Tuberculosis, or TB, as it’s commonly called, is a communicable infection that commonly attacks the lungs. A type of bacteria called Mycobacterium tuberculosis causes it and it can also spread to other parts of the body, like the brain and spine. Tuberculosis is an infection which spread through the droplets from the cough of an infected person which remained in the air for several hours. When the droplets are inhaled by another person, they travel down the person’s trachea to reach the lungs where they get deposited in the alveolar sacs. Here, the TB bacteria multiply, activating the body’s immune response resulting in macrophages surrounding the bacteria to form granulomas thereby containing the spread of the TB infection in the lungs. The patient tests positive for latent TB infection within eight to ten weeks.
Latent TB infection (LTBI) can progress to full-blown TB disease when the bacteria break out of the granulomas and multiply in the lungs making the patient sick from TB disease with the likelihood of infecting other individuals. This could happen immediately after the infection many years later or not at all. When the TB bacteria escaped from a granuloma and infect the person’s lungs, the condition is known as pulmonary TB. A cut section of such granulomas often shows a cheese-like appearance known as caseating necrosis. The primary site of TB infection in the lung is known as the Ghon focus and is usually seen in the upper part of the lower lobe or the lower part of the upper lobe. When the TB bacteria enter the bloodstream and spread to other part of the body, especially the lymph nodes, kidneys, brain or bones, the condition is known as extra-pulmonary TB. Typically, signs and symptoms may include malaise, fever, weight loss, and night sweats while a persistent cough is the most frequently reported symptom (Davies et al. 2014).
Patients that have lung disease generally present with a chronic cough that may be non-productive or productive that can be mucoid, mucopurulent, blood-stained or have massive hemoptysis. Other symptoms however are rare but may include chest pain and dyspnea (Heemskerk et al. 2015). After viewing this case study pertaining to Maria, it is obvious that she was under a lot of stress from how TB was affecting her life. Being a single mother with three boys in addition to an illegal residency status indicates a huge barrier for Maria which made her hesitant to seek medical help. A definite medical concern for Maria was when she did not feel better after the multiple drug treatment and was notified that she might need an adjunctive therapy in order treat her infection. Being told that she has multiple drug-resistant TB was a dilemma and is presented as the primary concern for her since it affects her financially, emotionally, physically and socially as she has no assistance for her children when she will be hospitalized in addition to missing work to undergo treatment.
According to Yong-Soo Kwon, 2017 from CMJ (Chonnam Medical Journal), in 2015, there were an estimated 1.4 million deaths from TB worldwide. There were an estimated 480,000 new cases of multi-drug-resistant (MDR)-TB presenting with resistance to both rifampin and isoniazid and an estimated 100,000 incident cases of rifampin-resistant TB.
Although the medications being used for the last forty years have shown high efficacy and safety, long periods of treatment and many drugs in combination are needed to cure tend to make patients less compliance when it comes to following through with the treatment regimen. Adherence to the treatment can be challenging if the duration is longer than six months, combination therapy is required, and side effects are unpleasant. Furthermore, the cost of medications can be a serious obstacle to adherence if not covered by the public health system. According to Munro, Simon, Volmink and el.,2007, up to half of all patients with TB do not complete treatment, which contributes to prolonged infectiousness, drug resistance, relapse, and death.
Defined by Wikipedia, community clinics are non-profit centers that play a vital role in assuring healthcare for those who are uninsured, underinsured or those who experience difficulties to care. They offer a “high quality, affordable, and comprehensive primary and preventative medical, dental, and mental health care.” The cost for TB screening, X-ray and treatment of LTBI at a subsidized community care center is outrageously lower than the unsubsidized clinic which can range approximately from $9-50 for the uninsured. According to an article on March 2016 in AMA Journal of Ethics, physicians should explain in great detail to the undocumented immigrants that the treatment for LTBI could increase the risk of hepatotoxicity which might require liver transplantation. Unlike the uninsured patients who are US citizens who may be eligible for transplant, undocumented patients won’t have that option since they are not eligible for most federal, means-tested public benefit such as Medicaid or marketplace exchange insurance plans established by the Patient Protection and Affordable Care Act. The only federal insurance available to the undocumented is Emergency Medicaid, which does not cover organ transplantation. Tuberculosis, although curable, is still one of the most contagious disease worldwide second to HIV/AIDS.
Due to its poor treatment adherence, it is a major cause of relapse and drug resistance therefore, advanced practice nurses have a critical role in supporting patients in TB treatment process. From educating patients and education to communities to providing medications and providing care, from observing and following up treatment to communicating with the patients are some of the key tasks by the advanced practiced nurses to support adherence. In settings where there is poverty, nurses could be a facilitator and provide nutritional and transportation support to increase adherence. By ensuring our patients to have good morale to complete their treatment will one day help eradicate TB for good worldwide.