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Exposure to Tuberculosis among Newborns in a Nursery: Decision Analysis for Initiation of Prophylaxis

Published online by Cambridge University Press:  21 June 2016

Frank E. Berkowitz ,
Johan L. Severens  and
Henry M. Blumberg
Frank E. Berkowitz*
Affiliation:
Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
Johan L. Severens
Affiliation:
Department of Health Organization, Policy and Economics, University of Maastricht, The Netherlands
Henry M. Blumberg
Affiliation:
Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
*
Department of Pediatrics, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Southeast, Atlanta, GA30303 (fberkow@emory.edu)
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Abstract

Objective.

Newborns in a hospital nursery were exposed to a mother whose sputum was direct-smear negative for acid-fast bacilli but culture positive for Mycobacterium tuberculosis. Given the low risk for exposure, the high susceptibility of infants to M. tuberculosis infection, and the possibility of hepatotoxicity due to isoniazid therapy, a decision analysis model was used to determine whether administration of isoniazid prophylaxis against tuberculosis is preferable to no administration of prophylaxis.

Design.

A decision analysis tree was constructed with software, using probabilities from the literature and costs from local health facilities. The expected values for each strategy were obtained, and sensitivity analyses were performed.

Results.

For the strategy in which prophylaxis was administered under direct observation (DO), the probability for survival was 0.999980. For the strategy in which no prophylaxis was administered, the probability of survival was 0.999950, which corresponds to 3 more deaths per 100,000 patients than with the DO prophylaxis strategy. The incremental cost-effectiveness of the DO prophylaxis strategy was $21,710,000 per death prevented. Sensitivity analysis for survival showed that the DO prophylaxis strategy was preferable to the strategy in which no prophylaxis is given if the probability of infection was >0.0002, the probability of tuberculous disease in an infected infant who did not receive prophylaxis was greater than 0.12, the probability of dying from tuberculosis was greater than 0.025, the probability of hepatotoxicity was less than 0.004, and the probability of dying from hepatotoxicity was less than 0.04. For the strategy in which prophylaxis was administered under non-DO conditions (ie, by parents), the incremental cost-effectiveness was $929,500 per death prevented, which is approximately 5% of the incremental cost-effectiveness of the DO prophylaxis strategy.

Conclusion.

This model provides a structure for determining the preferable prophylaxis strategies for different risks of exposure to tuberculosis in a nursery. Administration of prophylaxis is preferable to no administration of prophylaxis, unless the probability of infection is extremely low.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 27 , Issue 6 , June 2006 , pp. 604 - 611
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2006

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References

1.Kendig, EL, Rodgers, WL. Tuberculosis in the neonatal period. Am Rev Tubero Pulm Dis 1958; 77:418–422.Google Scholar
2.Kopanoff, DE, Snider, DE, Caras, GJ. Isoniazid-related hepatitis. A U.S. Public Health Service Cooperative Surveillance Study. Amer Rev Resp Dis 1978; 117:991–1001.Google ScholarPubMed
3.Hunink, MGM, Glasziou, PP, Siegel, JE, et al. Decision Making in Health and Medicine: Integrating Evidence and Values. Cambridge: Cambridge University Press, 2001.Google Scholar
4.Sox, HC, Blatt, MA, Higgins, MC, Marton, KI. Medical Decision Making. Boston: Butterworth-Heinemann; 1988.Google Scholar
5.Gross, R. Making Medical Decisions: An Approach to Clinical Decision Making for Practicing Physicians. Philadelphia: American College of Physicians; 1999.Google Scholar
6.TreeAge DATA 4.0 [computer program]. Williamstown, MA: TreeAge Software; 2002.Google Scholar
7.Light, IJ, Saidleman, M, Sutherland, JM. Management of newborns after nursery exposure to tuberculosis. Amer Rev Resp Dis 1974; 109:415–419.Google Scholar
8.Steiner, P, Rao, M, Victoria, MS, Rudolph, N, Buynoski, G. Miliary tuberculosis in two infants after nursery exposure: epidemiologic, clinical, and laboratory findings. Am Rev Resp Dis 1976; 113:267–271.Google Scholar
9.Burk, JR, Bahar, D, Wolf, FS, Greene, J, Bailey, WC. Nursery exposure of 528 newborns to a nurse with pulmonary tuberculosis. South Med J 1978; 71:7–10.Google Scholar
10.Myers, JP, Perlstein, PH, Light, IJ, Towbin, RB, Dinscoy, HP, Dinscoy, MY. Tuberculosis in pregnancy with fatal congenital infection. Pediatrics 1981; 67:89–94.Google Scholar
11.Spark, RP, Fox, C, Pock, NA, Opulski, A, Pedron, SL. Perinatal tuberculosis and its public health impact: a case report. Texas Medicine 1996; 92:50–53.Google Scholar
12.Bentley, FJ, Grzybowski, S, Benjamin, B. Tuberculosis in Childhood and Adolescence, with Special Reference to the Pulmonary Forms of the Disease. London: The National Association for the prevention of tuberculosis; 1954.Google Scholar
13.Davies, PDB. The Natural History of Tuberculosis in Children: A Study of Child Contacts in the Brompton Hospital Child Contact Clinic from 1930 to 1952. Edinburgh and London: E. and S . Livingstone; 1961.Google ScholarPubMed
14.Zeidberg, ID, Gass, RS, Dillon, A, Hutcheson, RH. The Williamson County tuberculosis study: a twenty-four-year epidemiologic study. Am Rev Resp Dis 1963;87:1–88.Google Scholar
15.Donald, PR, Beyers, N. Tuberculosis in childhood. In: Davies, PDO, ed. Clinical Tuberculosis. 2nd ed. London: Chapman and Hall Medical; 1998:205–222.Google Scholar
16.Ferebee, SH, Mount, FW. Tuberculosis morbidity in a controlled trial of the prophylactic use of isoniazid among household contacts. Amer Rev Resp Dis 1962; 85:490–521.Google Scholar
17.Cohn, DL, El-Sadr, WM. Treatment of latent tuberculosis infection. In: Reichman, LB, Hershfield, ES, eds. Tuberculosis: A Comprehensive International Approach. 2nd ed. Lung Biology in Health and Disease, vol. 144. New York: Marcel Dekker; 2000:471–502.Google Scholar
18.Tsevat, J, Taylor, WC, Wong, JB, Pauker, SG. Isoniazid for tuberculin reactor: take it or leave it. Am Rev Resp Dis 1988; 137:215–220.Google Scholar
19.Jordan, TJ, Lewit, EM, Reichman, LB. Isoniazid preventive therapy for tuberculosis: decision analysis considering ethnicity and gender. Am Rev Resp Dis 1991; 144:1357–1360.Google Scholar
20.Pope, AS, Sartwell, PE, Zacks, D. Development of tuberculosis in infected children. Am J Public Health 1939; 29:1318–1325.CrossRefGoogle ScholarPubMed
21.Comstock, GW, Livesay, VT, Woolpert, SF. The prognosis of a positive tuberculin reaction in childhood and adolescence. Am J Epidemiol 1974; 99:131–138.Google Scholar
22.Salpeter, SR. Fatal isoniazid-induced hepatitis: its risk during chemopro-phylaxis. West J Med 1993; 159:560–564.Google Scholar
23.Nolan, CM, Goldberg, SV, Buskin, SE. Hepatotoxicity associated with isoniazid preventive therapy: a 7-year survey from a public health tuberculosis clinic. JAMA 1999; 281:1014–1018.Google Scholar
24.Spyridis, P, Sinaniotis, C, Papadea, I, Oreopoulos, L, Hadjiyiannis, S, Papadatos, C. Isoniazid liver injury during chemoprophylaxis in children. Arch Dis Child 1979; 54:65–67.Google Scholar
25.O'Brien, RJ, Long, MW, Cross, FS, Lyle, MA, Snider, DE. Hepatotoxicity from isoniazid and rifampin among children treated for tuberculosis. Pediatrics 1983; 72:491–499.CrossRefGoogle ScholarPubMed
26.American Thoracic Society. Targeted tuberculin testing and treatment of latent tuberculosis infection. Am J Respir Crit Care Med 2000; 161:S221–S247.Google Scholar
27.American Academy of Pediatrics. Tuberculosis. In: Pickering, LK, ed. Redbook: 2003. Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003:657–659.Google Scholar
28.Byrd, RB, Horn, BR, Solomon, DA, Griggs, GA. Toxic effects of isoniazid in tuberculosis chemoprophylaxis: role of biochemical monitoring in 1,000 patients. JAMA 1979; 241:1239–1241.Google Scholar
29.Dash, LA, Comstock, GW, Flynn, JPG. Isoniazid preventive therapy: retrospect and prospect. Amer Rev Resp Dis 1980; 121:1039–1044.Google ScholarPubMed
30.Colice, GC. Decision analysis, public health policy, and isoniazid chemoprophylaxis for young adult tuberculin skin reactors. Arch Intern Med 1990; 150:2517–2522.Google Scholar