Barriers to diagnosing tuberculosis and performing contact investigations amongst the uninsured and non-English speaking populations.

Abstract

Background: Across the United States, providers are seeing an increase in active tuberculosis diagnosis. (Tuberculosis — United States, 2021 | MMWR (cdc.gov)). Particularly during Covid, many patients had a delay in diagnosis. This is a particular challenge for uninsured, non-English speaking patients.

Methods: Using a case study format, we will take a retrospective look at one case from the Coastal Health District TB Program, serving as an example of barriers that exist for this clientele. This patient was a non-US born woman in her 30s. She was undocumented, uninsured, and illiterate, and she worked as a cleaner at a hotel. She originally paid cash at an urgent care center due to a cough. After her chest xray was concerning, she was referred to get a chest CT. Because she had to pay out of pocket, this again delayed care. By the time our program received the referral, her delay of care was significant. Related to the length of time she had been infectious, her contact investigation was extensive, included mostly undocumented family members including children.

Results: Pt’s cough started in March, referral to the health department did not occur until August 28th. She had cavitation in her lung, and it took her nearly 2 months to become noninfectious. Of her 2 children, one was treated for latent TB infection, another treated as an active case. Total, we tested 28 people for her contact investigation. 6 had either a positive TB skin or blood test. 5 latent TB contacts completed LTBI treatment, and 1 active case completed treatment.

Conclusion: Delay of diagnosis and treatment let to more extensive illness, a long isolation period, infected many individuals, and created newer latent and active TB cases. Working with vulnerable patients who are undocumented, illiterate, and uninsured is complex and requires a holistic, flexible approach. Preventing future active TB cases requires better educating medical care providers on TB, and thorough contact investigations for each infectious TB case.

Keywords

tuberculosis, infectious, contact investigation, barriers

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Barriers to diagnosing tuberculosis and performing contact investigations amongst the uninsured and non-English speaking populations.

Background: Across the United States, providers are seeing an increase in active tuberculosis diagnosis. (Tuberculosis — United States, 2021 | MMWR (cdc.gov)). Particularly during Covid, many patients had a delay in diagnosis. This is a particular challenge for uninsured, non-English speaking patients.

Methods: Using a case study format, we will take a retrospective look at one case from the Coastal Health District TB Program, serving as an example of barriers that exist for this clientele. This patient was a non-US born woman in her 30s. She was undocumented, uninsured, and illiterate, and she worked as a cleaner at a hotel. She originally paid cash at an urgent care center due to a cough. After her chest xray was concerning, she was referred to get a chest CT. Because she had to pay out of pocket, this again delayed care. By the time our program received the referral, her delay of care was significant. Related to the length of time she had been infectious, her contact investigation was extensive, included mostly undocumented family members including children.

Results: Pt’s cough started in March, referral to the health department did not occur until August 28th. She had cavitation in her lung, and it took her nearly 2 months to become noninfectious. Of her 2 children, one was treated for latent TB infection, another treated as an active case. Total, we tested 28 people for her contact investigation. 6 had either a positive TB skin or blood test. 5 latent TB contacts completed LTBI treatment, and 1 active case completed treatment.

Conclusion: Delay of diagnosis and treatment let to more extensive illness, a long isolation period, infected many individuals, and created newer latent and active TB cases. Working with vulnerable patients who are undocumented, illiterate, and uninsured is complex and requires a holistic, flexible approach. Preventing future active TB cases requires better educating medical care providers on TB, and thorough contact investigations for each infectious TB case.