Control of Tuberculosis in the United States - Research Paper Example

Tuberculosis Control in the United States Introduction Tuberculosis (TB) is one of the most dangerous bacterial infections afflicting the worldwide population. It is an infection caused by the bacteria Mycobacterium tuberculosis (M. tuberculosis). It can affect any part of the body, but it primarily attacks the lungs. It is spread through inhalation of the TB bacteria released by coughing or sneezing TB patients. In 2005, about 1.6 million deaths were attributed to tuberculosis (World Health Organization, 2007). In the United States, the Centers for Disease Control (CDC) revealed that in 2007, about 13,000 TB cases were reported. California, Texas, New York, and Florida account for 48% of TB cases in the US with Hispanics representing the largest population of TB sufferers. Asians and African-Americans represent the second highest population with 26% each. Asians born outside the U.S. account for 43% of TB cases in the US; and overall, about 81% of TB sufferers are born outside the United States (Centers for Disease Control, 2007, p. 3). TB is an important problem in the United States and comparing previous annual figures on TB, cases are continuing to increase annually. It implies a need for US health authorities to re-evaluate the TB control and management programs in the U.S. to make them more responsive to this growing problem. Tuberculosis in the United States is transmitted through close contact with an active TB patient. Contact with a foreign-born immigrant with active TB is a way for this disease to infect others; other high risk individuals exhibiting active TB symptoms are also sources of TB infection in other individuals. The Mycobacterium tuberculosis bacteria would be present in the sputum of an active TB patient; a TB patient coughing or sneezing would release the bacteria to the air through droplets which may be inhaled by other people (Schoenstadt, 2008). The TB types which are present in the United States are: active TB, latent TB, and multi-drug resistant TB. Active TB is seen in full-blown TB patients who actively exhibit the symptoms of the disease; those with latent TB have the bacteria causing TB, but are asymptomatic; those with MDR-TB are those who do not respond to the first line of treatment for the disease (Wrong Diagnosis, 2009). This paper shall discuss tuberculosis – the disease process, transmission, detection, risk factors, prevention, and control measures in the United States. Disease Process Tuberculosis has undergone many transformations throughout history. The pathogenic organism of tuberculosis was discovered in 1882 and until the 1950s, people were unaware that properly treated TB patients could live healthy lives in the future. In 1943, an American scientist, Selman Waksman, found a treatment to destroy tuberculosis pathogen. In the decade that followed, two more drugs were discovered. This innovation helped many tuberculosis patients recover and successfully decreased the TB mortality rate in the United States. It was thought that within two decades the disease would die out or get completely eradicated (Dias-Baptista et al., 2008). It was a complete shock when there was a resurgence of the disease in the mid-1980s to the early 90s. Multi-drug resistant cases of TB also increased. As a result, the WHO announced TB a global public health crisis in 1993. The upsurge in communicable diseases was attributed to several factors like HIV epidemic in 1980s, aging of the world population, immigration to developed countries from countries where TB is common, the spread of TB in certain settings (for example, correctional facilities and homeless shelters), change in social structure and inadequate funding for TB control (Dias-Baptista et al., 2008). The pandemic had given rise to international surveillance. Countries created modern TB detection labs. Then, from 1993 onwards the rate of infected TB patients began to fall (Dias-Baptista et al., 2008). They still continue to fall especially in the United States. Recent developments in TB control in the United States mostly involve the identification of TB patients in their countries of origin. Positive TB patients are prevented from leaving their countries of origin until they are treated for their disease and subsequent sputum smears reveal a negative result. Doctors are also prevented from administering medical treatment to undocumented aliens who exhibit TB symptoms. At present such methods are being adapted by the United States in an effort to control the spread of TB in the population (Iseman & Stark, 1995). The United States is presently controlling the disease by maintaining the decline in TB incidence through the timely diagnosis of active TB alongside appropriate treatment of those with active TB. Another goal of TB control is to accelerate the decline of active TB through the treatment of those with latent TB infection. TB control in the United States also involves the development of new tools for diagnosis, treatment and prevention of the disease; the reduction of the global TB burden by increasing the participation of the United States in the worldwide TB programs; the mobilization of public support by engaging policy leaders and healthcare providers; and the monitoring the progress of the disease in the United States (Centers for Disease Control National Prevention Information Network, n.d). Multi-drug resistant tuberculosis is the form of TB which is resistant to two or more of the primary drugs for TB. This form of TB mostly affects foreign-born immigrants and HIV/AIDS patients. Management of MDR-TB, firstly involves the identification of the particular strain of the disease present in the patient. Treatment then follows drug therapy over many months, sometimes, even years. Compliance of treatment is monitored by health professional in instances of low compliance (Centers for Disease Control, 2001). The Food and Drug Administration has recently approved Rifater, a drug which combines the three main drugs against TB. As a result, the patient will now take one pill instead of three; and this drug has improved patient compliance for TB patients (American Lung Association, 2007). A low socio-economic status can bring about a conglomeration of factors that would eventually make a person vulnerable to tuberculosis (AIDS Education and Training Centers, 2009). In the United States, a large percentage of TB sufferers are poor, homeless, in prison, or living in close and crowded shelters. Drug and alcohol abuse is also a risk factor for tuberculosis with about 19% of cases reporting drug or alcohol abuse in the year before the TB diagnosis. Recent immigration to the United States from a nation with a high percentage of TB is also a risk factor for the development of the disease. Healthcare workers are also considered high-risk persons in developing TB because of their prolonged and repeated contact with patients. Aside from the above risk factors, in the United States, HIV-AIDS is also considered a risk factor for TB (Oeltman, et.al., 2006, as cited by Join Together, 2009). The compromised immune system of the HIV-AIDS patients makes them especially vulnerable to this disease. The disease can also give rise to a number of complications that the patient cannot resist. In some cases, it can bring about the patient’s death. Worldwide, TB accounts for 50% of deaths in HIV-AIDS patients (The U.S. President’s Emergency Plan for AIDS, 2009). In the United States, it is also one of the main causes of death in HIV-AIDS patients. The transmission is facilitated mainly through patient non-compliance. Some patients often forget to take their medications resulting to an ineffective TB therapy. Incomplete or interrupted treatment regimen for the treatment of the disease causes emergence of MDR-TB and increased possibility of transmission of the disease to other people. A patient who has started treatment for TB usually becomes non-infectious after a week of TB treatment. Hence, low compliance for those who cannot afford or who have limited access to the TB meds increases possibility of transmission (Bartley, 2001). Detection Various diagnostic tests are available in the United States to detect and diagnose TB. The Mantoux test or the PPD Test (Purified Protein Derivative) is one of the initial tests used to diagnose and detect this disease. It is used to detect TB infection in people within 6-8 weeks after initial exposure. Most individuals who have had previous exposure to the disease and to the bacteria causing the disease can have a positive Mantoux test (Wrong Diagnosis, 2009). Additional confirmatory tests need to be undertaken before a definitive TB diagnosis can be made. This test is usually done in the community health centres and other local health departments with the assistance and support of the Centers for Disease Control (Nies & McEwan, 2001, p, 687). Foreign-born immigrants and other high-risk groups are targeted by these testing centres for testing. In some schools, this test is undertaken on their foreign-born students and other foreign students (Conova, 2002). So far, this test is not reliable because it also detects latent TB and subjects who have undergone BCG vaccination identifying them as carriers of the TB bacteria (Centers for Disease Control, 2001). The latest diagnostic test being recommended by the CDC to detect TB is the QuantiFeron-TB Gold Test. At present, it is mainly being applied in the United States and other more developed nations. This is a blood test that helps detect active and latent tuberculosis. The patient’s blood is incubated with proteins from the TB bacteria. The presence of TB bacteria in the patient’s blood will make the immune cells in the blood sample respond to the proteins by producing interferon-gamma. Interferon-gamma is then detected by this test. A patient who tests positive in a Mantoux test because of a prior BCG vaccination will test negative in the QuantiFeron-TB Gold Test (eMedicine Health, 2009). The QuantiFeron-TB Gold Test is therefore more accurate than the Mantoux test and other diagnostic tests for the disease because it only detects active TB. This test is available in selected community health network clinics and administered only to high-risk patients. This test is being used to definitively identify the presence of the disease and to ensure that measures are immediately taken in their treatment (Department of Public Health, 2005, p. 2). Impact (Epidemiological, Social, Economic, and Political) The epidemiological impact of this disease has changed throughout the years. From 1985 to 1992, TB incidence increased. After massive and thorough control measures were applied, the numbers the incidence of the disease decreased and continued to decrease in the years that followed. However, the number of TB cases in foreign-born populations continued to increase and as was previously mentioned, they now make-up the bulk of TB sufferers in the U.S. As the cooperation of federal and private agencies has now been strengthened in order to fight this disease, the epidemiological impact of the disease in the United States is now in a very manageable level (McCray, et.al., 1997). The persistence of this disease in the United States is straining the socio-economic condition of those living in poverty. Hard-hit areas and social groups are experiencing a slow-down in their economic growth and progress. Immigrants who are trying to start a new life in the U.S. are experiencing economic difficulties while dealing with this disease and while trying to support their families. This disease is also impacting on urban areas, especially overcrowded and poverty-stricken areas with large refugee and immigrant populations. There is also a likely increase in the Multi-Drug Resistant strain of the disease among high-risk populations. The political implications of tuberculosis in the US are possible immigration policies that may be implemented on immigrants. Strict implementation of TB screening for immigrants entails policy change which should not be construed or interpreted as discriminatory towards immigrants and other visiting non-immigrants. “Overseas TB screening of non-immigrant visitors, who are unlikely to have active TB and even less likely to transmit it, will be of extremely low yield, would significantly deviate from the US ‘open-door’ policy for non-immigrants, and would have great logistical and political implications” (Council on Scientific Affairs, 2009). Some medical practitioners point out how illegal, discriminatory, and abusive practices have been applied to immigrants for the sake of public health. It is imperative then for immigration policies in relation to TB detection and prevention to be undertaken with political sensitivity and consciousness. Primary Control Measures Primary control of the disease involves the early identification and treatment of individuals with TB. Primary prevention and control also includes educating the public, health workers, and at-risk groups. It also includes economic and nutritional support for at-risk groups. HIV counselling is also recommended as an effective means of controlling the incidence of this disease (The Dental Learning Network, n.d). In the United States primary control efforts involve the early detection of TB in at-risk groups (Taylor, et.al., 2005). The initial screening process imposed by the Department of Foreign Affairs, with the assistance of the Department of Immigration are also control measures being applied in the United States. Legislative support is also one of the means by which primary prevention is achieved. In the United States, federal and state support helps set in place prevention and control programs for TB. Policies and national reporting, surveillance, analysis, oversight, monitoring, education, training, and research in aid of control and prevention of TB are also set by lawmakers and federal agencies (Taylor, et.al., 2005). In other parts of the world where TB is prevalent, the BCG vaccine is adopted as a primary control measure. In the United States, experts do not recommend the BCG vaccine. However, some practitioners advocate its use in situations where preventive measures are already inadequate. They especially recommend it for children who are exposed to high-risk and active TB patients (Starke, et.al., 1995). Secondary Control Measures Screening tests and preventive therapy are the secondary measures for TB control. Screening involves interview, medical history and physical examination; tuberculin skin test; chest radiograph; and bacteriologic examination of the sputum (The Dental Learning Network, n.d). The U.S. Centers for Disease Control recommend the test screening of international students coming from countries where TB is prevalent. Most schools in the United States have adopted this policy in order to help detect active TB among their foreign students (University of the Cumberlands, n.d). Screening is also required of foreign born children and immigrants upon their arrival in the United States. Immigrants who test positive under the Mantoux test subsequently undergo further confirmatory tests. Immigrants who are later confirmed to have latent TB infection are immediately treated. Follow-up screening after 6 months is usually undertaken in order to test delayed manifestations of the disease (Sadovsky, 2004). Screening tests for the homeless were also recommended by the CDC. Public clinics were set up in some areas with a large population of homeless individuals and the screening tests are done on subjects who voluntarily subject themselves to the screening (Kong, et.al., 2002). Screening tests for HIV-AIDS patients is also recommended by the CDC. At-risk health workers who have had contact with TB patients are also required to undergo screening tests. In prisons and detention facilities, regular screening is undertaken on inmates, especially those who are foreign-born (Saunders, et.al., 2001). Preventive therapy is implemented through the administration of anti-TB drugs. This reduces the possibility of transmitting the disease to other people. The WHO, with the assistance of public health agencies in countries where TB is prevalent, has adopted the TB-DOTS program (Directly Observed Treatment Shortcourse). This program involves the direct observation and monitoring by the public health workers of patient’s intake of the TB meds. This is primarily geared towards regimen compliance in the TB treatment. In the United States, the physician will first note and rule out current or previous TB disease and contraindications to isoniazid (INH) before it can be administered to the patient. The INH will then be administered daily for a minimum of six months for adults and nine months for children and adolescents. In HIV patients, INH treatment may continue for 12 months. For those who do not comply with the regimen, the DOPT (directly observed prevention therapy) is applied. The same concept as the DOTS program is implemented in the US; the health worker will watch the patient actually take the medication. For those who are resistant to INH, rifampicin is used. The health worker will again observe the patient’s intake of the medication and observe possible adverse reactions to the medication (The Dental Learning Network, n.d). Tertiary Control Measures Tertiary prevention of tuberculosis covers medical treatment using first line drugs, then using second-line drugs, and finally applying surgical intervention. Medical treatment includes isolation in order to prevent spread of the disease. Once treatment regimen is started, the patient usually becomes non-infectious within days. First line drugs are primarily the following: isoniazid, rifampicin, and pyrazinamide or ethambutol. INH may be used on its own as a preventive medicine or it may be used in combination with other TB meds to treat active TB. Rifampicin is also a bactericide for the TB bacteria. Pyrazinamide works on mycobacteria within the macrophages. Ethambutol is considered bacteriostatic on the TB bacteria. The second line of drugs for TB are the following: Para-aminosalicylic acid, Ethionamide, Cycloserine, Capreomycin, and Kanamycine. Surgical intervention is usually seen in the case of extra-pulmonary TB where surgical access is needed to obtain specimens on diseased sites (The Dental Learning Network, n.d). In the United States, tertiary control and prevention of tuberculosis also applies the above measures. More particularly, for the high-risk groups, the above measures are strictly adopted. These high-risk groups are particularly vulnerable to drug-resistant tuberculosis, hence would benefit from the application of the tertiary control program prescribed by the WHO and the CDC. For patients who are do not have the drug-resistant TB, the standard 9-month regimen based on INH and rifampicin is administered daily for 1-2 months, and twice weekly for the remaining 9 months (Brooks, et.al., 2007, p. 326). Surgical intervention in the United States is usually conducted on patients with lungs destroyed by multi-drug resistant TB. “The goal of surgery generally is removal of all gross disease with preservation of uninvolved lung tissue” (Schwartz, et.al., 2006, p. 416). Other indications for surgery may include: complications of previous surgery for TB; lung gangrene; biopsy to confirm diagnosis; complications of pulmonary scarring; pleural tuberculosis; and extra-pulmonary thoracic involvement (Schwartz, et.al., 2006, pp. 415-416). These surgical measures in the United States have mostly been conducted on at-risk groups, especially those with AIDS and those who are immuno-compromised. Weakness and improvements According to the WHO, despite developments in drug treatment, tuberculosis is still a dreaded disease. Dr. Margaret Chan, the director-general of the World Health Organization has expressed worry about the uncontrollable future of TB. Age old diagnostic tests are still being used to detect TB infection. It is worrisome that extensively resistant pathogens giving rise to extensively drug-resistant tuberculosis (XDR-TB) are not responding to two primary anti TB drugs (isoniazid, rifampicin) and not even more expensive second-line drugs like fluoroquinolones (LoBue et al., 2009). Old diagnostic methods like specimen handling, smear staining, adenosine diaminase activity, culture identification etc. may get replaced with new sophisticated diagnostic tools like automated culture methods, nucleic acid amplification methods, genetic identification methods and nonconventional phenotypic diagnostic methods (Palomino et al., 2007). Sending messages to patient’s mobile, medicine kits with built-in reminder alarms are also novel ideas to improve patient compliance. New high risk settings should be found out to implement effective TB prevention and control measures (Johnson, 2009). The WHO’s new Stop TB Strategy based on DOTS, Stop TB Partnerships and the International Standards for quality tuberculosis care are new strategies being considered. The Global Plan (2006–2015) to stop and eliminate TB is in the right direction; and 27 medicines, 15 diagnostics and 8 vaccines are in the production pipeline at various stages ranging from product development to clinical trials. Clinically approved drugs should immediately come into the market with fast licensing. This improved quality care would address the changing nature of the epidemic and meet the requirements of at risk patients. Works Cited Bartley, J., 01 March 2001, Preventing Transmission of TB, Infection Control Today, viewed 17 July 2009 from http://www.infectioncontroltoday.com/articles/402/402_131cover.html Brooks, G., et.al., 2007, Jawetz, Melnick & Adelberg's medical microbiology, USA: McGraw-Hill. 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