TB Unmasked: Healthcare Workers and the Global Tuberculosis Epidemic
By Roberta Attanasio
World TB Day, falling on March 24th each year, is approaching — it reminds us that tuberculosis (TB) is a massive global health problem. Indeed, according to the World Health Organization (WHO), tuberculosis is one of the world’s deadliest communicable diseases. It is second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent.
In 2013, an estimated 9.0 million people developed TB and 1.5 million died from it — mostly in developing countries. However, TB is curable and preventable. The WHO estimates that 37 million lives were saved between 2000 and 2013 through effective diagnosis and treatment. Despite the many saved lives, the death toll is still unacceptably high. Last month, Anthony S. Fauci, Director of National Institute of Allergy and Infectious Diseases, said: “Progress is being made in the international fight against TB; however, the disease remains entrenched in many countries, especially those in Sub-Saharan Africa.”
TB is caused by bacteria (Mycobacterium tuberculosis) that most often affect the lungs. It spreads from person to person through the air. When people with lung TB cough, sneeze or spit, they propel the TB bacteria into the air. A person needs to inhale only a few of these bacteria to become infected. About one-third of the world’s population has latent TB — people have been infected by TB bacteria but are not (yet) ill with the disease and cannot spread the bacteria.
When a person develops active TB (disease), the symptoms (cough, fever, night sweats, weight loss and others) may be mild for many months. For this reason, people with active TB may delay seeking care, and bacteria can spread to others. People ill with TB can infect up to 10-15 other people through close contact over the course of a year. Without proper treatment, up to two thirds of people ill with TB will die. Unfortunately, the vaccine currently available to prevent TB has limited efficacy.
Healthcare workers who come into contact with patients affected by active TB are at considerable risk of contracting the disease. Indeed, every day, millions of healthcare workers around the world put their lives at risk as they combat tuberculosis. They’re vulnerable to TB exposure and infection. And they deserve to be protected. Therefore, Aeras — a nonprofit biotech advancing the development of new tuberculosis vaccines for the world — launched the TB UNMASKED campaign on September 24, 2014. TB UNMASKED supports and empowers people who put themselves at risk of tuberculosis infection through caring for patients, and gives healthcare workers on the front lines of the TB epidemic the opportunity to tell their stories using photographs, videos, or text. These healthcare workers are literally dying while caring for others. Their stories are important and must be told.
Matthew Feldman, project manager of TB UNMASKED, said: “Our goal is to give all these health-care workers’ stories a larger platform so that they see themselves as a part of the global TB community and become empowered to seek better protection for themselves and their colleagues.”
Below is one of the stories:
Working in one of the major hospitals in Atlanta, Grady, I can honestly say that it is very scary to think that at any moment in our day we could come into contact with a person who has TB and not even know it. We see so many homeless people and people who are sick with symptoms but aren’t sure what they have yet. People come in and out of the hospital all the time and they cough and sneeze constantly, sometimes without covering their mouths. We don’t know if the person standing next to us is ill with a disease like TB that is transmitted from person to person through the air. I had a coworker tell me once that she became infected with TB cleaning a room where a patient had TB but it wasn’t confirmed by doctors so no precautionary actions were taken. Once they tested the patient for TB and it was positive they informed her that she should get tested and when she did she indeed had the disease. There is no telling how many people came in and out of that room unprotected before and after her. We only get tested for TB once a year. I feel that we should be tested more than once a year because of the 3-4 plus days we work we have the risk of becoming infected. It was a great idea to start TB unmasked because it is very important that our stories as healthcare workers be told.
The article stated that there are many health professionals who help patients with TB even though it is the infectious disease that can be severely affected. And I would like to leave comments about how arduously health professionals work to help patients’ illness.
In this article, the ER doctor, after the loss of his patient, he went outside of the hospital and crouched down and crying. And later, he returned to the ER to help patients again. I personally felt sorrowful and also touched by this doctor by realized how doctors are tough-minded and have good hearts. We should be grateful to health professionals who always be there to help us fighting disease or any other illness.
For many years, tuberculosis is constantly remains a dangerous epidemic. One must consider and think of those suffering from this bacterial infection of lower respiratory and as well as many lives have already ended by this chronic illness. Many more are at risk of suffering just because they have inhaled this microorganism. For instance, to bring awareness and raise some concern, why are individuals still suffering from this disease? It is very easy to predict in developing country, but hard to predict in countries with low disease ratio. There are many individuals who want to spread the awareness by joining the campaign. It is very heroic to show concern. As many know that TB is multi – drug resistant and remains latent which can be reactivated, there are many information provided by many health care organizations; for example, CDC has an excellent guideline for health-care workers and anyone who wants to follow. However, many who join campaign such as Doctors without Borders are at risk of getting contact with tuberculosis infection. I believe, each and everyone is trying to outcome with this chronic infection, many researchers are doing many trials and errors to develop the best result. I also believe that since it is technology era, more developing country can easily use resources to obtain knowledge about risk factors of any acute or chronic disease and disorders. As we know, that even infants (future generation) are being diagnosed with this illness in many countries, if the number is increasing then even USA will have a higher infant profile of TB. There are many factors which can play as protective measures to stop the spread among health-care workers, volunteers or any individuals who have concerns with TB. For example, fresh air lowers the concentration of bacteria, this can be controlled with a decrease in pollution. Any individuals who are diagnosed with TB should always use tissues to cough and could also be kept in isolation until the treatment is complete.
I agree that latency is an overbearingly large issue when it comes to combating tuberculosis. An article in the ATS Journals, stated that even though cases of tuberculosis have decreased over the years, cases of latent TB have been popping back up more often. For example, HIV in the past, when TB was attacking the U.S. in higher rates was not as much of an issue, but in the last few decades has been, due to its ability to cause you to become immunosuppressed and form a higher risk of latent TB to reactivate. Even now, the age group that latent TB has been targeting has been the older generation, due to their declining immune system.
In the U.S. and other countries, it is vital that we also focus on certain age groups and disease carrying individuals to educate about TB, when fighting to help health care workers in the field. I fully agree, that it is important to educate health workers of ways to prevent ways of obtaining TB from their patients or work environment, but I feel it is also important to help educate the general public in endemic areas of better ways to prevent themselves from spreading TB to others, as you stated with the pollution and coughing in tissues. Small tactics such as those could help make all the difference.
The concerns of health care providers obtaining TB should add fuel to the need of creating a vaccine that can eliminate all types of tuberculosis in all ages and in all countries. A vaccine to eliminate TB would spare patients of the harsh symptoms and sometimes harsher drug regimens they must take to overcome the disease. There are the physical aspects like the coughing with blood, fatigue, chest pain weight loss, and fever which are combated with drug treatments at clinics 6 days a week. There is also the psychological symptoms such as shame, loss of family and jobs, and deep depression. As stated in this article, health care workers make regular patient calls. This is highly dangerous, especially when the patient has a multi-drug resistant form of mycobacteria. As Americans we tend to think of this as mainly an issue in foreign countries. However recently (today) cases have popped up in Tennessee and even in a middle school in Atlanta. More funding needs to be placed in finding a working and long-lasting vaccine, especially for the health care providers who risk their lives by coming in contact with tuberculosis.
I completely agree that an effective, non-resistant tuberculosis vaccine is vital in eliminating the disease. We often consider healthcare workers as being superhuman and completely resistant to infections that the general population is susceptible to, but that’s not the case. Healthcare providers are continuously exposed to numerous diseases, and although actions are taken to protect against incredibly contagious diseases like TB, it is not always 100% effective. As mentioned, even in places like Atlanta and Tennessee, where there is plentiful healthcare, tuberculosis causes great complications in communities. Launching a campaign like TB UNMASKED would definitely shed some light on issues that are usually not taken into consideration. This could help accelerate research into finding and funding more effective means of treating this disease, not just at home, but abroad as well. This holds especially true for places where healthcare is poor and transmission of tuberculosis cannot be easily regulated like that in first world countries. As of right now, because it is so prevalent in developing countries and not so much in the United States, the effort to produce a more effective vaccine is lacking. With more awareness of the danger of the disease, this will hopefully change.
Healthcare workers who sacrifice their healthcare attending to those infected with Tuberculosis do deserve protection as Dr. Attanasio stated. A first line of defense would be for healthcare workers to wear more efficient respiratory protective gear. Currently, the CDC advises as a minimum protection, non-powered respirators with a rating of at least N95.1 This type of mask is usually a half mask that filters 95% of airborne particles. When these are used they should be properly fit to the face, with no gaps around the nose or mouth. If they are not properly fit then, they are ineffective at stopping the aerosol transmission of the TB bacterium. Increasing the minimum requirement for respiratory protection for high-risk healthcare workers would be one way to help control the spread of the disease. Using a Powered Air Purifying Respirator, known as a PAPR, would give the healthcare workers an added level of protection that not found with the currently recommended N95 masks. The PAPR is a battery-operated air filtering device. It draws in contaminated air from the environment, passes it through a series of fine particulate filters and then via a hose, it transports the purified air to the facemask.2 One may argue that the PAPR may be too cumbersome and too expensive to operate and maintain thus reducing compliance. If the CDC were to change the required minimum standard to the PAPR for protection against TB it would save lives and there is no price you can put on a life.
I agree healthcare workers who put their life at risk to care for infected patients with Tuberculosis do need a more effective protection but the Powered Air Purifying Respirator or PAPR will only add an extra level of protection if it is used correctly and working properly and that involves funding and time to make sure that the PAPR is always up to date and for programs and seminars to show healthcare workers how to correctly use the respirator. These programs discuss where, when and how to properly use and care for the PAPR. The CDC suggest that employers require an all-inclusive “written respiratory protection program” to ensure that the healthcare workers are fully acknowledged on how to properly wear and use the PAPR to be provided proper protection. OSHA also regulates to make sure that the correct information is covered in the respiratory protection programs. They also do fitting to make sure that the healthcare worker is wearing the appropriate size PAPR and fitting should be done every time before they come in contact with an infected patient. These seminars and programs are extremely important when it comes to protecting healthcare workers from Tuberculosis. In order to protect everyone else from TB, they must first protect themselves.
I do agree with the fact that healthcare workers need more protection due to the high amount of exposure to disease on a regular basis, but I do not think that the N95 or the PAPR are the best tools to use. Both must appropriately fit in order to work, the PAPR can range from 100-1000 dollars per person and that is difficult for smaller hospitals to pay. Even if hospitals pay for their personnel to use them, the PAPR is large and has a huge hose, blowing air that goes down and across the body to the battery pack and that seems very uncomfortable and might get in the way of the person doing their job. With the N95 respirator, most employees do not like to use them for their entire shift, complaining of communication problems and physical discomfort. According to an article I read (Novel H1N1 Influenza and Respiratory Protection for Health Care Workers) a study proved that no more than 30% of healthcare workers used the apparatus for a full work day, which is a waste of the hospital’s money. I think that there needs to be a more comfortable and disposable alternative to the face respirators supplied for healthcare workers and a simple filtrating mask for the incoming patients as well. That might contain more of the communicable diseases and reduce the occurence of nosocomial infections.
We always see doctors as the service provider but not as the service receiver. In other words, we fail to realize that they are humans and so they are susceptible to the same infection. It is disheartening that doctors are in fact going through this. Since someone has to take care of the infected, the doctors are at the fore front of the battle facing the situation. To prevent further infection of doctors, awareness should be created. The United States Department of Labor describes different ways that doctors could be exposed to TB and ways to prevent further exposure including proper outfit (respiratory protection). Having this knowledge will help the doctors protect themselves better. Some of the precautions mentioned by the Occupational Safety and Health Administration (OSHA) can be implemented in preventing occupational hazards. One of the ways to prevent doctors from getting infected is that patients who test positive to TB should be quarantined and put in different rooms based on their level of infection so that strains of TB will not be transferred from one patient to the other. This way, resistant strain does not increase in the population. Also, when doctors are going in to treat the patients, they are masked and well protected. Protective measures like providing protective gears should be implemented so that other doctors in developed countries will be willing to volunteer by going to the places with this epidemic as help the doctors. This will provide enough help in combating TB.
I agree with your statement about having more protective measures and equipment when dealing with infected patients. It’s very unfortunate that those who offer to help people in need are risking their lives against a disease that is curable and preventable. I believe the easiest form of prevention would be the use of proper respiratory masks by healthcare workers as well as infected individuals. In regions with high percentages of infected people, those who are affected with the mild symptoms should still be tested and treated if necessary. Infected individuals should be quarantined and treated immediately to help decrease the spread of the disease. The BCG (Bacille Calmette-Guerin) vaccine should also be administered to healthcare workers to reduce risk of infection, especially in areas with high populations of TB infected patients and areas with multidrug resistant TB strains where antibiotics are ineffective. Although treatment for drug resistant strains is difficult, it is still possible with the right combination and use of anti-tuberculosis drugs. Those infected with drug resistant strains should be quarantined and closely monitored during their treatment to ensure proper drug usage. Non drug resistant TB infected patients should also be closely monitored during treatment to prevent the strain from becoming drug resistant. Hopefully, vaccine companies can produce an effective TB vaccine that can be easily transported and administered to areas in need, such as the nano-patch that we have discussed before in class.
As Americans we are quite selfish and self-centered. We try to pretend as though we care about the rest of the world and we are trying to help, but we are not. We make non-profit foundations, collect money, and go to war all in the name of making the world a better place. This however is not as true as we would like to believe. If a disease is not actively affecting America and/or constantly in the media it is not a priority. We are blessed to have the most advanced technology and some of the greatest minds of the 21st century, so I find it difficult to believe that we are trying our best to find a vaccine for this disease. According to Flu.gov, the influenza virus mutates and changes constantly. It is interesting that every year we have an effective vaccine for that strain on the flu vaccine. Why? Due to the fact that influenza actively affects Americans as much as it affects the rest of the world. On the other hand, tuberculosis disease does not affects Americans nearly as much as it affects the rest of the world. I am greatly thankful that we are not as affected by TB as the rest of the world, but I know that if we were there would be a vaccine by now. We need to either stop being so selfish and use our blessings to help the rest of the world or stop making the rest of the world believe that we are “trying our best” to help them.
I slightly disagree with some of your comments, the flu vaccines are seasonal, predicted and they are not ALWAYS made correctly each year. Tuberculosis is a disease that is less understood by scientist; therefore, it would be a lot harder to quickly make an effective TB vaccine. There are many causes for the increased deaths from TB, such as drug resistant strains. Tuberculosis affects every person differently and it is difficult to understand why. I do not believe that you can accurately compare a flu vaccine and a Tuberculosis vaccine. It is not as simple as it seems. I do believe that scientists are doing more than you think they are to make an effective vaccine, I mean, why not?
As a capitalist nation the United States’ economy is driven by demand and sales. Idealistically in healthcare scientists would be working more diligently to cure diseases affecting huge majorities of the world. In the case of TB in the United States this may be an unfortunate case where the direction of our healthcare market does not align itself with TB research. TB is a much smaller problem in the United States than across the world and therefore large healthcare companies may not see potential to make money off of their investment into TB research. These financially driven healthcare decisions are the reason we have seen a huge drop off in antibiotic research. Although drug resistant bacteria are becoming more and more prominent every day there is currently very little research dedicated to inventing new antibiotics. This is because it can cost 1 billion dollars to invent a new drug that we will want to use as little as possible as to prevent resistance from occurring. Companies see that as a large investment with very little potential for return. This is an unfortunate side-effect, if you will, of healthcare in a capitalist society where the market lends itself to drugs such as Lipitor to deal with cholesterol that will be equally as effective and marketable now as they will be fifty years from now.
In light of World TB Day, giving patronage to one of the greatest killer worldwide through personal research, charity, or spreading awareness is a means to enact change. Everyone’s interests are different, but it would be ideal to have individuals who look to make contributions, in America or not, on matters like TB which manifests itself worldwide. Everything begins with the individual, a family, a community, and hopefully the world, so that there is focus on eradicating the many diseases that plague mankind. However, education, exposure, and even the self usually limit outreach.
Therefore, I doubt people are falsely “trying to do their best”, otherwise it defeats the purpose of active engagement. Rather, I counter the acts such as those by Aeras using TB UNMASKED in the blog as a great platform in hopes of change whose main ideal is focused on the greater good and not socioeconomic gains. TB, much like it’s great competitor HIV/AIDS, are deadly difficult conditions that are not fully understood, making research results lag to expectations. One must consider the great painstaking time that is allotted into research to enact proper therapeutic agents. To take the lens of the many unknown faces suffering from TB without knowing or even the health-care workers exposing themselves means to remain optimistic that efforts will yield a difference.
The workers who are risking their lives combatting TB are definitely heroes, so I commend their daily tasks. It is amazing to have visualized so many videos featuring healthcare workers who are selflessly making a difference through the job they loved to do. It is perfect inspiration; the fight continues and we will win the war!
As humans, it is natural for us to feel some form of empathy for our fellow mankind that fall into the traps of communicable infectious diseases. None of us are untouchable when it comes to infectious disease such as Tuberculosis (TB) since it can go undetected for such a long time.
To deem “Americans” as being “selfish” is a strong accusation as ethically we are endowed with an innate drive to want to help our fellow individuals. According to an old adage, “charity begins at home,” and that is why I believe that within the United States measures were taken by the Center for Disease Control and Prevent to provide guidelines for health workers to follow.
Now, beyond the American border it’s a different scenario in which Medical Students, volunteers, and health care workers are put at risk of contracting TB infections due to the unavailability of information in most undeveloped countries. Also, precautionary measure that have not be identified put in place in health care settings can attribute to TB transmission to health care workers.
I do not believe that it is under any pretense that America is not trying to help other underdeveloped countries with regards to the treatment of TB. We must understand that each individual are the ones that make America what it is on a global front. Furthermore, it all comes down to the individual and the sacrifices they are willing to make to help other individuals threatened by TB without knowing that in an instant their lives upon being infected with TB.
Based on research, I found documents issued by “Morbidity and Mortality Weekly Report (MMWR)” that pertains to “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings.” Only two articles specify guidelines for transmission prevention whichever issued in 1994 and 1995 consecutively. It has been two decades and under the CDCs umbrella the MMWR has not published any newer reports regarding TB transmission prevention as it relates to healthcare workers.
In conclusion, the question remains, “As an individual, how much of myself I am willing to sacrifice for the enhanced health of humanity?” We should not be pointing figures but should take responsibility in being receptive to information available about TB and giving support to health care workers that have succumbed in some form to TB and other infectious diseases. As, Dr. Uvistra Naidoo mentioned in the video, a healthcare worker is committed to administering care in an instance where an individual requires mouth to mouth resuscitation and does not seek to get as much a mask, because death may be imminent if care is not administered in a timely manner.
Whether or not we like to admit it or hear it out loud, we are selfish. An “innate drive” does not mean it is social practice today. We have an innate drive to avenge those who have wronged us but that does not mean we can go around punching anyone who steps on our big toe. Furthermore, “charity begins at home” is a great ideal and would be beautiful if we practiced it as a nation. Sadly, this is not factual. America is the “greatest nation on earth” if you are able to take care of yourself… or if you are desperately below the poverty line. If you are somewhere in the middle, you face many problems that no one else really cares about. If you are not fortunate to afford healthcare or poor enough to be on Medicaid, you just don’t have healthcare. No one cares about these peoples, there are no plans to help these people, and you don’t wake up in the morning thinking about these people. Why? Due to the fact that we are selfish. My problem doesn’t lie with the people who are selfish; my problem lies with those who are in denial about being selfish. Those who try to convince everyone that they are great humanitarians while at heart only doing it for the fame or personal gain. Even if you had 300 volunteer hours by graduation this doesn’t mean you aren’t selfish. You may want everyone to believe that you volunteered out of the kindness of your heart but deep down you know you did it for the recognition from the school, family, and friends. Likewise, as a nation, we do things for the recognition from the rest of the world. I am not saying that there are not genuinely kind –hearted Americans. As a matter of a fact, a great number of us genuinely want to help the less fortunate, here and abroad. However, the huge money hungry corporations often overshadow those people or they start out with great intentions of helping the world and become corrupt over the years. Any information that is quoted is derived from the media and the media can lead us to believe anything that it wants. Just because an article states that there have been 1000 man hours worth of research into finding a vaccine for TB, doesn’t mean it is true and it also doesn’t mean they were genuinely “trying their hardest” to find a vaccine. To be honest, researchers get paid regardless, as long as they are working on a project. When that project is over, they do longer get paid. This is not to say that all researchers prolong research for a paycheck, this is all just food for thought.
Although I don’t agree with the generalization that every American is void of empathy or true sincerity for those in other less developed countries suffering from disease, I do feel that we are often guilty of viewing many issues that affects humans worldwide through a telescope that only focuses on those on the United States home front. Furthermore, in this modernized day of age, social media has created a medium in which instant communication and exposure to different societies across the world has reached a global level far surpassing that of the most popular news media outlets. Consequently, many illness have become a “trend” across social media, in which we pour buckets of ice water over our heads to garner likes on social platform under the guise of raising awareness for a disease that has presumably gone largely unnoticed. Meanwhile, hundreds to thousands of healthcare workers, and under privileged citizens in developing countries are being plagued by the same diseases that have been debilitating large populations for decades due largely to the fact that these countries do not have the resources, knowledge, and specialized assistance that are available to first world nations such as America. Therefore, while I do believe that a strong sense of nationalism and self-individualism play a role in the Americans’ responses to certain illnesses and their risks to populations as a whole, I do not feel that TB or other illnesses that affect other countries more than U.S. have gone neglected or ignored in the minds of all Americans. The United States sends hundreds of healthcare workers to third-world and developing countries each year with the goal of combating the high morbidity and mortality rates amongst these populations. Furthermore, several studies conducted on healthcare workers and the risk of TB transmission from patients have all shown that risk of contracting TB is consistently higher among healthcare workers than the general population worldwide. Consequently, this suggests that the efforts all healthcare workers take to mitigate the pervasiveness of TB infections can at many times be more daunting than the prospect of infection itself. To accept these risks at face value and still possess a drive and desire to help those in need who would otherwise not receive it, requires an individual who is inherently more selfless than selfish at heart. To conclude, I feel that both America and other first world nations should utilize the media resources that are at our disposal today to shine light on the occupational risks healthcare workers face every day and increase salience in regards to cost effective methods that can further preventive treatment for these individuals.