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 is an infectious disease caused by a bacterium that usually affects the lungs (pulmonary), although it can affect other parts of the body such as the spine, or the brain (extra-pulmonary; Davies, 2003). Transmission of the TB bacteria 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, living in an urban area and immigration (RCN, 2012).
In the UK in 2011, the Health Protection Agency (HPA, 2012) reported a total of 8,963 cases of TB (a rate of 14.4 cases per 100,000 population).
Why is tb a public health issue.
From an historical perspective, several industrialised nations witnessed a progressive decline in the incidence of TB around the middle of the nineteenth century (Pratt, Grange & Williams, 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 such as targeted awareness raising activities (DH, 2004). Hollo et al. (2008) attribute the resurgence of TB to migratory movements of people from high incidence countries. Yet hardly any phenomena has 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 and other industrialised nations.
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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 (shall I include what epidemiology is here?); this covers surveillance and epidemiology and public health action; this covers interventions to promote health and prevent disease. The latter involves an intersectoral collaboration of local authorities, NHS trusts, Primary Care Trusts, community groups and individuals (Naidoo & Wills, 2005). Cowley (1999) 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. Why is TB a public health issuee? Tuberculosis specialist nurses who view TB control from a public health perspective can make an enormous 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 of healthcare professionals, collectively known as a TB service or team (Pratt, Grange & Williams, 2003). 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 comprise: 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 incorporated in TB nursing practice.
Although it may seem remote from practitioner’s daily concerns, policy context is essential. It is important to discuss policy context seeing as policies developed at national, regional, and local levels exert a powerful influence on practitioners’ ways of working (Naidoo & Wills, 2005). For example, a Tuberculosis specialist nurse will be aware of treatment completion targets that need to be met. There are TB policies and public health policies.
The following list outlines the public health interventions currently undertaken by TB specialist nurses in the UK. The remainder of this assignment will elaborate on each public health measure and where appropriate, will discuss the benefits each measure brings to the public’s health and the limitations to its application. The contributions of TB nurses and other frontline healthcare workers to TB management and prevention are as follows:
DO I NEED TO PUT BRIEF REASON WH THIS IS DONE FOR EACH ROLE – may be not as it is explained further in more detail.
i) Collect accurate TB surveillance data so as to monitor the changing epidemiology of new TB infections (HPA, 2012).
ii) Promptly diagnose and treat all active cases of clinically diagnosed TB (passive case finding; NICE, 2011)
iii) Screen high-risk groups and individuals for TB (active case finding; NICE, 2012)
iv) Administer the BCG vaccination to those who meet the criteria (DH,
v) Implement TB awareness raising activities.
Policy? Section on inequalities in health
Do I need to provide what epidemiology is?
i) Since 1912, it has been a legal requirement in England, Wales, and Northern Ireland for the clinician to report all cases of clinically diagnosed TB through a notification system in her or her area (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 2008/2009 ETS moved to a paperless system in which TB 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 TB 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. At a regional and national level, ETS allows public health directors to establish whether the targets set by the Chief Medical Officer are being met (DH, 2004). Although the level of completion and accuracy 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).
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 healthcare 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. The TB Nurse contributes greatly to meeting the objective of curing patients and protecting communities (reference). In spite of this benefit, constraints exist 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 four antibiotics which should be taken continuously for a minimum of six months. The development of drug resistance can manifest if there are interruptions in TB treatment or if patients take their medication in an haphazard manner. Undoubtedly, poor adherence or non-adherence can increase the risk of onward transmission (ref.)
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 a subset of shared decision making (Cushing & Metcalfe, 2007). This approach allows the patient to make an informed decision about their preferred course of treatment (Bell, 2007). Stategies 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). It is theorised that medication taking behaviour is driven by an implicit cost-benefit mechanism in which beliefs about the personal need for a prescribed medication (necessity) is evaluated against the beliefs about taking this medication (concerns) (Horne, 2006). This necessity-concerns framework has implications for clinical practice, given that the cost-benefit analysis can be modified through education (Horne, 2006). TB Nurses aim to elicit their patients’ concerns (e.g. side effects) and their perceived necessity for the medication (I require this medication to kill the TB bacteria) (find reference)
For some communities, TB is a frightening and stigmatising disease (Pratt et al. 2003). This perception can lead people to deny that they may have TB symptoms, and as such, are diagnosed too late because they are afraid of being rejected or excluded from their community if they seek treatment (Dean, 2012). An article published by the Nursing Standard outlines the essential public health activities undertaken by a HIV liaison nurse and a case worker who work in an ethnically diverse area of east London to reduce stigma around TB and HIV (Dean, 2012). TB is common amongst people living with HIV (Davies, 2003). Nurse Millett and case worker Dr Collinson hold clinics in community buildings and in soup kitchens that offer HIV and TB screening. Their aim is to normalise HIV and TB screening.
iii) There is a growing body of evidence that indicates that TB disproportionately affects certain marginalised groups in society (references). Hard-to-reach individuals account for a significant proportion of non-treatment adherent cases and highly infectious cases (Story et al. 2007 cited in Jit et al 2011). In response to this evidence, the Department of Health (DH) requested the National Institute for Clinical Excellence (NICE) to produce guidelines for Identifying and managing tuberculosis among hard-to-reach groups (NICE, 2012). The guidance stipulates that individuals are ‘hard-to-reach’ if their social circumstances, language or culture delay diagnosis and/or treatment. The guidelines advocate the use of active case finding. Effective active case-finding has several implications for enhancing public health. Corbett et al (2010) rightly argue that the success of active case finding should be measured by the number of future cases averted. Active case finding may detect and treat asymptomatic latent infection, at risk of reactivation by means of a positive skin test or more recently from a positive interferon gamma test (NICE, 2011), thereby reducing the development of active, infectious, symptomatic disease. NICE guidance recommends that specialist TB services produce a local health needs assessment on an annual basis so as to ensure the service reflects the needs of the area in which it operates. In areas of identified need (informed by the local health needs assessment), a programme of active case finding should be adopted using mobile digital radiography in areas where people characterised by homelessness and/or substance misuse can be found. (NICE 2012). This recommendation has been successfully trialled in London by the Find and Treat service which detects active cases of TB, and provides support for treatment completion to those identified by the service. Nurses, social workers and outreach workers are employed by the Find and Treat service. Jit and colleagues (2010) concluded that the find and treat service is a cost effective intervention. Yet, the research should be interpreted with some degree of caution as the researchers reported some limitations to the analyses. For example, the analysis was somewhat simplified and did not fully capture the benefits of the service such as the extent to which the screening unit averts secondary cases of TB.
Contact tracing is a cornerstone in the prevention of secondary cases of TB. The TB Nurse detects individuals who have been latently infected with the TB bacteria, and where appropriate, offers a preventative course of antibiotics known as chemoprophylaxis. The TB Nurse uses clinical judgement and decision making skills to establish which contacts need to be screened for TB, 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, immunocompromised individuals, and diabetics are given priority for screening. Contact investigations can be constrained. Those contacts who are well and are asymptomatic may not deem it necessary to attend for screening.
iv) The BCG vaccination is a cost effective primary preventative measure against childhood TB; primarily miliary TB and TB meningitis (Trunz et al. 2006). The vaccination is safe and offers infants an overall protective value of 75% against the disease. In 2005, the universal schools’ BCG programme was discontinued to reflect the changing epidemiology of new infections of TB in the UK (Fine, 2005). Current Department of Health guidelines 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 (DH, 2005). Midwives, health visitors, and nurses identify, test, and immunise eligible infants. Implementation of the selective programme by health professionals including midwives, and health visitors has been variable and the controversial issue of denying the vaccination to infants who do not meet the criteria remains. Evidence has been found that confusion in the areas of Birmingham and Solihull exists about which infants are eligible for the vaccination. Current guidelines may not be clear in cases of interracial parenting (Etuwewe et al. 2004).
Assessing the contribution of the BCG programme to TB control is difficult (Abubakar, 2011). Furthermore, there is evidence that BCG offers minimal protection beyond 10 years (Sterne et al. 1998).
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, equity, and education. The importance of fostering strong intersectoral collaborations cannot be overemphasised. Organisations that provide services to high-risk groups should, in partnership with local specialist TB teams, provide training to both staff and clients in TB symptom recognition and access to healthcare (NICE, 2012). As alluded to previously in this assignment, new infections of TB in the UK 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 standard clinical practice. To illustrate this, effective TB specialist services embrace an integrated approach that view financial, social, and health problems has highly affiliated with one another. This approach ensures that services have a maximum impact on health inequalities. Bothamley (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 public awareness and furthering community sesnsitization facilitating active engagement with communities. Indeed, TB nurses in the Birmingham area erected display stands at supermarkets, mosques, community centres, and hospitals. It is imperative that nurses ensure services accessible, and appropriate, and therefore used more effectively by the client group (Naidoo and Wills). Although increasing community involvement in TB projects should be clearly placed on the TB nursing agenda, services with fewer nurses are less likely to engage in health promotion activities (Bothamley et al. 2011).
Nurse help to develop Awareness raising materials and social marketing.
TB clinicians can routinely integrate
forces that constrain or contextualize practice.
May be reluctant to admit they have the disease.
Disproportionately affect the weaker subgroups in our society.
Strong collaboration, awareness raising matierals, theories? Empowerment.
policy – nurses involved in policy making
reducing the incidence and consequences of tuberculosis
Talk about theories?
. maps out a clear role for nurses in Public Health. A variety of public health approaches/principles are incorporated into TB nursing practice. The main public health interventions are as follows: TB Nurses consider the epidemiology of the infection so to prioritise their work at vulnerable individuals and communities.
The current literature is prompting the stop TB community to focus on health inequalities and the social determinants of health (e.g. poverty and deprivation; Rasanathan, 2011).
Despite improving signs such as the stabilisation of UK TB rates since 2005 and treatment completion, despite overwhelming stats, good progress has been made.
NICE, TB nurses should engage with the policy in order to maximise their contribution to public health. The guidance provides recommendations for populations and individuals.
Basic public health strategies in response to TB traditionally focus on testing,
Surveillance notifications, prevention, and control, each of which has multiple dimensions
Knowledge of determinants causes and distribution trends /patterns of disease is helpful to TB nurses’ understanding
NURSES CAN do a health needs assessment from a leadership perspective
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