ABSTRACT
Background. Understanding barriers and facilitators to latent tuberculosis infection (LTBI) diagnosis and care is needed to successfully treat children/adolescents with LTBI in the US. We explored physicians' perspectives on pediatric LTBI diagnosis and care, and strategies to improve care. Methods. We conducted a convergent mixedmethods study with physicians in Massachusetts. Participants were purposefully sampled from primary care clinics (n=10), clinics seeing immunocompromised patients (n=2), and TB clinics (n=2). Physicians participated in individual qualitative semi-structured interviews exploring experience and comfort with LTBI care, and perceived barriers and facilitators to care. We used applied thematic analysis to analyze transcripts. Participants completed surveys to assess comfort with LTBI care and volume of LTBI patients in their care. Results. Of the 25 physicians invited, 14 participated. Most participants reported 'medium' or 'high' comfort with current LTBI guidelines;volume of LTBI care varied by physician type (Table 1). Analysis revealed perceived barriers (Figure 1) at four steps of care: 1) identification of risk and testing for LTBI (e.g., family/patient risk perception, physician knowledge gaps), 2) completion of referral after a positive test (e.g., communication barriers), 3) treatment acceptance and initiation (e.g., lack of social support), and 4) treatment adherence and completion (e.g., adolescents' emerging autonomy). Facilitators such as protocolized screening, counseling strategies, free medication, and telehealth (Figure 2) overcame some barriers. Important emergent themes included: 1) COVID-19 has induced rapid positive and negative changes in LTBI care in primary care clinics;2) immigrant adolescents are uniquely at risk for disengagement due to lack of social support;and 3) physicians and clinics are ill-equipped to provide TB care for patients' close contacts, despite knowledge of need for care. (Table Presented) Conclusion. Lack of perceived risk, family and clinic resource constraints, and accessibility challenges hindered LTBI care;protocolized screening, telehealth, and free medications were among the facilitators that overcame some but not all barriers. These results will inform improvement of LTBI care within and between clinics.
ABSTRACT
Background. The American Academy of Pediatrics recommends tuberculin skin tests (TSTs) or interferon gamma release assays (IGRAs) to test for tuberculosis (TB) infection in children ≥2 years old, and prioritizes IGRA testing in Bacille Calmette-Guerin vaccine recipients due to cross-reactivity. TSTs require a return visit, which frequently results in loss to follow up. Growing evidence supports accuracy of IGRA testing in pediatric patients, including young children, leading to calls for preferential use of IGRA over TST. We sought to evaluate trends in IGRA use in children over time. Methods. We identified all TB infection tests conducted in children 5-17 years old at 2 academic medical systems in Boston from October 2015-January 2021. TSTs were identified using medication administration records, and IGRAs were identified using laboratory records. We computed the proportion of tests per month that were IGRA and TST. We used Pearson correlation to determine the association between month of testing and proportion of tests that were IGRAs. Results. 21,471 TB infection tests were obtained from 16,778 patients during our timeframe. Median age of testing was 13.4 years (IQR 9.2 - 16.2 years). During the study period, there was a significant increase in the monthly proportion of TB infection tests that were IGRAs (Pearson correlation coefficient 0.92, P < 0.001). The total number of tests performed per month also increased, with seasonal increases in testing in late summer and early fall and a substantial decline in testing early in the COVID-19 pandemic. Tuberculosis infection tests and proportion IGRA. Total number of tuberculosis infection tests per month and proportion of tests that were interferon gamma release assays, from October 2015 - January 2021. Conclusion. Use of IGRAs among patients age 5-17 years of age increased significantly overall and compared to TST in two large Boston healthcare systems over a 5-year period. These results suggest a shift towards blood-based TB infection testing in a low-burden setting, which may improve completion of the pediatric TB infection care cascade. Future research is needed to determine reasons for changing testing modalities, and similar patterns in other settings.