Abstract
Latent tuberculosis infection (LTBI) treatment in persons at increased risk of disease progression is a key strategy with the strong potential to increase rate of tuberculosis (TB) decline in the United States. However, LTBI treatment in homeless persons, a population at high-risk of active TB disease, is usually associated with poor adherence. We describe the impact of using directly observed treatment (DOT) versus self-administered treatments (SAT) as an adherence-improving intervention to administer four months of daily rifampin regimen for LTBI treatment among homeless adults in Atlanta. Retrospective analysis of clinical care data on 274 homeless persons who initiated daily rifampin treatment for LTBI treatment at a county health department between January 2014 and December 2016 was performed. To reduce bias from non-random assignment of treatment, an inverse probability of treatment weighted (IPTW) logistic regression model was used to assess the effect of treatment type on treatment completion. Subgroup analyses were performed to assess heterogeneity of treatment effect on LTBI completion. Of 274 LTBI treatment initiators, 177 (65%) completed treatment [DOT 118/181 (65%), SAT 59/93 (63%)]. In the fully adjusted and weighted analysis, the odds of completing LTBI treatment on DOT was 40% higher than the odds of completing treatment by SAT [adjusted odds ratio (95% CI), aOR: 1.40 (1.07, 1.82), p = 0.014]. The unstable nature of homeless persons’ lifestyle makes LTBI treatment difficult for many reasons. Our study lends support to the use of DOT to improve LTBI treatment completion among subgroups of homeless persons on treatment with daily rifampin.
Highlights
Tuberculosis (TB) is one of the top ten leading causes of death globally.[1]
Homeless persons with positive QFT or TST who presented at the TB clinic for evaluation were clinically assessed to exclude active TB disease and those diagnosed with untreated latent TB infection (LTBI) were offered preventive treatment with either four months of rifampin (4R) or three months of RifapentineIsoniazid (3HP) ((if they had lower than 2 weeks of consistent homeless shelter stay). [22]
777 (84%) presented at the TB clinic for clinical evaluation and 149 persons did not follow up for evaluation. Eight persons among those who attended the referral appointment did not complete the evaluation process. Two of these had sputum samples collected for acid-fast bacilli smear and culture but the patients did not return after the initial visit, one person signed a refusal for further evaluation and five left the clinic before a clinician could attend them
Summary
Tuberculosis (TB) is one of the top ten leading causes of death globally.[1]. In 2015, about 1.4 million deaths were attributed to TB, making it the global leading cause of death from an infectious disease, ahead of HIV/AIDS.[2]. Following the resurgence of the outbreak in 2014, several county-wide outbreak control measures were instituted.[21,22] One of these measures was the implementation of mandatory TB screening in all Atlanta homeless housing facilities in May 2015.[21,22] Prior to this, outbreak-related TB screening services were only provided onsite at the Fulton County health department or at sporadic intervals on mobile units sent out to the affected shelters. Each shelter user was expected to get screened for TB within 7 days of initial shelter entry and every 6 months thereafter to guarantee continued access to any of the shelters.[22] Both onsite (TB clinic) and offsite (shelter locations) TB screenings were performed using either tuberculin skin test (TST) or an interferon gamma release assay method (QuantiFERON Gold-in-tube tests (QFT)).[21,22] Homeless persons who tested positive for TB infection either through TST (>10mm induration) or QFT were referred to the health department for clinical evaluation. Homeless persons with positive QFT or TST who presented at the TB clinic for evaluation were clinically assessed to exclude active TB disease and those diagnosed with untreated LTBI were offered preventive treatment with either four months of rifampin (4R) (if patient had over 2 weeks history of consistent homeless shelter stay) or three months of RifapentineIsoniazid (3HP) ((if they had lower than 2 weeks of consistent homeless shelter stay). [22]
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