Boston program pushes preventive therapy
In Boston, TB controllers are like restaurateurs with a five-star menu and plenty of seating capacity: They’d like to see more business, especially from the city’s foreign-born communities.
Clearly, it’s epidemiology that’s driving that desire. So far this year, 85% of the city’s TB cases are foreign-born, says TB controller John Bernardo, MD. That’s already a jump from last year’s totals, in which foreign-born cases accounted for 72%.
One reason — home-grown TB is on the wane in the city. "TB among injecting drug users isn’t really a big issue here," says Bernardo. Plus, thanks to better case finding and screening in shelters, the city averages only two or three cases of TB a year among its homeless population.
An analysis of data from cases among the foreign-born makes a strong case for more preventive therapy, he says. "Lots of places report it’s the new arrivals among the foreign-born that are bringing TB," he says. "But here, the majority of patients have been here a little more than five years." Among age groups, there are two peaks: the first between 25 and 44 years old and a second smaller peak among those older than 65. "What that tells us is that we’re missing a lot of opportunities for prevention," Bernardo adds.
In the city’s network of community-based, primary-care health clinics, TB controllers have a ready-made venue for providing more preventive therapy. The clinics are staffed by members of the same population groups they serve, so that patients feel comfortable and welcome there, and TB control has provided staff members with extra TB training, shifting most of the follow-up activities away from the downtown TB clinic and into the neighborhoods. As a result, completion rates for patients on preventive therapy have jumped up to a satisfying 80%, says Bernardo. (For more information, see TB Monitor, August 1998, p. 91.)
Yet so far, only 350 to 400 foreign-born patients are getting preventive therapy from the clinics. He says that accounts for no more than 10% of the total number of potential candidates.
Two factors are keeping people away, according to Bernardo:
1. There is a stigma surrounding TB. "People are afraid of TB," he says. "They’re afraid of being labeled."
2. One of the two systems that traditionally have channeled patients to the clinics may soon shut down. "People come into the clinics either because they need a TB screening for their jobs or because their children were required by the schools to get periodic TB screening," Bernardo says.
The effect of a recent change in state law may cut back the number of school kids who are skin tested for TB, though, by leaving the decision of whether or not a child is at risk up to individual physicians. Bernardo worries that family physicians who are already pressed for time, or simply unaware of the risk factors involved, may elect to waive the screening.
The solution, as Bernardo sees it, is to form partnerships with community-based organizations (CBOs) that can help with education, outreach, and training. "We’ve got three CBOs champing at the bit to get going," he says. "The leaders within these communities have bought into the concept of prevention, and they see it as a need. Once you get the trust of the leadership, a lot of the mistrust about who we are and what we do tends to dissipate."
For starters, the project will hone in on two populations, Chinese and Hispanics, with strong family structures in which the mother is particularly influential, says Bernardo.
The idea is to convince mothers that it’s important to get their families — especially their children — to come into clinics for screening. "We’re focusing on youth because they’re the ones who are going to come down with TB, according to the epidemiology we’re seeing," he adds.
His department has limited its own role in the project to persuading CBOs of the importance of providing more prevention and to make the commitment to help, says Bernardo. He trusts that CBOs know their own communities well enough to come up with strategies for outreach and training that will work. TB and TB prevention won’t be the only items on the agenda, either. CBOs will try to increase awareness about the importance of screening for sexually transmitted diseases and HIV as well.
Finding new ways to reach out to the foreign-born has become "the heart and soul of our program," Bernardo says. "We have to become more attractive to our foreign-born communities. They’re either going to run away from us or run toward us."
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