Directly observed isoniazid preventive therapy for released jail inmates

A situational analysis of latent tuberculosis infection among incarcerated population in Japan

BACKGROUND

The World Health Organization recommends that systematic testing and screening of latent tuberculosis infection (LTBI) among the incarcerated population "should be considered", though based on evidence of either low or very low quality. However, in Japan, a TB middle-burden country, systematic screening for LTBI in correctional facilities is currently not conducted. As part of a larger study to determine the cost-effectiveness of LTBI screening in correctional facilities in Japan, this study was conducted to determine the situation of LTBI, including treatment outcome, among the incarcerated population in Japan, and provide the essential data for cost-effectiveness analysis.

METHOD

A cross-sectional study was conducted between 2017 and 2018 with public health centers which have one or more correctional facilities under their jurisdiction. Questionnaire surveys were sent to collect information on their policy of managing LTBI patients notified from correctional facilities, including whether or not there was a standardized procedure for initiating LTBI treatment, and also to collect sociodemographic information and treatment outcome of LTBI patients who were notified from the respective correctional facilities in 2015 and 2016.

RESULTS

The survey was sent to a total of 163 public health centers, out of which 133 (81.6%) responded. 8 of the 133 public health centers actively guided the correctional facilities regarding LTBI treatment initiation through a standardized procedure, while 115 either had not established such procedure or were unaware of how LTBI treatment was being initiated in the correctional facilities. A total of 91 LTBI patients were notified from the correctional facilities in 2015 and 2016, and the information of 89 were available for analysis. 82 were males, and 83 were Japan-born. Treatment outcome was known for 88 patients, of which 70 had completed treatment. Of the 18 who did not complete the treatment, 15 had been lost to follow-up upon release from the facilities. Among those who had been released whilst on treatment, the proportion of those who completed the treatment was higher in those patients who received pre-release visit by a public health nurse, than those who did not.

CONCLUSIONS

LTBI treatment was often being initiated without consideration for the patients' prison term. The treatment completion rate within jail was high, indicating the possibility that incarcerated population can benefit for LTBI treatment. On the other hand, the completion rate decreased significantly among those who had been released while still on treatment. In order to optimize the benefit, initiation of LTBI must carefully be considered upon the patient's prison term, as well as coordination among the relevant organizations to ensure continuity of care after release.

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.

The cascade of care in diagnosis and treatment of latent tuberculosis infection: a systematic review and meta-analysis

BACKGROUND

WHO estimates that a third of the world's population has latent tuberculosis infection and that less than 5% of those infected are diagnosed and treated to prevent tuberculosis. We aimed to systematically review studies that report the steps from initial tuberculosis screening through to treatment for latent tuberculosis infection, which we call the latent tuberculosis cascade of care. We specifically aimed to assess the number of people lost at each stage of the cascade.

METHODS

We did a systematic review and meta-analysis of study-level observational data. We searched MEDLINE (via OVID), Embase, and Health Star for observational studies, published between 1946 and April 12, 2015, that reported primary data for diagnosis and treatment of latent tuberculosis infection. We did meta-analyses using random and fixed effects analyses to identify percentages of patients with latent tuberculosis infection completing each step in the cascade. We also estimated pooled proportions in subgroups stratified by different characteristics of interest to assess risk factors for losses.

RESULTS

We identified 58 studies, describing 70 distinct cohorts and 748 572 people. Steps in the cascade associated with greater losses included completion of testing (71·9% [95% CI 71·8-72·0] of people intended for screening), completion of medical evaluation (43·7% [42·5-44·9]), recommendation for treatment (35·0% [33·8-36·4]), and completion of treatment if started (18·8% [16·3-19·7]). Steps with fewer losses included receiving test results, referral for evaluation if test positive, and accepting to start therapy if recommended. Factors associated with fewer losses were immune-compromising medical indications, being part of contact investigations, and use of rifamycin-based regimens.

INTERPRETATION

We identify major losses at several steps in the cascade of care for latent tuberculosis infection. Improvements in management of latent tuberculosis will need programmatic approaches to address the losses at each step in the cascade.

FUNDERS

Canadian Institutes of Health Research.

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.

Factors Associated With Noncompletion of Latent Tuberculosis Infection Treatment: Experience From the PREVENT TB Trial in the United States and Canada

BACKGROUND

Overall rates of noncompletion of treatment (NCT) for latent tuberculosis infection (LTBI) in the PREVENT TB trial were 18% for 3 months of directly observed once-weekly rifapentine (maximum dose, 900 mg) plus isoniazid (maximum dose, 900 mg) (3HP-DOT) and 31% for 9 months of daily self-administered isoniazid (maximum dose, 300 mg; 9H-SAT). NCT for LTBI reduces its effectiveness. The study objective was to assess factors associated with NCT for LTBI among adult participants enrolled at US and Canadian sites of the PREVENT TB trial.

METHODS

This was a post hoc exploratory analysis of the randomized, open-label PREVENT TB trial. Factors were analyzed by univariate and multivariate logistic regression (with enrollment site as a random effect).

RESULTS

From 6232 participants analyzed, 1406 (22.6%) did not complete LTBI treatment (317 NCT attributed to an adverse event [NCT-AE] and 1089 NCT attributed to reasons other than an adverse event [NCT-O]). The proportion of NCT-AE was similar with both regimens (3HP-DOT = 6.4% vs 9H-SAT = 5.9%; P = .23); NCT-O was higher among participants enrolled in 9H-SAT (9H-SAT = 24.5% vs 3HP-DOT = 12.7%; P = .02). Among those in the NCT-AE group, being non-Hispanic and receiving 3HP-DOT, having cirrhosis and receiving 9H-SAT, alcohol consumption among men, and use of concomitant medication were associated with NCT-AE. Among those in the NCT-O group, receiving 9H-SAT, missing ≥1 early visit, men receiving 9H-SAT, men with a history of incarceration, alcohol abuse, use ever of intravenous drugs, younger age receiving 9H-SAT, and smoking were associated with NCT-O.

CONCLUSIONS

Factors associated with NCT, such as missing a clinic visit early during treatment, might help identify persons for whom tailored interventions could improve completion of LTBI treatment.

CLINICAL TRIALS REGISTRATION

NCT00023452.

Evaluation of the isoniazid preventive therapy (IPT) program in Shurugwi District, Midlands Province, Zimbabwe, January 2013 to August 2014

Background

Midlands Province started implementing the Isoniazid (INH) preventive therapy (IPT) program in January 2013. Shurugwi and Gokwe North were the piloting district hospitals. In May 2014, four more districts hospitals (Gokwe South, Gweru, Kwekwe and Zvishavane) started implementing IPT. Shurugwi District decentralized the program to its rural health facilities in January 2014. A review of the Shurugwi IPT program, 2013 data, indicated that the majority of eligible clients were not started on IPT. None out of the 400 eligible clients were started on IPT in November against the 100 % target according to the World Health Organization and the National Tuberculosis (TB) Program. We conducted a study to evaluate the IPT program in Shurugwi District from January 2013 to August 2014.

Methods

The logical framework approach was used to evaluate inputs, processes, outputs and outcomes of the IPT program. An interviewer administered questionnaire was used to collect data from key informants. Checklists were used to collect data from IPT program records.

Results

Sixteen health facilities were implementing IPT in Shurugwi District. All the facilities had TB screening tools and three did not have TB screening algorithms. The district experienced medicine stock outs in 2013. One formal training at district level and on job trainings in implementing health facilities were done. From January 2013 to August 2014, Shurugwi District screened 6794 antiretroviral (ART) clients for TB. Out of those screened, 5255 were eligible for IPT and 2831 (54 %) were started on IPT. A total of 700 clients had completed the IPT 6 month’s course by August 2014. The dropout rate due to INH toxicity and TB was 0.6 % (n = 18) and 0.3 % (n = 8) respectively. Fifty-three advocacy and community sensitization meetings were done. The program had no Information Education and Communication (IEC) materials.

Conclusion

The IPT program in Shurugwi District achieved half its target. This could be due to inadequate formally trained staff, lack of IEC materials, inadequate advocacy and community sensitization, non-availability of the INH 300 mg single dose and inadequate INH 100 mg dose tablets in 2013. To improve the IPT program, there is need for routine advocacy, communication and social mobilization.

Risk factors for treatment default in close contacts with latent tuberculous infection

OBJECTIVE

1) To characterize risk factors for non-completion of latent tuberculous infection treatment (LTBIT), and 2) to assess the impact of LTBIT regimens on subsequent risk of tuberculosis (TB).

METHODS

Close contacts of adults aged ⩾15 years with pulmonary TB were prospectively enrolled in a multi-center study in the United States and Canada from January 2002 to December 2006. Close contacts of TB patients were screened and cross-matched with TB registries to identify those who developed active TB.

RESULTS

Of 3238 contacts screened, 1714 (53%) were diagnosed with LTBI. Preventive treatment was recommended in 1371 (80%); 1147 (84%) initiated treatment, of whom 723 (63%) completed it. In multivariate analysis, study site, initial interview sites other than a home or health care setting and isoniazid preventive treatment (IPT) were significantly associated with non-completion of LTBIT. Fourteen TB cases were identified in contacts, all of whom initiated IPT: two TB cases among persons who received ⩾6 months of IPT (66 cases/100 000 person-years [py]), and nine among those who received 0-5 months (median 2 months) of IPT (792 cases/100 000 py, P < 0.001); data on duration of IPT were not available for three cases.

CONCLUSION

Only 53% (723/1371) of close contacts for whom IPT was recommended actually completed treatment. Close contacts were significantly less likely to complete LTBIT if they took IPT. Less than 6 months of IPT was associated with increased risk of active TB.

Prevalence of tuberculosis symptoms and latent tuberculous infection among prisoners in northeastern Malaysia

SETTING

There are currently no routine screening procedures for active tuberculosis (TB) or latent tuberculous infection (LTBI) in Malaysian prisons.

OBJECTIVE

To determine the prevalence and correlates of LTBI and active TB symptoms among Malaysian prisoners with and without human immunodeficiency virus (HIV) infection using the tuberculin skin test (TST) and the World Health Organization TB symptom-based screening instrument.

DESIGN

A cross-sectional survey of 266 prisoners was performed in Kelantan, Malaysia. Consenting participants underwent two-step TST and were screened for active TB symptoms. Standardized cut-offs of respectively ≥5 and ≥10 mm were used to define reactive TST among prisoners with and without HIV. Clinical and behavioral data were assessed and HIV-infected prisoners were stratified by CD4 status.

RESULTS

Overall LTBI prevalence was 87.6%, with significantly lower TST reactivity among HIV-infected than non-HIV-infected prisoners (83.6% vs. 91.5%, P < 0.05); however, TB symptoms were similar (16.9% vs. 10.1%, P = 0.105). On multivariate analysis, previous incarceration (aOR 4.61, 95%CI 1.76-12.1) was the only significant correlate of LTBI. Increasing age (aOR 1.07, 95%CI 1.01-1.13), lower body mass index (aOR 0.82, 95%CI 0.70-0.96) and TST-reactive status (aOR 3.46, 95%CI 1.20-9.97) were correlated with TB symptoms.

CONCLUSION

LTBI is highly prevalent, associated with previous incarceration, and suggests the need for routine TB screening on entry to Malaysian prisons.

Impact of latent infection treatment in indigenous populations

The aims of the present study were to identify risk factors associated with latent tuberculosis (TB), examine the development of active disease among contacts, and assess the effectiveness of treating latent infection in indigenous Brazilians from January 2006 to December 2011. This was a retrospective study consisting of 1,371 tuberculosis contacts, 392 of whom underwent treatment for latent infection. Morbidity-from-TB data were obtained from the Information System for Disease Notification (SINAN) database, and the contacts’ data were collected from the clinical records using forms employed by Special Department of Indigenous Health (SESAI) multidisciplinary teams, according to SESAI’s instructions. The variables that were associated with latent infection among the contacts were age (odds ratio [OR]: 1.03; 95% confidence interval [CI]: 1.02–1.04) and close contact with a smear-positive index case (OR: 2.26, 95% CI: 1.59–3.22). The variables associated with the development of active TB among the contacts were a tuberculin skin test (TST) ≥10 mm (relative risk [RR]: 1.12, 95% CI: 1.07–1.17), age (RR: 1.01, 95% CI: 1.00–1.03), and treatment of latent infection (RR: 0.03, 95% CI: 0.01–0.27). The estimated number of latent infection treatments needed to prevent one case of active TB among the contacts was 51 treatments (95% CI: 33–182). In contacts with TST ≥10 mm, 10 (95% CI: 6–19) latent infection treatments were necessary to prevent one case of active TB. Age and close contact with a smear-positive index case were associated with latent TB. Screening with TST is a high priority among individuals contacting smear-positive index cases. Age and TST are associated with the development of active TB among contacts, and treatment of latent infection is an effective measure to control TB in indigenous communities.

Factors associated with failure to complete isoniazid treatment for latent tuberculosis infection in Rhode Island

BACKGROUND

The treatment of latent tuberculosis infection (LTBI) is essential for tuberculosis elimination in the United States, but the major limitation is poor adherence to therapy. To aid the design of targeted adherence interventions, we investigated the factors associated with noncompletion of isoniazid (INH) therapy for LTBI.

METHODS

A retrospective analysis of patients with who failed to complete vs those who completed 9 months of INH therapy at the RISE TB Clinic (Miriam Hospital; Providence, RI) in 2003 was performed. Factors associated with treatment noncompletion were examined using univariate and multiple logistic regression analysis.

RESULTS

Of 845 patients with LTBI, 690 patients (81.6%) initiated INH therapy, of whom 426 patients (61.7%) completed therapy, and 246 patients (35.6%) were lost to follow-up. Treatment was discontinued in 18 patients (2.6%). Patients who failed to complete therapy were younger (mean age, 30.6 vs 33.8 years, respectively; p = 0.006), and were more likely to be uninsured (42.9% vs 29.8%, respectively; p = 0.0004), to be postpartum (66.7% vs 37.3%, respectively; p = 0.043), and to report treatment side effects (54.8% vs 30.1%, respectively; p < 0.0001). Reported treatment side effects (odds ratio [OR], 3.6; 95% confidence interval [CI], 2.2 to 6.2) and lack of medical insurance (OR, 1.7; 95% CI, 1.1 to 2.7) were each associated with treatment noncompletion in a model including both. Also, pregnant women were more likely than nonpregnant women to fail to initiate INH treatment (52.1% vs 14.7%, respectively; p < 0.0001).

CONCLUSIONS

LTBI patients who are young, pregnant or postpartum, uninsured, and/or report treatment side effects may require additional case management to improve INH treatment completion rates.

Risk factors for tuberculin skin test positivity in an industrial workforce results of a contact investigation

OBJECTIVE

The objective of this study was to determine the prevalence of and risk factors for tuberculin skin test (TST) positivity among an industrial workforce employing many foreign-born workers after one employee was hospitalized for active tuberculosis (TB).

METHODS

A contact investigation was performed. We used crude odds ratios and a multivariate model to assess risk factors for TST positivity.

RESULTS

The rate of TST positivity was 37.1% (N=97). Twenty-nine of 36 (80.6%) workers from higher TB prevalence countries versus seven of 61 (11.5%) workers born in low-prevalence countries were positive. Workplace risk factors included using the lunchroom, carpooling with the case, or working on the same or subsequent shift. A total of 66.7% of immigrant workers denied previous screening.

CONCLUSION

TB contact investigations should probe into workplace transmission. Workplaces with workers from higher TB prevalence countries should consider pre-placement TB screening.

Public health and correctional collaboration in tuberculosis control

OBJECTIVE

To assess the extent that 20 large jail systems and their respective public health departments collaborate to prevent and control tuberculosis (TB).

METHODS

Data were collected through questionnaires sent to jail medical directors and TB control directors, interviews, and on-site observation in each of the jails.

RESULTS

Only 35% of jail systems and health departments reported having effective collaboration in TB prevention and control activities. Four barriers were reported by a majority of the jail systems: funding (65%), staffing (60%), staff training (55%), and communication (55%). Lack of advance notice of a patient's release was rated as the greatest barrier to discharge planning. Fifty percent of the jail systems reported that they scheduled appointments for soon-to-be released patients with TB, and 10% did so for patients being treated for latent TB infection (LTBI). Fewer patients actually received appointments: seven (39%) of 33 released patients with TB had documentation in their medical record of appointments, and one of 46 released patients on treatment for LTBI had them. Characteristics associated with increased collaboration include having designated liaisons between jail systems and health departments and holding periodic meetings of staff.

CONCLUSIONS

Health departments and jail systems in the same jurisdiction have implemented recommendations regarding collaboration to a limited extent. Such collaborations need strengthening, especially discharge planning and evaluation of TB control activities.

Priorities for the treatment of latent tuberculosis infection in the United States

BACKGROUND

The prevention of active tuberculosis through the treatment of latent tuberculosis infection is a major element of the national strategy for eliminating tuberculosis in the United States. Targeted treatment for persons who are at the highest risk for reactivation tuberculosis will be needed to achieve this goal. A more precise assessment of the lifetime risk of reactivation tuberculosis, usually estimated at 5 to 10 percent, could help to identify patients who are at the highest risk and motivate them to complete treatment. Currently, the rate of completion of treatment is low.

METHODS

Published reports were reviewed to obtain estimates of the risk of tuberculosis among persons with a positive tuberculin skin test. Using these data, I constructed a model to estimate the lifetime risk of tuberculosis among persons with specific medical conditions.

RESULTS

The lifetime risk of reactivation tuberculosis is 20 percent or more among most persons with induration of 10 mm or more on a tuberculin skin test and either human immunodeficiency virus infection or evidence of old, healed tuberculosis. The lifetime risk is 10 to 20 percent among persons with recent conversion of a tuberculin skin test and among most persons younger than 35 years of age who are receiving infliximab therapy and have induration of 15 mm or more on a tuberculin skin test. The risk is also 10 to 20 percent among children five years of age or younger who have induration of 10 mm or more on a tuberculin skin test.

CONCLUSIONS

Persons with these characteristics should be targeted for intensive efforts to ensure full treatment of latent tuberculosis. Improved rates of completion of treatment among such persons could help to eliminate tuberculosis in the United States.

Assessment of tuberculosis screening and management practices of large jail systems

OBJECTIVE

This descriptive study sought to explore the use and timeliness of tuberculosis (TB) screening and management activities in jail facilities.

METHODS

Study personnel visited 20 large U.S. jail systems and reviewed the medical records of 56 inmates who had recently been evaluated for TB disease and 376 inmates who were diagnosed with or confirmed to have latent TB infection (LTBI). Data from these records were analyzed to determine completion and timeliness of screening, diagnostic, and treatment activities.

RESULTS

In 14% of 56 inmates evaluated for TB disease and 24% of 376 inmates with LTBI, chest radiographs were either not performed or not documented. Of 48 inmates evaluated for TB disease who were not receiving treatment when admitted to jail, 10 had no record of sputum collection being done. A mean delay of 3.1 days occurred from symptom report to respiratory isolation. Time from tuberculin skin test reading to chest radiograph reading was a mean of 5.3 days in inmates evaluated for TB disease and a mean of 7.0 days in inmates with LTBI. Follow-up was arranged for 91% of released inmates who were on treatment for TB disease and only 17% of released inmates who were on treatment for LTBI.

CONCLUSIONS

Jail health information systems should be augmented to better document and monitor inmate health care related to TB. Completion rates and timeliness of TB screening, diagnostic, and treatment measures should be evaluated to identify areas needing improvement. Finally, mechanisms for continuity of care upon inmate release should be enhanced to promote therapy completion and prevent TB transmission in the community.

Assessment of tuberculosis screening and management practices of large jail systems

OBJECTIVE

This descriptive study sought to explore the use and timeliness of tuberculosis (TB) screening and management activities in jail facilities.

METHODS

Study personnel visited 20 large U.S. jail systems and reviewed the medical records of 56 inmates who had recently been evaluated for TB disease and 376 inmates who were diagnosed with or confirmed to have latent TB infection (LTBI). Data from these records were analyzed to determine completion and timeliness of screening, diagnostic, and treatment activities.

RESULTS

In 14% of 56 inmates evaluated for TB disease and 24% of 376 inmates with LTBI, chest radiographs were either not performed or not documented. Of 48 inmates evaluated for TB disease who were not receiving treatment when admitted to jail, 10 had no record of sputum collection being done. A mean delay of 3.1 days occurred from symptom report to respiratory isolation. Time from tuberculin skin test reading to chest radiograph reading was a mean of 5.3 days in inmates evaluated for TB disease and a mean of 7.0 days in inmates with LTBI. Follow-up was arranged for 91% of released inmates who were on treatment for TB disease and only 17% of released inmates who were on treatment for LTBI.

CONCLUSIONS

Jail health information systems should be augmented to better document and monitor inmate health care related to TB. Completion rates and timeliness of TB screening, diagnostic, and treatment measures should be evaluated to identify areas needing improvement. Finally, mechanisms for continuity of care upon inmate release should be enhanced to promote therapy completion and prevent TB transmission in the community.

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.

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.

Cost-effectiveness of tuberculosis prophylaxis after release from short-term correctional facilities

BACKGROUND

There is poor adherence with tuberculosis preventive therapy among patients released from short-term correctional facilities, leading to recommendations against screening for latent tuberculosis infection (LTBI) in this setting.

OBJECTIVES

To assess adherence to isoniazid preventive therapy (IPT) following release from short-term correctional facilities, and to estimate the cost-effectiveness of this practice.

METHODS

Records of individuals referred for IPT from the Connecticut Department of Corrections to the City of Hartford Chest Clinic between January 1993 and June 1997 were reviewed. The data abstracted included demographics, adherence to IPT, and the duration of IPT completed before release from prison. An analysis was performed to determine the cost-effectiveness of this program.

RESULTS

A total of 168 records were reviewed. The mean duration of IPT completed before release from prison was 8 weeks. Eighty-six subjects (57%) never came to clinic after release. Of the 64 subjects (43%) who attended clinic at least once, 35 subjects (55%) completed IPT and 29 subjects (45%) were unavailable for follow-up before completing therapy. Thirty-three of the 64 subjects (52%) who attended the clinic had to be restarted on IPT due to a prolonged lapse in therapy prior to the first visit. We estimate that $32,866 was spent on this program, but $42,093 in future costs associated with reactivation tuberculosis was prevented.

CONCLUSIONS

Adherence with IPT is poor in patients released from short-term correctional facilities. Nonetheless, this program was cost-effective. An alternative strategy may be to screen for LTBI among inmates of short-term correctional facilities but withhold IPT in inmates expected to be released before therapy would be completed. Instead, these inmates could be referred to an appropriate clinic after release. Prophylaxis may be started in subjects who keep an initial clinic appointment after release.

Acceptability of short-course rifampin and pyrazinamide treatment of latent tuberculosis infection among jail inmates

STUDY OBJECTIVES

To determine whether short-course treatment of latent tuberculosis infection (LTBI) with 2 months of rifampin and pyrazinamide (2RZ) is well tolerated and leads to increased treatment completion among jail inmates, a group who may benefit from targeted testing and treatment for LTBI but for whom completion of > or = 6 months of isoniazid treatment is difficult because of the short duration of incarceration.

DESIGN

Prospective cohort.

SETTING

Large, urban county jail.

PATIENTS

All inmates admitted to the Fulton County Jail who had positive tuberculin skin test results, normal findings on chest radiography, and expected duration of incarceration of at least 60 days.

INTERVENTION

Inmates were offered 2RZ via daily directly observed therapy for 60 doses as an alternative to isoniazid therapy.

MEASUREMENTS AND RESULTS

We measured the completion of 2RZ treatment and toxicity due to 2RZ treatment during incarceration. From December 14, 1998, through December 13, 1999, 1,360 new inmates had positive tuberculin skin test results and normal findings on chest radiography, and 168 new inmates had an expected duration of incarceration of > or = 60 days. One hundred sixty-six inmates (> 99%) were HIV-negative. Eighty-one inmates (48%) completed 60 doses of 2RZ treatment while incarcerated. Seventy-four inmates (44%) were released before completion. Treatment was stopped in 1 inmate (< 1%) for asymptomatic elevation of asparginine aminotransferase (> or = 10 times normal) and in 12 inmates (7%) for minor complaints. Twenty-one inmates had completed isoniazid treatment in the year before the availability of 2RZ, and 9 inmates completed isoniazid treatment in the year during the availability of 2RZ.

CONCLUSIONS

2RZ was acceptable to and well tolerated by inmates, and led to a marked increase in the number of inmates completing treatment of LTBI during incarceration.

Differences in contributing factors to tuberculosis incidence in U.S. -born and foreign-born persons

To determine the factors contributing to tuberculosis incidence in the U.S.-born and foreign-born populations in San Francisco, California, and to assess the effectiveness of tuberculosis control efforts in these populations, we performed a population-based molecular epidemiologic study using 367 patients with strains of Mycobacterium tuberculosis recently introduced into the city. IS6110-based and PGRS-based restriction fragment length polymorphism (RFLP) analyses were performed on M. tuberculosis isolates. Patients whose isolates had identical RFLP patterns were considered a cluster. Review of public health and medical records, plus patient interviews, were used to determine the likelihood of transmission between clustered patients. None of the 252 foreign-born cases was recently infected (within 2 yr) in the city. Nineteen (17%) of 115 U. S.-born cases occurred after recent infection in the city; only two were infected by a foreign-born patient. Disease from recent infection in the city involved either a source or a secondary case with human immunodeficiency virus (HIV) infection, homelessness, or drug abuse. Failure to identify contacts accounted for the majority of secondary cases. In San Francisco, disease from recent transmission of M. tuberculosis has been virtually eliminated from the foreign-born but not from the U.S.-born population. An intensification of contact tracing and screening activities among HIV-infected, homeless, and drug-abusing persons is needed to further control tuberculosis in the U.S.-born population. Elimination of tuberculosis in both the foreign-born and the U.S. -born populations will require widespread use of preventive therapy.

Purified protein derivative testing and tuberculosis preventive therapy for HIV-infected patients in New York City

OBJECTIVE

To determine whether Centers for Disease Control and Prevention recommendations for purified protein derivative (PPD) testing and tuberculosis (TB) preventive therapy for PPD-positive patients are implemented in HIV clinics.

DESIGN

Retrospective medical chart review.

SETTING

Ten hospital-based HIV clinics in New York City.

PARTICIPANTS

A total of 2397 patients with a first clinic visit in 1995.

OUTCOME MEASURES

PPD testing of eligible patients, and recommendation of preventive therapy and completion of regimen in PPD-positive patients.

METHOD

Outpatient medical records were abstracted for TB history, PPD testing, TB preventive therapy, and patient demographic, social and clinical characteristics. Multivariate analyses were performed using logistic regression.

RESULTS

Of 1342 patients with an indication for a PPD test, 865 (64%) were PPD tested in the clinic and 757 (88%) returned to have it read. Factors strongly associated with PPD testing in the clinic were number of visits, same sex behavior with men, and CD4+ lymphocyte count above 200 x 10(6)/l. Preventive therapy was recommended for 80% of newly identified PPD-positive patients and 22% of previously identified PPD-positive patients. Of 119 patients on preventive therapy in the clinic, 49 (41%) completed the regimen, 50 (42%) were lost to follow-up, and 20 (17%) discontinued therapy or their status could not be determined.

CONCLUSION

A significant number of missed opportunities to implement TB prevention practices were identified in HIV clinics. Focused attention in HIV clinics, and increased collaboration between HIV clinics and TB control programs may be needed to increase adherence to prevention guidelines.

Oxygen toxicity in mouse lung: pathways to cell death

Mice exposed to 100% O2 die after 3 or 4 d with diffuse alveolar damage and alveolar edema. Extensive cell death is evident by electron microscopy in the alveolar septa, affecting both endothelial and epithelial cells. The damaged cells show features of both apoptosis (condensation and margination of chromatin) and necrosis (disruption of the plasma membrane). The electrophoretic pattern of lung DNA indicates both internucleosomal fragmentation, characteristic of apoptosis, and overall degradation, characteristic of necrosis. Hyperoxia induces a marked increase in RNA or protein levels of p53, bax, bcl-x, and Fas, which are known to be expressed in certain types of apoptosis. However, we did not detect an increased activity of proteases belonging to the apoptosis "executioner" machinery, such as CPP32 (caspase 3), ICE (caspase 1), or cathepsin D. Furthermore, administration of an ICE-like protease inhibitor did not significantly enhance the resistance to oxygen. Additionally, neither p53-deficient mice nor lpr mice (Fas null) manifested an increased resistance to hyperoxia-induced lung damage. These results show that both necrosis and apoptosis contribute to cell death during hyperoxia. Multiple apoptotic pathways seem to be involved in this, and an antiapoptotic strategy does not attenuate alveolar damage.