Success story: Improving treatment for latent TB
Convenience, follow-up are key at Harlem Hospital
A newly hired health care worker tests positive in the tuberculin skin test. She comes from a country where TB is endemic, and she received the BCG vaccine as a child. She insists that it isn't a true positive and declines treatment for latent tuberculosis infection (LTBI).
This was once a common scenario at Harlem Hospital in New York City, which has a high proportion of foreign-born health care workers. In fact, it's a situation encountered by many hospitals around the country, as nurses travel here from the Philippines, India, Nigeria, and South Korea, helping to fill the U.S. nursing shortage.
Yet that attitude has been countered with a focus on education, follow-up, and convenience, as Harlem Hospital dramatically improved its rate of initiation and completion of treatment. Initially, only 62% of health care workers who were advised to take LTBI treatment started it, and only 12% completed it. With a fast-track program, the completion rate rose as high as 96%, reports Paul Colson, PhD, program director of the Charles P. Felton National Tuberculosis Center at Harlem Hospital.
Understanding the BCG effect
It takes a sustained effort to build awareness of the need for LTBI treatment, says Colson. "When someone tested positive and was appropriate for treatment, we made an effort to speak to them and answer any misconceptions."
For example, BCG causes a lot of confusion. "There's no indication that positive skin tests are consistently caused by BCG vaccination," he says. "If you come from a country that has so much TB that they vaccinate people, then you probably became infected with TB.
"The protective effect of BCG wanes over time," he says. "It hasn't even been definitively established in research how long BCG protects you. It's certainly not lifetime protection."
The use of the blood test, Quantiferon-TB Gold, offers a method for distinguishing between a BCG effect and TB infection. The blood test is more specific and produces fewer false positives than the tuberculin skin test.
In its 2005 "Guidelines for the Prevention of Mycobacterium tuberculosis in Health-Care Settings," the Centers for Disease Control and Prevention (CDC) advised: "In conjunction with a medical and diagnostic evaluation, health care workers with positive test results for M. tuberculosis should be considered for treatment of LTBI after TB disease has been excluded by further medical evaluation. Health care workers cannot be compelled to take treatment for LTBI, but they should be encouraged to do so if they are eligible for treatment."1
Here are some strategies that enabled Harlem Hospital to improve its LTBI treatment:
• Address misconceptions about LTBI. Health care workers may be confused about the recommended treatment for latent tuberculosis infection. In 2000, the CDC made a couple of important changes to its guidelines. Treatment with INH, the standard for LTBI, wasn't recommended for people older than 35. The CDC now says age should not be considered a factor in decisions about LTBI treatment. Also, prior to 2000, the INH treatment lasted for six months. Currently, the treatment period is nine months.
• Target your message. Foreign-trained health care workers, including physicians, may need peers from their home country who relay information about BCG, TB testing, and LTBI treatment. After all, their training may contradict the current CDC recommendations and can account for noncompliance. "It's almost like their training works against their accepting new information," he says.
• Make it convenient. Health care workers on LTBI treatment need initial education, then monthly appointments for follow-up, Colson says. They are seen by a "fast-track coordinator" and don't wait in the waiting room. Health care workers' charts are placed in a colored folder so they are easy to identify and retrieve. They complete a self-assessment tool to identify any possible side effects of the medication.
• Follow up with health care workers on treatment. The fast-track coordinator follows up if a health care worker misses an appointment and sets a new date. The clinic also can provide reminders via the intranet, for example.
• Spread the word about your LTBI clinic. If you have a dedicated program to treat both health care workers and patients from the community, make sure your staff know it exists. For example, you may create a brochure providing information about the clinic and the treatment.
Maintaining a high level of treatment completion requires some focus. If you let it slide, your rates may revert to prior levels, Colson cautions.
1. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. MMWR 2005; 54(RR17):1-141.