TMA Looks to Broaden Rules for Postexposure Prophylaxis
Public Health Feature — August 2014
Tex Med. 2014;110(8):39-41.
By Kara Nuzback
It's natural for physicians to want to keep people from getting sick. Sometimes, regulations stand in the way of giving proper treatment to those at risk of illness.
Pediatric infectious disease specialist Jane Siegel, MD, who works at The University of Texas Southwestern Medical Center in Dallas, says last September an 11-week-old infant came to the center from a facility outside the Dallas area. Dr. Siegel says at the time of transfer the infant was "very sick with pertussis."
Her team placed the infant on a ventilator and recommended the child's family, including the mother, father, and sibling, receive postexposure prophylaxis (PEP), or treatment administered immediately after exposure to an illness.
But Texas Medical Board (TMB) rules prevented the physicians from treating the infant's family because they had not established a "proper professional relationship" with anyone except the infant. Physicians in Texas can prescribe treatment to nonestablished patients only in cases of sexually transmitted diseases or when the governor declares a pandemic. (Read "EPT Permitted," December 2009 Texas Medicine, pages 55-58.)
Dr. Siegel says the mother and the sibling showed symptoms of respiratory distress. The mother reported she hadn't been vaccinated against pertussis during her last pregnancy.
The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices and the American Congress of Obstetricians and Gynecologists recommend pregnant women and other family members receive the tetanus, diphtheria, and pertussis (Tdap) vaccine during every pregnancy. She says it is possible the mother had pertussis and passed it to the infant.
"That's the typical story we hear," Dr. Siegel said.
She says the uninsured family was unable to get PEP from their local health department or to seek prescriptions for PEP from primary care physicians while the infant received treatment in Dallas, about 75 miles away from home.
"The last thing a mother will do is get on the phone about PEP when her baby is on a ventilator," she said. "She's not about to leave the bedside."
Physicians debated who would write the PEP prescription because technically it was against TMB rules to treat the family.
"It was an uncomfortable situation," she said. "And it's not an uncommon story."
The Texas Medical Association is working with TMB to change the rules associated with PEP to better enable physicians to implement CDC recommendations.
CDC, the American Public Health Association, and the American Academy of Pediatrics recommend PEP as a preventive measure for various infectious diseases, including pertussis and meningococcal meningitis, for family members or others in close proximity to patients with the illnesses. Depending on the illness, PEP can come in the form of antibiotics, vaccines, or immune globulins.
Access CDC's PEP recommendations for various illnesses on the CDC's website.
Ultimately, Dr. Siegel says, the infant's family members received an antibiotic prescription.
She says many physicians in similar situations face an uncomfortable dilemma: If they write PEP prescriptions for nonestablished patients to prevent the spread of disease, they're violating TMB rules.
"That's why we want to see a [rule] change," she said.
Closing the Gaps
The Texas Department of State Health Services (DSHS) received reports of nearly 4,000 cases of pertussis in 2013. As of May 1, DSHS reported more than 600 Texans had received pertussis diagnoses this year. For the most recent DSHS pertussis statistics, visit the DSHS website.
TMB limits PEP in most cases to an established patient of the prescribing physician. You may view the rule and criteria for establishing a proper professional relationship with a patient here.
Several states allow physicians to provide PEP to nonestablished patients for pertussis and other infectious diseases such as flu and chickenpox. Wendy Chung, MD, chair of TMA's Committee on Infectious Diseases, says Texas should be among those states.
In May, TMA's House of Delegates adopted recommendations in a report of the Committee on Infectious Diseases to work with TMB to allow physicians to implement recommendations for PEP approved by CDC and DSHS. The report calls for DSHS to inform physicians of the PEP recommendations and services available from state and local health authorities and for timely dissemination of information on preventable disease outbreaks to physicians.
Dr. Chung, who specializes in pediatric infectious diseases in Dallas and is the chief epidemiologist for Dallas County Health and Human Services, says the surge in pertussis cases last year highlighted chronic gaps in patient access to preventive antibiotics. The inability of physicians to prescribe PEP to household members of pertussis patients is one of those gaps, she says.
"There's been a need identified to allow physicians to prescribe these preventive antibiotics to close contacts of cases," she said.
In other words, if a physician diagnoses a child with pertussis, the physician should be able to prescribe antibiotics to the child and his or her immediate family members or other individuals who regularly come in close contact with the child.
In January, CDC released a video titled "Considerations for Antimicrobial Prophylaxis After Exposure to Pertussis," which encourages physicians to provide PEP to all household contacts of a pertussis patient.
"For the patient with resources and health insurance, getting PEP is not as much of a problem," Dr. Chung said.
But patients without primary care physicians or with limited access to primary care clinics can experience inordinate difficulties when attempting to obtain a prescription for PEP, she says.
In Favor of Change
TMB spokesperson Jarrett Schneider says TMB discussed the rule change at its May meeting and voted to publish the proposal in the Texas Register to allow public comment on the change.
At press time, Mr. Schneider said TMB would likely discuss whether to adopt the rule change at its June meeting.
"The board anticipates the amended rules will allow for more efficient and timely treatment of certain infectious diseases that are of primary public health concern," Mr. Schneider said in an email.
Lisa Cornelius, MD, DSHS infectious diseases medical officer, says allowing physicians to prescribe PEP to more people could help those with limited access to care get PEP more quickly and at a lower cost.
"That would speed up the interruption of disease transmission, resulting in fewer or less severe cases of the disease," she said.
She says DSHS has not formally analyzed potential costs or savings associated with expanding PEP, "but generally speaking, preventing disease saves money in the long run."
Antibiotics and doctor visits for a whole family can get expensive. Dr. Chung says without health insurance, one course of antibiotics for pertussis can cost up to $30. If a child with pertussis lives under the same roof as parents, siblings, and extended family, that means a doctor visit for every family member, Dr. Cornelius says.
"That's a lot of time and money that can be real barriers to the family getting prophylaxis at all," she said. "If the physician who diagnoses the pertussis case can write prescriptions for the whole family, you've saved the family the time and the cost of taking everyone to the doctor."
Dr. Chung says options have been limited for those without a primary care doctor to obtain a PEP prescription.
"Even when patients needing PEP have a primary care doctor, it is not uncommon to be told that it may be weeks before an appointment is available in a busy clinic," she said.
If TMB changes its rule, a child's primary care doctor could be allowed to prescribe PEP to an entire family immediately after exposure.
Kara Nuzback can be reached by telephone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.
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