Duke Researcher Wins NIH Award to Improve Tuberculosis Education In Rural Areas

By Duke Medicine News and Communications

DURHAM, N.C. -- Less than 10 years ago, scientists were predicting the imminent eradication of tuberculosis in the United States. Now, due mainly to the rise of TB in people living with HIV and the increase in immigration from Southeast Asia and Africa, TB once again poses a serious threat to U.S. public health.

North Carolina, whose incidence rate ranks in the middle of the 50 states, has a number of counties -- concentrated in the eastern portion of the state -- with TB incidence rates rivaling the nation's largest cities.

The declining incidence of TB nationwide during the late 1980s and early 1990s was accompanied by a decrease in federal spending on TB research and dwindling attention on the disease from the medical community.

"We're now finding that many health care providers are not adequately equipped to diagnose and manage patients with TB," said Duke University Medical Center TB specialist Dr. Carol Dukes Hamilton. "The situation is especially true in rural areas, where many providers have had minimal experience with TB."

To address this emerging problem, the National Heart, Lung, and Blood Institute awarded Hamilton and her Duke colleagues a Tuberculosis Academic Award to develop strategies to improve education for health care workers in the diagnosis and treatment of TB.

The five-year, $375,000 award by the National Institutes of Health agency is intended to help stem the rising incidence of tuberculosis in the United States. Three such awards have been granted each year for the past four years; the Duke award is one of few dealing with TB in rural settings.

Hamilton anticipates that the Duke materials and strategies can be used as a national model.

"TB is on the rise across the U.S., especially in the heavily populated urban areas," Hamilton said. "North Carolina's incidence is very interesting. While we rank 20th in terms of statewide incidence, we have certain counties whose incidence is as high as the urban areas such as New York or Detroit."

In North Carolina, the TB incidence rate is the highest in the eastern half of the state, Hamilton said. In descending order, the top five counties with the highest incidence of TB are Pitt (29.02 cases per 100,000 population), Lenoir (24.46), Wilson (22.18), Robeson (20.43) and Johnston (14.96).

"Interestingly, at least six counties with the highest incidence and the largest number of TB cases were not among the top 10 counties in terms of population," Hamilton said.

Further compounding the problem in North Carolina is that these rural areas are dramatically underserved by health care providers, especially physicians, according to Hamilton. Patients in these areas often are seen by family nurse practitioners or physician assistants, who have minimal training in infectious disease or pulmonary medicine, and who are less likely to be able to travel to receive further training.

Hamilton and colleagues will develop the educational materials for improving TB education initially for Duke medical students, house staff, nurses and physician assistants. Then, aided by computer and Internet technology, the researchers plan to take these newly developed educational tools to the practitioners out in the rural communities.

According to Hamilton, three distinct factors have led to marked increase in TB rates in the U.S.

"Probably the largest group get TB as a result of having their immune system weakened by AIDS," she said. "While the average person who has been exposed to TB has a 5 to 10 percent lifetime risk of getting sick with TB, HIV-infected people who have been exposed to TB have a 5 to 10 percent chance each year of getting sick with it.

"Secondly, the U.S. has seen a dramatic increase in immigration from Southeast Asia and Africa, where the TB rates are very high," she continued. "Lastly, the general breakdown in the fabric of society -- homelessness, poverty and drug abuse -- is a major contributor to the spread of the disease."

What makes the rise in TB so frustrating for physicians, Hamilton said, is that it is usually completely curable with drugs. However, the drugs must be taken every day for at least six to 12 months to eradicate the disease, but many patients, who can start feeling better within six weeks, stop taking the medications too soon.

Studies have shown that if health care workers go to the patients and observe them taking their medications, compliance rates are much higher, Hamilton said. However, in rural areas, where health care workers are already in short supply, this is not a practical solution.

"Not only does this non-compliance with medications allow the disease to return, but it also helps contribute to the emergence of drug-resistant strains of TB," Hamilton said. Trials are currently under way on a new anti-TB drug that only needs to be taken once a week.