HD39 - Long-Term Care of Infectious Tuberculosis Patients


Executive Summary:
The 1994 General Assembly adopted HJR 189 to address the need for facilities to isolate: (1) persons with infectious TB who refuse to take medications as prescribed and thereby place their contacts at risk for the disease and themselves at risk for the development of drug resistant TB, and (2) persons with drug resistant-TB who despite taking medications need voluntary isolation to prevent them from transmitting their infection to household members and other close contacts.

HJR 189 requests the Virginia Department of Health (VDH), in consultation with Virginia's teaching hospitals, to study the location of inpatient facilities tor long-term care of patients with TB. The facilities mentioned in the Resolution are state-funded teaching hospitals, private facilities, and Department of Mental Health, Mental Retardation and Substance Abuse Services facilities.

BASIC INFORMATION ABOUT TB

TB is not a highly communicable disease. Nationally, only about 30 percent of household contacts to an active case of pulmonary TB become infected. The percentage can increase with overcrowding in poorly ventilated environments. For this reason, TB is most common among persons living in crowded conditions. In Virginia, the reported cases of TB remained fairly steady from 1986 to 1991. Since 1991, reported cases have increased each year, the numbers for 1991, 1992 and 1993, being 379, 456 and 458 respectively. As of October 14, 1994, 264 cases of TB have been reported.

The percentage of TB cases reported in Virginia with resistance to at least one drug is also increasing. Drug resistant (DR)-TB could be prevented if patients complete treatment in accordance with their physicians' instructions. While the prevalence of drug resistant-TB in Virginia is still low (13 percent of TB cases tested fur drug sensitivity in 1993), it represents a significant increase over that of previous years. The course of treatment increases from approximately 6 months for drug sensitive-TB to 18-24 months or longer for drug resistant-TB; the cure rate decreases from nearly 100 percent to 60 percent, respectively.

CURRENT EFFORTS TO CONTROL THE SPREAD OF TB

All suspected cases of TB seen in local health departments are promptly evaluated and treatment ordered if indicated. However, some persons fail to take their medications for various reasons.

The Centers for Disease Control and Prevention (CDC) has identified non-compliance with treatment recommendations as a significant contributing factor in the resurgence of TB and DR-TB nationally. To combat non-compliance in Virginia, VDH strongly encourages the use of directly observed therapy (DOT) -- where a health care provider observes the patient ingesting medications. DOT is being implemented aggressively.

In addition, VDH has initiated a homeless incentive program to house homeless persons with TB in inexpensive motels in exchange for their willingness to comply with DOT. Such persons, especially those also infected with HIV, have displayed a need for access to housing and services for three primary reasons. First, they are at the greatest risk of continued homelessness, illness, and even death, due to their dual diagnoses. They have the greatest likelihood of transmitting TB because they tend to congregate in crowded, poorly ventilated settings (shelters). Lastly, their transient lifestyle seriously decreases the likelihood of successful treatment even with DOT.

VDH has made it a priority to identify hospitalized homeless persons with TB who are at risk of treatment non-compliance and to provide tor their living needs before they are discharged from the hospital.

Despite rigorous efforts to implement DOT and the success of the homeless incentive program, some persons adamantly refuse to take medications despite repeated counseling. They are a potential risk to the public and may need to be isolated. The 1993 General Assembly amended and enacted legislation for the isolation of such persons.

THE PROBLEM CONCERNING ISOLATION OF PATIENTS

Currently, the only properly equipped facility available for the isolation of non-compliant patients is the Greensville Correctional Center. However, judges are very reluctant to isolate patients in such a restrictive environment. Also, voluntary isolation because of homelessness or drug-resistant TB in compliant patients should not occur in a prison. Therefore, it is necessary to identify other suitable facilities. The number of persons requiring long-term inpatient care is expected to increase in the years ahead. Since 1987, 93 (3 percent) of 3,065 diagnosed TB cases have been lost to follow-up in Virginia. Selective use of the current legal isolation statute (§ 32.1-48.04) could reduce this percentage significantly in the future.

Voluntary isolation of DR-TB patients and homeless patients while infectious would serve to prevent new infections among persons with whom they have contact. Since 1990, 136 cases of drug resistant-TB have been identified in Virginia. Twenty-six were resistant to the two best anti-TB drugs - isoniazid and rifampin. This represents 1.5 percent of all reported cases over this time period. Patients with this resistance pattern remain infectious for weeks to months. and there is currently no proven treatment to protect infected contacts against future disease. Every effort must be made to ensure that these patients will not transmit their infection to uninfected persons. Based on these data, 4 to 5 percent of Virginia's TB cases could be candidates for long-term care. This translates to approximately 20 patients each year, for an average stay of 4 to 6 months. It is estimated that no more than 5 of these patients would be housed concurrently.

Facilities providing long term care for TB patients must be in compliance with the Occupational Safety and Health Administration's (OSHA) policy designed to reduce occupational exposure to TB, published October 8, 1993.

These facilities would ideally be capable of ensuring medical expertise in the management of TB patients, psychiatric consultation, substance abuse counseling, effective discharge planning, and secured rooms for patients under an order of legal isolation.

IDENTIFICATION OF AV.AILABLE FACILITIES

A committee represented by (among others) the state's three teaching hospitals, the Virginia Hospital Association, and the Virginia Chapter of the American Lung Association, met on July 19 to discuss the response to HJR 189. The task of the committee was to review the needs for long-term care of TB patients, identify facilities and estimate funding needs. The committee considered the advantages, disadvantages and costs associated with isolating patients at state assisted teaching hospitals, private hospitals, Veterans Administration hospitals, and facilities operated by the Department of Mental Health, Mental Retardation, and Substance Abuse Services.

RECOMMENDATION

After careful consideration of the relative merits and costs associated with establishing isolation rooms in the aforementioned facilities, the consensus was that the most effective and least expensive facilities, in order of preference, are the Central Virginia Training Center in Lynchburg, and the Veteran's Administration (VA) hospitals in Richmond, Hampton and Salem.

The training center has properly equipped and unused rooms that can be utilized without disrupting on-going activities within the facility. This facility would not require expensive room renovations to meet OSHA requirements. In addition, the average cost per patient decreases with multiple admissions in the training center. In all other options investigated, the cost per patient is constant. The VA hospitals have physicians who can manage TB patients, but do not have properly equipped rooms. It is unknown if the VA hospitals would be able or willing to house as many patients at one time as the training center. Lastly, and perhaps most importantly, the VA hospitals cannot currently provide this service. Therefore, the committee believes that the Central Virginia Training Center is the optimal facility, with the VA hospitals a close second.