On reportable infection, a frisky debate goes on

No way in Texas, but possibly in Mississippi

Last month’s story about the policy of making TB infection reportable — an unusual practice, but one that’s much admired in the few jurisdictions where it’s practiced — caught TB Monitor readers’ attention and drew a volley of responses.

When the state of Texas mandated the reporting of TB infection in children, the move turned out to be "an unmitigated disaster," says Jeff Starke, MD, chief of pediatrics at Ben Taub General Hospital in Houston.

"They didn’t really publicize it, so people didn’t know they were supposed to do it." But having done so probably wouldn’t have made that much difference, he adds. "We all know that anything that depends on reporting by physicians is doomed to failure."

In Mississippi, on the other hand, state TB control officer Mike Holcombe, MPA, says the state’s new policy of mandatory infection reporting — again limited to kids — may be giving TB controllers a leg up. The policy, inaugurated last October, mandates reporting of children ages 15 and under.

Holcombe says he can recall at least one instance in which a child’s positive skin test otherwise might not have been reported. Plus, an associate investigation of the child’s contacts led to the case that presumably had infected the child.

That illustrates the double usefulness of the policy, he adds. "First, we’re making sure children get appropriate preventive therapy. And second, because we view infections among children as sentinel events, we use the report as an opportunity to look for the source case."

Starke says he doesn’t think the second rationale counts for much because, in his view, associate investigations are often a wasted effort. "A lot of times, the skin test you’re working from is a false-positive," he says. "I’d rather talk about my two favorite activities, which are contact investigations and screening at-risk populations. That’s a better use of resources."

Tests may not be reliable, cost-effective

But what about infection reporting as an epidemiological tool? Starke still isn’t convinced because in the low-prevalence areas where reporting positive tests is doable, many positive skin tests are actually false. Spot surveys of tuberculin reactivity would be much better to get a sense of infection rates among various groups, he suggests.

Kimberly Fields, RN, chief of the TB control program in Washington state, also gives a thumbs-down to the policy, which Pierce County recently enacted for all ages. Because the state has a decentralized public health structure, Pierce County can certainly do as it likes, Fields adds, and she says it will be interesting to see how the new policy plays out.

For the moment, she’s skeptical. "Infection reporting is very resource-intensive. Someone has to be available to interpret the data and then probably to re-enter it. That all takes time and resources at a time when federal dollars are down."