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Student cohort: September 2018

Module code and name: NS521 – 19S1: Adult Community Nursing in Practice: Public
Health in Action

Word count: 1,514

Submission date: Tuesday 14th January 2020 before 1400 (2pm)

Seminar leader: Ashley Luchmun

Module leader: Dr Marianthi Alexandropoulou

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Summary

This report is written in regards to the prevalence of TB in the UK, particularly in the
London area, as well as national and local strategies to combat it’s spread. The report
finds that TB is in decline in the UK, that there are strategies in place at both national
and local level to reduce it further and these are largely focussed on prevention of the
spread of the disease

Introduction

Tuberculosis (TB) is a respiratory disease caused by the bacterium Mycobacterium

tuberculosis and one of the most widespread diseases in the world today. As of 2018
the World Health Organisation (WHO) estimates that approximately 25% of the global
population is infected with some form of the disease (WHO, 2019). The goal of this
report is to ascertain the extent of the spread of the disease, including a global and
national perspective, but with a particular focus on the London area. It will also look into
local and national strategies to combat the spread of TB in London and the UK in
general, and the role played by community nurses in implementing these strategies. It
will also consider the challenges of implementing health promotion strategies and the
role nurses play in doing so.

Epidemiology

The WHO Global Tuberculosis Report 2019 (WHO, 2019) estimates that approximately
1.5 million people worldwide died as a result of TB infection in 2018. They also recorded
484,000 cases of multi-drug resistant TB (MDR-TB), i.e. those forms of the disease
resistant to treatment by the two most powerful front-line drugs available, in the same
period.

According to Public Health England (PHE) figures for 2018, England alone saw 4,655
new cases of TB, which represents a decrease of 8%, or 415 fewer cases, from 2017.
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The most recent figures for MDR-TB in England, from 2015, show that approximately
1.5% of recorded cases of TB were of a multi-drug resistant type. (PHE, 2019)

London alone saw 1,919 new cases in 2017, which shows a reduction of 12% from
2016, but still represents an incidence rate 21.7 per 100,000 people. This is more than
three times the rate of 9.2 per 100,000 people for England as a whole (PHE, 2019a).
This is likely in large part due to the sheer population density of London, which has a
population of approximately 8.9 million people, more than all of both Scotland and
Northern Ireland combined.

Overall, England is at an all-time low of reported incidences of the disease since

records began in the 1980’s. The population group in the UK most likely to have some
form of TB is those born overseas in high-risk regions, the risk for people being born in
the UK being some 14 times lower than for those born outside. (PHE, 2019a) It is
possible that this has some bearing on conditions that enable the spread of TB, such as
large groups of people living in close proximity or in unsanitary conditions, as new
arrivals to the UK are more likely to fall victim to predatory practices by unscrupulous
landlords. Newham council in particular has made the prosecution of landlords who
overcrowd properties or fail to maintain them adequately a key priority in its TB strategy,
carrying out more than 1,500 convictions and cautions for such infractions by 2018.
(World TB Day – Uniting to End TB, 2017)

Income inequality also plays a role in the spread of TB, as those in the lowest 10%
income bracket are six times more likely to contract TB than the rest of the population.
This also ties in with social risk factors for the illness, as 13% of patients with TB will
have one or more, such as homelessness or a history of substance misuse. (PHE,
2019)

The strategies for combatting TB at a national level are laid out in the Collaborative TB
Strategy for England 2015 – 2020. This strategy lays out ten key priorities for
improvement and the means by which they would be achieved. The main focus of the
strategy is on detection and prevention, including implementing new entrant TB
screening, improving BCG vaccination uptake and improving access to services to
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ensure early diagnosis. (PHE, 2015) A 2013 study in Hammersmith & Fulham has
shown that of the incidences of TB in those born outside the UK very few had entered in
the previous two years, most being resident for ten years or more. This clearly
demonstrates the value of improved screening for TB as well as emphasising the need
for early diagnosis. A ten-year gap before commencing treatment is a significant window
of opportunity for the spread of TB in a densely populated city such as London.

Role of Community Practitioners

Community practitioners have a significant role to play in combatting the spread of TB,
although the specifics of their role will vary depending on their specialisation and area of
practice. Although there are specialist TB nurses, Rach (2017) points out that there is
currently no fixed pathway to becoming a TB nurse, rather an accumulation of
knowledge and experience.

As England is currently at an all-time low in terms of cases of TB and incidences of

MDR-TB are much lower than at a global level, preventing the spread of the disease
would seem to be the highest priority in order to successfully eliminate the disease from
the UK. The most straight-forward approach would be improved education amongst the
population, particularly in at-risk groups and in high incidence areas of the country.
Making people aware of the risks of the disease itself and the factors that can lead to
the spread of the disease would surely help to reduce the possibility of further
transmission. In addition to this, many people, particularly new entrants, may be
unaware of the services that are available to TB patients, or may perceive other barriers
to treatment, such as time off work or the belief that treatment would be expensive. The
NMC Code (2018) emphasises the importance of effective communication, including
use of easily understood language and due consideration being given to cultural
sensitivities to assist with understanding and responding to individual health needs.

Health Promotion

Taking a specific model of health promotion, Tannahil’s model suggests the intersection
of three aspects to health promotion; prevention, the reduction or avoidance of disease
and ill-health; health protection, safeguarding the health of a population through legal,
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fiscal or social measures; positive health education, use of communication to improve

well-being and reduce ill-health through improved knowledge and attitudes (QUB,
2009). This model suggests that health promotion does not exclusively focus on
prevention and disease reduction, or on structural and social change. In the case of TB,
a community practitioner would not only consider treatment of existing TB cases, but
also awareness campaigns to make potential patients aware of the risks of the disease
and also legislative action to disrupt the physical conditions that also assist the spread
of the disease (Jones and Naidoo, 2000).

Naturally there are challenges, to implementing any healthcare initiative. New entrant
screening, for example, would not have any bearing on already infected people who
enter the country through illegal means as they already bypass existing entrance
procedures. Also, maintaining patient engagement with treatment programmes is not
something that can be legally compelled, and so it is reliant on patients completing their
course of medication on their own initiative.

There are also ethical considerations to be grappled with as well. As Jones and Cribb
(2000) state “there is a potential for conflict between the principles of non-maleficence...
and... beneficence.” Of particular concern in the previous decade of government
austerity all levels of health providers have been forced to make difficult decisions in
regards to how to prioritise which services to fund. (King’s Fund, 2016) This runs the
risk that any health care activity engaged in may deprive another necessary programme
or initiative of the funding required to be implemented. Striking a balance between
helping the greatest number of people as opposed to not causing harm to other groups
through lack of action is a difficult task under ideal circumstances.

Conclusion

In conclusion, while TB is a wide-scale problem on a global level, in the UK as a whole

the disease is much more limited, the bulk of cases confined to larger cities, particularly
London and mostly in new entrants. However, the significant reduction in the prevalence
and spread of TB is largely due to persistent monitoring and interventions planned and
implemented at a national level, particularly screening and vaccination programmes.
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However local approaches are also necessary to accommodate the challenges found in
a particular location, based on population, demographics and the prevalence of the
disease. The major direct challenges for health authorities lie in engaging with at-risk
populations, and encouraging them not only to initiate treatment, but also to maintain
any course of treatment to completion and to change behaviours or circumstances that
can act as barriers to curing TB in infected people. Budgetary constraints are also a
significant concern as well, especially as demand continues to increase while budgets
stagnate, putting greater pressure on existing services and forcing providers to consider
where financial priorities should lie.
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References

 Jones L. and Cribb A. (2000) Promoting Health: Knowledge and Practice 2nd UK
Edn. Edited by J. Katz, A. Peberdy and J. Douglas. The Open University
 Jones L. and Naidoo J. (2000) Promoting Health: Knowledge and Practice 2nd UK
Edn. Edited by J. Katz, A. Peberdy and J. Douglas. The Open University
 Nursing and Midwifery Council (2018), The Code Page 9,
Section 7. Available at:
https://www.nmc.org.uk/standards/code
 Public Health England (2013) Hammersmith and Fulham TB Profile. Available at:
https://www.hammersmithfulhamccg.nhs.uk/media/69292/GB-8-Sept-Item-12-
Inner-NWL-plan-for-new-migrant-LTBI-app-C.pdf
 Public Health England (2015), Collaborative TB Strategy for England 2015-2020.
Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta
chment_data/file/403231/Collaborative_TB_Strategy_for_England_2015_2020_.
pdf
 Public Health England (2019) Tuberculosis in England 2019 Report: Executive
Summary. Available at:
https://www.gov.uk/government/publications/tuberculosis-in-england-annual-
report
 Public Health England (2019a) Tuberculosis in London Annual Review (2018
data). Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta
chment_data/file/833288/TB_2018_London.pdf
 The King’s Fund (2016) Six Ways in Which NHS Financial Pressures Can Affect
Patient Care. Available at: https://www.kingsfund.org.uk/publications/six-ways
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 Queen’s University Belfast (2009) Health Promotion. Available at:

https://www.qub.ac.uk/elearning/public/HealthyEating/HealthPromotion/
 Rach V. (2017) “How is the role of the tuberculosis nurse pivotal in the
multidisciplinary team?”, The British Student Doctor, 2018;2(1) pp 26-30.
Doi:10.18573/bsdj.31
 World Health Organisation (2019) Global Tuberculosis Report 2019. Available at:
https://www.who.int/tb/global-report-2019
 World TB Day – Uniting to End TB. (2017) Available at:
https://www.newham.gov.uk/Pages/News/World-TB-Day.aspx