Using a Survey to Assess LTBI in Foreign-Born College Students in the Southeastern Pennsylvania / Philadelphia Metropolitan Area

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1 Using a Survey to Assess LTBI in Foreign-Born College Students in the Southeastern Pennsylvania / Philadelphia Metropolitan Area by Sean Kerry Walter June 2011 A Community Based Master s Project presented to the faculty of Drexel University School of Public Health in partial fulfillment of the Requirement for the Degree of Master of Public Health.

2 ii TABLE OF CONTENTS Acknowledgements iii List of Tables iv Abstract v Problem Statement 1 Background 2 Hypothesis 7 Research Goals 8 Methods 10 Study Limitations 13 Research Findings 14 Analysis & Discussion 24 Policy Recommendations 29 Conclusion 32 Bibliography 34 Appendices Appendix A 36 Appendix B 37

3 iii ACKNOWLEDGEMENTS I would like to thank all those involved, for without their invaluable assistance and direction this project would not have happened. This task seemed daunting at first, but their help made the work manageable so that I could actually get it all done on time. Philadelphia Department of Public Health, Tuberculosis Control Program o Christina Dogbey, MPH Preceptor o Dan Dohony, MPH Secondary Preceptor Drexel University School of Public Health o Dennis Gallagher, MA, MPA Advisor Southeastern Pennsylvania College Health Nurses Association o Chris Rooney, BSN, RN, BC

4 iv LIST OF TABLES Table 1 Responses to Question #1 15 Table 2 Responses to Question #2 16 Table 3 Responses to Question #3 16 Table 4 Responses to Question #4 17 Table 5 Responses to Question #5 18 Table 6 Responses to Question #6 19 Table 7 Responses to Question #7 19 Table 8 Responses to Question #8 20 Table 9 Responses to Question #9 21 Table 10 Responses to Question #10 22

5 v ABSTRACT Using a Survey to Assess LTBI in Foreign-Born College Students in the Southeastern Pennsylvania / Philadelphia Metropolitan Area Sean Walter Christina Dogbey, MPH Tuberculosis (TB) in the United States (U.S.) has been declining steadily since the 1950 s; from 84,304 cases in 1953 to 11,545 in Accompanying this decline has been an increase in the proportion of foreign-born cases. In 1993, 29% of TB cases were foreign-born, but in 2009 they constituted 59%. 2 Philadelphia, Pennsylvania has seen a similar trend, where between 2007 and 2009, 53.2% of cases were foreign-born. 3 One of the Centers for Disease Control and Prevention s (CDC) strategy is to test recent arrivals from high-incidence countries for latent TB infection (LTBI). 4 One group not required to be tested is international students coming to the U.S. to attend college. This survey was developed to assess colleges in the Southeastern Pennsylvania and the Philadelphia metro area, focusing on screening and testing practices. We hope to determine if schools with TB screening policies are better prepared to prevent TB than those without a policy. This survey aims to get a baseline of information on what is occurring regarding TB risk in college students. In addition, the Philadelphia Department of Public Health s TB Control Program (PTBC) would like to get a sense of what effect a college-based TB screening policy has on preventing illness, as well as what assistance schools may require in relation to TB. The survey will be disseminated

6 vi electronically to the 32 schools that are members of the Southeastern Pennsylvania College Health Nurses Association (SPCHNA), as well as a number of non-member schools. Overall, in the past 5 years, 40.0% (14) of all schools had seen cases of TB on their campus. Also, most of the surveyed schools (88.6%) indicated that they have a TB screening policy in place at their institution. However, only 51.4% of respondents felt their school needed a prevention policy, and only 40% indicated having an established plan to address an outbreak of disease with their local health department. PTBC should provide assistance to area colleges to develop their own screening programs, as well as establish a database to track college TB cases. Also, studying the feasibility of adapting other states targeted testing guidelines for LTBI will also help to reduce the burden of TB.

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8 1 Problem Statement International students, coming to the United States (U.S.) with the purpose of attending college, are not required by the U.S. Department of State to be tested for Tuberculosis (TB). The problem being addressed with my specific topic (i.e. are more foreign-born students developing the disease, as opposed to U.S.-born students) is a proxy for the overall problem facing the U.S. with respect to TB. Has the increase in TB in the foreign-born also propagated an increase in foreign-born college students? Literature on TB in college students is sparse, and the decade during which articles appeared more frequently in scientific journals was the 1950s (and before). The congregative setting (i.e. students in close quarters dorms) of most college campuses makes the threat of TB especially significant because of the ease of transmission within such settings. In the Philadelphia metropolitan area there is a significant foreign-born population, which coincides with an increasing proportion of TB cases in that group. Considering this, the Philadelphia Department of Public Health s Tuberculosis Control Program (PTBC) has expressed an interest in learning more about what effect(s) this trend has had on the college student population. What is especially alarming about TB in college students is the potential for those with latent TB infection (LTBI) to develop active disease while in school. Since those with LTBI do not present with symptoms of active TB (e.g. bad cough, chest pains, coughing up blood, etc.) they do not seem as though they could be at a higher risk for developing the disease and spreading it on to others. 5 Thus, PTBC would like to know the nature of the disease on college campuses in the area, and what assistance, if any, they require in order to address the problem.

9 2 Background Tuberculosis is an infectious disease that was once prolific throughout the United States (U.S.). Similar to the cold, it is spread by airborne transmission, and only those who are sick with the TB germs (mycobacterium tuberculosis), generally in their lungs, are infectious. 6 Beginning around the 1970s, though, cases of communicable diseases in general were beginning to decline overall, while chronic diseases were becoming the primary cause of morbidity and mortality in the U.S. While TB has decreased in the U.S. overall, cases of TB are still rampant throughout many places in Africa, Southern Asia and Eastern Europe, with over one-third of the world infected. 7 Today, though, there is another alarming trend that is occurring all around the country with regard to TB. Since 2001, the cases of TB in the U.S. have come, in large part, from individuals who are foreign-born. In 1993, 29% of TB cases were foreign-born; while in 2009 the foreign-born accounted for 59% of cases. 8 This trend has also been seen in the Philadelphia metropolitan / Southeastern Pennsylvania area, where between the years 2007 and % of cases were foreign-born. 3 However, determining whether or not this trend has held true for individuals who attend college is difficult due to the lack of studies conducted in these populations. While college students have not been considered an at-risk group in the past, they do present a situation where TB could develop into a public health problem. TB was once one of the top-five leading causes of death in the U.S. in 1900, causing almost 200 deaths per 100,000 living citizens. 9 Since that time, there has been a significant decrease in the number of deaths, and in 2007 there were only 544 deaths in the U.S. caused by TB. 7 Active TB is an infectious disease that is easily spread from person to person via inhaling infected droplet nuclei, or by direct contact with an infected individual. 10 Although, coming into

10 3 contact with TB germs does not guarantee infection, with only 10% of those who become infected will go on to develop active TB. 10 Five percent of those will develop active TB within the next one to two years, while the remaining percentage will develop it at some point over the remaining course of their lives. Prevention of the disease is the most effective way to combat it in the population as curing the disease is much more difficult. Prevention of TB takes many forms, from screening and testing, to preventive prophylaxis. One of the simplest ways to screen for TB in college students is through the use of a questionnaire. With such a screening instrument, questions such as, Have you ever lived for two months or more in Asia, Africa, Central or South America, or Eastern Europe? can help to determine possible risk. 11 Screening tools also help to determine if further testing is warranted. Today, the most frequently used test to for TB is the Mantoux Tuberculin Skin Test (TST), which utilizes a purified protein derivative (PPD) tuberculosis antigen. Frequently the test is simply called a PPD, which refers to the tuberculin antigen that is injected intradermally on the underside of a person s arm. 10 The Mantoux TST is the most cost-effective way to assist with diagnosing TB, with the materials costing approximately $ Despite its low cost, there are some associated problems. One of the more significant problems is that if an individual received a TB vaccine in the past (the Bacillus Calmette-Guérin (BCG) vaccine) then there is a possibility that they may test positive (false positive). If an individual does test positive, then a second test may be repeated, which then may be followed up with a chest x-ray to confirm a positive test result. In the event that all tests are positive for TB, then the individual must start treatment (with Rifampin [RIF] or Isoniazid [INH]) immediately to prevent spreading the disease. Other tests that are used to diagnose TB include the Tine test and the Interferon Gamma Release Assay (IGRA). The Tine test, also known as a multiple puncture test due to its use of

11 4 several tines to penetrate the skin to inject the tuberculin, is not recommended for use anymore and has since fallen out of favor due to its inaccuracy and difficulty of administration. Currently, the CDC no longer recommends using the tine test. 13 IGRA tests are rising in popularity as they have multiple benefits over the more widely used Mantoux TST. One of the more notable benefits is that it will not produce a false-positive reaction in the event that a person has received a BCG vaccine in the past. 14 This is significant in the fact that most of the individuals who would have received a BCG vaccine come from many regions of the world that the World Health Organization (WHO) defines as high burden countries. 6 Also, where as the Mantoux TST may requires a second test to confirm a positive initial reading, the IGRA test only requires a single application. 14 However, the cost of the IGRA test is substantially more than the TST, as it can cost from $20 to over $ Choosing the right TB test will require careful consideration of the resources available, as well as the costs and benefits. A condition where a person may not be immediately infectious but they may test positive for TB is when they have LTBI. Diagnosis of LTBI occurs when someone is found to be harboring the TB bacillus in their lungs, yet they do not show symptoms of the disease. In this case, a person s immune system is strong enough to keep the germs suppressed. Some of the conditions that may cause LTBI to develop into active disease include meningitis, diabetes mellitus, being on immunosuppressive therapy, stress that can be associated with college, etc. Also, being around others who may have active disease increases the chances of LTBI developing into active disease. This is why LTBI presents such a danger in the college setting, because it increases the risk of reactivation into active disease. Students from all over the country and world congregate together in dormitories, and this represents a situation with the potential

12 5 for an outbreak. Fortunately, there have not been any major outbreaks of TB on U.S. college campuses in recent years. One problem of great concern that we are confronted with in regards to TB deals with drug resistance. These cases are much more difficult to treat, which inevitably makes them more life-threatening, not to mention more costly, as the available treatments become less effective. 15 While it is impossible to say that antibiotic resistance would never occur, since the bacteria naturally mutates after it replicates several million times, but the issue of improperly managed treatment is a contributing factor. 15 Also, as the resistance to current TB antibiotics increases, healthcare providers are forced to use more toxic drugs, especially to the liver, as well as those that are not as effective. 16 Two of the more well-known forms of drug-resistant TB include multi-drug resistant (MDR-TB) and extensively drug-resistant (XDR-TB). MDR-TB is defined as a person being infected with mycobacterium tuberculosis, but the standard drugs for treatment, isoniazid and rifampin, are ineffective. 17 In 2008, there were 440,000 cases of MDR-TB around the globe, with a large percentage of them, almost 50%, originating from India and China. 17 This situation is dire as the many problems associated with this particular bug are becoming critical. Two trends in particular that stick out are the rise in MDR cases in previously treated patients, and the failure to correctly diagnose the condition. Of 440,000 cases of MDR-TB in 2008, over three quarters occurred in patients who were previously treated for TB. 17 Failing to properly manage these cases will only lead to higher healthcare costs associated with treating more cases where resistance is found. Another issue of concern is the failure of TB programs to properly treat and diagnose cases of MDR-TB. 17 In the same year, 2008, only 30,000 cases (about 7%) of MDR were reported to the WHO, and unless there is a more concerted effort to catch these cases, the disease will only continue to proliferate. 17

13 6 Of even greater concern to the global public s health is the emergence of XDR-TB. This particular bug is resistant to all of the same drugs as MDR-TB, but it also is resistant to all fluoroquinolones (e.g. ciprofloxacin) and any of the second-line injectables (e.g. Amikacin). 17 Treatment of XDR can be a very long process, as well as extremely taxing on an individual s health. For example, in 2006, a Peruvian exchange student, Oswaldo Juarez, in Florida came down with a form of XDR-TB and spent almost two years recovering. Doctors told him that he only had one chance at life, and that if he went back home to Peru that he would probably die within a month. 18 While his treatment was ultimately successful, it was extremely expensive (approximately $500,000), and it still left doctors perplexed as to how to treat such difficult cases. 18 The examples of drug-resistant TB are reminders of why proper and timely treatment is of paramount importance. One of the most effective treatment management systems was developed by the WHO, and is known as Directly Observed Treatment short course, or DOTS. It is very cost-effective, and it has been shown to be very valuable in resource poor settings. 19 The basic principle behind the program is to have a trained community health worker take TB medications out to the patients and watch them consume the medications. This strategy helps to ensure that people are taking the right medication and are on the proper treatment regimens. The DOTS program has been shown to be successful in 80% of cases, and can help in restraining the proliferation of drug-resistant strains, which is critically important with MDR and XDR-TB on the rise. 19 However, the success of the program hinges on a committed political system and financial support for the medication, supervision by community workers, and monitoring and surveillance activities to assess the impact. 19 DOTS is not just used in foreign countries with high prevalence rates of TB, but it is also used here in the U.S. for case management.

14 7 The proper management of TB cases is critical to preventing outbreaks, as well as ensuring that drug resistance does not increase in society. This is an even more salient point for health officials on college campuses due to the congregative nature of the college environment (i.e. dormitories). Addressing TB on college campuses is a task that is left up to individual institutions, since it is not required by law. TB prevention policies can take the form of a letter addressing TST when foreign students arrive at school, as well as the actual TST itself. The aim of these policies is to minimize the occurrence of active TB on the campus and to offer preventive treatment to those students with positive TSTs and negative chest x-rays. 10 So far, due to the dearth of information in the scientific literature about TB on college campuses, it would be difficult to assess the effectiveness of these policies because such cases do not occur in great numbers. Hypothesis Considering that TB is not a serious problem in U.S. colleges and universities, my focus mainly became exploratory as we wanted to find out whether or not TB screening and prevention policies allow schools to better prepare to deal with a potential outbreak, should one ever arise. Thus, my main hypothesis became, Schools in the U.S. that have an established tuberculosis screening, or prevention, policy in place will be less likely to have experienced problems associated with the disease, as opposed to those without a policy. Considering that only 61% of all schools require TB screening of any kind, those without a policy may be placing themselves at greater risk in the event of students presenting with active disease. 20 In the event that analysis shows this hypothesis to be true, then it will be more of an impetus for schools without a policy, to adopt one.

15 8 In addition to my main hypothesis, another area of interest was whether or not there was any significance in TB prevention for a school to belong to a professional health organization. My preceptors and believed that if a school found it necessary to have their health faculty join such an organization, that they may be more likely to have a TB screening policy. This is also supported by a study by Hennessey et al., which looked at American College Health Association (ACHA) member schools versus non-member schools. They found that schools that belong to the ACHA were more likely than those who do not belong to have required tuberculosis screening policies. 20 In the same vein as the Hennessey study, I have been working in conjunction with the Southeastern Pennsylvania College Health Nurses Association (SPCHNA), a professional network of college and university nurses in the Philadelphia and surrounding area. Considering this, my secondary hypothesis is, Schools, whose health staff belongs to a professional health organization, will be less likely to have been burdened by tuberculosis, versus those whose health staff does not belong to a professional health organization. If this turns out to be true, that will reinforce the importance of having health staff become a part of such organizations, as well as maintaining vigilance towards TB. Research Goals Since this project is mainly exploratory in nature, my preceptors and I have set out a number of goals for what we would like to accomplish. The main goal of the project is to give a more recent picture of what TB looks like in the university setting. Since most of the literature on TB in college students is outdated, which is partly due to an overall decline of TB in the U.S., we also believe that the findings will revive the interest in the topic, as well as call attention to what could be a potential future problem. Additional goals for the project include:

16 9 Research the interest expressed by PTBC on how colleges perceive the disease in relation to their specific campus; Establish whether or not college health officials feel as though there is a need for a TB prevention policy on their campuses; Determine the proportion of colleges/universities in the Southeastern Pennsylvania / Philadelphia metro area with TB prevention policies in place; Describe the needs of health officials on college campuses in relation to TB, and how PTBC can possibly address those needs; Determine the benefits/detriments of implementing a TB prevention policy. We believe that it is critical to understand the needs that area colleges and universities may have because they may realize that since TB is not as much a problem now as it was in past years, that they may be underprepared to react to an outbreak. Also, for those schools who may be smaller, in terms of student population, they might feel that it would be more of a burden to implement a TB prevention policy, since they have never experienced any cases of TB on campus. One additional goal for the project is to be able to present the findings from the survey at one of the SPCHNA meetings. While this is not directly related to the research component of the proposed project, it will help in the sense that the SPCHNA president asked for my preceptors and I to present our findings at the project s conclusion. Also, at this meeting we would address any concerns about TB in the college setting, as well as any questions about implementing a TB prevention program and TB prevention in general.

17 10 Methods The proposed project revolves around a survey that will be administered to 32 different schools that are a part of the SPCHNA, and all are within the Southeastern Pennsylvania / Philadelphia metropolitan area. In addition to these 32 schools, a group of approximately 10 nonmember schools will be included to check for any differences in belonging to a professional health organization. A short, questionnaire (11 questions) was developed to assess the status of TB on college campuses, as well as to determine the needs of individual schools. In the event that there does seem to be a need for a prevention program, PTBC is prepared to share with the school(s) the Heartland National Tuberculosis Center (HNTC) guidance document on TB prevention (Note: this is only a possible ancillary aspect of the study design and NOT the main focus). The HNTC document is considered to be the gold standard in setting up a TB prevention policy on college campuses, and it is the approach that PTBC utilizes. The format of the survey will be electronic, and it will be sent out through the SPCHNA listserv, and for those not a part of the organization the survey link will be ed to individual health officials. Combining both the desire of PTBC to understand this problem and the reality that the majority of TB cases originate from the foreign-born has been the main impetus behind this project. While it is understandable that TB has not been a major focus of disease prevention on college campuses in recent years, the need is even more pressing when considering recent trends. The target population will be college health officials that work in the student health center on campus for the schools that belong to the SPCHNA. The same officials whose schools are not a part of the SPCHNA will also be sent out a survey. We have chosen to focus on nurses because we felt that they would be the best sources of information on TB in the student population at their institution. Also, they are more likely to interact with the students on a daily

18 11 basis, as opposed to the campus physician, which may only have limited times during the week to see students. In the event that a school does not have a student health center, the person in charge of student records would be the likely point of contact. The respondent must be a part of either the college health center, in the event that a school has a health center, or they must work with student health records, in the case that there is no health center on campus. The survey will primarily go to those whose health center position is their primary job (e.g. the registered nurses and nurse practitioners) because those who are there most often will be able to give the best information regarding the health status on campus. Individuals who would be excluded from the survey would be those who do not work in the health center or student health services, or those whose position in the health center is not their full-time job. The total sample size for this project will be fairly small due to the fact that my preceptors and I felt that it would be best to include only those schools that are within PTBCs jurisdiction, or those that PTBC would have the capacity to help. A total of 32 member schools (SPCHNA) and 3 non-members schools were included in the study. We felt that using a somewhat smaller contingent of non-member schools would be appropriate because of the desire to understand if involvement in a professional health organization had any effect on TB prevention activities. The main source of participants will be the SPCHNA, which is comprised of 32 member schools. This is a voluntary, professional health organization for nurses who work in college/university health centers. The non-member schools will come from internet searches for schools that are within the Philadelphia metropolitan area. Both groups were chosen because they are within the jurisdiction of the PDPH. The inclusion of the non-member schools serves as a rough match for the member schools. Matching criteria includes location of school, size of school, types of programs offered, proportion of international students (only to be included if this

19 12 information is available). The president of the SPCHNA was contacted in reference to this survey, and her support with implementation will consist of, but is not limited to, sending the survey out through their listserv, as well as providing reminders for members to participate. Thus far, the president of the SPCHNA has been very receptive to the idea, and agrees with the fact that an electronic survey will be the best possible option to obtain the most responses. Inherent in this project are a number of important variables. Some of the most important study variables in the proposed study include: number of TB cases; presence of a TB prevention policy; and proportion of high-risk students. Considering that it is unlikely that there were any recent cases of TB at the colleges, cases that occurred over the previous five years will be considered valid. Of course, any cases beyond five years are important, but they will not be included due to the fact that we would like to keep the data contained in the survey as recent as possible. Since having a TB prevention policy is considered important to the health of students, we want to know whether or not institutions have a policy on file. The health officials would be the most reliable source of information in this regard because they are probably the most familiar with the policy and how it is implemented at the school. The presence of students at high risk for TB is considered especially critical to know because of the potential to increase the risk for TB. The greater the proportion of high-risk students compared to low risk that are present, increases the probability of TB cases surfacing on campus. As mentioned before, the main instrument that will be used in the proposed project will be an 11-question survey. During the initial development phase of the survey, there were 15 questions pertaining to TB on college campuses. Considering that we want to maximize response rate, while still investigating the core research variables, several revisions occurred to get the survey down to 11 questions. Most of the questions will be yes/no, while one question will

20 13 involve the respondent checking options that apply to his or her institution. Surveys and the analysis will be completed via survey monkey, and the results will be entered into an excel spreadsheet. Following the study period, all surveys that have been returned will constitute those that will be analyzed for the final project. Those returned after the date will also be included for analysis, pending they do not come back more than two weeks late. We have determined that a response rate of 60% will be sufficient for analysis. However, if the response rate is too low (e.g. < 20%), then the analysis report will be more focused around methodological issues and what conclusions could have been drawn if we had obtained a higher response rate. Study Limitations One possible problem with the proposed project is a low response rate, which will inhibit the ability to come to any reasonable conclusions with certainty. In the event that there is a low response rate, then the ensuing analysis will consist of discussing why there might have been a low response rate and what could have been done to increase it. Also, conclusions will then revolve around what must occur in future studies to prevent cases of TB from spreading on college campuses. Another problem is that the sample size is fairly small which places a restriction on the results in terms of their ability to be generalized. Conclusions at that point would be pure speculation. A major limitation regarding the respondents to the survey, following the completion of the study period, was the low number of non-spchna member schools (only 3 out of 10 were reached). Lacking a basis for comparison limits the conclusions that can be drawn due to differences resulting from membership in a professional health organization. One possible reason for the low response rate is, unlike the SPCHNA members, there was no one point-of-contact source. A low response rate also limits the ability to generalize the results from the survey, making the ensuing analysis purely observational,

21 14 In addition to the limitations contained within the design of the survey, the subjects that will be receiving the survey also raise some important concerns. One is that some of the health officials that will be answering the questions on the survey may not have been at the institution long enough to remember any cases of TB that have occurred. Also, for those smaller schools that are without an on-campus health center, the person that may be in charge of student health records may not be familiar with individual cases of a disease. Thus, in such an instance, those responses would not be as useful. While we would not discount those responses, we did try to minimize the potential for receiving them by including schools with student health centers. Since we wanted to maximize our response rate, one limitation that would have benefitted the study would have been the inclusion of an open-ended question regarding the needs of the respondents. Such a question would have enabled the respondents to tell us, in their own words, what exactly they need in relation to the prevention of TB on their campuses. However, we felt this would have had a negative impact on the amount of completed surveys, so we did not include such a question. Research Findings Discussing the responses to the survey will take the following form. For each question, the question itself will be presented, as well as the overall corresponding responses. The results of each question will also be presented in graphical form, so as to give visual representation to the answers given by all of the 35 participants. Tuberculosis on college campuses occurs very sparingly, so for the first question respondents were asked about past cases of the disease. Specifically, the question was, Have there been any recent cases (last 5 years) of active tuberculosis (TB) or latent tuberculosis infection (LTBI) in students on your campus? There were a total of 14 (40%) Yes responses,

22 15 18 (51.4%) No s, and there were 3 people (8.6%) who indicated being Not Sure about TB on their specific campus. This question was designed to give us a sense of the impact that TB makes on the modern college campus, with a realization that this may be a condition that the respondents may not be too familiar with. Table 1 displays all 35 responses in graphical form. Table 1 Responses to Question #1 Critical to responding to a health crisis on campus is the presence of a student health center or clinic. Not only does this allow campus health officials to answer student questions regarding personal health, but it also allows for the treatment of various conditions and prescribing of medication. In this regard, the respondents were asked, Does your institution have a student health center or clinic on campus? Of the 35 completed surveys, 33 (94.3%) indicated that their school had a clinic, while only 2 (5.7%) responded that no such health center existed. Colleges without a health center on campus may just be too small, in terms of student population, and it may have been deemed unnecessary to provide such services. Table 2 displays all of the received responses.

23 16 Table 2 Responses to Question #2 Aside from being able to respond to an outbreak of the disease, the ability of a college or university to be able to screen for those who may be at high risk for being infected and potentially transmitting the disease is also of importance. Screening is a cost-effective way to prevent TB infection before the students get to school. We then asked respondents, Does your institution have a Tuberculosis (TB) screening policy in place for students? A total of 88.6% (31) responded that such a policy does exist, 8.6% (3) expressed no such policy was in effect at their institution, and 2.9% (1) was unsure. A proper screening policy protects not only those that do not have TB, but those with the disease as it allows the school s student health department to advise the infected person on proper diagnosis and treatment. 14 The results from question 3 can be seen in table 3. Table 3 Responses to Question 3

24 17 As students who screen positive for tuberculosis are identified, having additional plans, in the form of a prevention policy, will be useful in addressing the issue. Prevention plans go further than a simple screening policy as they take those who are identified as being at high risk and offer further testing (e.g. a PPD or IGRA) and possible treatment. During this second phase, staff will inform the students about further steps to be taken and guide them through the process. With this in mind, we then asked, Do you feel that there is a need for a TB prevention policy at your institution? A total of 18 (51.4%) indicated Yes, 11 (31.4%) indicated No, and 6 (17.1%) indicated that they were Not Sure. Avoiding an outbreak of TB should be a priority for all schools. 11 Table 4 displays the results from question 4. Table 4 Responses to Question 4 It is difficult to understate the importance of preventing cases of TB from proliferating on college campuses, but it is of equal importance not to subject, and possibly stigmatize, a certain segment of the student body. This is mainly in reference to foreign-born students from highburden countries because TB is not as endemic in the U.S. as it is elsewhere. Considering the implications of a potentially discriminatory screening policy, we asked respondents, Is TB

25 18 screening a requirement for ALL students prior to attending classes? Results were evenly split, as there were 17 (48.6%) Yes responses and 17 (48.6%) No responses. Only 1 (2.9%) indicated that they were not sure. The ACHA recommends that all students be screened for TB, and only those with identifiable risk factors should be tested. 14 Stigma is pervasive and it underlies the importance of screening all students. Question 5 s results are shown in table 5. Table 5 Responses to Question 5 Given that TB is not as much of a burden today as it was at the turn of the twentieth century, there is not as much concern in the general U.S. population. With the decline of tuberculosis, attention has shifted elsewhere and the disease has become a problem of the past. However, it is still important to remain vigilant, so as not to let a small problem escalate. It is then important to ask the health officials at colleges and universities about their perception of the issue. Respondents were asked, Do you feel that TB could be a health problem on your campus? Overall, 9 (25.7%) said that it was, 15 (42.9%) said that it was not, and 11 (31.4%) said that they were not sure if TB was a problem or not. The results from question 6 are displayed in table 6.

26 19 Table 6 Reponses from Question 6 There are some academic programs at colleges that require students to be tested because of the greater chances of becoming infected with TB, which raises their risk of spreading it to others. While such students may not necessarily be at higher risk for having the disease, those that study/work in health care settings, whether incoming or continuing, should be tested annually. 14,20 Survey recipients were then asked, Does your institution have academic programs (e.g. nursing, elementary education that require students to be screened for TB? 77.1% (27) said there are such programs on their campuses and 22.9% (8) reported there were no programs of that type. These responses are shown in table 7. Table 7 Responses to Question 7

27 20 In order not to expend extra tuberculosis testing resources on students who are not at a higher risk, it is necessary to identify those who are prior to the beginning of classes. Understanding that all colleges and universities differ in some respect with regard to the academic programs they offer, or the demographics of the students that attend, we felt that it was important to know what area schools were like. Thus, respondents were asked, Is there a high proportion of students at risk for TB in your student population (i.e. Do they fit into any one or more of the following categories)? Results and specific answers are shown in table 8. The entire answer for the first category is Arrive in the United States in the last 5 years from areas of the world where TB is common (for example, Asia, Africa, Russia, Eastern Europe, or Latin America), and the third choice was Serve high-risk clients (e.g. the homeless, low income groups with poor access to healthcare. Table 8 Responses to Question 8

28 21 Properly responding to an outbreak of TB on campus requires more than just an institutional screening/prevention policy. It is vital for schools to establish a relationship with the local health department, as they can provide an expanded range of services to the students, those which are usually outside the scope of the campus health center. 11 Coordination of activities between the two entities will ensure a seamless provision of services and clear communication in the event that cases of the disease should ever surface on campus. Thus, respondents were asked, Does your institution have a plan to address TB (**in the event of an outbreak**) with the local TB program/ health department in your area? Of the 35 completed surveys, 14 (40%) indicated they do, 12 (34.3%) said they do not, and 9 (25.7%) were unsure if such a plan was in place. Results for question 9 are shown in table 9. Table 9 Responses to Question 9 While developing this survey, we elicited the assistance of the Southeastern Pennsylvania College Health Nurses Association, a professional health organization composed of health officials at colleges and universities in southeastern Pennsylvania. Previous studies had similarly

29 22 looked at TB screening and prevention between schools that belonged to a professional health organization and those that did not, and this survey aimed to do the same, but with a Philadelphia/ southeastern PA focus. Considering this, the survey asked, Are you a member of the Southeastern Pennsylvania College Health Nurses Association (SPCHNA)? Results were as follows: 91.4% (32) indicated being members, 5.7% (2) indicated that they were not, and 2.9% (1) reported that they were a part of another organization, the ACHA. Table 10 displays the results from this question. Table 10 Responses to Question 10 Finally, to ensure that those received the survey it was intended for (i.e. college health officials), we asked for the job title of the respondents. The following results are grouped according to the similarity of their job descriptions: University/ College/ Health Room/ Staff/ School Nurse/ Registered Nurse (RN): Provides direct nursing care, patient teaching, physical assessment works as Registered Nurse as per state law.* *(C. Rooney, personal communication, April 27, 2011).

30 23 Director of Student Health Services/ Director of Health & Wellness Initiatives/ Director of Health & Wellness Center/ Director of Health Services: Management responsibility of all Student Health, policy and procedures.* Nurse Practitioner/ Nurse Manager: An RN Licensed in PA as Certified Registered Nurse Practitioner (CRNP). Works under the supervision of a physician. Able to prescribe medications and treatments. Directs patient care.* College Liaison: Health support staff that is not generally involved with the provision of health services.* RN Assistant Director of Student Health and Wellness: RN who serves as assistant to the Director of Health and Wellness. Would have management/administrative duties for day to day operations.* Public Health Nurse: Registered Nurse whose main focus would be the clinical components of working with maintaining public health on a campus. Would probably be responsible for all immunizations and would be a resource in the event of an epidemic on campus. Would be more likely to be directly connected to City/State/County Public Health Departments. Assists in policy and procedure development and adherence in public health issues.* Physician: Licensed MD or DO in the state of PA. May be the medical director of a Health Center and determine all policies and procedures for a health center.* Health Services Coordinator: Registered Nurse who serves as supervisor/administer of clinical health services.* *(C. Rooney, personal communication, April 27, 2011).

31 24 Analysis & Discussion While it is important to consider the many limitations inherent with this study, what this data is able to do is give a general picture of how health professionals at colleges and universities in Southeastern Pennsylvania and the Philadelphia metropolitan area feel with regard to TB. The data seems to suggest that TB still remains a disease that colleges view with concern, as evidenced by the majority of schools with a screening policy (see Table 3), even though less than a majority of them have seen a case in the past 5 years (see Table 1). Much of the data contained in this study confirms previous study results, but must be interpreted within the context of the geographical area and study population as indicated in the Methods section. The schools that indicated they had a tuberculosis screening policy in place for the students at the college or university they worked at (88.6%) did not have an overwhelming burden from the disease. In fact, less than half (45.2%) had seen a case of TB in the past 5 years. However, due to the fact that there was such a small sample size, this does not confirm my main hypothesis of schools with a screening policy in place will experience less of a burden due to TB than those without an established policy. What can be drawn from this data is that a TB screening policy may be effective, to some degree, in preventing cases from breaking out on campus. Or it could simply be that those schools were just lucky, and there were not enough risk factors present. There are a few things that can also be said about these results that can greatly impact how a person could have answered the questions. For example, in the event that the student health official had not been working at their current school for at least 5 years, they would not have been able to accurately answer the question. Also, the ability to recall, quite possibly, what may only be, a single case over the past five years could be quite difficult, considering that the respondent has seen many student patients.

32 25 The percentage of schools whose health staff belongs to a professional health organization (e.g. SPCHNA or ACHA) that have seen a case of TB in the past 5 years was slightly more than a third (36.4%). However, this is not able to prove my secondary hypothesis that schools with health staff belonging to a professional health organization will not have experienced as great an impact of TB because there was not a large enough comparison group. One observation that can be made is the possibility that institutions that hire staff actively involved with organizations like the SPCHNA or ACHA feel that they must be more vigilant in protecting their student populations, thus helping to prevent the appearance of disease on campus. There is also the potential for it to be purely happenstance. Of the 2 respondents who indicated that they were not members of professional health organizations, both indicated that they had seen cases in the past 5 years. This data is highly problematic in that there were only 2 nonmembers, thus no conclusions or generalizations can be made. When asked about having seen cases of TB in the past 5 years, there were a number of interesting observations that surfaced. The 14 schools who answered Yes, 100% (14/14) of them indicated having a TB screening policy in place for their students, but compared to the 18 who had not seen a case in the past 5 years, only 83.3% (15/18) had a screening policy in place. This could point to perceptions about the threat posed by the disease, or that its occurrence in such small numbers may not warrant action that may incur extra costs. However, the high proportions of both groups with a screening policy may indicate that most schools, whether or not they have seen a case of TB, believe that prevention is cost-effective in their approach towards a healthier campus. Feelings towards the need for a prevention policy were equally matched between those who had seen a case of TB in the past 5 years versus those schools who had not. For both groups,

33 26 50% of the respondents indicated feeling the need for a prevention policy on their campus. Some of the reasons that could explain this include: a belief that the threat posed by TB to their campus is minimal; implementing a prevention policy will incur greater costs and involve extra training for the existing staff; or the cases that had occurred on campus in the past happened only by chance and were not due to the enduring presence of TB. Still the need for a prevention policy, such as the one created by the Heartland National Tuberculosis Center, is important for halting the spread of disease on campus. One of the more concerning phenomena was schools that had seen a case of TB in the past 5 years were less likely to have a plan in place to address an outbreak with their local health department/tb control program, when compared to those who have not seen any cases. The main reason why this is so concerning is that even the presence of disease does not compel them to take further action towards addressing further cases in the future. The HNTC s Model Tuberculosis Prevention Plan for College Campuses stresses the importance of establishing such a relationship because there are many services that health departments can provide that the schools themselves may not have the capacity for (e.g. chest x-rays, TB drugs, etc.). 11 When analyzing membership in organizations like the ACHA or SPCHNA, there are many other observations that can be made. For member institutions it was highly likely (87.8%) for them to have a TB screening policy established for their students. This is similar to earlier study findings where 82% of ACHA member schools required screening, while only 53% of ACHA nonmembers had a screening policy in place. 20 This could indicate that member institutions believe in the protective qualities of screening tests and that they are a simple way to prevent outbreaks of infectious TB on campuses. An outbreak could start by an actively infectious person passing it on, or through a case of LTBI becoming infectious due to a

34 27 suppressed immune system. Also, by having a student screening policy, it limits the potential for expending limited testing resources on certain student populations that are not at usually high risk for TB. Despite such a high proportion of survey respondents being a part of a professional health organization and having a screening policy in place, a much smaller percentage felt that a TB prevention policy was necessary. Only 51.5% reported that they felt that their college or university needed a TB prevention policy, which is concerning because what will the student health center do if a student, or students, present with either active TB or LTBI? While a screening policy is a good way to minimize the potential for an outbreak, it does not usually provide the protocol for moving towards further testing and treatment options. This could be a reflection of institutions trying to determine the best use for the resources they have available to them, as opposed to addressing an issue that is not a serious problem on their campus. Examining member institutions by how many of them require screening for all students, only 48.5% had such a standard. While this does seem a bit disconcerting, it could just be due to an institution trying to maximize their resources and stretch an already tight college budget. This could also be due to a logistics issue, where the school is trying to determine how to best reach the most vulnerable segments of the student population. In that case, when examining professional health organization members, 75.8% of them required screening for students who are enrolled in certain academic tracts. This goes to show that some schools feel that it may not be the best use of available resources, and potentially costly in terms of money and labor, to screen all students for the disease. Another point of concern was that only 39.4% of school health staff belonging to a professional health organization indicated that their school has a plan in place to address an

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