176 COMMUNITY HEALTH
An initial report of a case of tuberculosis, for example,
will require that all persons who have contacted the patient
be skin tested (tuberculin test) several times for evidence of
existing tuberculosis; those persons who test positive must
be further examined to determine if active or progressive
disease is present. Prophylactic treatment with isoniazid
can be safely offered to persons with positive skin tests if
they are under the age of 35 or 40 years, but full therapeutic
courses of antibiotic drugs are recommended for those with
clearly evident pulmonary or extra-pulmonary infection. Some
strains of tuberculosis germs (mycobacteria) have arisen that
are resistant to several of the four customary therapeutic
drugs. The specific type of mycobacterium responsible for a
patient’s disease must be determined so that the initial drug
regime will be effective from the beginning, not after months
of partially effective therapy have elapsed and the infection
has not been controlled. To prevent the spread of drug resis-
tant mycobacteria, initial courses of multiple antituberculo-
sis drugs are individually administered by nurses who see to
it at each scheduled dosing that an infected patient ingests
the total amount of drugs that have been prescribed. This
mode of anti-tuberculosis therapy is “Directly Observed
Treatment” (DOT) and, while costly in staff time, it has
resulted in effective control of a dangerous disease. In many
political jurisdictions, when a patient with tuberculosis is
judged to be a public danger because of failure to cooperate
in treatment and control of the spread of infection, public
health officers can request courts to incarcerate that patient
so that treatment can be carried out under close supervision
to protect the public.
Reported tuberculosis has increased as a complication
of the human immunodeficiency virus (HIV), the causative
agent of the AIDS epidemic. Because of this, the Centers for
Disease Control (CDC) in Atlanta have advised state and local
health departments to tuberculin skin test all persons with HIV
infection.^10 Conversely, persons with tuberculosis are urged to
be tested for HIV, and the registries of patients with these two
diseases should be matched at least annually.^11
When many cases of enteric diseases are reported, either
localized as endemics or widespread as epidemics, health
departments mount intensive searches to determine the
nature and source of infections. Control measures to prevent
further spread can include mass vaccination, provision of
safe food supplies and potable water, official quarantine or
isolation of sick persons and their excreta, evacuation of crit-
ically ill persons for definitive therapy, and vigorous public
information programs to help uninfected persons at risk take
appropriate steps to avoid the disease.^12
Infectious disease outbreaks can result in heavy loads
of sick or injured persons that may overwhelm community
resources and require help from allied governmental or vol-
untary health providers for the short term as in disasters or
damage to water supplies, or over the long term to remedy
the ill effects of continued poverty or devastation.
Rats and mice, the animals chiefly regarded as signs
of environmental deterioration, easily find homes and food
in the debris customarily associated with poverty housing.
Rat urine spreads leptospirosis, an infection that results injaundice and occasionally renal impairment or aseptic men-
ingitis, but small children who must live in rat infested neigh-
borhoods are also at risk of rat bites. Major control projects
strive to teach communities to deny rats an access to food in
accumulated garbage, and eliminate easy harborage in piles
of casually discarded trash or poorly maintained, dilapidated
residential structures. Rats have proved to be courageous
adversaries and survive despite major attempts to eliminate
them with poisons, traps, gases, high frequency sound, and
education of human residents. Yet, the dangers from rat bites
are intolerable and health departments continue to war on rat
populations.ENVIRONMENTAL HAZARDSHuge plumes of dark smoke billowing from industrial stacks
was once a sign of a community’s prosperity, but no longer.
Oil and electricity heat have replaced coal as fuels for resi-
dences, industry, locomotives, and ships. Municipalities
have banned or severely curbed the operations of home and
apartment incinerators, and those that remain must have
stack scrubbers and other equipment to drastically reduce
emissions of particulates into the atmosphere. Half a cen-
tury ago, the dark, gray lungs of city dwellers that resulted
from inhalation of coal dusts and other particulates were
easily distinguished at autopsies from the pinkish gray ones
of rural citizens. Funded by federal grants, states are now
well equipped to measure gaseous atmospheric pollutants
and gather the data needed to support limiting toxic gas-
eous emissions by motor vehicles and major industries, and
human pulmonary health has markedly improved.
Control of hazardous materials (HAZMATs) may be
divided between health and other agencies yet emphasize
safe storage and transport to protect neighborhoods and
safe usages for workers. Local fire departments and state
fire marshals or departments of environment are charged
with the responsibility for containing spills and subsequent
decontamination. Fire officials, for example, at all times
carry handbooks and catalogs of toxic substances in their
vehicles, and have been trained in the appropriate responses
to hazardous spills. Frequent reconnaissance inspections of
known locations where hazardous materials are stored helps
to insure safe management of toxic materials. Departments
of public works, health, and police may also be called upon
to assist in management of spills.
Official health agencies now participate as consultants
for community health in air pollution management, or advi-
sors on the health aspects of building construction when
toxic substances are used incorrectly. When lines of author-
ity are not clear, duplication of municipal or county services
and conflicting regulations may result in failure to respond
promptly to early warning signs of environmental hazards.
Health officials may be called after a chemical spill has been
abated to counsel communities about possible delayed haz-
ardous effects on humans.
Health sanitarians and technical inspectors of other
agencies investigate complaints made by workers, nearbyC003_002_r03.indd 176C003_002_r03.indd 176 11/18/2005 10:17:41 AM11/18/2005 10:17:41 AM