Tackling TB in London

What: The London TB Extended Contact Tracing Project (LTBEx) is a Public Health England (PHE) funded outreach programme to enhance and improve TB incident management across London

Who: Sarah Murphy – Lead Nurse and TB Nurse Specialist

As well as a multidisciplinary team of clinical nurses, health protection specialist and a consultant in health protection

Background: Sarah Murphy is the lead nurse and a TB nurse specialist. Sarah started working in TB as she was interested in infectious diseases and health inequalities. She was a clinical TB nurse specialist in the acute trust and community for 8 years. This innovative project was an opportunity to combine and develop public health and clinical nursing skills.

Approach: Prevention and protection

Location: London

Speciality: Community and public health nursing

What initiative or project are you involved in?

The London TB Extended Contact Tracing Team is an innovative project that has created the first dedicated team of clinical nurses and public health specialists. The aim of the LTBEx project is to improve the prevention and control of TB in London by focusing on providing effective incident management and contact tracing, which is a cornerstone of TB control. TB remains a significant public health problem, with London experiencing some of the highest rates in Western Europe.

What prompted the work?

Prior to LTBEx, incidents were managed by London’s 4 Health Protection Teams (HPTs) and contact tracing was provided by approximately 30 TB clinics. An audit found that there were geographical variations depending on the interpretation of national guidance and availability of resources. TB Services are restricted by commissioning boundaries, and are usually unable to offer screening to those who live outside of their area. This was particularly a problem when trying to screen contacts from institutional settings (i.e. work, educational or community settings), where the contacts frequently live in different areas to the exposure. This would require multiple and time-consuming referrals to clinics. Due to considerable pressures on TB services, it was often not possible for clinic nurses to complete timely screening of large numbers. This had resulted in low uptake of screening, variation in screening pathways, poor collation of outcome and incomplete public health action.

How did you initiate the work?

In 2012, the Health Protection Agency Development Fund awarded funding to start the LTBEx pilot project, with supervision by the HPA London Regional Office. The funding and supervision was subsequently provided by Public Health England until March 2016. The multidisciplinary team has been recruited and trained and has developed skills in clinical and public health TB care. HPTs and TB clinics were consulted throughout the process and invited to join the advisory group. LTBEx has created an adaptive model to work in partnership with HPTs and TB Services. LTBEx has received positive feedback from HPT and TB colleagues that it is an acceptable and beneficial approach in TB control.

What difference has the project or initiative made?

LTBEx is taking an innovative and multidisciplinary approach as for the first time it is bringing together Public Health Specialists and clinical TB nurses into a single dedicated team that can lead on, or assist with, the entire process of TB incident management across London. LTBEx uses an ‘Active Case Finding’ model by providing onsite screening within institutional settings, such as: schools, colleges, workplaces, detection centres and hostels. By providing a more accessible service, we aim to reach and screen more people who have been exposed to TB than previously achieved. This is important to TB prevention as early identification of both active and latent TB cases not only improves the individual’s outcome, but also prevents onwards transmission to others.

By taking a pan-London approach we address previous geographical variations and are able to provide a consistent and standardised approach for all Londoners to tackle existing health inequalities and improve access to healthcare. We have created the first pan-London contact tracing database which is informing complete public health action and future evidence-based guidance. Screening in the community in institutional settings provides opportunities for health promotion, TB awareness sessions and addressing the stigma strongly associated with TB.

The LTBEx model has benefits for patients, healthcare professionals and the public’s health. LTBEx has improved patient’s experiences by providing accessible, timely and effective care by taking TB contact screening out into the community in the location where exposure occurred. This approach aims to address health inequalities and remove some barriers which prevent contacts attending clinics. Onsite screening is particularly valuable for screening children, young people or vulnerable adults, as they can be screened in a familiar and safe environment.

Data has shown that LTBEx has a minimum of 15% increase in uptake of contact screening, compared to when patients were referred to clinics. LTBEx onsite screening enables large numbers of contacts to be screened in a timely and systematic way, with minimal disruption to the TB clinic’s essential functions. It also facilitates timely collation of results and prompt identification of outbreak situations and the need for further public health action. By screening more people in a timely and effective way, we have been able to prevent future cases of TB disease which could lead to further onward transmission. Onsite screening also offers the opportunity for health promotion through awareness raising sessions and school assemblies.

What are the long-term objectives?

Unfortunately there is no longer any funding for the project.