Incidence of Tuberculosis and Multiple Drug Resistant TB are on the rise. The popular conception is that this disease, as old as humanity, is under control and being eradicated.

However, among certain disenfranchised and underserved populations, such as drug users, prison populations, HIV patients and refugees from high-risk countries, ripe conditions have led to a breeding ground for TB and MDR-TB. Therefore the nursing community must educate everyone they can, identify and be willing to intervene directly with underserved populations and utilize proper techniques and training.
During the first half of the 20th Century, TB was called " white plague " or "consumption" because it seemed to consume and waste a person from within, having traveled from the lungs to other parts of the body. It is a hardy organism spread in aerosol form by coughing, laughing or sneezing. A person can be a carrier, test positive but be non-contagious. They are not be considered to have TB the disease (Selekman 2006). A combination of at least four “front line” anti-TB drugs is used to prevent resistance to the organism (Kidder, 2003). Failing that, subsequent MDR-TB is treated with other more expensive drugs. Just as important as treatment are some nursing strategies that can be very effective at interrupting the spread of the disease.
Nurses must work hard to educate and dispel the many myths that surround TB. The majority of people believe it has been eradicated, at least in the developed countries. People are often shocked when they hear the diagnosis because they believe it leaves them stigmatized and unclean. They believe that only the down & out get TB, yet people from all social strata get TB. Some believe smoking causes it, or that it is hereditary. Effective education by nurses could overcome barriers such as fear and language and cultural differences. One commonly held belief that is true, is that high-risk groups including inmates, homeless, drug users and certain groups of immigrants are more at risk of contracting TB (Boutotte, 2000).
The second nursing strategy is to identify underserved populations and not only go to the source but be prepared to be flexible in implementing nursing interventions. Prisons and jails are a breeding ground for TB due to overcrowding. In addition there are other circumstances that a nurse should know about that contribute to the non-compliance of therapy. In the US, prisons in California and New York have had epidemics of resistant TB. In some prisons, it was discovered that prisoners would sell their medication or deliberately swap sputum samples. Some actually wanted to be sick to stay in the much nicer conditions that the infirmary afforded with no work duty assigned. Conversely, some inmates, believing it would hinder their release dates, bought clean sputum samples, or bribed poorly paid prison medical staff (MacNeil, 2005). In the prisons of Siberia, which are lacking in proper nutrition and appallingly overcrowded, there is a caste system, with Mafia-like bosses, middlemen and abused under castes, who may be beaten if they don’t hand up the valuable drugs to the bosses (Schwalbe, 2002). Of course Mycobacterium tuberculosis does not differentiate between murderers or petty thieves; nor prison guards and their families. It is equally important for the health of the general population that nurses seek out other disenfranchised groups such as the homeless, drug users and immigrants from certain high risk countries.
Fear of immigration authorities, language and cultural barriers, financial restraints, lack of health insurance and inadequate housing are factors that are often compounded by co-infection with other disease processes such as HIV. The only way to obtain compliance is to actually observe each dose administered (known as DOTS-Directly Observed Treatment Short-Course (Kidder, 2003). Compliance in following the drug regimen to its completion is even more difficult when the patient is transient, literally, such as drug users and the homeless population. Further, there is little incentive to continue the therapy when symptoms disperse and more immediate daily needs take prescedence. Dr. Paul Farmer showed that it was necessary to provide assistance with food and shelter to get better results while he worked With TB patients in Haiti (Kidder, 2003). While it requires extra work to bridge cultural, societal and physical barriers, studies also show a direct correlation to the amount of the care provider’s training and the success of implementing prevention and curative strategies (Khan, et.al, 2006).
What training and special protective measures are required by nurses to implement the third nursing strategy? First there are the basics; nurses should be actively on the lookout for patients with signs and symptoms of TB, particularly in high incidence settings. “Nurses should consider a patient to be highly infectious if he has a productive cough, pulmonary cavitation on a chest X-ray, hoarseness, laryngitis, and acid-fast bacillis (AFB) on a sputum smear, and he is not on an anti-tuberculosis drug regimen” (ICN TB Guidelines, 2004). In most cases, it is reportable to a state agency if there is a strong suspicion of infection. The suspected patient should be isolated and started on anti tuberculin drugs before confirmation of lab work. Instruct the patient to cover coughs and sneezes with a tissue or even to wear a mask. It is important that the tuberculosis (Mantoux / PPD) skin test be used as opposed to the older “Tine” test (four pin pricks), which has been deemed unreliable. Chest x-rays are often ordered as a follow-up. This illustrates the need for specialized training and indeed it is possible to become a TB specialist nurse. The work includes contact tracing to find the original carrier and screening close contacts. Being sensitive is also important as the patient may feel responsible for infecting others. The most important aspect of care is ensuring completion of the prescribed therapy. This may require the nursing support to be individualized and flexible.
It is not too hard to see how TB has spread beyond the breeding pools and into the general population and thus this emphasizes the importance of the nurse’s role in treatment and continuous monitoring. Underserved populations present unique challenges outside the classic nurse-patient model. However with diligence toward public education and one’s own education and training, and a little tenacity and flexibility, a nurse can make a difference with overlooked populations.

Bibliography





Boutotte, J., (2000), AFB isolation rounds: What your nurses need to know,
Nursing Management. 31(9), p 49(3), Retrieved October 11, 2007, from ProQuest database.

International Council of Nurses, (2004), TB guidelines for nurses in the care and control of tuberculosis and multi-drug resistant tuberculosis, Retrieved October 10, 2007, from http://www.icn.ch/tb/guide_chap2.htm.

Khan, K., Campbell, A., Wallington, T., Gardam, M., (2006), The impact of physician training and experience on the survival of patients with active tuberculosis, Canadian Medical Association. Journal, 175(7), p 749-753, Retrieved October 09, 2007, from ProQuest database.

Kidder, T. (2003), Mountains beyond mountains: The quest of Dr. Paul Farmer, a man who would cure the world. New York: Random House.

MacNeil, J., Lobato, M., Moore, M., (2005), An unanswered health disparity: tuberculosis among correctional inmates, 1993 through 2003, American Journal of Public Health. 95(10), p 1800-5 (6), Retrieved October 11, 2007, from ProQuest database.

Schwalbe, N., Harrington, P., (2002), HIV and tuberculosis in the former Soviet Union, The Lance, 360, p 19-20, Retrieved October 09, 2007, from ProQuest database.

Selekman, J., (2006), Changes in the screening for tuberculosis in children, Pediatric Nursing, 32(1), p. 73 (3)





New Verbiage


There are often barriers to any educational nursing intervention but specifically in the realm of teaching about Tuberculosis, several disadvantages are the misinformation that exists and the discrimination experienced. Effective education by nurses must over come myths such as the belief that TB has been eradicated, at least in the developed countries. People are often shocked when they hear the diagnosis because they believe it leaves them stigmatized and unclean. They believe that only the down & out get TB, yet people from all social strata get TB. Some believe smoking causes it, or that it is hereditary. The second disadvantage to education is the fear of immigration authorities, language and cultural barriers, financial restraints, lack of health insurance and inadequate housing are factors that are often compounded by co-infection with other disease processes such as HIV. Dr. Paul Farmer found that education about compliance was highly affected whether you had adequate shelter and food, or to put it another way when you are starving you aren’t so concerned about a missed dose even if it’s free (Kidder, 2003).
In Africa TB rates are high and effectiveness of treatment low. A lot has to do with the linking of TB to AIDS and inherit problems with teaching about that disease process. “Limited funding, governmental indifference or opposition, AIDS stigma, and social discomfort discussing sex were often cited as barriers.
It is not just enough to identify at risk populationsas a nursing invervention. The factors that make them hard to find, diagnose & treat are also factors that make them non-complainant with their treatments. Patients with or at risk for TB face discrimination, often because of its association with AIDS. Also, prison inmates homeless, drug users and immigrants from certain high risk countries are not often policy makers first priorities, if indeed, they are on the radar at all.
In Africa, the stigma of AIDS prevents people from readily seeking help until other disease processes including TB are well entrenched. Additionally wars and famine make a shambles of health care systems the populations become transient.
Prisoners face several of these problems. Often there is little staffing and little sympathy for the care of inmates. With limited resources it is hard to convince policy makers that $ and drugs should be used on this lowest caste of society. There are additional compliance/containment problems that typical nursing interventions are not geared toward. In some prisons, it was discovered that prisoners would sell their medication or deliberately swap sputum samples. Some actually wanted to be sick to stay in the much nicer conditions that the infirmary afforded with no work duty assigned. Conversely, some inmates, believing it would hinder their release dates, bought clean sputum samples, or bribed poorly paid prison medical staff (MacNeil, 2005).

Another problem is that government officials may not wish to acknowledge problems with treatment programs. Conversely government officials may have their own idea of what their own treatment program should look like and be dismissive of foreign intervention or non-profits whom they may feel are “irrelevant or even a nuisance.” (Naidoo, 2001)






Bibliography – New Research



Kelly, C., (2006) Psychological and socio - medical aspects of AIDS/HIV (Programs, resources, and needs of HIV-prevention nongovernmental organizations (NGOs) in Africa, Central/Eastern Europe and Central Asia, Latin America and the Caribbean. AIDS Care, 18(1), p. 12- 21, Retrieved from Proquest database January 30, 2008


Naidoo, K. (2001), The role of the nonprofit sector. In C. E. Koop, C. Pearson & M. Schwarz (Eds.), Critical issues in global health (pp. 406-415). San Francisco: Jossey-Bass.