In this issue...
1. Introduction
2. Short Course Therapy Regimens for Active TB Cases
3. What is Daily D.O.T.?
4. Use of Risk Assessments and Clearance Letters for DSS Licensed Facilities
5. Intermittent Treatment Regimens for HIV-Infected Individuals
6. New Discharge/Treatment Plan Template
This is the first edition of the DTC electronic bulletin, the AcidFast Blast. The Blast will be published as needed to allow for the rapid dissemination of urgent issues related to the treatment of TB in the Commonwealth of Virginia.
We hope that you find this first edition useful in your TB Control efforts. We welcome your feedback.
The current DTC recommendations for the induction phase of treatment for all active or suspected TB cases in Virginia, includes isoniazid, rifampin, pyrazinamide and ethambutol unless there are contraindications to one or more of these medications. Once susceptibility testing results are available, ethambutol can be discontinued if the isolate is susceptible to both isoniazid and rifampin. All health care providers are reminded that pyrazinamide must be continued for the full 8 week induction phase for the individual to qualify for 6-month short course therapy.
Frequently, questions arise about what constitutes daily Directly Observed Therapy (DOT). While "daily" implies Sunday through Saturday, the DTC standard daily DOT treatment plan calls for 5 doses per week observed with the remaining two doses self-administered (SAT). Though perhaps ideal, a 7x a week schedule is difficult to achieve. Therefore, soon to be released CDC/ATS/IDSA guidelines allow for M-F DOT with SAT on Sat/Sun and holidays. DTC endorses this plan for all local health departments across the Commonwealth. Any questions should be referred either to Dr. Koppaka or Jane Moore at 804-786-6251.
DTC has been working with the Department of Social Services (DSS) to provide guidance on issues related to screening policies for staff in various types of DSS licensed facilities across the state, including children's day care and residential facilities, adult day care facilities, and other types of DSS licensed facilities. DTC has been assured by licensing officials at DSS that a risk assessment and clearance letter is acceptable for meeting tuberculosis screening requirements for all types of DSS licensed facilities. Facilities needing clarification can be referred to the specific licensing agency at DSS at 804-692-1500. Please report continued problems in this area to Jane Moore, RN, DTC Nurse Consultant, 804-786-6251.
Data from ongoing CDC-sponsored clinical trials on the treatment of active tuberculosis disease in patients with AIDS indicate an increased risk of acquired rifamycin resistance in persons receiving rifampin, rifabutin or rifapentine while receiving treatment via an intermittent dosing schedule. Accordingly, DTC is recommending that all persons with TB/AIDS be treated using a standard, daily dosing schedule throughout the entire course of treatment. Although additional trials into the safety and efficacy of thrice weekly dosing are in progress, this regimen is NOT approved for use in treatment of TB/HIV patients in Virginia until results of these trials are available. Contact DTC if you have TB/AIDS patients on intermittent dosing regimens for additional recommendations.
A new Discharge/Treatment plan template has been placed on the DTC website (http://vdhweb/std/guidebook.asp#OnlineForms). (Or, you can click Revised Treatment Plan (pdf file) to access the form). Revisions to the form were made based on comments received from the field during district visits by the DTC Nurse Consultant. This new form will hopefully clarify who is responsible for providing information needed for the care and treatment of TB cases in Virginia. This is a template, NOT a required form. Providers/LHDs are welcome to modify the form as they wish. Even handwritten progress notes are acceptable, as long as the minimum information (that which is included on the form) is provided.