Turning the tide on tuberculosis
A tuberculosis contact tracing project that aims to end London’s reign as the ‘TB capital of Europe’ has been shortlisted for a sought-after Nursing Standard Nurse Award
Sarah Murphy: TB does not respect commissioning boundaries. Picture credit: Andrew Aitchison
The London TB Extended Contact Tracing Team (LTBEx) is a finalist in the Public Health Nursing category and will find out if it has won at a ceremony at the Savoy in London on May 1. The award is sponsored by Public Health England (PHE).
The team offers a new ‘personalised care and population health approach tailored to London’s specific needs’, achieving a significant increase in the number of identified cases by working throughout the capital as a whole, rather than in geographical areas.
It is the first dedicated team to have both public health specialists and clinical TB nurses. It can lead on, or support, all aspects of incident management across the whole of London in a standardised, timely and effective way.
TB remains a significant public health issue, even though it can be controlled through the early identification and treatment of new cases and the prevention of further cases through effective contact tracing of people who have been exposed.
The team takes contact tracing out into the community - known as ‘on site screening’. This ‘active case finding’ approach aims to reach and screen more people who have been exposed to TB.
The airborne infectious disease is strongly associated with poverty and health inequalities. It is found among marginalised groups with poor access to healthcare and often other health or social issues, such as unstable housing, vulnerable employment and addictions. Language barriers can also be a problem.
London has especially high rates of TB - more than any other comparable city in Europe and it accounts for more than one third of national cases - which has proved particularly difficult to address.
TB nurse specialist Sarah Murphy explains: ‘TB does not respect commissioning boundaries, especially in London where the population is especially mobile.
‘People may live in one area, attend college in another, work somewhere else and stay with friends or family at the weekend elsewhere. If someone has infectious TB and lives like most Londoners, then their contacts will also be spread across London.’
Before LTBEx, TB incidents in London were managed by four health protection teams and about 30 TB clinics. An audit found that the overstretched services usually could not offer screening to people outside their boundaries or on site.
‘This led to a low uptake of screening and poor collation of results,’ says Sarah. ‘Only 50% of workplace contacts attended screening.’
Referral systems were very complicated and there was a poor collation of outcomes. ‘We realised it was time for a new way and approach that was better for London and the people most at risk,’ says Sarah.
The team’s solution has been to take screening to schools, colleges, workplaces, detention centres and hostels. There, LTBEx nurses clinically assess contacts, perform tuberculin skin tests and phlebotomy and record all data into their database.
‘This has removed some of the barriers that prevent patients accessing services, such as stigma, language barriers, having to negotiate time off work or school, fear of hospital or not being able to afford the transport,’ explains Sarah.
‘And on site screening is particularly important for children and young people as they can be screened in a familiar environment with additional support of staff who they know and trust. Providing care in their own environment also makes it easier for screening vulnerable people.’
Working in the community also offers health promotion opportunities. The nurses often provide TB awareness sessions for parents and at school assemblies.
‘We are not re-inventing the wheel, but adding much needed capacity to our TB and health protection colleagues - we always working in partnership with them,’ Sarah says. ‘We’ve realised that we can add most value by focusing on providing contact tracing to large groups of people, by providing it where it is required – in the community where the exposure occurred.’
The team has created the first pan London TB contact screening database to ensure full and proper public health action is taken.
‘It is exciting that we are gathering unique data which we can use to develop new evidence-based recommendations and using it to motivate colleagues so they are more aware of the importance of contact tracing,’ says Sarah. ‘We are putting all the pieces of the jigsaw together to create a sound evidence base for future practice.’
There are always barriers to working in a new ways - in this case the team has had to overcome clinical governance structures, commissioning boundaries, and some attitudes of ‘we always do it like this’. ‘ We have worked carefully and closely with the more than 30 TB clinics to get them on board,’ adds Sarah.
The Nurse Awards judges recognised the difficulties in working across organisational boundaries and praised the team’s passion and the way it was dealing with a disease that still carries stigma in such a strategic way. Joanne McDonnell, senior nurse for mental health and learning disabilities at NHS England, adds: ‘This team is really professional and it is a good example of collaborative and forward thinking working as well as strategic thinking. They seize opportunities rather than are fearful of them.’
PHE London regional director Dr Yvonne Doyle is determined to turn the tide on the rising numbers of cases in London.
‘LTBEx is providing the much-needed skills and capacity to manage TB incidents in the capital. It is improving uptake for contact tracing and resulting in better outcomes. As it is a community-based initiative it also raises awareness and reduces stigma around TB.
‘The team has been well-received by both TB services and service users and is a promising complement to existing NHS services. The increase in screening uptake demonstrates that the project is overcoming barriers to accessing healthcare and addressing health inequalities.’
Funding is currently extended until September based on positive feedback from stakeholders and positive provisional data. The team is expecting the formal independent evaluation to be reported soon.
In the meantime, it is hoping its success will influence the approach to TB outside of the capital. ‘We think the project has national and international interest,’ says Sarah, ‘so we are attending conferences and recently provided expert testimony to NICE (National Institute for Health and Care Excellence).
‘We are reaching and screening more people who have been exposed to TB than before. We have picked up cases of active and latent TB and managed to get them into treatment much earlier than if we had not intervened. This not only improves the individual’s outcomes, but also prevents onward transmission.
‘We are absolutely committed to driving down London’s inexcusably high rates of TB and reducing health inequalities.’