TB Notes Newsletter
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Highlights From State and Local Programs
TB Housing Village for Homeless Patients, Yuma County, Arizona
In 2007, Arizona reported 301 cases of active tuberculosis (TB) disease, with a case rate of 4.7 per 100,000, exceeding the U.S. rate of 4.4. Yuma County, located along the U.S.-Mexico border in southwestern Arizona, had 25 TB cases and a case rate of 12.4 per 100,000 in 2007. In addition, the county’s population increased nearly 20% between 2000 and 2007.
In Arizona, the responsibility for care of TB patients belongs to the local health departments. The Tuberculosis Control Program of the Yuma County Public Health Services District provides diagnosis, case management, and treatment services for Yuma County residents with TB. Providing housing for homeless patients during treatment for active TB can be very difficult and expensive. Yuma County in Arizona sets an example of how this can be done in a cost-effective way.
In 2005, Yuma County had three homeless people with active pulmonary TB who were admitted to a local hospital. These homeless people were contagious and therefore unable to be discharged to a homeless shelter. All three were hospitalized for 2 to 3 months. The estimated cost per person to Yuma County for the hospital stays was $900 per day.
This prompted Yuma County’s government to find a more cost-efficient solution for managing infectious homeless patients with TB. The County held public meetings to gather public input and identify any community concerns or issues. In July 2005, Yuma County allocated $450,000 for housing of TB patients. Existing county property was made available as the site for the TB Housing Village.
The TB Housing Village was completed in March 2007. It includes four pre-fabricated housing units, with provisions for four additional units in the future. The housing units include a kitchen and were furnished with general household items such as a telephone and a television. The TB Housing Village also has an annual budget of $20,000 for maintenance and utilities; maintenance issues are addressed by the Yuma County General Services Department. A written TB Housing Village policy was developed.
In addition to providing housing, the Yuma County TB Housing Village provides meals three times a day, directly observed therapy, and case management services for homeless TB patients. This housing is also available for Yuma County residents who have contagious TB disease and need temporary housing, such as infectious parents of small children. TB public health staff members make daily visits to the patients for observation, assessment, case management, and directly observed therapy.
Since August 2007, five persons with active TB have been placed at the TB Housing Village. Of those five patients, one transferred to California during treatment and notification was sent to the local health department for follow-up; three are still on TB medications; and one completed treatment. The cost-savings are still unknown at this time; however, it is expected they will be significant when compared to housing costs for private facilities.
For Yuma County TB program staff, the biggest challenge has turned out to be the mental health issues of three of the five persons placed in the housing units. The National Coalition for the Homeless reports approximately 25% of the homeless suffer from mental illness and require ongoing access to a full range of treatment and rehabilitation services.
The TB program staff members were unaware at the time of placement that these individuals would require mental health services. For one resident requiring immediate mental health services and intervention, help was not available because of staffing issues at the local mental health agency. Thus, it might be useful to consider providing mental health screening for TB patients before placing them in the housing village, to ensure timely coordination of mental health services as well as to ensure the welfare and safety for the residents, county staff, and the property.
—Submitted by Angelito Bravo, MD; Karen Lewis,
MD; and Kristina Schaller
Arizona Department of Health Services, and Becky Brooks, Maria Nunez, RN, Monica Salgado, RN
Yuma County Public Health Services District
The Houston County Health Department in Warner Robins, Georgia, has formed a partnership with the Houston County Detention Facility to provide treatment for inmates with latent TB infection (LTBI) in a correctional setting, since early identification and successful treatment of persons with TB infection and disease remains the most effective means of preventing disease transmission. This joint venture best accomplishes the shared responsibility of the overarching activities between public health and corrections. The partnership will allow for the detection of substantial numbers of persons with LTBI who are at high risk for progressing to TB disease and would likely benefit from a course of treatment.
The need for this partnership became evident as the detention facility found it increasingly problematic to provide transportation of the inmates to the health department to receive the required services (e.g., monthly assessment, lab work, and medication). The detention facility had to assign an officer to transport one prisoner at a time to the health department. With up to 20 inmates a month needing clinical services, this was a time-consuming and costly procedure. In addition, the inmates would have to sit in the lobby with the assigned guard along with the other health department clients. This made some of the clients anxious. In March 2006, this partnership was initiated. Several persons were instrumental in bringing this partnership to fruition: Major Charles Holt, Jail Administrator, and Janet Willis, RN, Medical Nurse Director, Houston County Detention Facility; Wayne Mencer, District TB Outreach Worker; and Faye Mencer, RN, BSN, TB Program Manager, Houston County Health Department.
Ms. Mencer worked with the Houston County Health Department’s Nurse Manager, the District TB Coordinator, the District Health Director, and the District Pharmacy Coordinator to determine the process by which the infected inmates would be screened, evaluated, and given medication for treatment of LTBI. On a monthly basis, she visits the detention facility to perform inmate assessments, retrieve drawn blood samples (e.g., AST, HIV, etc.) to forward to the appropriate laboratory, and deliver the supply of LTBI treatment medication for each designated inmate to the facility’s Medical Nurse Director. While it can be a challenge to see a large number of clients at one time, prepare the blood samples, and keep up with the data entry into the computer, the benefits outweigh the challenges. By the jail clients being scheduled on one designated day, all can be seen and kept on the same monthly schedule for nurse evaluation and medication pick up. An additional key benefit of this partnership is the provision of PPD antigen (at no cost) to the detention facility by the health district. Approximately 340 inmates have been seen over the past 20 months.
Follow-up is imperative to ensure completion of LTBI treatment, particularly in short-term correctional facilities. Furthermore, inmates of correctional facilities have been reported to have relatively high rates of HIV infection; persons who are coinfected with HIV and M. tuberculosis are at high risk for progressing from LTBI to TB disease. When an inmate receiving LTBI therapy does not complete the recommended 9-month treatment regimen prior to release from the detention facility, it becomes the responsibility of the Houston County Health Department to contact the former inmate and arrange treatment completion. If the former inmate does not respond to the health department’s attempts to contact him, he is then referred to the TB Outreach Worker, Wayne Mencer whose responsibilities include, but are not limited to, in-depth follow-up by tracking the missing client, educating the client and his family, coordinating transportation to clinic appointments, and reporting back to the TB Program Manager.
With a sizeable percentage of inmates lacking any supplementary access to the health care system, correctional settings are becoming a crucial source of health information, intervention, and maintenance. Some of the benefits that are resulting from this partnership include prompt identification, evaluation, and treatment of inmates with LTBI; ensuring adherence to treatment via DOT; follow-up of released inmates regarding treatment completion; controlling TB among inmates and detention facility employees; reduced TB rates in community; and a decreased financial burden on the health district due to the proactive stance of newly formed partnership between public health and corrections. Since each case of TB disease begins as a contact, the team work between the Houston County Health Department and the Houston County Detention Facility in managing and treating TB in this target population equates to a win-win situation.
—Submitted by Faye Mencer, RN, BSN
Public Health Nurse Specialist
TB Program Manager, Houston County Health Department