Adolescents and TB: New Jersey's lesson
Unmonitored teens may flunk compliance
Earlier this year, New Jersey faced a situation that must have felt, at times, like El Niño had decided to work in some new and extra-strange way. In seven suburban high schools across the state and in two inner-city schools, nine unrelated teenagers fell ill with TB.
What made the situation especially frustrating was that for five of the teens, physicians had prescribed a course of isoniazid prophylaxis, yet all five defaulted. Nor was there evidence that someone, somewhere along the line checked to see if the kids were taking their medication.
So far, one student has died. The remaining cases have triggered a series of expensive and complicated contact investigations. (Recently, a 10th teen was added to the list of youths who had stopped taking preventive medication and subsequently developed active disease.)
"It's really a big mess," says Bonnie Mangura, MD, associate professor of clinical medicine at the National Tuberculosis Center of the New Jersey Medical School in Newark. "In terms of prevention, there have been so many missed opportunities here."
Experts on adolescent health say teens are one group at highest risk for nonadherence and need special measures that take their special characteristics into consideration. In some places, public health clinics are addressing teen noncompliance by asking school nurses and providers in school-based clinics to lend a hand with monitoring preventive therapy. (For more on this, see pp. 79, 80.) Whatever the New Jersey cases illustrate about teen noncompliance, they also speak volumes about the ways adolescents can slip through the cracks of even the best-intended TB control program.
To begin with, there's screening - a much murkier subject than most administrators would like. In New Jersey, some of the nine cases were, in fact, netted through school-based screenings; others were not.
A host of factors go into deciding which groups of kids, and which school districts, to target for PPD screening, experts say. "When you're talking about targeted screening, first you have to define the risk group," says Patricia Simone, MD, chief of the field services branch at the Division of Tuberculosis Elimination at the Centers for Disease Control and Prevention in Atlanta. "Then you have to find members of the group, evaluate them, and then devise a way to treat them. Otherwise, it's just a waste of time."
Many states, including New Jersey, have implemented policies that single out students who transfer into a school, whether from out of district, out of state, or out of the country. Those policies net students from high-prevalence counties or local school districts. In addition, many states also single out high-incidence districts for some screening - perhaps all kindergartners, all 13-year-olds, or both.
But with targeted screenings, the question is always whether the net is too narrow or too wide. Most people agree that massive schoolwide screenings are inefficient and nonproductive, but with that kind of screening abolished, some experts worry that replacement policies are missing some kids.
In Massachusetts, for example, the number of children placed on preventive medication as a result of the state's new policy - annual verbal screenings, and skin tests where indicated - has dropped off significantly. The decline has been so great that John Bernardo, MD, Boston's TB controller, says overlooked clinicians may reinterpret the policies to read, "Just screen the kids you think are high-risk." That's the kind of worry New Jersey administrators will address this fall when they meet to re-evaluate screening policies, says Ken Shilkret, the state's TB controller.
The New Jersey experience also shows how primary-care providers continue to err when it comes to preventive therapy. In two of the nine cases, teens whose chest X-rays indicated the presence of active TB were placed on a single medication; in a third instance, a teen whose first skin test was ambiguous was scheduled for a re-test but never received it.
Teens came back, but no one asked
Then there's monitoring. Here, evidence from the New Jersey episode is especially disheartening. No one seems to have asked the students placed on prophylaxis whether they were still taking their isoniazid (INH) - even when some of them returned one, two, or three months later to their providers for other reasons, Mangura says.
The fact that three of the five teens on INH were foreign-born may have had something to do with it. Despite guidelines to the contrary, too many providers still regard a history of a BCG vaccination as reason to discount a positive skin test, Mangura says. "You just don't see the same level of enforcement among physicians who share those misconceptions. You'd be surprised how many providers still aren't convinced."
In Boston, Bernardo and colleagues discovered something else that set apart foreign-born from other noncompliant kids. Although the foreign-born students were dependable when it came to swallowing their pills, they could not be relied on to get refills, Bernardo discovered.
The reason? Many of the kids were conscientious students who disliked taking time off from their studies to make the trek to the chest clinic.
Back in New Jersey, more problems emerged once the nine cases had been identified, Mangura says. In some instances, school nurses had duly recorded results of the students' baseline skin tests, but instead of expressing the data in terms of millimeters of induration, they just wrote "positive" or "negative," she says.
When it came time for contact investigations, such descriptions made it tough for investigators to decide when a student had converted and confounded decisions about whether to expand concentric circles of a contact investigation, she adds.
The episode was especially frustrating because children and teens are among the best candidates for prophylaxis, she says. "They're in a group where the benefits greatly outweigh the risks."
One solution - at least for the compliance piece of the problem - would have been to provide directly observed preventive therapy (DOPT) for the students, Mangura says. But resources are finite, and for older students, self-administered therapy, not DOPT, is the general rule in most places, Simone says.
Still, in some situations, it makes sense to ask school health care providers for help, she says. "As we move from case-finding and contact investigation, we need to be looking at more ways to do preventive therapy. Sometimes, if you put a little effort into the infrastructure, you find you have the ability to do good preventive therapy."