Melanie Swift, MD, on Factors Affecting Latent TB Treatment Among Health Care Personnel

In this podcast, Dr Swift discusses the findings of her recent study, which aimed to determine factors associated with acceptance and completion of latent tuberculosis (TB) treatment among health care personnel, whom studies have shown are less likely to accept treatment for latent TB than the general population.

Reference:

• Swift MD, Molella RG, Vaughn AIS, et al. Determinants of latent tuberculosis treatment acceptance and completion in healthcare personnel. Clin Infect Dis. 2020;71(2):284-290. doi:10.1093/cid/ciz817

Melanie Swift, MD, MPH, is an occupational medicine physician and internist at Mayo Clinic in Rochester, Minnesota.

TRANSCRIPT:

Christina Vogt: Hello everyone, and welcome back to another podcast. I’m Christina Vogt, associate editor of the Consultant360 Specialty Network. Today, I’m joined by Dr Melanie Swift, who is an occupational medicine physician and internist at Mayo Clinic in Rochester, Minnesota. Thank you for joining me today, Dr Swift.

Dr Swift: Thank you for having me.

Christina Vogt: Today, we’ll be discussing the findings of her recent study, “Determinants of Latent Tuberculosis Treatment Acceptance and Completion in Healthcare Personnel,” which was published in Clinical Infectious Diseases. So first, in your study, you and your colleagues found that health care personnel are less willing to accept treatment than other populations. Why do you think this was the case? Could you discuss factors that you and your colleagues identified that have an effect on acceptance and completion of latent TB infection treatment?

Dr Swift: Yes. First, let's just define terminology a little bit. Health care personnel is a term used by the CDC and others to encompass a large and diverse group of people who work in health care facilities. And they're both paid and unpaid personnel, like volunteers and students might not be paid. And that includes clinical staff and non-clinical people. So, it might be doctors, nurses, clinical techs that we think of traditionally as health care workers. It also includes non-clinical staff, like janitors and custodians, finance officers, people who work in engineering or facilities management or billing offices that aren't traditionally thought of as health care personnel. And it also includes, in many institutions, researchers.

So, we actually already knew from prior studies that, as a group, health care personnel were less likely to take latent TB treatment than others, but what we didn't know is whether that’s broadly applicable to all health care personnel, or if there's a specific group. Is it nurses that are not wanting to take treatment? Is it doctors? Is it anyone who works in a hospital? So, we wanted to really dive down into that broad categorization of health care personnel, and what we found was that compared to the non-clinical, administrative-type staff that don't have patient contact–that's what we kind of equated to the general population–compared to those non-clinical staff, it was really our physicians and researchers who were less likely to take treatment.

Christina Vogt: You and your colleagues concluded that improving rates of treatment for latent TB infection among health care personnel will require addressing cultural and occupational differences. Could you elaborate more on this?

Dr Swift: Yes. So, we found 2 kind of interesting findings that speak to some sub-populations within the broad population of health care personnel. So, one is, those physicians and researchers who were less than half as likely to accept treatment as non-clinical personnel–they tended to just say “no.” But if they said “yes,” they actually completed treatment at pretty high rate. They just weren't willing to accept it to start with. There was another population that just said “yes” more frequently, but didn't actually complete treatment, and that was health care personnel that had originated in a high TB-burden country. So, a country in which the rates are high and the absolute numbers of people with active tuberculosis are high. And so, we think that this is important, and this seemed consistent with our clinical observations over years of counseling people about latent TB treatment.

And so, I think that we have an opportunity to refine our messaging a little bit and to explore barriers to taking treatment and reluctance to take treatment. And I think that that's going to differ by the sub-populations and by individual factors. And we can't just say, “well, all health care personnel need more TB education.” It's really not it, because it was our highest-educated sub-population, our doctorate-level health care personnel, who were the most reluctant to accept treatment. I don't think it's a knowledge gap about what TB disease is, for instance, vs latent TB infection. I think that it is a different type of knowledge, and I think that it has to do with their need to really understand, what is the public health strategy here, and why has it changed? And why is it different in the United States than in other countries?

So, there's that sort of knowledge that can be eye-opening as I talk with physicians and researchers who are diagnosed, because they kind of know the numbers. They know that their risk of reactivation TB is only about 0.1% a year if they're a low-risk person. So, a 40-year-old physician knows that they've got about a 4% chance of getting active TB if they live to be 80 vs having to take the medication and having concerns about that. So, they see their personal risk is pretty low, but what they haven't really appreciated and probably don't know is that 80% of our active cases in the United States come from people with untreated latent TB, and that we actually have an aspiration to eliminate tuberculosis. And that's not something that I think most people are aware of: if we're going to eliminate tuberculosis in the US, we've got to treat latent TB. Yes, your individual risk is low, but if you could please do this, it would really help us advance our population goal and keep everyone else safer. And by the way, if you do reactivate, you won't have exposed your patients, and that may be the kind of conversation we need to have with this particular sub-population of people

Christina Vogt: What areas of future research are needed going forward?

Dr Swift: There's been a lot of recent research that really has clearly demonstrated that our short-course therapies are easier for people to tolerate and complete, and so, that's been very helpful and can be applied to health care workers, as well as non-health care workers, but I do think we need a little more research into the knowledge, attitudes, and beliefs of health care workers. I can make some assumptions, but we really have not delved into themes or particular barriers that might be experienced by health care personnel, and it's going to be different than the general population. When we talk about barriers to adherence to treatment in the general population, we are often talking about things like access to care, affordability of medication, transportation, etc. And those aren't going to be the barriers for most physicians and nurses and clinical personnel that are working in hospitals, but they're going to have other barriers, and they may experience stigma or feel a sense of stigma. As I said earlier, they may have a knowledge deficit about public health strategy in this area. And they may also have a little bit of a selective exposure to people who've had side effects from medication, and they may have some more sensitivity about and knowledge of potential medication side effects. And so, the conversation I think with them may need to be different. But first, we really need to understand what those barriers are and what the common barriers for taking treatment are among health care personnel in particular.

Christina Vogt: What key takeaways do you hope to leave with providers on this topic?

Dr Swift: I have a few. The first is that health care personnel as a population comprise a very heterogeneous population. It is extremely different to counsel someone here in Minnesota who was born and raised here and is working as a nurse's aide from someone who was born and raised in India and is coming here with 3 doctoral degrees to take care of a highly select group of patients. These are really 2 different conversations that we have to have, and it's not just health care personnel all fitting some particular mold.

The second is that, I do think there's barriers that differ by occupational subgroup that we should attend to, and that we need to be able to tailor education and that conversation to the particular needs of that occupational group, and particularly getting away from giving physicians and PhD researchers a standard patient education pamphlet about tuberculosis. That is not going to really influence them at all and may, in fact, insult them. Thirdly, I think that we need to raise awareness among health care personnel and the providers of care to health care personnel that the WHO does have a global plan to end TB, and that we must, in the United States, really focus on treatment of latent TB in order to meet this goal.

And then, one last takeaway from our study that I would just like to highlight is the dropout rate, which wasn't great–75% or so of the people who started treatment completed it, but of those who dropped out–they tended to do so during the first month, and I think therein lies an opportunity for clinicians who are treating individuals that they're starting on treatment for latent TB to build into their clinical process a follow-up, keeping in touch with that person for that first month of treatment, regardless of the treatment that they're taking, whether it's rifampin or INH or 3HP. Within that first month is when people may experience some hesitancy about continuing treatment. They may have second thoughts. They may talk to friends and family who’ve cast doubt on the wisdom of taking this medication, and they may have experienced a symptom that they attribute to a medication side effect, which may or may not be, and may or may not be a serious one. But, that's an opportunity to intervene and potentially help someone to feel more comfortable completing their course of therapy.

Christina Vogt: Thanks again for joining me today, Dr Swift.

Dr Swift: Thank you so much for having me.

Christina Vogt: For more podcasts like this, visit Consultant360.com.