In this issue...
Alert! Treatment Issues with Recent Arrivals from the Philippines
Issues Related to the Delivery of Medication to Patients
Frequency of Follow-up Sputum Collection for Pulmonary TB Patients
This is the second 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 second edition useful in your TB Control efforts. We welcome your feedback.
The Prince William Health District has reported several discrepancies in the immigration documentation on recent arrivals from the Philippines. In recent months, several patients have been evaluated who received pre-immigration evaluation at St. Luke's Hospital in Manilla, Philippines. The medical paperwork documented abnormal x-rays, three negative sputum smears, no treatment recommended and referral to private physicians for further evaluation. The patients were subsequently started on anti-TB treatment by other physicians or facilities prior to departure for the US. In one instance, the individual may have been severely under dosed. Districts should be alert for other recent arrivals from the Philippines as well as other parts of the world who may have been started on anti-tuberculosis drugs at some time after the immigration screening physical. If additional cases are found, they should be reported to Jane Moore, RN, MHSA at DTC.
Several concerns have arisen lately regarding the delivery of TB medications to patients in different settings. These involve both the daily and intermittent delivery of Directly Observed Therapy by Outreach Workers (ORWs) and monthly refills of medications for the treatment of latent TB infection (LTBI).
Directly Observed Therapy (DOT)
By definition, dispensing is the placement of medications into an unmarked container, which is then labeled with the name of a specific patient and instructions for administration. In Virginia, only registered pharmacists and public health physicians may perform this act. Neither nurses nor outreach workers are authorized to dispense medications. Therefore, the repackaging of medications into unmarked envelopes, or bottles which will then be labeled and distributed to patients is not permitted.
Medications for TB DOT should not be left in the home or other DOT locations except for weekend/holiday doses. Instead, the individual containers labeled by the pharmacist should be carried to the home, worksite, or other DOT locations by the nurse or ORW. Small coolers can be used during hot weather to transport the medications. If needed, a small cold pack can be placed in the cooler, but care must be taken to minimize accumulation of moisture inside the cooler and, more importantly, inside medication bottles as this can affect drug stability.
Administration is the act of removing the prescribed dose of medication from a labeled container and giving it to the patient for ingestion. Nurses and physicians are licensed to perform this act. Therefore, nurses can administer one dose of prescribed medications from bulk containers, if needed. DOT, which may include the act of administration may be performed without restriction by nurses or physicians. Because they are unlicensed, ORWs should, under optimal circumstances watch the patient remove and ingest the prescribed dose from the labeled containers, assuring that the correct number of tablets/capsules are removed and ingested. Prior to weekends or holidays, the nurse or ORW should watch the patient remove the correct number of pills for self-administration and place them in a container in a secure location. All staff, including unlicensed ORWs may assist in medication administration if the patient is unable do this on their own as, for example, in patients with physical limitations (visual impairment, arthritis). DTC recommends that ORWs and nurses use their judgment in determining the amount of assistance required for optimal medication administration.
Monthly refills of meds for treatment of LTBI
As long as the medication is appropriately labeled by a pharmacist, with the patient name and directions, the local health director may authorize staff other than nurses to deliver the refill to the patient. This authorization is based on the understanding that the medication has already been prescribed by appropriately licensed provider (MD, NP, PA) for the entire course of treatment. Unlicensed staff should be appropriately trained to discuss adherence and adverse drug effect issues with the patient. Staff should review potential adverse effects with the patient on each visit and remind the patient to call immediately if any symptoms or problems occur. If the patient voices any concerns, the refill should not be delivered by the non-licensed staff member. The patient should be immediately referred to a nurse for additional assessment and follow-up to determine if the medication should be delivered and continued or held pending medical review. The use of checklists to insure that appropriate information is reviewed with the patient concerning compliance, side effect and toxicity, and appropriate reminders is encouraged. Appropriate procedures for documentation of the patient encounter with symptom review and reminders should also be in place.
For patients with positive sputum smears, follow-up collections should be made every 2 weeks until the patient is presumed to be close to the point of smear conversion. The frequency of collections should then be increased to at least weekly to "catch" the point of conversion as precisely possible, so the patient can be released from isolation and return to normal activity.
Patients whose sputum specimens are initially negative on smear or whose sputum smears convert to negative during treatment should have monthly specimen collection until cultures have converted to negative. No further sputum collection is necessary beyond the point of culture conversion unless there is a clinical indication (e.g. recurrence or persistence of TB-like symptoms or treatment interruption) to resume collections. Individuals with MDRTB or HIV-TB may require additional sputum testing to monitor their clinical course.
Recommendations for Sputum Collection
Purpose |
Frequency |
Number of specimens |
Initial Monitoring for smear conversion |
Every 2 weeks after week 2 of therapy |
1 sample - Collection observed by health care worker |
Monitoring for imminent smear conversion |
Every few days to weekly |
3 samples on three different days - At least one should be observed by health care worker |
Monitoring for culture conversion |
Monthly |
3 samples on three different days - At least one should be observed by health care worker |
Monitoring after culture conversion |
Only if clinically indicated |
3 samples on three different days - At least one should be observed by health care worker |