A novel approach to monitoring adherence to preventive therapy for tuberculosis in adolescence

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.

Adolescent tuberculosis

Adolescence is characterised by a substantial increase in the incidence of tuberculosis, a known fact since the early 20th century. Most of the world's adolescents live in low-income and middle-income countries where tuberculosis remains common, and where they comprise a quarter of the population. Despite this, adolescents have not yet been addressed as a distinct population in tuberculosis policy or within tuberculosis treatment services, and emerging evidence suggests that current models of care do not meet their needs. This Review discusses up-to-date information about tuberculosis in adolescence, with a focus on the management of infection and disease, including HIV co-infection and rifampicin-resistant tuberculosis. We outline the progress in vaccine development and highlight important directions for future research.

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.

A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence

Different methods are available for measuring medication adherence. In this paper, we conducted a scoping review to identify and summarize evidence of all studies comparing the Medication Event Monitoring System (MEMS) with alternative methods for measuring medication adherence. A literature search was performed using the open database www.iAdherence.org that includes all original studies reporting findings from the MEMS. Papers comparing methods for measuring adherence to solid oral formulations were included. Data was extracted using a standardized extraction table. A total of 117 articles fulfilled the inclusion criteria, including 251 comparisons. Most frequent comparisons were against self-report (n = 119) and pill count (n = 59). Similar outcome measures were used in 210 comparisons (84%), among which 78 used dichotomous variables (adherent or not) and 132 used continuous measures (adherence expressed as percentage). Furthermore, 32% of all comparisons did not estimate adherence over the same coverage period and 44% of all comparisons did not use a statistical method or used a suboptimal one. Only eighty-seven (35%) comparisons had similar coverage periods, similar outcome measures and optimal statistical methods. Compared to MEMS, median adherence was grossly overestimated by 17% using self-report, by 8% using pill count and by 6% using rating. In conclusion, among all comparisons of MEMS versus alternative methods for measuring adherence, only a few used adequate comparisons in terms of outcome measures, coverage periods and statistical method. Researchers should therefore use stronger methodological frameworks when comparing measurement methods and be aware that non-electronic measures could lead to overestimation of medication adherence.

Adherence to isoniazid prophylaxis among HIV-infected children: a randomized controlled trial comparing two dosing schedules

BACKGROUND

Tuberculosis contributes significantly to morbidity and mortality among HIV-infected children in sub-Saharan Africa. Isoniazid prophylaxis can reduce tuberculosis incidence in this population. However, for the treatment to be effective, adherence to the medication must be optimized. We investigated adherence to isoniazid prophylaxis administered daily, compared to three times a week, and predictors of adherence amongst HIV-infected children.

METHODS

We investigated adherence to study medication in a two centre, randomized trial comparing daily to three times a week dosing of isoniazid. The study was conducted at two tertiary paediatric care centres in Cape Town, South Africa. Over a 5 year period, we followed 324 HIV-infected children aged >or= 8 weeks. Adherence information based on pill counts was available for 276 children. Percentage adherence was calculated by counting the number of pills returned. Adherence >or= 90% was considered to be optimal. Analysis was done using summary and repeated measures, comparing adherence to the two dosing schedules. Mean percentage adherence (per child during follow-up time) was used to compare the mean of each group as well as the proportion of children achieving an adherence of >or= 90% in each group. For repeated measures, percentage adherence (per child per visit) was dichotomized at 90%. A logistic regression model with generalized estimating equations, to account for within-individual correlation, was used to evaluate the impact of the dosing schedule. Adjustments were made for potential confounders and we assessed potential baseline and time-varying adherence determinants.

RESULTS

The overall adherence to isoniazid was excellent, with a mean adherence of 94.7% (95% confidence interval [CI] 93.5-95.9); similar mean adherence was achieved by the group taking daily medication (93.8%; 95% CI 92.1-95.6) and by the three times a week group (95.5%; 95% CI 93.8-97.2). Two-hundred and seventeen (78.6%) children achieved a mean adherence of >or= 90%. Adherence was similar for daily and three times a week dosing schedules in univariate (odds ratio [OR] 0.88; 95% CI 0.66-1.17; P = 0.38) and multivariate (adjusted OR 0.85; 95% CI 0.64-1.11; P = 0.23) models. Children from overcrowded homes were less adherent (adjusted OR 0.71; 95% CI 0.54-0.95; P = 0.02). Age at study visit was predictive of adherence, with better adherence achieved in children older than 4 years (adjusted OR 1.96; 95% CI 1.16-3.32; P = 0.01).

CONCLUSION

Adherence to isoniazid was excellent regardless of the dosing schedule used. Intermittent dosing of isoniazid prophylaxis can be considered as an alternative to daily dosing, without compromising adherence or efficacy.

TRIAL REGISTRATION

Clinical Trials NCT00330304.

Multi-level barriers to LTBI treatment: a research note

Background This study describes the barriers to effective and timely LTBI treatment encountered in a research study on INH adherence in Latino adolescents. Method Participant study logs were reviewed, results of continuing medical education pretests for medical providers were examined, and participating medical facilities were contacted in order to construct a profile of multi-level barriers to LTBI treatment. Results A total of 285 TST positive Latino (96%) high school students were recruited into the trial. We encountered a lack of understanding of the gravity of tuberculosis infection among both the public and providers of health care. Parents and adolescents cited competing priorities, transportation problems and financial constraints as reasons for non-compliance. Discussion Improved education of the public and physicians is needed regarding the gravity of the disease and the value of treatment, as well as public and financial support for LTBI treatment by both the government and the medical community.

Evidence-based assessment of adherence to medical treatments in pediatric psychology

OBJECTIVES

Adherence to medical regimens for children and adolescents with chronic conditions is generally below 50% and is considered the single, greatest cause of treatment failure. As the prevalence of chronic illnesses in pediatric populations increases and awareness of the negative consequences of poor adherence become clearer, the need for reliable and valid measures of adherence has grown.

METHODS

This review evaluated empirical evidence for 18 measures utilizing three assessment methods: (a) self-report or structured interviews, (b) daily diary methods, and (c) electronic monitors.

RESULTS

Ten measures met the "well-established" evidence-based (EBA) criteria.

CONCLUSIONS

Several recommendations for improving adherence assessment were made. In particular, consideration should be given to the use of innovative technologies that provide a window into the "real time" behaviors of patients and families. Providing written treatment plans, identifying barriers to good adherence, and examining racial and ethnic differences in attitudes, beliefs and behaviors affecting adherence were strongly recommended.

Adherence to antiretroviral medications in HIV: Differences in data collected via self-report and electronic monitoring

Controversy remains regarding the reliability of methods used to determine adherence to antiretroviral medication in HIV. In this study the authors compared adherence rates of 119 HIV-positive participants during a 6-month study, as estimated via electronic monitoring (EM) and self-report (SR). Adherence for both short (4-day) and long (4-week, or intervisit) periods was examined, as well as factors that underlie discrepancies between EM and SR. Results showed that intervisit EM estimates were consistently lower than those of SR. SR estimates based on shorter periods (4 days) were closer to those of EM. Higher discrepancies between EM and SR estimates were associated with lower cognitive functioning and externalized locus of control. These findings lend support for using both EM and SR methods; however, study design (e.g., length) and other factors (e.g., cognitive status, cost) should be considered.

Self-report INH adherence measures were reliable and valid in Latino adolescents with latent tuberculosis infection

BACKGROUND AND OBJECTIVE

To test the reliability and validity of 8-day and 30-day self-report measures of adherence to daily isoniazid (INH) for treatment of latent tuberculosis infection (LTBI).

METHODS

Participants were 286 Latino adolescents (ages 13-18, 55.6% male) with LTBI recruited from 10 public middle and high schools in San Diego County. INH adherence was measured monthly for up to 9 months by interview and urine specimens at unannounced visits. Reliability and validity analyses were performed within 5 consecutive months. Reliability was assessed by correlating: (1) 8- and 30-day INH adherence measures within each month; and (2) each of the two adherence measures across months. Validity was assessed by correlating reported measures with biological assays within each month.

RESULTS

Reliability tests yielded significant correlation coefficients (p < .05 to .001), both across measures (r = 0.71-0.93) and across time (r = 0.29-0.64 for 8-day recall; r = 0.32-0.69 for 30-day recall). Validity tests of both adherence measures were also significant (p < .05 to .001): 8-day recall (r(pb) = 0.52-0.72) and 30-day recall (r(pb) = 0.37-0.71).

CONCLUSION

Results suggest that impromptu recall measures of INH adherence, combined with urine collection, are reliable and valid in Latino adolescents.

Patient knows best: blinded assessment of nonadherence with antituberculous therapy by physicians, nurses, and patients compared with urine drug levels

BACKGROUND

Adherence with therapy is a wide spectrum of behavior rather than a categorical state. While extreme nonadherence is readily apparent, it is rare compared to lesser degrees of nonadherence, which are difficult to predict.

AIMS

To compare the accuracy of doctor, nurse, and patient prediction of adherence with antituberculous therapy with urine isoniazid levels.

METHODS

A prospective, blinded clinical study was conducted, comparing adherence to antituberculous therapy as reported by patients, doctors, and nurses with urine isoniazid levels. We studied 173 patients with active tuberculosis (TB) recruited over 3 years in two TB clinics in Victoria, Australia. Adherence was defined as six random urine isoniazid (INH) levels being >0. Blinded assessment of adherence was completed by doctors, nurses, and patients. Lid opening and closing of computerized pill bottles were measured in a random subsample.

RESULTS

Of 173 patients, the rate of nonadherence was 24% (41/173) by urine INH, 54% (93/173) by patient self-report, 11% (19/173) by doctor assessment, and 7% (12/173) by nurse assessment. The sensitivity of prediction of nonadherence was 76% for patient self-report, 24% for doctor assessment, and 19% for nurse assessment. The 10 patients who used computerized pill bottles were all (100%) noncompliant at some stage.

CONCLUSION

Nonadherence is common and poorly predicted by doctors and nurses, even those with extensive experience in treating TB. Contrary to popular belief, patient self-report is more reliable than doctor or nurse assessment of nonadherence. As clinicians, asking patients about adherence may be more valuable than attempting to judge for ourselves.

Somatic complaints and isoniazid (INH) side effects in Latino adolescents with latent tuberculosis infection (LTBI)

This study examined the potential effects of INH side effects and non-specific somatic complaints on medication adherence in 96 Latino adolescents participating in a controlled trial designed to increase isoniazid (INH) adherence. These participants (who received usual medical care) were interviewed monthly over 9 months. Participants were questioned regarding medication taking, the frequency of 15 INH-related side effects from the Physician's Desk Reference (PDR) [1], and 21 non-specific somatic complaints. Participants were aged 12-19 years, 53.1% were male, 66.7% were born in Mexico, 73% had no health insurance, and 52.5% were classified as bicultural. Approximately 70% of participants experienced at least one side effect during the trial. Side effects that occurred while taking INH were not significantly related to total number of pills taken; somatic complaints that occurred during 9 months of INH were significantly negatively related to cumulative adherence. Females reported significantly more somatic complaints at baseline than males.

Increasing Latino adolescents' adherence to treatment for latent tuberculosis infection: a controlled trial

OBJECTIVES

We sought to determine the efficacy of coaching Latino adolescents with latent tuberculosis infection to adhere to isoniazid treatment.

METHODS

Participants (n = 286) were randomly assigned to adherence coaching, attention control, or usual care groups. Adherence was measured via interviews and validated with urine assays.

RESULTS

Coaching resulted in significant increases in adherence compared with attention and usual care groups. Bicultural adolescents were more likely to be adherent than those most or least acculturated. Age and risk behavior were negatively related to adherence.

CONCLUSIONS

Coaching can increase Latino adolescents' adherence to treatment for latent tuberculosis infection and should contribute to tuberculosis control for adolescents at high risk of contracting the disease.

Follow-up of compliance with tuberculosis treatment in children: monitoring by urine tests

This study was designed to follow up patient compliance by detection of antituberculous drugs in urine during the course of treatment. It was conducted in the Outpatient Clinic of Pediatric Infectious Diseases, Sisli Etfal Hospital (Istanbul, Turkey). In total, 45 children with pulmonary tuberculosis participated. Patients were seen twice in the first month and once a month thereafter during the 6-month course of treatment. The second urine of the day was collected at each visit. Urine was tested for isoniazid (INH), rifampicin (RIF), and pyrazinamide (PZA). In the presence of these drugs or their metabolites, the addition of certain chemicals caused a color change in the urine. On day 15 of treatment, urine tested positive for INH in 82% of patients, for RIF in 67%, and for PZA in 73%. At the end of the second month, the ratio of adherence was 96, 89, and 96% for each drug, respectively. All patients were found to be adherent at months 5 and 6. We recommend detection of antituberculous drugs in urine to assess compliance to treatment. Once the defaulting patients were identified, adherence was improved by repeatedly providing patient education throughout the treatment.

Predictors of adherence to treatment for latent tuberculosis infection in high-risk Latino adolescents: a behavioral epidemiological analysis

The objective was to test whether theoretical variables predict adherence to treatment for latent tuberculosis infection in high-risk Latino adolescents. 286 Latino adolescents, age 13-18 years, were recruited from 10 middle/high schools in San Diego County, San Diego, USA. Participants completed a baseline interview and up to 9 monthly interviews. The cumulative number of pills consumed in 9 months was regressed on 16 independent variables, entered hierarchically in seven blocks. The final model accounted for 25% of the variance in adherence to isoniazid (INH), F (16, 230)=4.69, p<0.001. Adherence counseling (+), age (-), grades (+), being bicultural (+), and risk behaviors (-) were significantly related to adherence. Learning theories presume that adherence to medical regimens requires social support and freedom from physical and social barriers. Results support these theories. Future studies should explore additional precepts in order to identify additional predictors and to maximize adherence to INH among Latino adolescents and other high-risk populations. Doing so should decrease the risk of active TB among high-risk racial/ethnic and foreign-born populations.

Assessment of tuberculosis treatment completion in an ethnically diverse population using two data sources. Implications for treatment interventions

Many adolescents who are prescribed therapy for tuberculosis (TB) infection fail to complete it. This article presents the results of a demographic and epidemiological assessment of TB treatment completion in adolescent populations using (a) surveillance data from the Los Angeles Health County Department and (b) a prospective/retrospective medical chart review from targeted clinics. Patients who did not complete the 6-month recommended medical treatment for latent tuberculosis therapy (LTBI) averaged 13 weeks in care. Younger age (OR = 1.15; 95% CI 1.03-1.29), birth in the United States (OR = 1.92; 95% CI 1.14-3.22, compared to Mexico), and Asian ethnicity were associated with completion of care. In multiple logistic regression analysis, age (OR = .88; 95% CI .78-.98) and Latino ethnicity (OR = .53; 95% CI .29-.95) remained significant predictors of completion of treatment. These findings indicate the need for age-specific educational reinforcement and cultural differentials in completing care for LTBI.

Low level of compliance with tuberculosis treatment in children: monitoring by urine tests

Patient compliance should be ensured in an effective tuberculosis control programme. We measured patient compliance by detecting antituberculous drugs in the urine of 237 outpatients receiving one to three antituberculous drugs. Positive controls were 20 hospitalised patients, supervised to receive isoniazid (INH), rifampicin (RIF) and pyrazinamide (PZA), and negative controls were not on any drugs. Among the 237 study patients, only 67% were found to be taking the appropriate treatment and 8% had taken none. We conclude that a remarkable number of patients (33%) were non-compliant with treatment. The detection of antituberculous drugs in the urine is a quick, simple and inexpensive means of measuring adherence to treatment. Unless directly observed therapy (DOT) is adopted, we recommend routine urine testing for antituberculous drugs to identify defaulting patients.

Use of the urine color test to monitor compliance with isoniazid treatment of latent tuberculosis infection

STUDY OBJECTIVE

To apply the Arkansas color method in order to evaluate drug compliance and factors that can predict treatment adherence in patients being treated for latent tuberculosis infection (LTBI) with a single daily dose of isoniazid (INH).

DESIGN

Prospective study of adherence of 105 patients aged 1 to 75 years who were treated with a single daily dose of INH for LTBI.

INTERVENTIONS

Patients or their parents were interviewed regarding parameters that may affect compliance. Urine samples were collected and tested for INH metabolites with the Arkansas color method.

RESULTS

Nonadherence to treatment was found in 28.5% of patients. There was no statistically significant correlation among the following parameters: gender; age; diagnosis; mode of administration (self or parents); duration of treatment; dose of INH per weight; or interval since last intake of dose. Twenty-six patients were randomly checked for treatment adherence on two separate visits, and nonadherent patients were informed immediately and their condition was fully explained to them. Five of six patients who were nonadherent in the first visit and were examined twice became adherent in the second visit. Three of 20 patients who were adherent in the first visit became nonadherent.

CONCLUSION

Almost one third of the patients who received LTBI treatment with INH were nonadherent to treatment. No factor was found to predict adherence. The Arkansas method can be used by the family physician and is a simple, immediate method to follow-up patients with LTBI who are treated with INH.