Duval County Health Department
Implementation of a Shelter Card System in Duval County, Florida-- One Step Toward Ending TB
DEMOGRAPHICS: The Florida Department of Health in Duval County (DOH-Duval) is in Jacksonville, Florida which has over 1 million residents. The population is closely split between male and female residents with 48.6% of population being male and 51.4% female. The average household income is $63,979. With regard to race and ethnicity, 61.1% of the population is Caucasian, 30.1% African American, 4.5% Asian, 0.2% Native American, and 1.3% Other, with 8.6% of the population being Hispanic.
BACKGROUND: From 2004-2011, Duval County experienced one of the most extensive tuberculosis (TB) outbreaks within the homeless population in local area shelters. The CDC was invited to assist DOH in the investigation. Cases genotyped revealed the increase in a specific cluster of TB as well as a proportionate increase amongst the homeless population in this cluster, indicating an increase in transmission. Statistics from 2004-2012 noted by the CDC report indicate homeless clients made up 43% of the active TB cases of this outbreak. (MMWR/Notes from the Field/July 20, 2012/Vol. 61/No. 28). The goal of implementing the DOH Duval shelter card system and partnering with local homeless shelters was to decrease the spread of TB.
METHOD: A system of routine testing and assessment of the county's homeless clients seeking admittance to area shelters was implemented. The clients must have a current shelter card that indicates they have been tested (annually) and assessed by DOH for symptoms of TB every 2 months. Through informal and formal agreements with area homeless shelters, clients are required to have a shelter clearance card the next business day after initial check in with the shelter.
RESULTS: During 2013, shelter card clients were not delineated separately from other walk-in clients for the clinic. As a result, no data for shelter card clients in 2013 can be assessed. During 2014, 16 shelter card clients were found to have latent TB infection (LTBI). Of those identified, 12 (75%) started LTBI treatment and 7 (58%) completed treatment. Of those who did not complete treatment, 1 chose to stop, 2 had adverse reactions, and 2 refused further treatment. During 2015, 35 shelter card clients were identified as LTBI. Of those identified, 16 (46%) started treatment and 7 (44%) have completed treatment. Of those who have not completed treatment, 5 were lost to follow-up and 3 moved with follow-up unknown and 1 chose to stop due to adverse reaction. During 2014 and 2015, no clients were identified through our screening process as active disease. However, there were 4 active disease cases in 2014 and 5 active disease cases in 2015 that had a history of using the local shelters. These were discovered after being admitted to a local hospital.
CONCLUSIONS: This system has been instrumental in interrupting the transmission of TB amongst the homeless population in area shelters. Routine assessment and annual testing have been effective in early detection of clients with symptoms of TB and improved diagnosis and treatment of clients exposed to TB.
We learned that although we initiated informal agreements with all of the local shelters, there were shelters that required a formal agreement in order to ensure continued participation in the program. We have initiated formal memorandums of agreement with local shelters and are in the process of completing the final versions of those agreements. The DOH-Duval program administrator provides ongoing support, training, and education for the shelter by meeting with the shelter administrators and attending the local homeless coalition meetings. The medical director also meets with the DOH-Duval TB team and shelter administrators as needed to provide agency updates, troubleshoot, and to show support for the collaboration.
As a best practice, we use short course therapy on our shelter card clients to promote adherence and completion. Use of incentives such as gift cards or bus passes for return appointments or directly observed therapy (DOT) also helps promote medication adherence.
When setting up your shelter card walk-in schedule, it is important to know when the check-in time and line formation starts at your local shelters. The clients will be eager to get their shelter card and leave to get in line at the shelter.
Above all it is important to be flexible!
The DOH-Duval Shelter Card System was developed in 2013 response to a TB Outbreak in Jacksonville, Florida which made local and national news. What was concerning about this outbreak was that it was tied to a specific genotype and it occurred predominately in the homeless population. The homeless point in time counts for 2014 and 2015 were 2049 and 1853 respectively. We managed to screen 75% of the homeless population in 2014 and 81% of the homeless population in 2015. Prior to DOH-Duval implementing the Shelter Card System, there was no screening process in place for the homeless population. The current process provides an established method of screening the homeless population to ensure that we are able to eliminate transmission and prevent outbreaks. This system of care is innovative and it utilizes evidence based practice by using short course direct observed treatment with 3HP (Isoniazid and Rifapentine combination) for all homeless LTBI clients. References include CDC guidelines found at http://www.cdc.gov/tb/topic/treatment/ltbi.htm and the article Cost-effectiveness of a 12-dose regimen for treating latent tuberculous infection in the United States. Int J Tuberc Lung Dis. 2013 Dec;17(12):1531-7. doi: 10.5588/ijtld.13.0423.
The goal was to eliminate transmission of TB in the homeless population. We dedicated staff members to do shelter cards. There is a Licensed Practical Nurse assigned to do shelter cards and a Registered Nurse to assist when needed. Meetings were held with homeless shelter administrators to make them aware of the problem and discuss implementation of the Shelter Card System. Initially, the agreements were verbal and we got support from the shelters; however, in order to ensure the sustainability of the program we initiated memorandums of agreement with each of the 3 local shelters-- Trinity Rescue Mission, City Rescue Mission, and Sulzbacher. The final versions of the MOAs are in the process of being completed. The DOH-Duval program administrator provides ongoing support, training, and education for the shelter by meeting with the shelter administrators and attending the local homeless coalition meetings. The medical director also meets with the DOH-Duval TB team and shelter administrators as needed to provide agency updates, troubleshoot, and to show support for the collaboration. There were no startup costs. We utilized staff that were already employed by DOH-Duval and created the shelter cards internally. No cost analysis was done.
The goal was to eliminate transmission of TB in the homeless population.This system has been instrumental in interrupting the transmission of TB among the homeless population in the homeless shelters. In the process, we were able to heighten the public's awareness of TB and provide education on environmental controls for the shelters. Routine assessment and annual testing have been effective in early detection of clients with symptoms of TB and improved diagnosis and treatment of clients exposed to TB. The DOH-Duval program administrator provides ongoing support, training, and education for the shelter by meeting with the shelter administrators and attending the local homeless coalition meetings. The medical director also meets with the DOH-Duval TB team and shelter administrators as needed to provide agency updates, troubleshoot, and to show support for the collaboration. When initiating a shelter card program, it is important to plan data collection and tracking of the program data before the system is initiated. DOH Central Office in Tallahassee, Florida was extremely helpful with providing programmatic guidance and help with gathering and analysis of data. Our local DOH lacked the resources at the start of the program implementation to do all of the analysis. We are now able to track the data ourselves, but continue to consult with them as needed. We have decreased our rates in Duval and increased the number of clients we screen.
DOH-Duval is committed to sustaining this program. To that end, we have entered into formal agreements with the local homeless shelters. Without formal agreements, we run the risk of shelters opting not to enforce the process when the weather turns cold and more people require sheltering. When we can, we have employees go directly to the shelters to provide the cards. Occasionally we have clients who are difficult and don't comply with treatment or the shelter card process. We have incentives available to encourage compliance. The local shelter executives are excited about the program, in fact, for a time one of the shelters instituted their own shelter card program, but decided to encourage their clients to come to us because of the level of resources that we have. We also have local support from the executive team, as well as support from the TB Control Section of the Bureau of Communicable Diseases at the state level Department of Health (Central Office). The program is woven into our current clinical practices and multiple team members are well versed in the program. It is important for us to continue to communicate with our local partners to make sure we continue to provide education and training for them, as well as educational materials. We do not want people to become lackadaisical in their processes, nor do we want to lose the support we have gained over the years. While we have not done a cost/benefit analysis we do know that our efforts have aided in quelling the transmission among the homeless population. And where we once made front page news for what was probably the worse TB outbreak in the history of Duval County, we are now looked at as a source of innovation and public health expertise. We want to encourage other counties to institute similar practices, so that one day we truly can eliminate TB.
Colleague in my LHD|E-Mail from NACCHO