1.11: The cough heard ‘round the world- working with tuberculosis
Introduction
Tuberculosis (TB) is the world’s leading killer amongst infectious diseases. In 2017, 1.6 million people died from TB, making it one of the top ten causes of mortality worldwide. 1 TB is preventable and curable, but elimination remains a challenge. Worldwide, the regions with the highest number of cases of TB are Southeast Asia and Africa, accounting for approximately two-thirds of the reported cases. 2 As such, the elimination of TB is a key priority of the WHO, 3 included in the Sustainable Development Goals (SDGs) with a target to “end the epidemics of AIDS, TB, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases” by 2030. 3
In the United States specifically, public health initiatives within health departments and TB control programs had a tremendous impact on the prevention and management of TB. 5 Although it remains a concern, the rate of TB in the United States continues to drop slowly. A total of 9,105 TB cases (a rate of 2.8 cases per 100,000 persons) were reported in the US in 2017. This is a decrease from the number of cases reported in 2016 and the lowest case count on record. 6 However, due to the ongoing public health implications of the disease, TB remains a focus area in the Healthy People agenda for the nation. Included in the specific topics and objectives are goals to reduce TB, increase the completion rate of all TB patients who are eligible to complete therapy, and to increase the percentage of contacts to sputum smear-positive TB cases who complete treatment after being diagnosed with latent TB infection (LTBI) and initiated treatment for LTBI. 7
Elimination of TB will require a worldwide effort to decrease transmission for active cases, access to quick treatment, as well as strategies to screen for and manage latent TB infection. The USPSTF recommends screening for latent TB infections in populations at increased risk. 8 Cases of active TB must be treated quickly, as the disease is contagious, with an estimated capacity of a single person with untreated and active disease to infect as many as 15 people within a year. 1 Drug resistance is also a concern, with over half a million new cases of TB in 2017 demonstrating resistance to first-line therapy, including 82% with multi-drug resistant TB (MDR-TB). 1 Effective treatment requires adherence to complex medication regimens over several months. 9 Management requires trained health care providers who are able to provide long-term, patient-centered care.
Case (part 1)
BR is a 38-year-old female nurse who works full time at a local academic hospital within the United States. A couple of months ago, she traveled to India in order to spend time with her family and experience the community in which her parents were raised. During the month BR spent in India, she was in close contact with various friends and family, as well as many members of the local community. Upon her return to the US, BR returned to her job as a bedside nurse, moved in with her fiancé, and resumed volunteering on the weekends at a local homeless shelter. She is also excited for an upcoming trip to Singapore but is anxious about the 24 hours of flying that it will involve.
Due to her role as a healthcare worker, BR was recently required to be screened for TB during the hospital’s annual TB testing period. Much to BR’s surprise, the healthcare worker who read her PPD skin test reaction stated that she had a positive result of 11 millimeters. Thinking that this could be a false-positive test, BR agrees to get further testing completed including a chest x-ray
- How common is TB worldwide and within the US? Which countries have the highest incidence of TB? Which countries have the highest rates of drug resistant TB?
- What are some factors that have contributed to the rise and fall of TB infections around the world? What are some barriers to combating the disease worldwide?
- How are tuberculin skin testing reactions interpreted? Does the classification of positive tuberculin skin test reactions differ depending on patient risk factors?
Case (part 2)
After some consideration, BR decided that she was too busy planning her rapidly approaching Singapore trip to squeeze in doctors’ appointments and, therefore, would postpone any further testing until her arrival back in the US. She argued that “she didn’t look sick and had no cough” and could not possibly be infectious. Five days later BR boarded a flight from John F. Kennedy airport in New York to Hong Kong International airport and then a separate flight from Hong Kong to Singapore Changi airport. Enduring the 24 hours of travel she proceeded to enjoy her trip according to her itinerary and two weeks later reversed her trip from Singapore to Hong Kong and then from Hong Kong to New York.
- Which factors influence the extent to which communicable diseases are transmitted? How is TB transmitted, and why is that important to public health?
- How do you explain to BR some of her risk factors for contracting TB?
Case (part 3)
Upon returning to the US, BR’s chest x-ray showed abnormalities and her physicians performed further testing to confirm a diagnosis of TB and to obtain a sample isolate. BR did not understand how this could be possible, since she did not have any symptoms of an active infection. While awaiting further testing on her isolate by the CDC, BR was started on standard therapy for the treatment of TB and was advised by her providers to refrain from any further travel. It was also advised that any family members, friends or coworkers that had been in close contact with BR also be tested for TB. Additional testing by the CDC of her TB isolate confirmed MDR-TB, and BR’s physicians told her that she would have to undergo more extensive treatment in isolation until she was no longer infectious.
- What are considered common treatments for active TB and what is the typical duration of treatment?
- What are risk factors for multidrug resistant TB? How does treatment differ if a patient is diagnosed with MDR-TB?
Case (part 4)
With the knowledge that a passenger onboard recent international flights had been traveling with active TB infection, the CDC began trying to track down all passengers and crewmembers who were on the commercial flights of which BR had been a passenger. It was highly suggested that these individuals also get tested for TB after having been in a confined space for many hours with an infected person. The CDC placed a specific focus on the flights from New York to Hong Kong, due to the duration of the flight, and extra attempts were made to get in touch with the passengers seated close to BR during the time of travel. Additionally, the hospital where BR was actively employed had to alert all employees and patients, who had been in close contact with her for extended periods of time, to consider undergoing additional TB testing.
- What is the risk of communicable diseases being transported on board an aircraft? Does the duration of the flight have any impact on risk?
- What is the incubation period for TB, and does that affect the timing of testing for individuals who may have been exposed?
- Is there a role in the future for a coordinated, international approach to data collection and operational decision-making, and what is the role of the US in these discussions?
- Does the US government have the authority to isolate or quarantine individuals traveling to and from the US if they are deemed a public health risk?
Author Commentary
Treatment for TB is a long and challenging process. It is difficult for patients and for the health systems that are funding these long, expensive treatments. While the WHO and others are spearheading shorter MDR-TB treatment regimens, 10 challenges still exist in bringing the disease under control. 11 Newer drugs that are less toxic, require shorter treatment durations, and are less expensive are needed. While new drugs are being developed, it is a slow process. The required research and development prospects are thin, 1 and pharmaceutical industry spending in this area is continuing to decline. 12
At one time, TB was viewed as a disease of despair – affecting those with low-incomes, substandard housing, and little access to care. TB is still linked with health disparities; however, with as many as 36% of those with active TB going unrecognized in a world with millions of people with active disease, 1 TB is a disease that knows no boundaries. This puts the US population at risk. It is clear investments also need to be made into TB screenings and prevention. While UN SDGs aim to end the TB epidemic by 2030, major gaps exist in the funding required to reach this goal. 12
As health care providers, we need to be able to recognize the signs and symptoms of TB and to link our patients to care, but that is not enough. We need to be advocates for our patients and for our communities. We need to speak up and work with policymakers to tackle social determinants of health and TB. As pharmacists, we call ourselves the “drug experts.” TB is a disease with massive drug impacts, and if we truly are public health professionals and drug experts, we cannot stay silent.
Patient Approaches and Opportunities
While the therapeutics of TB treatment is not the focus of this chapter, it is important for public health providers – especially pharmacists – to understand patients’ treatment burden. Drug-susceptible TB treatment typically lasts at least six months with the intensive phase including four drugs. 9 Drug-resistant TB regimens are generally considerably longer – some as long as 24 months – often with regular injections. 10 These drugs also have significant side effects, and patients with the disease are often grappling with stigma. This is concerning as patients who abandon treatment midcourse not only do not improve, but they are more likely to develop a resistant form of TB. As such, it is vital that patients are adequately prepared and that trusting relationships are built so that our patients can seek guidance if support is needed during the treatment process.
Adherence to TB treatment is vital because with proper treatment TB is curable. It is important that as pharmacists we properly counsel patients on their medications and help them develop adherence strategies. These concepts need to be reinforced during every pharmacy visit. Patients who are not compliant with their medications should be connected with a public health department to investigate enrolling in a Directly Observed Therapy (DOT) program where a healthcare worker can observe the patient taking medications each day. The Missouri Department of Public Health and Senior Services, for example, has an eDOT program where healthcare providers can remotely observe the patient taking medications either in real time or via recordings. 13
While overcoming the worldwide TB burden can seem like a daunting task, pharmacists have an opportunity to play a vital role in the battle against TB. By building relationships with our patients, we can help them to process and overcome stigma, work together to navigate cultural differences and help to increase adherence. We are also at the front lines and can help to identify patients with TB symptoms and refer them to the appropriate healthcare provider.
Related chapters of interest:
- Ethical decision-making in global health: when cultures clash
- An ounce of prevention: pharmacy applications of the USPSTF guidelines
- HIV and hepatitis C co-infection: a double-edged sword
- Sex education: counseling patients from various cultural backgrounds
- The Sustainable Development Goals and pharmacy practice: a blueprint for health
- Unexpected souvenirs: parasitic and vector-borne infections during and after travel
- Travel medicine: what you need to know before you go
External resources:
- Missouri Department of Health and Senior Services Tuberculosis Case Management Manual: https://health.mo.gov/living/healthcondiseases/communicable/tuberculosis/tbmanual/pdf/Chap9.pdf
- WGBH (Television station: Boston, Mass.) & Vulcan Productions. (2005). Rx for survival: A global health challenge . Boston, MA: WGBH Boston Video. DVD available or available online at: http://www.pbs.org/wgbh/rxforsurvival/index.html
- Global TB report through WHO: https://www.who.int/tb/publications/global_report/en/
- CDC Respiratory protection fact sheet: https://www.cdc.gov/tb/publications/factsheets/prevention/rphcs.htm
- Rise of MDR-TB in Russia: https://www.ncbi.nlm.nih.gov/books/NBK62453/
- WHO Drug-Resistant TB: https://www.who.int/tb/areas-of-work/drug-resistant-tb/global-situation/en/
- CDC Tuberculin Skin Testing fact sheet: https://www.cdc.gov/tb/publications/factsheets/testing/skintesting.htm
- Tuberculosis and Air Travel: Guidelines for Prevention and Control: https://www.ncbi.nlm.nih.gov/books/NBK143710/
- CDC Isolation and Quarantine: https://www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html
References
- Tuberculosis. The global fund to fight AIDS, tuberculosis and malaria; 2018. Available from: https://www.theglobalfund.org/en/tuberculosis/ . Accessed October 26, 2018.
- WHO Global tuberculosis report 2018. https://www.who.int/tb/publications/global_report/en/ . Accessed October 26, 2018.
- The End TB Strategy. http://www.who.int/tb/End_TB_brochure.pdf?ua=1 . Accessed October 26, 2018.
- Sustainable Development Goals Goal 3: Ensure healthy lives and promote well-being for all at all ages. https://www.un.org/sustainabledevelopment/health/ . Accessed October 26, 2018.
- Achievements in public health, 1900-1999: Control of infectious diseases. MMWR 1999;48(29):621-629.
- CDC. Tuberculosis (TB) data and statistics. https://www.cdc.gov/tb/statistics/default.htm . Accessed Oct. 26, 2018.
- Immunizations and Infectious Diseases. https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives . Accessed October 26, 2018.
- US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for latent tuberculosis infection in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;316:962-969.
- Nahid P, Dorman SE, Alipanah N, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America clinical practice guidelines: Treatment of drug-susceptible tuberculosis. CID. 2016;63(7):853-867.
- Treatment of Tuberculosis: Guidelines. 4th edition. Geneva: World Health Organization; 2010. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138752/ . Accessed October 26, 2018.
- The shorter MDR-TB regimen. Geneva: World Health Organization; 2016. Available from: https://www.who.int/tb/Short_MDR_regimen_factsheet.pdf . Accessed October 26, 2018.
- Treatment Action Group. The ascent begins: tuberculosis research funding trends, 2005–2016. New York: Treatment Action Group; 2015. Available at: http://treatmentactiongroup.org/sites/default/files/TB_FUNDING_2017_final.pdf . Accessed October 26, 2018.
- Missouri Department of Health and Senior Services Tuberculosis Case Management Manual. 2018. Available from: https://health.mo.gov/living/healthcondiseases/communicable/tuberculosis/tbmanual/pdf/Chap9.pdf . Accessed October 26, 2018.