Case Study 12 Annie Christian, Molly Heinlein, Garrett ... · CASE STUDY 12: TUBERCULOSIS 3 Health: Tuberculosis History Tuberculosis is an infectious disease in which the bacterium,

Running Head: CASE STUDY 12: TUBERCULOSIS

Case Study 12

Annie Christian, Molly Heinlein, Garrett McBroom, Arohi Patel

HPRB 3700

29 November 2018

CASE STUDY 12: TUBERCULOSIS

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Table of Contents

Case Study ……………………………………………………………………………………….2

Health …………………………………………………………………………………………….3

Culture ………………………………………………………………………………………….24

Needs Assessment ………………………………………………………………………………34

Resources ……………………………………………………………………………………….42

Sustainable Solution …………………………………………………………………………...54

Resource Handout ……………………………………………………………………………...57

Critical Reflection – Arohi …………………………………………………………………….58

Critical Reflection – Molly ……………………………………………………………………...60

References ………………………………………………………………………………………62


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Case Study 12: Tuberculosis

Mateo is a pilot for a large commercial airline. He has had a cough for some time but has

not felt ill. Today his routine tuberculin skin test indicates he has been exposed to TB. More

information is needed to determine what strain of TB he has, but his work is immediately

suspended. Additional laboratory tests will determine if the strain he has is drug resistant. He has

visited his family in Mexico relatively recently but does not know how he contracted the disease.

He feels strong, in the prime of his life, and wants to go back to work. What steps are now

necessary to help Mateo and the people (including his wife and children as well as family in

Mexico) with whom he has been in contact? What agencies in the community will be involved?

How will his work be affected?


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Health: Tuberculosis History

Tuberculosis is an infectious disease in which the bacterium, Mycobacterium

tuberculosis, infects the body of the host organism and attacks all parts of the body, especially

the lungs (Centers for Disease Control and Prevention, 2016b). Tuberculosis (TB) is one of the

top 10 causes of death worldwide and has contributed to over 1.6 million deaths in 2017 alone

(World Health Organization, 2018b). In addition, nearly two billion people are infected

worldwide with tuberculosis, which is roughly one third of the world’s population (Centers for

Disease Control, 2005). Tuberculosis is the leading killer of HIV-positive individuals causing

about 40% of HIV deaths in 2016. This is due to the high risk HIV-positive people have for TB

because of their decreased immune function (World Health Organization, 2018b). Moreover,

more than 95% of TB deaths occur in low- and middle-income countries (National Institute of

Allergy and Infectious Diseases, 2017). In 2014, 9.6 million people were exposed to and caught

the TB disease with 1.5 million people dying and approximately 480,000 people developed

multidrug-resistant TB (National Institute of Allergy and Infectious Diseases, 2017).

Mycobacterium tuberculosis, discovered in 1882 by scientist Robert Koch, has been

designated into several bacterium species including Mycobacterium bavis, Mycobacterium

africanum, Mycobacterium canetti, and Mycobacterium microti. Tuberculosis is most commonly

caused by M. tuberculosis, which is a rod shaped, non-spore forming, aerobic bacterium

(Knechel, 2009). Tuberculosis is challenging to treat because of its diverse defense mechanism

and ability to adapt to hostile environments. Each bacterium contains a very thick cell wall which

makes the organism’s barrier biochemically diverse.


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Tuberculosis is highly contagious and can spread from person to person, usually through

the air such as when a person infected with TB coughs, sneezes, or spits into the surrounding

atmosphere (Centers for Disease Control and Prevention, 2016e; World Health Organization,

2018b). Mycobacterium tuberculosis can infect other organs in the body by growing in the lungs

of the host and spreading to other parts of the body through the bloodstream (Centers for Disease

Control and Prevention, 2016e). With humans, the bacterium must be inhaled through the nasal

or oral cavities and must make its way down the respiratory tract. Travelling to the lungs, down

the bronchi, into the bronchioles, and being deposited in the alveoli, the bacterium begins its new

life cycle. Once detected in the alveoli, the body’s natural defense mechanisms swing into action.

Macrophages, the body’s immune system cleanup crew in the alveoli, engulf the foreign

bacterium. However, the tuberculosis bacterium’s thick cell wall allows it to stem its demise

inside the macrophage. Instead of being destroyed, the bacterium begins dividing every 25-32

hours (Knechel, 2009). With the progression of the bacterium’s population, the body then forms

granulomas around the macrophages, containing the tuberculosis bacteria. These granulomas

form lesions in the lungs and lead to the eventual necrosis of the infected tissues. In a healthy

individual, the necrotic lesions will undergo fibrosis, trapping the live bacterium within.

However, if the lesions do become exposed again, due to illness or trauma, the live bacterium

will enter an active form again (Dench, Sulistyo, Fahroni, Philippa, & Medicine, 2015). In

immunocompromised individuals, the bacterium will continue to divide, increasing its numbers.

During this early disease progression, the body’s immune system detects there is a mass

infection, stimulating the increase of T cell receptors on the alveolar macrophages. Once

accomplished, detection of the bacterium can now be confirmed through medical tests, roughly

2-12 weeks after initial infection (Dench et al., 2015).


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Risk Factors for Tuberculosis

The two main populations that have an increased risk for obtaining the tuberculosis

disease include those with medical conditions that cause a weakened immune system and those

who may already have weakened immune systems such as children (Centers for Disease Control

and Prevention, 2016h). For the first population, immunosuppression can be caused by an HIV

infection, substance abuse, diabetes mellitus, low body weight, and organ transplants (Centers

for Disease Control and Prevention, 2016h). With a weak immune system, the body is more

susceptible to diseases because the immune system is not strong enough to fight off the

infections attacking the cells. In accordance to the second major population at risk for

tuberculosis, children who were exposed to TB before two years of age or after ten years are at a

greater risk for developing active tuberculosis, and are at the highest risk for TB mortality

following exposure (Narasimhan, Wood, MacIntyre, & Mathai, 2013). Next to the young age

population, all age groups are affected by the disease, especially people who live in developing

countries since these countries have high incidence and prevalence of all TB cases and deaths

(World Health Organization, 2018b).

HIV co-infection is the most dominant immunosuppressive risk factor for developing

active tuberculosis (Narasimhan et al., 2013). For those infected with HIV, tuberculosis is the

most common disease to occur and is a major cause of HIV-related death (World Health

Organization, 2018b). Moreover, there is a twenty-six to thirty-one percent increased chance of

developing tuberculosis for people living with HIV than for individuals without HIV (World

Health Organization, 2014). In addition, there were 1.3 million deaths in 2016 caused by

tuberculosis alone, 374,000 of these deaths are attributed to individuals who are HIV-positive

(World Health Organization, 2018b). Countries in Sub-Saharan Africa have the highest


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prevalence, accounting for 74% of all HIV/TB cases in 2016 (Narasimhan et al., 2013; World

Health Organization, 2018b). HIV co-infection also increases the risk of latent TB reactivation

and can increase TB progression after primary infection or reinfection (Narasimhan et al., 2013).

Furthermore, co-infection also advances HIV progression through elevated immune activation

(Narasimhan et al., 2013).

Tuberculosis has multiple risk factors such as smoking, alcohol use, diabetes mellitus,

and malnutrition which increase the susceptibility and incidence of TB. Smoking tobacco

increases the risk for tuberculosis threefold. There is a high smoking prevalence among those

infected with TB, which contributes to the heavy tuberculosis burden. In addition to increasing

susceptibility and incidence of tuberculosis, smoking is seen as an independent risk factor for

reoccurrence of tuberculosis for both current smokers and former smokers (Jee et al., 2009).

Cigarettes increase susceptibility to tuberculosis by reducing immune functions, increasing

defective clearance of mucosal secretion, and worsening phagocytic abilities of alveolar

macrophages ((Narasimhan et al., 2013). Moreover, smoking affects the structure and function of

the lungs while affecting host defenses in both the lungs and the body, which compounds to

affect the immune system negatively (Jee et al., 2009). Furthermore, tuberculosis is related to the

obstruction of airflow in the lungs, which corresponds to smoking, a primary factor in chronic

obstructive pulmonary disease (Jee et al., 2009). Because of the effect of smoking on the

structure and function of the lungs, as well as the connection between airflow obstruction,

tuberculosis, and smoking, smoking may lead to a worsened prognosis of tuberculosis (Jee et al.,

2009). Reducing tobacco smoking can reduce TB incidence as there are countries and cities such

as Rio de Janeiro, Brazil which are adding smoking cessation programs to their TB prevention

and treatment services (World Health Organization, 2009, 2018a).


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In addition to smoking, alcohol use triples tuberculosis risk, and is a risk factor for TB

treatment non-adherence. In countries that experience high prevalence of alcohol use disorders,

alcohol use is typically a comorbidity among those with tuberculosis and is a significant

population level risk factor for tuberculosis (World Health Organization, 2018a). Through

excessive alcohol use, functions of the immune system can be impaired which can lead to the

development of tuberculosis (Volkmann, Moonan, Miramontes, & Oeltmann, 2015). In addition,

excessive alcohol use correlates to transmission of tuberculosis as well as adverse treatment

outcomes (Volkmann et al., 2015). One of the reasons why alcohol use is important in

association to tuberculosis is the failure of accurate medication functioning due to alcohol

consumption causing immunosuppression and changes in pharmacokinetics (Volkmann et al.,

2015). Hepatic damage due to the metabolism of alcohol increases adverse treatment outcomes

because tuberculosis treatment medications are processed in the liver, which is damaged due to

alcohol consumption (Volkmann et al., 2015). Without a normal functioning liver, tuberculosis

treatment drugs cannot elicit the removal of the disease. In addition, people with excessive

alcohol consumption might be unable to complete the full course of the treatment prescriptions,

leading to the need of Directly Observed Therapy (DOT) for tuberculosis. DOT requires active

supervision by a health care worker, leading to increased need of human resources (Volkmann et

al., 2015). Decreasing alcohol consumption prior to or during the development of tuberculosis

helps decrease the likelihood of tuberculosis incidence for someone.

Diabetes prevalence is increasing around the world, predominantly in low and middle-

income countries and countries where there is a high burden of tuberculosis (Geneva: World

Health Organization, 2008). Having diabetes mellitus triples one’s risk for tuberculosis, which

can negatively impact glycemic control in diabetics and the clinical course of TB (World Health


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Organization, 2018a). Diabetes directly compromises immune responses, accelerating TB

progression (Narasimhan et al., 2013). In addition, there is a link between smoking, diabetes

mellitus, and tuberculosis in which cigarette smoking leads to increased inflammation and

oxidative stress in body cells, resulting in the risk of developing diabetes mellitus. Both diabetes

and cigarette smoking lead to an increased risk for developing tuberculosis (Workneh, 2017).

Diabetes mellitus is a risk factor for tuberculosis. Having a healthier diet with physical activity

interspersed in daily life activities will decrease the risk for developing diabetes mellitus, which

in turn, decreases the risk for developing tuberculosis.

Moreover, malnutrition is a risk factor for tuberculosis as well because it leads to

compromised immune functions and is therefore prevalent among people experiencing

tuberculosis (World Health Organization, 2018a). Malnutrition is most common in countries

with high TB burden, because countries that have a high TB burden tend to be developing

countries, which are more likely to have malnutrition as a common health problem (Geneva:

World Health Organization, 2008). While malnutrition can lead to tuberculosis, tuberculosis can

also lead to malnutrition because of changes in appetite and in metabolic processes (Narasimhan

et al., 2013). Even at the end of tuberculosis treatment, which improves nutritional status, many

people are still malnourished. Malnutrition comes in various forms, but commonly, deficiencies

in protein, energy, and/or micronutrients such as vitamins and minerals can lead to an increased

risk of tuberculosis (Geneva: World Health Organization, 2008). Improving overall nutritional

status can prevent tuberculosis (World Health Organization, 2018a).

Lastly, homelessness affects tuberculosis as well because six percent of tuberculosis

cases were among people experiencing homelessness for at least one year before their diagnosis.

In addition, people experiencing homelessness are at an increased risk for comorbidities such as


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HIV and substance abuse which can lead to the advancement of tuberculosis. Furthermore, many

people who experience homelessness gather in shelters which also puts them at greater risk for

tuberculosis transmission (Khan et al., 2018).

Tuberculosis Symptoms and Diagnosis

Tuberculosis has varying degrees of manifestation, ranging from mild forms to severe,

life-threatening cases. The clinical manifestations of tuberculosis are: latent, primary, primary

progressive, and extrapulmonary (Salinas & report, 2016). Tuberculosis can cause zero to

multiple symptoms depending on the form of TB contracted by the infected host (Centers for

Disease Control and Prevention, 2016b). Individuals in all stages carry the tuberculosis

bacterium in some form, but the bacterium may not be active. If the host has contracted a latent

TB infection (LTBI), no symptoms will appear because this form of the disease is non-

contagious and inactive since the bacteria are trapped in the necrotic tissues formed by

granulomas (Pai et al., 2016). Within the tissues, the bacteria can survive for a lifetime. If the

necrotic sacs do ever rupture, or the host becomes immunocompromised, the active bacteria may

expand to other tissues leading to infection (Knechel, 2009). While a host with LTBI cannot

spread the infection to others, a TB test will demonstrate the host as tuberculosis-positive and

without treatment, the host may later develop active TB disease, especially if the host’s immune

system becomes compromised (Centers for Disease Control and Prevention, 2017d). Although

those tests might be positive, a person will have a normal chest x-ray and negative sputum smear

with the latent form of TB (Centers for Disease Control, 2016a). Approximately a quarter of the

world’s population is infected with a strand of latent TB infection. This means it is unlikely that

they will become ill with the disease unless their immune systems are compromised due to

malnutrition, smoking, and being HIV-positive (World Health Organization, 2018b).


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Individuals with a weakened immune system or any other disease present, such as HIV or

diabetes, have a greater chance of the bacteria becoming active and therefore experiencing active

tuberculosis (World Health Organization, 2016b). Individuals with the latent infection must seek

treatment so that it does not progress to the active form of the disease (Centers for Disease

Control, 2016a). Active tuberculosis is contagious, causes multiple symptoms, and can even be

life-threatening (Pai et al., 2016). Examples of symptoms caused by active tuberculosis disease

are chest pains, fever, weight loss, coughing up blood or phlegm deep inside the lungs, and a

persistent cough for three or more weeks (Centers for Disease Control and Prevention, 2016f; Pai

et al., 2016). Furthermore, it takes months for symptoms such as coughing, fever, and night

sweats to arise, which may cause those who have tuberculosis to delay seeking treatment and can

allow them to infect anywhere between 10-15 other people in a year (World Health

Organization, 2018b). TB has a natural progression in the form of phases if the active form is

contracted. Beginning with the primary phase, all individuals infected with the bacterium will

show symptoms and will have an active infection.

The primary phase is characterized by the expansion of the necrotic lesions as

surrounding tissue become infected once the bacterium invades (Brighenti and Joosten, 2018).

Though the infection spreads, it is usually localized to the pleura cavity, remaining within the

lungs. In the next phase, the primary progressive phase, the disease becomes quite aggressive.

Roughly five to ten percent of infected individuals have the bacterium develop into the active

form of the tuberculosis disease (Centers for Disease Control, 2014). During this phase,

symptoms become pronounced and aggressive, typically leading to hospitalization. The final

stage of the disease progression is the most life-threatening. Once an individual enters the

extrapulmonary stage, advanced medical measures must be taken (Sasindran and Torrelles,


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2011). The extrapulmonary stage is characterized by the spread of the tubercular bacterium

outside of the lungs into other tissues such as lymphatic tissue (Centers for Disease Control,

2013). Disseminated tuberculosis, or tuberculosis in the blood, can be quite dangerous, leading to

an acidic blood pH level and eventual septicemia. If the bacterium reaches the brain, tubercular

meningitis can occur. Furthermore, the bacterium can cause inflammation of the meninges

surrounding the brain, leading to brain swelling and increasing intracranial pressure and the

likelihood of death (Saleh, Saeedi, and Pooran, 2014).

Prevention

In the United States, there are three main strategies for the prevention and control of

tuberculosis: (i) identifying and treating people infected with TB; (ii) finding people exposed to

infectious TB, evaluating them for active Mycobacterium tuberculosis and providing treatment;

and (iii) testing high risk populations for latent TB and treating those who are infected to prevent

disease progression (Jeffries, Lobue, Chorba, Metchock, & Kashef, 2017). As stated previously,

many people with latent tuberculosis never develop active, infectious TB, but populations who

are at higher risk, such as those infected with HIV and young children, should seek treatment to

prevent the development of active tuberculosis (Jeffries et al., 2017).

There are ways to prevent becoming infected with the tuberculosis disease; one of the

most important methods is receiving the TB-prevention vaccine, Bacillus Calmette-Guérin

(BCG) (American Lung Association, 2018b). While the vaccine is effective in children, it is less

effective in adults, who are at the greatest risk for TB (American Lung Association, 2018b). In

addition, the vaccine is not common in developed countries such as the United States because

there is a lesser likelihood of developing TB in the United States than in developing countries,

where TB is more common (American Lung Association, 2018b). In addition to the low risk of


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TB infection in the United States, another reason most people do not get the BCG vaccine is

because of its interference with TB testing when it comes to the Tuberculin Skin Test (TST) and

its reactivity (Centers for Disease Control and Prevention, 2016c). Another important method to

prevent TB is to avoid long time exposure and close contact in areas that are crowded, enclosed,

and contain people with TB (Centers for Disease Control and Prevention, 2016g).

One of the major concerns about tuberculosis is the emergence of a drug-resistant strand

of tuberculosis. There are two concerning strands of drug-resistant tuberculosis: Multidrug-

resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) which is a more serious

form of MDR-TB (World Health Organization, 2018b). Both of these strains are characterized

by their resistance to certain drugs that treat tuberculosis, which is extremely important and

detrimental to the efforts made by multiple national and international agencies for controlling

tuberculosis (Nathanson, Nunn, Uplekar, Floyd, & et.al, 2010).

MDR-TB and XDR-TB are concerning strains of tuberculosis that are emerging at a rapid

rate, causing detrimental effects on the global ability to control the disease. The best way to treat

MDR-TB is not through treatment, but through prevention of its emergence to fully eliminate the

disease (Nathanson et al., 2010). The occurrence of MDR-TB comes from incorrect treatment of

TB through misdiagnosis or low treatment adherence as well as when MDR-TB is spread

through the community through airways and inhaled by others who then develop the disease

(Fox et al., 2017). The prevention and management of multidrug-resistant tuberculosis is related

to the shortage of healthcare providers in most developing countries because many health care

providers with effective treatment medications for tuberculosis work in the private sector

(Nathanson et al., 2010). By engaging all types of healthcare providers such as voluntary, public,

and private, prevention and management of MDR-TB could be increased for the better,


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especially if national tuberculosis programs are involved in terms of leadership roles, training

and guidance, financial support, and supervision (Nathanson et al., 2010).

The most important prevention for MDR-TB is through use of the Directed Observed

Therapy (DOT) program, which aids to prevent further transmission of the disease. The purpose

for DOT therapy is so that people follow through and finish their treatment (Tuberculosis

Prevention and Control Unit). If the treatment is fully finished then they are cured of TB and can

keep relapses to a minimum. DOT is when a supervisor, such as a healthcare professional, is

watching the person experiencing tuberculosis on a daily basis to see if the treatment regimen is

being followed correctly. The observation can be done face to face or via video chatting, but it is

done to ensure that the person with TB is following the correct dosage and at the proper time for

maximum effectiveness of the treatment (Tuberculosis Prevention and Control Unit). As well as

focusing on the medications, the purpose of DOT is to focus on the individual and his or her

health and wellbeing together (Tuberculosis Prevention and Control Unit). The DOT observer

can help to make positive changes in the individual's life to help improve the quality of it and

make it easier to take the medications. VDOT, which is the same as DOT, is known as video

observed therapy, however instead of being observed in person, the individual with TB can be

observed via an electronic device (Tuberculosis Prevention and Control Unit). DOT is

administered through delivering the medications needed for the treatment regiment, checking for

side effects occurring due to the medication, watching the individual experiencing TB physically

digesting the medications, documenting the visits, and answering any available questions

(Minnesota Department of Health, 2016). Furthermore, the DOT program has successfully

treated approximately 36 million people and saved 6 million people globally between the years

of 1995 and 2008 (Nathanson et al., 2010).


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With tuberculosis, the common risk factors encountered are smoking, alcohol

consumption, diabetes, and malnutrition. Understanding the various risk factors that contribute to

a reduction in health status is important for further understanding numerous methods to reduce

the risk of contracting and transmitting an infection. Smoking is a strong risk factor for

tuberculosis contraction and can significantly reduce the ability of treatment methods in ridding

the individual of the infection. Individuals who smoke have demonstrated defected alveolar

macrophages, the body’s immune cells, which detect and entrap the tuberculosis bacterium

(Gleeson et al., 2018). Reducing smoking habits and potentially engaging in complete cessation

of smoking can eliminate many risks associated with tuberculosis. Many programs are present to

promote the cessation of smoking, and many employers offer incentives to quit smoking; service

industry establishments no longer allow for smoking inside, and social support groups exist to

help reduce smoking. Social support and behavioral interventions have been shown to

significantly reduce smoking habits, leading many individuals to quit smoking all together

(Soulakova et al., 2018).

Alcohol use has been shown to triple the risk of contracting and transmitting tuberculosis

(Simou, Britton, and Leonardi-Bee, 2018). Alcohol use, like smoking, poses a large risk for

tuberculosis infection. Many methods for reduction and cessation of alcohol consumption have

been suggested to reduce the risks associated with alcohol. Similar to smoking, programs

developed using social support groups and various behavioral interventions have shown promise

in reducing alcohol consumption. A new form of intervention has arisen in the recent decade,

targeting alcohol consumers through the internet. Known as AlcoholEdu, data has shown those

who perceived the information and passed the associated test had significantly fewer alcoholic

beverages on average and showed more respite from drinking all together (Hustad et al., 2010).


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With the high risk correlated with drinking and tuberculosis, it is pertinent to reduce the intake of

alcohol to improve the chance of not contracting tuberculosis and subsequent infections.

Countries with a high prevalence and incidence of tuberculosis are also seeing a rise in

diabetes rates as well. Diabetes increases metabolic strain on the body and can reduce immune

responses in the process. Diabetes has been shown to reduce immunity and immune response to

the presence of the tuberculosis bacterium (Brighenti and Joosten, 2018). Lifestyle intervention

has been shown to be highly effective for preventing diabetes (Ramachandran and Snehalatha,

2011). Lifestyle intervention methods include nutritional education programs, increasing

physical activity, and improving social support about changing one’s lifestyle. In developing

countries, the use of counseling and educational methods to improve diet and physical activity

levels showed positive results and were effective in reducing the risks of developing diabetes

(Rawal et al., 2012). Reducing the rise in diabetes plays a key role in reducing the risks of

contracting tuberculosis.

Most individuals positive for tuberculosis also are diagnosed as malnourished due to the

reduction in immune response and bodily functioning (World Health Organization, 2018a).

Malnutrition varies in degree, however, across the board it reduces the body’s ability to properly

function. Without a nutrient-rich diet, the body can become susceptible to tuberculosis. Many

global initiatives have arisen to fight malnutrition in developing countries where tuberculosis is

most prevalent. The Centers for Disease Control and Prevention (CDC), in 2000, initiated the

International Micronutrient Malnutrition Prevention and Control program aimed at providing

foods rich in iron, vitamin A, iodine, folate, and zinc to populations in developing countries.

Here in the United States, where obtaining food is not as much of a struggle, prevention may be

easier. Diets rich in necessary minerals, vitamins, and nutrients can alleviate the risk of


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malnutrition. Reduction in carbohydrates, higher intake in fiber, reducing saturated fat intake,

lower salt and sugar intake are highly advised to promote proper nutrition and improve overall

health (Misra et al., 2011). With improved nutritional intake, health and immune functions will

improve reducing the risk of obtaining tuberculosis.

Testing for Tuberculosis

There are multiple ways to test for and diagnose tuberculosis. One method is through the

Tuberculin Skin Test (TST), which is used to screen for tuberculosis and is required by most

health organizations before anyone is allowed to work or volunteer (American Association for

Clinical Chemistry, 2017). Other reasons to get tested for tuberculosis could be that schools or

employers require a skin test, there are symptoms and signs that relate to tuberculosis or the area

that the person lives in is at high risk (American Association for Clinical Chemistry, 2017). The

TST can be performed on almost anyone, including children, infants, pregnant women,

individuals living with HIV, and people who have previously had a BCG shot (Centers for

Disease Control, 2016c). A healthcare provider administers the skin test with no preparation

needed. The TBT is a two-step process in which a needle is used to inject a purified protein

derivative solution under the first layer of the skin of the inner forearm (American Association

for Clinical Chemistry, 2017). Once injected, a small, skin colored bump will develop (Centers

for Disease Control, 2016c). Then, the health practitioner that injected the solution will examine

the area of the injection site to evaluate if any reaction occurred within 48- 72 hours of receiving

the vaccine (American Association for Clinical Chemistry, 2017). Signs of a reaction will be a

raised, hard area or swelling area that will be measured.

In addition to the Tuberculin Skin Test, another test used to screen for TB is the

Interferon Gamma Release Assay (IGRA) test. During this test, the person’s immune system is


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tested against TB in a laboratory by gauging the reaction from the blood being exposed to TB

bacteria (Centers for Disease Control, 2016c). The Interferon Gamma Release Assay test

examines white blood cells to determine if there are any gamma interferons released by those

white blood cells when they are exposed to specific TB antigens (American Association for

Clinical Chemistry, 2017). This test requires a blood sample to extract viable white blood cells

which can be tested as long as it is within a designated window of time (American Association

for Clinical Chemistry, 2017). A positive IGRA means that the person has been infected with the

TB bacteria, and either has latent or active tuberculosis (Centers for Disease Control, 2016c).

The IGRA test can be used in place of a TST, but only one test should be used.

When it comes to the Tuberculin Skin Test, there are different results and interpretations

(American Association for Clinical Chemistry, 2017). The diagnosis of tuberculosis occurs with

a positive result in which there is a red and swollen circle at the site of the injection. However,

the presence of a swollen and red circle does not determine the diagnosis and exposure, the

diameter of the swollen circle is the determining factor (American Association for Clinical

Chemistry, 2017). There is no one consistent size that indicates the presence of TB, rather it

varies between the health status and the age of the individual (American Association for Clinical

Chemistry, 2017). Different, positive reactions to the injection can occur depending on the health

status of the person. In addition, a positive result for both types of tests does not explain which

type of TB an exposed person has, but rather demonstrates that the individual has had exposure

to either active or latent tuberculosis (American Association for Clinical Chemistry, 2017).

Group 1 5mm or greater HIV-positive individuals,

organ transplant individuals,

recent contact with TB

disease positive being


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Group 2 10mm or greater Injection drug users, recent

immigrants, children under 4

years of age, Mycobacterium

clinical lab professionals

Group 3 15mm or greater Any persons with no known

risks of tuberculosis

Figure 1. Different injection site diameters based on individual health status by grouping (American Association for

Clinical Chemistry, 2017).

To diagnose a latent TB infection, suspected individuals need a test and a physical

medical evaluation. After obtaining both a TB screening test and a physical medical

examination, if individuals have been diagnosed with the latent infection, they can receive

treatment based off their chances of activating the TB disease (Centers for Disease Control,

2016a).

When a positive, active diagnosis of tuberculosis is suspected, further testing such as

chest X-rays and acid-fast bacilli (AFB) laboratory testing can confirm or reject the diagnosis

(American Association for Clinical Chemistry, 2017). In addition, the person must undergo a

physical exam and release medical history and another laboratory test can determine whether or

not the tuberculosis diagnosis contains a drug- resistant strain (Centers for Disease Control,

2016a). With the mandatory chest X-ray, if the results appear normal, then the individual is a

host for the inactive bacteria. The individual will show no symptoms at all and will appear to be

healthy (Salinas & report, 2016). However, if the individual shows an abnormal chest image with

granulomas and necrotic tissues, then the active bacterium is present and further medical

attention is needed.

On the other hand, a negative result does not mean the tested individual does not have

any exposure to tuberculosis, although it is most likely that the tested individual does not have


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tuberculosis (American Association for Clinical Chemistry, 2017). If the person is infected and

has a negative result, the immune system of the infected individual did not respond to the antigen

in the test or it was too early to detect the exposure since it takes about six weeks after exposure

to demonstrate a positive reaction (American Association for Clinical Chemistry, 2017). A

follow up test or extra testing through different methods will help in confirming the diagnosis if

the health practitioner suspects exposure and infection (American Association for Clinical

Chemistry, 2017).

Furthermore, there are false-positive test results which is seen more with Tuberculin Skin

Tests since the Tuberculin Skin Test includes people who have received the Bacille Calmette-

Guérin vaccine, which contains strains from a tuberculosis bacterium (American Association for

Clinical Chemistry, 2017). The BCG vaccine has no effect on the Interferon Gamma Release

Assay test because the IGRA test measures white blood cells, not antibodies (American

Association for Clinical Chemistry, 2017). While both tests are not interchangeable, either one

can be used in most cases although the Centers for Disease Control and Prevention does

recommend the IGRA test for individuals who have received the BCG vaccine or are less likely

to comply to a Tuberculin Skin Test. On the other hand, the CDC recommends the Tuberculin

Skin Test to be used for children under the age of five (American Association for Clinical

Chemistry, 2017). With an 86 percent sensitivity, 95 percent specificity, and 95 percent

accuracy, the skin test is extremely useful in determining a diagnosis of tuberculosis (Dench,

Sulistyo, Fahroni, Philippa, & Medicine, 2015).

Treatment

Tuberculosis is a curable infectious disease, as there are treatment options available to

those who have contracted TB. Treatment for the latent TB infection can only be started once TB


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disease has been ruled out (Centers for Disease Control, 2018a). To receive treatment there is a

hierarchy of who needs to be treated first, with priority given to people who have a positive TST

test, people with a TST reaction of 5 mm or more that are HIV infected, in contact with an active

TB disease, and organ recipients (Centers for Disease Control, 2018a). Priority is then given to

people who have a TST reaction of 10 mm or more and are from countries that have high TB

prevalence, drug users, and children under 4 years of age (Centers for Disease Control, 2018a).

Treatment of tuberculosis which is not multidrug resistant includes the use of first-line anti-TB

drugs which are four antimicrobial drugs (isoniazid, rifampin, ethambutol, and pyrazinamide)

taken daily for 6-9 months (Centers for Disease Control and Prevention, 2018c; World Health

Organization, 2018b). The treatment of the affected person will vary from person to person and

will always be given in shorter regimens when possible.

Once a regiment is completed, there is still a continuation phase that can last up to 7

months (Centers for Disease Control, 2018b). Problems with treatment occur after 2-4 weeks,

when people often stop treatment because they already feel better or because of negative side

effects of the treatment. Treatment must occur at a constant rate otherwise those infected with

TB will remain infected or the bacteria may become resistant to the drugs administered (Centers

for Disease Control, 2018b).

One of the main reasons tuberculosis is emerging in today’s world is because of drug-

resistant strains of tuberculosis. MDR-TB and XDR-TB are important strains of tuberculosis to

consider because MDR-TB causes resistance to two important anti-TB drugs, isoniazid and

rifampicin, that are the first defense when a person has contracted TB, but this strand of TB is

curable with second-line drugs which are limited, expensive, and require extensive

chemotherapy (World Health Organization, 2018b). The reason XDR-TB is more serious than


21

MDR-TB is because that strand of TB cannot be fought against using first defense or second

defense anti-TB drugs. Extensively drug-resistant TB is resistant to isoniazid, rifampin,

fluoroquinolone, and at one out of the three second-line drugs (Centers for Disease Control

and Prevention, 2018c). Usually people who have contracted the XDR-TB strand have no

treatment options other than those second-line drugs (World Health Organization, 2018b).

MDR-TB most often occurs in people who have had TB in the past, but can also present

in people who have never had TB before. Most commonly, people become infected with MDR-

TB by coming into contact with people who already have MDR-TB. MDR-TB is more difficult

and expensive to treat than drug-susceptible TB (Centers for Disease Control and Prevention,

2017a). With MDR-TB, the use of injectable second-line drugs such as amikacin, kanamycin, or

capreomyscin can treat the disease; however, it is complicated and may not work all the time,

especially with a strand of XDR-TB (Centers for Disease Control and Prevention, 2018c). In

addition, the second-line drugs are not only more expensive, but also contain more side effects

and adverse conditions compared to the first-line drugs as well as have a longer duration period

for treatment (National Institute of Allergy and Infectious Diseases, 2017).

Since multidrug-resistant tuberculosis requires such strong antibiotics, side effects are

common and can be quite severe. Jaundice and dark urine are common side effects along with

fever and vomiting. In some cases, the complications caused by the antibiotics ultimately lead to

death (Munro et al., 2007). Side effects do depend on an individual’s sensitivity to the drug as

well as the individual drugs (American Lung Association, 2018a). Some of the other side-effects

associated with both the first-line and second-line drugs include loss of appetite, nausea,

vomiting, yellowish skin or eyes, fever for longer than 3 days, abdominal pain, tingling fingers

or toes, skin rash, easy bleeding, aching joints, dizziness, tingling or numbness around the


22

mouth, easy bruising, blurred or changed vision, ringing in the ears, and hearing loss (American

Lung Association, 2018a). Multidrug-resistant tuberculosis often takes anywhere from 18-24

months to cure and can cost 100 times more than treatment for drug-susceptible tuberculosis

(Bojorquez et al., 2013). Although TB prevention and control efforts are reducing tuberculosis

incidence, the development of MDR-TB threatens to setback all TB advancements and turn

tuberculosis into an untreatable disease (Bojorquez et al., 2013).

After being diagnosed with tuberculosis, whether or not the infectious disease is drug-

resistant, there are certain expectations that need to be met and continued throughout the course

of the disease (American Lung Association, 2018a). It is necessary that the infected individual

take the medications and antibiotic drugs as prescribed and finish the full course of medication;

stopping too soon in the medication course could allow for another onset of the disease, which

could become contagious and be spread around to people near and around the infected individual

(American Lung Association, 2018a). Moreover, not completing the full course of the

medications can cause the bacteria to become resistant to antibiotics, making it even harder to

fight (American Lung Association, 2018a).

Because MDR-TB may occur due to mismanagement of TB treatment, one of the best

approaches to solving MDR-TB is using the DOT program on most, if not all individuals

experiencing TB since the DOTS program ensures mandatory supervision of the treatment

regimen. The DOTS therapy decreases the likelihood of incomplete or errant treatment which

increases the risk of drug-resistance (Minnesota Department of Health, 2016). The DOT program

has shown promise in reducing the nonadherence of medication regiments, improving the

likelihood an infected individual will successfully finish treatment and reduce the probability of

transmitting the disease further (Curry International Tuberculosis Center, 2018). Furthermore,


23

with active TB disease of all strains, while treatment takes place, the contagious factor of TB is

still present and the disease can spread from person to person as it takes time before the disease

becomes non-contagious (American Lung Association, 2018a). There is considerate evidence

that states the contagious factor of tuberculosis is no longer prevalent after completing at least

several weeks of effective treatment for tuberculosis (New York State Department of Health,

2018).


24

Culture:

Tuberculosis has been prevalent for hundreds of years. It is thought that, through

traveling, the bacterium has been transferred and has infected numerous populations all over the

world. In places like North America, Australia, and New Zealand, the TB disease did not impact

these populations until pioneers landed (Barberis, Bragazzi, Galluzzo, & Martini, 2017). North

Americans experienced the tuberculosis epidemic during the 18th and 19th centuries (Daniel,

2006). Since those times, the incidence and prevalence of tuberculosis in North America have

decreased, substantially in the United States. On the other hand, other countries still experience

outbreaks that can be transmitted, especially when people return from traveling abroad. Those

who travel to or were born in countries with high M. tuberculosis rates are most likely to have

the disease. In 2016, sixty-eight point five percent of all TB cases occurred among those who

were not born in the U.S. (Centers for Disease Control and Prevention, 2017c) and 87 of cases in

2015 were in racial and ethnic minorities (Centers for Disease Control and Prevention, 2016a). In

2015, Hispanics accounted for twenty-eight percent of all tuberculosis cases in the United States

at 2,694 cases (Centers for Disease Control and Prevention, 2016i). The rate of disease for

Hispanics was 4.8 cases per 100,000, which is eight times higher than the rate for white, non-

Hispanics (Centers for Disease Control and Prevention, 2016i).

Determinants such as race/ethnicity, geography, past medical conditions, and other social

problems can impact transmission and rates of infection of tuberculosis. Due to history, some

people of different races or ethnic groups are more reluctant to trust the healthcare system and

also face greater obstacles when trying to receive aid (Centers for Disease Control, 2016 ).

Minorities in the United States including Hispanics, African Americans, and Asians have

significantly higher tuberculosis rates compared to Caucasians. Geographic disparities can also


25

influence prevalence. States such as California and Texas who share the border with Mexico

have a greater number of cases TB than other states. Depending on which regions and types of

areas people live in, they are more likely to be affected by the TB bacteria (Centers for Disease

Control, 2016 ).

Tuberculosis rates for the U.S.-born population have decreased over the past 20 years, yet

for foreign-born persons, TB rates have remained at a constant thirteen times greater rate than for

those who are U.S.-born (Baker, Winston, Liu, France, & Cain, 2016). Tuberculosis affects

population groups differently since racial and ethnic minorities made up more than eighty

percent of the TB cases and foreign-born persons made up nearly seventy percent of the minority

TB cases in 2016 (Khan et al., 2018). In addition, Hispanics accounted for nearly thirty percent

of cases. The countries with the highest rates of tuberculosis include Mexico, the Philippines,

India, Vietnam, and China, although there was an overall decline of twenty percent in TB cases

from all foreign-born populations from 2007 to 2011 (Baker et al., 2016). Baker et al. (2016)

concludes that for Mexico, the reduction in TB rates are due to a reduction in population, not a

case rate decline, and that therefore, if travel to and from Mexico were to increase, then

tuberculosis rates would also increase. However, the reduction in TB rates in Philippines, India,

Vietnam, and China is associated with a case rate decline and is not related to immigration.

Finally, there are four possible reasons for the decline in TB case rates among new foreign-born

entrants to the United States: more tuberculosis screening abroad based on culture, a reduced TB

morbidity in countries of origin, diverse entrants, and reduced TB transmission rates in the U.S.

(Baker et al., 2016).

While tuberculosis has declined in all racial/ethnic groups in the United States, the

disease is still disproportionately higher in Hispanics/Latinos than other racial/ethnic groups. The


26

main reasons for the disproportionate burden are due to being born in or traveling to countries

with higher tuberculosis rates, residing in overpopulated areas, and overall a larger burden of

comorbidities associated with tuberculosis (Centers for Disease Control and Prevention, 2016i).

Hispanics/Latinos are the highest at risk for TB in the United States and had the largest

percentage of total number of reported TB cases (twenty-nine) in 2014 (Centers for Disease

Control and Prevention, 2017b). Furthermore, TB cases are higher in people who were not born

in the United States, with sixty-eight point five percent of all the reported TB cases in 2016

occurred to individuals not born in the United States (Centers for Disease Control and

Prevention, 2017e). In the U.S. under the Patient Protection and Affordable Care Act, provisions

for expanded health insurance improved early diagnosis and treatment, and included public

health functions such as surveillance, outbreak and contact investigations, directly observed

treatment, access to treatment, laboratory services, clinical consultation, policy development,

consultation and training, screening in immigrants and refugees, and using quarantine when

necessary (Balaban et al., 2015).

Some of the reasons why Hispanics/Latinos have a higher incidence rate of tuberculosis

are the same for other racial and ethnic groups as well (Centers for Disease Control and

Prevention, 2016d). For example, many people do not want to take medications long term, which

is concerning because the treatment for TB, both latent and active, takes several months to

produce the desired effect and fully treat and cure the infected individual (Centers for Disease

Control and Prevention, 2016d). Furthermore, language and cultural barriers may steer people

away from obtaining medical care due to stigmas associated with the healthcare field, a lack of

medical knowledge, or a lack of English language proficiency (Centers for Disease Control and

Prevention, 2016d).


27

There is a strong association between poverty and tuberculosis, as it is known to affect

the economically disadvantaged more than those of a higher socioeconomic status (Barter,

Agboola, Murray, & Bärnighausen, 2012). Tuberculosis tends to have a greater effect among

disadvantaged countries and the more destitute communities within these countries. Furthermore,

persons who are of a lower socioeconomic status are at a greater risk for TB, tend to have a

greater tuberculosis prevalence, have worse results, and show worse treatment adherence.

Likewise, tuberculosis can lead to poverty because it weakens one’s strength so that they are not

able to work and the disease itself can be a burden because of the financial cost of treatment.

Half of tuberculosis patients expressed financial complications because of their tuberculosis, and

expressed that the costs are equivalent to more than 10 percent of their annual income (Barter et

al., 2012).

Moreover, many Hispanic-Americans perceive their health status as being a gift from

God, whether or not they still believe in the cultural folk system rooted in Hispanic culture

(Galarraga & Policy, 2007). Much of this cultural folk system is focused around the imbalances

between hot and cold, supernatural triggers, and envy. This rudimentary form of healthcare,

though endearing and engrained in Hispanic culture, can be a cause for delay when an ill

Hispanic-American foregoes immediate medical help. Furthermore, Hispanic culture is one

woven around the family. In such culture, the family is not always seen as the nuclear family.

Families can span many members and generations. When decisions of healthcare are brought up,

usually the entire family is questioned about their own thoughts. When exploring healthcare

options with a Hispanic-American, it is wise to understand delineation to agreement may take

some time. In addition, historically in the United States, minority groups have carried a

disproportionate burden when it comes to healthcare. Including Hispanic-Americans, the greatest


28

factors in healthcare arise from inadequate healthcare coverage, the language barrier, a lack of

minority physicians, and healthcare provider biases (Galarraga & Policy, 2007). Hispanic-

Americans also make up the largest population of uninsured individuals. Without insurance,

many treatment options are not feasible. Also, more than fifty percent of Hispanic-American

families are in poverty.

Other social disparities that could impact tuberculosis incidence rates include

incarceration, housing insecurity, and age. The incarcerated population is more susceptible to the

TB bacteria because the population includes people who are already at a greater risk of

contracting the bacteria. Since four to six percent of the United States TB reports come from

correctional facilities, there should be more done to help protect the environment to make it safer

so that inmates risk of getting TB is decreased (Centers for Disease Control, 2016 ). Tuberculosis

rates are also higher for local inmates rather than federal or states inmates, and from 2002 to

2013, twenty percent of U.S.-born and ten percent of foreign-born inmates experienced

homelessness before being diagnosed with tuberculosis (Khan et al., 2018).

Mexico has a high incidence rate for tuberculosis, around 22 per 100,000 population

(World Health Organization, 2016a). In addition, men in Mexico are more susceptible to

tuberculosis than women, especially those above the age of 14 (World Health Organization,

2016a). Mexico has a high endemic of tuberculosis, which increases the likelihood of one

developing TB (Shelton, 2015). There are cases of TB throughout the entire country of Mexico,

but the most affect group of people are those that live large cities and concentrated areas such as

Tijuana, Tabasco, and Veracruz (Health Secretary, 2016).

Mexico does have prevention measures in place to aid in decreasing the amount of TB

cases that emerge in the country’s population (Health Secretary, 2016). Mexico’s main method


29

of prevention is through the BCG vaccination which is given to all newborn babies universally

free of charge in order to avoid and prevent the onset of severe forms of tuberculosis such as

those that attack the central nervous system (Health Secretary, 2016). Moreover, Mexico offers

free treatment in all units of the National Health System for Tuberculosis since the disease is

treatable and curable; the treatment lasts for 6 months with no interruptions in the course of drug

consumption (Health Secretary, 2016). Complying to the treatment completely without taking

self-measures and assessments on health is the only way to cure the disease completely and

prevent the bacteria from becoming drug-resistant, which would lead to a different treatment

which lasts for more than 2 years (Health Secretary, 2016). While Mexico has a high endemic of

tuberculosis, there are a variety of measures put in place to aid the population in fighting against

tuberculosis as well as ensuring the prevention of the disease.

In Mexico, tuberculosis is generally diagnosed by a positive acid-fast bacilli (AFB) smear

(Hernández-Garduño, Mendoza-Damián, Garduño-Alanís, & Ayón-Garibaldo, 2015). Present

guidelines in Mexico demand that people with positive AFB are diagnosed with TB, even

without the culture results because it is more hazardous to avoid treatment even if the culture

results come back negative (Hernández-Garduño et al., 2015). Relying on AFB smear to

diagnose tuberculosis is risky because this would include nontuberculosis mycobacterium and

multidrug-resistant bacterium, so many people could potentially receive the wrong treatment

(Hernández-Garduño et al., 2015). Overall, Mexico lacks access to new, fast and affordable

diagnostic tests which would greatly improve appropriate diagnosis in high risk groups and allow

for correct treatment to reduce transmission and disease (Hernández-Garduño et al., 2015).

Migrant farmworkers are at high risk for developing tuberculosis because those living on

the U.S.-Mexico border often live in areas that are overcrowded, unsanitary, and vulnerable to


30

disease (Oren et al., 2016). The U.S.-Mexico border accounts for nearly thirty percent of total

tuberculosis cases in the United States and Mexico. Migrant farmworkers are six times more

likely to develop active tuberculosis than the average American worker because of limited access

to health care, language barriers, lack of education, long working hours, and more (Oren et al.,

2016). This greater risk for tuberculosis is consistent with the higher rates of active and latent TB

in their country of origin. In addition, while latent tuberculosis rates in the United States are only

around five percent, in migrant farmworkers they are as high as seventy-five percent (Trapé-

Cardoso, Subaran, Bracker, Sapiain, & Gould, 2008). In one study on migrant farmworkers from

Mexico in Connecticut, an estimated twenty-six percent of the workers were shown to have

latent tuberculosis. Although this number is lower than the estimated number of workers

expected to have latent TB, it is anticipated that as more migrant farmworkers seek work, rates of

latent TB will also increase (Trapé-Cardoso et al., 2008).

Mexico’s social security program, Insituto Mexicano de Seguro Social, along with state-

run insurance programs, have covered employees in registered Mexican businesses (Wassink,

2018). However, the majority of Mexicans are laborers in small firms which are not registered,

regulated, or taxed by the government, so employees do not receive health coverage, pensions, or

formal contracts (Wassink, 2018). This means that many rely on small clinics, pharmacies, and

self-medication for medical treatment. In 2003, the government created Seguro Popular to

increase health coverage for family workers, agricultural laborers, artisans and traders, laborers

in unregistered firms, and small business owners (Wassink, 2018). Since 2012, Seguro Popular

has enrolled more than 50 million people (Wassink, 2018). Yet there is still greater need for

targeted policies to improve access to health care, as many migrants feel as though self-

medication and small clinics are their only choices for medical treatment, which does not utilize


31

preventive services and creates financial risk if a health emergency were to occur (Wassink,

2018).

Currently, the Mexico health care system holds early detection of tuberculosis over the

idea of mass vaccination (Gerberry and Milner, 2012). This system was shown to work well in a

country with exceptional healthcare, such as Germany, the United Kingdom, and the United

States. However, in countries like Ghana and Mexico, the current methods are failing the

populations. The World Health Organization recommends that for countries with a high burden

of infection rates, a mass vaccination policy should be adapted (Gerberry and Milner, 2012).

With the recent climate affecting the US-Mexico border, it is notable that the incidence of

tuberculosis in the United States, during past mass migration across the border, has been caused

more by US citizens than immigrants migrating from Mexico (Borgdorff, Behr, Nagelkerke,

Hopewell, and Small, 2000).

There needs to be some form of communication between the United States and Mexico

about TB incidence especially if there is travel between the two countries. The TB bacteria is

everywhere and affects a multitude of countries including Mexico. As of 2014, the prevalence

rate was point zero two seven percent and the incidence rate was point zero two one percent.

These numbers have steadily been decreasing, but still allow for people of Mexico to be

susceptible to the disease (Centers for Disease Control, 2017). The CDC has worked with the

Mexico National Tuberculosis Program (NTP) to help expand the treatment plans and strategies

that will increase control of TB especially on the Mexico- US border. The CDC also provides

support in trainings, research and anything else that Mexico needs to help combat and control the

TB bacteria (Centers for Disease Control, 2017). Mexico has improved the country’s TB

problem by working with the United States to improve coordination and technical assistance.


32

This is to help improve care for migrant families and people with tuberculosis. Mexico has also

launched a pilot TB infection control project with help from training centers. This plan is to

develop baseline assessments of facilities that house people with TB, the control plans for those

people and other assessments (Centers for Disease Control, 2017). Mexico continues to work

with the United States to help with their programs for those that are near and surround the

border.

Furthermore, there are guidelines in place for both the US and Mexico to facilitate

coordination between the two states in a public health event such as an outbreak of infectious

diseases (Centers for Disease Control and Prevention, 2018a). Part of the guidelines is Operation

Protocol, made in July 2015, to allow communication between public health entities in the U.S.

and Mexico about disease (Centers for Disease Control and Prevention, 2018a). In addition, the

operation aids in promoting effective collaboration between the two countries and their public

health systems as well as providing a clear plan with a step-by-step process to maximize

productive binational collaboration and prevent miscommunication (Centers for Disease Control

and Prevention, 2018a). This is one of the ways the United States can contact Mexico about the

possible infection and spread of tuberculosis of an individual in the United States through the

exposure to tuberculosis from someone in Mexico.

Lastly, there is another program with both Mexico and the United States, set up by the

Centers of Disease Control, called the CureTB program to prevent the spread of tuberculosis

among people who cross international borders (Centers for Disease Control and Prevention,

2018b). The main goal of the program is the reduction in tuberculosis transmission as well as the

reduction of drug-resistant tuberculosis (Centers for Disease Control and Prevention, 2018b).

One of the main ways the program sets out to accomplish this goal is to establish connections


33

between people from the United States who travel internationally, especially into countries with

high rates of tuberculosis, and the healthcare services that are available (Centers for Disease

Control and Prevention, 2018b). The healthcare services are not just those in the United States,

but also services in other countries through contracting health departments and healthcare

providers (Centers for Disease Control and Prevention, 2018b). This is a program that can

establish a connection between the United States and Mexico for communication about the

condition Mateo is in and how to help those in his family that may have or have been exposed to

tuberculosis.

The program has services to educate people about TB and motivate them to continue to

adhere to their course of treatment in order to cure the infected individual of the disease in any

country that is a part of the program (Centers for Disease Control and Prevention, 2018b). In

addition, the program collects and provides high quality clinical information to healthcare

providers, so the program can gather information from Mexico and offer it to the United States

as well as vice-versa for the ongoing diagnosis and treatment of Mateo and his family in Mexico

(Centers for Disease Control and Prevention, 2018b).


34

Needs Assessment:

Tuberculosis is a contagious disease, yet it spreads in a specific way: through the air from

one person to another (Centers for Disease Control and Prevention, 2016e). The bacteria causing

tuberculosis is released into the air when someone with the active tuberculosis disease coughs,

speaks, or sings (Centers for Disease Control and Prevention, 2016e). Tuberculosis bacteria is

not transferred from person to person through the actions of shaking someone’s hand, sharing

food or drink, touching bed linens or toilet seats, sharing toothbrushes, and kissing (Centers for

Disease Control and Prevention, 2016e). When someone with the active form of tuberculosis

releases the bacteria into the air through the airways, people in a close vicinity of the infected

person may breathe in the bacteria and become infected (Centers for Disease Control and

Prevention, 2016e). People do not transmit tuberculosis bacteria equally however; if someone is

on the medical treatment for tuberculosis, the strength of the bacteria decreases (Kanabus, 2018).

In addition, the strength of someone’s cough increases or decreases the strength of the bacteria

(Kanabus, 2018). If the bacteria is inhaled by someone else, the bacteria can settle in the lungs

and grow; the bacteria can move to different body parts such as the kidneys through the

bloodstream as well once the it settles down and increases in number (Centers for Disease

Control and Prevention, 2016e).

Although anyone can contract tuberculosis, some are at a higher risk of contraction than

others. Tuberculosis is likely to be found in areas where people are in close contact for a

prolonged period of time. Therefore, tuberculosis is much more likely to spread to coworkers or

those living in the same household rather than a complete stranger (Guinn & Rubin, 2017). This

makes transmission in cockpits on long flights very likely, since the bacteria can stay alive in the

air for a few hours if the air is lacking in freshness and sunlight such as in a cockpit of a plane,


35

since fresh air and sunlight scatters and kills bacteria respectively (Kanabus, 2018). The risk of

infection is related to the infectiousness of the individual who has TB, the susceptibility of those

exposed to tuberculosis, the duration of the exposure, the proximity to the source, and the

efficiency of cabin ventilation (World Health Organization, 2008). On commercial aircrafts, air

quality is high and tends to be cleaner than in the majority of buildings. For short flights, the risk

of transmission is small, but for longer flights of 8 hours or more, there is risk of increased

exposure and risk of contracting tuberculosis because of being confined to one space for such a

large amount of time (World Health Organization, 2008). The accessibility and greater duration

of travel, along with the increased number of travelers, increases the risk of exposure to

infectious TB.

Frequent travelers and those who may face prolonged exposure to tuberculosis should

receive a TB skin test or blood test before leaving the country (Centers for Disease Control and

Prevention, 2014a). If the test is negative, they should receive more testing 8-10 weeks upon

their arrival back in the United States. Furthermore, annual testing is recommended for those

who frequently come into contact with those who may be infected with TB (Centers for Disease

Control and Prevention, 2014a).

People who should be tested for tuberculosis include people who have spent time with

someone infected with TB disease, people from a country with high rates of TB, people who

work in high-risk areas for TB transmission, healthcare workers who work with people with TB,

and youth exposed to adults who are at a greater risk for latent TB infection or TB disease

(Centers for Disease Control and Prevention, 2016j). The risk of contracting tuberculosis

increases in areas with high rates of TB such as Latin America, Africa, Asia, the Caribbean, and

Eastern Europe (Mayo Clinic, 2018b). The majority of people who have latent tuberculosis


36

infection never develop tuberculosis disease, however some who may be at risk include people

experiencing HIV, people who recently became infected with TB bacteria, infants and small

children, intravenous drug users, people who experience other diseases that weaken the immune

system, older people, and people who did not receive proper treatment for TB previously

(Centers for Disease Control and Prevention, 2016j).

While there are no symptoms for latent tuberculosis infection and it is not contagious, the

bacteria can multiply and develop into tuberculosis disease (Centers for Disease Control and

Prevention, 2018c). Therefore, latent TB infection needs to be treated to prevent the onset of

tuberculosis disease. This can be done through isoniazid, rifapentine, or rifampin (Centers for

Disease Control and Prevention, 2018c). All treatment regimens are effective, but people with

TB should be prescribed shorter regimens to better ensure adherence, the isoniazid and

rifapentine regimen lasts 3 months. Populations which should receive priority in latent TB

treatment include (1) those with a positive tuberculosis blood test; (2) those with a tuberculin

skin test reaction of 5 mm or more and are HIV-infected, have had recent contact with active TB,

those with fibrotic changes on chest radiograph, those who have received an organ transplant,

and those who are immunosuppressed; and (3) those with a TST reaction of 10 or more who are

from countries with higher rates of tuberculosis, intravenous drug users, employees in high risk

settings, mycobacteriology laboratory workers, and children younger than 4 years, or youth

exposed to adults who are at high-risk for developing TB (Centers for Disease Control and

Prevention, 2018c).

There needs to be increased access to MDR-TB (multidrug-resistant TB) treatments for

those that are experiencing antibiotic-resistant strains of TB. A way to improve the treatments of

MDR-TB is to provide a priority ranking system (World Health Organization, 2018d) There are


37

low success rates in countries, but if there was increasing access to high ranked medicines, then

the people could have a better chance at treating the MDR-TB. There are more changes that are

being made to the regimens to help people to continue the medicine and reap the benefits. One of

the changes is getting rid of the injectable versions and replacing them with oral forms. The

injectable versions were painful and caused adverse side effects that steered people away from

continuing the treatment regimen that was suggested.

The World Health Organization is working to modify the guidelines for MDR-TB so that

the new treatments are available for those that are experiencing MDR-TB. This is to prevent the

spread of TB whether it is drug resistant or not. They are working to form stakeholder task

forces that will work to create programs for this treatment. They will be comprised evidence-

based interventions to produce the best results (World Health Organization, 2018d)

For Mateo, he most likely has the active form of tuberculosis because he has had a

persistent cough for some time, which is one of the symptoms of the disease. It is still

undetermined whether or not Mateo has a normal active form of tuberculosis or a drug-resistant

form of tuberculosis. Because Mateo has the active form of the disease, he has the possibility of

spreading it to the people surrounding him. Since he spends a lot of time with his family, his wife

and children, and they breathe in the same air in the household, they are primarily at risk of

inhaling tuberculosis bacteria and becoming infected with the disease. In addition, other people

that may be at risk for becoming infected or are infected already include his family in Mexico,

where he went on vacation and obtained the active form of tuberculosis. His family members

could have had the disease, or Mateo could have possibly spread the disease to other family

members after he obtained it because he was residing with them for a period of time in close

corridors. Mateo’s friends could be at risk as well if he has been coughing and expelling


38

tuberculosis bacteria in their vicinity because it is the primary way of transferring the disease.

Furthermore, Mateo’s coworkers can be at risk if they are spending a lot of time with him when

he is coughing or speaking and breathing in the air that he is coughing and expelling bacteria out

to. The person most at risk through his work is his co-pilot because they are together in an

enclosed cockpit with limited air, which Mateo is contaminating every single time he coughs,

speaks, or sings into it. Mateo can lessen, but not completely eliminate, the risk of others

obtaining the tuberculosis disease by staying in a ventilated room and covering his mouth or

wearing a mask whenever he sneezes, coughs, or speaks (Mayo Clinic, 2018a).

Like many other infectious agents posing threats to health of populations today, a vaccine

for tuberculosis does exist. The BCG vaccine is the only vaccine currently available to help

prevent tuberculosis (Anderson and Doherty, 2005). As one of the top ten leaders of mortality

and the culprit of almost 2 million deaths a year, the use of the BCG vaccine is widely accepted

as the best method for preventing tuberculosis (World Health Organization, 2018b). However,

here in the United States, the vaccine is not readily administered. The BCG vaccine shows

increased immunity to tuberculosis for 10-20 years when administered in infants and young

adolescent stages (Anderson and Doherty, 2005). This implies the vaccine could be beneficial if

administered with other booster shots and vaccines given during the early stages of one’s life.

Other than the United States, where tuberculosis rates are not that high, elsewhere in the

world, the use of the BCG vaccine is more prevalent. Though BCG is readily available,

accessing it can pose various challenges. In Mateo’s case, he has recently visited Mexico to see

his family, a country that has a high prevalence of tuberculosis (World Health Organization,

2016a). If Mateo’s family transmitted the infection to him, it is pertinent that they to receive

treatment. But in Mexico, garnering the necessary treatment and BCG vaccine can be difficult.


39

Without long term health insurance, many individuals will face challenges acquiring

treatment and may even develop drug resistance in their futile attempt to treat the infection

(Fitchett et al., 2011). The shared border between Mexico and the United States, along with fluid

travel, legal and illegal, pose a threat to the health of Americans and Mexicans who may or may

not be infected. In the case of Mateo, his travels to Mexico could have exposed him, but being a

US citizen affords him proper tuberculosis treatment; treatment for his Mexico-residing family

may not be achievable though. Luckily for Mateo, since he is a commercial airline pilot he

benefits from having good health insurance through the airline. Since he and his insurance can

afford to pay for the TB services and treatment, he will be charged for the services. Assuming

that he is a member of the Delta flight crew, his insurance covers him and his family. Delta

provides health and insurance coverage to both full-time and part-time employees and their

eligible dependents (spouse and children). The domestic partner program includes coverage for

medical along with other services (Delta Airlines, 2018). Medical coverage can be selected

through three different types of medical options that depend on where you live. The account-

based plan that he has provides medical coverage for many services that encompass routine

checkups, emergencies, and surgeries.

While employees for Delta have these services, they also have the freedom to choose

which doctors and offices they want to see (Delta Airlines, 2018). This only applies to the spouse

and children of the employee, so Mateo’s family in Mexico will not benefit from this insurance.

While it is likely that Mateo might have given his copilots and flight crew tuberculosis, they will

all have the same insurance that will cover their TB services and can conveniently get tested for

it. The insurance benefits also include flexible spending accounts to cover eligible expenses and

they have employee assistance programs to focus on mental and emotional well-being. If needed


40

to, the employees have the opportunity to take time off while still getting paid and not needing to

worry about money (Delta Airlines, 2018). Any coworkers that have spent a prolonged period of

time in close corridors with Mateo such as his copilots would need to undergo testing for

tuberculosis. In addition, Mateo’s family such as his wife and children will also need to undergo

tuberculosis tests to ensure whether or not they have the infectious disease.

In addition, after approximately two to three weeks of taking all of the medications, the

contagious factor of tuberculosis will subside and the person experiencing tuberculosis will not

be likely to spread the disease to others (Centers for Disease Control and Prevention, 2014b).

The AFB smear must come back negative as well to ensure that the tuberculosis infection is not

contagious. If the medical professional observing the person experiencing tuberculosis deems the

contagious factor null and agrees to ending isolation, the individual experiencing tuberculosis

can return to the daily routine and go back to work or school as long as there is continuation of

consumption of medications (Centers for Disease Control and Prevention, 2014b). Once Mateo

completes enough of his medication course to be cleared on being contagious, he will be allowed

to return to work for Delta as long as a medical professional determines the disease is not

contagious anymore.

In Mexico, some families will combine modern-day medicine with their traditional

medicine. If they cannot afford the health services than they will rely on just the traditional

medicines (U.S. Department of Health and Human Services, 2008). In addition, they will go to

their family members, friends, and neighbors for help which could potentially transmit the

disease. They will go to herbalists, therapist, midwife, and even a holistic healer before getting

pharmaceutical medicine for their illness (U.S. Department of Health and Human Services,

2008). For Mexicans that have TB, there are many different ways that they can receive the TB


41

treatment. If they are living in the US legally than they can go to their local health departments to

receive services and treatments so that they do not give anyone else, especially in the US, the

disease. If someone is living in the United States and does not want to divulge their TB status

then they may travel to Mexico to receive the antibiotics for the treatment regimen (U.S.

Department of Health and Human Services, 2008). This is regardless of their insurance status,

and this will lower the price of the medicines. To receive these antibiotics, a prescription is rarely

necessary. This is because some pharmacists are not authorized to sell medicines. This can be

bad for those seeking treatment because they can be given wrong doses of the treatment

medication, or inadequate or incomplete regimens for tuberculosis treatment (U.S. Department of

Health and Human Services, 2008). This is harmful to everyone because if someone is not

treated effectively and efficiently for tuberculosis, there is a potential that their strain will

become drug-resistant and will be harder to treat. Therefore, they need adequate doctors and

pharmacists so that they can receive the right course of treatment and correct treatment regimen

for their strain of the disease. Although the cases of TB are decreasing in Mexico, the drug-

resistant strains are becoming more prevalent (U.S. Department of Health and Human Services,

2008). To combat drug- resistant strains, Mexico implemented the DOT (directly observed

treatment) short course. They made this treatment one hundred percent available to all Mexicans,

but still need more research and new treatment options to combat MDR- TB (U.S. Department of

Health and Human Services, 2008)


42

Resources:

Health Departments:

In the state of Georgia, the state and local health departments are fully equipped to

examine, test, and diagnose an individual suspected of latent tuberculosis or tuberculosis disease.

Directly observed therapy (DOT) is the gold standard for treatment of care by health department

staff in Georgia. The health department staff will identify any person(s) who may have

tuberculosis in any form, administer a tuberculin skin test, read the reaction site, and properly

diagnose an individual (Emory University, 2014). From there, the health department will provide

laboratory services, offer appropriate therapy, and notify all individuals who could have become

infected from the person with TB. Much of the care provided can be covered by the majority of

insurance providers and Medicare/Medicaid members (Northeast Health District, 2018).

Georgia Department of Public Health

The Georgia Department of Public Health has a Tuberculosis Policy and Procedure

Manual from 2016 that all Georgia health departments must follow. The manual contains

guidelines to assist the state, local, and district health departments in controlling, monitoring, and

treating the tuberculosis disease and infection for the state. Although there are the rules to

follow, every case does not directly follow all the provided guidelines and in addition to this

manual, judgement by a clinician can be used to assess the illness. These standards and

guidelines have been established by many credible research centers that work to control TB

(Tuberculosis Prevention and Control Unit).

The Georgia TB program is legally responsible for all TB clients in Georgia no matter

who provides the services to the person to diagnose and treat the disease or infection. The TB


43

services are available to all that fall within the criteria without a concern whether or not the client

is able to pay or not. These services are to be provided at all local county health departments,

district health offices, in the private medical sector, and other public agencies, as well as the

Georgia TB program (Tuberculosis Prevention and Control Unit). Depending on which level of

government, whether state, local, or county, there are different responsibilities for each one. At

the state level, they are required to provide medical consultation to district contract physicians,

local health departments, provided physicians, and other providers and agencies. They have other

responsibilities that overlook the statewide TB programs.

The person in charge of the district TB program is the district health director

(Tuberculosis Prevention and Control Unit). The director ensures that the TB management in the

district is ample and providing the best care possible. The director implements the guidelines,

policies, procedures and protocols for the county health departments. The district health directors

act as advocates and maintain relationships with the health care providers, local health

department, contract TB physician, as well as any and all legal partners (Tuberculosis Prevention

and Control Unit). The district health directors work with others in the community to assess the

needs and resources of the community and to make sure that the policies and laws are being

upheld and followed. The district TB program also covers responsibilities for the contract

physician or consultant and the TB coordinators (Tuberculosis Prevention and Control Unit).

At the county level, the directors are responsible for the medical supervision and case

management of all known TB cases and suspects to prevent the spread of TB within the county.

The main people in charge in the county are the TB nurse and the communicable disease

specialist or outreach worker. The nurse works directly with people with TB to help prevent the

spread of TB (Tuberculosis Prevention and Control Unit). This means that the nurse provides all


44

necessary testing, home visits, care plans and follow up, and much more. The nurse also

collaborates with local physicians, hospitals, substance abuse centers, correctional facilities and

community organizations. By collaborating with an abundance of local centers, the nurse is able

to promote TB education with treatments, care, and social services for TB clients within the

community. In addition, the nurse takes over the role that the communicable disease specialist or

outreach worker would perform if one is not present in the county (Tuberculosis Prevention and

Control Unit).

The communicable disease specialists or outreach workers assist with cases to identify

infected persons and who they might have come into contact with. They can also provide the

tuberculin skin testing, venipuncture, and sputum collection if trained and are delegated by the

district health director to perform those tasks. They also provide DOT (Directly Observed

Therapy), follow ups with clients, and help to coordinate transportation for individuals for their

clinic appointments (Tuberculosis Prevention and Control Unit). The community disease

specialists or outreach workers aim to bring awareness about the disease to the community by

educating their clients and their families.

The tuberculosis services that are provided are for both the active and latent viruses, are

to protect the health of the community. These services are to be given to a client, regardless if

they can pay for them or not because controlling the spread of the disease is the most crucial

service (Tuberculosis Prevention and Control Unit). For those that can pay, Medicaid and third-

party payers can potentially be billed for their services, but not for the TB medications. This is

because the medications are purchased by the state for a discount price from the federal drug

pricing program and are given to all district TB programs. This helps to make sure that clients do

not have to choose between money and their health (Tuberculosis Prevention and Control Unit)


45

If clients are to be billed then it will be upon a sliding scale in the county, but they are not to be

denied the treatment if they are unable to pay even the minimum (Tuberculosis Prevention and

Control Unit). Sometimes, the health department has an agreement with local facilities to send

their employees to the local health department to cover the cost of those services (Tuberculosis

Prevention and Control Unit). If the client is in a high-risk population, the individual should

incur either no charge or minimal charges from the county health department TB. This is because

the benefit of providing the services to prevent a case outweighs the cost of the actual service.

The health departments are more concerned on preventing an outbreak of TB that could have

been stopped (Tuberculosis Prevention and Control Unit)

For medical care, sometimes the physicians will see every individual with the TB

infection in their area, while sometimes they just regularly check the charts and consult the

nurses on treatment and progress (Tuberculosis Prevention and Control Unit). The nurses have

protocols to follow for both the latent tuberculosis infection and the tuberculosis disease for the

uncomplicated pulmonary type. For those that do not follow under the specificity of the protocol

and are not an uncomplicated pulmonary case, they will be managed by the physician who will

deal with the medicines and treatment plans. If people are also being treated by a private

physician, they need to work together with the district contact physician for the care and

treatment, and also collaborate any other departments that are being involved (Tuberculosis

Prevention and Control Unit). The nurses will care for people under protocols and respond to the

district contract physician rather than the community’s.

There are guidelines for all diagnostics, treatment, clinical care, case management, and

infection control that all the physicians, nurses, and medical personnel are obliged to follow to

control the disease and prevent it from expanding to other areas. There are multiple visits that an


46

individual with TB needs to make. The medical staff has to make sure that the individual is

following all the medications and preventative measures that were assigned to them by their care

personnel (Tuberculosis Prevention and Control Unit). First, there is an office visit where people

fill out all forms for the plan of care and consent agreements, along with other pertinent personal

and emergency information. These clinic visits are required once a month at the very least,

depending on the severity of the case, more than one may be recommended; these clinical visits

are also known as home visits. Every known active TB case have at least one home visit to

evaluate the living conditions (Tuberculosis Prevention and Control Unit). Home visits are to

make sure that the people experiencing tuberculosis are in the best conditions, such as isolation

from others that could potentially contract the disease.

For at-risk populations, the Georgia health departments provide a program that binds the

HIV and TB case management. Since the people experiencing one or both diseases are part of

such a high risk group, when they go to the health department to get their test results from the

skin test, they are not charged or have any other barriers with care or medication (Tuberculosis

Prevention and Control Unit). IGRA testing can also be done through a Georgia Public Health

Lab because it is prioritized for specific areas that have a high number of foreign-born people

and homeless people, and other TB outbreaks. This is because these people can easily contract

the disease and spread it to other people (Tuberculosis Prevention and Control Unit). State TB

services are available across the state, they include each county and district. The state TB

program keeps a list of current single occupancy motels in the area to house the homeless clients

to promote isolation and better continuation of treatment (Tuberculosis Prevention and Control

Unit). They can provide a multitude of services ranging from psychosocial assessments, referrals

to other beneficial resources, phone and onsite consultation with difficult cases, counseling for


47

people and their family, and assistance to the districts with whatever they need. Psychosocial

assessment is an important service because it encompasses homelessness, uninsured, little to no

income, substance abuse, mental health, undocumented people, and other critical aspects. These

assessments help to determine appropriate services and treatment plans for the client

(Tuberculosis Prevention and Control Unit).

The state services program includes an evaluation so that the person with TB can identify

the pros and cons during their therapy session so that they can optimize their treatment plan and

have the best outcome. The different types of therapy offered by the health department are DOT

and VDOT, which is to ensure that people follow through and finish their treatment

(Tuberculosis Prevention and Control Unit). DOT begins when the person is a suspected or

active case. They will be in isolation until their AFB smear comes back negative. The results

usually come back 2 weeks into the dosing regimen. Some people take longer to show a negative

AFB smear, but once they do and are no longer coughing up the bacteria they no longer have to

be in isolation. Since they no longer have to be in isolation they are free to go back to work (D.

M. Cross, 2018). If the treatment is fully finished then the clients will be cured of TB and can

minimize the potential for a relapse.

Having the infection of tuberculosis can take a toll on people and for them to start and

continue their medication while still staying in good spirits is a vital part of this process to

contain the infection (Tuberculosis Prevention and Control Unit). The DOT observer can help to

make positive changes in the individual's life to help improve the quality of it and make it easier

to take the medications. In Georgia, DOT is the norm to assure that the individual gets the best

treatment that is available to prevent further complications. VDOT stands for video directly

observed therapy, this is essentially the same as DOT, but instead of in person it is via an


48

electronic device (Tuberculosis Prevention and Control Unit). This is so that the individual with

TB has more flexibility in what they can do and where they can go. If they have a confirmed or

suspected active case they will begin on DOT, but eventually can switch over to VDOT after 8

weeks, if the clinician allows it. Although this might be more convenient than DOT, it is not for

everyone and there are criteria that include an evaluation of the individual to make sure that the

person is the best candidate and will follow through with the protocols. If someone is using

VDOT and the circumstances change, it is required that they start using DOT again. For a

physician to administer either DOT or VDOT, there is a rigorous training process to ensure that

they are qualified enough and can perform the needed tasks (Tuberculosis Prevention and

Control Unit). It is required that either VDOT or DOT lasts the entire time of treatment which is

about 6 months. It usually consists of a schedule of daily DOT for 2 months or 40 doses and then

biweekly for a total of 36 does which ends up being 4 months (D. M. Cross, 2018).

Clarke-County Health Department

In Athens Clarke-County, the best available place for aid against tuberculosis is the

health department for the county. The health department for Athens Clarke-County is given a

sum amount of money, around $150,000 a year, to deal with all cases of tuberculosis (D. Cross,

2018). The person who looks over this specific TB program is the Athens-Clarke county district

health director, Dr. Claude A. Burnett, MD, MPH (Athens-Clarke County Unified Government,

2018 ). The department does not care if the person has insurance or not; the department will treat

them regardless of health insurance (D. Cross, 2018). Anyone that is suspected of being an active

case will first be checked on by the nurse; the nurse will then perform quantiferon test to

determine whether or not that person has the mycobacterium tuberculosis infection (D. Cross,


49

2018). A quanitferon test measures an individual’s white blood cells and is a one of the

interferon gamma release array tests (American Association for Clinical Chemistry, 2017). The

health department provides free quantiferon tests for tuberculosis especially for those people who

have gotten the Bacillus Calmette-Guerin (BCG) vaccine or come from a county with a high

incidence rate of tuberculosis such as Mexico(D. Cross, 2018). The health department does not

offer to administer the purified protein derivative (PPD) tuberculosis skin test for free; it will

cost money to receive that test, but the quantiferon test is very accurate in its results so the PPD

test is not necessarily needed (D. Cross, 2018).

When a case is identified and referred to the health department, the health department,

which usually refers to the head of the infectious diseases’ section of the health department,

identifies the areas of contact and the people that the infected individual has been in contact with

such as in the household, at work, at church, or any other social event. All of the contacts who

have been in close corridors for a prolonged period of time with the infected individual are tested

for tuberculosis through the quantiferon test (D. Cross, 2018). If the results are negative, the

individuals are identified as individuals with a latent tuberculosis infection (LTBI). If any of the

test results show a positive remark, the individuals are sent for chest x-rays and checked for

symptoms to determine if they have tuberculosis and determine if it is a multidrug-resistant strain

or not (D. Cross, 2018). In addition, if the results are positive, the individuals, especially the

infected individual, will be put in isolation (D. Cross, 2018). Luckily, the American Lung

Association helps out a lot for cases of tuberculosis in Athens Clarke-County; the American

Lung Association will pay for an isolated individual and his or her family’s land, water, and

electricity bills for the months of isolation if help is needed (D. Cross, 2018). In addition, they

provide shelter for infected individuals that are homeless; they provide assistance to all affected


50

individuals because the isolated individuals will not be allowed to attend work during their time

in isolation (D. Cross, 2018).

The Clarke-County health department’s infectious disease section has treatments and

prescription medications for every kind of tuberculosis including multidrug-resistant (MDR) and

extensively drug-resistant (XDR) (D. Cross, 2018). In addition, the employees of the infectious

disease department will watch and monitor the infected individuals throughout their entire course

of treatment to ensure that they are consuming their pills every day (D. Cross, 2018). This

prevents the potential threat of an infected individual spreading it to someone else. Moreover, the

department will continue to monitor the individuals that are tuberculosis cases two months after

they finish the entire treatment course by administering a chest x-ray to determine if the

tuberculosis has fully cleared (D. Cross, 2018). The CDC provides the protocols for every aspect

that pertains to TB at the health department such as testing, treatment, and isolation. Every aspect

other than the PPD skin test for tuberculosis is free for the infected individual because of the

high risk of exposure of tuberculosis (D. Cross, 2018). The Athens Clarke-County health

department does not wish to change or receive anything for their program because the program is

optimal; instead, the head of the infectious diseases’ department wishes that people in general

were more aware of tuberculosis and the disease’s presence in today’s society because the

disease is not eradicated (D. Cross, 2018). Even though the incidence rate may not be very high

in the United States compared to other countries such as Mexico, the disease is still an issue in

the nation and people are still susceptible to obtaining the disease from others who are infected

with tuberculosis. Furthermore, the head hopes that the spread of awareness for tuberculosis

occurs through primary care physicians (D. Cross, 2018). Primary care physicians do not usually

include tuberculosis screenings during their typical screenings for diseases, so the head wishes


51

that the primary care physicians are more aware and spread more awareness about the presence

of tuberculosis through administering tests and screenings for the disease if symptoms are

presented (D. Cross, 2018). In effect, this would decrease the amount of people that would

potentially be infected with the disease.

Lastly, if an infected individual comes to the health department with an active case of

tuberculosis yet without knowledge on what type of tuberculosis such as normal, multidrug-

resistant, or extensively drug-resistant, the health department would give him/her three sputum

tests for tuberculosis (D. Cross, 2018). This is done by testing the bacteria in the phlegm

coughed by the lungs for tuberculosis germs (D. Cross, 2018). In addition, the department would

immediately put the infected individual under isolation, ensure that the individual wears a mask

around others, and keep the individual away from the outdoors and other people with the

exception of visits to the doctor’s office (D. Cross, 2018). Additionally, the infected individual

would receive medication for tuberculosis that follows the medication course for normal

tuberculosis until the result of the sputum comes back (D. Cross, 2018). Furthermore, the

department would go back around the three-month mark to examine everyone the infected

individual has been in close contact with such as family, friends, and coworkers and test those

individuals for tuberculosis through the quantiferon test (D. Cross, 2018). If the infected

individual has recently visited a country with a high incidence or high endemic rate of

tuberculosis, the health department would establish contact with the country to inform the nation

of the situation and of the people who may be at risk of exposing others to tuberculosis (D.

Cross, 2018).


52

Centers for Disease Control and Prevention

The CDC, located in Atlanta, GA within Fulton County, is the forerunner for disease

surveillance, epidemiological research, and treatment guidance for various infectious diseases.

On the subject of tuberculosis, the CDC website hosts a plethora of useful information for an

individual who has been infected and is considering what their next step is and what their options

might be. Various infographics depicting symptoms and vectors for disease transmission, links to

web pages detailing treatment methods for a positive infection, and several programs initiated in

the state of Georgia, the United States, and coalition efforts between Mexico and the US can be

find on the CDC tuberculosis search page. Any individual can access the site, toggle through the

assorted information, and acquire any relevant material they deem useful for treatment and care.

One form could be through the Binational Border Infectious Disease Surveillance

Program (BIDS) which is a program of the CDC that works with the four US states alongside the

border of Mexico for collaboration on all levels to improve the prevention, detection, and

reporting of infectious diseases of binational importance, which includes tuberculosis along with

other diseases such as Zika and Influenza (Centers for Disease Control and Prevention, 2018a).

Through the program, there are ways to contact the Mexican government to inform them about

an infectious disease presence. The program has a systematic communication channel amongst

the partners to allow for swift preparation against any infectious disease outbreaks (Centers for

Disease Control and Prevention, 2018a). In addition, they maintain a regular notification channel

between the two countries about any binational disease events and outbreaks so that the US and

Mexico border state health officials are well informed about the health issues occurring in their

area (Centers for Disease Control and Prevention, 2018a).


53

Lastly, there is another program with both Mexico and the United States, set up by the

Centers of Disease Control, called the CureTB program. It is to prevent the spread of

tuberculosis among people who cross international borders (Centers for Disease Control and

Prevention, 2018b). The main goal of the program is the reduction of the transmission of

Tuberculosis as well as the reduction of drug-resistant tuberculosis (Centers for Disease Control

and Prevention, 2018b). One of the main ways the program sets out to accomplish this goal is to

establish connections between people from the United States who travel internationally,

especially into countries with high rates of tuberculosis and have healthcare services available

(Centers for Disease Control and Prevention, 2018b). The healthcare services are not just those

in the United States, the program includes services in other countries as well as by contacting

health departments, healthcare providers, and others (Centers for Disease Control and

Prevention, 2018b). This is a program that can establish a connection between the United States

and Mexico for communication about the condition Mateo is in and how to help those in his

family that may have or have been exposed to tuberculosis.

The program has services to educate people about TB and motivate them to continue to

adhere to their course of medications to completely treat and cure the infected individual of the

disease in any country that is a part of the program (Centers for Disease Control and Prevention,

2018b). In addition, the program collects and provides high quality clinical information to

healthcare providers, so the program can gather information from Mexico and offer it to the

United States as well as vice-versa for the ongoing diagnosis and treatment of Mateo and his

family in Mexico (Centers for Disease Control and Prevention, 2018b).


54

Sustainable Solution

While there are extensive available resources and treatments for tuberculosis to help

remedy the disease, there needs to be a bigger solution to address tuberculosis as a re-emerging

disease. One of the ways to provide a sustainable solution for tuberculosis is increasing

awareness for the disease, especially with the help of primary care physicians. Primary care

physicians spend the most time with the general public who demonstrate symptoms of

tuberculosis compared to other health professionals. Instead of brushing off the symptoms as

another disease such as pneumonia, the primary care physicians should preemptively screen for

tuberculosis if the symptoms do appear. If the primary care physicians increase screenings for

tuberculosis, there could be an increased chance of catching tuberculosis cases and treating them

earlier. It is also important that primary care physicians inform the people that they are treating,

and understand themselves, that although tuberculosis does not have a high incidence rate and is

no longer a major issue in the United States, it is still a serious disease that spreads easily and

needs to be treated properly.

An increase in primary care physicians screening for tuberculosis means that primary

care physicians need to be more accessible to the general public. One of the best sustainable

solutions for increasing accessibility to primary care physicians is through universal health care.

Furthermore, coupling with universal health care, more incentives must be given to medical

students to forgo specialty training and choose to be a primary care physician. There is a growing

shortage of primary care doctors in the United States, which makes receiving more

encompassing medical care difficult to obtain. In the event someone does need specialty care, a

referral from a primary care physician, as required by certain insurance plans, is harder to

acquire.


55

Of most importance to the identification, containment, and treatment of tuberculosis is

funding. In Georgia, funding is allocated by the state government. All the available funds must

be split between the eighteen public health districts of this state. In many cases, the funding is apt

for the tuberculosis cases acquired during the fiscal year. However, in counties such as Dekalb

and Fulton which have higher incidence rates of tuberculosis, the funding garnered to this health

district is ultimately inadequate. The burden for continuing care without state funding now falls

on the shoulders of the health district and cuts have to be made elsewhere. To prevent this

shortage of funding from occurring, surveillance methods should be increased. If predictions for

yearly incidence of tuberculosis were more in depth, funding for the year could be better

allocated and awarded to the counties that will see a higher incidence, therefore needing more

funds. Furthermore, reducing the cost of medical supplies needed such as sputum sampling,

medications, and doctor visits could significantly alleviate the overall cost, for the state, when it

comes to caring for the sick individuals.

Multidrug resistant TB is becoming more prevalent due to the infection mutating and

being able to resist more than one of the medications for the TB infection. This leads to a greater

problem because some people are unable to get the treatment they need. This causes their lives to

be disrupted because they have to be kept in isolation to make sure not to infect anyone else,

while also not being able to treat their disease (Cros et al., 2015). More research needs to be done

to test and create newer drugs that can attack the MDR-TB, while also minimizing the side

effects from them. Since kids are also likely to contract the disease more easily and if there is a

chance that they are infected they immediately have to be treated, we need to find ways to make

their treatments better and more enjoyable, while also trying to reduce the number that are

contracting the disease (Cros et al., 2015). This means that solution could be working with


56

pharmacists to produce children-friendly treatments that do not hinder their well-being and do

not produce adverse side effects. For medications that do produce side effects, there needs to be

the appropriate one readily on hand, that can deter major discomfort from the side effects (Cros

et al., 2015).

Solutions that the WHO has worked on implementing include better and quicker access

to diagnose the MDR-TB. The main goal is to speed up detection and improve the treatment

outcomes (World Health Organization, 2018c). This would be possible by using a rapid

diagnostic test, as well as shorter and cheaper drug treatment regimens. This would allow more

people to be able to be seen and diagnosed quicker so that they can immediately start their

treatment and hopefully not infect other people. Another solution that they suggest is to ensure

that the second line of drugs for the MDR-TB are accessible and useful in treating the TB (World

Health Organization, 2018c).

Tuberculosis and HIV are also closely linked, as many infected with HIV die from TB

coinfection. In people living with HIV, latent tuberculosis can quickly develop into active TB,

further weakening the immune system (Centers for Disease Control, 2016b). Tuberculosis can

then progress quickly from disease to death. Therefore, education and increasing awareness on

TB and HIV coinfection is important, so that people are aware of any major risks they may

face. Those with HIV should also be closely monitored and tested to ensure that they do not

develop TB, or so that their latent TB does not progress into active TB (Centers for Disease

Control, 2016b)


57

Resource Handout:

Group 12 Tuberculosis

GEORGIA DEPARTMNET OF PUBLIC HEALTH State of Georgia Building, 2 Peachtree St #5, Atlanta, GA 30303 Phone: 404-657-2700, website: https://georgia.gov/agencies/georgia-department-public-health The Georgia department of public health is the major agency in Georgia that works to prevent and control diseases, promote health and well-being, and also to help and prepare for disasters from a public health standpoint. They have many divisions within this agency that serve to organize and delegate tasks between the 159 county health departments and 18 public health districts in Georgia. Their main task is Health Promotion and Disease Prevention, and Infectious Disease and Immunizations. CLARKE COUNTY HEALTH DEPARTMENT 345 North Harris St, Athens, GA 30601 Phone: 706-389-6921, website: http://publichealthathens.com/wp/clinics/health-departments/clarke-county/ The Athens Clarke County Health Department offers a multitude of services for chronic diseases, pregnancy, immunizations, and TB testing and treatment. The TB testing that they provide is available for a small fee, but sometimes on a sliding scale. If someone that has TB comes in, they can administer treatment regimens. CENTERS FOR DISEASE CONTROL AND PREVENTION 1600 Clifton RD, Atlanta, GA 30333 Phone: 1-800-232-4636, website: www.cdc.gov The Centers for Disease Control and Prevention, known as CDC, is the main national public health institute in the United States. They provide information for anything and everything involving health from ADH, cancer, the flu, and Tuberculosis. They have safety precautions for injuries, immunizations, environmental hazards, workplace safety, emergency preparedness and other diseases. They work to improve the public’s health for healthy living everywhere.

http://publichealthathens.com/wp/clinics/health-departments/clarke-county/

http://publichealthathens.com/wp/clinics/health-departments/clarke-county/

http://www.cdc.gov/


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Critical Reflection - Arohi

Gathering information from community agencies is an important task when participating

in a needs assessment; while community agencies may have a large amount of information on

their website, the best information is one gathered directly from the agencies through answers to

personalized questions. The community agency chosen for the group working on the tuberculosis

case study was the Clarke County Health Department. The major challenge that caused the most

difficulty for the group was trying to set up a time to meet with the site due to conflicting

schedules with the group members, however, the members worked it out in the end and had a

great visit with the site. The site supervisor was extremely helpful and insightful; the supervisor

offered immense amounts of information and knowledge on the subject and on the activities of

the Clarke County Health Department and all that the department has to offer for people

experiencing tuberculosis.

Through the site visit, the group learned that the main goal of the infectious diseases

section of the health department was to control the infectious disease so that there is no epidemic

or outbreak occurring in the nation. Because the county health department’s main needs are to

protect the population of the county as a whole, the health department does not care about an

individual’s ability to pay for treatment. The county health department has funding allocated to

them by state and national departments and agencies of public health to pay for all necessary

testing and treatment options for people experiencing tuberculosis. This is a prime example of

how health policy is being enacted to help provide free and accessible care for people because it

is necessary and it will benefit the health of the population of the nation overall.

For my future, I am interested in obtaining a Masters’ of Public Health in the field of

Epidemiology and one of my passions in Epidemiology is Infectious Diseases, which is the


59

category of disease that tuberculosis falls under. Through the site visit as well as doing immense

and extensive research for completing the case study project, I have gained multiple insights on

infectious diseases, which will benefit myself in my career path hopefully. The case study project

in total has increased my passion and interest in infectious diseases as a whole, especially with

tuberculosis because the infectious disease of tuberculosis is re-emerging around the world

including the United States. Some of the insights I learned through the whole assignment was

how extensive the research on topics such as infectious diseases needs to be to cover the all of

the aspects to ensure that every area is noted for and not forgotten. With infectious diseases in

particular, there are multiple diseases that can and have become multidrug-resistant or even

extremely drug-resistant, which is detrimental to the health of the individual experiencing the

infectious disease since most infectious diseases require antibiotics to treat such as tuberculosis.

The need for in depth research on multidrug-resistant strains, diagnoses, and treatment is

extremely high because of the increasing possibility of diseases becoming multidrug-resistant.

Furthermore, I learned about providing a multitude of sustainable solutions for infectious

diseases that do not just include vaccinations. For example, tuberculosis has a vaccine which is

administered in high endemic countries, however, the vaccine is not very effective so it is not

administered or required in the United States, along with the fact that the United States does not

have an extremely high endemic rate of tuberculosis. Through the case study, one main deal that

stood out is the importance of providing treatment to all individuals to protect the health of the

nation as a whole. While vaccines are a while to protect national health, there are not the only

way to do so and there are other sustainable solutions that can aid in protection such as

increasing awareness for medical professionals to catch diseases early instead of waiting for

worse outcomes.


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Critical Reflection – Molly

This group chose to visit the Clarke County Health Department for the required site visit.

The visit to the health department was very informative thanks to Ms. Cross. Due to difficulty in

finding a time where all group members were able to visit the health department together and

limited availability on Ms. Cross’ part, the site visit was pushed back until the end of October,

which did make it difficult to work and write together with information the group had not yet

gathered. However, Clarke County Health Department and Ms. Cross were very informative, as

many resources the group found online were not nearly specific enough on how different

providers and departments handle tuberculosis. Being able to sit down with a professional and

ask previously formulated questions was beneficial because the group was able to ask relevant

questions on how the Clarke County Health Department specifically handles tuberculosis

outbreaks. The group learned about treatment and free testing in Clarke County, the division of

funds among other districts, protocols, and isolation. None of this information was shared on the

health department’s website, so that site visit was essential to understanding resources available

for this case study in Athens.

As a senior at the University of Georgia, my plans for the future include pursuing my

Masters’ of Public Health in Health Policy and Management. Although I am still unsure exactly

what I would like to do, I know that I am interested in healthcare management and

administration work. My interest also lies in global health and specifically infectious diseases

such as tuberculosis. Tuberculosis continues to affect so many people, and has such high rates in

developing countries such as Mexico. Therefore, understanding tuberculosis, how it works, along

with different treatment options is beneficial for my future career plans, and this site visit gave

insightful information on how one county in Georgia deals with tuberculosis.


61

This site visit as well as continuing research on tuberculosis for this case study taught me

how detrimental multidrug-resistant tuberculosis can be for one’s health. I had no idea the cost or

how difficult treatment adherence could be because MDR-TB treatment takes longer and

requires daily medication for many months, and my knowledge on treatment options was very

limited.

In addition, I did not know how disproportionately tuberculosis affects foreign-born

persons in the United States compared to U.S.-born persons, and the burden became even greater

when looking specifically at Hispanics/Latinos. Foreign-born persons are at a thirteen times

greater rate of tuberculosis than U.S.-born persons, and Mexico continues to be one of the top

five countries with the highest incidence rate for tuberculosis, mainly because of poorer living

conditions such as overcrowding and a greater burden of comorbidities associated with

tuberculosis.

I was also unaware of how certain disparities such as incarceration and homelessness had

an effect on tuberculosis, as the incarcerated population is at a greater risk for contracting

tuberculosis, and many who are diagnosed with tuberculosis have previously experienced

homelessness. Thus this case study taught me the importance of understanding how different

populations are affected by a disease, and not just looking at the general population. It is

important to target different groups, whether it be racial/ethnic minorities or those experiencing

homelessness, to understand why certain groups are at a much higher risk of developing the

disease and how to reduce its incidence.

Overall, this group worked very well together. The group utilized Groupme as the main

form of communication, and while organizing a time to visit the health department together was

challenging, that was the only concern during the entire semester of working together. Groupme


62

proved to be effective and efficient, and the group had no problem dividing the work load. Each

member contributed in one way or another and remained attentive and respectful of each other.

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Case Study 12 Annie Christian, Molly Heinlein, Garrett ... · CASE STUDY 12: TUBERCULOSIS 3 Health: Tuberculosis History Tuberculosis is an infectious disease in which the bacterium,

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