This site is intended for health professionals only

Tuberculosis care in the community

There is a widely held belief, particularly amongst people in higher income countries, that tuberculosis (TB) has been eradicated.1 In reality, eradication is as far away as ever from being achieved in the foreseeable future.2 Primarily transmitted via the airborne route through the inhalation of infected droplets, the tubercle bacillus remains the biggest killer in the world as a single pathogen.3 Despite TB being a largely curable illness and the combined efforts of global initiatives to reduce the incidence of TB, the World Health Organization estimates that there were 8.8 million cases of TB, causing nearly 1.2 million deaths, in 2010.4


In the UK, whilst TB mortality is very low, TB morbidity has been consistently rising, save for a small reduction in the number of TB cases reported nationally in 2010.5 Published figures from the Health Protection Agency (HPA) show that there were 8,483 TB cases notified in the UK in 2010, giving a national rate of 13.6 cases per 100,000.5 There is preliminary evidence that the number of TB cases has increased by 5% in the UK in 2011.6 Although the majority of cases (39% in 2010) occur in London, most urban centres are seeing higher rates of TB, principally (although not exclusively) among those born abroad. TB presents a challenge to health professionals because around one in ten people affected by TB in 2010 were reported to have at least one social risk factor of homelessness, drug or alcohol misuse or imprisonment.5 TB undeniably disproportionately affects people from poorer socio-economic backgrounds, many of whom are from the most marginalised communities.7

Screening for tuberculosis in the community
The World Health Organisation estimates that an untreated TB-contagious individual may infect between 10 and 15 other people every year.8 Transmission usually requires prolonged contact (eight hours or more) with a person with infectious TB in a confined, especially poorly-ventilated, space.9,10 Children and those with immune-compromising conditions are at higher risk of being affected.9


Contact tracing involves identifying the closest contacts of those with active TB and then to offer appropriate screening. Contact tracing is undertaken to identify both active cases of TB and those infected with latent TB infection, who maybe at higher risk of developing illness later in life.9 TB contact tracing and screening is commonly undertaken by local specialist nurses based upon national recommendations contained in the recently partially updated NICE clinical TB guideline covering all aspects of TB diagnosis, treatment, prevention and control in England/Wales.9 The Health Protection Network (2009) has published similar guidance for Scotland.12


Although most contact tracing and screening focuses on an individual's household, it is not uncommon to have to carry out these procedures in other community settings, including offices, factories, hospitals, nursing homes, places of worship, schools, colleges, universities, hostels and prisons. Managing an isolated case in such settings (referred to as a 'TB incident') or a scenario involving two or more epidemiologically-linked cases of recently transmitted TB in the same place (a 'TB outbreak')13 involves a number of important elements (see Box 1).


TB specialist nurses, working with other members of the multi-disciplinary team, are pivotal in devising and delivering incident and outbreak contact tracing and screening. Bothamley et al14 suggest that insufficient TB nurses are a primary cause for local failure to implement the clinical aims of national TB control programmes.


As the incidence of TB declines in the general population, those affected are increasingly from higher risk groups (also referred to as 'hard-to-reach' groups) such as recent migrants, substance misusers, the homeless and prisoners - although there is likely to be overlap among people from these groups.15 The recently published guideline by the National Institute for Health and Clinical Excellence, Identifying and Managing Tuberculosis Among Hard To Reach Groups,16 reinforces and strengthens previous recommendations that those in higher-risk hard-to-reach groups should be targeted for local active and latent TB screening programmes.


An example of project is the London 'Find and Treat' programme that utilises a mobile digital radiographic unit in active TB case-finding. A recent evaluation suggests the project to be both cost and clinically effective.11 Unfortunately, there are significant variations in the local implementation of national recommendations across the country.15

Hard-to-reach groups
The most challenging aspect of tuberculosis care is working with those from hard-to-reach groups, so-called because their social circumstances, language, culture or lifestyle make it difficult for them to access diagnostic, care and treatment services.16


One of the key aims of care is to ensure that individuals affected by TB are able to fully complete their minimum six month course of TB therapy and to prevent them being lost to follow-up.9,16 A tool to assist in addressing this problem is directly observed therapy (DOT) whereby an individual takes medication in the presence of a third party who has agreed to undertake this responsibility. Commonly given as three times weekly intermittent therapy in higher doses, this means that whilst concordance maybe improved, the risk of side-effects increases.9


There are many practical psycho-social issues that those from hard-to-reach groups are likely to need assistance to enable them to concord with their TB treatment plans (see Box 2). Although the care of patients from hard-to-reach groups is expected to be managed by TB nurse specialists with enhanced case management skills,16 other health and social care professionals have a responsibility to contribute to ensuring that individual needs are addressed. Advocacy and negotiating skills are particularly pertinent to this potentially rewarding area of work.
 
Care of tuberculosis patients in the home and clinic environment
Following diagnosis, TB is, for the most part, managed in the community. In most areas, patients attend an out-patient clinic for regular review throughout their treatment, with care being case-managed at home by TB specialist nurses.
Moreover, patients only need to be in hospital if there is a definite clinical or socio-economic need, such as homelessness.9 In the absence of such needs, in-patients may be discharged home after they have commenced a standard course of TB treatment. Patients with sputum smear positive (open) TB, are normally regarded as being infectious for the first two weeks after starting their TB medications.9

Infection control measures in the home setting are aimed at reducing the likelihood of transmission to those same household and to visitors.9,17 Box 3 shows the recommended advice that should be given to patients.


Standard treatment for TB in the UK consists of a six-month regimen involving four drugs for two months: rifampicin, isoniazid, pyrazinamide and ethambutol with the first two continued for a further four months.9 Healthcare professionals involved in the care of patients affected by TB need to be aware of the potential side-effects of TB medicines, particularly signs of hepatoxicity such as jaundice, nausea and vomiting, and to report them to an appropriate person without delay.

Despite being curable, TB is still associated with stigma and fear for many, making support and empathy an integral part of the patient's psychological care.18

Conclusion
In summary, nurses are at the heart of the delivery of TB care for patients affected by TB. Nurses frequently signpost and advocate for patients to help them to access and navigate complex health and social care systems, are involved in educating patients, carers and the general public and in supporting individuals to overcome the often stigmatising effects of illness.19


As Pratt and van Wijgerden19 succinctly put it, “without competent nursing management, the care and treatment of people with TB will be substantially impoverished and their chances of recovery diminished.” Current developments in diagnostics, non-medical prescribing and cohort review are opening up new opportunities for innovative nursing practice that reflects the multi-dimensional nature of TB.

References
1.    Lawlor, M. Lurking threat. World of Irish Nursing and Midwifery 2007;15(7):22-3.
2.    Jassal, MS, Bishai, WR. Epidemiology and Challenges to the Elimination of Global Tuberculosis. Clin Infect Dis 2010;50(3):S156-S164.
3.    Raja A. Immunology of tuberculosis. Indian J Med Res 2004;120(4):213-32.
4.    World Health Organisation. Global Tuberculosis Control 2011. Geneva: World Health Organisation; 2011.
5.    Health Protection Agency. Tuberculosis in the UK: 2011 report. London: Health Protection Agency; 2011.
6.    Health Protection Agency. More than 9,000 TB cases reported in 2011. London:  Health Protection Agency; 2012
7.    Siddiqi K, Barnes H, Williams R. Tuberculosis and poverty in the ethnic minority population of West Yorkshire: an ecological study. Commun Dis Public Health 2001;4(4):242-6.
8.    World Health Organization. Tuberculosis Factsheet No. 104. Geneva: WHO; 2010. Available at: http://tinyurl.com/3ge23gl.
9.    National Institute for Health and Clinical Excellence. Clinical Diagnosis and Management of Tuberculosis and Measures for its Prevention and Control. Clinical Guideline 117. London: National Institute for Health and Clinical Excellence: 2011.
10.    Farmer T. Tuberculosis Contact Investigations: A Review of the Literature. Toronto: Toronto Public Health; 2006. Available at: www.toronto.ca/health/tb_prevention/pdf/literature_june2006.pdf.
11.    Jit,M, Stagg, H, Aldridge, R, White, P, et al. Dedicated outreach service for hard to reach patients with tuberculosis in London: observational study and economic evaluation. Brit Med J 2011;343:d5376.
12.    Health Protection Network. Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control in Scotland. Health Protection Network Scottish Guidance 5. Glasgow: Health Protection Scotland; 2009.
13.    Health Protection Agency. Guidance for Health Protection Units on responding to TB incidents and outbreaks in prisons. London: Health Protection Agency; 2010.
14.    Bothamley GH, Kruijshaar ME, Kunst H, et al. Tuberculosis in UK cities: workload and effectiveness of tuberculosis control programmes. BMC Public Health 2011;11:896.
15.    Abubakar I, Stagg HR, Cohen T, Mangtani P, et al. Controversies and unresolved issues in tuberculosis prevention and control: a low-burden-country perspective. J Infec Dis 2012: Epub ahead of print.
16.    National Institute for Health and Clinical Excellence. Identifying and managing tuberculosis among hard-to-reach groups. Manchester; National Institute for Health and Clinical Excellence: 2012.
17.    World Health Organization. WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households. Geneva; WHO: 2009.
18.    Courtwright A, Turner AN. Tuberculosis and Stigmatization: Pathways and Interventions. Public Health Rep 2010;125(Suppl 4):34-42.
19.    Pratt RJ, van Wijgerden J. Nursing care of patients with tuberculosis In: Schaaf HS, Zumla A. eds. Tuberculosis: A Comprehensive Clinical Reference. London: Elsevier; 2009.
20.    Royal College of Nursing. Tuberculosis case management and cohort review. London; Royal College of Nursing: 2012.
21.    London Assembly Health Committee. Tuberculosis in London. London: London Assembly; 2003. Available at: http://legacy.london.gov.uk/assembly/reports/health/tb.pdf
22.    World Health Organization. Tuberculosis and Air Travel: Guidelines for Prevention and Control. Geneva: WHO; 2008.