TB Nurse Case Management Davenport, Iowa September 27 28, 2011 Directly Observed Therapy and Case Studies Bridget Konz, RN September 28, 2011 Bridget Konz, RN has the following disclosures to make: No conflict of interest. No relevant financial relationships with any commercial companies pertaining to this educational activity. 1
Why Do we DO IT? Bridget Konz, RN Iowa Department of Public Health September 2011 Fighting bone TB in children in salt water and sea air. New York, NY area 2
Fathers of Multi-Drug TB Therapy Aminosalicylic acid (PAS) 1943 Isoniazid (INH) 1952 Streptomycin 1943 TB Sanatoria Closed Waverly Hills Tuberculosis Sanatorium, 1926. Courtesy of the University of Louisville 3
Patients were sent home Nurse Marguerite White showing Alice Jane Holden, tuberculosis patient, how to make her own paper cups which can be burned after use in her home on La Delta Project. Thomastown, Louisiana 1940 And Home Treatment Began Photo circa 1950. Photos courtesy of the Visiting Nurse Service of New York. 4
Father of Modern DOT 1965 Denver, Co. Dr. John Sbarbaro begins a program of outpatient DOT, high dose, twice-a-week intermittent therapy First time in western world Replaced physical quarantine with chemical quarantine What is DOT? Directly Observed Therapy At each encounter: Check for side effects Verify medication Watch patient take pills Document the visit 5
DOT is NOT DOD Dropped of at the door SOT Self-observed therapy FOT Family/friend observed therapy DOT Visits Can Also Include: Appointment reminders Patient and family/social education Incentives Providing social services 6
Who is DOT for? All patients are candidates Patients with drug-resistant TB Patients receiving intermittent therapy Persons at high risk for non-adherence, such as Homeless or unstably housed persons Persons who abuse alcohol or illicit drugs Persons who are unable to take pills on their own due to mental, emotional, or physical disabilities Children and adolescents Persons with a history of non-adherence DOT and Extrapulmonary TB? YES! Same chance for resistance if meds not taken correctly Same public health responsibility for treatment 7
DOT in Alternate Locations The patient's home The patient's workplace School Restaurant Other agreed-upon location Disadvantages of DOT Is time consuming Is labor intensive Can be insulting to some patients Can imply that the patient is incapable or irresponsible Can be perceived as demeaning or punitive 8
Advantages of DOT Ensure the patient completes an adequate regimen Monitor the patient regularly for side effects and response to therapy Identify problems that might interrupt treatment Helps the patient become noninfectious sooner But MORE Importantly DOT prevents: Treatment Relapse Treatment Failure Development of Drug Resistance 9
Impact of DOT - Baltimore Community-wide DOT introduced when the city has the 6 th highest rate of TB in the US. Baltimore Top 5 Cities Top 20 Cities 1981 35.6% 52.4% 34.1% 1992 17.2% 53.5% 33.6% % Change -51.7% +2.1% +1.8%* Although AIDS rates were higher in three of the other six highest TB cities, the rate of AIDS increase was highest in Baltimore (171%). Poverty, unemployment, immigrant, and MDRTB rates were all similar *when Baltimore is removed JAMA 1995 274:945 Iowa TB Cases By Mode Of Treatment Administration 10
TX failure is defined as? A. The patient dies despite being on appropriate TX regimen. B. Patient liver enzymes exceed 5X x normal limit of recommendation drugs are DC. C. Culture conversion is not documented. D. Cultures fail to convert after four months of treatment. MDR-TB is defined as resistance to? A. INH/RIF B. INH/PZA/EMB C. RIF/PZA/EMB D. SM/RIF/levo 11
DOT SPECIAL SITUATIONS DOT for Latent TB Infection High risk for developing TB Young children HIV-infected Other immunosuppressed persons Consider twice weekly DOT 900mg INH (weight dependent) 12
DOT for WPP Window Period: The period of time between which a person is exposed to an infectious organism (TB) and when that organism (TB) becomes detectable via a test (TB skin test). For children younger than 5 years of age who have been exposed to someone with infectious TB, the window period is the interval between the first and second round of testing (8 10 weeks). Counting doses Two acceptable regimens both accepted by CDC/ATS/IDSA : 5 days/week DOT dosing, adding missed doses to the end of treatment. 5 days/week DOT dosing but not adding missed doses to the end of treatment. Option is given to allow patients to selfadminister weekend doses. Iowa TB Program Position: Either regimen is effective treatment. However, the Program s preference is for patients receiving daily therapy to have 5 days/week DOT dosing, with patients selfadministering weekend doses (this should be documented as 5 day/week DOT). 13
Iowa DOT Incentive Funding Case Study: Alexander DOT for Alexander WPP for Children? DOT for other family/work contacts? 14