21 yo man born in Turkey• TST = 8mm• CXR Findings/Impression
– patchy density right infrahilar region and right lower lobe
– early or mild RLL infiltrate• QFT = negative
www.ph.lacounty.gov/tb
Confidential Morbidity Report of Tuberculosis Suspects & Cases
How Do You Report
• Fax or mail Confidential Morbidity Report (CMR) to the TB Control Program office
• Telephone report to the TB Control Program office
• Submit laboratory report to the TB Control Program office
Reporting Process
TB Control Program receives, reviews, and assesses incomingCMR reports from various sources
Public Health Center based on address of residencePublic Health Nurse Supervisor receives, reviews, and assesses referrals from TBC and assigns the TB suspect/case to a PHN
PHN reviews and assesses referral:• TB case management is conducted/PHN Standards of Care• Works in collaboration with inter‐disciplinary team
Forwards to
Forwards to
What is new in TB Reporting?
• Los Angeles County TB Control Program may collect I-693s from Civil Surgeons
• All TB test results will be requested, both positive and negative
• We have health officer authority under CA Health and Safety Code section 120175 to conduct surveillance and to prevent disease
• Fax to our TB Control Program
State supportsTB data collection
Next Steps
• An applicant has LTBI, wants to take treatment, and has health insurance
• What to do?– Refer to PMD– Helpful if you provide documentation– Submit I-693 to TBCP if we’ve requested
Next Steps
• An applicant has LTBI, wants to take treatment, but doesn’t have health insurance
• What to do?
Referrals to Public Health for LTBI treatment
• Who to refer?– All LTBI patients without health insurance– All LTBI patients without medical homes
LTBI is not an exclusion for immigration medical clearance
• How to refer?– Use the same CMR form for reporting TB suspects
and cases– Indicate medical conditions that confer higher risk– Indicate foreign-birth from high-incidence country
Write in under “Remarks”at the bottom of the page:
• Country of birth• Medical comorbidities
that confer higher risk
(HIV, diabetes,TNF-alpha blockers, etc)
Reporting Process
TB Control Program receives, reviews, and assesses incomingCMR reports
Public Health Center based on address of residencePublic Health Nurse Supervisor receives, reviews, and assesses referrals from TBC and assigns the TB suspect/case to a PHN
PHN reviews and assesses referral:• Prioritizes appointments• Works in collaboration with inter‐disciplinary team
Forwards to
Forwards to
What can the patient expect?• Public Health Center will contact patient for
appointment• Appointments prioritized based on comorbidities• Wait time could be up to 3 months• Initial visit with MD or Extended Role Nurse• Subsequent visits with nursing• No charges, no copays for visits• Medications are free• We offer 3HP, rifampin, INH
What else can we doto help our applicants?
• Refer applicants to obtain medical coverage
• Provide education about how to navigate our complicated health care system and find a medical home
Medical Coverage Options
• My Health LA (MHLA)• Covered California
My Health LA (MHLA)
• No cost health care program for LAC residents• Need LAC address, or statement of
homelessness• Target is uninsured and un-insurable persons• >18 yo• Income limits (<=138% FPL)• Receive services through County facilities
(Department of Health Services) OR its affiliate clinics “Community Partners”
Covered California
• CA’s version of ACA• For all persons lawfully present in CA• Includes immigrants• Immigration status kept confidential• Does not affect permanent residency application• Can be eligible for Medi-Cal or discounts for
private insurance• Those not lawfully present may still qualify for
Medi-Cal, need to apply to find out
Questions?
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