Fear, embarrassment, and relief: the tuberculosis epidemic and public health

Controlling tuberculosis in an urban emergency department: a rapid decision instrument for patient isolation

OBJECTIVES

This study examined whether data routinely available in emergency departments could be used to improve isolation decisions for tuberculosis patients.

METHODS

In a large emergency department in New York City, we compared the exposure histories of tuberculosis culture-positive and culture-negative patients and used these data to develop a rapid decision instrument to predict culture-positive tuberculosis. The screen used only data that are routinely available to emergency physicians.

RESULTS

The method had high sensitivity (.96) and moderate specificity (.54).

CONCLUSIONS

The method is easily adaptable for a broad range of settings and illustrates the potential benefits of applying basic epidemiologic methods in a clinical setting.

Tuberculosis risk in the hospital dental practice

Tuberculosis has re-emerged as a serious public health concern. Multidrug-resistant strains and an increase in the number of high-risk groups are posing a difficult problem for health care providers. The risk of TB transmission in hospital dental practices is potentially increasing. A 20-question survey was mailed to the membership of the American Association of Hospital Dentists, addressing various issues relating to tuberculosis. One hundred thirty-two surveys were analyzed. Twelve per cent of respondents reported at least one TB skin test conversion by a dental provider within the past year at their institution. Five respondents reported one dental provider contracting TB through patient contact. Oral TB was reported in 21 cases. Over 34% reported that active TB patients are not isolated to negative-pressure isolation rooms, 45% reported that patients are allowed to frequent public areas, and only 59% believed that drug compliance monitoring was adequate. Over 86% support TB screening in the Hospital Dental Practice. It was concluded that Hospital Dental Practice personnel may be at increased risk for exposure to TB. Dental providers must exercise strict TB prevention and employ meticulous referral and follow-up procedures for high-risk patients.

A new role for community organizations in the prevention and control of tuberculosis

The resurgence of tuberculosis in the United States has forced public health officials to reconsider the most appropriate strategies for its prevention and control. Many recent reports have suggested that the priority of public health programs should be to identify those with active tuberculosis and ensure that these individuals complete medical treatment. While this goal is necessary, it is not sufficient. First, it does not acknowledge the difficulty that health care agencies have in contacting and engaging those at highest risk of active tuberculosis. Second, it fails to address the broader social factors that have contributed to the reemergence of epidemic tuberculosis. This report describes an alternative strategy in which community organizations play a significant role in TB prevention and control. An examination of two previous efforts, the community TB programs of the first part of this century and the community AIDS prevention programs of the last decade, provides suggestions for specific activities that community organizations can carry out in order to control TB. To fulfill this expanded role, community organizations will need new resources, technical assistance, and training.

Multidrug-resistant tuberculosis: meeting the challenge

Both public and private institutions are mobilizing to combat drug-resistant TB--indeed, to eliminate all TB. Meeting this goal will require a three-pronged approach: 1) prophylactic isoniazid treatment of latent TB, 2) multidrug (at least six agents in some cases) treatment of active TB to eradicate resistant strains, and 3) correction of the social conditions that have contributed to the current epidemic.

Implications of directly observed therapy in tuberculosis control measures among IDUs

Tuberculosis (TB) is a rapidly growing problem among injecting drug users (IDU), especially those infected with human immunodeficiency virus. The authors review IDUs' responses to current TB control strategies and discuss the implications of their findings for the proposed implementation of directly observed therapy (DOT), a method for ensuring that patients take prescribed medication. Field workers carried out 210 ethnographic interviews with 68 IDUs in a Brooklyn, NY, community during 1990-93. Case studies suggested that many IDUs are uninformed about TB and often misinformed about their personal TB status. Ethnographic interviews and observations indicated that the threat of TB-related involuntary detainment may lead IDUs to avoid TB diagnostic procedures, treatment for TB, or drug abuse treatment, and to avoid AIDS outreach workers and other health-related services. IDUs who tested positive for the purified protein derivative (PPD) of TB sometimes have left hospitals before definitive diagnoses were made, because of a perceived lack of respectful treatment, fear of detention, or lack of adequate methadone therapy to relieve the symptoms of withdrawal from drugs. Current TB diagnosis and treatment systems are, at best, inadequate. The threat of TB-related detention discourages some IDUs from seeking any type of health care. There is an urgent need to educate IDUs about TB and to educate and sensitize health care providers about the lifestyles of IDUs. DOT may help in servicing this difficult-to-serve population, particularly if techniques are incorporated that have been developed for other successful public health interventions for IDUs.