Increasing adherence for latent tuberculosis infection therapy with health department-administered therapy

Four months of rifampicin monotherapy for latent tuberculosis infection in children

Diagnosing and treating latent tuberculosis infection (LTBI) is an important part of efforts to combat tuberculosis (TB). The Korean guidelines for TB published in 2020 recommend 2 LTBI regimens for children and adolescents: 9 months of daily isoniazid (9H) and 3 months of daily isoniazid plus rifampicin. Isoniazid for 6-12 months has been used to effectively treat LTBI in children for over 50 years. However, a long treatment period results in poor patient compliance. This review summarizes pediatric data on the treatment completion rate, safety, and efficacy of 4 months of daily rifampicin (4R) and evaluates the pharmacokinetics and pharmacodynamics of rifampicin in children. The 4R regimen has a higher treatment completion rate than the 9H regimen and equivalent safety in children. The efficacy of preventing TB is also consistent with that of 9H when summarizing reports published to date. A shorter treatment period could increase patient compliance and, therefore, prevent TB in more patients. By using an effective, safe, and highly compliant regimen for the treatment of children with LTBI, we would become one step closer to our goal of eradicating TB.

Digital health use in latent tuberculosis infection care: A systematic review

PURPOSE

With one-quarter of the world's population estimated to have latent tuberculosis infection (LTBI), it is important that the drop-outs from the LTBI cascade of care are minimized. Digital health technology could play an important role in case detection and treatment adherence. This study aims to evaluate the use and impact of digital health technology in LTBI care.

METHODS

A systematic literature search was conducted on six electronic databases from database inception until May 31st 2021. Studies that reported on the clinical use or economic analysis of digital health technology for LTBI care were included. Two investigators independently evaluated, extracted relevant studies, and assessed the risk of bias of using the Cochrane tools. The studies were synthesized qualitatively.

RESULTS

Fifteen articles describing 14 studies were included. Voice and/or textual reminders and synchronous video call to improve LTBI treatment adherence were the most commonly examined digital health interventions. Other interventions examined the use of mobile phones to improve the number of patients who returned for tuberculin skin test follow-up measurement (screening retention) and eLearning videos to enhance health literacy in LTBI care. The economic analysis supported the use of textual reminders in LTBI treatment as a cost-effective option for widescale implantation.

CONCLUSIONS

Despite limited evidence on the effects of digital health technologies in LTBI, available studies suggest they are at least equivalent to current practice. This means digital health can potentially supplement current practice, to constantly monitor and engage with people undergoing LTBI screening or treatment, as an initiative to ensure the provision of continuous and optimal care to all LTBI-affected individuals.

Tuberculosis Infection in Children and Adolescents: Testing and Treatment

Tuberculosis (TB) remains an important problem among children in the United States and throughout the world. There is no diagnostic reference standard for latent tuberculosis infection (also referred to as tuberculosis infection [TBI]). The tuberculin skin test (TST) has many limitations, including difficulty in administration and interpretation, the need for a return visit by the patient, and false-positive results caused by cross-reaction with Mycobacterium bovis-bacille Calmette-Guerin vaccines and many nontuberculous mycobacteria. Interferon-gamma release assays (IGRAs) are blood tests that use antigens specific for M tuberculosis; as a result, IGRAs yield fewer false-positive results than the TST. Both IGRAs and the TST have reduced sensitivity in immunocompromised children, including children with severe TB disease. Both methods have high positive predictive value when applied to children with risk factors for TBI, especially recent contact with a person who has TB disease. The advantages of using IGRAs and diminished experience with the placement and interpretation of the TST favor expanded use of IGRAs in children in the United States. There are now several effective and safe regimens for the treatment of TBI in children. For improved adherence to therapy, the 3 rifamycin-based regimens are preferred because of their short duration. Daily isoniazid can be used if there is intolerance or drug interactions with rifamycins. A TB specialist should be involved when there are questions regarding testing interpretation, selection of an appropriate treatment regimen, or management of adverse effects.

Low uptake of isoniazid window prophylaxis in patients exposed to a health-care worker with pulmonary tuberculosis in a paediatric ward

AIM

A nurse on a paediatric multidisciplinary ward was diagnosed with smear-positive pulmonary tuberculosis. Children <2 years old, immunocompromised, or >40 h of contact (n = 173) were contact-traced.

METHODS

Children received clinical review, chest X-ray, tuberculin skin test (TST; <5 years old) and/or an interferon-gamma release assay (Quantiferon TB-Gold, ≥5 years old). Infants <6 months old or children <5 years old screened <2 months from exposure were recommended isoniazid window prophylaxis (WP) until a repeat TST at 6 months old or 8-10 weeks after the last exposure to the index case, respectively. Empiric treatment for latent tuberculosis infection (LTBI) was individually considered for immunocompromised patients.

RESULTS

Of 173 children (135 immunocompetent, 38 immunocompromised), two were uncontactable, seven refused screening and two immunocompromised children excluded. Eight of 126 immunocompetent children were diagnosed with LTBI (initial TST positive n = 7, TST conversion n = 1); seven started isoniazid. Thirty-two of 36 immunocompetent children were recommended WP; 15 accepted (one non-compliant after 1 month). Six of seven immunocompromised children accepted empiric LTBI treatment due to severe immunosuppression/initial indeterminate Quantiferon TB-Gold result. Of 15 immunocompromised children offered WP, only five accepted.

CONCLUSIONS

There was high acceptance of screening but low uptake of isoniazid WP in high-risk children exposed to pulmonary tuberculosis. Perception of exposure risk and chemoprophylaxis should be explored further.

A scoping review of paediatric latent tuberculosis infection care cascades: initial steps are lacking

BACKGROUND AND OBJECTIVES

Identifying and treating children with latent tuberculosis infection (TB infection) is critical to prevent progression to TB disease and to eliminate TB globally. Diagnosis and treatment of TB infection requires completion of a sequence of steps, collectively termed the TB infection care cascade. There has been no systematic attempt to comprehensively summarise literature on the paediatric TB infection care cascade.

METHODS

We performed a scoping review of the paediatric TB infection care cascade. We systematically searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane and Embase databases. We reviewed articles and meeting abstracts that included children and adolescents ≤21 years old who were screened for or diagnosed with TB infection, and which described completion of at least one step of the cascade. We synthesised studies to identify facilitators and barriers to retention, interventions to mitigate attrition and knowledge gaps.

RESULTS

We identified 146 studies examining steps in the paediatric TB infection care cascade; 31 included children living in low-income and middle-income countries. Most literature described the final cascade step (treatment initiation to completion). Studies identified an array of patient and caregiver-related factors associated with completion of cascade steps. Few health systems factors were evaluated as potential predictors of completion, and few interventions to improve retention were specifically tested.

CONCLUSIONS

We identified strengths and gaps in the literature describing the paediatric TB infection care cascade. Future research should examine cascade steps upstream of treatment initiation and focus on identification and testing of at-risk paediatric patients. Additionally, future studies should focus on modifiable health systems factors associated with attrition and may benefit from use of behavioural theory and implementation science methods to improve retention.

Window Period Prophylaxis for Children Exposed to Tuberculosis, Houston, Texas, USA, 2007-2017

In this retrospective study, we assessed the safety of window period prophylaxis and proportion of tuberculin skin test (TST) conversions in children <5 years of age who were exposed to an adult with tuberculosis disease during 2007-2017. Children included in this study had unremarkable examination and chest radiograph findings and negative test results for TB infection. In total, 752 children (41% cohabitating with the index patient) received prophylaxis during the window period, usually directly observed therapy with isoniazid. Hepatotoxicity and tuberculosis disease did not develop in any child. TST conversion occurred in 37 (4.9%) children and was associated with the index patient being the child's parent (odds ratio 3.2, 95% CI 1.2-8.2). TST conversion was not associated with sputum smear results, culture positivity, or cohabitation. Thresholds for initiation of window prophylaxis in exposed young children should be low given the safety of medication and difficulties with risk stratification.

Lessons learned from two interventions designed to increase adherence to LTBI treatment in Latino youth

Effort is required to meet the Healthy People 2020 goal of tuberculosis (TB) disease reduction to 1 new case per 100,000 in the United States (US) and reduce burden among those disparately affected. Preventing new cases by reducing conversion from latent TB infection (LTBI) to infectious disease is one approach to reducing disease burden. This paper describes the outcome of a trial designed to determine if LTBI-positive youth prescribed daily Isoniazid with peer counseling would achieve higher adherence than attention control participants. The paper also compares adherence to a previous trial. 263 students age 15.9 years (SD = 1.2), 51.7% female, 96.2% Latino, 43.7% foreign-born were randomly assigned to condition. Adherence was measured by self-report validated by metabolite analysis. Outcome analyses used number of pills taken and proportion of youth consuming 80% of medication. There was no significant difference by condition for either analysis. Thirty-seven percent of adherence participants completed treatment versus 40% of controls. Without a usual-care control group we were unable to determine whether conditions were equally effective or ineffective. The study's inability to pay for treatment resulted in the intervention being tested in the context of compromised access to care. Still to be determined is whether same-age peers can influence adherence among Latino adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT00233168.

Treatment of tuberculosis infection in children

INTRODUCTION

Identifying and treating children with tuberculosis (TB) infection in both low and high-TB burden settings will decrease the incidence of TB disease worldwide. Areas covered: This review covers each of the available TB infection treatment options for children based on effectiveness, safety, tolerability and treatment completion rates. Six to 9 months of daily administered isoniazid is no longer the treatment of choice for many children with TB infection. Shorter, rifamycin based, TB infection treatment regimens are effective, safe and easier for children to complete. Fluroquinolone-based regimens are recommended for the treatment of children infected by a source case with drug-resistant TB. Directly observed therapy (DOT) programs improve childhood TB infection treatment completion rates. Expert commentary: As shorter, rifamycin-based, TB infection treatment regimens offer superior treatment success rate in both adults and children; the widespread use of these regimens has huge potential to decrease the burden of TB disease worldwide. The implementation of these programs will involve improving patient access to the medications, decreasing their cost to the patient, and the use of novel electronic methods to document patient treatment completion.

Impact of nursing interventions on adherence to treatment with antituberculosis drugs in children and young people: A nonrandomized controlled trial

AIM

To evaluate the association of a new nursing intervention on the adherence to antituberculosis treatment in a paediatric cohort (<18 years).

BACKGROUND

Tuberculosis remains a public health problem worldwide. The risk of developing tuberculosis after primary infection and its severity are higher in children. Proper adherence to antituberculosis treatment is critical for disease control.

DESIGN

Nonrandomized controlled trial; Phase 1, retrospective (2011-2013), compared with Phase 2, prospective with intervention (2015-2016), in a referral centre for paediatric tuberculosis in Spain (NCT03230409).

METHODS

A total of 359 patients who received antituberculosis drugs after close contact with a smear-positive patient (primary chemoprophylaxis) or were treated for latent tuberculosis infection or tuberculosis disease were included, 261 in Phase 1 and 98 in Phase 2. In Phase 2, a new nurse-led intervention was implemented in all patients and included two educational steps (written information in the child's native language and follow-up telephone calls) and two monitoring steps (Eidus-Hamilton test and follow-up questionnaire) that were exclusively carried out by nurses.

RESULTS

Adherence to antituberculosis treatment increased from 74.7% in Phase 1% to 87.8% in Phase 2 (p = 0.014; Chi-square test), after the implementation of the nurse-led intervention. In Phase 2, nonadherence was only associated with being born abroad (28.6% vs. 7.8%; p = 0.019; Chi-square test) and with foreign origin families (27.3% vs. 0%; p < 0.0001; Chi-square test).

CONCLUSION

The nurse-led intervention was associated to an increase in adherence to antituberculosis treatment. Immigrant-related variables remained major risk factors for sub-optimal adherence in a low-endemic setting.

Completion Rate and Safety of Tuberculosis Infection Treatment With Shorter Regimens

BACKGROUND

The traditional treatment of tuberculosis (TB) infection (9 months of daily isoniazid [9H]) is safe but completion rates of <50% are reported. Shorter regimens (3 months of once-weekly isoniazid and rifapentine [3HP] or 4 months of daily rifampin [4R]) are associated with improved adherence in adults.

METHODS

This was a retrospective cohort study (2014-2017) of children (0-18 years old) seen at a children's TB clinic in a low-incidence nation. We compared the frequency of completion and adverse events (AEs) in children receiving 3HP, 4R, and 9H; the latter 2 regimens could be administered by families (termed self-administered therapy [SAT]) or as directly observed preventive therapy (DOPT); 3HP was always administered under DOPT.

RESULTS

TB infection treatment was started in 667 children: 283 (42.4%) 3HP, 252 (37.8%) 9H, and 132 (19.8%) 4R. Only 52% of children receiving 9H via SAT completed therapy. Children receiving 3HP were more likely to complete therapy than the 9H (SAT) group (odds ratio [OR] 27.4, 95% confidence interval [CI]: 11.8-63.7). Multivariate analyses found receipt of medication under DOPT (OR: 5.72, 95% CI: 3.47-9.43), increasing age (OR: 1.09, 95% CI: 1.02-1.17), and the absence of any AE (OR: 1.70, 95% CI: 0.26-0.60) to be associated with completing therapy. AEs were more common in the 9H group (OR: 2.51, 95% CI: 1.48-4.32). Two (0.9%) children receiving 9H developed hepatotoxicity; no child receiving 3HP or 4R developed hepatotoxicity.

CONCLUSIONS

Shorter regimens are associated with increased completion rates and fewer AEs than 9H.

Tuberculosis in Infants and Children

One million children develop tuberculosis disease each year, and 210,000 die from complications of tuberculosis. Childhood tuberculosis is very different from adult tuberculosis in epidemiology, clinical and radiographic presentation, and treatment. This review highlights the many unique features of childhood tuberculosis, with special emphasis on very young children and adolescents, who are most likely to develop disease after infection has occurred.

Adherence to Antituberculosis Drugs in Children and Adolescents in A Low-Endemic Setting: A Retrospective Series

Adherence to antituberculosis drug regimens is critical for the prevention and treatment of tuberculosis in pediatrics. In a large retrospective series of children and adolescents in Barcelona, Spain, completion of treatment was worse among patients treated for latent infection, compared with those treated for active tuberculosis or receiving primary chemoprophylaxis. Toxicity and cultural and language barriers were identified as predictors of nonadherence.

Increased adolescent knowledge and behavior following a one-time educational intervention about tuberculosis

OBJECTIVE

To evaluate the impact of a tuberculosis (TB) educational intervention (EI) on change in adolescent student knowledge and participation in a TB prevention program.

METHODS

From 2/2013-5/2015, students from 2 high schools in Houston, TX participated. The 25-min EI discussed TB bacteriology, epidemiology, symptoms, and indications for TB testing/treatment. Students completed pre- and post-quizzes. Immediately after the EI, students were invited to participate in voluntary TB risk-factor screening, testing and treatment. At 6 months, focus groups were conducted.

RESULTS

895 students attended the EI. 827 students (92%) completed the EI quizzes. Knowledge improved by 12% (pre: 70%; post: 82%, p<0.001); 78% shared their TB knowledge. Following the EI, 671/827 (81%) enrolled in a TB prevention program. Focus groups indicated that the EI stimulated student learning about TB and increased their willingness to participate.

CONCLUSION

A brief, one-time, TB EI is an effective method to encourage adolescents to learn about TB and motivate their uptake of TB risk-factor screening, testing and treatment. Similar EIs should accompany TB prevention programs targeting adolescents.

PRACTICE IMPLICATIONS

The study's procedures could be considered for incorporation into school-based TB prevention programs to improve the identification, testing and treatment of adolescents at risk for TB.

Treatment of Latent Tuberculosis Infection

There are approximately 56 million people who harbor Mycobacterium tuberculosis that may progress to active tuberculosis (TB) at some point in their lives. Modeling studies suggest that if only 8% of these individuals with latent TB infection (LTBI) were treated annually, overall global incidence would be 14-fold lower by 2050 compared to incidence in 2013, even in the absence of additional TB control measures. This highlights the importance of identifying and treating latently infected individuals, and that this intervention must be scaled up to achieve the goals of the Global End TB Strategy. The efficacy of LTBI treatment is well established, and the most commonly used regimen is 9 months of daily self-administered isoniazid. However, its use has been hindered by limited provider awareness of the benefits, concern about potential side effects such as hepatotoxicity, and low rates of treatment completion. There is increasing evidence that shorter rifamycin-based regimens are as effective, better tolerated, and more likely to be completed compared to isoniazid. Such regimens include four months of daily self-administered rifampin monotherapy, three months of once weekly directly observed isoniazid-rifapentine, and three months of daily self-administered isoniazid-rifampin. The success of LTBI treatment to prevent additional TB disease relies upon choosing an appropriate regimen individualized to the patient, monitoring for potential adverse clinical events, and utilizing strategies to promote adherence. Safer, more cost-effective, and more easily completed regimens are needed and should be combined with interventions to better identify, engage, and retain high-risk individuals across the cascade from diagnosis through treatment completion of LTBI.

Optimizing the management of children with latent tuberculosis infection

INTRODUCTION

The management of latent tuberculosis (LTBI) in children represents an important issue for paediatricians because of the disease burden, the lack of a gold standard for the diagnosis and the high annual risk of progression to active disease. Areas covered: A review of English language articles on LTBI in children, published between the 1st of January 2010 and the 1st of July 2016, was conducted using multiple keywords and standardized terminology in PubMed database. This review provides an updated overview of the available tests for LTBI diagnosis in children, management strategies and treatment options. Expert commentary: Two tests are available for LTBI diagnosis: tuberculin skin test and interferon-gamma release assays, both with a suboptimal specificity and sensitivity, and both with the lack of capability in distinguishing between infection and disease. Several new markers have been identified but further studies are needed. Among all treatment regimes, because of the high safety and efficacy profile showed and to avoid the poor completion rate, the treatment with a three-month course of isoniazid and rifampicin is currently recommended. New vaccines are needed because of the spread of the disease despite BCG vaccination in high risk countries. Currently, 15 new vaccines are in the pipeline.

Safety and Adherence for 12 Weekly Doses of Isoniazid and Rifapentine for Pediatric Tuberculosis Infection

Traditional treatment of tuberculosis infection (TBI) is efficacious, but adherence is low. Eighty children with TBI received a 12-dose once-weekly isoniazid/rifapentine regimen; 79 (99%) completed therapy, 94% reported no adverse events, 1 child had mildly elevated transaminases but 1 adolescent later developed pulmonary TB. Isoniazid/rifapentine is safe, is well tolerated and has much higher completion rates than traditional TBI regimens.

School-based Study to Identify and Treat Adolescent Students at Risk for Tuberculosis Infection

BACKGROUND

Screening for and treating tuberculosis (TB) infection in children and adolescents is an effective way of decreasing future TB cases. However, current approaches leave many children at risk for TB unidentified.

METHODS

We recruited adolescent students from 2 public high schools (a magnet and a low-income) in the Houston Independent School District. Compared with the magnet school, the student population at the low-income school was larger, primarily Hispanic and economically disadvantaged. Students were educated about TB, and parents completed a risk factor questionnaire. Students with TB risk factors were tested using 2 interferon gamma release assays (IGRAs). Those with a positive IGRA received a 12-dose regimen of weekly isoniazid/rifapentine (3HP) administered via direct observation at school.

RESULTS

Nine hundred twenty-five students received TB education; 73% of their parents submitted the TB questionnaire. Eighty-six percent of students (n = 415) with a TB risk factor identified on the study questionnaire agreed to IGRA testing. Sixteen students had at least one positive IGRA (1% [magnet], 4.1% [low-income]; P = 0.005). Recent student travel to a high-risk country (7) or contact with TB disease (2) were associated with IGRA positivity (P < 0.05). All students with a positive IGRA accepted, tolerated and completed 3HP treatment at school.

CONCLUSIONS

School-based TB education, screening, testing using IGRAs and administration of 3HP treatment is feasible to improve the identification and treatment of adolescent students at risk for TB.

Interventions for improving adherence to treatment for latent tuberculosis infection: a systematic review

BACKGROUND

Latent tuberculosis infection (LTBI) control relies on high initiation and completion rates of preventive treatment to preclude progression to tuberculosis disease. Specific interventions may improve initiation and completion rates. The objective was to systematically review data on determinants of initiation, adherence and completion of LTBI treatment, and on interventions to improve initiation and completion.

METHODS

A systematic review of the literature (PubMed, Embase) published up to February 2014 was performed. Relevant prospective intervention studies were assessed using GRADE.

RESULTS

Sixty-two articles reporting on determinants of treatment initiation and completion were included and 23 articles on interventions. Determinants of LTBI treatment completion include shorter treatment regimen and directly observed treatment (DOT, positive association), adverse events and alcohol use (negative association), and specific populations with LTBI (both positive and negative associations). A positive effect on completion was noted in intervention studies that used short regimens and social interventions; mixed results were found for intervention studies that used DOT or incentives.

CONCLUSION

LTBI treatment completion can be improved by using shorter regimens and social interventions. Specific needs of the different populations with LTBI should be addressed taking into consideration the setting and condition in which the LTBI treatment programme is implemented.

Initiation and completion rates for latent tuberculosis infection treatment: a systematic review

BACKGROUND

Control of latent tuberculosis infection (LTBI) is an important step towards tuberculosis elimination. Preventive treatment will prevent the development of disease in most cases diagnosed with LTBI. However, low initiation and completion rates affect the effectiveness of preventive treatment. The objective was to systematically review data on initiation rates and completion rates for LTBI treatment regimens in the general population and specific populations with LTBI.

METHODS

A systematic review of the literature (PubMed, Embase) published up to February 2014 was performed.

RESULTS

Forty-five studies on initiation rates and 83 studies on completion rates of LTBI treatment were found. These studies provided initiation rates (IR) and completion rates (CR) in people with LTBI among the general population (IR 26-99 %, CR 39-96 %), case contacts (IR 40-95 %, CR 48-82 %), healthcare workers (IR 47-98 %, CR 17-79 %), the homeless (IR 34-90 %, CR 23-71 %), people who inject drugs (IR 52-91 %, CR 38-89 %), HIV-infected individuals (IR 67-92 %, CR 55-95 %), inmates (IR 7-90 %, CR 4-100 %), immigrants (IR 23-97 %, CR 7-86 %), and patients with comorbidities (IR 82-93 %, CR 75-92 %). Generally, completion rates were higher for short than for long LTBI treatment regimens.

CONCLUSION

Initiation and completion rates for LTBI treatment regimens were frequently suboptimal and varied greatly within and across different populations.

Managing tuberculosis infection in children in the USA: an update

The rate of tuberculosis (TB) disease has steadily declined in the last two decades in the USA, and over two-thirds of all cases now occur in foreign-born persons. Further declines in the incidence of TB will be most impacted by identifying and treating persons with TB infection. However, difficulties in accessing care, poor specificity of diagnostic tests and long courses of therapy historically have led to suboptimal screening of groups at high risk for infection, false-positive test results from cross-reaction with the bacille Calmette-Guérin vaccine and low treatment completion rates, respectively. This article reviews newer testing and treatment strategies for TB infection emphasizing risk and benefits of testing and treating.

Influence of nursing interventions on adherence to treatment with antituberculosis drugs in children and young people: research protocol

AIM

To evaluate the efficacy of nursing interventions on adherence to antituberculosis medication in a paediatric cohort (aged 0-18 years) and to identify the risk factors for non-compliance.

BACKGROUND

After primary infection, children have a higher risk of developing tuberculosis and the severity of the disease is worse in children. Adherence to treatment is essential to control both latent infection and tuberculosis disease.

DESIGN

Phase 1: retrospective descriptive analysis (n = 270) in children and young people receiving antituberculosis treatment. Phase 2: quasi-experimental, longitudinal, prospective study (n = 100). The results of the two phases will be compared.

METHODS

Phase 1: in children followed up during the period 2011-2013 (non-intervention group), the level of adherence and its associated epidemiological, sociocultural and clinical risk factors will be analysed. Phase 2: educational (written information in the child's mother tongue and follow-up telephone calls) and monitoring (Eidus-Hamilton test and follow-up questionnaire) nursing interventions will be implemented. The results of the two phases will be compared. The definitive Nurse-led Follow-up Programme will then be designed. This project was funded in October 2013.

DISCUSSION

The risk factors for poor adherence to antituberculosis therapy need to be identified to optimize treatment success in latent tuberculosis infection and disease in children and young people. Simultaneous application of several educational and monitoring methods in nurse-led follow-up shall improve adherence in children and adolescents in our setting. These results may also be applicable in other settings, where tuberculosis is more prevalent and directly observed treatment strategies are not available.

Old and new approaches to diagnosing and treating latent tuberculosis in children in low-incidence countries

PURPOSE OF REVIEW

The primary purpose is to review guidance on the testing and treatment of latent tuberculosis infection (LTBI) in children. Most children and adults with LTBI have positive tuberculin skin test (TST) or interferon gamma release assay (IGRA) results, normal examinations, and normal chest radiographs. Diagnosis of and treatment completion for LTBI are critical to diminish future cases of tuberculosis (TB) disease.

RECENT FINDINGS

Children should be screened for TB risk factors, and only children with risk factors should be tested with either a TST or an IGRA. IGRAs measure interferon gamma production by lymphocytes after they are stimulated ex vivo by antigens that are primarily Mycobacterium tuberculosis-specific. The foundation of LTBI therapy in the United States has been 9 months of daily isoniazid, but shorter treatment regimens now exist, including a 12-dose regimen of weekly isoniazid and rifapentine. These shorter regimens are associated with higher completion rates.

SUMMARY

There are two distinct modalities for LTBI diagnosis and several treatment regimens that can prevent TB disease in infected children. The selection of treatment regimen should take several factors into consideration, including adherence, drug susceptibility results of the presumed source case (if known), safety, cost, and patient preference.

[Factors associated with treatment adherence for tuberculosis infection]

OBJECTIVE

To analyze adherence to treatment of tuberculosis infection and to identify risk factors for its compliance.

DESIGN

An observational historical cohort study.

SETTING

Hospital Universitari Sant Joan d'Alacant (Alicante).

PARTICIPANTS

All patients with a tuberculin skin test (TST) done during tuberculosis contact tracing during 6 years.

RESULTS

We included 764 tuberculosis contacts in the analysis. 59.7% of the 566 patients who completed the contact tracing, had tuberculosis infection (TI). Of the patients with TI, 45.6% had not started treatment for tuberculosis infection (TTBI). Factors associated with not starting TTBI were: age (36-65 years, RR: 5.8; 95% CI: 1.2-27.5, and > 65 years, RR: 11.3; 95% CI: 2.0-64.0), the social relationship with TB case (RR: 2.2; 95% CI 1.2-3.8), and the TST reaction (≥ 15mm; RR: 0.5; 95% CI: 0.3-0.9). The completion rate for TTBI was 80.4% among people who started therapy. The treatment regimen was associated with greater compliance to TTBT (7-9H, RR: 12.7; 95% CI: 1.5-107.3).

CONCLUSIONS

The treatment compliance rate of Tuberculosis infection was high among people who started therapy. Almost a half of the contacts with TI did not start treatment, and associated factors were: age, social relationship, and the TST reaction. The treatment regimen was associated with greater compliance. It is important to know the factors associated with adherence to treatment of TI in each health area, and focus efforts on risk groups; thereby approaching the global control of tuberculosis.

Factors associated with failure to complete isoniazid therapy for latent tuberculosis infection in children and adolescents

BACKGROUND

Completion of the recommended 9-month course of isoniazid to treat latent tuberculosis infection in children remains poor and is often affected by adverse effects, including hepatitis, to medication. We evaluated the frequency of isoniazid therapy completion and factors associated with failure to complete therapy in patients aged 0-18 years.

METHODS

We performed a retrospective review of medical records for patients aged 0-18 years who were referred for isoniazid therapy between January 2005 and August 2011 at 2 California county sites: a public health department and a pediatric latent tuberculosis infection clinic. Medication adherence to isoniazid therapy was measured by monthly pill count.

RESULTS

There were 1872 eligible patients who were referred for isoniazid therapy. Of the 1587 patients who met inclusion criteria and initiated treatment, 1235 patients (78%) completed the 9-month therapy, including 1046 of 1308 patients aged <15 years (80%) and 189 of 268 patients aged 15-18 years (71%). Factors that were significantly associated with failure to complete therapy included age 15-18 years, non-Hispanic race, development of hepatitis, and symptoms of adverse effects. The association between age and the development of hepatitis was similar for male and female patients.

CONCLUSION

Failure to complete isoniazid therapy in patients aged 0-18 years is affected by older age, non-Hispanic race, development of hepatitis, and symptoms of adverse effects. Additional support is needed for adolescents to complete therapy for latent tuberculosis infection.

Completion of Latent Tuberculosis Therapy in Children: Impact of Country of Origin and Neighborhood Clinics

BACKGROUND

Successful treatment of latent tuberculosis infection (LTBI) is an important objective in the United States' strategy for tuberculosis (TB) control. We review the impact of demographic variables and community treatment upon completion of medical therapy of LTBI in a large pediatric cohort.

METHODS

We performed a retrospective analysis of prospectively collected data from children referred for evaluation and treatment of LTBI. Children were followed in the main hospital TB clinic or in 1 of 2 hospital-run neighborhood clinics. Those completing and not completing medical treatment were compared based on demographic and history variables, clinic location, and distance to clinic. Propensity score techniques were used to match children treated at the main hospital and neighborhood clinics on collected demographic and history variables.

RESULTS

Of 1516 children evaluated, 1184 (78.1%) initiated medical therapy and returned for at least 1 visit. Of these, treatment was completed by 89.2% (166 of 186) of children in the neighborhood clinics versus 83.2% (830 of 998) of children in the main hospital TB clinic (P < .037). Neighborhood and main hospital clinic children did not differ in rates of completion when propensity score-matched groups were compared. Country of origin was the most important factor in determining both initiation and completion of therapy.

CONCLUSIONS

Obstacles remain for successful initiation and treatment of children from identified geographic regions. Most of the dropout occurs early in treatment, and use of neighborhood clinics does not provide an obvious advantage when similar patient groups are compared. Emphasis upon initial education and early non-clinic follow-up may be useful in enhancing therapy completion.

Treatment of Latent Tuberculosis Infection in Children

Treatment of latent tuberculosis infection (LTBI) is an effective way of preventing future cases of tuberculosis disease. We review pediatric and adult studies of LTBI treatment (isoniazid and rifampin monotherapy, isoniazid plus rifampin, isoniazid plus rifapentine, and rifampin plus pyrazinamide). Based upon this review and our pediatric experience, we can offer recommendations for routine (isoniazid) and alternative courses of therapy.

Serial T-SPOT.TB and quantiFERON-TB-Gold In-Tube assays to monitor response to antitubercular treatment in Italian children with active or latent tuberculosis infection

We performed a prospective study to investigate T-SPOT.TB and QuantiFERON-TB Gold In-Tube (QFT-G-IT) dynamics during antitubercular treatment in active tuberculosis (TB) or latent TB. Eighteen children with latent TB and 26 with TB were enrolled. At 6 months of follow-up reversion rate was 5.88% (95% CI:0-13.79) for QFT-G-IT; 9.09% (95% CI:0.59-17.58) for T-SPOT.TB (P=0.921) in TB cases. Significant decline in quantitative response was observed exclusively in TB cases. Our results suggest that serial IGRA have limited use in children receiving antitubercular treatment.