Latent Tuberculosis Infection: The Physician's Role in Tuberculosis Control
Am Fam Physician. 2009 May 15;79(10):845-846.
Active tuberculosis continues to be a major cause of mortality worldwide. In response to the resurgence of tuberculosis in the late 1980s, the Advisory Council for the Elimination of Tuberculosis reaffirmed its commitment to eliminate tuberculosis in the United States, and the Institute of Medicine created a plan to reach that goal.1,2 Improvements in infection control and treatment strategies have led to a significant decrease in the incidence of tuberculosis over the past decade.3 However, several challenges to successful elimination of tuberculosis in the United States remain. One of the most important challenges is the persistence of a substantial number of persons with latent tuberculosis infection (LTBI) who are at risk of progression to active tuberculosis.1 These persons must be identified through targeted testing, and be administered a potentially curative course of treatment. Our article in this issue of American Family Physician addresses identification and treatment of LTBI.4
Although the responsibility for tuberculosis control in the United States resides primarily within the public health sector, continuing progress toward elimination of tuberculosis requires the collaboration of a broad range of persons and institutions, including physicians, civil surgeons (physicians officially designated by U.S. Citizenship and Immigration Services), community health centers, hospitals, academic medical centers, community organizations, medical professional organizations, long-term care facilities, correctional facilities, and the pharmaceutical industry.2 Physicians in the nonpublic health sector play an important role in tuberculosis control; they are usually the first source of care for persons with LTBI and may provide ongoing management. This role will further expand as the incidence of tuberculosis decreases, with resulting reductions in funding for tuberculosis control programs. Yet, it has been reported that physicians are often insufficiently knowledgeable about tuberculosis, may not follow recommended treatment guidelines, and do not interact effectively with public health programs.2
In an era of declining tuberculosis incidence, maintaining clinical expertise in detection and treatment of tuberculosis is particularly challenging. Nevertheless, physicians should be able to screen all new patients for risk factors for LTBI and progression to active tuberculosis, administer and read tuberculin skin tests, rule out suspected active tuberculosis, treat LTBI and monitor such treatment, and accurately document completion of treatment. Physicians also need to become familiar with state laws for reporting LTBI and state programs that support screening, diagnosis, and treatment of LTBI. Some local health departments are equipped to manage LTBI in high-risk populations (e.g., foreign-born persons from countries with high prevalence of tuberculosis). However, the standards of care and the availability and scope of such programs vary by jurisdiction, so it is important for physicians to be informed about the practices of their local agencies.
Tuberculosis control is crucial in high-risk groups, such as children younger than four years, persons with human immunodeficiency virus infection, and employees and residents of congregate living facilities (e.g., prisons, homeless shelters). Of particular importance is the recognition and treatment of LTBI in foreign-born persons and racial and ethnic minorities because these populations bear a disproportionate burden of active tuberculosis in the United States.3 Although the number of tuberculosis cases among foreign-born persons has decreased in recent years, disparities persist between foreign-born persons and persons born in the United States. These disparities are likely because of an increase in the proportion of persons coming from countries of high tuberculosis prevalence and because of cultural and linguistic barriers that affect access to medical care.2,3
Federal agencies are responsible for ensuring that legal immigrants and refugees are appropriately evaluated for tuberculosis before arrival in the United States, and for notifying local tuberculosis control programs of the arrival of persons with suspected tuberculosis. However, it is important for physicians to remember that not all foreign-born persons have undergone this screening process (e.g., unauthorized immigrants). These persons may need to be evaluated for tuberculosis in the medical clinic in which they establish care.
To help ensure successful treatment of LTBI, physicians need to collaborate with public health agencies to educate patients about the health implications of LTBI and motivate them to accept medical care. For example, public health nurses are able to make home visits, if needed, to monitor compliance or adverse effects of medications in patients who have difficulty returning regularly to the physician's office. Additionally, physicians can obtain up-to-date information from their local health department, including data on high-risk groups in the community and the latest treatment recommendations. Studies in various populations undergoing LTBI treatment show that interventions, such as adherence counseling, health education, and financial incentives, improve LTBI treatment completion rates, are cost-effective, and may be easily completed at clinic visits.5-7 These partnerships and creative interventions, and the active involvement of family physicians and other primary care clinicians are vital to achieving our national goal of eliminating tuberculosis.
1. Advisory Council for the Elimination of Tuberculosis (ACET). Tuberculosis elimination revisited: obstacles, opportunities, and a renewed commitment. MMWR Recomm Rep. 1999;48(RR-9):1–13.
2. Taylor Z, Nolan CM, Blumberg HM, for the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America. Controlling tuberculosis in the United States [published correction appears in MMWR Morb Mortal Wkly Rep. 2005;54(45):1161]. MMWR Recomm Rep. 2005;54(RR-12):1–81.
3. Centers for Disease Control and Prevention. Trends in tuberculosis—United States, 2007. MMWR Morbid Mortal Wkly Rep. 2008;57(11):281–285.
4. Hauck FR, Neese BH, Panchal AS, El-Amin W. Identification and management of latent tuberculosis infection. Am Fam Physician. 2009;79(10):879–886.
5. Kominski GF, Varon SF, Morisky DE, et al. Costs and cost-effectiveness of adolescent compliance with treatment for latent tuberculosis infection: results from a randomized trial. J Adolesc Health. 2007;40(1):61–68.
6. Nyamathi AM, Christiani A, Nahid P, Gregerson P, Leake B. A randomized controlled trial of two treatment programs for homeless adults with latent tuberculosis infection. Int J Tuberc Lung Dis. 2006;10(7):775–782.
7. Tulsky JP, Hahn JA, Long HL, et al. Can the poor adhere? Incentives for adherence to TB prevention in homeless adults. Int J Tuberc Lung Dis. 2004;8(1):83–91.
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