Jun 23, 2020 in Informative

Tuberculosis

Tuberculosis (TB) is a significant public health issue globally with statistics showing that approximately one-third of the global population suffer the disease. It makes TB treatment and control a priority for health practitioners. The current paper explores key issues associated with TB, including its transmission and pathophysiology, implications of treatment regimen, role of community clinics in assisting TB patients, and the implications of TB for critical care and advanced practice nurses.

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Transmission and Pathophysiology of TB

The transmission of TB is mainly through air, wherein TB is spread from an infected individual to another vulnerable people via airborne particles referred to as droplet nuclei. The droplet nuclei comprise of tiny water particles containing the TB bacteria that are discharged when an individual affected by laryngeal or pulmonary TB shouts, sings, talks, or coughs. It is imperative to highlight that TB transmission does not occur through surface contact but through air, thus, TB cannot be transmitted through touching. The transmission of the disease occurs when an exposed individual inhales the nuclei droplets holding the M. tuberculosis (Mycobacterium tuberculosis). As a result of it, the droplet nuclei move through the nasal passages or the mouth, reaching the respiratory tract, to the alveoli. TB transmission has been found to depend on a number of factors, including susceptibility/immune status of the vulnerable person, the environment, duration, frequency, and proximity of the exposure. The level of infectiousness of the individual also determines the rates of transmission, which influences the number of tubercle bacilli that he/she releases into the air. In particular, persons expelling many tubercle bacilli tend to be more infectious relative to those expelling few of them.

With respect to TB pathophysiology, infection often occurs when the inhaled droplet nuclei having the tubercle bacilli reach the alveoli in the lungs. This process is followed by the destruction of the great number of tubercle bacilli with the help of macrophages found in the alveoli. Nevertheless, A few tubercle bacilli might spread via either the bloodstream or the lymphatic channels to reach other organs and tissues, including those parts of the human body that are more susceptible to TB, such as bone, brain, kidneys, lung apex, and regional lymph nodes. The dissemination process prompts the immune system to respond accordingly, wherein failure of the immune system to control the tubercle bacilli results in the development of TB.

Clinical Manifestations of TB

TB patients exhibit a number of symptoms, including persistent cough that lasts for approximately three weeks or longer, the presence of respiratory tract diseases, particularly involving the larynx, chest pains, fatigue, hemoptysis, fever, night sweats, and weight loss. It is imperative to note that the development of TB differs in each patient depending on the immune system status. The stages for TB progression include latency, primary disease, primary progressive disease, and extrapulmonary disease. Moreover, each stage has dissimilar clinical manifestations. The latent TB is normally not characterized by the symptoms associated with the disease. TB patients at this stage are not infectious and do not feel sick. Nevertheless, the tubercle bacilli remain in the body, and can be reactivated if the immune system is weakened. The primary disease stage is characterized by asymptomatic TB, although diagnostic tests can reveal the presence of the disease. The primary progressive TB is the early infection stage characterized by non-specific symptoms, such as night sweats, chills, fever, weight loss, and malaise. The extrapulmonary TB stage is characterized by the increase in immunosuppression, wherein TB spreads to other parts of the body, including the central nervous system, lymphatic system, bones, and the genitourinary system. Possible TB symptoms during this stage include bloodstream infection, weakness, and weight loss.

Primary Medical Concerns for the Patient

The primary medical concerns for the patient deal with the TB-related symptoms that she exhibits, including coughing, weight loss, and night sweats. The second important medical concern is that the patient has not yet received a Bacillus Calmette-Guerin vaccine, which is a medication used against TB. The physical examination also showed that the patient had axial and cervical lymphadenopathy. Moreover, the patient also tested positive for TB. Another important medical concern for the patient is that she was showing signs of multi-drug resistant form of the disease.

Primary Psychosocial Concerns for the Patient

There is a number of psychosocial concerns related to the patient. One of the most important among them is the fact that the patient is an illegal immigrant from Peru, which makes her hesitant in seeking for medical treatment. Another psychosocial concern for the patient relates to the burden of single motherhood and taking care of her three sons. Being diagnosed with TB presented considerable challenge with respect to working full-time and taking care of her three sons. Another psychosocial concern emanates from the stress following the realization that the patient had multi-drug resistant TB. It poses a challenge regarding her ability to handle the health crisis.

Implications of the Treatment Regimen

TB treatment adherence is a dynamic and complex aspect characterized by diverse factors that affect the treatment-taking behavior of patients. TB can be cured through effective and uninterrupted therapy. Therefore, treatment adherence is a crucial requirement in ensuring that TB patients are cured, as well as in controlling TB spreading, and lessening drug-resistance. Studies indicate that incomplete treatment adherence is a key challenge in controlling TB. The treatment adherence of the disease presents a considerable challenge for patients subjected to lengthy treatment durations, combination therapy, and unpleasant side effects. A research study by Anaam, et al. reported 16.3 percent non-compliance rate of TB treatment, which they attributed to a number of factors, including patient’s knowledge regarding TB, stigma, family support, employment, waiting time, travelling time, literacy, and residence place. The World Health Organization reported that the global prevalence of TB treatment defaults at 10 percent. 

Globally, the WHO estimates that 5 percent of TB cases are multi-drug resistant. The WHO also reported that 3.5 percent of new TB patients are often multi-drug resistant. Non-compliance of the disease treatment has been associated with a number of outcomes, including the risk of acquiring drug resistance and longer treatment. For instance, Sharma, et al., found that non-adherent TB patients had a relative risk rate of 5.6 when compared to adherent patients with respect to acquiring drug resistance. They also indicated that non-adherent patients needed longer therapy (560 days) when compared to adherent patients (324 days). 

Role of the Community Clinic in Assisting Patients

Community clinics play an integral role in ensuring access to healthcare, particularly for those individuals who lack healthcare insurance, as well as the ones facing other barriers to access care, such as illegal residency. Sia & Wieland indicated that patients receiving the care services at community clinics or health centers incur significantly lesser medical expenses. In this respect, Lareau & Mealer estimate that annual costs of care per patient in community clinics is USD 455, which is lower than that of office-based medical providers of USD 657 per patient annually. Community clinics utilize the comprehensive model, which has been established to offer both cost-effective and high-quality care that lowers visits to the emergency departments, as well as the hospitalizations frequency. When analyzing the medical records of patients who visited community clinics, Sia & Wieland reported that the quality of care for these patients was either comparable or better than the care provided in other types of facilities. Such assumption based on higher rates of cancer screening, higher rates of vaccinations, visits to the emergency department, and lower hospitalizations. Across the US, Medicaid patients who visited community clinics have lower chances of hospitalization for avoidable conditions by 11-22 percent. Moreover, they are 19 percent less likely to visit the emergency department for avoidable conditions. Adashi, Geiger and Fine further point out that patients visiting community clinics have relatively shorter stays in hospitals and lower rates of hospital admission. In general, these findings indicate that community clinics play an integral role in catering for the patients through dealing with the barriers that hinder them from accessing care. For example, considering the undocumented patients, it should be noted that community clinics do not check residency status when providing care. 

In addition to providing cheap care services, community clinics also facilitate access to discounted medications, especially for the vulnerable population, such as the low-income and the uninsured individuals. According to Adashi, Geiger, & Fine, community clinics can reduce the cost of accessing drugs for patients by almost 50 percent depending on the type and volume of drugs acquired. Essentially, community clinics benefit from reduced prices for prescription drugs and are able to realize their mission to community. Thus, it can be inferred that community clinics play an essential role in ensuring that vulnerable populations, such as undocumented immigrants, access high quality care at a relatively low cost.

Resources that Exist for TB Treatment in Community Health Centers around the United States

Community clinics have vast resources that can facilitate TB treatment. First, they have medical staff having adequate skills and knowledge required for conducting TB assessment of patients, diagnosis, and treating the illness. Another important resource that community clinics enjoy is close working relationships with clinical laboratories, hospitals, and consultant physicians. In addition, community clinics have close working ties with the public health agency working in their respective jurisdiction. Thirdly, Stark & Laudato point out that community clinics have the resources for conducting TB diagnostic services, such as chest radiographs and M. tuberculosis cultures. Another critical resource that community clinics can offer is providing discounted medications. In this respect, community clinics are eligible to participate in the 340B program, which was established by the Federal Government in 1992 that demands drug manufacturers to offer outpatient medications to qualified healthcare facilities at significantly lower prices.

Subsidized and Unsubsidized Cost of Treatment

The subsidized cost of treatment refers to the medical expenses that a patient is assisted to pay. The assistance could come from an employer who is paying a portion of the treatment cost or from a federal program, such as Medicaid. On the other hand, the unsubsidized treatment expenses refer to the ones that have to be paid for the treatment by the patient him/herself. For patients, the subsidized cost of treatment is much lower as compared to the expenses incurred by the unsubsidized individuals.

Implications of TB for Critical Care and Advanced Practice Nurses

Critical care and advanced practice nurses should play a crucial role in TB treatment and prevention. Sia & Wieland stated that TB control should be priority for nurses. Consequently, they should embark on contact investigation of all the individuals who made contacts with the infected person before treatment initiation. Moreover, the nurses should perform contact investigation on patients with active TB. Another implication of TB for nurses is targeted treatment and testing. In such case, the nurses target people who are at-risk of TB-reactivation or suffering from new TB infections, such as employees working at facilities with high exposure risk. Such facilities include homeless shelters, healthcare facilities, and prisons, where the health care practitioners contact with recent immigrants from countries where TB is widespread or with patients having active TB. Individuals with high TB reactivation risk include those with Human Immuno-deficiency Virus (HIV) and those taking immunosuppressive medications.

Conclusion

TB is a devastating illness globally. The patients suffering the disease exhibit various signs, such as persistent cough that lasts for approximately three weeks or longer, the presence of respiratory tract diseases, such as, for example, chest pains, the larynx, fatigue, fever, night sweats, hemoptysis, and weight loss. Efforts aimed at controlling and eliminating the disease have been hindered by lack of access to care, global migration, and drug resistance. In addition, effective treatment requires patient compliance to regimen. TB treatment adherence presents a substantial challenge for patients subjected to lengthy treatment durations, combination therapy, and unpleasant side effects. At the same time, community clinics are essential component of TB treatment and prevention. It is caused by the fact that they offer care services to the individuals facing different barriers to accessing care at other facilities in the healthcare system, such as undocumented immigrants. Moreover, community clinics reduce the treatment costs and facilitate access to discounted drugs. The implications of TB for critical care and advanced practice nurses include contact investigation on patients with active TB, as well as targeted treatment and testing.

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