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Tuberculosis: a ghost from the past

Tuberculosis is still rife in some parts of the community. But even where it remains rare, community practitioners need to be alert to its seriousness.

Tuberculosis (TB) is perceived as a disease of the past – an illness harking back to Victorian Britain associated with images of gaunt patients dying in impoverished surroundings. It was an insatiable killer then and is still potentially fatal.

In the UK, cases of TB became much less common in the mid-1980s but saw a resurgence in the following two decades (TB Alert, 2017). And while the past four years have seen a decline in rates – in England, there were 5758 cases in 2015 compared with 8280 in 2011, according to Public Health England (PHE) (2016) – the UK still has one of the highest levels of incidence in Western Europe.

‘A lot of people, healthcare professionals included, are unaware of the real picture of TB in this country,’ says Gini Williams, nurse consultant for the charity TB Alert and a former health visitor. 

‘Many believe it to have been eradicated, but it never has been. And it is a serious and painful bacterial disease. The fear of it is still rife.’

 

Urban risks

The reason that awareness of the disease can be patchy is because it is less common in some parts of the UK than in others. It tends to be concentrated in large urban areas, says Gini. A staggering 40% of TB cases in England are found in London, one of the highest rates in a capital city in Western Europe (PHE, 2016). This is possibly connected to higher levels of homelessness, drug and alcohol use in cities.

Around the UK, many areas have dedicated TB services and in Scotland and England, coordinated national strategies are in place to reduce TB incidence. The Collaborative tuberculosis strategy for England 2015 to 2020, developed by PHE and NHS England, improves access to services
– ensuring early diagnosis – and screening. It also set up seven TB control boards. 

‘It’s an important and much-needed national response,’ says Gini. 

However, what shouldn’t be overlooked is the role of community practitioners in helping to curb TB cases and expedite treatment. 

 

A key role in identification

‘Health visitors, community nurses and school nurses are those well placed to spot the signs early, which is key to timely treatment and preventing onward transmission. So practitioners need to have a good knowledge and awareness of TB,’ she advises (see box on page 36). Even in areas where there may be just a handful of sufferers, practitioners need to stay alert to the problem, she warns.

Those at greatest risk of TB include people who come from or have spent time in places with high levels of TB such as Africa, South-east Asia, China, Russia and Eastern Europe (NHS Choices, 2016). In England, the rate of TB in the population not born in the UK is 15 times higher than in the UK-born population, and 73% of all TB cases notified in 2015 were born abroad (PHE, 2016). 

‘Globalisation means people are travelling or moving from high-incidence countries to different parts of the UK. So TB can develop anywhere, not just in the big cities,’ says Gini.

Plus TB bacteria can actually lie dormant (see panel, right) in the body without causing any symptoms and reactivate at any time. ‘That could happen in weeks or years – there is no way of knowing when it might develop into illness.’

Community practitioners’ first responsibility is to investigate levels of TB in their area, Gini advises, and then find out about local TB services. So how might a health visitor support a family with possible TB symptoms? Being able to spot the signs is essential. 


 

TB – the lowdown

What is TB? 

TB develops when Mycobacterium tuberculosis bacteria are inhaled into the lungs, causing infection. TB can spread within the lungs (pulmonary TB) or to other parts of the body (extrapulmonary TB). The infection can be controlled by the body’s immune system. However, the inactive bacteria can remain latent for months, even years, before developing into illness. 

Is it infectious? 

It spreads between people in close contact spending prolonged periods together. The risk of infection is very low where contact is brief.  

Symptoms

Common symptoms are a cough for three weeks or longer – which may be bloody – weight loss, loss of appetite, high temperature or fever and lack of energy. Extrapulmonary symptoms include swollen throat, aches and pains in joints and severe headache. 

Diagnosis 

Tests for TB include chest x-rays, sputum tests and scans. The Mantoux  (or tuberculin skin) test is also used.

Treatment

Usually, a combination of antibiotics is taken for at least six months. The emergence of TB strains resistant to drugs is an increasing problem worldwide. 

Prevention

The BCG vaccine doesn’t stop someone being infected but it stops the illness progressing. It should be offered to key eligibility groups. 

(Sources: NHS Choices, 2016; The Truth About TB, 2017; WHO, 2017a)


Signs and symptoms

‘A health visitor needs to be aware of the general health of all the people living in that household, not just a child’s. So it’s about being vigilant, noticing when a person may be coughing persistently or if a family member hasn’t been well for a while, then sensitively asking questions such as whether they have seen a GP and what treatment they have been given,’ says Gini.

‘It’s worth also bearing in mind social risk factors such as a history of drug misuse, alcohol misuse, poor diet, homelessness or imprisonment – although TB can affect anyone.’

Typical symptoms to look out for include an unresolved cough, or coughing up blood, fever, night sweats, loss of appetite and rapid weight loss for no apparent reason, advises Gini.

School nurses and nursery nurses should similarly be aware of symptoms and not overlook possible signs from teachers or staff, she adds. Wherever a case of TB is suspected, the next step will be to contact either the GP or the local TB service.

 

Treatment and care

Catherine Mullarkey is senior TB health visitor with Leeds Community Healthcare NHS Trust. She works as part of the local TB nursing service that comprises both specialist nurses and health visitors. She explains that treatment for TB requires a combination of drugs – commonly, isoniazid, rifampicin, ethambutol and pyrazinamide. Since the course lasts six months, this can take its toll on patients.

‘Specialist health visitors and nurses are vital at this time to ensure patients are completing their treatment. By visiting them we can see first-hand some of the barriers they may face in taking their medication, such as a chaotic lifestyle, and can help deal with some of the problems.

‘Some people feel quite unwell and need support. Or they may need help with side effects such as nausea, for which we can make sure they are prescribed an antiemetic.’

Social stigma

‘There is still a big social stigma around TB,’ Catherine says. ‘It can be associated with being poor or dirty, so people can feel reluctant to admit they are suffering symptoms. Health visitors can help dispel those myths and encourage people to come forward by promoting the message that anyone can get TB.’

Community practitioners should also be aware of who is eligible for the BCG vaccination and TB screening – for example, new entrants to the UK from high-incidence countries. ‘Cases may be reducing,’ Catherine says, ‘but we need to work hard at eradicating it. That’s the aim, anyway.’

Scientists at Oxford and Birmingham made a breakthrough towards this goal earlier this year, when they succeeded in isolating different strains of the disease using genome sequencing. This quick diagnosis means that patients can begin their recovery straight away. This prompted health secretary Jeremy Hunt to say:
‘We can move closer to what we all want, which is to eradicate TB from the shores
of the country.’

The discovery is all the more welcome after experts have warned that a rise in drug-resistant strains of TB is endangering the ultimate goal of eliminating the disease.


Resources


References

Health Protection Scotland. (2016) Respiratory infections. See:
www.hps.scot.nhs.uk/resp/wrdetail.aspx?id=70846&wrtype=9 (accessed 19 September 2017).

NHS Choices. (2016) Tuberculosis. See: nhs.uk/Conditions/Tuberculosis/Pages/Introduction.aspx (accessed 19 September 2017).

Public Health Agency Northern Ireland. (2015) Epidemiology of tuberculosis in Northern Ireland (annual surveillance report 2015). See: www.publichealth.hscni.net/sites/default/files/N%20Ireland%20TB%20Surveillance%20Report%202015.pdf (accessed 19 September 2017).

Public Health England. (2016) Tuberculosis in England 2016 report (presenting data to end of 2015). See: tbalert.org/wp-content/uploads/2016/09/PHE_TB_Annual_Report_2016.pdf (accessed 19 September 2017).

Public Health England. (2015) Collaborative tuberculosis strategy for England: 2015 to 2020. See: gov.uk/government/publications/collaborative-tuberculosis-strategy-for-england (accessed 19 September 2017).

Public Health Wales. (2016) Tuberculosis in Wales annual report (presenting data to the end of 2015).
See: www.wales.nhs.uk/sites3/Documents/457/Wales2015AnnualTBReport%5Fv1.pdf
(accessed 19 September 2017).

TB Alert. (2017) UK stats and targets. See: tbalert.org/about-tb/statistics-a-targets/uk-stats-and-targets (accessed 19 September 2017).

The Truth About TB. (2017) Your essential guide to TB. See: thetruthabouttb.org/do-i-have-tb/testing-for-tb (accessed 19 September 2017).

WHO. (2017a) Tuberculosis. See: who.int/tb/areas-of-work/drug-resistant-tb/en/ (accessed 19 September 2017).

WHO. (2017b) Tuberculosis. See: who.int/mediacentre/factsheets/fs104/en/ (accessed 19 September 2017).

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