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Starke SJ, Martinez Rivera MB, Krishnan S, Shah M. Randomized Controlled Trial of Clinical Guidelines Versus Interactive Decision-Support for Improving Medical Trainees' Confidence with Latent Tuberculosis Care. J Gen Intern Med 2024; 39:951-959. [PMID: 38062221 PMCID: PMC11074081 DOI: 10.1007/s11606-023-08551-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/17/2023] [Indexed: 05/08/2024]
Abstract
BACKGROUND In order to eliminate tuberculosis (TB) in the USA, primary care providers must take on an expanded role in the diagnosis and management of latent tuberculosis infection (LTBI). Clinical practice guidelines and recommendations exist for LTBI management, but there is a need for innovative tools to improve medical students' and residents' knowledge of evidence-based practices for LTBI testing and treatment. OBJECTIVE To assess the impact of LTBI-ASSIST, a free online decision support aid, as a novel educational tool and mechanism of delivering clinical practice guidelines for medical trainees. DESIGN A single site, randomized controlled trial of trainees delivered by electronic survey. INTERVENTIONS Medical students and Internal Medicine residents at the Johns Hopkins University School of Medicine. PARTICIPANTS Participants were randomized in 1:1 ratio to receive the US clinical practice guidelines and recommendations for Latent TB management (control arm) or the guidelines plus an introduction to LTBI-ASSIST (LTBI-ASSIST arm) as they completed a case-based knowledge assessment and reported confidence with domains of LTBI care. MAIN MEASURES (1) Proportion of questions answered correctly on a case-based knowledge assessment; (2) change in reported confidence with domains of LTBI care. KEY RESULTS One hundred and thirty participants completed the knowledge assessment. Those randomized to receive the LTBI-ASSIST Tool performed better on the case-based knowledge assessment with a mean score of 75.9% (95% CI: 70.6-81.1), compared to 57.4% (52.8-62.0) in the group that received the guidelines only (p <0.001). Similarly, the LTBI-ASSIST group reported a higher change in confidence (measured as post-assessment confidence minus pre-assessment confidence), compared to the control group, in six of the seven domains of LTBI care. CONCLUSIONS LTBI-ASSIST can be an effective supplement to existing guidelines in educating medical trainees and helping providers find evidence-based, guideline-supported answers for questions encountered in clinical practice. TRIAL REGISTRATION NIH Clinical Trial Registry No. NCT05772065.
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Affiliation(s)
- Samuel J Starke
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Marina B Martinez Rivera
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Sonya Krishnan
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Maunank Shah
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Ekramnia M, Li Y, Haddad MB, Marks SM, Kammerer JS, Swartwood NA, Cohen T, Miller JW, Horsburgh CR, Salomon JA, Menzies NA. Estimated rates of progression to tuberculosis disease for persons infected with Mycobacterium tuberculosis in the United States. Epidemiology 2024; 35:164-173. [PMID: 38290139 PMCID: PMC10832387 DOI: 10.1097/ede.0000000000001707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND In the United States, over 80% of tuberculosis (TB) disease cases are estimated to result from reactivation of latent TB infection (LTBI) acquired more than 2 years previously ("reactivation TB"). We estimated reactivation TB rates for the US population with LTBI, overall, by age, sex, race-ethnicity, and US-born status, and for selected comorbidities (diabetes, end-stage renal disease, and HIV). METHODS We collated nationally representative data for 2011-2012. Reactivation TB incidence was based on TB cases reported to the National TB Surveillance System that were attributed to LTBI reactivation. Person-years at risk of reactivation TB were calculated using interferon-gamma release assay (IGRA) positivity from the National Health and Nutrition Examination Survey, published values for interferon-gamma release assay sensitivity and specificity, and population estimates from the American Community Survey. RESULTS For persons aged ≥6 years with LTBI, the overall reactivation rate was estimated as 0.072 (95% uncertainty interval: 0.047, 0.12) per 100 person-years. Estimated reactivation rates declined with age. Compared to the overall population, estimated reactivation rates were higher for persons with diabetes (adjusted rate ratio [aRR] = 1.6 [1.5, 1.7]), end-stage renal disease (aRR = 9.8 [5.4, 19]), and HIV (aRR = 12 [10, 13]). CONCLUSIONS In our study, individuals with LTBI faced small, non-negligible risks of reactivation TB. Risks were elevated for individuals with medical comorbidities that weaken immune function.
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Affiliation(s)
- Mina Ekramnia
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston MA, USA
| | - Yunfei Li
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston MA, USA
| | - Maryam B Haddad
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta GA, USA
| | - Suzanne M Marks
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta GA, USA
| | - J Steve Kammerer
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta GA, USA
| | - Nicole A Swartwood
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston MA, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven CT, USA
| | - Jeffrey W Miller
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston MA, USA
| | - C Robert Horsburgh
- Departments of Epidemiology, Biostatistics, and Global Health, Boston University School of Public Health and Department of Medicine, Boston University School of Medicine, Boston MA USA
| | - Joshua A Salomon
- Center for Health Policy / Center for Primary Care and Outcomes Research, Stanford University, Stanford CA, USA
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston MA, USA
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston MA, USA
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Malden DE, Wong RJ, Chitnis AS, Im TM, Tartof SY. Screening Practices and Risk Factors for Co-Infection with Latent Tuberculosis and Hepatitis B Virus in an Integrated Healthcare System - California, 2008-2019. Am J Med 2024; 137:258-265.e3. [PMID: 38000687 DOI: 10.1016/j.amjmed.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 10/08/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Hepatitis B virus (HBV) and latent tuberculosis infection are associated with a significant global burden, but both are underdiagnosed and undertreated. We described the screening patterns and risk factors for co-infection with latent tuberculosis and HBV within a large healthcare system. METHODS Using data from Kaiser Permanente Southern California during 2008-2019, we described HBV infections, defined as a positive HBV surface antigen, e-antigen, or DNA test, and latent tuberculosis, defined as a positive Mantoux tuberculin skin test or interferon-gamma release assay test. We estimated adjusted odds ratios (aOR) for co-infection among screened adults with either infection. RESULTS Among 1997 HBV patients screened for latent tuberculosis, 23.1% were co-infected, and among 35,820 patients with latent tuberculosis screened for HBV, 1.3% were co-infected. Among HBV patients, co-infection risk was highest among Asians compared with White race/ethnicity (29.4% vs 5.7%, aOR 4.78; 95% confidence interval [CI], 2.75-8.31), and persons born in a high-incidence country compared with low-incidence countries (31.0% vs 6.6%; aOR 4.19; 95% CI, 2.61-6.73). For patients with latent tuberculosis, risk of co-infection was higher among Asian (aOR 9.99; 95% CI, 5.79-17.20), or Black race/ethnicity (aOR 3.33; 95% CI, 1.78-6.23) compared with White race/ethnicity. Persons born in high-incidence countries had elevated risk of co-infection compared with persons born in low-incidence countries (aOR 2.23; 95% CI, 1.42-3.50). However, Asians or persons born in high-incidence countries were screened at similar rates to other ethnicities or persons born in low-incidence countries. CONCLUSIONS Latent tuberculosis risk is elevated among HBV patients, and vice versa. Risk of co-infection was highest among persons born in high-incidence countries and Asians. These findings support recent guidelines to increase HBV and tuberculosis screening, particularly among persons with either infection.
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Affiliation(s)
- Debbie E Malden
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, Calif.
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, Calif; Gastroenterology Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif
| | - Amit S Chitnis
- Tuberculosis Section, Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, San Leandro, Calif
| | - Theresa M Im
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, Calif
| | - Sara Y Tartof
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, Calif; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif
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Adusumelli Y, Tabatneck M, Sherman S, Lamb G, Sabharwal V, Goldmann D, Epee-Bounya A, Haberer JE, Sandora TJ, Campbell JI. Pediatric Tuberculosis Infection Care Facilitators and Barriers: A Qualitative Study. Pediatrics 2024; 153:e2023063949. [PMID: 38327249 DOI: 10.1542/peds.2023-063949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND A total of 700 000 US children and adolescents are estimated to have latent tuberculosis (TB) infection. Identifying facilitators and barriers to engaging in TB infection care is critical to preventing pediatric TB disease. We explored families' and clinicians' perspectives on pediatric TB infection diagnosis and care. METHODS We conducted individual interviews and small group discussions with primary care and subspecialty clinicians, and individual interviews with caregivers of children diagnosed with TB infection. We sought to elicit facilitators and barriers to TB infection care engagement. We used applied thematic analysis to elucidate themes relating to care engagement, and organized themes using a cascade-grounded pediatric TB infection care engagement framework. RESULTS We enrolled 19 caregivers and 24 clinicians. Key themes pertaining to facilitators and barriers to care emerged that variably affected engagement at different steps of care. Clinic and health system themes included the application of risk identification strategies and communication of risk; care ecosystem accessibility; programs to reduce cost-related barriers; and medication adherence support. Patient- and family-level themes included TB knowledge and beliefs; trust in clinicians, tests, and medical institutions; behavioral skills; child development and parenting; and family resources. CONCLUSIONS Risk identification, education techniques, trust, family resources, TB stigma, and care ecosystem accessibility enabled or impeded care cascade engagement. Our results delineate an integrated pediatric TB infection care engagement framework that can inform multilevel interventions to improve retention in the pediatric TB infection care cascade.
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Affiliation(s)
- Yamini Adusumelli
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | | | | | - Gabriella Lamb
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Vishakha Sabharwal
- Section of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Don Goldmann
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | | | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas J Sandora
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Jeffrey I Campbell
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
- Section of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
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Hackley M, Thampy D, Waseh S, Feldman SR, Blauvelt A, Weinberg JM, Schwartzman S, Liao W, Prussick R, Cohen JM, Hsu S. Increased risk of severe generalized pustular psoriasis due to tuberculosis screening delay for spesolimab initiation. J Am Acad Dermatol 2024; 90:408-410. [PMID: 37821053 DOI: 10.1016/j.jaad.2023.09.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/24/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Madison Hackley
- Department of Dermatology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Daphne Thampy
- Department of Dermatology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Shayan Waseh
- Department of Dermatology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Steven R Feldman
- Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Jeffrey M Weinberg
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sergio Schwartzman
- Hospital for Special Surgery, New York Prsebyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Wilson Liao
- Department of Dermatology, University of California San Francisco, San Francisco, California
| | - Ronald Prussick
- Department of Dermatology, George Washington University, Washington, DC
| | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Sylvia Hsu
- Department of Dermatology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania.
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Cochran J, Tibbs A, Haptu HH, Paradise RK, Bernardo J, Tierney DB. Scaling Up Latent Tuberculosis Infection Testing and Treatment for Non-US Born Patients in a Federally Qualified Community Health Center. J Immigr Minor Health 2023; 25:1482-1487. [PMID: 37429968 PMCID: PMC10632217 DOI: 10.1007/s10903-023-01514-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/12/2023]
Abstract
In the United States (US), tuberculosis elimination strategies include scaling up latent tuberculosis infection (LTBI) diagnosis and treatment for persons at risk of progression to tuberculosis disease. The Massachusetts Department of Public Health partnered with Lynn Community Health Center to provide care to patients with LTBI who were born outside the US. The electronic health record was modified to facilitate collection of data elements for public health assessment of the LTBI care cascade. Among health center patients born outside the US, testing for tuberculosis infection increased by over 190%. From October 1, 2016 to March 21, 2019, 8827 patients were screened and 1368 (15.5%) were diagnosed with LTBI. Using the electronic health record, we documented treatment completion for 645/1368 (47.1%) patients. The greatest drop-offs occurred between testing for TB infection and clinical evaluation after a positive test (24.3%) and between the recommendation for LTBI treatment and completion of a treatment course (22.8%). Tuberculosis care delivery was embedded in the primary care medical home, bringing patient-centered care to those at high risk for loss to follow up. The partnership between public health and the community health center promoted quality improvement.
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Affiliation(s)
- J Cochran
- Massachusetts Department of Public Health, Boston, MA, USA.
| | - A Tibbs
- Massachusetts Department of Public Health, Boston, MA, USA
| | - H H Haptu
- Lynn Community Health Center, Lynn, MA, USA
| | - R K Paradise
- Institute for Community Health, Malden, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - J Bernardo
- Massachusetts Department of Public Health, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - D B Tierney
- Massachusetts Department of Public Health, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
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7
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Zorilla RA, Shikuma CM. A Literature Review on the Adherence to Screening Guidelines for Latent Tuberculosis Infection Among Persons Living With HIV. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2023; 82:289-295. [PMID: 38093759 PMCID: PMC10713737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Human immunodeficiency virus (HIV) infection increases the risk of reactivation of latent tuberculosis infection (LTBI). Although antiretroviral therapy decreases the progression of LTBI to tuberculosis disease (TBD), persons living with HIV (PLHIV) still have higher risk of TBD compared to the general population. LTBI screening is recommended for all newly diagnosed PLHIV to prevent TBD. However, several studies from low TBD incidence countries have reported sub-optimal implementation of these guidelines. This review aims to assess published studies on adherence to LTBI screening among PLHIV by identifying factors and determinants that affect the implementation of LTBI screening among PLHIV in low TBD incidence countries. Electronic databases were used to search for articles describing the adherence to LTBI screening guidelines. Fourteen studies were included in the final review. Ten studies assessed the frequency of PLHIV getting LTBI screening, and 4 studies assessed the compliance of health care providers in implementing the guidelines. PLHIV who were screened for LTBI ranged from 22.4% to 85%, of which 0.8% to 25.6% had positive results. Only 20% to 57.4% of surveyed physicians implemented the guidelines. Country of birth was an independent predictor of receiving LTBI screening. LTBI screening guidelines are inconsistently performed resulting in missed opportunities for TBD prevention. A comprehensive screening policy involving testing all PLHIV may be the best approach, rather than a targeted approach testing foreign-born individuals only. This will minimize missing domestic cases that can worsen disparity in HIV and tuberculosis infection among minority groups, including Asians, Native Hawaiians, and Pacific Islanders.
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Affiliation(s)
| | - Cecilia M. Shikuma
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI
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8
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Campbell JI, Tabatneck M, Wilt GE, Sun M, He W, Musinguzi N, Hedt-Gauthier B, Lamb GS, Goldmann D, Sabharwal V, Sandora TJ, Haberer JE. Area-Based Sociodemographic Factors Associated with Latent Tuberculosis Infection in a Low-Prevalence Setting. Am J Trop Med Hyg 2023; 109:595-599. [PMID: 37580031 PMCID: PMC10484283 DOI: 10.4269/ajtmh.22-0788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 06/08/2023] [Indexed: 08/16/2023] Open
Abstract
Area-based sociodemographic markers, such as census tract foreign-born population, have been used to identify individuals and communities with a high risk for tuberculosis (TB) infection in the United States. However, these markers have not been evaluated as independent risk factors for TB infection in children. We evaluated associations between census tract poverty, crowding, foreign-born population, and the CDC's Social Vulnerability Index (CDC-SVI) ranking and TB infection in a population of children tested for TB infection in Boston, Massachusetts. After adjustment for age, crowding, and foreign-born percentage, increasing census tract poverty was associated with increased odds of TB infection (adjusted odds ratio [aOR] per 10% increase in population proportion living in poverty: 1.20 [95% CI, 1.04-1.40]; P = 0.01), although this association was attenuated after further adjustment for preferred language. In separate models, increasing CDC-SVI ranking was associated with increased odds of TB infection, including after adjustment for age and language preference (aOR per 10-point increase in CDC-SVI rank: 1.08 [95% CI, 1.02-1.15]; P = 0.01). Our findings suggest area-based sociodemographic factors may be valuable for characterizing TB infection risk and defining the social ecology of pediatric TB infection in low-burden settings.
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Affiliation(s)
- Jeffrey I. Campbell
- Section of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Mary Tabatneck
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Grete E. Wilt
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Mingwei Sun
- Center for Research Information Technology, Boston Children’s Hospital, Boston, Massachusetts
| | - Wei He
- Center for Research Information Science and Computing, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicholas Musinguzi
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Gabriella S. Lamb
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Don Goldmann
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Vishakha Sabharwal
- Section of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Thomas J. Sandora
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts
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Bruxvoort KJ, Skarbinski J, Fischer H, Li Z, Eaton A, Qian L, Spence B, Wei R, Rieg G, Shaw S, Tartof SY. Latent Tuberculosis Infection Treatment Practices in Two Large Integrated Health Systems in California, 2009-2018. Open Forum Infect Dis 2023; 10:ofad219. [PMID: 37265669 PMCID: PMC10230566 DOI: 10.1093/ofid/ofad219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/19/2023] [Indexed: 06/03/2023] Open
Abstract
Background Treatment of latent tuberculosis infection (LTBI) is highly effective at preventing active tuberculosis (TB) disease. Understanding LTBI treatment practices in US health system settings is critical to identify opportunities to improve treatment prescription, initiation, and completion, and thus to prevent TB disease. Methods We assessed LTBI treatment practices among a cohort of adults after their first positive LTBI test (tuberculin skin test [TST] or interferon gamma release assay [IGRA]) between 2009 and 2018 at 2 large integrated health systems in California. We described the prescription, initiation, and completion of LTBI treatment (isoniazid [INH], rifampin, and rifamycin-INH short-course combinations) by demographic and clinical characteristics. We used multivariable robust Poisson regression to examine factors that were independently associated with treatment prescription and completion. Results Among 79 302 individuals with a positive LTBI test, 33.0% were prescribed LTBI treatment, 28.3% initiated treatment, and 18.5% completed treatment. Most individuals were prescribed INH (82.0%), but treatment completion was higher among those prescribed rifamycin-INH short-course combinations (69.6% for INH + rifapentine and 70.3% for INH + rifampin) compared with those prescribed INH (56.3%) or rifampin (56.6%). In adjusted analyses, treatment prescription and completion were associated with older age, female sex, more comorbidities, immunosuppression, not being born in a high-TB incidence country, and testing positive with IGRA vs TST. Conclusions LTBI treatment is underutilized, requiring tailored interventions to support treatment prescription and completion for patients with LTBI.
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Affiliation(s)
- Katia J Bruxvoort
- Department of Epidemiology, School of Public Health,University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Infectious Diseases, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, USA
| | - Heidi Fischer
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Zhuoxin Li
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Abigail Eaton
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lei Qian
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Brigitte Spence
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Rong Wei
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Gunter Rieg
- Department of Infectious Diseases, South Bay Medical Center, Kaiser Permanente Southern California, Harbor City, California, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Sally Shaw
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
| | - Sara Y Tartof
- Division of Epidemiologic Research, Department of Research and Evaluation, Kaiser Permanente Southern California,Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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10
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Campbell JI, Tabatneck M, Sun M, He W, Musinguzi N, Hedt-Gauthier B, Lamb GS, Domond K, Goldmann D, Sabharwal V, Sandora TJ, Haberer JE. Multicenter Analysis of Attrition from the Pediatric Tuberculosis Infection Care Cascade in Boston. J Pediatr 2023; 253:181-188.e5. [PMID: 36181869 DOI: 10.1016/j.jpeds.2022.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/12/2022] [Accepted: 09/23/2022] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To characterize losses from the pediatric tuberculosis (TB) infection care cascade to identify ways to improve TB infection care delivery. STUDY DESIGN We conducted a retrospective cohort study of children (age <18 years) screened for TB within 2 Boston-area health systems between January 2017 and May 2019. Patients who received a tuberculin skin test (TST) and/or an interferon gamma release assay (IGRA) were included. RESULTS We included 13 353 tests among 11 622 patients; 93.9% of the tests were completed. Of 199 patients with positive tests for whom TB infection evaluation was clinically appropriate, 59.3% completed treatment or were recommended to not start treatment. Age 12-17 years (vs < 5 years; aOR 1.59; 95% CI, 1.32-1.92), non-English/non-Spanish language preference (vs English; aOR, 1.34; 95% CI, 1.02-1.76), and receipt of an IGRA (vs TST, aOR, 30.82; 95% CI, 21.92-43.34) were associated with increased odds of testing completion. Odds of testing completion decreased as census tract social vulnerability index quartile increased (ie, social vulnerability worsened; most vulnerable quartile vs least vulnerable quartile, aOR, 0.77; 95% CI, 0.60-0.99). Odds of completing treatment after starting treatment were higher in females (vs males; aOR, 2.35; 95% CI, 1.14-4.85) and were lower in patients starting treatment in a primary care clinic (vs TB/infectious diseases clinic; aOR, 0.44; 95% CI, 0.27-0.71). CONCLUSIONS Among children with a high proportion of negative TB infection tests, completion of testing was high, but completion of evaluation and treatment was moderate. Transitions toward IGRA testing will improve testing completion; interventions addressing social determinants of health are important to improve treatment completion.
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Affiliation(s)
- Jeffrey I Campbell
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA.
| | - Mary Tabatneck
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Mingwei Sun
- Center for Research Information Technology, Boston Children's Hospital, Boston, MA
| | - Wei He
- Center for Research Information Science and Computing, Massachusetts General Hospital, Boston, MA
| | - Nicholas Musinguzi
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Gabriella S Lamb
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA
| | - Kezia Domond
- Center for Global Health, Massachusetts General Hospital, Boston, MA
| | - Don Goldmann
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA
| | - Vishakha Sabharwal
- Division of Pediatric Infectious Diseases, Boston Medical Center, Boston, MA
| | - Thomas J Sandora
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA
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Foppiano Palacios C, Medvedeva N, Cheung H, Cohen E, Azar MM, Malinis M. The cascade of care in testing and treatment of latent tuberculosis infection in liver transplant candidates. Transpl Infect Dis 2023; 25:e13999. [PMID: 36484433 DOI: 10.1111/tid.13999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/03/2022] [Accepted: 11/16/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Testing and treatment for latent tuberculosis infection (LTBI) can mitigate risk of active tuberculosis (TB) post-liver transplant (LT). Testing and treatment completion rates have been reported low in this population. Our study aims to quantify the proportion of LT candidates who completed LTBI care cascade in our center. METHODS A retrospective chart review was conducted on LT candidates from 2012 to 2021. Primary outcome was the proportion of patients who completed each cascade stage. Secondary outcome was an analysis of factors associated with positive and indeterminate LTBI testing. RESULTS Of the 273 LT candidates, 265 (97.1%) were referred to transplant infectious disease (TID), 264 (96.7%) had orders for interferon-gamma release assay (IGRA), 262 (96%) underwent TID evaluation, and 259 (94.9%) completed IGRA. Twenty had LTBI, and 18 were treatment naïve and recommended for treatment. Of the 18, 15 (83.3%) agreed to therapy, 14 (77.8%) initiated treatment, and 12 (66.7%) completed treatment. No posttransplant TB reactivation occurred. Patients born in Asia, previous incarceration, past military service, and granuloma findings on chest imaging were likely to have positive IGRA (p < .05). Older age and travel to TB-endemic countries were likely to have indeterminate IGRA (p < .05). Indeterminate IGRAs were more common in QuantiFERON (QTF)-Gold Plus TB (15.3%) versus QTF-Gold TB (9.3%, p < .001). CONCLUSIONS High rates of LTBI testing and treatment initiation and completion can be attributed to a standardized process that includes TID evaluation. Future studies in larger cohort are needed to better understand factors that can optimize the completion rates of LTBI treatment in LT candidates.
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Affiliation(s)
- Carlo Foppiano Palacios
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Natalia Medvedeva
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Harry Cheung
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth Cohen
- Department of Pharmacy Services, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Marwan M Azar
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Maricar Malinis
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Surgery (Transplant), Yale University School of Medicine, New Haven, Connecticut, USA
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Association of Sociodemographic Factors with Tuberculosis Outcomes in Mississippi. Diseases 2023; 11:diseases11010025. [PMID: 36810538 PMCID: PMC9944444 DOI: 10.3390/diseases11010025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/09/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023] Open
Abstract
Tuberculosis (TB) is one of the leading causes of death worldwide. In the US, the national incidence of reported TB cases was 2.16 per 100,000 persons in 2020 and 2.37 per 100,000 persons in 2021. Furthermore, TB disproportionately affects minorities. Specifically, in 2018, 87% of reported TB cases occurred in racial and ethnic minorities in Mississippi. Data from TB patients from the Mississippi Department of Health (2011-2020) were used to examine the association between sociodemographic subgroups (race, age, place of birth, gender, homelessness, and alcohol use) with TB outcome variables. Of the 679 patients with active TB cases in Mississippi, 59.53% were Black, and 40.47% were White. The mean age was 46 ± ten years; 65.1% were male, and 34.9% were female. Among patients with previous TB infections, 70.8% were Black, and 29.2% were White. The rate of previous TB cases was significantly higher among US-born (87.5%) persons compared with non-US-born persons (12.5%). The study suggested that sociodemographic factors play a significant role in TB outcome variables. This research will help public health professionals to develop an effective TB intervention program that addresses sociodemographic factors in Mississippi.
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Froessl LJ, Abdeen Y. Pseudomembranous Tracheobronchitis due to Mycobacterium tuberculosis. Cureus 2021; 13:e17173. [PMID: 34532194 PMCID: PMC8436727 DOI: 10.7759/cureus.17173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2021] [Indexed: 11/05/2022] Open
Abstract
Although the incidence is declining in the western world, Mycobacterium tuberculosis remains one of the most common infectious organisms responsible for significant morbidity and mortality worldwide. Pulmonary tuberculosis (TB) is the most commonly seen presentation; however, TB can affect nearly any of the body's organ systems. Endobronchial TB (EBTB) can complicate pulmonary TB or more rarely present as an isolated finding. It is essential to recognize and treat this condition promptly, as it can develop into tracheobronchial stenosis and chronic respiratory failure. Here we discuss the case of a 43-year-old female with a left upper lobe cavitary lesion who presented with weight loss, dyspnea, and hoarseness. After failing multiple courses of antibiotics, the patient underwent bronchoscopy, and pseudomembranous tracheobronchitis (PMTB) was diagnosed. Cultures of endobronchial samples grew Mycobacterium tuberculosis. Standard anti-TB quadruple therapy was initiated, and the patient clinically improved. Several subtypes of EBTB have been identified earlier. However, to the best of our knowledge, tuberculous PMTB has not previously been reported. This case allows us to consider the diagnostic and therapeutic implications of this condition.
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Affiliation(s)
- Luise J Froessl
- Medicine/Pulmonary, Baylor College of Medicine, Houston, USA
| | - Yazan Abdeen
- Pulmonary and Critical Care Medicine, Pulmonary and Sleep Physicians of Houston, Webster, USA
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