House calls by community health workers and public health nurses to improve adherence to isoniazid monotherapy for latent tuberculosis infection: a retrospective study.

BACKGROUND: Patient adherence to isoniazid (INH) monotherapy for latent tuberculosis infection (LTBI) has been suboptimal despite its proven efficacy. Various strategies have been studied to improve adherence, but all have been based at a clinic or treatment program. At the Santa Clara Valley Tuberculosis Clinic, it was our practice to refer a subset of high-risk LTBI patients to the Public Health Department for monthly follow-up at home instead of at the clinic. Our goal was to assess whether house calls by community health workers and public health nurses affected INH adherence or frequency of adverse effects. METHODS: We retrospectively studied 3918 LTBI patients who received INH. At the discretion of the treating physician, 986 (25.2%) received house calls instead of clinic follow-up. Home-based follow-up included language translation, medication delivery, assessment of compliance with pill counts, monitoring for adverse effects, and active tracking of noncompliant patients. We assessed differences in patient characteristics, treatment completion, and reasons for treatment discontinuation between patients followed at home versus in the clinic. Multivariate analyses to address possible referral bias or confounding were performed using logistic regression. RESULTS: More patients followed with house calls completed INH treatment (90% home versus 73.2% clinic). This was the case across all subgroups of patients, including those with historically the lowest adherence: patients from correctional and rehabilitation facilities (77.8% home versus 46.9% clinic), postpartum women (86.4% home versus 55.6% clinic), and patients aged between 18 and 35 years (87% home versus 63.1% clinic). After adjusting for age, place of birth, referral category (TB contacts/skin test converters, correctional/rehabilitation patients, postpartum women, tuberculin positive patients from other screening), and prescribed INH regimen duration (9 versus 6 months), home-based follow-up of LTBI patients was a significant predictor of treatment completion (AOR 2.94, 95% CI: 2.33, 3.71). Patients followed at home were 21% more likely to complete therapy (ARR 1.21, p<0.001). Risk of adverse effects was similar between the two types of follow-up. CONCLUSION: Home-based follow-up of LTBI patients taking isoniazid was associated with improved treatment completion and no increase in adverse effects regardless of patient characteristics or prescribed duration of INH therapy.

Active and latent tuberculosis in patients with systemic lupus erythematosus living in the United States.

BACKGROUND: The prevalence and clinical course of tuberculosis infection have not been well described in patients with systemic lupus erythematosus (SLE) in the United States. OBJECTIVE: This study documents the demographic, clinical, and laboratory characteristics and outcomes of patients with SLE and latent tuberculosis infection (LTBI) or active TB in an ethnically diverse clinic. METHODS: We conducted a retrospective review of clinical records of patients with SLE followed during 2005 in a county community hospital rheumatology clinic, with a large immigrant population. Clinical characteristics were analyzed according to the patients' ethnicity, tuberculin skin test (TST) results, and history of treatment for latent or active TB. RESULTS: Data regarding a history of active TB or TST status were available for 187 of 220 patients seen in 2005 (85%). The prevalence of TB infection was highest in patients from TB endemic areas. Fourteen patients (7%) had active TB and 33 patients (18%) had LTBI. Among the 6 patients who developed active TB after the onset of SLE, 2 had pulmonary, 1 had extrapulmonary, and 3 had disseminated TB. Laboratory features and treatment regimens for SLE were similar in patients with a history of TB infection and in patients with a negative TST. CONCLUSIONS: A significant number of patients with SLE in a county clinic population in the United States had LTBI or TB. Treatment of active TB and latent TB yielded good outcomes with no deaths. US clinicians should consider screening SLE patients for LTBI, especially those from TB endemic areas.

Peripheral tuberculous lymphadenitis: epidemiology, diagnosis, treatment, and outcome.

We reviewed 106 patients referred to our institution for treatment of peripheral tuberculous adenitis to establish the epidemiologic, clinical, and pathologic manifestations of this disease. Tuberculous lymphadenitis occurred predominantly in young, foreign-born women a mean of 5 years after arrival in the United States. Tuberculin skin tests were positive in 94% of cases. Lymphadenopathy occurred most frequently in the neck (57%) or supraclavicular area (26%) and involved 1-3 nodes. Forty (38%) patients had an abnormal chest radiograph consistent with granulomatous infection. Culture-positive pulmonary tuberculosis was diagnosed in 41% of those patients with abnormal chest radiographs. Fine needle aspiration was an essential step in the evaluation and diagnosis of tuberculous lymphadenitis. Granulomas were seen in 61% of fine needle aspirates and 88% of surgical biopsies. Positive cultures for Mycobacterium tuberculosis were obtained from 62% of fine needle aspirate samples and 71% of excisional biopsies. The presence of necrosis and/or neutrophilic inflammation in tissue samples correlated with culture positivity. Given the high yield of positive cultures from fine needle aspirates, surgery was rarely indicated as an initial step in immunocompetent adults. In this cohort, 101 patients received a final diagnosis of peripheral tuberculous lymphadenitis. Eighty-two percent received their entire therapy under direct observation, and response to antituberculous therapy was uniformly successful. Paradoxical expansion of adenopathy was seen in 20% of all patients and was more commonly noted in human immunodeficiency virus-seropositive patients. We present a diagnostic algorithm based on our experience.

Decreasing intestinal parasites in recent Northern California refugees.

Beginning in 2005, the Centers for Disease Control and Prevention (CDC) expanded the overseas presumptive treatment of intestinal parasites with albendazole to include refugees from the Middle East. We surveyed the prevalence of helminths and protozoa in recent Middle Eastern refugees (2008-2010) in comparison with refugees from other geographical regions and from a previous survey (2001-2004) in Santa Clara County, California. Based on stool microscopy, helminth infections decreased, particularly in Middle Eastern refugees (0.1% versus 2.3% 2001-2004, P = 0.01). Among all refugees, Giardia intestinalis was the most common protozoan found. Protozoa infections also decreased somewhat in Middle Eastern refugees (7.2%, 2008-2010 versus 12.9%, 2001-2004, P = 0.08). Serology for Strongyloides stercoralis and Schistosoma spp. identified more infected individuals than stool exams. Helminth infections are increasingly rare in refugees to Northern California. Routine screening stool microscopy may be unnecessary in all refugees.

Ebola hemorrhagic fever in the era of bioterrorism.

Viral hemorrhagic fevers are among a small group of infectious diseases considered potential candidates for use as agents of bioterrorism. Ebola hemorrhagic fever, the focus of this article, has the highest mortality rate of the viral hemorrhagic fevers and has no effective treatment. It is transmitted easily to family members and health care professionals not following universal precautions. The history of this infection, its clinical presentation, and epidemiology are discussed. Attention is paid to the immunopathogenesis of the disease with a focus on pulmonary involvement. Recommendations for infection control and Ebola virus' potential as a bioterrorism agent are addressed.