Stigma and Therapy Completion for Latent Tuberculosis among Haitian-origin Patients

A prospective cohort study of LTBI treatment conducted within the Haitian population of South Florida investigated the predictive association between illness-related stigma among patients near the beginning of treatment and completion of preventive therapy. Factors associated with perceived stigma were also investigated. Ninety patients from Broward and Palm Beach counties were administered a questionnaire that included items related to illness history, perceptions and understanding of latent tuberculosis, and a 25-item stigma scale adapted from previously developed measures of tuberculosis-related stigma. Therapy completion was determined through a follow-up chart review. Data analyses compared patients who completed therapy with those who defaulted on a number of variables including perceived stigma. No association was found between perceived stigma or demographic characteristics and adherence to preventive therapy. Perceived stigma was associated with patient report of illness-related distress and was higher among patients who were lost to follow up. Some evidence suggested that stigma was higher among contacts of cases, patients with limited understanding of the condition, and patients who were more closely monitored during treatment. Case management should focus on patient-centered approaches to education and counseling about LTBI that address patient understanding of the condition and concerns about its physical and psychosocial effects

Tuberculosis Screening and Treatment of Latent Tuberculosis Infection among International College Students

Tuberculosis (TB) remains in the crosshairs of many public health policies worldwide that are taking aim at eradicating this potentially curable and preventable illness. Although tuberculosis (TB) incidence has been declining in the United States for over a decade, it still remains a serious public health concern. Currently, there is no public health policy that requires the screening of non-immigrant international university students visiting the United States. Given the rising numbers of visiting international students, this population has come under scrutiny as potential vectors of transmission of TB into the United States. Foreign-born persons from countries with consistently elevated TB prevalence rates constitute an important high risk group for both TB exposure and infection in this setting. Although some universities have their own public health protocols, not all universities have a policy of screening international, non-immigrant students for TB. To further investigate the situation, we reviewed the medical charts of international students visiting the University of Florida. Students who visited the health department for evaluation of TB skin tests from January1998 to February 2002 were studied. Of the students with a positive tuberculin test (skin test \u3e10mm induration), 97.6% had normal chest radiographs. Only 31 students (10.8%) agreed to undergo treatment for latent TB infection (LTBI), of which only half completed a six to nine month course and 86.8% were lost to follow-up. To attempt complete eradication of TB from the United States, universities with at-risk populations should consider the implementation of strict guidelines and well defined policies for the screening, follow-up and treatment of active and latent TB in international students

Health care workers' recommendations for strengthening tuberculosis infection control in the Dominican Republic

Objective. To describe health care workers' practical recommendations for strengthening adherence to Mycobacterium tuberculosis infection control practices in their health institutions and elsewhere across the Dominican Republic. Methods. In this qualitative study, 10 focus groups, with a total of 40 clinicians (24 physicians, 16 nurses), were conducted in 2016 at two tertiary-level institutions in the Dominican Republic. Grounded theory guided the analysis to expand on health care workers' recommendations for empowering clinicians to adhere to M. tuberculosis infection control practices. To ensure reliability and validity, the authors analyzed data and incorporated both peer debriefing with qualitative experts and participant feedback or validation on the final themes. Results. Six emerging themes were described: 1) education and training; 2) administrative policy; 3) infrastructure policy; 4) economic allocations; 5) research; and 6) public health policy. Conclusions. Future efforts may combine the health care workers' recommendations with evidence-based strategies in M. tuberculosis infection control in low-resource settings. This could pave the way for interventions that empower health care workers in their application of M. tuberculosis infection control measures in clinical practice

Management and diagnosis of tuberculosis in solid organ transplant candidates and recipients: Expert survey and updated review,

Background: Optimal screening and management of latent tuberculosis infection (LTBI) and active tuberculosis (TB) in solid organ transplant (SOT) candidates and recipients is necessary to prevent morbidity and mortality.Methods: We conducted a cross-sectional survey of TB and transplant experts across the United States reviewing the clinical practice preferences on key management issues related to LTBI and TB in SOT candidates and recipients.Results: Thirty TB and 13 SOT experts were surveyed (response rate = 53.8%). Both groups agreed that tuberculin skin test (TST) and chest x-ray screening in SOT candidates was useful (78.6% and 84.6%, respectively). TST after SOT was not useful for most transplant experts and TB experts (0% vs. 32.1%, respectively), but both groups were split on usefulness of interferon gamma release assays (IGRA) in SOT recipients (42.9% TB experts vs. 46.2% SOT experts). Most experts recommend LTBI treatment prior to SOT if close monitoring is assured (82.1% TB experts vs. 76.9% transplant experts). LTBI treatment with isoniazid was preferred for patients on calcineurin inhibitors. Evaluation for suspected TB in SOT recipients varied, but most TB experts favored sputum testing (88.9%) whereas most transplant experts favored bronchoscopic testing (69.2%). Preferred TB treatment regimens in SOT recipients were similar to regimens recommended for immunocompetent patients.Conclusions: Most TB and transplant experts recommend evaluation and treatment for LTBI in SOT candidates. Liver transplant candidates, however, should only be treated if close monitoring can be assured and after consulting with a hepatologist. Practice preferences varied regarding the initial diagnostic approach for suspected TB in SOT recipients; however, most experts agreed that SOT recipients should receive similar treatments as immunocompetent patients. Keywords: Tuberculosis, Transplantation, Surve

Allelic Diversity of Clinical M. tuberculosis Complex Isolates in Florida, 2009–2013.

<p>Allelic Diversity of Clinical M. tuberculosis Complex Isolates in Florida, 2009–2013.</p

Spatiotemporal Clustering of <i>Mycobacterium tuberculosis</i> Complex Genotypes in Florida: Genetic Diversity Segregated by Country of Birth

<div><p>Background</p><p>Tuberculosis (TB) is caused by members of the <i>Mycobacterium tuberculosis</i> complex (MTBC). Although the MTBC is highly clonal, between-strain genetic diversity has been observed. In low TB incidence settings, immigration may facilitate the importation of MTBC strains with a potential to complicate TB control efforts.</p><p>Methods</p><p>We investigated the genetic diversity and spatiotemporal clustering of 2,510 MTBC strains isolated in Florida, United States, between 2009 and 2013 and genotyped using spoligotyping and 24-locus MIRU-VNTR. We mapped the genetic diversity to the centroid of patient residential zip codes using a geographic information system (GIS). We assessed transmission dynamics and the influence of immigration on genotype clustering using space-time permutation models adjusted for foreign-born population density and county-level HIV risk and multinomial models stratified by country of birth and timing of immigration in SaTScan.</p><p>Principal Findings</p><p>Among the 2,510 strains, 1,245 were reported among foreign-born persons; including 408 recent immigrants (<5 years). Strain allelic diversity (<i>h</i>) ranged from low to medium in most locations and was most diverse in urban centers where foreign-born population density was also high. Overall, 21.5% of cases among U.S.-born persons and 4.6% among foreign-born persons clustered genotypically and spatiotemporally and involved strains of the Haarlem family. One Haarlem space-time cluster identified in the mostly rural northern region of Florida included US/Canada-born individuals incarcerated at the time of diagnosis; two clusters in the mostly urban southern region of Florida were composed predominantly of foreign-born persons. Both groups had HIV prevalence above twenty percent.</p><p>Conclusions/Significance</p><p>Almost five percent of TB cases reported in Florida during 2009–2013 were potentially due to recent transmission. Improvements to TB screening practices among the prison population and recent immigrants are likely to impact TB control. Due to the monomorphic nature of available markers, whole genome sequencing is needed to conclusively delineate recent transmission events between U.S. and foreign-born persons.</p></div

Characteristics of Genotyped Tuberculosis Cases in Florida, 2009–2013.

<p>Characteristics of Genotyped Tuberculosis Cases in Florida, 2009–2013.</p

Optimal Testing Choice and Diagnostic Strategies for Latent Tuberculosis Infection Among US-Born People Living with Human Immunodeficiency Virus (HIV).

BackgroundIncreased risk of progression from latent tuberculosis infection (LTBI) to tuberculosis (TB) disease among people living with human immunodeficiency virus (HIV; PLWH) prioritizes them for LTBI testing and treatment. Studies comparing the performance of interferon gamma release assays (IGRAs) and the tuberculin skin test (TST) among PLWH are lacking.MethodsWe used Bayesian latent class analysis to estimate the prevalence of LTBI and diagnostic characteristics of the TST, QuantiFERON Gold In-Tube (QFT), and T.SPOT-TB (TSPOT) among a prospective, multicenter cohort of US-born PLWH ≥5 years old with valid results for all 3 LTBI tests using standard US cutoffs (≥5 mm TST, ≥0.35 IU/mL QFT, ≥8 spots TSPOT). We also explored the performance of varying LTBI test cutoffs.ResultsAmong 1510 PLWH (median CD4+ count 532 cells/mm3), estimated LTBI prevalence was 4.7%. TSPOT was significantly more specific (99.7%) and had a significantly higher positive predictive value (90.0%, PPV) than QFT (96.5% specificity, 50.7% PPV) and TST (96.8% specificity, 45.4% PPV). QFT was significantly more sensitive (72.2%) than TST (54.2%) and TSPOT (51.9%); negative predictive value of all tests was high (TST 97.7%, QFT 98.6%, TSPOT 97.6%). Even at the highest cutoffs evaluated (15 mm TST, ≥1.00 IU/mL QFT, ≥8 spots TSPOT), TST and QFT specificity was significantly lower than TSPOT.ConclusionsLTBI prevalence among this cohort of US-born PLWH was low compared to non-US born persons. TSPOT's higher PPV may make it preferable for testing US-born PLWH at low risk for TB exposure and with high CD4+ counts