Nursing Practice

Review
Tuberculosis

Keywords: Tuberculosis/
Early diagnosis/Respiratory
This

article has been double-blind

peer reviewed

Tuberculosis is now a significant public health issue, and nurses need to know
itssigns and symptoms and which groups at increased risk of infection

How nurses can support

early diagnosis of TB
In this article...
 ow TB is transmitted
H
Signs and symptoms of TB
Groups at a high risk of TB infection
Author Sarah Murphy is TB nurse specialist
at London TB Extended Contact Tracing
Team, Public Health England.
Abstract Murphy S (2015) Nurses role in
improving early diagnosis of TB. Nursing
Times; 111: 13, 12-14.
Tuberculosis has re-emerged as a
significant public health issue in the UK.
Early diagnosis is essential to improving
patients outcomes and reducing the time
they are infectious. Nurses in all areas of
healthcare are well positioned to facilitate
earlier diagnosis of the disease. This article
looks at barriers and possible solutions.

SPL/Peter Lamb

aving declined throughout

most of the last century, tuberculosis has re-emerged as a significant public health problem.
The UK is experiencing some of the highest
rates of TB infection in western Europe,
prompting Public Health England to identify it as a key priority (PHE, 2014a).
The World Health Organization (2014a)
has identified TB, a serious but treatable
disease caused by Mycobacterium tuberculosis, as one of the worlds most significant
infectious causes of illness and death.
Although TB is primarily a disease of the
lungs (pulmonary TB), it can infect other
parts of the body (extrapulmonary TB),
including the lymph nodes, bones and
central nervous system. The infection is
spread through airborne transmission and
only cases in the lungs, larynx or tonsils
are considered infectious.

How TB is transmitted

When a person with infectious TB coughs

or sneezes, bacteria are expelled into the
air in respiratory droplets (Fig 1). These can
be inhaled by others and drawn into the

alveoli of their lungs, which initiates an

immune system response. If the immune
system kills the bacteria, they are cleared
from the body but, if not, the body
becomes infected with TB.
The bodys immune response is often
able to contain and inactivate TB bacteria;
the person is then said to have latent TB
infection (LTBI). This is asymptomatic and
not infectious, so it cannot be passed on;
however, there is a 10% lifetime chance
that the bacteria can reactivate and cause
TB disease. Activated LTBI is most likely to
occur in the first two years of infection, or
in patients who are immunocompromised
by other illness or old age (Williams, 2008).
If the immune system is unable to kill or
contain the bacteria, they can continue to
grow and multiply, causing sickness. This
is called active TB disease.

5 key
points

The UK has
some of the
highest
tuberculosis
infection rates in
Western Europe
10-30% of
people
exposed to TB will
become infected
More than one
in four patients
with pulmonary TB
start treatment
more than four
months after the
onset of symptoms
As well as
the lungs,
TB affects many
other organs
A proactive
approach may
be needed to find
TB cases

2
3

4
5

Signs and symptoms of TB

Symptoms of active TB disease can develop

weeks or even years after infection. They
vary depending on the site of the disease
for example, prolonged cough is associated with pulmonary TB, while localised
swelling is associated with lymph node TB.
Box 1 lists the most common signs and
symptoms; TB should be considered if any
of these have been present for more than
three weeks.

Diagnosis and treatment

Investigations used to diagnose active pulmonary TB include chest X-ray, multiple

sputum samples checking for acid-fast
bacilli, and Mycobacterium culture.
Sputum samples are crucial to confirm
diagnosis, assess infectiousness, determine drug sensitivities and inform public
health action. Sputum samples can be

12 Nursing Times 25.03.15 / Vol 111 No 13 / www.nursingtimes.net

X-rays are used to diagnose active TB

6 - 7 JULY 2015, BIRMINGHAM

CONGRESS

produced spontaneously or by induced

sputum or gastric washing (National Institute for Health and Care Excellence, 2011).
In extrapulmonary TB, biopsy and
needle aspiration should be considered
and a chest X-ray should be performed to
exclude respiratory involvement.
However, if there are clinical symptoms
consistent with TB, NICE (2011) recommends treatment is started without
waiting for culture results. TB is treatable
and, after two weeks of medication,
mostpatients are no longer infectious.
However, where there is drug resistance,
this can take longer and require closer
monitoring of sputum samples. A TB case
manager often a nurse specialist supports the patient to adhere to a combination of medications for a minimum of
sixmonths.

Role of nurses in controlling TB

To control the spread of TB and ultimately

eliminate the infection, control programmes must be focused on:
Prompt identification of new cases;
Timely start and support for patients to
complete treatment;
Prevention of new cases.
Early diagnosis is pivotal, as it not only
improves patient outcomes but also
reduces the possibility of onward transmission to others who are in close and regular contact with the patient. In the UK,
between 2004 and 2013, more than a
quarter of patients with pulmonary TB
started treatment more than four months
after the onset of symptoms, and the proportion of cases with this delay has risen
slightly in the past three years (PHE, 2014b).
Drug resistance is a growing problem
and is linked to failures to diagnose, prevent and adequately treat TB. A new fiveyear TB strategy for England aims to
address this and sets a target of 80% of
people with pulmonary TB starting treatment within three months, and 100%
within six months of the onset of symptoms (PHE and NHS England, 2015).
Nurses are essential to TB control and
elimination. While some specialist nurses

Box 1. Signs and

symptoms of TB
Cough
Haemoptysis
Fatigue
Fever
Night sweats
Loss of appetite
Unintentional weight loss

FIG 1. tb infection and testing

Exposure
to infectious TB
Exposure to infectious TB

TB infection
TB infection1030%
10-30%

No TB infection
70-90%
Active TB
disease 10%

LatentLatent
TB infection
TB infection90%
Patient reacts to
Tuberculin
skin test
protein from
is widely
used
dead
TB
bacteria
to test for
latent TB

care solely for TB patients, the vast

majority work in other areas and encounter
patients for a wide variety of reasons.
These nurses are in an ideal position to
identify possible cases of undiagnosed TB
and refer these patients to TB services to
achieve earlier diagnosis. It is therefore
important that all nurses are aware of the
signs and symptoms of TB (Box 1), especially those who work with high-risk populations, such as migrants, substance
users, homeless people and patients who
are HIV positive.

TB diagnosis pathways

The WHO (2011) describes two pathways to

TB diagnosis: the patient-initiated
pathway; and the screening pathway.
The patient-initiated pathway is often
called passive case finding as it depends on
patients presenting themselves to healthcare services, whereas the screening
pathway is called active case finding as
itinvolves targeting and screening highrisk populations.
The patient-initiated pathway includes
five steps, each of which can present a
potential barrier to early diagnosis:
Recognition of symptoms by the sick
individual or carer;
Accessing an appropriate
healthcare provider;
Identification of patients with
suspected TB by healthcare workers;
Accessing correct diagnostic tests;
Referral to specialist services.
Understanding and addressing these
barriers could increase early diagnosis.

Reactivation
10%

Why do patients present late?

TB does not respect socioeconomic or geographical boundaries, and anyone with

significant exposure can be infected; however, within many developed countries, TB
is concentrated in hard to find and hard
to reach populations (van Hest et al, 2014).
The vast majority of cases of TB are concentrated in large urban areas, with
London accounting for the highest proportion of cases in the UK (PHE, 2014b).
Zenner et al (2013) said risk factors for
TB were often linked with: migration from
an area with a high incidence of TB; lifestyle (such as homelessness or substance
misuse); or imprisonment. Access to
healthcare can be problematic for these
vulnerable groups, who are typically less
engaged with services than the general
population (Zenner et al, 2013).
Even when a service is deemed universal
and there are no direct costs to patients,
other important barriers can hinder access
(WHO, 2014b). These include marginalisation, language, stigma and discrimination. Factors such as unemployment, lack
of knowledge of health services, homelessness and concerns regarding immigration
status have been associated with delayed
access to care in developed countries
(French et al, 2009).
The WHO (2014) suggests that
improving access to high-quality TB services to ensure optimal TB management
includes: outreach, community screening
clinics and providing patient-centred, culturally sensitive and holistic care. NICE
(2012) has issued guidance for accessing

www.nursingtimes.net / Vol 111 No 13 / Nursing Times 25.03.15 13

Nursing
Times.net

Nursing Practice
Review
Tuberculosis
hard-to-reach populations and national
charity TB Alert (www.tbalert.org.uk)
coordinates community awareness activities that engage and use peer educators.

Delays before diagnosis

Even once a patient has presented to

healthcare services, TB might not be diagnosed promptly. Patients can present at a
variety of settings, most commonly primary care or accident and emergency
departments. Delays can occur if there are
low levels of TB awareness and clinical suspicion among health professionals, delays
in collecting appropriate diagnostic samples and complicated referral procedures
to specialist services.
Public Health England (2013) found that
patients with extra-pulmonary disease
were more likely to experience a longer
delay than pulmonary cases. This could be
due to the slower onset and wider range of
symptoms, which health professionals
might not associate with TB. There can
also be difficulties in obtaining microbiological samples; in 2013, only 59% of all
new TB diagnoses were confirmed by laboratory culture (PHE, 2014b).
Abubakar et al (2012) suggested that,
until there are high levels of awareness for
TB in all patient groups, early diagnosis
will not be achieved.
An essential part of a TB nurse specialists role is to promote awareness among
health and social care professionals, in
particular, those who work with high-risk
communities (Royal College of Nursing,
2012). Griffiths et al (2007) found evidence
that a primary care educational intervention to promote screening could improve
early identification of both active and
latent TB infection.

More proactive approaches

It is not necessary, practical or cost effective to screen everyone within the UK for
TB. However, potential groups for active
case finding are:
High-risk populations;
Those in high-risk occupational
settings, such as staff in health, elderly
and psychiatric care settings;
Patients with comorbidities for
example, those who are HIV positive
(Zenner et al, 2013).
Van Hest et al (2014) highlighted that
high population densities create specific
opportunities for TB transmission, but
also enable specific interventions that
would not be efficient or effective in a general population. Initiatives such as the find
and treat teams mobile X-ray unit, which
aims to access hard-to-reach groups by

Box 2: Actions for

promoting earlier
diagnosis of TB
Promoting awareness of TB
Increasing clinical suspicion of TB
Early collection of diagnostic samples
(such as sputum)
Simple referral pathways
Active case finding in high-risk
populations

visiting homeless hostels and soup

kitchens across London, have been found
to be effective (Story et al, 2012).
Within the UK, close contact (often in
the household or workplace) is the dominant cause of TB transmission (Begun et al,
2013). The aim of contact tracing is to identify and screen people who have had regular and prolonged exposure to infectious
TB. Unpublished data from PHEs London
TB Extended Contact Tracing Team shows
that on-site screening in community and
institutional settings (such as schools and
workplaces) is effective at detecting both
active and latent infection.
In about two-thirds of TB patients who
were born outside the UK, the disease is
not due to recent transmission, but reactivation of infection acquired abroad
(Abubakar et al, 2012). Screening and
treating latent infection in new migrant
populations is an important public health
action as it could reduce a significant proportion of TB cases. However, in the UK,
Pareek et al (2011) found screening for
latent TB infection was highly variable,
deviated from national guidance and was
inversely related to regional TB burden.

Conclusion

A delay in TB diagnosis causes poorer outcomes and increases opportunities for

transmission. Control of the spread of TB
requires early diagnosis and support for
patients to ensure they complete treatment
to reduce the time they are infectious.
Examining and addressing the barriers
of the patient-initiated pathway will assist
in achieving earlier diagnosis (Box 2). This
requires multiple actions including promoting the awareness of TB, increasing
clinical suspicion, early collection of diagnostic samples (for example sputum) and
simple referral pathways. In addition,
active case-finding initiatives are necessary to identify people who are at a higher
risk of TB infection but might not have
started the patient-initiated pathway.
With improved surveillance data, barriers to early diagnosis can be identified

14 Nursing Times 25.03.15 / Vol 111 No 13 / www.nursingtimes.net

For more articles on respiratory nursing, go

to nursingtimes.net/respiratory

and used to inform better-targeted interventions. Ultimately, TB control in the UK

also depends on global programmes, and
requires collaborative working and
sharing
evidence-based
approaches.
Nurses in all areas of healthcare are essential to TB care and control. NT
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