Patient navigator's role in latent tuberculosis infection at a New York City Health Department Chest Clinic

Background

Philippines is one of the top ten countries of birth among individuals with tuberculosis in New York City (NYC). The NYC Health Department (HD) screened Filipino-born New Yorkers for latent TB infection (LTBI), but few of those tested positive completed evaluation and treatment.

Objective

To increase the proportion of Filipinos with a positive QuantiFeron-TB Gold Plus (QFT-Plus) complete LTBI evaluation and treatment.

Methods

Nine community-based LTBI screening events were conducted during September-December 2021. Patients with positive QFT-Plus results were offered no-cost LTBI evaluation and treatment at HD Chest Clinic. The HD engaged culturally- and linguistically-competent Filipino patient navigators (PN) to facilitate LTBI evaluation and treatment.

Results

Of 77 Filipinos screened, 17 (22%) tested positive. Fourteen (82%) were evaluated for LTBI; eight of the 14 (57%) completed LTBI treatment.

Conclusions

Pairing patients with culturally- and linguistically- competent Filipino PNs contributed to an increase in the proportion of Filipinos with a positive QFT-Plus who completed LTBI evaluation and treatment. TB prevention programs may wish to consider PNs in LTBI patient care.

Adverse events among persons with TB using in-person vs. electronic directly observed therapy

BACKGROUND: We evaluated patient safety within a randomized crossover trial comparing electronic directly observed therapy (eDOT) to in-person DOT (ipDOT) in persons undergoing TB treatment in New York City, NY, USA.METHODS: Participant symptoms, symptom severity, and clinical management were documented. We assessed adverse event reports (AERs) by DOT method during the two-period crossover. Using Cox proportional-hazards mixed-effects models, we estimated the adjusted hazard ratio (aHR) of participants reporting an adverse event (AE) vs. not reporting an AE.RESULTS: Of 211 participants, 57 (27.0%) reported AEs during the two-period crossover; of these, 54.4% (31/57) were reported while using eDOT vs. 45.6% (26/57) while using ipDOT. Controlling for study group and period, the aHR for eDOT vs. ipDOT was 0.98 (95% CI 0.49-1.93). Although statistically not significant, the wide confidence intervals suggest that a significant association cannot be entirely ruled out. Gastrointestinal symptoms were most frequently reported (42.1%, 24/57). AER types and severity did not differ significantly by DOT method. Days from symptom onset to medical attention was similar across DOT methods (median: 1.0 day, IQR 0.0-2.0). No participants switched DOT methods due to AERs or monitoring concerns.CONCLUSION: Further evaluation to ascertain whether AERs differ when patients use eDOT vs. ipDOT is warranted.

Challenges associated with electronic and in-person directly observed therapy during a randomized trial

BACKGROUND: Electronic directly observed therapy (eDOT) has been proposed as an alternative to traditional in-person DOT (ipDOT) for monitoring TB treatment adherence. Information about the comparative performance and implementation of eDOT is limited.METHODS: The frequency of challenges during DOT, challenge type, and effect on medication observation were documented by DOT method during a crossover, noninferiority randomized controlled trial. A logistic mixed-effects model that adjusted for the study design was used to estimate the percentage of successfully observed doses when challenges occurred.RESULTS: A total of 20,097 medication doses were scheduled for observation with either eDOT (15,405/20,097; 76.7%) or ipDOT (4,692/20,097; 23.3%) for 213 study participants. In total, one or more challenges occurred during 17.3% (2,672/15,405) of eDOT sessions and 15.6% (730/4,692) of ipDOT sessions. Among 4,374 documented challenges, 27.3% (n = 1,192) were characterized as technical, 65.9% (n = 2,881) were patient-related, and 6.9% (n = 301) were program-related. Estimated from the logistic model (n = 6,782 doses, 173 participants), the adjusted percentage of doses successfully observed during problematic sessions was 21.7% (95% CI 11.2-37.8) for eDOT and 4.2% (95% CI 1.1-14.7) for ipDOT.CONCLUSION: Compared to ipDOT, challenges were encountered in a slightly higher percentage of eDOT sessions but were more often resolved to enable successful dose observation during problematic sessions.

Cost savings associated with video directly observed therapy for treatment of tuberculosis

OBJECTIVE: To calculate the per-session and annual direct program costs to implement directly observed therapy (DOT) for tuberculosis treatment and to conduct a cost attribution analysis under varying proportions of DOT utilization for four DOT types.DESIGN: Program data covering the study period from September 2014 to August 2015 in New York City (NYC) were used to conduct a retrospective bottom-up micro-costing economic evaluation. For each DOT type, potential per-session and annual program savings were estimated as the cost averted by adopting a uniform distribution of DOT alternatives. Sensitivity analyses explored aggregate cost impacts of unequal distributions.RESULTS: There was a total of 38 035 unique DOT visits, of which 12 002 (32%) were clinic-based (CDOT); 15 483 (41%) were field-based (FDOT); 7185 (19%) were live-video (LVDOT); and 3365 (9%) were recorded-video (RVDOT). The per-session direct costs (in 2016 $US) for DOT services delivered during the study period were $8.46 for CDOT; $19.83 for FDOT; $6.54 for LVDOT; and $5.35 for RVDOT. Sensitivity analyses supported the main findings.CONCLUSIONS: Significant cost savings were estimated with increased utilization of VDOT. Assuming equivalent treatment adherence, duration, completion, and adverse events across DOT types, RVDOT was the modality that most minimized cost.

Improved treatment completion with shorter treatment regimens for latent tuberculous infection

SETTING

Four New York City (NYC) Health Department tuberculosis (TB) clinics.

OBJECTIVE

To assess the effectiveness of preferentially offering two shorter treatment regimens-4 months of daily rifampin (4R) and 3 months of once-weekly isoniazid and rifapentine (3HP)-as an alternative to 9 months of daily isoniazid (9H) for the treatment of latent tuberculous infection (LTBI).

DESIGN

Retrospective analysis of patients treated for LTBI from January to June 2015. Poisson regression with robust standard error was used to examine the factors associated with treatment completion.

RESULTS

Of the patients on 9H, 49% (27/55) completed treatment compared with 70% (187/269) of patients on 4R (P = 0.003) and 79% (99/125) of patients on 3HP (P < 0.001). When adjusting for age, sex, and TB risk factors, patients on 4R (adjusted risk ratio [aRR] 1.39, 95%CI 1.07-1.81) and 3HP (aRR 1.67, 95%CI 1.27-2.19) were more likely to complete treatment than patients on 9H. Treatment was discontinued due to side effects in 1% (3/269) of patients on 4R, 2% (2/125) of patients on 3HP, and 4% (2/55) of patients on 9H.

CONCLUSIONS

Most patients were placed on shorter regimens for LTBI treatment, and higher treatment completion was observed. Encouraging community providers to use shorter regimens for LTBI treatment would reduce the TB disease burden in NYC.

Enhancing management of tuberculosis treatment with video directly observed therapy in New York City

SETTING

Directly observed therapy (DOT), the standard of care for monitoring patients on treatment for tuberculosis (TB), requires substantial health department resources, and can be inconvenient and disruptive for patients.

OBJECTIVE

To determine whether video technology for remote observation of patients on anti-tuberculosis treatment (VDOT) is as effective as in-person DOT.

DESIGN

Eligible TB patients in New York City were prospectively enrolled in VDOT from September 2013 to September 2014. We compared treatment outcomes and worker output for VDOT and in-person DOT.

RESULTS

Among 390 patients on DOT for the treatment of TB, 61 (16%) were on VDOT and 329 (84%) on in-person DOT. Adherence to scheduled VDOT sessions was 95% (3292/3455) compared to 91% (32 204/35 442) with in-person DOT (>P < 0.01). VDOT enabled a DOT worker to observe a maximum of 25 patients per day, similar to DOT workers who observed patients in clinic (n = 25), but twice that of DOT workers who observed patients in the community (n = 12). Treatment completion with VDOT was similar to that with in-person DOT (96% vs. 97%, P = 0.63). The primary problems encountered during VDOT sessions were interruption of video and audio connectivity.

CONCLUSION

Implementation of VDOT resulted in successful anti-tuberculosis treatment outcomes while maximizing health department resources.

Transmission trends for human immunodeficiency virus associated tuberculosis in New York City

SETTING

Since 1992, tuberculosis (TB) control measures have reduced incidence rates in New York City and elsewhere. Nevertheless, trends have not been uniform in all demographic groups.

OBJECTIVE

To characterize the epidemiology of human immunodeficiency virus (HIV) associated TB in New York during the 1990s, we analyzed social, demographic and clinical characteristics and genetic data on Mycobacterium tuberculosis isolates among persons with known HIV-status.

DESIGN

A retrospective case-control study to compare patients with HIV-associated TB and patients with TB alone.

RESULTS

Of 546 patients (70.5%) in the Department of Health Tuberculosis Control Registry treated for TB, 385 also had documented HIV status; 198 were HIV-infected (51%) and 187 (49%) were not. Genotype analysis of the 385 M. tuberculosis isolates identified 200 (52%) clustered strains, representing recent transmission. Although the overall percentage of TB cases associated with restriction fragment length polymorphism (RFLP) clustering fell over the period studied, HIV-associated cases were still much more likely to be associated with clustering than non-HIV-associated cases.

CONCLUSIONS

Continued attention is required to contain the spread of TB in this vulnerable population.

Tuberculosis and HIV infection: epidemiology, immunology, and treatment

Tuberculosis and HIV have combined to present a major threat to global public health. Each disease has a negative effect on the other, and mortality in patients with both tuberculosis and HIV is higher than that caused by either condition alone. In regions such as sub-Saharan Africa, as many as a third or more of all patients with tuberculosis have concomitant HIV infection. In urban centers in developed nations, HIV co-infection may also be quite common. Treatment of latent tuberculosis infection in persons with HIV is successful in preventing many cases of active disease, and newer ultra-short course regimens, such as those consisting of 2 months of rifampin and pyrazinamide, should aid in this effort. Diagnosis and treatment of active tuberculosis in HIV-infected patients may be difficult. Although treatment of active tuberculosis is generally successful in patients with HIV, drug interactions between anti-tuberculosis medications and antiretrovirals often complicate the matter, and expert guidance should be sought for proper management.

HPLC purification of synthetic oligodeoxyribonucleotides containing base- and backbone-modified sequences

Applications for a new polymer resin, PolyFlo, are described for both the small-scale and large-scale purification of synthetic oligodeoxyribonucleotides varying in length from 18-41 bases. The unique properties of this innovative resin provide > 95% purified full-length oligodeoxyribonucleotides with greater than 90% yield starting from either crude trityl-on or trityl-off unmodified as well as base (biotin)- or backbone (e.g., phosphorothioate)-modified products. Full biological activity of recovered nucleic acid is retained, and the resin is capable of removing contaminating endotoxins during purification. The resin performance is predictable and reliable. The resin can be regenerated easily and is particularly economic when employed directly in ammonia or with the trityl-off option. PolyFlo meets the requirements of current Good Manufacturing Practices.