Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510, USA.
J Community Health. 2013 Oct;38(5):941-50. doi: 10.1007/s10900-013-9704-y.
Despite its benefit for treating active tuberculosis, directly observed therapy (DOT) for latent tuberculosis infection (LTBI) has been largely understudied among challenging inner city populations. Utilizing questionnaire data from a comprehensive mobile healthcare clinic in New Haven, CT from 2003 to July 2011, a total of 2,523 completed tuberculin skin tests (TSTs) resulted in 356 new LTBIs. Multivariate logistic regression correlated covariates of the two outcomes (a) initiation of isoniazid preventative therapy (IPT) and (b) completion of 9 months of IPT. Of the 357 newly positive TSTs, 86.3 % (n = 308) completed screening chest radiographs (CXRs): 90.3 % (n = 278) were normal, and 0.3 % (n = 1) had active tuberculosis. Of those completing CXR screening, 44.0 % (n = 135) agreed to IPT: 69.6 % (n = 94) selected DOT, and 30.4 % (n = 41) selected self-administered therapy (SAT). Initiating IPT was correlated with undocumented status (AOR = 3.43; p < 0.001) and being born in a country of highest and third highest tuberculosis prevalence (AOR = 14.09; p = 0.017 and AOR = 2.25; p = 0.005, respectively). Those selecting DOT were more likely to be Hispanic (83.0 vs 53.7 %; p < 0.0001), undocumented (57.4 vs 41.5 %; p = 0.012), employed (p < 0.0001), uninsured (p = 0.014), and have stable housing (p = 0.002), no prior cocaine or crack use (p = 0.013) and no recent incarceration (p = 0.001). Completing 9 months of IPT was correlated with no recent incarceration (AOR 5.95; p = 0.036) and younger age (AOR 1.03; p = 0.031). SAT and DOT participants did not significantly differ for IPT duration (6.54 vs 5.68 months; p = 0.216) nor 9-month completion (59.8 vs 46.3 %; p = 0.155). In an urban mobile healthcare sample, screening completion for LTBI was high with nearly half initiating IPT. Undocumented, Hispanic immigrants from high prevalence tuberculosis countries were more likely to self-select DOT at the mobile outreach clinic, potentially because of more culturally, linguistically, and logistically accessible services and self-selection optimization phenomena. Within a diverse, urban environment, DOT and SAT IPT models for LTBI treatment resulted in similar outcomes, yet outcomes were hampered by differential measurement bias between DOT and SAT participants.
尽管直接观察治疗（DOT）在治疗活动性肺结核方面具有益处，但在具有挑战性的城市内部人群中，对潜伏性肺结核感染（LTBI）的 DOT 研究还很少。利用康涅狄格州纽黑文市综合移动医疗诊所 2003 年至 2011 年 7 月的问卷调查数据，共完成了 2523 例结核菌素皮肤试验（TST），结果发现 356 例新 LTBI。多变量逻辑回归分析了两个结果的协变量：（a）开始异烟肼预防性治疗（IPT）和（b）完成 9 个月的 IPT。在 357 例新 TST 阳性者中，86.3%（n=308）完成了筛查性胸片（CXR）：90.3%（n=278）正常，0.3%（n=1）患有活动性肺结核。在完成 CXR 筛查的人群中，44.0%（n=135）同意接受 IPT：69.6%（n=94）选择 DOT，30.4%（n=41）选择自我管理治疗（SAT）。开始 IPT 与无记录身份（优势比[OR]为 3.43；p<0.001）和出生于结核病患病率最高和第三高的国家（OR 分别为 14.09 和 2.25；p=0.017 和 p=0.005）相关。选择 DOT 的人更有可能是西班牙裔（83.0%比 53.7%；p<0.0001）、无记录身份（57.4%比 41.5%；p=0.012）、就业（p<0.0001）、无保险（p=0.014）和有稳定住房（p=0.002），无近期可卡因或快克使用史（p=0.013）和无近期监禁史（p=0.001）。完成 9 个月的 IPT 与无近期监禁史（优势比 5.95；p=0.036）和年龄较小（优势比 1.03；p=0.031）相关。SAT 和 DOT 参与者在 IPT 持续时间（6.54 比 5.68 个月；p=0.216）和 9 个月完成率（59.8%比 46.3%；p=0.155）方面没有显著差异。在城市移动医疗样本中，LTBI 的筛查完成率较高，近一半人开始接受 IPT。无记录身份、来自结核病高流行国家的西班牙裔移民更有可能在移动外展诊所自行选择 DOT，这可能是因为 DOT 提供了更具文化、语言和后勤可及性的服务，以及自我选择优化现象。在一个多样化的城市环境中，DOT 和 SAT 用于 LTBI 治疗的 IPT 模型产生了相似的结果，但结果因 DOT 和 SAT 参与者之间的差异测量偏差而受到阻碍。
