AcidFast Blast - May 2004

Vol. 3, No. 2

In this issue...
DTC Congratulates the Spittoon Winners for 2003
Report on DTC Medication Survey Undertaken in 2003
Additional Information from DCLS Regarding Communications and Expectations
In Reprise, Protocol for Obtaining Telephone Reports
TB Drugs and Ototoxicity

DTC Congratulates the Spittoon Winners for 2003

The winners of the 2003 Traveling Spittoon Awards were recently announced at the World TB Day Presentations held statewide on March 25th. DTC would like to congratulate all of the winners on their accomplishments during 2003. Two of the winners, Alexandria and Eastern Shore, were first time winners of this award !!

Northern Region - Alexandria Health District
Northwestern Region - Rappahannock Health District
Central Region - Richmond City Health District
Eastern Region - Eastern Shore Health District
Southwest Region - Roanoke Health District

The award criteria for 2003 included the number of cases who complete treatment in one year or less, the number of cases on directly observed therapy (DOT), and the number of contacts who complete treatment for LTBI. In addition, complicating factors, such as HIV co-infection, homelessness, substance abuse, resistance to rifampin, or recent immigration are also considered in determining a district's performance score.

Report on DTC Medication Survey Undertaken in 2003

In mid-2003, DTC undertook a survey of the 35 heath districts regarding problems encountered in treatment TB patients appropriately and adequately under the current payment system for TB medications. The survey involved all reported cases from 2002 and cases reported in 2003 through mid-May. Responses were received from 34 of 35 health districts. This translated into study population 394 cases.

During this time period 38% (13 of 34) of districts impacted by increased number of cases and 21% (7 of 34) of districts were impacted by MDRTB cases.

Analysis of the responses regarding eligibility determinations for the study population indicated that 56% (220/394) of the cases were listed as "A" patient. An additional 7% (26/394) of the cases had an eligibility code of B-E, so that 62% (246/394) received some level of health department subsidy for their TB medications. Few of the patients (3%, 10/394) received Medicaid and 14% were listed as full pay (54/394). Information was not available for 21 % (84/394) of the cases. Reasons for the missing information was due to variety of reasons including death, refusal, availability of meds via private insurance, or moved prior to completing the eligibility process.

Of the individuals with an insurance drug benefit, 21 % (38/182) of the cases experienced difficulty meeting co-pays and for 36% (50/145) of the cases there was ongoing difficulty in using an outside pharmacy. Treatment issues related to financial problems occurred in 6% (24/394) of the cases and 4% (15/394) of the cases experienced a treatment interruption related to financial issues. Overall, 17% (68/394) experienced some type of difficulties with payment issues.

Completing the eligibility process was a problem for 29% of the cases (113/394). Patients could experience more than one type of difficulty in completing the process. Lack of documentation was a problem for 43% (169/394) of the cases experiencing difficulties. Infectiousness (30%m 118/394) and Immigration status (27%, 208/394) were frequently listed as barriers in completing the eligibility process.

Issues other than financial also had a impact on providing treatment for TB cases at the local level. 12% of cases (48/394) had some type of specialized need requiring extra service on the part of health departments. This ranged from injectable medications, IV administration of meds for drug resistant TB, or other special needs, such as crushing and time required for the administration of meds to small children or the elderly.

As part of the overall survey, a survey of practices in states bordering Virginia was also completed. Currently, all states bordering Virginia pay for TB medications.

Additional Information from DCLS Regarding Communications and Expectations

DTC recently sent an email regarding issues related to difficulties in obtaining TB specimen results via phone, especially when the submitters were other than a local health department. In order to foster better communications, DCLS has provided some additional information that they would like to share with the local health departments.

Normal working hours are 8:15 AM - 5:00 PM, Monday through Friday.When submitting specimens for tuberculosis culture, please write the patient name and date of collection on the specimen tube. A self-stick label may be used for this purpose, if needed.The laboratory request should include the patient name, address, county of residence and collection date of the specimen.DCLS processes specimens every morning and then prepares a smear and inoculates culture media for each specimen. This is a lengthy process and takes most of the morning. Because of this and to minimize work disruptions, phone calls during this time period are discouraged.Smear specimen results are usually ready after 3:00 PM.All positive smear results on new patients are phone to the submitter and health department the day the specimen is processed.Once acid-fast growth is detected in culture, an M. tuberculosis complex or M. avium complex DNA probe may be performed.All positive M. tuberculosis complex probe results on new patients are phoned to the submitter and health department.
Drug studies on M. tuberculosis cultures are performed and the detection of drug resistance is phone to the submitter and health department

In Reprise, Protocol for Obtaining Telephone Reports

The following is the text of the protocol for obtaining telephone reports from DCLS that was distributed earlier by email to all local health departments.

To address everyone's needs and concerns, DCLS and DTC have developed the following protocol for obtaining phone reports from the lab regardless of the original submitter.

Requests for verbal reports on specimen results can be made to DCLS if the results are urgently needed for patient management decisions. The PHN or other health department employee should provide the name of the patient, the date of collection, the origin of the specimen, if known, etc., along with the name of the requester. If the requester is known to DCLS staff, results will be given at that time. Otherwise, the procedure outlined below will be followed.Both the DCLS staff member and the requester will hang up. As soon as practical, DCLS will then return the call to the main health department number published on the VDH web site and ask for the requester, and provide the results.
Hard copy reports will be provided through normal distribution channels.

TB Drugs and Ototoxicity

[The following information is adapted from a presentation by Cheryl E. Rice, M.S. CCC-A, Audiologist with the Speech and Hearing Clinic of the Fairfax County Health Department.]

Drugs from many different categories can be ototoxic. These include some types of diuretics such as furosemide, antimalarial agents, and chemicals such as lead and mercury. Of importance in TB Control are the ototoxic effects of the aminoglycosides (streptomycin, kanamycin, Amikacin and capreomycin).

The aminoglycosides are commonly used antibiotics worldwide due to their high effectiveness and low cost. First discovered in 1944 by Selman Waksman, streptomycin was the first successful therapy against tuberculosis. Reports of the ototoxic effects of streptomycin began to be reported in 1945 and additional aminoglycosides were developed in the hopes of minimizing these effects. All aminoglycosides possess some degree of ototoxicity.

Hearing loss from these medications begins initially in the higher frequencies, 4000-8000 Hz, and then progresses to the lower frequencies. Hearing loss can begin almost immediately or can be delayed. As the aminoglycosides are retained in the inner ear longer than in the blood stream, the loss can be progressive for up to one year following treatment. The damage to the ear starts in the outer hair cells that line the base of the cochlea, finally progressing to nerve fiber degeneration.

The risk for damage increases with the length of time the medication is used, with increased dosages, with the use of multiple ototoxic drugs and with insufficient kidney function. Risk may also be increased with a history of previous ototoxicity or exposure to ototoxic drugs or a possible interaction between ototoxicity and noise induced hearing loss.

The normal hearing threshold for all frequencies is in 10-25 decibels range. Hearing loss is defined as mild in the 26-45 decibel range, moderate in the 46-70 decibel range, severe in the 71-90 decibel range and profound over 90 decibels.

Some points to remember:

Avoid other ototoxic medications while patients are on aminoglycosides.
Avoid exposure to loud noise while on aminoglycosides.
Avoid aminoglycosides if the patient was previously exposed to ototoxic drugs.
If possible, patients should have a baseline audiogram prior to initiation of treatment with aminoglycosides
DTC recommends monthly assessment of hearing while patients are on ototoxic medications. Patients should be assessed for symptoms such as tinnitus and vertigo in addition to hearing.
Patients with any symptoms of hearing or vestibular toxicity should be referred immediately for evaluation. If possible, the medication should be discontinued. However, in cases of drug resistance, this may not always be possible.

Additional information on These Topics
Centers for Disease Control and Prevention. Treatment of Tuberculosis, American thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003;52(No. RR-11)

http://www.vestibular.org/ototox.html

Anderson, Philip, Knoben, James and Troutman. Handbook of Clinical Drug Data, 10th Edition. McGraw Hill:2002.

Last Updated: 01-05-2007

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