Harris County Public Health
2Video Directly Observed Therapy (VDOT) - A Useful Approach to Tuberculosis Treatment in a Natural Disaster
Harris County Public Health (HCPH) is the county health department serving Harris County, Texas jurisdiction. Harris County covers 1778 square miles with 4.34 million people and ranks as the 3rd most populous county in the nation. The tuberculosis (TB) case rate in Harris County as a whole is twice the US and the Texas rate (7.6 cases per 100,000 population). The standard of care for TB treatment is Directly Observed Therapy (DOT) to treat active TB. In 2014, HCPH TB Elimination Program implemented asynchronous Video Directly Observed Therapy (VDOT) for TB treatment. This smartphone-based technology allows individuals to remotely record medication doses and submit video on a HIPAA compliant platform.
On August 25-30, 2017, Hurricane Harvey made landfall in Texas. Roads were deemed impassable and most medical services were interrupted for healthcare and delivery. During Hurricane Harvey, 47 TB patients were on DOT and 61 patients were on VDOT for the treatment of active TB disease or TB infection (TBI) in Harris County. It was vital that TB treatment and services would continue with little to no interruptions so that patients could continue receiving treatment to reduce the risk of drug resistance, re-infection, and spread of disease in Harris County during Hurricane Harvey.
VDOT is an innovative, patient-centered approach for treatment of TB and is acknowledged for patient flexibility, autonomy, privacy, high treatment adherence rate, and cost-effectiveness. VDOT has allowed flexibility for patients and TB staff as the patient can submit medication videos remotely and staff can watch video submissions asynchronously. During the hurricane, VDOT allowed patients to continue submitting videos. It also ensured that patients were accounted for during and after the hurricane.
Prior to the hurricane, the TB Elimination Program activated established protocols for providing patients with medications to take on their own, and for providing contact information in case of displacement. DOT patients were given a week's supply of TB medication so that they would be able to self-medicate if necessary. VDOT patients were given a month supply of medication so that they could continue treatment during and after the hurricane. The Nurse Case Managers maintained a secured line list of patients to monitor conditions and treatment during/after the storm. Dedicated TB staff were able to remotely view and approve videos of patients taking their medicine.
A milestone achieved by utilization of VDOT for TB treatment during the event of a natural disaster consists of continuation of treatment without interruption. Out of the 61 VDOT patients treated during the 16 days that the HCPH TB team was operating in disaster response mode, 59 continued without disruption. Traditional DOT patients, on the other hand, were required to self-medicate, which does not count towards the completion of TB treatment. Therefore, therapy was prolonged for an average of 16 days in this group.
VDOT allowed 59 out of 108 patients to continue without any extension of treatment due to Hurricane Harvey. Because patients continued submitting their videos remotely to the HIPAA compliant platform, 59 patients were accounted for during and after Hurricane Harvey. The major public health impact of practice was VDOT patients were able to continue their treatment and it reduced the risk of drug resistance, re-infection, and spread of the disease in the county for TB disease patients.
To learn more about Harris County Public Health's TB Elimination Program, please visit us at: http://publichealth.harriscountytx.gov/Services-Programs/Programs/TBElimination. HCPH's VDOT implementation guide can also be found at:
Category 4 Hurricane Harvey made landfall in Harris County on August 26, 2017. Heavy flooding and extreme rainfall brought on by the hurricane halted many medical services and made transportation very difficult throughout Harris County. Hurricane Harvey posed a threat for the interruption of TB treatment and services due to impassable/closed roads, flooding, and road hazards with transportation for patients and staff
On August 26, 2017, there were 108 patients receiving treatment for TB from HCPH. 61 patients out of 108 were on VDOT for treatment of active TB disease or TBI. This includes patients taking their medication daily, once a week, biweekly, or three times a week. Out of the 61 patients, 30 had active TB disease and 31 patients had TBI.
97% (59 out of 61) of VDOT patients that were undergoing treatment when Harvey made landfall did not have any treatment interruptions. Out of the 61 VDOT patients, 59 continued without disruption. One patient was stuck at work and was without TB medication. The other patient had to be evacuated without TB medications. Both were able to resume TB treatment after 2 and 12 days, respectively. For DOT patients, they were required to self-medicate and treatment was prolonged for an average of 16 days. VDOT has been shown to be a useful tool in the treatment of TB during a natural disaster.
Located near the Gulf of Mexico, Harris County is prone to flooding and hurricanes. HCPH and the TB Elimination Program must always have a plan in place in any case of a natural disaster. The Atlantic hurricane season lasts from June 1 to November 30 of each year. Therefore, HCPH continues to update and improve its preparedness plan for hurricane season. Harris County has a preparedness plan and Continuity of Operations Plan (COOP) set in place in case of any natural or man-made disaster. In accordance with TB's established protocols, a month's supply of medication for VDOT patients are to be given out and a week supply given to DOT patients. Secured line lists of patients are to be made so that the staff are aware of how many patients are currently being treated so that they could be accounted for during and after the hurricane. Staff members are given designated tasks, such as watching VDOT videos remotely during the hurricane so they are aware of any patients missing doses for a prolonged time frame during the natural disaster.
HCPH's preparedness plan is continuously being revised to better improve preparedness. VDOT in itself allows TB Elimination Program to be prepared because patients can continue to submit videos remotely so that there is no interruptions to their TB treatment. Thereby, their completion date for TB therapy will not be extended due to a natural disaster. By having a preparedness plan set in place and by using VDOT as an auxiliary mode of TB therapy, 55% of patients that were undergoing TB treatment in Harris County during Hurricane Harvey did not have any interruptions or any extension of treatment.
Although VDOT has been in use by Harris County since 2014, Hurricane Harvey marks the first time Harris County has used VDOT in a natural disaster of this magnitude. By continuing to use VDOT in accordance with its implementation guides and using the preparation plans set forth by Harris County Public Health, TB found much success with the use of VDOT during a natural disaster. The patients who were enrolled on VDOT continued their treatment throughout the hurricane and was given a supply of medication large enough to last them throughout the period of time that HCPH had limited operations due to Hurricane Harvey. VDOT showed its success through its flexibility, asynchronous and remote nature. The patients were able to submit the videos from wherever they were hunkered down and the VDOT champion was able to view the videos in a remote location.
Goal: To utilize asynchronous VDOT services for the continuation of TB treatment using mobile technology over a HIPAA compliant platform during a natural disaster in Harris County.
To maintain patient flexibility, autonomy, and privacy
To reduce the excessive cost burden associated with TB treatment due to Harvey
To continue TB treatment while maintaining the high adherence rate during Harvey
In October 2014, HCPH implemented VDOT as an auxiliary TB treatment strategy in addition to ongoing traditional DOT services. Due to its highly successful positive response from TB patients, high treatment adherence, and cost-effectiveness; VDOT has become an integral part of TB treatment at Harris County.
Being a coastal region, Harris County is repeatedly at risk for natural disasters, such as hurricane and floods over a six month long hurricane season. To be prepared for a natural disaster, Harris County Public Health Tuberculosis Elimination Program has an active ongoing plan for emergency situations. This plan was fully implemented at HCPH one week pre-disaster preparation phase with aim to successfully continue TB treatment of 108 TB patients without any interruptions, where 61 were on VDOT and 47 were on DOT. During pre-Harvey preparation phase, HCPH TB Elimination Program ordered and delivered in advance thirty days medication to all VDOT patients and seven days medication to DOT patients. Harris County case registry staff assisted in ordering medication, which were further delivered by outreach staff to each TB patient. A VDOT outreach staff member was assigned to remotely review and approve patient's medication videos on the secured platform. In addition, during pre-Harvey preparation, HCPH nurses reviewed each patient chart, ordered and performed required lab tests, X-rays, and updated alternative contact information on each patient.
During Harvey, all VDOT patients were informed to continue their treatment on VDOT, whereas DOT patients were advised to take self-medication until further orders. All TB patients were advised to go to the hospital in the case of emergency or if any side effects of medications occurred. HCPH VDOT staff remained in continuous contact with VDOT patients. HCPH TB nurses were also available through a 24/7 hotline to answer any patient's query regarding TB medication, side effects, and other health issues.
HCPH TB Elimination set up a protocol for TB patients eligibility criteria on VDOT. Patients who are medically stable, have knowledge and ability to operate a cellular phone, ability to open medication packets, identify each medication, and are able to store 30 days medication safely at home fit the VDOT criteria. All VDOT patients should take the first 30 doses of their treatment on DOT. Patients who are at high risk of non-adherence (e.g. homeless, history of recent substance abuse, noncompliance, or memory impairment) are not eligible to enroll on VDOT. VDOT Patients who requested to return on DOT for valid reasons, and any changes in mental health status of VDOT patients should be placed back on DOT. TB patients who were already on VDOT were able to continuously receive VDOT services during the hurricane. However, due to widespread damage across Harris County, excessive flooding, impassable roads, and shortage of staff, DOT services were not able to resume for 16 days. So during the post- Harvey response efforts, few DOT patients, who met eligibility criteria, were also placed on VDOT for continuation of the treatment.
HCPH TB department started preparation one week prior to Harvey and post-hurricane response efforts remained active until 30 days after.
HCPH TB clinical team, TB administrative team, TB leadership team, and TB patients were recognized as internal key stakeholders in the pre-hurricane, during, and post hurricane response period. HCPH VDOT clinical team (TB providers, TB nurses, TB case registry staff, VDOT champion and TB outreach workers) helped in pre-planning work and also remained a great assistance during and post hurricane response efforts. VDOT administrative staff, including the TB program manager and other administrators, assisted in the designing and implementation of hurricane preparation plan, remaining available and supportive for assistance during and post-Harvey. TB patients remained in close contact with VDOT nurses and outreach staff during and post-hurricane. The support of the HCPH TB Elimination program helped patients continue their treatment.
Other external stakeholders were Department of State Health Services (DSHS) and VDOT software platform providers. HCPH Tuberculosis Elimination program continuously updated DSHS on pre, during, and post Harvey activities in Harris County, including VDOT patients treatment. The VDOT software provider was also in continuous contact with HCPH to check if the software was working up to standards.
VDOT use during hurricane did not add any additional cost to the health department.
During the aftermath of Harvey, due to excellent planning and continuous response efforts of the HCPH Tuberculosis Elimination Program, 59 of 61 VDOT patients were able to continue their treatment on account of VDOT services. These VDOT patients were able to record and submit their medication videos onto the HCPH secured platform, which were remotely viewed and approved by HCPH VDOT staff. Whereas, 47 DOT patients had their treatment prolonged due to interruption of DOT services during and post hurricane for 16 days, 2 of 61 VDOT patients missed their treatment for 2 and 12 days, respectively, due to evacuation. On the other hand, 47 DOT patients took TB self-medication for 16 days, which were not counted toward their treatment completion. This evaluation was performed by reviewing patient charts from HCPH outreach workers, data collected from electronic medical records, and monthly compliance reports of patients. Descriptive analysis was performed using hurricane data.
Evaluation after Harvey showed that ordering and delivering one month medication to VDOT patients was a useful approach and helped patients towards the completion of their treatment. The availability of VDOT staff services for active disease patients in particular, helped patients to complete their treatment at the assigned time, reducing the chances of drug resistance and spread of infectious disease. HCPH TB Elimination Program successfully met the goal continuing VDOT patients' treatment via a HIPAA compliant platform.
Due to the catastrophic flooding of roads, residential areas, and road hazards, traditional DOT services were interrupted for 3 weeks. It was difficult for DOT workers to know about the flooded/safe areas. During Harvey and 30 days post response period, most of the HCPH staff were assigned to post Harvey response activities. Thus, the TB department worked with limited staff and resources to carry out the essential core TB functions.
During disastrous situations, DOT patients should be evaluated, so that they could be placed/switched to VDOT if they meet VDOT eligibility criteria. In theory, HCPH's Video Directly Observed Therapy platform can also be used to send education, awareness messages regarding precautions and health measures (hand washing, flood water safety, drinking water, food safety, mosquito prevention) to take during hurricane, and health aids as well as shelter aids available in the area. There is a need for continuous surveillance of TB patients in post-hurricane period. DOT services should be armed with resources of information regarding shelters, safety, hospitals, and cleaning homes. It is necessary for every health department to identify essential staff that can carry out core TB functions, while the department is responding to post Harvey response activities.
Despite the disruption of the healthcare system and delivery during Harvey, VDOT was proven as a beneficial treatment strategy in treating patients. Coinciding with literature and HCPH cost-effective analysis on VDOT, VDOT was proven as a cost effective approach with 38%, 72%, and 63% cost reduction as compared to DOT from three funding years of 2014-2015, 2015-2016, and 2016-2017 (October 1-September 30). It has been evident that VDOT has proved a successful approach in providing patient flexibility, autonomy due to its asynchronous nature, anecdotal reductions in driving incidents amongst HCPH TB staff, and an increased medication adherence rate over time. In addition, HCPH experienced an additional useful feature of the VDOT, as an essential and useful approach to TB treatment during disastrous situations. VDOT not only helps TB patients to continue their treatment, but also reduces the risk of spread of disease and drug resistance due to irregular treatment. HCPH's use of VDOT during a disaster response could serve as a model for other local health departments wishing to implement technological solutions that help to assure continuity of care for patients receiving TB treatment.
I am a previous Model Practices applicant