SUBJECT
Title
AUTHORIZATION TO ACCEPT FUNDING FOR TUBERCULOSIS CONTROL AND TREATMENT, AND REFUGEE HEALTH ASSESSMENT SERVICES, AUTHORIZATION TO ACCEPT ANTI-TUBERCULOSIS MEDICATION, AND AUTHORIZATION TO APPLY FOR ADDITIONAL FUNDING OPPORTUNITIES (DISTRICTS: ALL)
Body
OVERVIEW
The County of San Diego (County) Health and Human Services Agency, Public Health Services, Tuberculosis Control and Refugee Health Branch (TBCRHB) operates programs including the Tuberculosis Control Program (TB Control Program) and Refugee Health Assessment Program (RHAP). The TB Control Program detects, mitigates, and prevents the spread of Tuberculosis (TB) in our community through treatment, case management, contact investigation and education, and is supported through a combination of federal, State, and local funding.
In addition to providing grant funding, the California Department of Public Health (CDPH) Tuberculosis Control Branch (CDPH TBCB) operates both a Medication Support Program and Drug Stockpile that distributes anti-TB medications to local TB programs at no cost. When CDPH TBCB purchases anti-TB medication that is due to expire in the same year, local TB programs are notified of the availability and requested to apply as soon as possible. Due to limited supply, the anti-TB medication donations are often reserved within days.
Additionally, grant funds from CDPH support the Refugee Health Assessment Program (RHAP) to provide newly arrived refugees, asylees, victims of trafficking, and other eligible entrants with culturally and linguistically appropriate health assessments, including follow-up and referrals for health conditions identified in the assessment process. The County contracts with community providers to complete comprehensive health assessments that focus on screening for and prevention of communicable and chronic diseases, assessments of immunization status for children and adults, mental health screenings, and referrals to health providers for further medical evaluation. Treatment for both communicable and chronic conditions occurs within the first three months of arrival. These efforts allow the County to monitor and evaluate the health statuses for refugee populations, and to promote the health of newcomers to our community. The County uses the data to develop prevention and intervention strategies, and to allocate resources to reduce disparities and prioritize health equity.
Today’s action seeks Board authority to authorize the Agency Director, Health and Human Services Agency, upon receipt, to execute documents related to:
• The acceptance of TB Control Cooperative Grant funds from the CDC for the term January 1, 2025, through December 31, 2025, for approximately $1,780,240.
• The acceptance of TB treatment and control grant funds from the CDPH for the term July 1, 2024, through June 30, 2025, for approximately $890,885.
• The application for and acceptance of anti-TB medications from CDPH TBCB.
• The acceptance of the Refugee Health Assessment Program and Refugee Health Promotion Project grant funds from the CDPH for the term October 1, 2024, through September 30, 2025, for approximately $692,000.
• The application for additional TB control and treatment and refugee health assessment services funding opportunities.
This item supports the County vision of a just, sustainable, and resilient future for all, specifically those communities and populations in San Diego County that have been historically left behind. These efforts support our ongoing commitment to the regional Live Well San Diego vision of healthy, safe, and thriving communities. This will be accomplished by building a better service delivery system to reduce the spread of disease and improve health outcomes in San Diego County.
RECOMMENDATION(S)
CHIEF ADMINISTRATIVE OFFICER
1. Waive Board Policy B-29, Fees, Grants, Revenue Contracts - Department Responsibility for Cost Recovery, which requires prior approval of grant applications and full-cost recovery of grants.
2. Authorize the acceptance of approximately $1,780,240 in grant funds from the Centers for Disease Control and Prevention for the period of January 1, 2025, through December 31, 2025, for tuberculosis control and treatment services, and authorize the Agency Director, Health and Human Services Agency, upon receipt, to execute all required grant documents, including any annual extensions, amendments and/or revisions that do not materially impact the services or funding level.
3. Authorize the acceptance of approximately $890,885 in grant funds from the California Department of Public Health for the period of July 1, 2024, through June 30, 2025, for tuberculosis control and treatment services, and authorize the Agency Director, Health and Human Services Agency, upon receipt, to execute all required grant documents, including any annual extensions, amendments, and/or revisions that do not materially impact the services or funding level.
4. Authorize the application for and acceptance of anti-tuberculosis medication from the California Department of Public Health to support tuberculosis treatment, and authorize the Agency Director, Health and Human Services Agency, or their designee, to execute any related documents.
5. Authorize the acceptance of approximately $692,000 in grant funds from the California Department of Public Health for the period of October 1, 2024 through September 30, 2025, for the Refugee Health Assessment Program and Refugee Health Promotion Project to provide refugee health assessment services, and authorize the Agency Director, Health and Human Services Agency, upon receipt, to execute all required grant documents, including any annual extensions, amendments, and/or revisions that do not materially impact the services or funding level.
6. Authorize the Agency Director, Health and Human Services Agency, to pursue future funding opportunities to support tuberculosis control and treatment and refugee health assessment services.
EQUITY IMPACT STATEMENT
The County of San Diego Health and Human Services Agency, Public Health Services, Tuberculosis Control and Refugee Health Branch programs, as well as the San Diego County Tuberculosis Elimination Initiative, focus on providing and expanding equitable access to healthcare. Examples include offering transportation services to medical appointments, housing for individuals experiencing homelessness while receiving Tuberculosis treatment, and free screening and treatment for uninsured and underserved populations.
Tuberculosis (TB) disproportionately impacts underserved communities, with high burden areas coinciding with southern and central geographic regions of San Diego County that receive low health equity scores. The majority of persons diagnosed with TB in San Diego County in 2023 were born outside the U.S. (66% of total cases). The highest proportion of new cases, regardless of birth country, occurred in Hispanics (51% of total cases), followed by Asian/Pacific Islanders (30% of total cases). Of the new TB cases born in the U.S., (34% of total cases), 66% of U.S.-born cases were Hispanic. Additional risk factors include drug use (19%), homelessness (13%), and incarceration (6%).
Data from the U.S. Refugee Admission Program indicates that 4,319 refugees arrived in California from October 1, 2023, through May 31, 2024. According to the California Department of Social Services Refugee Programs Bureau, San Diego is a designated refugee-impacted county. The Refugee Health Assessment Program (RHAP) provides culturally and linguistically-appropriate comprehensive health assessments not only to these newly arrived refugees but also Special Immigrant Visa holders, asylees, federally-certified victims of trafficking, and other eligible entrants. RHAP focuses on screening for and prevention of communicable diseases; early identification and diagnosis of chronic diseases and other important conditions; assessment of immunization status for children and adults; mental health screening; and referral to health providers for further medical evaluation, treatment, and follow-up. In Fiscal Year (FY) 2021-2022, a total of 1,759 eligible persons in San Diego County received a health assessment through RHAP, with 82% of those individuals completing the health assessment with 90 days of their arrival in the United States.
SUSTAINABILITY IMPACT STATEMENT
The proposed actions support the County of San Diego (County) Sustainability Goal #2, to provide just and equitable access to County services, particularly in the investment in the chronically underserved communities that are disproportionately impacted by tuberculosis (TB). These actions support Sustainability Goal #3 by transitioning to a green, carbon-free economy, by continuing to transition delivery of services to telehealth platforms whenever possible without sacrificing quality, and thereby decreasing vehicle mileage for clients and employees. Additionally, today’s actions support Sustainability Goal #4, by protecting the health and well- being of everyone in the region, ensuring access to medical care for those with TB who need care, and providing newly arrived refugees, asylees, victims of trafficking, and other eligible entrants, with culturally and linguistically appropriate comprehensive health assessments.
FISCAL IMPACT
Recommendation #2: Authorize Acceptance of Approximately $1,780,240 from the Centers for Disease Control and Prevention
Funds for this request are included in the Fiscal Year (FY) 2024-2026 Operational Plan in the Health and Human Services Agency. If approved, this request will result in estimated costs of $1,391,160 and estimated revenue of $890,120 for FY 2024-25 and estimated costs of $1,391,160 and estimated revenue of $890,120 for FY 2025-26. The funding source is the Centers for Disease Control and Prevention. A waiver of Board Policy B-29 is requested because the funding does not offset all costs. These unrecovered costs are estimated to be $501,040 annually in FY 2024-25 and FY 2025-26. The funding source for these costs will be existing Realignment. The public benefit for providing these services far outweighs the B-29 unrecoverable costs. There will be no change in net General Fund costs and no additional staff years.
Recommendation #3: Authorize Acceptance of Approximately $890,885 from the California Department of Public Health
Funds for this request are included in the FY 2024-2026 Operational Plan in the Health and Human Services Agency. If approved, this request will result in estimated costs of $1,298,069 and estimated revenue of $890,885 for FY 2024-25. The funding source is the California Department of Public Health. A waiver of Board Policy B-29 is requested because the funding does not offset all costs. These unrecovered costs are estimated to be $407,184. The funding source for these costs will be existing Realignment. The public benefit for providing these services far outweighs the B-29 unrecoverable costs. There will be no change in net General Fund costs and no additional staff years.
Recommendation #4: Authorize Application for and Acceptance of Anti-Tuberculosis Medication
There is no fiscal impact related to this recommendation. There will be no change in net General Fund costs and no additional staff years.
Recommendation #5: Authorize Acceptance of Approximately $692,000 from the California Department of Public Health
Funds for this request are included in the FY 2024-2026 Operational Plan in the Health and Human Services Agency. If approved, this request will result in estimated costs of $544,735 and estimated revenue of $519,000 for FY 2024-25 and estimated costs of $181,578 and estimated revenue of $173,000 for FY 2025-26. The funding source is the California Department of Public Health. A waiver of Board Policy B-29 is requested because the funding does not offset all costs. These unrecovered costs are estimated to be $25,735 for FY 2024-25 and $8,578 for FY 2025-26. The funding source for these costs will be existing Realignment. The public benefit for providing these services far outweighs the B-29 unrecoverable costs. There will be no change in net General Fund costs and no additional staff years.
Recommendation #6: Authorize Pursuit of Future Funding Opportunities
There is no fiscal impact related to this recommendation. There will be no change in net General Fund costs and no additional staff years.
BUSINESS IMPACT STATEMENT
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Details
ADVISORY BOARD STATEMENT
Public Health Services presented these recommendations to the Health Services Advisory Board at its meeting on July 9, 2024.
BACKGROUND
The County of San Diego (County) Health and Human Services Agency, Public Health Services, Tuberculosis Control and Refugee Health Branch (TBCRHB) operates programs including the Tuberculosis Control Program (TB Control Program) and Refugee Health Assessment Program (RHAP).
Tuberculosis Control Program
Tuberculosis (TB) is a communicable bacterial disease transmitted from person-to-person through shared indoor air space. The infectious period usually lasts weeks to months, and treatment can take six to 18 months. Groups disproportionately affected by TB include individuals experiencing homelessness, and persons with diabetes, kidney failure, cancer, and HIV infection. Complications are most common in children under the age of five and the immunocompromised, and can result in strokes, hearing and vision loss, and developmental disabilities.
The TB Control Program detects, mitigates, and prevents the spread of TB in our community through treatment, case management, contact investigation. Since 2020, TB cases in California have been increasing each year, for a total increase of 24% over the last four years, returning to case numbers not seen since before the COVID-19 pandemic (CDPH TB Control Branch, TB in CA: 2021 Snapshot, February 2024). In 2023, TB incidence in San Diego County was 7.4 cases per 100,000 persons (County of San Diego, Tuberculosis in San Diego County, March 2023), which is higher than California’s annual TB incidence of 5.4 cases per 100,000 persons (CDPH TB Control Branch, TB in CA: 2021 Snapshot, February 2024). In 2023, the County reported 243 new active TB cases, a 17% increase compared to 208 cases in 2022 (County of San Diego, Tuberculosis in San Diego County, March 2023). Potential reasons for the increase include resumption of normal activities after COVID-19, resumption of travel and migration between California and elevated TB areas, and people seeking health care and providers and public health programs resuming testing for TB.
Only a small portion of TB-infected individuals develop the disease immediately. Most people infected with TB harbor the undetected bacteria in their bodies, which is referred to as latent TB infection (LTBI). LTBI cannot be transmitted to others, but without treatment, these individuals have a 5-10% percent risk of reactivation and progression to infectious TB disease in their lifetimes. Among people with LTBI, an estimated 25% are aware of their infection and only 15% receive treatment (County of San Diego, Tuberculosis in San Diego County, March 2023). An estimated 85% of people in California with active TB began as LTBI, therefore treatment for LTBI remains an important prevention opportunity.
Based on California Department of Public Health (CDPH) estimates in 2019, approximately 175,000 San Diego County residents are infected with LTBI. County TB Clinics provide short-course medication regimens to treat LTBI, an evidence-based practice recommended by the Centers for Disease Control and Prevention (CDC).
Despite the high prevalence of TB disease in the San Diego region compared to both California and the United States, the County Public Health Services TBCRHB meets or exceeds state and national quality measures, including in the National TB Indicators Project. Examples include, but are not limited to:
• Proportion of TB patients who complete TB treatment within 12 months
o 89.7% TBCRHB, compared to 85.8% for the state and 85.3% nationally
• Proportion of contacts to people with contagious TB who start treatment for LTBI
o 86.9% TBCRHB, compared to 71.0% for the state and 76.4% nationally
• Proportion of contacts to people with contagious TB who complete treatment for LTBI
o 90.6% TBCRHB, compared to 73.4% for the state and 79.7% nationally
Anti-TB Medication
In addition to providing grant funding, the CDPH Tuberculosis Control Branch (CDPH TBCB) operates both a Medication Support Program and Drug Stockpile through which CDPH distributes anti-TB medications to local TB programs at no cost. When CDPH purchases anti-TB medication that is due to expire in the same year, local TB programs are notified of the availability and requested to apply as soon as possible. Due to limited supply, the anti-TB medication is often reserved within days. Further, given that occasional drug shortages impact the ability to provide timely and effective treatment for people with TB, timely authorization to access the CDPH TB Drug Stockpile would improve the resilience of the County TB Control Program.
Refugee Health Assessment Program
The Refugee Health Assessment Program (RHAP) provides newly arrived refugees, asylees, victims of trafficking, and other eligible entrants with culturally and linguistically appropriate health assessments, including follow-up and referrals for health conditions identified in the assessment process. The County has contracted with community providers to complete comprehensive health assessments that focus on screening for and prevention of communicable diseases; early identification and diagnosis of chronic diseases; assessment of immunization status for children and adults; mental health screenings; and referrals to health providers for further medical evaluation and treatment within the first three months of arrival. Early assessment and diagnosis of diseases and conditions allows the County to monitor and evaluate the health statuses for refugee populations, and to promote the well-being of newcomers to our community. The County uses the data to develop prevention and intervention strategies, and to allocate resources to reduce disparities and prioritize health equity.
During Fiscal Year (FY) 2021-2022, a total of 1,759 eligible persons received a health assessment through RHAP, with 82% of those individuals completing the health assessment with 90 days of their arrival in the United States. In FY 2022-2023, 1,656 eligible persons received a health assessment, with 82% of those individuals completing the health assessment within 90 days of arrival.
The Refugee Health Promotion Program (RHPP) provides additional resources to support RHAP-eligible persons who are identified to have serious physical and mental health conditions. The program provided assistance to 125 unique individuals during the semi-annual reporting period from October 1, 2023, to March 31, 2024. These 125 persons came from 13 different countries and 41% of these clients were children under the age of 18. All clients served were referred to ongoing care, and 98% of those clients referred for ongoing primary or specialty care kept their first appointment.
Today’s action seeks Board authority to authorize the Agency Director, Health and Human Services Agency, upon receipt, to execute documents related to:
• The acceptance of TB Control Cooperative Grant funds from the CDC for the term January 1, 2025, through December 31, 2025, for approximately $1,780,240.
• The acceptance of TB treatment and control grant funds from the CDPH for the term July 1, 2024, through June 30, 2025, for approximately $890,885.
• The application for and acceptance of anti-TB medications from CDPH TBCB.
• The acceptance of the Refugee Health Assessment Program and Refugee Health Promotion Project grant funds from the CDPH for the term October 1, 2024, through September 30, 2025, for approximately $692,000.
• The application for additional TB control and treatment and refugee health assessment services funding opportunities.
Today’s actions will result in estimated costs of $3,233,964 and revenue of $2,300,005 in FY 2024-25, and estimated costs of $1,572,738 and revenue of approximately $1,063,120 in FY 2025-26, for a total of $4,806,702 in estimated costs and $3,363,125 in estimated revenue through FY 2024-26. The grant agreements will not cover all costs due to limitations in the availability of federal and State funding and waiver of Board Policy B-29 is requested because the funding does not offset all costs. These unrecovered costs are estimated at $933,959 in FY 2024-25 and $509,618 in FY 2025-26. The funding source for these costs will be existing Realignment. The public benefit of providing these services for TB control, treatment, and refugee health assessment services far outweighs these costs. These services are available to all San Diego County residents with TB, regardless of insurance status, County TB Clinic patients, and refugees, which ensures anyone can seek care for TB and refugees can receive patient navigation, health assessments, case management, contact investigation, and linkage to medical care. Without countywide TB treatment and control services and refugee health services, untreated TB and other communicable diseases would more easily spread throughout San Diego County.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s proposed actions support the Equity (Health) and Community (Quality of Life) initiatives in the County of San Diego’s 2024-2029 Strategic Plan. This is accomplished by preventing and controlling the spread of tuberculosis, one of the leading infectious causes of death in the world today and providing equitable access to health services for newly arrived refugees, asylees, victims of trafficking, and other eligible entrants.
Respectfully submitted,
EBONY N. SHELTON
Chief Administrative Officer
ATTACHMENT(S)
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