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?