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Tuberculosis care: Olympics 1948 vs 2012

Coincidentally, July 2012 will see London hosting the Sixth Conference of the Union Europe Region/International Union Against Tuberculosis and Lung Disease entitled Tuberculosis and Lung Disease: Threats and Promises. That London should host such a major international scientific conference is both timely and apt. London is facing a tuberculosis (TB) threat with the highest TB rate of any capital city in Western Europe (London Health Programmes, 2011) and Newham has the highest TB rate in London at 128 per 100000 (Health Protection Agency (HPA), 2011a). The resurgence of TB in London and other UK cities over the past few decades has been well documented but despite promises of action from the Government to deal with its rising incidence, there is still a lack of political will to fund the necessary measures. This article compares and contrasts the nature of TB care and treatment in 1948 with that of today. Contemporary issues in TB control and prevention are discussed as well as the role of the nurse in meeting the associated challenges.

Kelvin Karim

Tuberculosis (TB) is a multi-faceted illness associated with a long and fascinating history. Although much has changed in the diagnosis, treatment and prevention of TB over the past six decades, many of the challenges remain remarkably similar. In developing solutions to these challenges, key stakeholders and politicians would do well to learn from some of the more effective strategies from the pre-chemotherapy era. Despite working with insufficient resources, nurses have historically contributed significantly to the work of the multidisciplinary teams in delivering care to patients and families, as well as in implementing national TB control and prevention programmes. The current resurgence of TB in the UK makes it imperative to achieve consistently and appropriately-funded TB services across the country. Whether NHS commissioners and politicians will engage with nurses and others in the reconfigured NHS to achieve this, however, remains to be seen. Key words: Tuberculosis n History n Sanatoria n Hard-to-reach groups n Nursing role here is great anticipation in the air as London prepares to host the 2012 Olympic Games for the first time since 1948.The Games in 1948 were staged on a shoestring budget of just 760000, incredibly, returning a 29000 profit (Hampton, 2011). Taking into account required security measures, the 2012 Games are looking at a cost of 11 billion (House of Commons Committee of Public Accounts, 2012). However, the Games have injected significant investment into the London Borough of Newham, one of the most deprived areas in the country (Department of Health (DH), 2011). Moreover, a London Health Commission/ London Development Agency commissioned report (2004) suggests that the Olympic legacy will include long-term and wide-ranging health and social benefits for the communities of East London and beyond.
Kelvin Karim is TB Clinical Nurse Specialist, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield. Accepted for publication: June 2012

Abstract

TB epidemiology in 1948 and 2012

In 1948, there was good reason to fear being diagnosed with TB. The epidemiology of TB in that era meant young adults were largely affected, particularly in the 2535 year age group (Davies, 2005). Women in this age group were also thought to be susceptible to TB, possibly owing to an increased risk during pregnancy (Springett, 1950). A significant number of children would also have acquired latent TB infection and the youngest were at highest risk of developing frequently fatal forms of the disease such as miliary TB and TB meningitis (Davies, 2005). In older age groups, males seemed to be at highest risk (Wilkins, 1956). The increased prevalence of smoking, especially among males in this period, may have also contributed to this heightened risk (Lowe, 1956). With the exception of the interwar years, the TB rate had been steadily falling in England and Wales from the beginning of the twentieth century. In 1948, 43971 cases of respiratory TB and 8605 cases of non-respiratory TB were reported. There were also 15600 TB deaths resulting in a mortality rate of 36.5 per 100000 (HPA, 2011b; 2011c). Although the post-war period saw a dramatic fall in TB child mortality in

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England and Wales, there were still 1562 child deaths in 1948 (Lorber, 1953). However, the same downward trend was not seen in Scotland where the number of cases continued to escalate (McDonald and Springett, 1954). For reasons that were not entirely clear, the TB rate in Scotland had risen to 66 per 100000 by 1948 (Elliot, 1949) and Glasgow had the highest TB death rate in Britain (Stein, 1950). Although TB mortality in the UK in 2012 is very low, TB morbidity has been consistently rising, save for a small reduction in the number of TB cases reported nationally in 2010. Latest available figures from the HPA (2011d) show that there were 8483 TB cases reported in the UK in 2010, a national rate of 13.6 cases per 100000. London accounts for the lions share of cases (39%) at a rate of 42 per 100000. Parts of London have particularly high TB rates, including Newham, Brent and Hounslow (HPA, 2011a), with comparable rates to those in China, Sudan and Romania (World Health Organization (WHO), 2012). TB continues to primarily affect young adults between 15 and 44years of age (60%). Those over 65 and under 5years of age accounted for 15% and 2% of cases respectively in 2010. Overall, TB affected slightly more males than females (HPA, 2011d). Over 70% of TB cases in the UK are people born overseas, particularly in South Asia and sub-Saharan Africa, with the largest proportion being of Indian (25%), white (22%) and black African (19%) ethnicity (HPA, 2011d). Fortunately, multidrug-resistant TB (MDR-TB), which is defined as being resistant to at least rifampicin and isoniazid, remains low. Of the TB cases confirmed microbiologically in 2010, only 1.3% were reported as multidrug resistant. This is, nevertheless, an increase on the 0.9% in 2000 (HPA, 2011d). acid (PAS) and isoniazid orally for 1824months (Medical Research Council, 1955; Davies, 1999). As TB predominantly affected younger men and women of working age, European governments became increasingly aware of the economic impact (Bryder, 1988). Hardy (2003) suggests that there was a post-war effort to control TB by ensuring that those with infectious disease were removed from the community. Efforts were re-doubled to admit patients to institutional settings such as TB hospitals and sanatoria. However, even after the creation of the NHS in 1948, there were insufficient beds to meet the demand. In December 1948, the Minister of Health, Aneurin Bevan, conceded that sanatoria admission waiting lists were several months long and that this was owing to a shortage of trained nursing staff (Hansard, 1948). The nineteenth century German physician, Hermann Brehmer, acknowledged to be the founding father of TB sanatoria, believed that rest, appropriate exercise and good nutrition could strengthen the heart, improve the circulation and, therefore, heal the lungs (Warren, 2006). After 1859, when Brehmer opened the first sanatoria in Germany, sanatoria sprang up all over Europe and North America. The Brompton Hospital Sanatorium at Frimley, perhaps one of the most famous sanatoria in England, opened its doors to TB patients in 1905 (Bignall, 1979). The mainstay of TB treatment in sanatoria was, therefore, a daily regimen of care based on improved dietary intake, exposure to fresh air and sunshine, mental tranquillity, rest and graded exercise (Teller, 1988). Such therapies became a thoroughly established ritual in sanatoria (Duarte and Lpez, 2009) and often formed the backdrop for many literary works including Thomas Manns famous novel, The Magic Mountain, and Richard Yatess short story, No Pain Whatsoever. Later in the nineteenth century, rest regimens were supplemented with lung collapse procedures. Originally initiated by the Italian physician Carlo Forlanini in 1888, collapse procedures sought to rest the diseased part of the lung, thereby promoting closure of the tuberculous cavities and healing by scar formation (Morlock, 1931). The most common procedure in sanatoria involved creating an artificial pneumothorax. Some of the other collapse procedures used to treat TB were phrenic nerve cutting/ crushing, pneumoperitoneum, plombage and thoracoplasty (Bignall, 1979; Mehta et al, 2010). Collapse procedures were not without risk to patients. While some patients may have benefited, the evidence base for these interventions was limited. Moreover, there was a lack of studies to rigorously test the longer term benefits to patients (Pesanti, 1995). Historically, nurses have played a significant role in the care of TB patients and the prevention of the spread of TB. Kirby (2010) suggests that the value of the nursing contribution in sanatoria has not always been recognised. Kirby argues

TB treatment and care in 1948 and 2012

Although the first reasonably successful antibiotic, streptomycin, was discovered in the 1940s, it was not available to most people until much later. The drug was in short supply in Britain and needed to be evaluated for the treatment of TB in humans (Ryan, 1992). Ryan observes that millions of sufferers worldwide had suffered the appalling torment of knowing that there was a treatment available that might cure them, only to be told by their doctors that they could not get hold of it (Ryan, 1992: 359). Author, George Orwell, was a notable exception in that he was able to use his connections to obtain streptomycin in 1948/49 (Holme, 1997). The official chemotherapy era did not arrive until the discovery of isoniazid in 1952. Professor Sir John Croftons pioneering work in the 1950s demonstrated that TB drugs used in combination brought more successful outcomes. Treatment, therefore, consisted of streptomycin by intramuscular injection for 3months and para-aminosalicyclic

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Box 1: Some of the care skills of the TB sanatoria nurses

Physical Personal care assistance for patients on bed rest, especially after collapse procedures n Expertise in assisting in technical procedures and post operative care of the patient including wound management n Terminal care for dying patients n Prevention of infection/hygiene advice to patients and families n Administering TB drugs including streptomycin by intramuscular injection Psychological n Communicating with patients with empathy n Dealing with loss and bereavement Social n Measures to relieve patient boredom, including supporting hobbies and interests n Advice following discharge home taking account of stigma attached to TB
n

access evidence-based TB care pathways in a user-friendly format (NICE, 2012b). In the modern era, hospital nurses are likely to encounter TB patients less frequently and for shorter periods of time. While less than 40% of patients have their TB diagnosed as hospital inpatients (HPA, 2011d), the majority of TB care now takes place in the home setting. In most areas, individuals will attend outpatient clinics for regular review throughout their treatment with care case-managed at home by TB specialist nurses.

The context of contemporary care and treatment

The next part of this article addresses the context in which contemporary TB care and treatment takes place in the UK. Relevant contextual factors include multiculturalism, poverty and stigmatisation. Unlike their counterparts in 1948, modern nurses in urban areas work with patients from a wide variety of ethnicities and cultures. As TB predominantly affects those born overseas, it is important that nursing care and treatment takes account of an individual patients health and social beliefs.The challenge for nurses in a multicultural society is to strive for culturally competent practice. Cultural competence is a more modern concept that requires practitioners not only to be culturally aware and sensitive but to have the ability and willingness to recognise and challenge discriminatory practices (Papadopoulos et al, 1998). Similar to their counterparts in 1948, modern nurses work with patients living in poverty. In 1948, and the prechemotherapy era in general, TB patients often experienced poor housing, lack of sanitation, overcrowding and harsh working conditions (Weiss and Addington, 1998). As housing, working conditions and public health measures improved, the numbers of TB cases fell (Fairchild and Oppenheimer, 1998). Today, those living in poverty continue to be disproportionately affected by TB. Those from poorer socioeconomic groups and marginalised communities are at the highest risk (Siddiqi et al, 2001). Indeed, TB is increasingly being confined to individuals with one or more social risk factors or behaviours. Therefore, those considered to be at the highest risk include some migrants, those engaging in alcohol and/or drug misuse, the homeless or those in prison.

that sanatoria nurses demonstrated a blend of technical and emotional skills that enabled them to deliver individualised care wherever possible, even if this meant their collusion with patients to break sanatoria rules. Despite working in hostile conditions, sanatoria nurses often made the patients stay bearable (Kirby and Madsen, 2009). Box 1 summarises some of the key nursing skills required of nurses working in sanatoria. For patients being cared for at home, TB health visitors or district nurses often visited. Their main role was to give advice about infection control in the home setting, to reduce transmission of disease to others and to support the patient. With the advent of chemotherapy, this role extended to ensuring adherence to the treatment plan (Davies, 1999). District nurses were also instrumental in ensuring that patients received their streptomycin injections (Hunt, 2012). Although the modern treatment of TB began with the discovery of isoniazid, further breakthrough did not arrive until the discovery of rifampicin in 1965. It then became possible to shorten TB treatment to 6months in most cases (Nuermberger et al, 2010). By the 1970s, the modern shortcourse TB therapy came into routine use in the developed world (Yew and Leung, 2005). Box 2 shows the current standard TB treatment regimen. The advent of curative treatment saw the demise of sanatoria, surgery for TB was rarely needed and, for the most part, TB could be treated at home (Davies, 1999). Since the 1970s, TB has been a fully curable illness using standard treatment regimens except in the case of MDR-TB when the outcome is less certain. Evidence-based guidelines from the National Institute for Health and Clinical Excellence (NICE) (2011) are available to guide best practice in the treatment, prevention and control of TB and clinicians are now able to

Box 2: Standard recommended regimen for respiratory tuberculosis (with drug discovery dates)
Six-month course consisting of: n Two months rifampicin (1965), isoniazid (1952), pyrazinamide (1970) and ethambutol (1968) n Further four months rifampicin and isoniazid
Source: National Institute for Health and Clinical Excellence, 2011; Yew and Leung, 2005

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Collectively, these individuals have been described as being from hard-to-reach groups (HPA, 2011d; Abubakar et al, 2012). TB nurses commonly deal with housing and welfare benefits issues on behalf of patients. Many patients are homeless, in poor accommodation, have insufficient food and are often unable to afford the fares to/from hospital. Although NICE (2012a) has suggested the use of financial incentives to assist patients in adhering to their treatment plan, there are no allocated budgets to facilitate this in practice. Worse still, there is evidence to suggest that social inequalities and the gap between rich and poor in the UK are widening (National Equality Panel, 2010). Like nurses in 1948, modern nurses also have to work with patients who feel stigmatised by a TB diagnosis. Although the causes are complex, the consequences may be significant as it may hinder access to appropriate services because individuals are less likely to be diagnosed promptly and to complete their treatment (Courtwright and Turner, 2010). Although stigma seems to be universal, it may be perceived and experienced differently across cultures (Weiss and Ramakrishna, 2004). Modern TB nurses also encounter patients who are experiencing a double-stigma as a result of being co-infected with TB and HIV. In 2008 co-infection was estimated to be around 7% in the UK, although the precise number of co-infected individuals is not known (HPA, 2010). Co-infected individuals, especially women, are reported to feel more vulnerable to greater stigmatisation (Deribew et al, 2010; Daftary, 2012). a wider range of nursing skills, it has been suggested that the number of patients on the caseload be restricted to 20 as opposed to the suggested number of 40 (NICE, 2012a). As laudable as these aims are, the prospect of achieving this nurse/patient ratio consistently across the country does not look promising in the current political and economic climate.

Identifying active pulmonary TB among those using homeless or substance misuse services
Contact investigation, aimed at detecting new cases and preventing future cases has long been a part of TB and prevention control programmes (Abubakar et al, 2012). Nurses have played a central role in active case-finding. This recommendation suggests that there is a need for active case-finding using mobile digital radiography in appropriate settings where homeless people and substance misusers congregate. The idea is, of course, not new. Mass miniature radiography (MMR) was used very successfully for the detection of TB in the general UK population between the 1940s and 1960s (Holland et al, 2006). Since the disbanding of MMR, very few programmes have been set up. One exception is the London Find and Treat programme, involving the use of mobile digital radiography. This nurseled multidisciplinary project has evaluated well and has been found to be cost effective (Jit et al, 2011). There are, however, reports in the press that the ongoing funding of this project may be under threat (Jack, 2010).

Managing TB in hard-to-reach groups

It has been known for some years that if TB rates are to be reversed in the UK, measures need to be targeted at those at highest risk (Anderson et al, 2007). The recently published NICE (2012a) guideline, Identifying and Managing Tuberculosis Among Hard-to-Reach Groups, sets out 16recommendations to achieve better treatment and prevention and a reduction of TB transmission in the general population. The following recommendations are, in the authors view, crucial to achieving the stated objectives.

Identifying and managing active and latent TB: vulnerable migrants

There is evidence to suggest that many migrants are from deprived communities (Siddiqi et al, 2001) and some will be vulnerable as a result of language barriers (NICE, 2012a). While there is evidence that targeted screening of individuals from higher incidence TB countries is particularly effective in identifying latent TB, there is considerable deviation from existing national guidance (Pareek et al, 2011). Nurses are involved with migrant screening initiatives around the country but there is a lack of consistency of services, largely owing to lack of funding.

Commissioning multidisciplinary TB support for hard-to-reach groups

As we have seen from the pre-chemotherapy era, the management of TB has always required a multidisciplinary approach. In recent years, the nursing contribution has been increasingly recognised as integral to the work of the multidisciplinary team (Bothamley et al, 2011). TB nurses have for some time acted as case managers in respect of patients on their caseload. However, there is renewed emphasis on enhanced case management in situations where the patients needs are particularly complex (Royal College of Nursing, 2012). As enhanced case management draws upon

Rapid-access TB services
An important part of TB control is ensuring timely access to health services. Prompt diagnosis is, therefore, imperative. In 1948, Stradling highlighted that GPs often delayed or failed to refer their patients with suspected TB (Stradling, 1948). There is evidence to suggest that many GPs still have a low threshold for suspecting a TB diagnosis resulting in delays and/or adverse outcomes for patients (Griffiths and Martineau, 2007). The education role of TB specialist nurses is an important addition but more needs to be done to ensure that all GPs (and other primary care professionals) have an

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awareness of the symptoms that may suggest a TB diagnosis and to undertake appropriate early investigations and/or prompt referrals (London Health Programmes, 2011).

Accommodation during treatment

In the same way that sanatoria nurses once did, TB specialist nurses regard ensuring successful patient concordance with prescribed TB treatment as a core role. It is integral to achieving a cure and protecting public health. A goal of achieving 85% completion rates has been set out in the Chief Medical Officers TB Action Plan (Donaldson, 2004). This is particularly difficult to achieve in respect of the many TB cases in hard-to-reach groups. Directly observed therapy (DOT) is one strategy that may be used to facilitate successful completion of treatment and to prevent the patient being lost to follow up. However, providing DOT for an increasing number of patients is stretching current resources to the limit. It is not clear how many patients require DOT annually but it is likely to exceed the 11% of cases in 2010 highlighted by the HPA (2011d). Despite the use of DOT, a number of patients still fail to complete a full course of TB treatment. For many patients, taking their TB treatment is not a high priority as they struggle with obtaining the basics of shelter and food for their survival. The closure of sanatoria has meant that there is nowhere for patients to go if they need inpatient care and support to complete their TB treatment. While it is true to say that the question of whether sanatoria were successful or not remains controversial (McFarlane, 1989; Condrau, 2010), many argue that their closure was a big mistake. The Royal College of Physicians of Edinburgh, for example, suggests that whatever their deficiencies, these institutions at least provided the discipline for administering regularly and meticulously whatever therapy was on offer (Holme, 1997: 31). In the authors view, there was much to commend sanatoria care with the emphasis on fresh air, rest, exercise, good nutrition and psychological support. There is a compelling argument for the reinstatement of similar facilities for the management of TB among the homeless and those from other hard-to-reach groups. For an increasing number of complex cases, the availability of appropriate accommodation may be the key factor in determining whether a successful cure is achieved or not.

appropriate infection control measures aimed at reducing disease transmission, promoting patient concordance with TB medications, education about TB treatment and prevention, as well as supporting patients commonly experiencing fear and stigmatisation. There is also much to be learned from the pre-chemotherapy era. While sanatoria have been the subject of criticism, their demise has left a major gap in service provision, especially for the homeless and others who need access to accommodation, care and support to facilitate successful completion of their treatment. It has been clear for some time that TB is increasingly affecting those predominantly from hard-to-reach groups suggesting a direct link with poverty and widening social inequalities. Nevertheless, national recommendations to overhaul TB control and prevention and to mitigate some of the effects of poverty have been in the public domain for a number of years. Unfortunately, many of the key recommendations have not been implemented and funded consistently across the UK. The present lack of funding is reminiscent of the failure of health services to provide inpatient TB care and treatment to all of those who needed them in 1948. To that extent, TB remains the Cinderella service that it has always been. The Government has argued that the new NHS reforms focus on the needs of patients as well as empower health professionals (DH, 2010). The acid test for the success of these reforms is whether the services and measures needed to significantly reduce the incidence of TB are commissioned and appropriately funded consistently across the UK. The early signs are not good. The much publicised Pan-London TB Plan (London Health Programmes, 2011), which had been scheduled to launch in April 2012, has been derailed by the current NHS reorganisation. Nurses have historically contributed greatly to TB treatment, control and prevention in the UK. There is no reason to believe that this will change. Contemporary nurses do, however, have an opportunity to demonstrate leadership by ensuring that TB is accorded the priority it deserves from NHS service commissioners. The 2012 Olympic Games may draw attention to the relatively high rates of urban TB while the media spotlight is on London. However, whether or not this ultimately leads to progress in the reconfigured NHS is BJN another question entirely. Conflict of interest: none.
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Conclusion
In the period since 1948, TB in the UK has shifted from being an illness that frequently resulted in death to one that is mostly curable. Although there have been a number of developments in nursing care over the past six decades, remarkable similarities remain. Like their 1948 counterparts, modern nurses are engaged in implementing

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Key points
n Modern treatment has rendered TB a largely curable illness n TB is increasingly affecting those from hard-to-reach groups n There is much to be learned from the pre-chemotherapy era in the contemporary management and prevention of TB n Increased funding and political commitment is required to implement existing national TB management, control and prevention guidelines consistently across the country

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Copyright of British Journal of Nursing is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Copyright of British Journal of Nursing is the property of Mark Allen Publishing Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.