DOT in the schools gives good results
Early call at the clinic works in Newark
Since most teens spend a lot of their time in school, TB control programs in some areas are turning to schools to boost compliance among teen-agers on preventive therapy.
In Boston, a partnership between the public health department and school-based health centers at several high schools has increased completion rates for preventive therapy to an impressive 95%, says Karen Hacker, MD. Hacker is director of adolescent and school services for the Boston Public Health Commission, and president of National Assembly of School-Based Healthcare.
In Newark, pediatric experts at the TB Model Center have begun recruiting help from school nurses in three urban counties. They hope eventually to expand the program to cover the whole state, says Lillian Pirog, RN, BSN, PNP, pediatric clinician at the Model Center.
TB clinics initiated both ventures, but the services provided in the two places vary in scope and content.
In Boston, school-based health centers - the big comprehensive clinics in more than 1,000 high schools across the nation - have been turned into points of contact for students. Instead of receiving directly observed preventive therapy (DOPT), the Boston students simply come in once a month to pick up their pills, Hacker says. In New Jersey, school nurses actually provide DOPT, watching as students take their pills, says Pirog. In each case, the result is the same: Adherence among teens on preventive therapy has improved.
In many ways, schools provide the ideal setting for monitoring preventive therapy, says Anju Sikand, MD, assistant professor of pediatrics in the Division of Adolescent Medicine at the Children's Hospital of Michigan in Detroit. "If I know there is a school-based clinic or a school nurse, I always try to get them involved," Sikand says. "It's so accessible - kids just come in for a quick visit, without the parent having to drive them somewhere. If the students have questions, they can get the answer right away, which is very important with kids this age."
In Boston and Newark, TB specialists faced different challenges, Hacker and Pirog say. In Boston, the problem wasn't compliance but lack of access. "Many of our skin-test-positive students are Asian, and they're really invested in getting an education," Sikand says. "They would take their medicine, but they didn't want to leave school to go to a clinic." Using the clinics as a pick-up point "was exactly what these families wanted."
Not so in Newark, Pirog says. Operating with a no-excuses, one-strike policy, she gives every teen one chance at self-administration. "And even though we may document that they pick up the pills, more and more I find that doesn't mean they actually take them," she says. As for teens who skip out on a clinic visit, they quickly find it's DOPT for the duration.
School nurses overlooked
In some jurisdictions, overworked school nurses don't have the time to do DOPT, Pirog and Hacker say. Some harried school nurses see more than 200 children a day, Pirog says; already, their duties typically include dispensing Ritalin and helping asthmatic kids with inhalers or diabetic kids with insulin injections. When she began surveying nurses about their attitudes on the subject, the prospect of adding another daily duty didn't set well with everyone, Pirog says.
Many nurses fret about the prospect of tracking down absentee students, and some believe parents should give teens their meds, not the schools.
Pirog looked for ways around those hurdles. In busy clinics, it helps for teens to come in early in the morning, before the rush begins, she says. Keeping juice or crackers on hand ensures they won't have to take a pill on an empty stomach. (Teens prefer coming early, too, she says; that way, they don't miss lunch with their friends.)
Giving isoniazid on a twice-weekly, not daily, schedule makes it easier to cope with absentee teens. By giving the medicine on Mondays and Thursdays, a teen who misses school one of those days has another shot on Tuesday or Friday. For more difficult cases, the public health clinic sends its own outreach worker to teens' homes.
As for the belief that parents should do the job instead of the schools, Pirog explains it's not possible for many parents. "I had one mother tell me the other day that she works five jobs, and she can't remember to give her child the medicine," she says. Even without five jobs, it's hard. "You can't control teens' behavior like you can younger children," Pirog points out. "They say, `Leave me alone; I'll take the pill.' But you look, and they haven't opened the bottle."
Summers are tough, Hacker and Pirog say, because kids aren't in school. Often, foreign-born children travel abroad to spend summers with relatives while their parents work, Pirog says. She stresses how taking the INH protects them from reinfection from active cases they encounter.
The TB clinic tries to make it easy on kids who stay in the city, with long hours to accommodate everyone's schedules. Teens often prefer to come to the clinic early, so they don't have to wait for someone to show up at their homes.
Pirog is working on a pocket-size manual for school nurses who give DOPT. It should be ready by fall and will be available through the Centers for Disease Control and Prevention in Atlanta, she says.
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