Population Lucinda Gardner MSPH Epidemiologist Communicable Disease Control Objectives Overview of a LHD experience with a complex casecontact investigation Describe how to implement a novel referral strategy to improve contact investigations ID: 1042931
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1. Genotype Cluster Investigation Within A Homeless PopulationLucinda Gardner, MSPHEpidemiologistCommunicable Disease Control
2. ObjectivesOverview of a LHD experience with a complex case/contact investigationDescribe how to implement a novel referral strategy to improve contact investigationsIdentify community partners that can help with contact investigation in hard-to-reach populations
3. TB in Sonoma County
4. TB in Sonoma CountyTypically see 9-13 active TB cases per year (average 10)In 2017, 7 cases; 1.4 cases per 100,000In 2016, 12 cases; 2.4 cases per 100,000 Rank 33rd among CA CountiesAge range 23-87 (all but 3 aged 40 years or younger)71% non US-born
5. Sonoma County TB ProgramTB cases are managed within the Communicable Disease Program1 dedicated PHN1 part-time MD1 part-time CDI4 other PHNs available to support investigationsEpi support as needed
6. Sonoma County TB Case ManagementSonoma follows the CDPH/CTCA Joint Guidelines for TB Case Management: Core Components.Utilizes CDPH expertise and Francis Curry International Tuberculosis Center when necessary.Relies on the collaboration with community partners to treat cases.Providers refer suspect cases to Sonoma County Public Health (SCPH)~60 per yearReviewed by PHN and MDIf criteria met, request sputumSpecimens tested by Sonoma County Public Health LaboratorySCPH provides medical oversight for all cases and case management for most casesWork with primary care for other health conditionsSCPH staff assigned for DOTContact investigations handled by Sonoma County Public Health
7. Case CharacteristicsCase 1Aug 2015, incidental finding of cavitary pulmonary nodule on CTTB follow up recommended but not doneHospital did not notify PHSept/Oct 2017, +PPD, +CXR reported to PHJan 2018, LTFU/Non-compliant with TB treatmentMay 2018, resurfaced with symptoms, 3+, hemoptysis weight lossCurrently on DOT set to complete in early spring 2019
8. Case CharacteristicsCase 2Jan 2018 presented to clinic with COPD exacerbation and wheezingFeb 2018, another visit for cough/resp. PPD placed (no reading)Mar 2018, another visit for COPD exac. and LE swelling. QFT done (positive). CXR ordered.Apr 2018, another visit for CHF, LE swellingMay 2018, CXR completed, abn (looked like CHF, blood work showed CHF, reported to PH)July 2018, 4+On DOT set to complete in late spring 2019
9. Cluster InvestigationCommon factors:Genetic matchHomelessSmoke cigarettesUse methamphetaminesLived same region of the countyHowever:No clear linkCould not identify overlapping social networkNamed contacts are very difficult to track downComplications:Distrust of governmentImportant to stay in region (wooded area, rural)Gang affiliation (1 case)Resistance to western medical practices (chest x-rays, antibiotics)
10. Timeline and CDPH Assistance
11. Action Plan – Targeted Health OutreachOffer screening for priority diseasesTB, HIV, Syphilis Vaccination clinicInfluenza, Hepatitis A Possible opportunity to enroll participants for Whole Person CareRefer known contacts to events for screening
12. Results – Health ScreeningPrior to Outreach20 contacts identified and tested8 reactors, 12 negativeScreening Clinics2 locations, 2 dates, 36 participants29 homeless29 screened for TB (25 homeless)21 gift cards issuedSeveral high risk contacts to Case#24 reactors7 screened for Syphilis (all negative)12 screened for HIV (all negative)
13. Lessons LearnedUtilization of community partnersNatalie, RN homeless outreach nurse at RRHCCooperation with jailHospital relationshipCDPH assistanceValue of building relationshipsBuild trust, needed multiple encountersIncentivesMeet people where they areFlexibleRemember the larger goal
14. Thank you and DisclosuresThis presentation reflects the hard work and dedication of the Sonoma County Communicable Disease Team, including the following:Rebecca Purcell, PHNMary Miller, PHNLindsey Totah, PHNArcelia Reyes-Delgado, PHNMiranda Patrick, PHNEmely Hernandez, PHNAlan Powell, PHIJohanna Ruiz, PHNBob Benjamin, MD MPHKaren Holbrook, MD MPHAs well as our community partners and the extensive guidance and assistance from CDPH. Lucinda Gardner, MSPH, EpidemiologistSonoma County Department of Health Services(707) 565-4533lucinda.gardner@sonoma-county.orgI, the undersigned, declare that within the past 12 months neither I, nor any immediate member of my family, have had a financial relationship or any conflict of interest with any commercial interest that may have a direct bearing on the subject matter of the CME activity. In addition, I do not intend to include information or discuss investigational or off-label use of pharmaceutical products or medical devices.