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Nurses in community health centers can help treat pediatric LTBI
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Community health centers can facilitate treatment of latent tuberculosis infection, boosting completion of treatment, according to study results.
Janine Young, MD, of Yale University School of Medicine, and colleagues examined 150 Mexican immigrant children aged 12 months to 18 years from the Denver area who were diagnosed with latent tuberculosis infection (LTBI) between November 2006 and March of 2009.
For the purpose of the study, patients needed to have 6 months of treatment to qualify for completion. Young and colleagues evaluated treatment completion by nurses in a community health center (CHC) that serves as a medical home and compared CHC treatment with a health department TB clinic.
The researchers said 74% of the 150 patients completed treatment at the Westside Family Health Center CHC; 19% were transferred to a school-based clinic or TB clinic; 3% never started treatment. Twenty-two did not complete the treatment at Westside, with researchers reporting that one had developed isoniazid hepatitis and the other 21 patients were lost to follow-up. Keys to completion in treatment were younger age of the patient, fewer days between the skin test reading and the chest radiograph and already being an established patient at the CHC.
“Improving the accuracy of diagnosis of LTBI using interferon-gamma release assays, using shorter course treatments, and treating the child in a medical home setting, including CHCs and private practices using well-trained nurses should be studied in further research,” the researchers concluded.
Disclosure: Dr. Young reports no relevant financial disclosures.
Perspective
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Jeffrey R. Starke, MD
One of the biggest problems in the prevention of TB in children is the long length of therapy required to treat TB infection. Although 9 months of isoniazid treatment is efficacious, it is much less effective in clinical practice because of low rates of adherence to treatment. This study achieved an admirable 81% completion rate with monthly visits to the child’s medical home at a community health center, although the actual adherence measured by number of doses received could not be accurately determined (an issue with most studies).
Our recent study from the Children’s Tuberculosis Clinic in Houston (Cruz AT. Pediatr Infect Dis J. 2012; 31:193-195) demonstrated a 9-month isoniazid completion rate of 49% with self-medication; 85% when medicine was supplied monthly and the family received telephone reminders weekly from the health department; and 93% when the treatment was administered twice weekly under health department directly observed therapy (DOT). It is obvious that ensuring adequate adherence with a 9-month course of isoniazid often requires a great amount of resources that many public health programs cannot afford. We need shorter regimens!
In several European countries, 3 months of daily isoniazid and rifampin are used to treat TB infection with apparent success. In the US, a 12-week, once-weekly (only under DOT) regimen of isoniazid and rifapentine (Priftin, Sanofi-Aventis), a long-active rifamycin, has been shown to be safe and at least as effective as a 9-month course of self-administered isoniazid for patients aged at least 13 years, and this regimen is now recommended, where it is available, by the CDC for adults and adolescents. Unfortunately, safety, tolerability and efficacy of this regimen in younger children has not yet been assessed.
Several new anti-TB drugs are in various stages of development, and it will be essential that they be evaluated in children of all ages, not only for treatment of TB disease, but also for candidate drugs in short-course treatment regimens for TB infection.
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