Healthy You Healthy Hennepin

Delgermaa with her daughter

TB Takes Tough Treatment

October 2016

February 2016 -- Delgermaa Lkhasuren, a 29-year-old University of Minnesota grad student and Fulbright scholar from Darkhan, Mongolia, was eight months pregnant when she developed a cough.

It wouldn’t go away.

At a midwife’s urging, Lkhasuren visited the university’s Delaware Street Clinic. The staff diagnosed her with tuberculosis (TB) disease.

TB is the world's leading infectious disease killer, with more deaths per year than HIV or malaria. Although it's curable and preventable, TB kills three people per minute -- almost 2 million per year, including 500+ Americans.

After her diagnosis, Lkhasuren was referred to Hennepin County Public Health’s TB Program and assigned to Bryan Rock, M.D., an infectious disease specialist. Rock immediately placed Lkhasuren on anti-tuberculosis medications.

In the TB program, Lkhasuren also received medical case management from a TB nurse. Phosy Boualouang, a senior community health worker, visited Lkhasuren’s apartment each day to watch her take her meds and to look for treatment side effects and barriers. Boualouang reported her observations back to the nurse case manager.

This approach is called directly observed therapy, and it’s the gold standard for TB treatment.

TB is the world's leading infectious disease killer, with more deaths per year than HIV or malaria. Although it's curable and preventable, TB kills three people per minute -- almost 2 million per year, including more than 500 in America.


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TB is caused by Mycobacterium tuberculosis bacteria. A person with TB in their lungs can send aerosolized bacteria into the air when they cough, sneeze, spit, sing, or yell. In the short span that the bacteria are airborne, another person can inhale that air and the bacteria can enter their lungs.

Initially, a person who inhales TB bacteria doesn’t have symptoms. In some cases, their immune system can fight off the germs and they don’t develop an infection. In other cases, an infection occurs but produces no symptoms; this is referred to as latent TB infection (LTBI).

About one-third of the world's population has LTBI. Without preventive treatment, about five to 10 percent of them – like Lkhasuren -- will develop a more dangerous type of TB: TB disease.

People at high risk of developing TB disease are those with weak immune systems -- especially people with HIV, diabetes, cancer, and organ/tissue transplants. Due to their immature immune systems, children younger than five are also more susceptible. People at high-risk of exposure to TB include foreign-born people from endemic countries (i.e., countries where the infection regularly occurs) and people who live in homeless shelters and corrections facilities.

A person with TB disease may experience a cough, chest pain, weakness, weight loss, fever, and night sweats. If the disease is in the lung they’re considered contagious.

Delgermaa with Phosy
Delgermaa's anti-TB medications
Delgermaa with her outreach worker Phosy



March 12, 2016 -- Five days after her diagnosis, Lkhasuren gave birth to her daughter in isolation, wearing a surgical mask. Less than a week later, additional lab tests revealed that she had drug resistant TB. As a result, Rock placed Lkhasuren on a heavier regimen of anti-tuberculosis medications.

In March, epidemiologists from Hennepin County Public Health’s TB Program also TB tested Lkhasuren’s classmates at the Humphrey School of Public Affairs – as well as other people with whom she’d had significant contact. No one tested positive.

Through it all, Lkhasuren continued directly observed therapy.

During each visit, Boualouang gave Lkhasuren tips (e.g., “Take your meds with food”) and made sure she took every pill. She also helped Lkhasuren remember her doctor’s appointments and took stock of Lkhasuren’s medication side effects -- skin discoloration, anemia, and stiff muscles. Boualouang reported all concerns to the TB nurse case manager.

The support was pivotal.

“What is shown, is that TB drugs are hard drugs to take,” says Dean Tsukayama, M.D., Hennepin County Public Health Clinic’s medical director. “There are lots of pills and lots of side effects, and it’s very easy not to be strictly compliant. But the problem with this disease it that is has public health implications; if it’s not cured it can be passed on to other people, and if the treatment is not right the TB can develop drug resistance. That’s why directly observed therapy is important.”

Staff at the Hennepin County TB clinic



May 2016 -- At the end of the academic year, Lkhasuren and her family planned to return to Mongolia. Instead, they received a letter from the Centers for Disease Control-Minneapolis Quarantine Station (CDC) saying that Lkhasuren, like others with TB disease, was banned from air travel.

So Lkhasuren remained in Minnesota, receiving directly observed therapy from Boualouang. Several times a month, she also visited the Hennepin County Public Health Clinic, where TB Program providers monitored her heart and liver function and her iron and potassium levels – all things that can be affected by TB medications.

You need to be creative to solve the problems that are there with TB. It’s more than just drugs ... It’s goodwill, cooperation, and doing the best you can.
Dean Tsukayama, M.D., Hennepin County Public Health Clinic’s medical director



August 2016 -- By the end of the summer, Lkhasuren was having mixed emotions.

She cried when she described her skin discoloration, anemia, stiff muscles, and other medication side effects. She also expressed worries about her future health, and wondered if she’d ever be free from TB. It can take up to six months and possibly as long as one year to kill non-drug resistant TB germs. Drug resistant TB disease, like Lkhasuren’s, is more complicated but, according to Tsukayama, a person receiving drug resistant TB treatment in the United States should expect at least a 75 percent cure rate.

Despite the uncertainties and related negative emotions, Lkhasuren was grateful for her medical care and also excited; after three clear sputum samples, she’d recently received another letter from the CDC saying that she’d been cleared for air travel.

At the end of the month, Lkhasuren and her family packed up their belongings and flew home. Before her departure, Rock gave Lkhasuren instructions on how to continue TB treatment in Mongolia.

Looking ahead: During her Fulbright Scholarship, Lkhasuren completed a master’s in public policy at the University of Minnesota’s Humphrey School of Public Affairs. Her focus was community economic development. Lkhasuren is passionate about children and hopes to help Mongolian youth.

To learn more about TB, visit:


Written by: Lori Imsdahl

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