Very few anti-tuberculosis drugs are available in standardized, commercially prepared liquid formulations. Periodically, reports are received from around the state concerning children receiving TB medications in a liquid form prepared by a compounding pharmacy. Use of these locally prepared products is not recommended and is discouraged by the VDH TB Control program (DDP-TB). Due to the high sugar concentration in most of the liquids used to prepare these types of medications, there is a high risk that the anti-tuberculosis medication itself can be inactivated. There are also issues with the stability of the products in general as well as with maintaining the active ingredients in a uniform suspension for administration.

DDP-TB maintains a supply of pill crushers and cutters to assist districts in preparing the medications for administration. Medications should not be mixed into food or liquids for administration until just before it will be administered.

The following information on drug administration to children has been re-printed from the Francis J. Curry National Tuberculosis Center’s Drug-Resistant Tuberculosis – a Survival Guide for Clinicians, page 110. http://www.nationaltbcenter.edu

• Approximate doses of medications are adequate. Exact doses of pill fragments and portions of capsules are impossible to attain. If the child’s dose is 100 mg and the drug comes as a 250 mg table, 2 tablets will supply 5 doses. Any small discrepancy in dosing will even out over time.
  
• Cut tablets into approximate fragments (freeze ethionamide in a small plastic bag before dividing into fragments); crush fragments for smaller children.

• Jiggle capsules open and approximate fractions for serial doses.

• Mix crushed tablets or capsule contents into a small amount of vehicle.

• Some powder will suspend into a liquid well and can pass through a syringe. A dispenser with a bigger opening, such as a medicine dropper, is better than a syringe and will deliver a greater proportion of the drug without sticking the syringe.

• If mixing the medicine in a vehicle before delivery, use a small amount of the vehicle. The child will not want not take many spoonfuls of the drug. Many children will prefer the crushed pills or granules delivered with a soft vehicle.

• Alternatively, a thin layer of a soft vehicle can be placed on the spoon, the powder or pill fragment layered on top, followed by another layer of soft vehicle (making a medication sandwich and preventing drug taste in the vehicle itself).

• Immediately after the medication is given, give good untainted food or drink to clear the palate.

• Give lots of praise and incentives.

• Some drugs can be mixed in a small amount of liquid and given to babies via a special medicine-dispensing pacifier or bottle. Some babies will reflexively suck the medication from a bottle while they sleep. Give water in a clean bottle afterwards to rinse the medicine out of the mouth.

• Be flexible, but firm. The child should get a few choices, but not whether or not to take the medicine.

• The method of delivery may need to be changed throughout the course of treatment.
  

As part the risk assessment and targeted screening process, questions often arise concerning the definition “high prevalence country” for the purposes of completing the risk assessment tool and determining who should receive a tuberculin skin test (TST).
An easy rule of thumb is to consider all countries high prevalence except the US, Canada, Western Europe, Australia and New Zealand. As usual there are exceptions to everything, including “rules of thumb” as countries like Spain and Portugal do not make the exception list. The following is a more complete listing of exception countries based on data from the 2006 World Health Organization (WHO) Global TB Control Report.
As part of the materials distributed for the recent XDR contact investigation, the CDC recently defined high prevalence countries as those having a case rate of > 20 cases per 100,000. Individuals from countries with rates less than 20 per 100,000 should only be tested if they are symptomatic or have another individual risk factor.

Tuberculosis Recognition Award by American Lung Association

The Tuberculosis Recognition Award is given annually by the American Lung Association to honor significant contributions to the prevention and control of tuberculosis in the Commonwealth.   This year’s award recognizes two individuals for excellence in TB lab services.  It was not until recently that TB lab personnel have been considered “TB professionals” by the national public health TB community.  That is amazing, because the lab is critical to TB control.  The lab confirms whether the patient has TB or not, determines if the patient is considered infectious or non-infectious, and if their particular strain of TB has drug resistance. 

Carol Campus has worked at the Division of Consolidated Laboratory Services (popularly know as the State Lab) for 27 years -- most of which has been in the TB lab. She has been the Senior Scientist in TB for the last 10 years helping the lab grow during changes in methodology, technology, staffing, and their recent move to a new building. Carol's dedication to customer service and skills as a mycobacteriologist has helped maintain the lab’s commitment to provide accurate results in a timely fashion. It is my pleasure to present you with this award. 

For nearly 25 years, Mary Louise Kolodziej has been a mycobacteriologist for the Fairfax County Health Department.  She was instrumental in helping the County lab become a full service TB lab.  She is well known for her tireless outreach to the local public health nurses and has been a trainer of state and county TB nurses.  It is my pleasure to present you with this award.

2007 Annual Spittoon Award Winners

The winners of the 2006 Traveling Spittoon Awards were recently announced at the World TB Day Presentations held at Natural Bridge on March 22nd. DDP-tb would like to congratulate all of the winners on their accomplishments during 2006

The Spittoon Award is given to the district in each region that achieves the highest score on a number of criteria.  The award criteria for 2006 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.