Latent tuberculosis infection (LTBI) treatment is a cornerstone of tuberculosis (TB) elimination in the United States. Historically, LTBI treatment required lengthy regimens; a new 3-month, weekly isoniazid (INH) and rifapentine (RPT) regimen has improved completion rates, despite requiring directly observed therapy (DOT). Although this regimen has been recommended by CDC and used by TB programs, 3HP uptake in a national health system has not been described. We examined the barriers to 3HP adoption and use in the Indian Health Service (IHS). TB incidence in this population remains more than twice the U.S. national rate.
RPT orders were deemed a surrogate marker for 3HP use. RPT dose order data for FY 2012–2015 from the IHS National Pharmaceutical Supply Service Center were analyzed. All federal sites and the majority of tribal facilities use a common VISTA-based electronic health record (EHR) system. In addition, an on-line survey was sent to all IHS and tribal pharmacy directors in the 12 IHS administrative regions to assess EHR medication ordering rules and other barriers related to 3HP use.
Initial RPT orders occurred <30 days of the 3HP guidelines publication. Orders have been received from the 8 most populous regions. Orders from a Southwest region comprised 12,576/22,400 (>56%) of all doses. Three ordering spikes of >1,000 RPT doses were linked to contact treatment in TB outbreaks (Fig 1). Doses were shipped to federal (56%) and tribal (44%) facilities. Forty-seven pharmacy directors from 10 IHS regions submitted survey responses. While 80% reported anti-TB medication availability, only 26% confirmed 3HP education and 20% cited 3HP as their primary LTBI regimen. Only 48% identified DOT structures available for 3HP administration. Order sets and medication guidance for anti-TB medications were incorporated into the EHR at only 20% of sites.
As a national health system with a high-risk population, the IHS was an early adopter of 3HP for LTBI treatment. The 3HP protocol has been used in response to TB outbreaks and its adoption has spread gradually to the majority of regions. Lack of provider education, lack of convenient EHR ordering options, and lack of availability of DOT remain barriers to the broader acceptance of the regimen.
N. Nwana, None
M. Bartholomew, None