Interview failures boost rates for black children
March 1, 1999 4 minutes read
Interview failures boost rates for black children
Outreach workers will receive more training
What’s going on with African-American children in Alabama? That’s a question TB researchers have been trying to answer since 1990, when cases among black children began a steady rise that has shown no sign of stopping.
Many of the childhood cases are the result of contact investigation failures, research suggests. Failures can occur when investigators don’t probe hard enough or when patients or their families decide to stonewall the investigation, says Michael Kimerling, MD, MPH, lead researcher and assistant professor at the schools of medicine and public health at the University of Alabama in Birmingham.
To some degree, the rise in case rates among black children simply reflects two bigger shifts in the epidemiology of the disease, Kimerling says. "More and more, TB is becoming a disease of minorities, and at the same time the median age of cases is dropping."
Even so, TB controllers in the state were struck when, in 1996, the line tracking case rates among black children and the line for tracking them among white adults actually crossed. "We felt that was extremely significant," Kimerling says.
When he and others began to analyze what kinds of cases among African-American children could have been prevented, they found four kinds of problems at work, he says.
The first were communication problems between states, which can take the shape either of poor communication or none at all, he says. That is, investigators in one state fail to find out their patient has family in another state, or they fail to let TB controllers in another state know about the family. "So later we find out there’s an aunt or uncle from Detroit, for example, who came to spend Christmas . . . and a childhood case has occurred," Kimerling says.
The second problem is the failure of adult patients to complete prophylaxis. Adults who develop active disease as a result may infect children; the children frequently go on to develop active disease themselves.
In other instances, contact investigations don’t proceed in a timely fashion, and children are infected and develop TB.
The fourth problem, interview failures, appears to be most significant, but it also is the most complicated, Kimerling says. Often, the trouble isn’t that interviewers fail to bring up the topic of children; rather, it’s that they don’t succeed in getting accurate information.
Why families and patients don’t tell
The idea that subjects would withhold such information intentionally may strike outsiders as puzzling. Why, after all, would an adult choose to risk the life of a child by not disclos-ing her existence? How could an investigator fail to discover whether there are children in the household?
Michael Holcombe, Mississippi’s state TB controller, agrees with Kimerling that it’s not uncommon for adults to withhold information about children. He recalls one such case vividly: Family members conferred among themselves and decided that an infant in the household hadn’t undergone enough exposure to warrant naming him. Tragically, the infant subsequently developed TB meningitis and died.
Other times, the logic behind the decision to withhold information reflects a subject’s personal priorities. A man may be reluctant to name youngsters in a household where he’s living surreptitiously, for fear the family will be evicted or otherwise penalized. A busy single mother, dreading the prospect of having to take her kids to a public health clinic for months of preventive treatment, decides it would be easier not to disclose her children’s existence.
Whatever the circumstances that contribute to the problem of interview failure, Kimerling says his state will put outreach workers and others responsible for investigations through a course of retraining. The idea is to make investigators more alert to obstacles in the investigatory process and teach them how to make sure they ask the right questions, he adds.
Holcombe and Kimerling concede that in some situations, no amount of investigation will uncover children as contacts. The aim is to minimize such occurrences, they say.
"You’ve got to work smart as well as hard in a contact investigation," Holcombe says. "You have to be a good observer." That means that first off, investigators must make sure they spend time in a patient’s home, he says.
"You have to look at what kinds of pictures are on the wall, or sitting out on dressers and tables," he adds. "Notice who’s running in and out of the house, who’s playing in the yard, who’s coming to visit. Pay attention to the local chitchat among the neighbors." Such activities are time-consuming, of course, and time isn’t always a luxury that’s available to busy public health nurses who may be juggling dozens of priorities, he adds.
Besides time, another important factor often lacking in contact investigations is experience, adds Holcombe. "Often it’s the most inexperienced staff who do follow-up on TB cases," he says. "Let’s face it: TB’s not the most popular program. It’s hard work, and you’re dealing with patients not just for a few days, but for months on end."
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