Can Primary Care Drive Tuberculosis Elimination? Increasing Latent Tuberculosis Infection Testing and Treatment Initiation at a Community Health Center with a Large Non-U.S.-born Population.

Community health centers (CHC) play a key role in latent tuberculosis infection (LTBI) testing and treatment. We performed a retrospective analysis of LTBI testing and treatment among pediatric and adult patients at a CHC with a large non-U.S.-born (USB) population during a series of quality improvement (QI) interventions from 2010 to 2019. Among 124,695 patients with primary care visits, 40% of patients were tested for tuberculosis (TB) infection and among those tested, 20% tested positive, including 39% of adults aged 50-79 years. Compared to adults aged 18-49 years, children aged 6-17 had increased odds of LTBI testing and treatment initiation [odds ratio and 95% confidence interval 3.23 (3.10, 3.36) and 1.41 (1.12, 1.79), respectively], while age ≥ 65 was associated with lower odds of both testing and treatment initiation. Over the analysis period, coinciding with unfunded QI interventions intended to reduce barriers to LTBI care, there was a significant increase in the proportion of patients receiving LTBI testing for both adults (6% to 47%, p < 0.001) and children (23% to 80%, p < 0.001). During the analysis period, there was also a significant increase in the proportion of patients receiving prescriptions for LTBI treatment, as well as provider use of evidence-based strategies including rifamycin-based treatment. Our study suggests that primary care interventions can reduce barriers to LTBI treatment and drive TB elimination.

Association of Tumor Necrosis Factor α Inhibitor Use with Diagnostic Features and Mortality of Tuberculosis in the United States, 2010-2017.

BACKGROUND: An elevated risk of tuberculosis (TB) disease in persons who have received tumor necrosis factor alpha inhibitor medications (TNF-α inhibitors) has been reported for nearly two decades, but clinical diagnostic features and outcomes of TB in this population remain poorly described. METHODS: We analyzed national surveillance data for TB cases among persons aged 15 years and older reported in the United States during 2010-2017 and associated mortality data reported through 2019 to describe the clinical characteristics of those receiving TNF-α inhibitors. RESULTS: Of 70 129 TB cases analyzed, 504 (0.7%) of the patients had TNF-α inhibitor use reported at TB diagnosis. Patients with TNF-α inhibitor use at TB diagnosis were more likely than TB patients not receiving TNF-α inhibitors to have TB diagnosed in extrapulmonary sites in conjunction with pulmonary sites (28.8% vs 10.0%, P < .001). Patients receiving TNF-α inhibitors were less likely to have acid-fast bacilli noted on sputum smear microscopy (25.6% vs 39.1%, P = .04), and more likely to have drug-resistant disease (13.5% vs 10.0%, P < .001). TB-attributed deaths did not significantly differ between patients receiving and not receiving TNF-α inhibitors (adjusted odds ratio, 1.46 [95% confidence interval, .95-2.26]). CONCLUSIONS: Clinicians evaluating TNF-α inhibitor-treated patients should have a high index of suspicion for TB and be aware that extrapulmonary or sputum smear-negative TB disease is more common in these patients. No significantly diminished survival of TB patients treated with TNF-α inhibitor therapy before TB diagnosis was noted.