Epidemiology Paper: Focus on Tuberculosis

Nowadays, tuberculosis (TB) is a significant public health concern. If diagnosed and treated early, this disease is curable, for example, an estimated 54 million lives were saved between 2000 and 2017 (World Health Organization, 2018). Still, despite the gains made in the control of TB transmission, concerns arise that extra effort is critical for the eradication of the disease that currently ranks second after (HIV) in the cause of deaths from infectious diseases. Therefore, the Sustainable Development Goals and 2014 WHO End TB Strategy have a shared health target to lower the rates of TB morbidity, mortality and the unreasonable costs associated with the disease by 2030 (Abbott & Elliott, 2017). To achieve its goal of ZERO TB deaths worldwide by 2030, the World Health Organization continues to urge the collaboration and commitment of all governments and health organizations to mobilize social and political goodwill to ensure their progress in the elimination of TB as a public health burden (World Health Organization, 2018). The insight into the clinical characteristics of tuberculosis, factors that contribute to its development, and its epidemiologic triangle will help identify the role of community health nurses in containing the disease, the contribution of the National Tuberculosis Controllers Association in fighting the pandemic, and the global implication of the disease.

Description of Tuberculosis and the Demographic of Interest

Tuberculosis, or pulmonary tuberculosis (TB), refers to a contagious infection that targets the lungs. The main cause of this disease is Mycobacterium tuberculosis, a small slowly growing bacterium that only survives in people (Craig, Daftary, Engel, O’Driscoll, & Ioannaki, 2017). Another name for this bacterium is Koch’s bacillus, named after Robert Koch, the scientist who discovered it in 1892) (Craig et al., 2017). Tuberculosis has various symptoms, the knowledge of which will help in combatting it. However, infected persons may not develop any symptoms since the bacterium can live in the body without someone developing any sickness. Most people become infected with the latent TB infection, whereby the immune system fights the bacteria before they spread. Thus, research indicates that roughly one-quarter of the world’s population (over 2 billion people) has latent TB (Arshad et al., 2014). Within a few weeks or even years, those infected with TB bacteria face a 5–15% lifetime risk of contracting the disease since the infection may begin to multiply and TB takes an active form (Centers for Disease Control, 2018). Symptoms associated with tuberculosis include severe cough (with or without blood in sputum) that lasts for three weeks or longer, chest pains, fatigue, chills, fever, wheezing, profuse sweating at night, the loss of appetite, and drastic weight loss. In a single year, those with active form of TB can infect 10–15 other people (Craig et al., 2017). Therefore, it is critical to seek an early and proper treatment to lower the chances of transmitting the disease.

TB spreads through the direct transmission of droplet nuclei. These particles are airborne. When a person with active TB coughs, sneezes, sings, laughs, or talks, they release tiny droplets containing bacteria, and if someone lowered immunity inhales the germs, they may get infected within 2-12 weeks (Centers for Disease Control, 2018). Although TB targets the lungs, if left untreated, it also attacks and damages other body parts, including the spine, the brain, and kidneys. Complications associated with TB infections including spinal/back pain and a fatal form of meningitis (World Health Organization, 2018). Early treatment of tuberculosis is critical to for the prevention of its transmission.

With a prompt diagnosis and proper treatment, TB is treatable and curable. Thus, blood tests reveal whether one has been infected with TB bacteria, while further tests, including chest x-ray and a sample of sputum, can help detect whether the person has an active form of this disease (Arshad et al., 2014). Treatment implies the use of antibiotics, including isoniazid, rifampicin, pyrazinamide, and ethambutol, while a full recovery is possible within four-six months (Arshad et al., 2014). A successful treatment emphasizes a close cooperation between the patient and the healthcare providers who offer supervision and support during the process. However, a failure to adhere fully to medication can result in multidrug-resistant TB (MDR-TB), which requires stronger antibiotics, or a more fatal form of TB, called extensively drug-resistant (XDR-TB) that resists practically every known drug (Craig e al., 2017). Thus, it is critical for patients to achieve a full recovery to prevent transmission or the development of drug-resistant forms of TB.

The United States continues to enhance efforts to control the transmission of tuberculosis. In 2017, 9,105 TB cases were reported in the United States, a 1.6% decline from 2016 (Centers for Disease Control, 2018). Moreover, the national incidence rate of TB was 2.8 cases per 100,000 persons, which constituted a 2.3% decrease from 2016 (Centers for Disease Control, 2018). Recent data from 2016 approximate that 528 deaths in the United States are attributable to TB, which is an increase from 470 deaths in 2015 (Centers for Disease Control, 2018). At the same time, there is a disproportional burden of TB among minority populations. For example, in 2017, 35.7% of TB cases were reported among Asians, 28.2% among Hispanics/Latinos, and 21% of Blacks had this disease. Furthermore, the TB burden among the White population was 11.8%, 1.2% for Pacific Islanders, and 1% among Native Americans (Centers for Disease Control, 2018). Overall, the 2017 approximation for people with latent TB infection in the USA was 13 million (Centers for Disease Control, 2018). Therefore, despite the progress made, more effort is still critical to curb the transmissions of this disease.

Tuberculosis, both latent and active, is a reportable disease. All US states have mandated their healthcare providers to report confirmed or suspected cases of TB to local health departments within a time frame of 24 hours of identification (Centers for Disease Control, 2018). Additionally, healthcare providers should report patient status to the local health officer every three months or as per requested time. Such a reporting ensures timely public health follow-up measures to curb disease transmissions.

Determinants of Health and Their Contribution to the Development of Tuberculosis

The determinants of health that have a significant impact on the development of TB include socio-economic, comorbidity, and socio-cultural factors. Individuals with low economic status face the highest risk of infection and transmission of TB due to their limited choices in life. Such factors as crowded and poorly ventilated living and working environments, which arise from poverty, pose a direct risk factor for TB infection and transmission (Abbott & Elliott, 2017). Additionally, malnutrition among the poor is a significant factor for developing active TB due to a weakened immune system. Furthermore, one’s low economic status hinders access to health services for an early diagnosis, undermines treatment adherence, contributes to lack of health knowledge, which leads to the exposure to significant TB risk factors such as illicit drug use, smoking, and alcohol abuse (Abbott & Elliott, 2017). Poverty also promotes homelessness and imprisonment, which puts individuals at higher risk for developing TB (Abbott & Elliott, 2017). Overall, social economic factors increase the chances of TB transmission and development.

Comorbidity factors, including HIV and diabetes, also promote the development of TB. The most potent immunosuppressive risk factor for developing active tuberculosis is HIV co-infection. For example, research indicates that persons with HIV are 20 to 30 times more likely to develop an active form TB than those who are HIV negative (Abbott & Elliott, 2017). Tuberculosis is the primary cause of HIV-related mortality, and it remains the most notable presenting illness for people living with HIV. Similarly, diabetes increases the risk of TB; for example, the rates of this disease are 2-3 times higher in people with diabetes than in the general population (Craig et al., 2017). Therefore, the co-management of comorbidities ensures a timely treatment and prevention of the disease under discussion.

Socio-cultural factors, especially stigma, also promote the development of tuberculosis. Even in cases when diagnosis and treatment are easily available and affordable, transmissions of this disease continue to grow due to this factor (Craig et al., 2017). For example, in some societies, a stigma arises from myths about transmission and prejudice that links TB to HIV/AIDS, which prevents individuals from seeking diagnosis and treatment (Craig et al., 2017). Consequently, infected individuals continue to spread the disease.

The Epidemiologic Triangle as It Relates to Tuberculosis

The epidemiologic triangle offers an insight into the role of the host, agent, and environmental factors in the transmission of tuberculosis. Thus, host factors include those with compromised immune systems, especially individuals who have HIV, malnutrition, or diabetes, those who abuse alcohol or use illicit drugs, and the homeless as well as the residents of correctional facilities (Abbott & Elliott, 2017). The etiological agent is a bacterial organism Mycobacterium tuberculosis, found in the lungs, while environmental risk factors for TB include poverty, indoor air pollution, and overcrowded living conditions (Abbott & Elliott, 2017). In the tuberculosis chain of infection, microorganisms (Mycobacterium tuberculosis) leave the body of the infected person (reservoir) by means of droplets that escape through the respiratory tract (port of exit), specifically the nose and throat during coughing or sneezing (Centers for Disease Control, 2018). The transmission of the disease happens through a direct contact, during which a susceptible host (person with compromised immunity) inhales the microorganism through the port of entry (same as port of exit), which is the nose and mouth, and the pathogen reservoir continues replenishing (Abbott & Elliott, 2017). Therefore, breaking the chain of infection can prevent the disease transmission.

A special notification for the general public implies raising awareness on the need to break or interrupt the chain of infection to control the transmission of tuberculosis. For example, controlling or eliminating the agent at the source of transmission presupposes, for example, the introduction of the cough etiquette, whereby individuals sneeze or cough into a handkerchief or tissue to prevent the release of TB bacterium into the air and wash hands thoroughly afterwards (Abbott & Elliott, 2017). Additionally, people should follow the isolation guidelines when required, for example, in cases of not adhering to treatment, or they should ensure a proper ventilation of spaces as well as encourage regular screening to detect and treat latent TB infection before it can transform into an active form (Centers for Disease Control, 2018). Breaking the chain of infection greatly contributes to the goal of TB control .

Role of the Community Health Nurse

Community health nurses find cases, report, collect and analyze data as well as conduct follow-ups to control the transmission of tuberculosis. During case finding, nurses liaise with healthcare workers and facilities that provide services to individuals who are high risk for TB transmission, including hospitals, residential homes for persons living with HIV/AIDS or for intravenous drug users, homeless shelters, and correctional facilities (Arshad et al., 2014). The nursing practitioner performs tuberculosis testing with the patient’s consent to confirm the presence of TB bacterium and reports to the senior medical personnel.

The next step of nursing practitioners is critical one since it implies the collection and analysis of data. Thus, the community health nurse gathers critical patient information to determine the extent of the illness, including its acuity and symptoms, as well as the patient’s information such as current and prior medical history, contacts with other TB cases, a previous history of this disease, other chronic conditions, and current medication (Arshad et al., 2014). Additionally, nurses investigate those individuals with whom the patient might have come into contact, including family, coworkers, and so on, with the intention to ensure that they undergo treatment to prevent further transmission (Abbott & Elliott, 2017). Overall, data collection and analysis form the basis for initiation of treatment and care as well as TB control activities.

A follow-up is another part of care delivery to TB patients. For instance, the nurse offers counseling and addresses patient concerns, explains the potential side effects of medications, and maintains regular medical supervision to ensure a continuous and uninterrupted adherence to medication (Arshad et al., 2014). Community health nurses also educate TB patients and their families on how to lead healthy lifestyles by stopping smoking and using drugs or alcohol, maintaining their hygiene, and so on to avoid developing drug resistance or disease transmission. The dissemination of information regarding tuberculosis to patients’ families is significant for the reduction of any TB-related stigma.

National Organization that Addresses Tuberculosis

A notable organization, which is engaged in the efforts of curbing the spread of TB through raising awareness and offering policy advocacy programs, is the National Tuberculosis Controllers Association (NTCA). The organization’s vision is to ensure “A world free of tuberculosis” (National Tuberculosis Controllers Association, 2018) through its involvement in local, state, and territorial TB control programs. The organization boasts of a wide array of healthcare professionals, including physicians, nurse practitioners, and lab technicians who collaborate with local service providers in various activities, including expanding access to high-quality care, funding local communities to improve the health of TB patients, and promoting outreach programs to encourage diagnosis and adherence to treatment. Furthermore, NTCA has made efforts in the advocacy for policy changes in the control of tuberculosis. Recently, the organization formulated the “Menu of Suggested Provisions for State Tuberculosis Prevention and Control Laws”, offering a legal insight into policy makers as they enact, amend, and implement laws to prevent and control TB (National Tuberculosis Controllers Association, 2018). Therefore, the organization hopes to curb fight the spread and transmission of tuberculosis.

Global Implication of Tuberculosis

While the United States and other developing countries have made significant gains in the control of tuberculosis transmission, the global perspective is rather grim. For instance, in 2017, approximately 10 million people, or 5.8 million and 3.2 million women, contracted TB; moreover, 1.6 million died from the disease, including 300,000 of those living with HIV (World Health Organization, 2018). Additionally, about 1 million children (0–14 years) contracted the disease, and 230,000 of them succumbed to TB-related complications (World Health Organization, 2018). Furthermore, the Western Pacific region and a part of South-East Asia accounted for 62% of new TB cases, while 25% of them were registered in Sub-Saharan African (World Health Organization, 2018). Some of the most affected countries in the high-burden regions include India, China, Indonesia, the Philippines, Brazil, Nigeria, Bangladesh, and South Africa (World Health Organization, 2018). Factors attributing to the increased rate of tuberculosis spread in these regions include high incidences of poverty, high burdens of HIV infections, increased cases of diabetes, and prevalence of drug-resistant strains of TB. Nevertheless, endemic countries strengthen their fight against the pandemic through various strategies.

High burden countries adopt various interventions to curb the transmission of tuberculosis. For example, India has heightened its commitment to achieve the universal access to TB care following its campaign for a “TB-Free India” (World Health Organization, 2018). Moreover, the Ministry of Health expands the capacity to test patients rapidly for drug-resistant TB and initiates the use of bedaquiline, a new WHO-recommended drug in MDR-TB treatment since this country has the highest global rate of multidrug-resistant TB (World Health Organization, 2018). Additionally, South Africa continues to expand significantly access to Xpert MTB/RIF, a WHO-recommended rapid molecular test for drug-resistant TB to ensure a proper diagnosis (World Health Organization, 2018). Furthermore, both Brazil and Vietnam invest in research efforts to drive down the TB burden. For example, Brazil has formed a national network of TB researchers (REDE-TB) who have been mandated with clinical trials and operational research priorities. Additionally, Vietnam has introduced VICTORY, or Viet Nam Integrated Centre for Tuberculosis and Respirology Research, to develop tools to prioritize interventions for MDR-TB (World Health Organization, 2018). Obviously, these countries hope to make significant gains to lower the high rates of TB transmissions.

Conclusion

Evidently, more effort is required to end the pandemic of tuberculosis in the world. The bacteria called Mycobacterium tuberculosis is the cause of this disease, and its transmission happens through tiny droplets that escape when an infected person coughs and sneezes. The symptoms of the disease include severe cough, chest pains, drastic weight loss, fatigue, fever, and so on. TB is curable when diagnosed early and treated properly. Some of the determinants of health that promote the development of TB include socio-economic, comorbidity, and socio-cultural factors. Additionally, the epidemiologic triangle of tuberculosis includes the host factors, including those with compromised immunity such as HIV-infected individuals, diabetics, and those with malnutrition. The etiologic agent is the bacterium Mycobacterium tuberculosis found in the lungs, while environmental risk factors include indoor air pollution and overcrowded living conditions. Community health nurses significantly contribute to the control of TB transmission through playing their roles, while such organization as the National Tuberculosis Controllers Association continue to heighten efforts to curb TB by introducing awareness programs and advocacy. The increased global prevalence of tuberculosis has been registered in high-burden countries, but such nations as India, South Africa, Brazil, and Vietnam have adopted interventions to control the transmission of this disease. Overall, the combined efforts in the fight against tuberculosis offers hope that eventually, TB will be eliminated.

Ethical Dilemma in Nursing

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