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The War on Tuberculosis – DOTS in Newark, NJ

This article originally appeared in the American Journal of Nursing here: http://journals.lww.com/ajnonline/Fulltext/2010/07000/The_War_on_Tuberculosis.14.aspx

Haile Meskel emerges from his Newark, New Jersey, row house and slips into the passenger seat of a shiny, late-model sedan, where a woman waits for him, a tiny white envelope and bottled water at the ready. He swallows a handful of pills as the woman watches. Within a couple of minutes the transaction is over.

leifer and meskel
Haile Meskel, an Ethiopian immigrant living in Newark, New Jersey, wouldn't have access to life-saving tuberculosis treatment if not for Gloria Leifer's daily DOT visits. Photos courtesy of Sibyl Shalo.

To the casual observer, this might look like one of the many furtive, illegal transactions that take place in this city every day—but it’s no drug deal. This is an example of directly observed therapy (DOT), which many public health and infectious disease experts believe is the single best method of treating people infected with tuberculosis and controlling the spread of multidrug-resistant and extensively drug-resistant strains in the United States and around the world.

The woman in the car, Gloria Leifer, is a public health representative for the Waymon C. Lattimore Practice, a tuberculosis program affiliated with the University of Medicine and Dentistry of New Jersey and the New Jersey Medical School Global Tuberculosis Institute (GTBI). GTBI is one of several programs funded by the Centers for Disease Control and Prevention (CDC) to provide training and medical consultation services. And although the group offers numerous medical and social services, DOT is the centerpiece of its success; 845 visits were logged in December 2009, which indicates a 99% adherence rate among its patients.

The idea behind DOT is simple: do whatever it takes to ensure that tuberculosis patients take the right doses of the right medications at the right time. The execution of DOT, however, is no easy task. Leifer meets some of her patients every day, some twice or three times a week. Most meetings are in or in front of patients’ homes, often in her car. Some she visits at work. Some she has to track down, triangulating by cell phone until she catches up with them. But she always makes the connections because she knows that for those who can’t make it to the clinic, she’s the only hope they have of receiving treatment and, from a public health perspective, she’s the front line of the war against drug resistance.

Lillian Pirog, RN, PNP, the program’s director, describes DOT as the standard of care. “It’s expensive and time and labor intensive, but it’s cheaper than treating multidrug-resistant tuberculosis,” she says.

leifer and factory worker
Leifer meets with factory worker Miguel Jimenez at his workplace. Without her help, he says, his tuberculosis might go untreated.

According to Lee Reichman, MPH, MD, executive director of the GTBI and professor of medicine and preventive medicine at the New Jersey Medical School, the global death toll from tuberculosis is staggering, especially when compared with death rates from other diseases that receive significantly more attention from the news media and government agencies. In a recent press briefing, he cited World Health Organization (WHO) data showing that in 2007, 1.77 million people died of tuberculosis, 456,000 of whom also had HIV. (For more statistics on tuberculosis from the WHO, see 2009 Tuberculosis Facts at http://bit.ly/bCchF2.) In contrast, the WHO reported some 18,001 deaths from the 2009 pandemic H1N1 virus as of May 2010 and 813 deaths attributed to severe acute respiratory syndrome (SARS) as of July 2003. The media coverage of those events was ubiquitous.

“We need to recognize that there are more than 9 million new active drug-sensitive cases of tuberculosis globally that could be feeding drug resistance,” he said, adding that preventing or treating tuberculosis properly “should be everybody’s priority.”

Chrispin Kambili, MD, assistant commissioner and director of the New York City Department of Health and Mental Hygiene’s Bureau of Tuberculosis Control and a medical officer with the CDC’s Division of Tuberculosis Elimination, agrees, crediting DOT with the low number of tuberculosis cases seen in New York City in 2008, about 900; the rate was the fifth consecutive record low, although New York’s rate is still three times the national average. He attributed this and other compelling statistics, including reductions in cases originating in the United States and in multidrug-resistant cases of more than 90% and 95%, respectively, to the effectiveness of the DOT program.

Kambili also cited data showing that a decline in the number of tuberculosis cases in New York City correlates with an increase in the percentage of patients enrolled in the DOT program. Specifically, in 1991, 20% of people known to have tuberculosis were enrolled, and there were nearly 4,000 cases in the city. By contrast, in 2006 more than 70% of people known to be infected were enrolled in the DOT program, and there were about 1,000 cases.

JUST AN AIRPLANE RIDE AWAY

leifer and villalva
Leifer makes daily visits to Crecenciana Villalva, a Mexican immigrant living in Newark, not only to ensure her compliance with her tuberculosis treatment regimen, but also to help connect her to other, nonmedical, city services.

One of the challenges in enrolling tuberculosis-infected patients in the DOT program is that many are undocumented immigrants frightened that they’ll be deported if their status is discovered.

“Nearly 70% of patients come from countries where people die from tuberculosis because they lack access to care,” says Pirog. “And the immigration crackdown sends these undocumented patients underground, so they postpone treatment or withhold information.”

According to the WHO’s 2009 Tuberculosis Facts, the top five countries of origin of tuberculosis cases are India, China, the Russian Federation, South Africa, and Bangladesh. Another challenge is keeping track of infected people as they travel in and out of the United States.

“Patients do a lot of international travel, but we try to keep them here,” says Pirog. “Still that’s not always possible, so our nurses coordinate with the health departments in patients’ home countries and make sure they get their medications there and get care.”

NURSES ON ALERT

Contacting foreign health services is just one of the many responsibilities nurses have as part of the Waymon C. Lattimore Practice. Another is investigating the homes of new patients as they’re identified, to find out where they were exposed to infection and whom they’re exposing at home and on the job. Targeted testing of the highest risk group follows and sometimes reveals additional cases.

“Nurses are in charge of the teams,” says Pirog. “They go to hospitals to review charts and orders and make sure patients are identified, treated, and enrolled in the practice, and they manage the public health representatives.”

Considering the varied settings in which nurses work and the wide range of populations they encounter, it’s impossible to underemphasize the need for vigilant observation of patients’ symptoms and investigation of their social and work situations to maximize the early identification of tuberculosis infections in the community. Nurses who work in schools, clinics, hospitals, long-term care or corrections facilities, or who work with injection-drug users, heavy alcohol users, and homeless patients should be on the lookout for tuberculosis.

Unfortunately, tuberculosis infection isn’t always obvious; it doesn’t always present with a cough, night sweats, or other typical symptoms. A case in point: one of Leifer’s patients, Crecenciana Villalva, a Mexican immigrant, didn’t know she was infected with tuberculosis until severe headaches sent her to the ED last September. A computed tomographic scan of her brain revealed an extrapulmonary form of tuberculosis in her pituitary gland.

Today Villalva reports feeling well, with no headaches, and has an appointment with her physician to develop a plan for the next phase of her treatment. In the meantime, she says she’s extremely grateful for the DOT visits, without which she’d be unable to afford treatment.

Villalva also benefits from a clever incentive program offered by the Lattimore practice: with support from the American Lung Association, the public health representatives give patients $10 gift cards to the chain grocery store Pathmark, to help with groceries and encourage patients’ ongoing compliance. Leifer also helps her patients—many of whom live in extreme poverty—with logistics, such as finding employment, transportation, and referrals to food banks.

ONLY EFFECTIVE TREATMENT WILL CURB RESISTANCE

Reichman, Pirog, and many other experts agree that clinicians are sometimes unaware of current, state-of-the-art tuberculosis treatment and that they either undertreat or mistreat patients, unknowingly contributing to resistance. Intending to make treatment more palatable for their patients, they either split doses or use the wrong combination of medications, or they don’t use a combination at all.

“Part of nursing case management is coordinating with physicians and other hospitals caring for patients,” says Pirog. “Nurses are responsible for questioning physicians’ orders or doses” if they seem suspect, she says, “because tuberculosis is a subspecialty and requires specific knowledge of treatment regimens.”

Pirog doesn’t simply sit on the sidelines, shaking her finger at clinicians who don’t keep up withcurrent guidelines. She’s deeply involved in the training and education of physicians and nurses all around the country, from hosting conferences on proper tuberculin skin testing to leading Webinars that train nurses in tuberculosis case management.

In the meantime, she encourages all health care professionals, patients, and family members who have questions about tuberculosis or its treatment to call the experts at the Global Tuberculosis Institute, toll free, at (800) 4TB-DOCS (482-3627).—Sibyl Shalo, BSN, RN

Shorter Course, Greater Compliance

Overall, the outlook for the U.S. war on tuberculosis is good; new case rates are declining year by year, and the development of new drugs promises to improve and, most important, shorten the treatment time (currently drug treatment takes six to nine months, which challenges even the most enthusiastic patient’s ability to remain compliant). According to Mel Spigelman, MD, president and chief executive officer of the nonprofit partnership TB Alliance, that goal is on the front burner of research and development efforts in both the public and private sectors. In fact, his organization’s vision is to develop treatments that will cure tuberculosis in 10 days.

© 2010 Lippincott Williams & Wilkins, Inc.

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