Cultural case management of latent tuberculosis infection.

SETTING: The proportion of tuberculosis (TB) among foreign-born individuals in the United States is steadily increasing. Treatment of latent TB infection can prevent future cases of disease, although generally only 60% of patients who start a 6-month regimen of isoniazid complete therapy. OBJECTIVE: Cultural case management--employing case manager cultural mediators who serve patient-defined needs in addition to performing TB control functions--may improve results of testing and treatment in one high-risk group, new refugees. DESIGN: A cultural case management approach was established for finding and treating latent TB infection among three groups of new refugees: from the former Soviet Union (FSU), former Yugoslavia (FY), and Somalia. RESULTS: From July 1999 through December 2000, treatment was offered to 442 refugees, of whom 389 (88%) started and 319 (82%) completed therapy. The completion rate among starters from the FSU was 76%, for those from FY it was 94% and for those from Somalia it was 88%. Among all refugees to whom treatment was offered, 319/442 (72%) completed therapy. CONCLUSION: Cultural case management may be a useful tool for expanding treatment of latent TB infection among foreign-born individuals.

A high tuberculosis case-fatality rate in a setting of effective tuberculosis control: implications for acceptable treatment success rates.

Worldwide, the case-fatality rate of smear-positive pulmonary tuberculosis among persons on treatment is 3.8%. We assessed the case-fatality rate among such patients in Baltimore between January 1993 and June 1998. Tuberculosis incidence was < 17/100 000 population, and 99% of patients received directly observed therapy. Of 174 patients, 42 (24%) died on treatment. Patients who died were older (mean age 62 vs. 47 years; P < 0.001) and were more likely to have underlying medical conditions. In multivariate analyses, older age, diabetes mellitus, and renal failure were independently associated with an increased risk of death. With effective control, tuberculosis may become concentrated in older persons with chronic diseases and be associated with high case-fatality rates. In such settings, acceptable treatment success rates may need to be revised.

Modeling the epidemiology and economics of directly observed therapy in Baltimore.

SETTING: From 1958 to 1978, Baltimore maintained one of the highest pulmonary tuberculosis (TB) rates in the US. But, from 1978 to 1992 its TB rate declined by 64.3% and its ranking for TB fell from second highest among large US cites to twenty-eighth. This TB trend coincided with the implementation of an aggressive directly observed therapy (DOT) program by Baltimore's Health Department. OBJECTIVES: We used modeling to estimate the range of TB cases prevented in Baltimore under DOT. Case estimates equal the difference between the observed number of TB cases in Baltimore versus the expected number if Baltimore's TB trend was replaced by the TB trend for the US (low estimate) or the TB trend for all US cities with over 250,000 residents (high estimate). Economic savings are estimated. RESULTS: Without DOT we estimate there would have been between 1,577 (53.6%) and 2,233 (75.9%) more TB cases in Baltimore, costing $18.8 million to $27.1 million. Cases prevented and expenditures saved increased with increased DOT participation. CONCLUSION: Our model predicts that Baltimore's TB decline accompanying DOT resulted in health care savings equal to twice the city's total TB control budget for this period. These results are most plausibly due to DOT, since it was the only major change in Baltimore's TB control program, and rising TB risk factors-AIDS, injection drug use, poverty-in a city where TB had been epidemic should have triggered a TB increase as in comparable US cities, rather than the observed decline. As national TB rates continue to decline it will be important to identify ways to capture and reinvest these savings to support effective TB control programs.

Directly observed therapy for treatment completion of pulmonary tuberculosis: Consensus Statement of the Public Health Tuberculosis Guidelines Panel.

OBJECTIVE: To evaluate evidence on the relative effectiveness of directly observed therapy in achieving treatment completion for pulmonary tuberculosis. PARTICIPANTS: A panel of 11 practitioners representing the public health, behavioral, and clinical management of tuberculosis was convened by the Council on Linkages Between Academia and Public Health Practice in 1995 to develop public health guidelines for tuberculosis treatment completion. EVIDENCE: English-language articles identified through MEDLINE (1966 to August 1, 1996) with original data on directly observed therapy, supervised therapy, compliance, treatment completion, case management, and treatment adherence for tuberculosis. CONSENSUS PROCESS: Each eligible article underwent structured review by at least 2 panel members for study design, sample size, evaluation methods, and treatment completion as the primary outcome. The full panel was convened twice, with intercurrent small group meetings, conference calls, and summary workshop to review findings. Recommendations made through this process were drafted by the panel chair and circulated twice for additional panel comments. CONCLUSIONS: Treatment completion rates for pulmonary tuberculosis are most likely to exceed 90%, as recommended by the Centers for Disease Control and Prevention, when treatment is based on a patient-centered approach using directly observed therapy with multiple enablers and enhancers. Other less intensive interventions, including nonsupervised strategies and modified approaches to directly observed therapy, are unlikely to achieve this recommended treatment completion goal. Directly observed therapy also appears to be cost-effective compared with self-administered therapy, although data on cost-effectiveness are limited.

The Baltimore City Health Department program of directly observed therapy for tuberculosis.

To address the vexing problem of treatment completion for tuberculosis patients, the Baltimore City Health Department (BCHD) in 1981 implemented a community outreach strategy employing directly observed therapy (DOT). By 1995, the incidence of tuberculosis in Baltimore had declined 61.7%. This BCHD program has reduced the need for patient incentives by providing nearly 90% of all DOT at either the patient's home, workplace or school; or drug treatment facility, city jail, or nursing home. Today, the proportion of all TB cases in Baltimore receiving DOT through the program approaches 90%, treatment completion rates exceed 90%, sputum-conversion rates among DOT-managed cases are nearly double the rates of privately treated cases, and drug resistant organisms remain rare (0.57% of all isolates, 1989-1993). This article describes the interworkings of this community-based program.

Case characteristics and trends in pediatric tuberculosis, Maryland, 1986-1993.

OBJECTIVE: To identify case characteristics and trends in the incidence of pediatric tuberculosis (TB) in Maryland during the national resurgence of the disease. METHODS: The authors conducted a retrospective review of the 248 cases of TB in children ages 19 and younger reported to the state registry between 1986 and 1993. RESULTS: The incidence of pediatric TB in Maryland, while showing a downward trend between 1986 and 1993, was characterized by a bimodal pattern, with one peak in children younger than age 5 and another peak in adolescents. Certain case characteristics differed significantly according to age: adolescents with TB were more likely to have positive AFB smears, positive cultures, and cavitary X-rays than children in the 0-4 age group. On the other hand, PPD results did not differ significantly by age. Children with TB came from households in zip code areas for which the median family income was lower and the rate of unemployment was higher than comparable statewide figures. CONCLUSIONS: Study findings indicate that (a) the general decline in adult TB in Maryland was accompanied by a decline among children; (b) age-specific case characteristics continue to be useful in clinical decision making for children with suspected TB; and (c) a state TB registry may prove useful not only in tracking disease trends and monitoring statewide control efforts but also in confirming case characteristics, all of which are important disease control issues in a time of fiscal downsizing.

Sexually transmitted disease control in the era of managed care: "magic bullet" or "shadow on the land"?

Sexually transmitted diseases (STDs) are a major public health problem. In the United States, nearly 12 million STD infections occur annually, generating estimated direct annual health care costs exceeding $12 billion. Lifetime costs may total $88 billion. Meanwhile, inflation-adjusted public funding for STD clinical care and control decreased over the past two decades. Previous STD control officials warned that declining support for STD control programs would result in program elimination and increased rates of STDs ("Brown's Law"). Effective public health and primary prevention efforts have been difficult to implement because of societal sensitivities about sexuality, and the curative rather than preventive focus of our health care system. Proven cost-effective medical interventions, such as chlamydia screening, have not been universally implemented because of health care system inefficiencies, whereby public STD clinical services generate private sector savings not reinvested into these public prevention programs. However, the dramatic growth in managed care presents opportunities, as well as risks, for better STD management.

Cost-effectiveness of directly observed versus self-administered therapy for tuberculosis.

Decision analysis was used to compare three alternative strategies for a 6-mo course of treatment for tuberculosis: directly observed drug therapy (DOT), self-administered fixed-dose combination drug therapy, and self-administered conventional individual drug therapy. Estimates of effectiveness were obtained from the published literature. Estimates of costs were obtained from the literature and the Baltimore City Health Department. Both DOT and fixed-dose combination therapy were less costly and more effective than conventional therapy, although DOT was most cost-effective. In total, the average cost per patient treated was $13,925 for DOT, $13,959 for fixed-dose combination therapy, and $15,003 for conventional therapy. Per 1,000 patients treated, 31 relapses and three deaths could be expected for DOT, 96 relapses and eight deaths for fixed-dose combination therapy, and 133 relapses and 13 deaths for conventional therapy. The marginal cost-effectiveness of DOT relative to fixed-dose combination therapy was most sensitive to variability in the direct cost of DOT and less sensitive to relapse rates for DOT and fixed-dose combination therapy. The inferior cost-effectiveness of conventional therapy was not sensitive to plausible variability in cost or effectiveness. Both DOT and fixed-dose combination therapy were cost-effective relative to conventional therapy, although DOT is probably most cost-effective.

Eleven years of community-based directly observed therapy for tuberculosis.

OBJECTIVE: To evaluate community-based directly observed therapy (DOT) for tuberculosis (TB) control. DESIGN: Ecological study. METHODS: Three comparisons were made in this descriptive study. (1) An 11-year retrospective comparison of TB case rates, sputum conversion rates (SCRs), rates of therapy completion, and confounding factors (acquired immunodeficiency syndrome [AIDS], immigration, unemployment, and poverty) in Baltimore, Md, with those of the five major US cities having the highest TB incidence in 1981 but which did not have comprehensive DOT programs. (2) An 11-year trend of TB in Baltimore and the 19 major US cities with the highest TB incidence in 1981. (3) A 7-year trend in TB in both city groups between 1985 and 1992. SETTING: Twenty US metropolitan cities with more than 250,000 residents. RESULTS: Since 1981, Baltimore experienced the greatest decline in TB incidence (35.6 cases per 100,000 population, 1981; 17.2 cases per 100,000 population, 1992 [-51.7%]), and city rank for TB (sixth in 1981, 28th in 1992). Conversely, the average incidence of TB increased 2.1% in the five-city cohort and increased 1.8% in the 19-city cohort. Since 1985, TB incidence increased 35.3% in the five-city cohort and 28.5% in the 19-city cohort, but declined 29.5% in Baltimore. From 1986 through 1992, Baltimore's DOT-managed cases had the highest annual SCRs at 3 months (mean, 90.7%), and the highest completion rates for standard anti-TB therapy (mean, 90.1%) when compared with the five cities. These trends could not be attributed to differentials in AIDS, immigration, poverty, or unemployment. Increasingly, more Baltimore cases were treated under DOT (86.5%, 1993) over time. Disease relapse rates remained low, even among HIV-infected patients. Within Baltimore, the documented SCR was significantly higher among DOT-managed cases compared with non-DOT-managed cases (P < .05); multidrug resistance remains rare (0.57%). Within Maryland, Baltimore accounted for 44.4% of all TB cases in 1981, compared with 28.7% in 1992 (P < .001). CONCLUSIONS: In contrast to the national TB upswing during the 1980s, Baltimore experienced a substantial decline in TB following implementation of community-based DOT, despite highly prevalent medicosocial risk factors. Directly observed therapy facilitated high treatment completion rates and bacteriologic evidence of cure. Directly observed therapy could help reduce TB incidence in the United States, particularly in cities with high case rates.

Effectiveness of supervised, intermittent therapy for tuberculosis in HIV-infected patients.

OBJECTIVE: To evaluate the effectiveness of supervised therapy for tuberculosis (TB) in patients with HIV infection. DESIGN: Retrospective, chart review. PATIENTS: Patients with TB and HIV infection. SETTING: Urban, public TB clinic. MAIN MEASURES AND RESULTS: A total of 107 patients with TB and HIV infection were studied. Most were men (78%), African American (91%), uninsured or on Medicaid (88%), and 67% were injecting drug users. TB was diagnosed before AIDS in 31% of subjects, at the time of AIDS in 32%, and after AIDS in 37%. Clinical features varied by stage of HIV disease. Sixteen patients received no therapy and died before TB was diagnosed, 10 died during the first 8 weeks of treatment. Seventy-eight patients received > 8 weeks therapy, of whom 48 (62%) were given directly observed therapy twice weekly and 30 (38%) received self-administered daily therapy. Patients who received directly observed therapy were more likely to complete 6 months of therapy (96 versus 76%, P = 0.02) and more likely to survive after therapy ended (85 versus 57%, P = 0.01). By logistic regression, directly observed therapy, AIDS diagnosed before TB, and age were significantly associated with survival outcome. CONCLUSION: Directly observed therapy for TB in patients with HIV infection is highly effective and associated with better adherence to therapy and survival.

Preventive health care in six countries: models for reform?

International systems are frequently offered as models for health care reform. This study, focusing on preventive services for children and pregnant women in six industrialized countries, finds that a broad range of preventive services can be provided through health care systems with divergent financing and cost containment, utilizing multiple entry points into the health care system, and employing targeted programs for high-risk patients. Despite variability in form and financing, health outcomes are not compromised, suggesting that health care reformers in this country need not be restricted to any single model to strengthen preventive health care for children and pregnant women.

Serodiagnosis of visceral leishmaniasis in an American Peace Corps volunteer.

A case of visceral leishmaniasis in a young American Peace Corps volunteer is reported. Both clinical and epidemiologic evidence strongly supported the diagnosis; however, hepatic and splenic aspirates for the causative organism were negative. The diagnosis was eventually confirmed through serology, employing indirect immunofluorescence and complement fixation testing of serum. The patient clinically responded dramatically to sodium stibogluconate, the drug of choice for the treatment of visceral leishmaniasis. This case is significant because it alerts the physician to an unusual cause of fever of unknown origin in residents of the Western nations and demonstrates the potential usefulness of serology in diagnosing visceral leishmaniasis when the infecting organism cannot be isolated.