Drew A. Harris

Prevalence and Incidence of Latent Tuberculosis Infection in Georgian Healthcare Workers

Background Tuberculosis is a major occupational hazard in low and middle-income countries. Limited data exist on serial testing of healthcare workers (HCWs) with interferon-γ release assays (IGRAs) for latent tuberculosis infection (LTBI), especially in low and middle-income countries. We sought to evaluate the rates of and risk factors for LTBI prevalence and LTBI test conversion among HCWs using the tuberculin skin test (TST) and QuantiFERON-TB Gold In-tube assay (QFT-GIT). Methods A prospective longitudinal study was conducted among HCWs in the country of Georgia. Subjects completed a questionnaire, and TST and QFT-GIT tests were performed. LTBI testing was repeated 6-26 months after baseline testing. Results Among 319 HCWs enrolled, 89% reported prior BCG vaccination, and 60% worked in TB healthcare facilities (HCFs). HCWs from TB HCFs had higher prevalence of positive QFT-GIT and TST than those from non-TB HCFs: 107/194 (55%) vs. 30/125 (31%) QFT-GIT positive (p<0.0001) and 128/189 (69%) vs. 64/119 (54%) TST positive (p = 0.01). There was fair agreement between TST and QFT-GIT (kappa = 0.42, 95% CI 0.31–0.52). In multivariate analysis, frequent contact with TB patients was associated with increased risk of positive QFT-GIT (aOR 3.04, 95% CI 1.79–5.14) but not positive TST. Increasing age was associated with increased risk of positive QFT-GIT (aOR 1.05, 95% CI 1.01–1.09) and TST (aOR 1.05, 95% CI 1.01–1.10). High rates of HCW conversion were seen: the QFT-GIT conversion rate was 22.8/100 person-years, and TST conversion rate was 17.1/100 person-years. In multivariate analysis, female HCWs had decreased risk of TST conversion (aOR 0.05, 95% CI 0.01–0.43), and older HCWs had increased risk of QFT-GIT conversion (aOR 1.07 per year, 95% CI 1.01–1.13). Conclusion LTBI prevalence and LTBI test conversion rates were high among Georgian HCWs, especially among those working at TB HCFs. These data highlight the need for increased implementation of TB infection control measures.

State Health Policy for Terrorism Preparedness

State health policy for terrorism preparedness began before the terrorist attacks on September 11, 2001, but was accelerated after that day. In a crisis atmosphere after September 11, the states found their policies changing rapidly, greatly influenced by federal policies and federal dollars. In the 5 years since September 11, these state health policies have been refined. This refinement has included a restatement of the goals and objectives of state programs, the modernization of emergency powers statutes, the education and training of the public health workforce, and a preparation of the health care system to better care for victims of disasters, including acts of terrorism.

Pneumococcal Vaccination Strategies. An Update and Perspective

Streptococcus pneumoniae is an important global pathogen that causes a wide range of clinical disease in children and adults. Pneumococcal pneumonia is by far the common presentation of noninvasive and invasive pneumococcal disease and affects the young, the elderly, and the immunocompromised disproportionately. Patients with chronic pulmonary diseases are also at higher risk for pneumococcal infections. Substantial progress over the century has been made in the understanding of pneumococcal immunobiology and the prevention of invasive pneumococcal disease through vaccination. Currently, two pneumococcal vaccines are available for individuals at risk of pneumococcal disease: the 23-valent pneumococcal polysaccharide vaccine (PPV23) and the 13-valent pneumococcal protein-conjugate vaccine (PCV13). The goal of pneumococcal vaccination is to stimulate effective antipneumococcal antibody and mucosal immunity response and immunological memory. Vaccination of infants and young children with pneumococcal conjugate vaccine has led to significant decrease in nasal carriage rates and pneumococcal disease in all age groups. Recent pneumococcal vaccine indication and schedule recommendations on the basis of age and risk factors are outlined in this Focused Review. As new pneumococcal vaccine recommendations are being followed, continued efforts are needed to address the vaccine efficacy in the waning immunity of the ever-aging population, the implementation of vaccines using two different vaccines under very specific schedules and their real world clinical and cost effectiveness, and the development of next generation pneumococcal vaccines.

Multidrug-Resistant Tuberculosis. Recommendations for Reducing Risk during Travel for Healthcare and Humanitarian Work

Healthcare and humanitarian workers who travel to work where the incidence of multidrug-resistant tuberculosis (MDR TB) is high and potential transmission may occur are at risk of infection and disease due to these resistant strains. Transmission occurs due to inadequate transmission control practices and the inability to provide timely and accurate diagnosis and treatment of persons with MDR TB. Patients risk exposure if active TB is unrecognized in workers after they return to lower-risk settings. Guidance for risk reduction measures for workers in high-risk areas is limited, and no studies confirm the efficacy of treatment regimens for latent TB infection due to MDR TB. Bacille Calmette-Guérin (BCG) vaccination decreases the risk of active TB and possibly latent infection. IFN-γ release assays differentiate TB infection from BCG vaccination effect. A series of risk reduction measures are provided as a potential strategy. These measures include risk reductions before travel, including risk assessment, TB screening, education, respirator fit testing, and BCG vaccination. Measures during travel include use of respirators in settings where this may not be common practice, transmission control practices, triaging of patients with consistent symptoms, providing education for good cough etiquette, and provision of care in well-ventilated areas, including open air areas. Risk reduction measures after return include TB screening 8 to 10 weeks later and recommendations for management of latent TB infection in areas where the likelihood of MDR TB exposure is high.

Determinants of Tuberculosis Infection Control–Related Behaviors Among Healthcare Workers in the Country of Georgia

OBJECTIVE To better understand tuberculosis (TB) infection control (IC) in healthcare facilities (HCFs) in Georgia. DESIGN A cross-sectional evaluation of healthcare worker (HCW) knowledge, beliefs and behaviors toward TB IC measures including latent TB infection (LTBI) screening and treatment of HCWs. SETTING Georgia, a high-burden multidrug-resistant TB (MDR-TB) country. PARTICIPANTS HCWs from the National TB Program and affiliated HCFs. METHODS An anonymous self-administered 55-question survey developed based on the Health Belief Model (HBM) conceptual framework. RESULTS In total, 240 HCWs (48% physicians; 39% nurses) completed the survey. The overall average TB knowledge score was 61%. Only 60% of HCWs reported frequent use of respirators when in contact with TB patients. Only 52% of HCWs were willing to undergo annual LTBI screening; 48% were willing to undergo LTBI treatment. In multivariate analysis, HCWs who worried about acquiring MDR-TB infection (adjusted odds ratio [aOR], 1.7; 95% confidence interval [CI], 1.28-2.25), who thought screening contacts of TB cases is important (aOR, 3.4; 95% CI, 1.35-8.65), and who were physicians (aOR, 1.7; 95% CI, 1.08-2.60) were more likely to accept annual LTBI screening. With regard to LTBI treatment, HCWs who worked in an outpatient TB facility (aOR, 0.3; 95% CI, 0.11-0.58) or perceived a high personal risk of TB reinfection (aOR, 0.5; 95% CI, 0.37-0.64) were less likely to accept LTBI treatment. CONCLUSION The concern about TB reinfection is a major barrier to HCW acceptance of LTBI treatment. TB IC measures must be strengthened in parallel with or prior to the introduction of LTBI screening and treatment of HCWs.

Improving the asthma disparity gap with legal advocacy? A qualitative study of patient-identified challenges to improve social and environmental factors that contribute to poorly controlled asthma

ABSTRACT Objective: To identify challenges that disadvantaged adults with asthma face in mitigating social and environmental factors associated with poor symptom control. Methods: Using a community-engaged approach, we partnered with a community health center in New Haven, CT to conduct in-person interviews and a written survey of asthmatic adults with poor symptom control. Using the constant comparative method, we analyzed participant interviews to establish emerging themes and identify common barriers to improved outcomes. Through a written survey utilizing clinically validated questions, we assessed information on access to medical care, asthma control, and selected social and environmental risk factors. Results: Twenty-one patients (mean age 47, 62% female, 71% Black, 95% insured by Medicaid) participated. The average Asthma Control Test (ACT) score was 11.6. Seventy-six percent of participants were currently employed and of those, 75% reported work-related symptoms. Among participants currently in housing, 59% reported exposure to domiciliary mice and 47% to mold. We identified three themes that summarize the challenges the study participants face: 1) Lack of knowledge about home and workplace asthma triggers; 2) Lack of awareness of legal rights or resources available to mitigate adverse conditions in the home or work environment; and 3) Fear of retaliation from landlords or employers, including threats of eviction, sexual assault, and job loss. Conclusion: Patients with poorly controlled asthma in a disadvantaged urban northeast community identified common barriers in both the domestic and work environments that impeded attainment of symptom control. These challenges may be best addressed through legal advocacy for those most at risk.

Community-based Participatory Research Is Needed to Address Pulmonary Health Disparities

Socioeconomic and racial disparities in the outcomes of medical management remain common across pulmonary diseases in the United States and worldwide. Acknowledging this, the American Thoracic Society recently put forth recommendations to advance respiratory health equity. Through engagement of vulnerable communities in search of collaborative solutions to improve health disparities, community-based participatory research embodies concepts essential to the American Thoracic Society mission for respiratory health equity. The purpose of this commentary is to provide an overview of the principles of community-based participatory research and the application of this approach to addressing inequity in the outcomes of treatment for lung disease. Community-based participatory research aims to decrease health disparities by recognizing the social and ecological paradigms of health care and by partnering community members with academic researchers in all aspects of the research process. Community partners are uniquely poised to offer insight into local culture, circumstances that guide health behaviors, and other challenges to improve their own communitys health. Sustainable interventions, either through strengthening existing community assets or through community empowerment and local capacity building throughout the research process, are essential to the success of community-based participatory research. The National Institutes of Health and other funding agencies offer funding opportunities to support specific interventions aimed at engaging community members in the research process. In pulmonary medicine, community-based initiatives have focused primarily on improving pediatric asthma outcomes. Using a community-based approach in adult asthma and other pulmonary diseases could be an ideal manner in which to decrease pulmonary health disparities.