Transcript TPHA Conference April 15, 2009 State of Texas Health

Riding the Waves
September 16 & 17, 2010
“Public Health Strategies to
Address STDs, HIV & TB in Texas”
David Lakey, M.D.
Commissioner
Texas Department of State Health Services
Texas Department of State Health Services (DSHS)
Became Operational on September 1, 2004
Health Department
Mental Health Agency
Substance Abuse Agency
2
Department of State Health
Services
• Vision — A healthy Texas
• Mission — To improve health and
well-being in Texas
3
4
U.S. Life Expectancy at Birth
70
60
1918 Flu
Epidemic
50
40
30
1900
1910
1918
1920
1930
1940
1950
1960
5
Life Expectancy in Texas
Total and by Race, 1989 - 2007
6
Increased Life Expectancy Driven
by Public Health Improvements
80
Increased years due to
public health measures:
25
60
40
20
0
77 years
Increased years due to
medical care advances:
5
47 years
1900
2000
Source: Ten Great Public Health Achievements -- United States, 1900-1999 MMWR, April 02, 1999 / 48(12);241
243 http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm
7
Impact of Vaccines in the
20th Century
Disease
20th Century
Annual Morbidity
2006 Total
% Decrease
Smallpox
48,164
0
100
Diphtheria
175,885
0
100
Pertussis
147,271
15,632
89
Tetanus
1,314
41
97
Polio (paralytic)
16,316
0
100
Measles
503,282
55
>99.9
Mumps
152,209
6,584
96
Rubella
47,745
11
>99.9
Congenital rubella
823
1
99.8
Haemophilus
influenzae (<5 yrs)
20,000 (est.)
208
99
(serotype B or unknown
serotype)
8
Number of Cases and Incidence of
Hep-A in Texas, 2000 - 2009
9
Number of Cases and Incidence of
Hep-B, Acute in Texas 2000 - 2009
10
Leading Causes of Death
•
•
•
•
•
1900
Pneumonia
Tuberculosis
Diarrhea
Heart Disease
Intracranial Lesions
•
•
•
•
2007
Heart Disease
Cancers
Accidents
Cerebrovascular
Disease
• Chronic Lower
Respiratory
Diseases
11
Ten Leading Causes of Death in
Texas, 2007
12
Ten Leading Causes of Death in
Texas, Ages 18 – 44 Years, 2007
13
Infectious Diseases no Longer Leading
Causes of Death in the United States
However:
• ~1 million Americans infected with HIV
– ¼ are unaware of their infection
•
Chronic liver disease: 10th leading cause of death in U.S.
– More than half of these deaths due to viral hepatitis
– Hepatitis C is most common blood-borne disease in U.S.
• ~19 million cases of non-HIV STDs occur each year
– Chlamydia and gonorrhea are most commonly reported infectious
diseases
• ~10-15 million in U.S. have latent TB infection
– 13,767 had TB in 2006
Furthermore:
Infectious Disease are inherently contagious and can quickly resurge
14
Texas’ Major Infectious Disease
Challenges: STDs
• ~ 87% of the top ten reported infectious diseases
are sexually transmitted, including Chlamydia,
gonorrhea, syphilis and HIV
• In 2009, 139,600 STD infections, excluding
HIV / AIDS, were reported in Texas
– an increase of 2% from 2008
• Texas’ ranking among states (2008):
– 4th in syphilis rates
– 15th in gonorrhea rates
– 17th in Chlamydia rates
15
Cases
Chlamydia Cases by Year of Report:
Texas, 2000-2009
110,000
100,000
90,000
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
Males All Ages
Females Other Ages
Females Age 15-24
63%
63%
63%
63%
62%
62%
60%
59%
58%
58%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
16
Gonorrhea Case Rates in Texas By
Race / Ethnicity, 1999 - 2009
17
Primary & Secondary Syphilis Case
Rates in Texas, 1999 - 2009
18
Texas’ Major Infectious Disease
Challenges: HIV/AIDS
• Between 2002 - 2008, the number of living HIV/AIDS
cases in Texas rose ~6% a year
– The increase reflects extended survival due to better
treatment and not an increase in new diagnoses
• During the same period, new HIV diagnoses stayed
stable at ~4,500 per year, and deaths at ~1,200 year
• In 2008, the rate among blacks was 4 - 5 times
higher than the rates in whites and Hispanics
– Blacks also had the highest number and rate of newly
diagnosed infections
• 5-7 times higher than the rates for Hispanics and whites
19
Newly Diagnosed HIV Cases, Deaths, &
Persons Living with HIV (Texas, 1980-2008)
70000
New HIV Cases / Deaths
7000
Living with HIV
6000
5000
60000
50000
New HIV Cases
40000
4000
30000
3000
20000
2000
10000
1000
Deaths among HIV Cases
0
0
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08
Year
20
Persons Living with HIV
8000
Persons Living
with HIV, 1987
21
Persons Living
with HIV, 1997
22
Persons Living
with HIV, 2007
23
Newly-diagnosed HIV Cases*:
Texas, 1999-2008
7000
AIDS
HIV
6000
Cases
5000
4000
3000
2000
1000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
* AIDS cases were diagnosed with AIDS within 1 month of HIV diagnosis 24
Racial Disparity in Persons Living
with HIV/AIDS in Texas (2001 – 2006)
25,000
1000
23,119
868.3
900
22,439
20,000
800
15,000
14,417
15,184
10,000
Rate per 100,000
Number
16,388
700
615.9
600
500
400
300
8,936
5,000
200
100
0
196.7
146.6
170.2
128.4
0
2001
2002
2003
2004
2005
2006
2001
2002
Year
White
Black
Hispanic
White
2003
2004
Year
Black
2005
2006
Hispanic
25
Newly-diagnosed HIV Cases by
Race/Ethnicity: Texas, 2008
Texas Population
n=24,383,647
New HIV Cases
n=4,293
White
29%
48%
43%
11%
36%
Black
Hispanic
26%
5%
Other/Unknown
2%
26
Rate of New HIV Diagnoses by Sex
& Race / Ethnicity
Source: 2010 Texas Integrated Epidemiologic Profile for HIV/AIDS Prevention and
Services Planning: HIV/AIDS in Texas, Department of State Health Services, Publication
Number E13-11937 (Revised April 2010).
27
Texas’ Major Infectious Disease
Challenge: TB
• Texas ranks 2nd in the United States in number of TB
cases after California
– Approximately 13% of all US cases are from Texas
• The number of Texas cases has declined by ~15%
since 1998
• The rate has decreased from 9.1 per 100,000 in 1998 to
6.0 in 2009
• The percent of foreign born TB cases continues to rise
as does the incidence of:
– Multidrug-resistant (MDR) cases, and
– Comorbidities
– Makes effective treatment more challenging
28
Number of TB Cases
Texas 1999-2008
1700
1670
1640
1630
1650
Cases
1580
1600
1566
1539
1550
1524
1496
1510
1501 1501
1500
1450
1400
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
29
Tuberculosis Incidence Rates Along
Texas-Mexico Border,
Texas 1999-2008
Cases per 100,000 population
14
12.5
13.1
13.3
13.1
12.8
12.9
12.3
12.2
11.1
11.6
6.1
6.1
5.8
5.6
2005
2006
2007
2008
12
10
8
6
7.7
6.6
4
7.1
6.5
6.5
6.8
2
0
1999
2000
2001
2002
2003
2004
Year
Texas Border
Texas NonBorder
30
TB Case Rates in Texas, by Race
2000 - 2009
31
Number of Foreign-Born TB
Patients in Texas, 2000 - 2009
32
Syndemics
(Overlapping Epidemics)
• Similar or Overlapping at-risk Populations
• Disease Interactions
–
–
–
–
Common transmission for HIV, hepatitis & STDs
STDs increase risk of HIV infection
HIV is greatest risk factor for progression to TB
HIV accelerates liver diseases associated with viral hepatitis
• Social Determinants
• Prevention and Control
– Control of TB, viral hepatitis and STDs needed to protect health
of HIV-infected persons
– Challenges in funding, delivery, monitoring and quality of
prevention services
33
Modernizing Prevention Responses
• Improve data systems
• Embrace new technologies that improve
early diagnosis and treatment
• Embrace the use of social media for
information & interventions
• Support implementation of US Preventative
Services Task Force recommendations
– Only 1/3 of sexually active young females are
receiving recommended screenings in Texas
34
Essential Partners for Infectious
Disease Control
•
•
•
•
•
•
•
Local health departments
Regional public health
State program
National – CDC
International
Academia
Private sector
35
The DSHS HIV / STD Program
• The HIV / STD Program prevents the spread of HIV
and other STDs and minimizes disease complications
and costs by:
–
–
–
–
Providing information & education
Using evidence-based interventions, counseling, screening and testing
Partner elicitation and notification, and
Medical and social services
• The HIV / STD Program consists of 2 branches, the
TB / HIV / STD Epidemiology & Surveillance Branch
and the HIV / STD Prevention & Care Branch
– Both branches are located in the TB/HIV/STD Unit
• The program provides some direct services
– Local health departments and community organizations provide
most HIV/STD-related services through contracts with DSHS
36
HIV / STD Program Priorities
•
Increase
– the number of Texans living with HIV who get
treatment
•
Reduce
– new HIV infections
– new STD infections
– late diagnosis of HIV infection
– racial/ethnic disparities in HIV and STD
•
Enhance HIV/STD surveillance
•
Promote integration of services
37
Program Collaboration & Service
Integration (PCSI)
• PCSI is an approach to integrate the responses to
interrelated health issues, activities & prevention
strategies to facilitate comprehensive, client-focused
services
• One key DSHS value is to develop and expand
integration of public health, mental health, substance
abuse and other behavioral services
• HIV and STD programs have been successfully
integrated at DSHS since 1987
• In late 2008, surveillance and epidemiology functions
were integrated for TB, HIV, and STD
38
HIV Funds Received
(FY 2010-2011)
• Legislature instructed DSHS to target ~$4.4 million each
year to increase HIV testing in high morbidity areas
– Houston and Dallas given top consideration
• The DSHS HIV program worked with numerous internal
and external partners to create the Test Texas HIV
Coalition and:
– Form a peer network to increase adoption of routine testing
recommendations
– Provided increased access to training and technical assistance
• DSHS ramped up contractual activity with large hospital
emergency departments, jails and community health
clinics to provide routine HIV testing
39
HIV Expanded Testing Initiative
• Funds for enhanced testing efforts
targeted correctional facilities,
Emergency Departments & FQHCs
• HIV NAAT testing took place in the Dallas
County Health Department lab to indentify
acute HIV infections
• All Texas public health labs now use
state-of-the-art amplified testing
technology to provide rapid results for
HIV and other STDs
40
Routine HIV Tests Conducted by
Routine HIV Testing Projects Funded by DSHS
& City of Houston, 2009
Source: Department of State Health Services Program data, HIV/STD Prevention and
Care Branch
41
HIV Expanded Testing Initiative
• DSHS is committed to the expansion of
routine, integrated HIV testing in health care
settings
–
–
–
–
Key strategy for reducing new HIV infections
Working to expand routine HIV testing within DSHS
Recruit and support of new facilities and clinics
Support general education and diffusion of routine
testing practices, especially among private physicians
42
Expedited Partner Therapy (EPT)
• EPT treats sex partners of persons with an STD
without an intervening medical evaluation or
professional prevention counseling of the
partner
– Typically through patient-delivered partner therapy
• The Texas Medical board has endorsed EPT
• DSHS has created an EPT fact sheet
– Explains why a health care provider would use EPT, and
– How it works
– Fact sheets to educate partners are available at
http://www.dshs.state.tx.us/hivstd/ept/default.shtm
43
HIV Counseling, Testing & Referral
(CTR) for High-Risk Individuals
• CTR programs:
– Inform individuals of their HIV status
– Encourage risk behavior change, and
– Link clients to appropriate services
• The Texas HIV/STD Program currently funds 23
programs
• In 2009, DSHS CTR contractors performed over
30,000 HIV tests
– With a new positivity rate of 1.0%
• In addition to our long history working with CTR
programs:
– DSHS implemented social networking strategies in late 2009 to improve
the identification of newly HIV infected persons
44
Advances in TB Care
• New diagnostic tests will provide more
specific diagnosis
– Skin test 100 years old, but still in widespread use
– Currently, 2 FDA-approved blood tests in use in
limited areas of Texas
• Drug sensitivity tests
– New genetic tests detect drug resistance mutations
to critical drugs (INH & rifampin) more quickly
– Conventional tests take about 28 days but genetic
tests can be completed in 2 days
• New TB drugs currently in clinical trials
• Potential development of vaccines
– May be years in the future
45
Treatment Challenges
• Treatment is now primarily
outpatient
• Requires legwork
• Requires meticulous follow up
46
Infectious Disease Successes:
Tuberculosis
U.S. Bi-national Initiatives:
• CureTB is a US-Mexico bi-national tuberculosis referral
program that, since 1997, has facilitated continuity of
care of TB patients moving between the United States
and Mexico
Texas “Sister City” Bi-national Initiatives:
•
•
•
•
•
•
Brownsville and Matamoros
McAllen and Reynosa
Laredo and Nuevo Laredo
El Paso and Juarez
Eagle Pass and Pierdas Negras
Del Rio and Ciudad Acuña
47
TB Funds Received
(FY 2010-2011)
• Appropriated ~$7,000,000 for the biennium for
TB prevention and control to:
– Support increased prevention and control activities at
the regional and local level
– Support special projects at the regional and local level
to focus on:
•
•
•
•
Blacks at increased risk,
Patient-centered interventions,
Homeless persons with TB, and
Children with TB who need case management
48
The Texas Center for Infectious
Disease (TCID)
• TCID is a DSHS facility. It is the largest
new construction in the US in the last 50
years for inpatient care & treatment for TB
patients. It provides:
– Patient care,
– Scientific investigation,
– Therapeutic and educational services supporting
public health needs
• TCID's Outpatient Clinic also serves as
one of the state's Hansen Disease Clinics
• Construction completed on 22SEP10
49
Texas Center for Infectious
Disease (TCID)
50
Texas Center for Infectious
Disease (TCID)
51
Major Issues During 82nd
Legislative Session
•
•
•
•
Redistricting
Immigration issues
Healthcare reform
Budget challenges
– Previous Reductions
– Budget reduction schedule
– Growth of entitlement programs
– Requests for new or expanded programs
52
DSHS Legislative
Appropriations Request
• DSHS continues reductions made in the current
biennium as part of the HHS System approach to
the 5% reduction to the budget
– The request includes additional 10% GR reduction options.
• DSHS prioritized options to mitigate the impact on
community services and safety net health
programs
• The LAR includes 12 exceptional items to:
– Maintain operating capacity in existing program
– Ensure compliance with state and federal requirements, and
– Move health forward in Texas
53
FY 2012-3 Base by Strategy
GOAL
2010-11All Funds
2012-13 All Funds
A. Preparedness & Prevention
Services
1,243,611,434
1,086,689,573
B. Community Health Services
3,706,877,855
3,656,431,475
C. Hospital Facilities and Services
874,304,269
883,276,458
D. Consumer Protection Services
145,847,016
145,049,554
E. Indirect Administration
112,204,513
117,068,159
78,392,897
64,129,014
6,161,237,984
5,952,644,233
F. Capital Items
TOTAL
54
FY 2010-11 Appropriations
(By Goal)
$1,000
$900
$800
(in millions)
$700
$600
GR
GRD
$500
$400
$300
$200
$100
$0
Goal A
Goal B
Goal C
Goal D
Goal E
Goal F
55
Ten Percent Reduction Options
(By Strategy)
Strategy
Description
First 5%
Second 5%
Total
A.2.1
A.2.1
A.3.1
A.3.1
A.3.1
A.3.3
A.3.3
A.3.3
A.3.4
A.3.5
B.1.1
B.1.2
Immunizations – Adult
Immunizations – Children
Children’s Outreach Health Program
Diabetes
Obesity Prevention
Kidney Transportation
Donate Life Registry
Kidney Medical
Children with Special Health Care Needs
Epilepsy
Farmer’s Market
Women & Children’s Services – Dental Services
1
0
0.5
0.5
1
4.5
0.4
1
0
0.45
0.85
0
0
7.7
0
0.5
0
0
0
6
24
0
0
1.6
1
7.7
0.5
1
1
4.5
0.4
7
24
0.45
0.85
1.6
B.1.4
B.2.1 – B.2.4
Primary Care
Community Mental Health Services
6
35.3
3
47.9
9
83.2
B.2.5
B.3.1
B.3.3
Substance Abuse Intervention
EMS/Trauma
Indigent Health Care Reimbursement to UTMB
4
20
4.5
0
5
4
4
25
8.5
B.3.4
C.1.2
C.1.3
D.1.4
E.1.1 – E.1.3
County Indigent
South Texas Health Care system
State Mental Health Hospital System
Massage Therapy
Support Activities
6
2.5
30
0
0.7
0
2.5
14.8
1.5
0.7
6
5
44.8
1.5
1.4
119.2
119.2
238.4
TOTAL
56
Ten Percent Reduction Options
• $137 million – Reductions in State Mental Health Hospital
capacity, Community Mental Health Services for adults
and children, and Substance Abuse Intervention services
• $58 million – Reductions in several programs that
provide health and dental services, including
vaccination, primary care and services for children with
special health care needs, among others
• $41 million – Reductions in funding for uncompensated
care reimbursed to counties and hospitals, as well as
prevention and education programs
• $3 million – Reductions in support and administrative
savings
57
Exceptional Item Requests
• Exceptional Items in priority order,
ranked according to:
– Maintaining current services
– Ensuring compliance with state and
federal requirements
– Moving health forward in Texas
58
Exceptional Item Requests
Maintain Current Services
• Maintain current services and gaps
• $57.4 million GR/AF
– Increasing caseload – HIV and Kidney Health Care
– Annualized Services - MH Forensic Facility, Regulatory,
Newborn Screening and Vital Statistics
– Increasing Cost
– Vehicles
• Maintain Hospital Operations
• $42.6 million GR/AF
– Increasing Cost – Medication, Medical services, food, supplies
and utilities
– Salary Increase for critical positions
– Additional Staffing Requirements
– After Hours Pharmacy Coverage
59
Exceptional Item 1
FY 2012
FY 2013
Biennium
HIV Medications
---
22,668,987
22,668,987
Kidney Health Care
---
846,983
846,983
Montgomery County Annualized
7,500,000
15,000,000
22,500,000
Regulatory Services Annualized
2,510,780
2,510,779
5,021,559
Newborn Screening Annualized
479,793
479,973
959,586
Vital Statistics Annualized
220,796
220,795
441,591
1,710,535
2,915,060
4,625,595
151,357
174,176
325,533
12,573,261
44,816,573
57,389,834
Agency Costs – Utilities,
Transportation, Postage
Replace Aging Vehicles
Total
60
Texas’s Funding for HIV
2009
2010
2011
2012
2013
State GR
$ 51.4 M
$ 55.0 M
$ 55.1 M
$ 55.0 M
$ 55.0 M
Federal
Funds
$125.2 M
$141.0 M
$132.6 M
$ 113.0 M $111.8 M
Total
$176.6 M
$196.0 M
$ 187.7 M $ 168.0 M $166.9 M
61
Exceptional Item Requests
(continued)
Maintain FY10-11 Services
• Return to regular FMAP after ARRA Expiration and
Restore ARRA TANF ($6.7 million GR/AF)
– Maintain Current Capacity at North Texas State Hospital
– Restore TANF Funds for Family Planning Services
• State Hospital Capacity ($22.3 million GR/ $24.6
million AF)
– Alternatives to hospitalization for long term patients
– Stipends for Psychiatrist and Nurse Practitioner Residents
– Peer Support
• Hospital Equipment/Repair and Renovation ($15.5
million GR/ $84.4 million AF)
– Critical equipment
– Vehicles
– Building Renovation and Repair
62
Exceptional Item Requests
(continued)
Compliance with State/Federal Statutes
• Patient safety ($5.5 million GR/AF)
– Healthcare associated infections and preventable adverse
events
– Statewide prevention efforts
– Quality assurance teams
• Food and Environmental Safety ($5.7 million GR/AF)
– Improve the detection and investigation of food-borne illnesses
– Increase efficiencies in regulatory processes by sharing data
and providing access to license and enforcement cases online
– Improve the collection and investigation of blood lead testing to
identify and screen children who are at risk for lead poisoning
63
Exceptional Item Requests
(continued)
Move Health Forward
• Healthy babies ($11.7 million GR/$12.9 million AF)
– Reduce 3 main causes of infant mortality (SIDS, prematurity,
birth and genetic defects) through a public-private partnership
– Sustain and improve the collection of birth defect data
– Expand newborn screening and case management for the
secondary panel of newborn screening conditions
• Community MHSA services ($18.6 million GR/$21
million AF)
– Collaborative projects for jail diversion
– Comprehensive prevention and treatment response targeted at
border communities
– Expand capacity of the Clinical Management Behavioral Health
System
64
Exceptional Item Requests
(continued)
• Obesity prevention ($4 million GR/AF)
– Evidence based obesity prevention and control in communities
to improve nutrition and increase physical activity
• Preventable hospitalization ($5.1 million GR/AF)
– Reduce preventable hospitalizations with grant funding
• Infectious disease prevention ($11.3 million GR/AF)
– Increased capacity at the Texas Center for Infectious Disease
– Improve TB identification and treatment
– Reduce the number of pediatric hospitalizations due to
gastroenteritis
– Improve reporting and surveillance tools
65
Infectious Disease Prevention
Exceptional Item 12
FY 2012
FY 2013
Biennium
Texas Center for Infectious
Disease – Full Capacity
1,435,654
2,380,154
3,815,808
Tuberculosis and Pediatric
Protection
1,467,352
1,566,058
3,033,410
Improve immunization data
collection and other
surveillance systems
3,250,000
1,250,000
4,500,000
Total
6,153,006
5,196,212 11,349,218
66
Summary
• Due to improvement in public health, the mortality of
infectious diseases as a whole has significantly
decreased over the last century
• However, STDs and HIV continue to cause
significant morbidity and their rates continue to
increase
• Gradual improvements in TB morbidity in Texas
• Success of new tools and strategies to fight these
disease
• A difficult legislative session lies ahead
• Partnerships are essential to continue progress
67
Thank You!
Incidence of Hepatitis C, Acute in Texas,
2000-2009
250
1.2
1
0.8
150
0.6
100
0.4
50
0.2
0
0
2000
2001
2002
2003
Case count
2004
2005
Incidence Rate
2006
2007
2008
2009
Rate per 100,000 population
Number of Cases
200
Texas Public Health Successes
• Childhood Immunizations
– Texas was named the most improved state in childhood immunizations
by the U.S. Centers for Disease Control and Prevention
– San Antonio/Bexar County was named the most improved city/county
• Preparedness
– Texas one of 7 states with highest score by TFAH
– H1N1 and Hurricane responses
• Tobacco
– The number of communities with smoke-free ordinances has increased
from two in 2000, to 47 in 2009
• Increased funding
– During 81st Legislative session, 12 of 13 exceptional items were partially
funded to include: obesity, family planning, TB, HIV testing, community
mental health, Cystic Fibrosis, disaster response and regulatory services
– Total increase $230 million over biennium
• Substance abuse Medicaid benefit
• Improved mental health crisis services
70