TB

“Tuberculosis (TB) from my own understating is the infection of the lungs. After reading through and doing some research on TB, I’m able to say that as health workers we should not unmind this infection because of its transmission mode, complication and fatality rate. As cited by the Journal of Microbial Pathogenesis (2020). TB is among the fatal diseases that spread through the air, it is a caused by an acid fast bacillus (AFB) called Mycobacterium tuberculosis. Tuberculosis mainly affects the lungs, but if not treated effectively it can lead to other health problems in other organs such as the kidney, spine causing Spain deformity or brain causing meningitis hence causing death. It is contagious has it spreads through air as a result of careless spitting, coughing and sneezing without the use of handkerchief or any protection devices such as masks. As these droplets are lighter than air, it gets carried away and inhaled by a susceptible host. According to the Centre for Disease Control and Prevention (CDCP) ( 2019), it states that this TB disease is an opportunist infection meaning that it can easy cause illness to people with compromise immune system such as HIV or diabetes. For reality one country or nation under the sun doesn’t have TB. The most affected area in the world that has the highest TB rate are the region of South East Asia and Africa as stated by the CDCP (2019) which accounted about 70% of overall global tuberculosis. Studies shows that the dramatic increase of TB infection began in 1985 as a result of increase in HIV infection rate in Africa. Whereby in 2017, an estimated 10 million incident of TB cases were found and 1.6 million TB death occurred. As for Fiji, as recorded in the Fiji Journals of Public Health (2016) describes Fiji an island which is located in the center of the Pacific Ocean, consisting of about 332 islands, land mass of 18,333 km2 whereas our population hasn’t even reached a million. Due to its demography area and weather patterns it has enable the TB bacteria to thrive in its landscape. Let me take you back to 2002 to 2013 whereby a total of 1,890 tuberculosis cases were recorded in Fiji as documented in Fiji Journal of Public Health (2016). In addition to this finding it also states that by the year 2011, “Fiji had an incidence rate of 27/100,000 and prevalence rate of 40/100,000 population”. Still in the year 2011, there were 213 active cases of TB as compared to 2010 which recorded about 191 cases. In comparison to the data collected in 2012, report on TB incidence in Fiji was 24 cases, prevalence was 30 per 100,000 persons, and the case-fatality rate was 1.7. (Emergency Infection Disease, 2016). By the year 2018, Fiji incidence for TB (per 100,000 people) was reported at 54 as cited in Trading Economics (2020) in addition to this document it also states that it mostly affects the age group between the ages of 15- 55 years old as this groups are mostly exposed to risky behaviors and factors relating to health determinants either socially or environmentally. As a result male dominant the female. As for our children since they are one of the vulnerable groups an estimation of 7 to 11% of total TB cases recorded, mostly in children under the age of 15 years. And in 2015, there were over 360 cases of TB that was diagnosed and treated as presented by the Ministry of Health during a TB conference held in one of the resorts in Fiji. (Fiji Sun, 2017). Tuberculosis as already mention above is a contagious disease mainly because it spreads rapidly due to its mode of transmission which is air-born. There are two form of TB, a latent TB and active TB. (AIDSinfo, 2020). To elaborated more on this two form of diseases, firstly latent TB is actually the bacteria is in your body but doesn’t grow or spread therefore it doesn’t make that particular person to feel sick or to have symptoms. It can’t spread from one person to another but it can advance to TB disease if you tend to be sick. As for active TB, the bacteria is grows rapidly in your body, symptoms are showing and it is spreadable therefore early presentation to health facility is important at this stage. Signs and symptom of TB as stated by Mayo clinic Tuberculosis (2020) are as follows:• A cough that lasts for more than three (3) weeks• Chest pain• Coughing out blood ( Hemoptysis)• Unintentional weight lost• Feeling tired all the time (Fatigue)• Night sweats• Chills• Loss of appetiteBefore any clinician can diagnose a disease, it is important to gather all the necessary information from the client. Gathering the medical history and perform a physical examination as necessary. From my past year of experience working as either a hospital or public health nurse there are a few diagnostic test taken to rule out TB. Upon obtaining all necessary data’s from the patient first and for most a blood screening test, it is done upon arrival of patient. Collection of full blood counts (FBC), urea and creatinine (U&E) test and most importantly Blood culture test. Moreover, a common test performed is the Montoux tuberculin skin test (TST). The Montoux tuberculin skin test as quoted by Minnesota department of health is “performed by injecting a small amount of fluid called tuberculin into the skin in the lower part of the arm.” The test is read within 48-72 hours whereby the clinician will be looking for formation of rashes around the injection site. Since patients main chief complaint was the unresolved cough for more than three weeks, the clinician will order for a Chest radiology (chest X-ray). This x-ray will indicate lesions and its location but unfortunately not all lesions are TB related. Early morning sputum test is another way to rule out TB in a patient. Patient is adviced to collect early morning sputum for three consecutive days. The sputum will be test for any presences of acid fast bacilli (AFB). With all the four tests coming back as positive, it indicates that the client is a confirmed TB case and needs to be isolated as soon as possible. People with weak immune system are more likely to develop TB infection. These are people suffering from HIV, diabetes, cancer and malnutrition. Other contributing factors such as poverty and substance use, tobacco use, overcrowding and living with an infected TB client increases the chance of inhibiting the deathly disease. If TB is not successfully treated and managed according complications may occur. As mentioned earlier untreated TB can lead to spine deformity, brain meningitis, TB of the eye, TB of the kidney, Skeletal TB etc. How is this possible? The AFB has infected the blood and has travelled through the blood streams to this fragile organs causing other TB infection. As we try to solve or treat and prevent TB from spreading, there are always barriers or challengers faced either in the governmental level such as the ministry of health, the community health nurse or the community as a whole. One of the most difficult issues to address are lifestyle disease and communicable diseases, for example dealing with opportunistic infection such as TB. Therefore, the ministry of health puts together policies and guidelines to improve the management of such infection. But unfortunately, there will always be challenges faced inhibiting the delivery of servicers to either prevent, cure or manage the infection. Therefore the burden on the health services or the challenges faced by Ministry of Health and Medical Servicers in Fiji in regards to TB is firstly, the limited number of trained human resources in the clinical and public health system for management TB prevention, care and control services. In order to effectively manage TB we need capable people who are highly skilled with TB epidemiology, these people need to go and further their knowledge through education, workshops, conference etc. One is to train a person another is to deliver the service. This is where the gaps are breeched, one can get trained have the skills and knowledge but to deliver the services to the community is another issue as one has to try to change the behavior of a particular person or identified target group. Secondly, the limited resources for financing outreach activities as well as for contact tracing. Money is everything when it comes to providing accessibility of these activities the community. Cost of fuels in transportation, buying educational material for health education, and follow up patients on compliances. Thirdly, challenges in ensuring adherence to TB treatment as patient refuse to take drugs. Since all drugs has its side effects, some people tend to not take their medication because (i) they feel that they are cured that’s why they won’t complete the duration of the drugs, (ii) they feel weak or dizzy as this are some side effects of the drugs, (iii) they don’t believe in modern modification by rely on traditional healers and lastly because it’s their right to refuse any treatment. Fourthly, decrease in nutritional status. People are less active as compared to before they prefer to sell their vegetables and crops in exchange in buying imported food from our supermarkets. Contributing to the rise of anemia, malnutrition, obesity and non-communicable diseases. And lastly the high rate of diabetes, which makes it impossible to cure TB because of drug interaction. Effective control on TB is not the responsibility of the health care worker alone; it is the responsibility of each individual to prevent the spread of disease. TB is treatable and curable. How can this be achieved? Let’s look at the 5 action areas of health promotion and relating this to wellness approach or also known as the rainbow approach. Firstly by building a healthy public policy. Policies are made to protect and govern an individual irrespective of gender, culture, religion or race. Some of the acts or policies put in place regarding veneral diseases as stated by the government of Fiji as quoted in one of Sr Susana Tukana’s lecture notes, 2020 are: (i). Person suffering from veneral disease to be treated until cured. (ii). Compulsory examination and treatment of veneral disease. These two acts states that people with diseases such as TB are to be assessed, diagnosed and fully treated until they are successfully cured from the infection. Secondly, creating a supportive environment. Ensure that infection control measures are in place in the community but at the same time there is no stigmatization or discrimination in the community relating to people with TB. Ensure that basic needs are met such as clean water, air, food and adequate shelter). Advocating on proper nutrition, regular exercise and avoid risky behavior such as drugs, alcohol etc. Conduct awareness on what TB is, how it is spread & its management so that the community are well informed. Also advice the community to always seek medical assistance when necessary and not to rely more on tradition healers. Thirdly is to strengthen community action. The community is educated on the epidemiology of the TB infection, how it is transmitted and most importantly is that it is curable and also preventable. Family plays an important role in maintaining a highest level of health as well as diseases. As quoted in Family focus and community orientation in tuberculosis control (2011) “The family is not only the strongest affective bond among individual, but also in is their basis of the social identity and material and spiritual survival, through which their way of life is constructed.” As a community health nurse you should provide social, mental and spiritual support to client’s with TB. In addition to this it is important to encourage the community on prevention, diagnosis, medication compliance and care. Activities such as community mobilization to promote effective communication and participation among community members to generate demand for TB prevention. Advocate on TB prevention is taken up to school, churches and workplace and disseminated in other community activities to support primary health care services. It is important to educate people on TB and don’t discriminate TB victims. Likewise, community participation is important as this will install in them a sense of ownership towards their health as they feel empowered to take control of their individual health. Fourthly, is to develop personal skills. Heath education is prominent. Initiate activities to help build knowledge and foster positive attitudes and practices that contribute to efforts to stop TB. Use appropriate education material to appropriate age group, don’t use medical jargon or open ended questions, also maintain eye to eye contact at all time when education talks and use simple words. As a community nurse you should know the communities level of intelligence or their level of literacy. Conducting health education that will influence changes in the risky behaviors so that they can take control of their health. Try to involve former and current TB patient into the health education program as this bring more self-reliance and empowerment to the community. Lastly, re-orienting health services. Use the two preventative measure, primary prevention, BCG vaccination, isolate the client from others and wear mask that is if in the health facility setting. Secondary prevention, involves early detection and screening such as tuberculin skin test, chest x-ray and treating the infection before it can spread to another.A community health nurse is someone that is knowledge, skillful, approachable and knows the catchment area at heart. One that is an active leader when it comes to management of any infection weather contagious or not. Role as a community health nurse for TB management, follow up on the client’s medication compliance/ adherence. Contact tracing if any new cases appears, contacting tracing includes person’s address, number in the family, housing etc. Advocate on hygiene, nutrition, physical exercise and to refrain from risky behavior such as drug, alcohol, smoking Tabaco. Firstly hygiene demonstrate the 5 steps of hand washing. And explain to them when to do hand washing that is after coughing, sneezing using their hand. Encourage them to carry handkerchief everywhere they go. Put all their bedding out in the sun as this kills bacteria. Secondly, advise them to eat healthy foods as this strengthens their immune defense mechanism. As for food preparation, the community health nurse can request the dietician to talk on food preparation. Thirdly, advice the community on physical exercise. Physical exercise is not only running, jogging, it also includes working in the plantation. Encourage them on the 5:30 wellness. Lastly, to refrain from risky behavior as this will contribute to relapse in known cases. It is also important to encourage the community to take care of its environment and its surrounding. “No spitting”, “No littering”, advocate on a Tabbaco and alcohol free setting. Because a healthy community will result in a healthy nation”.