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Tuberculosis (TB) is an infectious disease caused by the bacteria Mycobacterium tuberculosis. Tuberculosis can affect various organs in the body (extra pulmonary form) but most commonly affects the lungs (pulmonary form). It is an airborne disease transmitted primarily through aerosols of an infected individual’s cough or sneeze TB usually occurs in a latent form, having no symptoms and about 10% of the latent form will progress to an active disease with a 50% mortality rate if left untreated. Individuals with the latent disease cannot transmit the disease during the latent period.
Risk factors for contracting TB include contact with someone with active TB, overcrowding especially where vulnerable populations are crowded (prisons, shelters, homes), malnutrition, poverty, other chronic lung disease, smoking, injection drug use, alcoholism, conditions that depress the immune system (use of corticosteroids, HIV infection, diabetes mellitus, pregnancy), elderly and young populations. Common symptoms of TB include chronic cough productive of blood-stained sputum, low grade fever, night sweats, loss of weight, weakness and fatigue, loss of appetite. Symptoms could also be specific to the organs affected.
Diagnosis of active TB involves obtaining a good clinical history which will identify the risk factors and symptoms mentioned above, radiological tests (chest X-rays), microbiological tests (sputum or other body fluid culture) and DNA testing like the GeneXpert automated diagnostic test. Latent TB is diagnosed by the tuberculin skin test using purified protein derivative (also called Mantoux or PPD test) or by conducting other blood tests.
Treatment of TB is complex and requires administering multi drug therapy over a long period. Directly Observed Treatment, Short course (DOTS) refers to a WHO global plan to stop TB and involves five points of action including government commitment, diagnosis, directly observing drug treatments, drug supply and standardized case recording and reporting. Multi drug resistant TB is now an emerging problem and needs to be addressed in TB control programs.
Worldwide, TB is said to have affected up to one third of the population. It is estimated that in 2017, up to 9 million new cases were recorded with 1.5 million deaths from TB. It is mostly a disease of developing countries. While only about 10% of people in the United States (U.S.) test positive for a Mantoux test, up to 80% of people in developing countries of Asia and Africa test positive. The emergence of the HIV/AIDS pandemic is responsible for the increase in TB incidence because of the depressed immune system that makes it easy for the latent form to become active. In the U.S. TB incidence rate has reduced from 52.6 per 100,000 in 1953 to 3.0 in 2017. This is a remarkable improvement resulting from effective public health interventions however, the incidence continues to be threatened by HIV prevalence as well as increasing immigration from developing countries with high TB incidence and prevalence. According to CDC, Maryland’s TB rate is above national average rate (>2.8). Baltimore City in Maryland has a population of 620,961 and has recently started experiencing an increase in TB cases. Within the last two years, there has been an increase in reported cases of TB in Sand town Winchester/Harlem community.
Sand town Winchester/Harlem community is located towards the West of Baltimore and is known to be underserved and burdened with many socio-economic challenges. A few indicators from the Baltimore Neighborhood Indicator Alliance1 reveal the worrying socio-demographic characteristics of this community compared to the rest of Baltimore.
There has been a recent increase in reported cases of TB over the past 2 years in the Sand town Winchester/Harlem community in Baltimore City. Sand town Winchester/Harlem community is an underserved community characterized by low income inhabitants and overcrowded living conditions in public housing facilities. The community characteristics point to many risk factors for TB infection and spread such as poverty.
According to the report Sand town-Winchester/Harlem Park neighborhood had the highest incarceration rate among those communities in Baltimore. With a lower educational attainment, 34 percent of Sand town-Winchester/Harlem Park residents do not have a high school diploma or GED and 52 percent of people ages 16-64 are unemployed. Not only does the Sand town-Winchester/Harlem Park experience incarceration more intensely than other neighborhoods, it also faces the most concentrated challenges related to work education, health and housing.
The challenges that Baltimore communities face contribute to a cycle of incarceration, poverty, and lost opportunity. Redirecting people and funds away from prison would help Baltimore City address these persistent challenges and barriers to the success of each community. Specific indicators of the challenges faced by this community is listed below.
The summary table below shows how Sand town-Winchester/Harlem Park compares to the other 54 Baltimore neighborhoods in terms of underlying factors that affect health and health opportunities—the social determinants of health.
Poverty is a powerful determinant of tuberculosis. Crowded and poorly ventilated living and working environments often associated with poverty constitute direct risk factors for tuberculosis transmission. Undernutrition is an important risk factor for developing active disease. Poverty is also associated with poor general health knowledge and a lack of empowerment to act on health knowledge, which leads to risk of exposure to several tuberculosis risk factors, such as HIV, smoking and alcohol abuse. An analysis of the problem is helpful to better understand the root causes for appropriate direction of intervention design.
A symbiotic relationship exists between TB and poverty. New TB infection is not just the product of poverty, but also creates poverty. Understanding the connection between TB and poverty is a powerful first step towards breaking this vicious cycle. Fighting TB and poverty together is necessary to accelerate economic and social growth and consequently reduce the global burden of TB. TB is a disease of poverty. It is widely recognized that the poorer the community, the greater the likelihood of being infected with the TB germ and developing clinical disease. A lack of basic health services, poor nutrition and inadequate living conditions all contribute to the spread of TB and its impact upon the community. An absence of good quality health care facilities is common in poor communities. With no health services to diagnose or treat patients, there is a longer delay between disease and cure, perpetuating the spread of TB. This study aims to reduce the incidence of TB in Baltimore City and control TB spread by addressing poverty.
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