Challenges in LTBI care in the United States identified using a nationwide TB medical consultation database.

BACKGROUND: Identifying and treating individuals with latent TB infection (LTBI) represents a critical and challenging component of national TB elimination. Medical consultations by the Centers for Disease Control and Prevention (CDC) funded TB Centers of Excellence (COEs) are an important resource for healthcare professionals (HCPs) caring for individuals with LTBI. This study aimed to identify the most common clinical concerns regarding LTBI care and to describe epidemiologic and clinical features of patients discussed in these consultations. METHODS: This mixed-methods study randomly sampled 125 consultation inquiries related to LTBI from the COEs' medical consultation database in 2018. Text from consultation records were reviewed and coded to identify reasons for the inquiries and common epidemiologic and clinical patient characteristics. RESULTS: The most common topics of inquiry for consultation included accurate LTBI diagnosis (36%), management of LTBI treatment-related issues (22%), and choice of appropriate LTBI treatment regimen (17%). Patients for whom consultations were requested commonly had another medical condition (34%), were non-U.S. born (31%), were children (25%), and had a history of travel to TB-endemic areas (18%). CONCLUSION: Our findings emphasize the challenge of managing patients with either suspected or confirmed LTBI, highlighting the need for ongoing medical consultation support for nuanced clinical and epidemiologic scenarios.

CONTEXTE: L'identification et le traitement des personnes atteintes d'infection tuberculeuse latente (LTBI) sont des composantes essentielles et difficiles de la stratégie nationale d'élimination de la TB. Les consultations médicales des TB Centers of Excellence (COE), financés par les Centres pour le contrôle et la prévention des maladies (CDC), sont d'importantes ressources pour les professionnels de santé qui prennent en charge les personnes atteintes de LTBI. Cette étude avait pour objectif d'identifier les problèmes cliniques les plus fréquents en matière de prise en charge de la LTBI, et de décrire les caractéristiques épidémiologiques et cliniques des patients évoquées lors de ces consultations. MÉTHODES: Cette étude à méthodes mixtes a sélectionné de manière aléatoire 125 demandes de consultations relatives à la LTBI à partir de la base de données des consultations médicales du COE en 2018. Les notes des dossiers de consultation ont été revues et codées pour identifier les raisons des demandes, ainsi que les caractéristiques cliniques et épidémiologiques fréquentes des patients. RÉSULTATS: Les raisons les plus fréquentes de demandes de consultation étaient diagnostic précis de LTBI (36%), prise en charge des problèmes liés au traitement de la LTBI (22%) et choix d'un schéma thérapeutique approprié de la LTBI (17%). Les patients pour lesquels des consultations étaient demandées avaient fréquemment une autre pathologie (34%), n'étaient pas nés aux États-Unis (31%), étaient des enfants (25%) et avaient des antécédents de voyage dans des zones où la TB est endémique (18%). CONCLUSION: Nos résultats mettent l'accent sur les défis de la prise en charge des patients avec une LTBI présumée ou confirmée, soulignant le besoin d'aide continue aux consultations médicales pour des scénarios épidémiologiques et cliniques nuancés.

Multidrug-resistant tuberculosis care in the United States.

BACKGROUND: To examine the utilization of the Tuberculosis (TB) Centers of Excellence (COE) medical consultation service and evaluate how these services were being employed for patients in relation to multidrug-resistant TB (MDR-TB).METHODS: Medical consults are documented in a secure database. The database was queried for MDR-TB consultations over the period 1 January 2013-31 December 2017. All were analyzed to assess provider type, center, setting, year of call, and type of patient (pediatric vs. adult). A subgroup was randomly selected for thematic analysis.RESULTS: The centers received 1560 MDR-TB consultation requests over this period. Providers requesting consults were primarily physicians (55%). The majority of requests were from public health departments (64%) and for adult patients (80%). Four major topic areas emerged: 1) initial management of MDR-TB, 2) MDR-TB longitudinal treatment and complications, 3) management of persons exposed to MDR-TB, and 4) MDR-TB treatment completion.CONCLUSIONS: Analysis of these consultations provides insight into the type of expert advice about MDR-TB that was provided. These findings highlight topics where increased medical training and education may help to improve MDR-TB-related practices.

Resilience and extensively drug-resistant tuberculosis: the unlikely ally.

Despite recent advances and well-known treatment options, cure rates for resistant tuberculosis (TB) cases remain extraordinarily low. We present in first person the case of a patient who suffered from TB for over 7 years, and travelled to four countries in search of a cure. This experience shows how resistance patterns worsen under poor programme conditions and illustrates many of the obstacles faced by patients to obtain appropriate care: late diagnosis, lack of experienced care capacity and drug availability, and absence of psychosocial support during toxic and lengthy regimens. In addition to new tools, patient-centred systems are needed to tackle the drug-resistant TB epidemic.

Defining the research agenda to measure and reduce tuberculosis stigmas.

Crucial to finding and treating the 4 million tuberculosis (TB) patients currently missed by national TB programmes, TB stigma is receiving well-deserved and long-delayed attention at the global level. However, the ability to measure and evaluate the success of TB stigma-reduction efforts is limited by the need for additional tools. At a 2016 TB stigma-measurement meeting held in The Hague, The Netherlands, stigma experts discussed and proposed a research agenda around four themes: 1) drivers: what are the main drivers and domains of TB stigma(s)?; 2) consequences: how consequential are TB stigmas and how are negative impacts most felt?; 3) burden: what is the global prevalence and distribution of TB stigma(s) and what explains any variation? 4): intervention: what can be done to reduce the extent and impact of TB stigma(s)? Each theme was further subdivided into research topics to be addressed to move the agenda forward. These include greater clarity on what causes TB stigmas to emerge and thrive, the difficulty of measuring the complexity of stigma, and the improbability of a universal stigma 'cure'. Nevertheless, these challenges should not hinder investments in the measurement and reduction of TB stigma. We believe it is time to focus on how, and not whether, the global community should measure and reduce TB stigma.