Latent tuberculous infection in the United States and Canada: who completes treatment and why?

OBJECTIVES: To assess latent tuberculous infection (LTBI) treatment completion rates in a large prospective US/Canada multisite cohort and identify associated risk factors. METHODS: This prospective cohort study assessed factors associated with LTBI treatment completion through interviews with persons who initiated treatment at 12 sites. Interviews were conducted at treatment initiation and completion/cessation. Participants received usual care according to each clinic's procedure. Multivariable models were constructed based on stepwise assessment of potential predictors and interactions. RESULTS: Of 1515 participants initiating LTBI treatment, 1323 had information available on treatment completion; 617 (46.6%) completed treatment. Baseline predictors of completion included male sex, foreign birth, not thinking it would be a problem to take anti-tuberculosis medication, and having health insurance. Participants in stable housing who received monthly appointment reminders were more likely to complete treatment than those without stable housing or without monthly reminders. End-of-treatment predictors of non-completion included severe symptoms and the inconvenience of clinic/pharmacy schedules, barriers to care and changes of residence. Common reasons for treatment non-completion were patient concerns about tolerability/toxicity, appointment conflicts, low prioritization of TB, and forgetfulness. CONCLUSIONS: Less than half of treatment initiators completed treatment in our multisite study. Addressing tangible issues such as not having health insurance, toxicity concerns, and clinic accessibility could help to improve treatment completion rates.

Factors associated with identifying tuberculosis contacts.

SETTING: Little is known about why some tuberculosis (TB) patients identify few or even no contacts. OBJECTIVES: To describe patient perceptions of the contact investigation interview and determine potential factors associated with identifying TB contacts. DESIGN: A total of 13 focus groups were conducted: 10 groups with previously smear-positive pulmonary TB patients born in the United States or Mexico, and three with program staff to discuss attitudes toward and perceptions of the contact investigation interview. Patients were recruited into separate groups by country of birth and number of contacts identified. RESULTS: The data indicated that patients-even those who identified few contacts-overwhelmingly reported identifying contacts easily and willingly. Understanding the purpose of the contact investigation and seriousness of TB facilitated naming contacts, while miscommunication and misconceptions about TB hindered the process. Patients felt strongly about informing their contacts before the health department contacted them. Staff respondents reported that education and effective communication were critical during contact investigation interviewing. CONCLUSION: Data indicated that patients, including those identifying few contacts, reported wanting to name their contacts. However, misconceptions may affect their understanding of who their contacts are, and hence the quantity and quality of the contacts identified. These findings underscore the need for effective communication and education.

TB perspectives among a sample of Mexicans in the United States: results from an ethnographic study.

OBJECTIVE: A study was conducted to describe the sociocultural aspects of tuberculosis (TB) among Mexicans in the U.S. and to provide TB programs with practical recommendations for serving this population. METHODS: In-depth, structured, open-ended interviews were conducted with 50 persons from Mexico living in the U.S. Local bilingual, bicultural researchers conducted the interviews with respondents recruited from TB clinics and surrounding communities. Both qualitative and quantitative strategies were used to analyze the data. RESULTS: We found diverse TB perceptions and attitudes, but few were associated with specific participant characteristics. We detected widespread misperceptions about TB transmission and low perceptions of risk. Anticipated TB stigma among those with no history of disease was qualitatively greater than reported stigma among those who had TB disease. We also detected missed opportunities for TB education. Reported barriers to care included lack of transportation, limited clinic hours, cost of services, inconvenient clinic location, and communication problems with staff. CONCLUSIONS: To address the diverse needs of Mexican-born clients, we recommend that TB programs provide culturally-appropriate, patient-centered care. We suggest several strategies aimed at raising risk awareness and reducing stigma. Finally, we encourage programs to facilitate access by providing language-appropriate services, extending clinic hours, and facilitating transportation.

Outcomes of contact investigations of infectious tuberculosis patients.

The objective of this study was to describe outcomes of tuberculosis (TB) contact investigations, factors correlated with those outcomes, and current successes and ways to improve TB contact investigations. We abstracted clinic records of a representative U.S. urban sample of 1,080 pulmonary, sputum-smear(+) TB patients reported to CDC July 1996 through June 1997 and the cohort of their 6,225 close contacts. We found a median of four close contacts per patient. Fewer contacts were identified for homeless patients. A visit to the patient's residence resulted in two additional (especially child) contacts identified. Eighty-eight percent of eligible contacts received tuberculin skin tests (TSTs). Recording the last exposure date to the infectious patient facilitated follow-up TST provision. Thirty-six percent of contacts were TST(+). Household contacts and contacts to highly smear(+) or cavitary TB patients were most likely to be TST(+). Seventy-four percent of TST(+) contacts started treatment for latent TB infection (LTBI), of whom 56% completed. Sites using public health nurses (PHNs) started more high-risk TST(-) contacts on presumptive treatment for LTBI. Using directly observed treatment (DOT) increased the likelihood of treatment completion. We documented outcomes of contact investigation efforts by urban TB programs. We identified several successful practices, as well as suggestions for improvements, that will help TB programs target policies and procedures to enhance contact investigation effectiveness.