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Managing the increasing incidence of tuberculosis

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VOL: 103, ISSUE: 14, PAGE NO: 23

Provisional data from the Health Protection Agency (HPA, 2007) shows that cases of tuberculosis (TB) in England, Wa...

Provisional data from the Health Protection Agency (HPA, 2007) shows that cases of tuberculosis (TB) in England, Wales and Northern Ireland rose by 2% last year, up from 8,008 cases reported in 2005 to 8,171 in 2006. These figures represent a rate of 14.8 cases per 100,000 population in 2006 compared with a rate of 14.5 per 100,000 in 2005 (provisional figures).

RISING INCIDENCE

The highest rate of disease was observed in London. The provisional figure here was 45.8 per 100,000 population, which accounted for 42% of the total number of reported cases, followed by the West Midlands, Yorkshire and Humberside and the North West.

While London continues to account for the highest proportion of the cases that are reported, the provisional figures show there has been a decrease in that area from 3,541 cases in 2005 to 3,445 in 2006.

The HPA has reported a steady increase in the number of new diagnoses of TB in recent years, according to finalised figures that are available up to 2005. These show that in 2000 there were 6,323 new diagnoses, which rose steadily to 7,321 in 2004 followed by a large increase to 8,113 in 2005.

The agency said it was too early to tell whether the provisional results for 2006 signified a slowing in the overall trend of increase in the number of cases.

However, it added that the fact there were still more new cases diagnosed each year meant that 'heightened efforts' should be continued with those most affected by TB, and the key to reducing levels of TB was a focus on early diagnosis and appropriate treatment.

In addition, a survey by the British Thoracic Society found that 88% (43 out of 49) TB specialists believe the number of TB cases in the UK will continue to rise during the next five years (BTS, 2007).

RESOURCES

The BTS survey highlighted a failure to implement the government's TB action plan (DH, 2004), with 78% of TB leads reporting no significant change in provision of resources to implement the plan and nearly one in ten (8%) witnessing a decline in resources.

The BTS found that, as financial pressure on NHS trusts grows, resources allocated for TB are threatened, with TB nurse specialist posts in particular coming under a great deal of pressure.

In its online survey carried out in March this year, the BTS found that over a third (35%) of TB leads claimed the nurse specialist posts were under threat or review due to financial pressures (BTS, 2007).

The society pointed out this threat to specialist nurses was happening in spite of the fact that NICE guidance emphasises that TB respiratory nurses are essential for the management of patients, their families and carers and other contacts, as well as for ensuring screening programmes are run for new arrivals to the UK.

Of those who said the post was under threat or review, 29% said it was due to the loss or reallocation of current TB nurse sessions, and 65% said it was because the TB nurses' job plans were currently under review by management.

The BTS survey, which was carried out among 54 out of 184 TB leads contacted across the UK (including any healthcare professional in charge of managing TB including TB nurses, consultants and other specialists) found that nearly a quarter estimated that only 0-25% of TB cases were managed with input from TB specialist nurses having sole responsibility for TB.

These findings on nurse posts build on data from a previous BTS survey of TB nurses, which found that 17% had been interviewed about their jobs, 42% did not believe they had been banded appropriately as part of Agenda for Change, and 24% reported vacancies were not being filled.

Further research from the charity TB Alert (2007) shows that five out of 11 high-incidence areas for the disease in the UK do not meet the recommended 1:50 TB nurse-to-patient ratio.

DIAGNOSIS AND MANAGEMENT OF TB

NICE guidance (2006) provides recommendations for the diagnosis of both the respiratory and non-respiratory forms of active TB. Nurses need to be aware that a person with respiratory TB may have a variety of symptoms including a persistent cough, chest pain, blood in the sputum, weakness, weight loss and loss of appetite (see box, p23).

The guidance recommends that anyone suspected of having respiratory TB should first be given a chest X-ray. If this suggests the presence of TB, other tests should then be arranged (NICE, 2006).

Although the disease usually affects the respiratory system, TB can also affect other parts of the body, such as the lymph nodes, kidneys and bones.

To diagnose active non-respiratory TB, NICE recommends discussing the advantages and disadvantages of biopsy and needle aspiration with the patient, and provides a list of possible samples to send for TB culture.

For the treatment of active TB, the guidance stresses that patients with a diagnosis of active TB should be referred to a 'physician with training and experience in treating patients with TB'.

For drug treatment of active TB it outlines the following measures:

- The standard recommended regimen is six months of isoniazid and rifampicin initially, plus pyrazinamide and ethambutol for the first two months;

- Use fixed-dose combination tablets as first choice;

- In all types of non-respiratory TB, daily dosing should be used as the first choice. This regimen is for fully drug-susceptible TB at all sites except the central nervous system, and for patients of all ages, including those who are HIV positive;

- A thrice-weekly regimen should be considered for patients receiving directly observed therapy (where patients are observed taking the medication). A twice-weekly regimen should not be used.

Nurses can play a crucial role in adherence to treatment regimens due to the extent of their patient contact. NICE recommends that patients should be involved in treatment decisions at the outset, and the importance of adherence should be emphasised.

The guidance states that everyone with TB should know who their named key worker is and how to contact them. The worker should educate the patient about TB and involve them in achieving adherence.

In addition, TB services should provide written patient information in languages used locally and in other formats as appropriate. It also outlines possible interventions if a patient defaults from treatment, such as:

- Reminder letters in appropriate languages;

- Health education counselling;

- Patient-centred interview and health education booklet;

- Home visits;

- Patient diary;

- Random urine tests and other monitoring (for example, pill counts);

- Information about help with paying for prescriptions;

- Help or advice about where and how to access social security benefits, housing and social services.

The guideline also covers preventing transmission and treating latent TB as well as BCG vaccination (see www.nice.org.uk).

CONCLUSION

The continuing increase in reported cases of TB means nurses have a key role to play in detection and treatment and in encouraging adherence to treatment.

WHAT IS TUBERCULOSIS?

- Tuberculosis is a bacterial infection. It usually affects the lungs, gradually destroying tissue, but it can affect other parts of the body such as the lymph nodes, kidneys, spine and brain. It is fatal if not treated.

- It is caused by a germ (the bacterium Mycobacterium tuberculosis) usually spread in the air. It is caught from another person who has TB of the lungs when that person coughs or sneezes. Infection with the TB germ may not develop into TB disease. Only some people with TB in the lungs are infectious to other people, and even then close and prolonged contact with them is needed to be at risk of being infected (HPA, 2007).

- TB disease develops slowly in the body and it usually takes several months for symptoms to appear. Any of the following symptoms may suggest TB: l Fever and night sweats; l Persistent cough; l Losing weight; l Blood in sputum (phlegm or spit) at any time.

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