Public health obligation to prevent TB transmission

Economic incentives aren’t typically the first line of defense during an outbreak, but in the case of the current tuberculosis outbreak in Alabama they make sense

Identifying patients with tuberculosis and then ensuring those patients complete treatment is a longstanding public health problem. An Alabama county health department's decision to pay patients to be screened and treated reignited national interest in TB patient screening. We asked public health experts Ray Barishansky and Catherine Counts to debate, from an EMS perspective, this controversial decision. Make sure to read Ray Barishansky's view and share your thoughts in the comments.

By Catherine R. Counts

The recent tuberculosis outbreak in Marion, Alabama, has resulted in a controversial public health program paying people to get tested for TB. Although more than 1,000 people have been tested through this program, that only represents 10 percent of the county’s population. While economic incentives are not recommended as the first step in prevention, this is an active outbreak that has taken at least three lives. Additionally, 20 individuals have tested positive for active TB, while 47 have tested positive for latent TB. The need to identify as many infected individuals as possible outweighs any negative consequences of this controversial program.

World Health Organization guidelines
Since the debate continues in the United States over whether or not health is a human right versus a privilege, it is not surprising that there is such a divided opinion on this topic. However, as someone who views health as a basic human right I agree with the World Health Organization’s ethical guidelines for TB prevention, care and control some of which include:

  • Governments have the obligation to provide free and universal access to diagnostic testing and then treatment.
  • The use of incentives, financial or otherwise, are appropriate in order to ensure adherence to treatment.
  • Involuntary isolation should only be used as a last line of defense for preventing the spread of TB.

Although these recommendations do not touch directly on the topic of paying community members to be tested, the use of this tactic is necessitated by the historical distrust of the medical ivory tower in an impoverished, predominantly African-American community.

An ounce of prevention is worth a pound of cure
There is no reason for society to allow the equivalent of a modern day Typhoid Mary to exist when we have the resources necessary to test, treat, and therefore prevent additional infections. This means testing everyone in the area that could potentially be infected.

Although those with the latent version of TB are not infectious, 5-10 percent will eventually develop active TB without treatment, at which point they can spread the disease to those previously uninfected. Identifying those with a latent infection allows infectious disease experts to then better identify previously unknown disease carriers.

Treating latent TB isn’t inexpensive, but the cost is substantially less than the cost to treat active TB infections. This is particularly true among cases of drug-resistant TB, which often develop in patients that either did not complete their original course of treatment or initially received an inappropriate level of treatment.

Importance to EMS personnel
Health care providers are at an increased risk of contracting TB. The physical confines of providing care in the back of an ambulance make this particularly true for EMS personnel. Providers should be tested regularly to ensure that they are not infected. If they test positive, it becomes paramount that they receive the appropriate treatment immediately so as to protect themselves, their families, their coworkers and their patients. If diagnosed with active TB they should be removed from service until medically cleared.

In the case of the current outbreak, testing the community is acting as a protective measure for EMS and other health care providers. This allows individuals to know their status, so if they enter the health care system they are able to notify providers immediately thus ensuring appropriate personal protective equipment can be utilized during the provision of care.

Learn more about infectious disease history, prevention, assessment and spread from these websites:

About the author
Catherine R. Counts is a doctoral candidate in the department of Global Health Management and Policy at Tulane University School of Public Health and Tropical Medicine where she also previously earned her Master of Health Administration. Counts has research interests in domestic health care policy, quality and patient safety, organizational culture and prehospital emergency medicine. She is a member of AcademyHealth, Academy of Management, the National Association of EMS Physicians, and National Association of EMTs.

Counts is the author of a blog focused on applying the concepts of health services research to the field of prehospital emergency medicine. Connect with her on Twitter or contact her via email at

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