The aim of this assignment is to identify and discuss the public health roles of specialist nurses and other frontline healthcare workers in the management and prevention of tuberculosis (TB). TB is an infectious disease caused by a bacterium that usually affects the lungs, although it can affect other parts of the body (Davies, 2003). Transmission occurs when an infectious person expels bacteria into the air by means of coughing (WHO, 2012). Although anyone can develop TB, the burden of the disease is highest in vulnerable populations that are characterised by behaviours or social characteristics such as homelessness, substance misuse, imprisonment, and immigration (RCN, 2012).
Historically, several industrialised countries witnessed a decline in the incidence of TB around the middle of the nineteenth century (Pratt et al. 2005). But in recent decades, this decline has reversed (WHO, 2012). The present trend has alerted the UK government to the seriousness of this new threat. In 2004, the Chief Medical Officer's TB Action Plan, Stopping Tuberculosis in England (DH, 2004) set out clear steps to reduce the risk of new infections of TB by means of organised public health efforts (DH, 2004). Hollo et al. (2008) attribute the resurgence of TB to migratory movements of people from high incidence countries. Yet hardly any phenomena have a single cause. Abubakar et al. (2011) argue that multiple factors have allowed TB to return as a serious public health challenge in the UK.
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Acheson, (1988) defined modern public health as 'the science and art of preventing disease, prolonging life and promoting health through organised efforts of society'. Lawrence & May (2003) assert that modern public health practice comprises two types of activity: public health as a resource; this covers surveillance and epidemiology and public health action; this covers interventions to promote health and prevent disease. Cowley (1999, p.126) states:
'Activities are justified as public health interventions if their main purpose is to contribute to the health of the whole population they serve, even though they meet the immediate health needs of individuals and families along the way'.
TB specialist nurses who view TB control from a public health perspective can make an important contribution to reducing the pool of infection in the community, and thereby preventing further transmission (Lawrence & May, 2003).
TB Nurses work within a specialist multi-disciplinary team, collectively known as a TB service (Pratt et al. 2005). The Royal College of Nursing (RCN, 2007) published a useful document titled Nurses as Partners in Delivering Public Health. In this document, the key aims of delivering public health through nursing services are summarised. These aims include: encouraging healthy behaviours so as to increase life expectancy; targeting vulnerable populations so as to minimise health inequalities; and increasing the awareness of positive healthy behaviours in communities. These aims are achievable through a variety of public health interventions that are integrated into TB nursing practice.
It is important to briefly discuss policy context seeing as policies developed at national, regional, and local levels exert a powerful influence on practitioners' priorities and ways of working (Naidoo & Wills, 2005). Although it may seem remote from nurses' daily concerns, policy context plays an important role. For example, a tuberculosis specialist nurse will be aware of treatment completion targets that need to be met (HPA, 2012). There are specific TB policies and general public health policies that guide the public health work of TB nurses.
The following list outlines the public health interventions undertaken by TB nurses in the UK. This assignment will elaborate on each public health measure and provide a discussion of the benefits each measure brings to the public's health and the limitations to its application, where applicable.
i) To collect accurate TB surveillance data so as to monitor the changing epidemiology of new TB infections.
ii) To promptly diagnose and treat all active cases of clinically diagnosed TB in a specific geographical region (passive case finding).
iii) To screen high-risk groups and individuals for TB (active case finding).
iv) To administer the BCG vaccination to those who meet the criteria.
v) Implement TB awareness raising activities.
i) Since 1912, it has been a legal requirement in the UK for the clinician to report all cases of clinically diagnosed TB through a notification system (NOIDS; McCormick, 1993). In an endeavour to improve the ability to monitor the epidemiology of TB, the Health Protection Agency (HPA) implemented a surveillance database known nationally as Enhanced TB Surveillance (ETS). In 2008, ETS moved to a system whereby Nurses upload notification data directly onto an online national database. This relatively new concept has been welcomed by TB Nurses who view the system as a positive innovation that strengthens their autonomy and responsibility as public health practitioners (RCN TB Nurses Forum 2008/2009). The public health implications of using high-quality surveillance technology are far-reaching. At a local level, ETS can alert nurses to local trends, for example, a high incidence of drug resistant TB in a localised area. Although the level of completion for ETS meets national targets for most variables, a recent report published that information regarding 'sputum smear status' (i.e. infectiousness) was available for little over half of all cases notified in 2010 (HPA, 2011).
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ii) The principal approach to detecting cases of TB in the UK is by means of passive case finding (NICE, 2011). This cost effective approach relies on patients presenting themselves to primary care settings with symptoms of TB. A public health benefit of this approach is that cases of TB are diagnosed early and patients start their treatment promptly; rendering those with infectious TB non-infectious. In spite of this benefit, there are constraints that challenge nurses' ability to promote early diagnosis and/or cure cases of TB. One such constraint is poor adherence to anti-TB medication (Coker, 1999 & Haynes et al. 2008). Standard TB treatment comprises a combination of antibiotics which should be taken continuously for a minimum of six months. The development of drug resistance can manifest if there are interruptions in patients' treatment (Bell, 2007). Undoubtedly, poor or non-adherence can increase the risk of onward transmission (WHO, 2012).
Increasingly, TB specialists have adopted the principles of medication concordance (Horne, 2006). This involves a consultation between the practitioner and patient that is based on shared decision making (Cushing & Metcalfe, 2007). This approach allows the patient to make an informed decision about their preferred course of treatment (Bell, 2007). Strategies such as DOT (directly observed treatment) which involves patients being observed ingesting every dose of their anti-TB medication, can be adopted. However, this approach is resource intensive and can be difficult to implement particularly in TB services that have inadequate staffing levels (RCN, 2012).
For some communities, TB is a frightening and stigmatising disease (Pratt et al. 2005). This perception can lead people to deny that they have TB symptoms because they are afraid of being excluded from their community if they seek treatment (Dean, 2012). An article published by the Nursing Standard outlines the public health activities of a HIV liaison nurse and a case worker in an ethnically diverse area of east London (Dean, 2012). Nurse Millett and case worker Dr Collinson hold clinics in community buildings and in soup kitchens and offer HIV and TB screening. Their primary aim is to normalise HIV and TB screening, thereby minimising the stigma around TB and HIV.
iii) Hard-to-reach individuals account for a significant proportion of non-adherent and highly infectious cases (Story et al. 2007 cited in Jit et al 2011). In response to this evidence, NICE (2012) produced guidelines for Identifying and managing tuberculosis among hard-to-reach groups. Individuals are 'hard-to-reach' if their social characteristics, language or culture delay diagnosis and/or treatment. This guidance advises specialist TB services to produce a local health needs assessment on an annual basis so as to ensure that their service reflects the needs of the area in which it serves (a 'bottom up' approach (Cowley, 1999)). In areas of identified need, a programme of active case finding should be adopted using mobile digital radiography in areas where people characterised by homelessness and/or substance misuse are found (NICE 2012). This recommendation has been successfully trialled in London by the Find and Treat service which detects active cases of TB among socially excluded individuals, and provides support for treatment completion to those identified by the service. A collaboration of nurses, social workers and outreach workers are employed by this innovative service. Jit and colleagues (2010) conclude that the Find and Treat service is a cost effective intervention. However, this research should be interpreted with a degree of caution because the researchers report some limitations to the analyses. For example, the analyses did not fully capture the extent to which the screening unit averts secondary cases of TB (Jit et al. 2010).
Contact tracing is a cornerstone in the prevention of secondary cases of TB (Pratt et al. 2005). The TB Nurse detects individuals who have latent asymptomatic infection, thereby reducing the development of active, infectious disease. Using clinical judgement, the TB nurse makes a decision about which contacts (i.e. household, workplace) require TB screening - this will be dependent on the infectiousness of the index case, and intensity of exposure. Contacts with an increased risk of infection such as pre-school children are given priority for screening.
iv) The BCG vaccination is a cost effective primary preventative measure against childhood TB that offers infants an overall protective value of 75% (Trunz et al. 2006). In 2005, the universal schools' BCG programme was discontinued to correspond with the changing epidemiology of TB in the UK (Fine, 2005). Current Department of Health guidelines (2005) state that BCG should be given to infants who live in areas in which there is an incidence rate of 40 cases per 100,000 or greater and/or have parents or grandparents who were born in a high incidence country. Implementation of the programme by midwives, health visitors, and nurses has been variable, and the contentious issue of denying the vaccination to infants who do not meet the criteria remains (Abubakar et al. 2011). Indeed, confusion has been found amongst practitioners in the areas of Birmingham and Solihull regarding infants' eligibility for the vaccination (Etuwewe et al. 2004). Current guidelines may not be clear in cases of interracial parenting (Etuwewe et al. 2004). Furthermore, there is evidence indicating that BCG offers minimal protection beyond 10 years post immunisation (Sterne et al. 1998).
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v) TB Nurses contribute to the development of greater public awareness by embracing the health promotion principles advocated by the World Health Organisation (WHO, 1986) - community action, strong intersectoral collaboration, and equity. The importance of fostering strong intersectoral collaboration cannot be overemphasised. Organisations that provide services to high-risk groups work in partnership with some local specialist TB teams to provide training to both staff and clients in TB symptom recognition (NICE, 2012). As discussed previously, new infections of TB primarily occur in socially and economically disadvantaged groups and in migrants from countries with a high incidence of TB. Moszynski (2010) upholds that health inequalities lie at the heart of the UK's rising number of TB cases. From a practitioner's perspective, activities to tackle inequalities can be routinely integrated into clinical practice. To illustrate, effective TB services apply an integrated approach that views financial, social, and health problems as highly associated with one another. This approach ensures that services have a maximum impact on health inequalities.
Bothamley et al. (2011) completed an audit of TB control programmes in the 10 most populous urban areas in the UK. Nurses in Birmingham reported delivering seminars in nursing and care homes; training community nurses about TB, and organising educational meetings for ethnic minorities across the city. Events such as World TB Day can be used as an excellent opportunity for increasing community engagement. It is imperative that nurses ensure that services are accessible, and appropriate, and therefore used more effectively by the client group (Naidoo and Wills, 2005). Although furthering community involvement in TB projects should be clearly placed on the nursing agenda, services with fewer nurses are less likely to engage in health promotion activities (Bothamley et al. 2011).
To conclude, TB Nurses and other health professionals are an important component in achieving the aims of the TB Action Plan set by the Chief Medical Officer in 2004 (DH). Specialist TB teams utilise a variety of methods to reduce the pool of infection in the community, thereby preventing onward transmission of the disease. To summarise, these methods include: acquiring an understanding of the epidemiology of this infectious disease; promptly diagnosing and treating TB cases; active case finding; implementing the selective BCG programme; and engaging in health promotion strategies. As discussed in this assignment, there are forces that constrain nurses' ability to apply these public health interventions; namely, poor adherence to treatment, fear and stigma, limited efficacy of the BCG vaccination, health inequalities, and inadequate resources. Looking to the future of TB control, intensive, sustained and cost effective efforts are required. From a nursing perspective, initiatives should focus on enhancing nursing representation in policy development and strategic decision making, increasing nurses' capacity at management level, and integrating TB education into the nursing curriculum to develop nursing competencies.