A Pilot Project for School-Based Screening and Treatment ......LTBI Project Poster_mb Feb1-2_SG...
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§ 2017 Tuberculosis (TB) rate per 100,000 person § United States – 2.8 § San Diego County – 7.1 § 80% of cases could have been prevented by treating latent TB infection (LTBI) § California spent $78 million for treatment of active TB in 2018. § 5 cases of active TB in San Diego County public high schools during 2018 demonstrate the need for effective prevention interventions. § Adolescents are at higher risk of progressing to active TB disease after exposure. A Pilot Project for School-Based Screening and Treatment of Latent TB Infection Isis Y. Cunningham, BSN, RN, CPN, FNP/PNP-DNP Student 1 – Susannah Graves, MD, MPH 2 – Mary Barger, PhD, MPH, BSN 1 – Marti Brentnall, MPH 2 – Howard Taras, MD 3,4 BACKGROUND This evidence-based project aimed to increase awareness about tuberculosis, increase screening, and offer shorter regimens of LTBI treatment in the school setting. PURPOSE CONCLUSIONS/IMPLICATIONS PROJECT PLAN PROCESS COST-BENEFIT ANALYSIS § Total cost of materials for this project = $1000 § Treatment cost of active TB = $34,000/case § Treatment cost of drug resistant TB = $110,000/case § Testing 1000 students after exposure = $40,000 § Its low cost and the use of existent processes & resources makes it beneficial and replicable among other schools. IDENTIFIED TB RISK FACTORS PROGRAM RESULTS § A one-time education intervention increased awareness and knowledge about TB among students. § There was a high percentage of students at risk for TB, many of whom were not previously tested. § These results highlight the need to increase TB risk awareness and screening among adolescents. § Requiring the completion of a TB risk assessment as part of the health requirements for high school admission may increase screening rates among this population and prevent future active cases. § A TB risk assessment will now be included in admission packages at this school. § Access to TB screening in SDIR was granted to the school nurse as a result of this project. § 50% of TB test results were entered in SDIR by the school nurse, thus improving the quality of data. § We were unable to assess the feasibility of offering 3HP via DOT at school but this should be considered for future projects. • High school registration • TB education intervention to Freshman students with pre/post test 1. TB Risk Assessment Distribution • Incentives – Raffle of wireless headphones and movie tickets 2. TB Risk Assessment Returned • Recommendation for TB testing if at-risk • Letter to child’s provider with option for 3-month regimen of isoniazid-rifapentine (3HP) via directly observed therapy (DOT) at school 3. Confidential Package Distribution • Tested? - Student to bring results to school nurse • Incentives – Target gift cards/raffle of headphones • Access to the San Diego Immunization Registry (SDIR) was granted after follow-up was completed • TB testing and results were checked in SDIR • School nurse entered missing data from records in county immunization database 4. Phone Call Follow-Up • To be prescribed by child’s provider • 3HP to be given via DOT at school • Rifampin and Isoniazid regimens to be given at home • Incentives – $50 Walmart gift card for treatment completion (at home or school) 5. LTBI Treatment Options Freshman Students n = 294 Returned TB Risk Assessment 56 (19%) TB Risk Positive 24 (43%) Prior TB Test 3 (12.5%) Tested AFTER Program 4 (16.7%) Tested >8 yrs ago 7 (29.2%) NEVER Tested 10 (41.7%) Testing Current - All Negative 7 (29.2%) Testing NOT Current 17 (70.8 %) TB EDUCATION INTERVENTION RESULTS 60.5 84.7 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 Pre-Test Post-Test Average Scores on TB Knowledge 135 43 33 9 5 170 26 18 4 8 0 20 40 60 80 100 120 140 160 180 Agree completely Agree somewhat Neutral Disagree somewhat Disagree completely Would Agree to TB Testing PREQ7 POSTQ7 152 25 31 9 10 181 22 14 7 4 0 20 40 60 80 100 120 140 160 180 200 Agree completely Agree somewhat Neutral Disagree somewhat Disagree completely Would Agree to be Treated for LTBI PREQ8 POSTQ8 Positive Change > Neutral – 14% Negative Change < Neutral – 3.5% Positive Change > Neutral – 15% Negative Change < Neutral – 2% 70% 17% 9% Improved Knowledge About TB Agree completely Agree somewhat Neutral Disagree somewhat Disagree completely ACKNOWLEDGEMENTS Lincoln High School: Jose Soto-Ramos, Principal; Bree-Anna Williamson, RN; Martha Jazo-Bajet, RN County of San Diego, Health and Human Services Agency (HHSA), Tuberculosis Control Branch: Yolanda Lopez, TB Outreach Educator; Marisa Moore, Epidemiologist Captain; Christine Murto, Refugee Health Coordinator; Antonette Antonio, NP AUTHOR AFFILIATIONS AND CORRESPONDENCE 1 University of San Diego, 2 County of San Diego HHSA, 3 San Diego Unified School District, 4 University of California San Diego Correspondence: Isis Cunningham [email protected]; References upon request. Mean Difference 24.57 (95% CI:21.14-28.01) TB Risk Factor (n=25) n (%) 1. Been around someone who had TB 0 (0) 2. History of positive TB test (self/family) 7 (28) 3. Born in a high-risk country outside the US 7 (28) 4. Been to a high-risk country for > 3 weeks 4 (16) 5. Goes to Mexico frequently 8 (32) 6. Ever eaten queso fresco or unpasteurized dairy 9 (36) 7. Been around someone who is homeless, used drugs, or was recently in jail 4 (16) 8. Takes Prednisone or other medicines that lower the immune system 2 (8) 9a. Ever taken medicine for a positive TB test 1 (4) 9b. Completed treatment 1 (4) Note: 10 (40%) of students had >2 risk factors *Student who completed LTBI treatment was excluded from at -risk group. *Questions 3 and 4 were changed after registration to include name of country. *Questions adapted from SD County TB Risk Assessment and recommendations from the SD Pediatric TB Task Force. PROGRAM RESULTS February 27, 2019
Transcript of A Pilot Project for School-Based Screening and Treatment ......LTBI Project Poster_mb Feb1-2_SG...
§ 2017Tuberculosis(TB)rateper100,000person§ UnitedStates– 2.8§ SanDiegoCounty– 7.1
§ 80%ofcasescouldhavebeenpreventedbytreatinglatentTBinfection(LTBI)
§ Californiaspent$78millionfortreatmentofactiveTBin2018.
§ 5casesofactiveTBinSanDiegoCountypublichighschoolsduring2018demonstratetheneedforeffectivepreventioninterventions.
§ AdolescentsareathigherriskofprogressingtoactiveTBdiseaseafterexposure.
APilotProjectforSchool-BasedScreeningandTreatmentofLatentTBInfectionIsisY.Cunningham,BSN,RN,CPN,FNP/PNP-DNPStudent1 – SusannahGraves,MD,MPH2 –
MaryBarger,PhD,MPH,BSN1 – MartiBrentnall,MPH2 – HowardTaras,MD3,4
BACKGROUND
Thisevidence-basedprojectaimedtoincreaseawarenessabouttuberculosis,increasescreening,andoffershorterregimensofLTBItreatmentintheschoolsetting.
PURPOSE
CONCLUSIONS/IMPLICATIONS
PROJECTPLANPROCESS
COST-BENEFITANALYSIS§ Totalcostofmaterialsforthisproject=$1000§ TreatmentcostofactiveTB=$34,000/case§ TreatmentcostofdrugresistantTB=$110,000/case§ Testing1000studentsafterexposure=$40,000§ Itslowcostandtheuseofexistentprocesses&resources
makesitbeneficialandreplicableamongotherschools.
IDENTIFIEDTBRISKFACTORS
PROGRAMRESULTS
§ Aone-timeeducationinterventionincreasedawarenessandknowledgeaboutTBamongstudents.§ TherewasahighpercentageofstudentsatriskforTB,manyofwhomwerenotpreviouslytested.§ TheseresultshighlighttheneedtoincreaseTBriskawarenessandscreeningamongadolescents.§ RequiringthecompletionofaTBriskassessmentaspartofthehealthrequirementsforhighschool
admissionmayincreasescreeningratesamongthispopulation andpreventfutureactivecases.§ ATBriskassessmentwillnowbeincludedinadmissionpackagesatthisschool.§ AccesstoTBscreeninginSDIRwasgrantedtotheschoolnurseasaresultofthisproject.§ 50%ofTBtestresultswereenteredinSDIRbytheschoolnurse,thusimprovingthequalityofdata.§ Wewereunabletoassessthefeasibilityofoffering3HPviaDOTatschoolbutthisshouldbe
consideredforfutureprojects.
• Highschoolregistration• TBeducationinterventiontoFreshmanstudentswithpre/posttest
1.TBRiskAssessmentDistribution
• Incentives– Raffleofwirelessheadphonesandmovietickets
2.TBRiskAssessmentReturned
• RecommendationforTBtestingifat-risk• Lettertochild’sproviderwithoptionfor3-monthregimenofisoniazid-rifapentine (3HP)viadirectlyobservedtherapy(DOT)atschool
3.ConfidentialPackageDistribution
• Tested?- Studenttobringresultstoschoolnurse• Incentives– Targetgiftcards/raffleofheadphones• AccesstotheSanDiegoImmunizationRegistry(SDIR)wasgrantedafterfollow-upwascompleted
• TBtestingandresultswerecheckedinSDIR• Schoolnurseenteredmissingdatafromrecordsincountyimmunizationdatabase
4.PhoneCallFollow-Up
• Tobeprescribedbychild’sprovider• 3HPtobegivenviaDOTatschool• RifampinandIsoniazidregimenstobegivenathome• Incentives– $50Walmartgiftcardfortreatmentcompletion(athomeorschool)
5.LTBITreatmentOptions
FreshmanStudentsn=294
ReturnedTBRiskAssessment56(19%)
TBRiskPositive24(43%)
PriorTBTest3(12.5%)
TestedAFTERProgram4(16.7%)
Tested>8yrs ago7(29.2%)
NEVERTested10(41.7%)
TestingCurrent- AllNegative7(29.2%)
TestingNOTCurrent17(70.8%)
TBEDUCATIONINTERVENTIONRESULTS
60.5
84.7
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
Pre-Test Post-Test
AverageScoresonTBKnowledge
135
4333
9 5
170
2618
4 8
0
20
40
60
80
100
120
140
160
180
Agreecompletely Agreesomewhat Neutral Disagreesomewhat
Disagreecompletely
WouldAgreetoTBTesting
PREQ7 POSTQ7
152
25 31
9 10
181
2214 7 4
0
20
40
60
80
100
120
140
160
180
200
Agreecompletely Agreesomewhat Neutral Disagreesomewhat
Disagreecompletely
WouldAgreetobeTreatedforLTBI
PREQ8 POSTQ8
PositiveChange>Neutral– 14%NegativeChange<Neutral– 3.5%
PositiveChange>Neutral– 15%NegativeChange<Neutral– 2%
70% 17%
9%
ImprovedKnowledgeAboutTB
Agreecompletely AgreesomewhatNeutral DisagreesomewhatDisagreecompletely
ACKNOWLEDGEMENTSLincolnHighSchool:JoseSoto-Ramos,Principal;Bree-AnnaWilliamson,RN;MarthaJazo-Bajet,RNCountyofSanDiego,HealthandHumanServicesAgency(HHSA),TuberculosisControlBranch:YolandaLopez,TBOutreachEducator;MarisaMoore,EpidemiologistCaptain;ChristineMurto,RefugeeHealthCoordinator;AntonetteAntonio,NP
AUTHORAFFILIATIONSANDCORRESPONDENCE1UniversityofSanDiego,2CountyofSanDiegoHHSA,3SanDiegoUnifiedSchoolDistrict, 4UniversityofCaliforniaSanDiegoCorrespondence:[email protected];Referencesuponrequest.
MeanDifference24.57(95%CI:21.14-28.01)
TBRiskFactor(n=25) n(%)1.BeenaroundsomeonewhohadTB 0(0)2.HistoryofpositiveTBtest(self/family) 7(28)3.Borninahigh-riskcountryoutsidetheUS 7(28)4.Beentoahigh-riskcountryfor >3weeks 4(16)5.GoestoMexicofrequently 8(32)6.Evereatenqueso frescoorunpasteurizeddairy 9(36)7.Beenaroundsomeonewhoishomeless,used
drugs,orwasrecentlyinjail4(16)
8.TakesPrednisoneorothermedicinesthatlowertheimmunesystem
2(8)
9a.EvertakenmedicineforapositiveTBtest 1(4)9b.Completedtreatment 1(4)Note:10(40%)ofstudentshad>2riskfactors
*StudentwhocompletedLTBItreatmentwasexcludedfromat-riskgroup.*Questions3and4werechangedafterregistrationtoincludenameofcountry.*QuestionsadaptedfromSDCountyTBRiskAssessmentandrecommendationsfromtheSDPediatricTBTaskForce.
PROGRAMRESULTS
February27,2019
