Author: schuetz.10

Barriers to Care

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Personal, Provider and Systematic Barriers

Patient level barriers

  • fear of side effects
  • duration of treatment
  • stigma
  • financial concerns (losing pay and taking time off work)
  • lack of knowledge of LTBI
  • confusion about the effectiveness and coverage of the Bacillus Calmette-Guerin (BCG) vaccine
  • unsatisfactory relationships with healthcare workers in the past (Katrak & Flood, 2018; Liu et al., 2018; Oren et al., 2017)

Provider level barriers

  • limited resources
  • longer appointments needed for these patients due to complex health needs
  • lack of support from specialists
  • knowledge gaps in healthcare workers on testing and interpretation of results
  • lack of compensation for LTBI care
  • lack of perceived benefit to patients
  • inadequate methods of charting (Alsdurf & Menzies, 2020; Katrak & Flood, 2018; Liu et al., 2018; Oren et al., 2017)

 

System level barriers

  • lack of funding
  • perceived low priority for LTBI testing and treatment
  • absence of comprehensive LTBI management strategies
  • lack of research
  • gaps in identification of household contacts
  • need for increased public awareness and education
  • global inconsistency in testing and treatment
  • the need to incorporate recommendations of USPSTF into practice (Alsdurf & Menzies, 2020; Liu et al., 2018; Palmer et al., 2017; Pareek et al., 2016; Sotgiu et al., 2017)

 

Alsdurf, H., & Menzies, D. (2020). Identifying Gaps in the Quality of Latent Tuberculosis Infection Care. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 18. doi:10.1016/j.jctube.2020.100142

Katrak, S., & Flood, J. (2018). Latent Tuberculosis and Current Health Disparities in California: Making the Invisible Visible. American Journal of Public Health, 108(S4), 245. doi:10.2105/AJPH.2018.304529

Liu, Y., Birch, S., Newbold, K., & Essue, B. (2018). Barriers to treatment adherence for individuals with latent tuberculosis infection: A systematic search and narrative synthesis of the literature. The International Journal of Health Planning and Management, 33(2), 433. doi:10.1002/hpm.2495

Oren, E., Bell, M., Garcia, F., Perez-Velez, C., & Gerald, L. (2017). Promoting adherence to treatment for latent tb infection through mobile phone text messaging: Study protocol for a pilot randomized controlled trial. Pilot and Feasibility Studies, 3, 15-15. doi:10.1186/s40814-017-0128-9

Palmer, J., Allen, L., & Walton, W. (2017). CE: Tuberculosis: A New Screening Recommendation and an Expanded Approach to Elimination in the United States. The American Journal of Nursing, 117(8), 24-34. doi:10.1097/01.NAJ.0000521946.45448.90

Pareek, M., Greenaway, C., Noori, T., Munoz, J., & Zenner, D. (2016). The impact of migration on tuberculosis epidemiology and control in high-income countries: A review. BMC Medicine, 14.

Sotgiu, G., Dara, M., Centis, R., Matteelli, A., Solovic, I., Gratziou, C., . . . Battista, M. (2017). Breaking the barriers: Migrants and tuberculosis. Presse Medicale (paris, France : 198, 46(2), 11. doi:10.1016/j.lpm.2017.01.013

Who is at Risk for LBTI?

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Some people are more at risk for contracting LBTI. These “at risk” groups of people include:

  1. Health care workers: Health care workers are often in close contact to patients with active TB.
  2. Homeless populations: Homeless people are more likely to suffer from malnutrition, sleep in close living quarters such as shelters or homeless camps, and suffer from substance abuse.
  3. Communal living: Communal living includes persons who live in a space where large numbers of people share a common space. These communal living spaces include prisons, nursing homes, and homeless shelters. There is a greater risk here because of the close proximity people have to one another.
  4. Poverty: Those living in poverty often have crowded living environments, lack of healthy foods, poorly ventilated housing. Crowded living environments puts people closer to one another, which increases the chances of catching TB. Lack of health foods contributes to poor health and a weakened immune system, which prevents the body from fighting off infections. Poor ventilation allows TB to remain suspended in the air longer, increasing the likelihood of contracting the disease.
  5. Weakened immune system: A weakened immune system is common in people with HIV, IV drug users, those living in poverty, homelessness, and those with health conditions such as diabetes, cancer, rheumatoid arthritis, Crohn’s disease, low body weight, organ transplants, long-term corticosteroid treatments, and children under 5. A weakened immune system prevents the body from fighting infections as well as someone with a strong immune system.
  6. Immigrating from a country that has a high incidence of TB: If the incidence of TB is higher than 20/100,000 people in a country, then that country is considered a high-risk country. This website will show the incidence in each country: World Health Organization – TB Incidence

 

This is an example of what you would see on the website looks like

and where you would look to find the incidence rate

 

TB Alert. (2020). Who is at Risk of TB? https://www.tbalert.org/about-tb/what-is-tb/who-is-at-risk-of-tb/

Center for Disease Control (CDC). (2020). Tuberculosis (TB): TB Risk Factors. https://www.cdc.gov/tb/topic/basics/risk.htm

National Jewish Health. (2020). Tuberculosis: Risk Factors. https://www.nationaljewish.org/conditions/tuberculosis-tb/risk-factors#:~:text=You%20are%20at%20risk%20of%20TB%20infection%20if,farm%20camp%2C%20prison%20or%20jail%2C%20or%20nursing%20home.

World Health Organization (WHO). 2020. Tuberculosis Profile. https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&lan=%22EN%22&iso2=%22AF%22&main_tabs=%22est_tab%22

Resources for Healthcare Providers Treating Patients with LTBI

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Resources and Information for Professionals

OHIO Laws and Rules for TB

TB in Specific Populations

STOP TB Poster

Treatment Options

There are three options for treatment recommended by CDC and National Tuberculosis Controllers Association (NTCA) are medications but taken in different combinations and/or different length of time. Treatment options are selected based on patient’s overall state of health, effectiveness of medication and regimen that will provide the least hepatoxicity or damage to the liver.

The three recommended medication combinations are:

  1. isoniazid and rifapentine weekly for 3 months
    1. Adults and children >2 years old, HIV positive patients are able to take this regimen through direct observation therapy and has the highest rates of completion (Fox et al., 2017; Sterling et al., 2020).
    2. Downfalls to this regimen is cost and the number of pills that need to be taken at one time; 10 pills compared to 2-3 in other regimens (Sterling et al., 2020).
  2. rifampin daily for 4 months
    1. Preferred treatment for HIV-negative adults and children of all ages, has the lowest rate of hepatoxicity, and high rate of completion (Fox et al., 2017; Sterling et al., 2020).
    2. Downfalls to this regimen is that there are many drug interactions with warfarin, oral contraceptives, azole antifungals, HIV antiviral therapy (Sterling et al, 2020).
  3. isoniazid and rifampin daily for 3 months (Sterling et al., 2020).
    1. Recommended for HIV-positive adults and children
    2. Downfalls for this treatment is that patients tend to discontinue treatment due to adverse side effects (Sterling et al., 2020).

 

Fox, G., Dobler, C., Marais, B., & Denholm, J. (2017). Preventive Therapy for Latent Tuberculosis Infection—the Promise and the Challenges. International Journal of Infectious Diseases, 56, 68-76. doi:10.1016/j.ijid.2016.11.006

Sterling, T., Njie, G., Zenner, D., Cohn, D., Reves, R., Ahmed, A., … Belknap, R. (2020). Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recommendations & Reports, 69(1): 1-11. http://web.b.ebscohost.com.proxy.lib.ohio-state.edu/ehost/pdfviewer/pdfviewer?vid=12&sid=d8fb7fe7-b6c4-42d1-ad01-7dcabe316909%40pdc-v-sessmgr03

 

Scaling Up Management of LTBI

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Let your patients know that if they are told they have LTBI, they are not alone.

Here are a list of resources that you can share with patients to help

explain and alleviate the stress and anxiety surrounding LTBI. 

 

Difference between TB and Latent TB

 

Patient Stories

 

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Incentives

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Smokers, alcohol/drug users, LTBI patients living on the street or in shelters, health care workers, and women all have poor adherence rates and are less likely to complete treatment (Liu et al., 2018). Encouraging research within these populations to discover why adherence rates are low and developing strategies to improve treatment is needed. Goldberg et al. (2004) reported that implementing culturally appropriate programs that focus on specific migrant populations increased the rate of completion from 37% to 82% among new refugees in the United States. Closer monitoring, incentive programs, cultural case management and continuing education have proven successful within these populations.

The use of  and culturally sensitive care are the most common reported interventions; home visits and incentive programs are the least utilized incentives. – this data is from the survey from the Facebook Nurse Practitioner page.

 

CULTURALLY SENSITIVE CARE

Goldberg et al. (2004) reported that implementing culturally appropriate programs that focus on specific migrant populations increased the rate of completion from 37% to 82% among new refugees in the United States. Tavares et al. (2019) reports that barriers to care for migrants include limited socioeconomic resources, communication and cultural barriers, lack of knowledge about the functioning of the healthcare system, and lack of knowledge about migrant and refugee health issues

Health campaigns that focus on cultural needs of migrant communities would help to raise awareness and improve health literacy.

Enabling heath care systems to adopt recommended strategies through “improved dissemination of policy, tracking and measuring LTBI outcomes, and reducing financial barriers” (Katrak et al., (2018), p. 54), is necessary to overcome barriers to care.

The use of interpreters, enlisting family support, the use of social workers to help patients navigate the health care system, and education for health care providers on migrant care is essential.

HOME VISITS

90% of LTBI patients in the United States complete treatment when they received home follow-up instead of clinic follow-up (Chang et al., 2013)

Working with organizations within the community to provide support

INCENTIVE PROGRAMS

Programs to increase compliance (Pai et al., 2015) include:

  • Grocery gift cards
  • Free lunch
  • Bus passes
  • Work excuses
  • Paid time-off
  • Phone cards

Liu et al. (2018) found that patients that received immediate, rather than delayed, incentives had higher completion rates, especially among the homeless and drug users. Suggestions include cash and noncash incentives – free lunch, grocery gift certificates, phone cards and bus tokens

EXPLANATION OF CARE

Assess knowledge of ways to prevent spread (Nyamathi et al., 2008)

Health campaigns that focus on cultural needs of migrant communities would help to raise awareness and improve health literacy.