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Correspondence |

Development and Implementation of a Cohort Review for Latent TB InfectionLatent TB Infection Cohort Review FREE TO VIEW

James D. Mancuso, MD, DrPH, MPH; Christopher L. Aaron, DO
Author and Funding Information

From the Uniformed Services University of the Health Sciences (Dr Mancuso); and the Fort Belvoir Community Hospital (Dr Aaron).

CORRESPONDENCE TO: James D. Mancuso, MD, DrPH, MPH, Tropical Public Health, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814; e-mail: James.mancuso@usuhs.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(1):e25-e26. doi:10.1378/chest.14-2315
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Published online
To the Editor:

Finding and managing cases of latent TB infection (LTBI) is a critical element of TB control and prevention.1 The US Centers for Disease Control and Prevention (CDC) recommend that in low-incidence settings, TB control programs conduct cohort reviews on patients with LTBI to enhance program quality.2 However, although the methods of cohort review for TB disease are well established,3 methods for implementing LTBI cohort reviews have not yet been established or reported in the literature. We report the design and implementation of a cohort review for LTBI in the low-incidence setting of the US Army.

Table Graphic Jump Location
TABLE 1 ]  Comparison of US Army Indicators With CDC Performance Targets and US National Averages

CDC = US Centers for Disease Control and Prevention; IGRA = interferon-γ release assay; TST = tuberculin skin test.

The methods used for the LTBI cohort review were developed and modified from those described previously by the CDC for TB disease.3 The data collection instrument was modified from that used by the CDC, including demographics; clinical, radiographic, and laboratory case characteristics; deployment and travel history; and treatment adherence and other outcomes. A stratified random sample of LTBI cases was selected from three heterogeneous US Army installations.

Two hundred ninety-four TB tests were performed on the 215 subjects at time of evaluation. The top three reasons for testing were deployment (38%), accession (24%), and confirmatory testing (21%). Table 1 compares treatment indicators with performance targets. Of the 194 in whom LTBI was diagnosed, 146 (75%) initiated therapy. Completion of therapy was good (78%) once initiated, but unnecessary delays in treatment initiation occurred because of provider deferral, particularly at time of entry into military service. Most testing (93%) was done among low-risk subjects despite CDC and US Department of Defense guidelines discouraging this.4,5 Most of the tests (76%) performed to “confirm” a positive test were also positive but led to average delays in treatment of 1.7 years. Deferral led to worse treatment outcomes both in completion of therapy and time to treatment. Despite the availability of an electronic TB registry, data quality did not meet performance targets.

This cohort review suggested that TB control in the US military can be improved by (1) reducing overtesting, (2) increasing completion of LTBI treatment, (3) reducing treatment delays, and (4) ensuring data accuracy. As the incidence of TB declines in the United States, more cities, counties, and states will become low-incidence settings. This report describes a method of operationalizing this type of cohort review. Like the cohort review for TB disease, program improvement will only be achieved through accountability and continued action based on the findings of program outcomes.

Acknowledgments

Other contributions: The material has been reviewed by the Uniformed Services University. There is no objection to its presentation or publication. The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official, or as reflecting true views of the Uniformed Services University, Department of the Army, or the Department of Defense.

Jereb JA. Progressing toward tuberculosis elimination in low-incidence areas of the United States. Recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR Recomm Rep. 2002;51(RR-5):1-14. [PubMed]
 
 CDC Division of Tuberculosis Elimination: TB Cohort Review Guidance. Rutgers Global Tuberculosis Institute website. http://globaltb.njms.rutgers.edu/downloads/courses/CDC%20Guidance%20on%20TB%20Cohort%20Review.pdf. Accessed August 8, 2014.
 
Centers for Disease Control and Prevention. Understanding the TB Cohort Review Process: An Instruction Guide. Atlanta, GA: Department of Health and Human Services; 2006.
 
Assistant Secretary of Defense for Health Affairs. Guideline for Tuberculosis Screening and Testing. Washington, DC: Department of Defense; 2012.
 
American Thoracic Society. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR Recomm Rep. 2000;49(RR-6):1-51.
 

Figures

Tables

Table Graphic Jump Location
TABLE 1 ]  Comparison of US Army Indicators With CDC Performance Targets and US National Averages

CDC = US Centers for Disease Control and Prevention; IGRA = interferon-γ release assay; TST = tuberculin skin test.

References

Jereb JA. Progressing toward tuberculosis elimination in low-incidence areas of the United States. Recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR Recomm Rep. 2002;51(RR-5):1-14. [PubMed]
 
 CDC Division of Tuberculosis Elimination: TB Cohort Review Guidance. Rutgers Global Tuberculosis Institute website. http://globaltb.njms.rutgers.edu/downloads/courses/CDC%20Guidance%20on%20TB%20Cohort%20Review.pdf. Accessed August 8, 2014.
 
Centers for Disease Control and Prevention. Understanding the TB Cohort Review Process: An Instruction Guide. Atlanta, GA: Department of Health and Human Services; 2006.
 
Assistant Secretary of Defense for Health Affairs. Guideline for Tuberculosis Screening and Testing. Washington, DC: Department of Defense; 2012.
 
American Thoracic Society. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR Recomm Rep. 2000;49(RR-6):1-51.
 
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