16 IN FOCUS
and may become active later , especially if the immune system is weakened . This is why it is also called ‘ the hidden disease ’.
A recent report from the WHO found that before the pandemic , many countries were making progress , but access to TB services was a challenge , and global targets for prevention and treatment will likely be missed without urgent action and investment . According to WHO , 1.4 million people died from TB-related illnesses in 2019 . Of the estimated 10 million people who developed TB that year , some three million were not diagnosed with the disease , or were not officially reported to national authorities .
On 20 November 2020 , WHO and other organisations launched a global action plan to accelerate access for children to HIV and TB diagnostics and medicines . It was recognised there was a lot of cross-over with TB and AIDS . In 2018 an estimated 36,000 children who were living with HIV died from TB across the globe , the health organisation said . At the launch , Dr Tereza Kasaeva , director of WHO ’ s global TB programme , said : ‘ Any child who dies from TB , HIV , Covid-19 or any infectious disease is one too many ’.
Prevention and treatment But tackling TB is not easy . The BCG vaccination only offers , at best , 80 % protection – and this only lasts for around 15 years . It does reduce the likelihood of infection and importantly ( especially in very young children ) it reduces the
It is crucial that TB patients take their medication exactly as prescribed , and this is why monitoring is often necessary chance of an infected person getting the severe form . A few new vaccines to replace the BCG are at trial stage , but are still nowhere near licensing stage .
Since 2005 , therefore , the policy of immunising all adolescents has changed . Broadly , the policy at the moment is to vaccinate babies , but only babies living in an area where the incidence of TB is higher than 40 cases to every 100,000 – or babies with parents or grandparents born in countries where TB is endemic . Unvaccinated adults under 35 are recommended to have the vaccination if they ’ re working with people or animals that are likely to have TB .
For people who do develop TB , the standard treatment is usually a mixture of four antibiotics – isoniazid , rifampicin , pyrazinamide , ethambutol – for a period of two months and then two antibiotics for a further four months . One of the challenges , though , is the length of treatment and the severity of side-effects , especially as most people start to feel better after the first month . It is crucial that patients take their treatment as prescribed and complete the course , to ensure they are completely cured and prevent them developing drug-resistant TB .
Drug-resistant TB has become a major global problem and is one of the big examples of antibiotic resistance . This form of TB requires a longer course of treatment , possibly over 18 months , with different combinations of drugs that can have more side-effects . These side-effects include nausea or dizziness , skin rashes , pins and needles , flu-like symptoms and occasionally jaundice . There are new drugs now available for treating this form of TB , but there are concerns that these too will become ineffective . At the moment , however , nearly 90 % of cases of TB and 48 % of cases of drug-resistant TB are cured worldwide .
TB in prisons : a QNI project
There is a high prevalence of TB in prisons . PHE data released in 2018 showed 13 % of people with TB have a ‘ social risk factor ’ such as a homelessness , a history of substance misuse or time spent in prison .
In 2018 , the Queens Nursing Institute ( QNI ) announced 10 nurse-led projects that would receive a year-long programme of professional and financial support . One of them was to offer screening and treatment for latent TB for a cohort of prisoners at HMP Birmingham , along with raising awareness of TB more generally in the prison population ( including the staff ).
Hanna Kaur is the TB representative for the RCN ’ s public health forum , which is the partner on the QNI screening project at HMP Birmingham .
She says : ‘ The outcomes showed that knowledge about TB was increased within the prison , and the prison nursing staff gained confidence in the assessment and referral to the TB service . A total of 10 prisoners were identified as having latent TB . Of these , eight agreed to have treatment and were either followed up at the prison , at another prison or in the community . One prisoner who was admitted to hospital was found to have active pulmonary TB .’
‘ Without the QNI project test result , this would have put a large number of individuals and staff at risk ,’ explains Sue Boran , QNI director of nursing programmes .
Observing treatment As already explained , it is important to support patients through treatment , even though this may be more challenging during Covid times . TB treatment can be complicated and some patients have difficulties sticking to it . Directly Observed Treatment ( DOT ) initiatives are one way of supporting people to complete their treatment . TB nurses , outreach volunteers or trained volunteers meet regularly with patients to watch them take their medication . This may take place at the patient ’ s home , in a clinic or pharmacy , or even a local shop . DOT ensures that the right medication is taken in the right doses , at the right time , for as long as it ’ s required .
Ms Kaur says : ‘ Around 30 % of our patients go on to DOT . It has to be sold to them right at the beginning that it ’ s going to benefit them . It is not just us watching them take the medicine – we support them and assess for side-effects .’ More recently , there is the option of video-observed treatment ( VOT ). This is done on a phone or app . ‘ It tends to be for younger people but is offered to everyone ,’ says Ms Kaur . This has , of course , become particularly useful over the past year . ‘ When the Covid-19 pandemic started , we switched everyone feasible to VOT .’
Ms Kaur points out it is vital for nurses to be aware of the symptoms of TB . ‘ It ’ s important for practitioners to know the symptoms , and take note of the people whose symptoms have been passed over . Remember that there are also extrapulmonary and latent forms of TB . And be aware of infection control measures when you suspect or know that someone has the disease .’
It is vital not to stop the fight against TB , even though this might be difficult during a global pandemic . The WHO warns : ‘ While experience on Covid-19 infection in TB patients remains limited , it is anticipated that people ill with both TB and Covid-19 may have poorer treatment outcomes , especially if TB treatment is interrupted .’
Radhika Holmström is a health journalist with a special interest in TB nursinginpractice . com Winter 2021