In my role as a TB Nurse Consultant, I lead the East Dorset TB Service. Based at University Hospitals Dorset, my colleague Susie Barrett and I facilitate the diagnosis of, and provide nurse-led treatment and management for, all cases of tuberculosis (TB) and latent TB infection across East Dorset. Although based in a hospital, we also provide community care. We were very pleased to achieve second place in the Infection Control Nurse of the Year category of the BJN Awards 2020.
Pete
This story began with a prolonged hospital admission for Pete, a 58-year-old polite man who was a rough sleeper. He became homeless after losing his job. Pete was suffering from TB, which had damaged his lungs, rendering him infectious to others.
Without UK citizenship and not having been employed in the past 6 months, the local council's social care and housing departments' assessments concluded that Pete had ‘no recourse to public funds’ and was not eligible for their support.
Discharging Pete back into homelessness, where daily adherence to 6 months of TB treatment was unlikely to be maintained, was just too risky. The only short-term option was for Pete to remain an inpatient while agencies negotiated who would pay for his accommodation and sustenance once discharged. After 3 months and several multi-agency teleconferences, shared financial agreements between the NHS and local authorities enabled Pete to relocate to live near his son. With this support, Pete recovered from his TB. Remaining sober, Pete regained regular employment and even took up jogging.
The social and financial impact of Pete's TB extended further than the need for treatment, food and accommodation; a much-needed hospital bed had been taken up during the winter season, with an estimated cost of £25 000. Having been coughing for 6 months, it was also highly likely that Pete had infected other homeless people.
The TB problem
An estimated 23% of the global population is thought to have a latent TB infection (Houben and Dodd, 2016). Around 10 million people fall ill with active TB each year and it remains one of the top 10 causes of death, and the leading cause of death from a single infectious disease (caused by the bacterium Mycobacterium tuberculosis), ranking above HIV/AIDS (World Health Organization, 2019).
In 2018, 4655 people were notified with TB in England, a rate of 8.3 per 100 000 population (Public Health England (PHE), 2019). Of these, 13.3% had a social risk factor such as homelessness, drug or alcohol addiction or a history of imprisonment (Nguipdop-Djomo et al, 2020), the highest proportion since data collection began in 2010. Social risk factors are associated with infectious pulmonary TB, higher rates of drug resistance and higher mortality rates (PHE, 2019).
Health screening event
Before hospital admission, Pete had spent 6 months sofa-surfing and sleeping rough. He often attended a Salvation Army rough sleepers' drop-in centre for food, support and to socialise with other homeless people. The centre supports around 80 people a day but this is a transient group, so it was impossible to determine who Pete may have infected with TB.
In conjunction with local health agencies, an agreement to fund a homeless TB and health screening event was reached. Additional hepatitis, housing, GP, mental health, street services and addiction teams were invited to join the event, held in a church hall opposite a local homeless drop-in centre. More than 200 posters and leaflets were distributed to addiction services, GP surgeries, shelters, day centres and soup kitchens (Figure 1), and the event was also advertised on social media. Thirty-six staff and volunteers from the street service teams were given TB education and briefed to spread the word about key locations where buses and taxis would pick up homeless people to bring them to the event.
During the planning, it was anticipated that perhaps 30 or 40 people would attend for screening. Largely due to the tremendous efforts of the Salvation Army and street service teams rounding people up, a massive 140 people who were sleeping rough attended the event.
In total, 138 received a chest X-ray from a mobile X-ray van, 86 received a TB screening blood test and 78 were screened for bloodborne viruses.
Five people from this screening cohort have now been diagnosed with active TB and given treatment (Figure 2). Twelve people were diagnosed with latent TB, of which 7 agreed to treatment. One person was diagnosed with lung cancer and referred to our oncology team and 10 people with abnormal chest X-rays not consistent with TB were referred to their GP for consideration of further investigations. Three people were diagnosed with hepatitis C infection.
The local drug and alcohol team registered five new clients and re-engaged with one client who had previously been non-compliant. Of the 19 individuals seen by the GP, two were newly registered and eight were given follow-up appointments. One client was given an immediate referral to mental health services for acute psychosis. Three clients were housed on the day by the local authority housing team.
Feedback from the homeless people who attended was extremely positive, with expressions of gratitude and feeling valued (despite having to queue for tests). Comments from those who attended included:
The high attendance rate shows that homeless people are concerned about their health and will engage with health care when barriers are removed.
However, because the event was so successful, the aftermath swamped our tiny TB service. For several months we found ourselves cross-matching results, ensuring that client and GP communication was accurate and patients were offered appropriate follow-up, investigations, treatment and advice. The largest challenge, however, was trying to get each homeless person who had been diagnosed with active or latent TB fully engaged with the housing, addiction, mental health and benefits support needed to help them through a 3–6 month course of TB treatment.
Becky
Becky's case offers an example of the wider barriers to health faced by homeless people with TB. Becky, who was 34, had attended the TB screening day and tested positive for latent TB infection. We later found Becky living between the streets and a garden shed. She fully engaged with further investigations and agreed to take a 3-month course of treatment.
Before starting treatment Becky required emergency accommodation, a mental health assessment with changes to her psychiatric treatment, access to a food bank, referral for an intra-uterine coil and TB counselling. Becky coped well with her treatment until domestic/behaviour problems temporarily forced her back on to the streets with nothing but a jar of coffee and her TB medicines. Back to square one, the referral process restarted and, along with considerable multi-agency support, Becky completed her 3 months of treatment. By achieving this, Becky will help prevent onward transmission of TB to others.
Albert
Crucially, active surveillance was offered to those who declined latent TB treatment. This included a combination of appointments, phone calls, chest X-rays and sputum analysis. It was through this surveillance that Albert was later diagnosed with active pulmonary TB 5 months after the screening event.
Albert, who was 46, was sleeping rough in a tent behind local beach huts and drinking up to 3 litres of spirits a day. He provided a sputum sample during one of his follow-up appointments, which revealed that he had developed active respiratory TB. Albert was located and admitted to hospital for investigations and initiation of TB treatment.
As a direct result of the collaborative relationship established with the housing team during the homeless screening event (and as a great relief to our hospital bed management team), Albert was able to be discharged into local emergency accommodation within 4 days of his admission to hospital, a huge improvement over Pete's 3-month admission.
Albert received daily, then weekly, supervision from the TB team and worked incredibly hard to refrain from drinking alcohol. Apart from TB, depression and alcoholism, Albert's main barrier to recovery stemmed from being an unemployed foreign national. Not only was he penniless ‘without recourse to public funds’, he had also lost his passport, which prevented him from legally working in the UK and he could not afford new passport fees or to travel to apply for a new one.
As with so many cases of TB within underserved populations, it was abundantly clear that successful TB treatment and recovery from alcoholism would only be achieved if Albert was able to regain his ability to achieve independence. Without this, he would lose his emergency accommodation at the end of his TB treatment and likely slip back into homelessness, depression and alcoholism. Understanding this, Chesthelp, a local TB charity, kindly funded Albert and a chaperone to travel to London by bus, then a taxi to his home country's embassy and paid for a replacement passport. Sandwiches were packed for the journey by the Salvation Army team to prevent the need to hand over cash.
Defying any concerns that we might never see him again, Albert returned that evening and a month later, armed with a new passport, he applied for UK residency, opened a bank account and applied for work. Albert has now completed his TB treatment; he is contributing to our local economy, self-funding his accommodation and is working full time in a well-known food outlet. It is nearly a year since he last drank any alcohol.
‘The high attendance rate shows that homeless people are concerned about their health and will engage with healthcare when barriers are removed’
Conclusion
Infection control encompasses far more than the essentials such as decontamination, personal protective equipment and handwashing. It requires co-ordinated multi-agency collaboration to tackle fundamental barriers to health such as unemployment, homelessness, addictions, poverty and mental health problems. Effective TB control demands that we address these wider barriers and, where appropriate, move health care away from traditional hospital-based clinics into our communities where direct engagement and patient support is desperately needed.
We need to challenge our prejudices and believe in people's innate ability and desire to stand on their own feet.
This experience has shown our team that homeless people are just as concerned about their health as the next person and, if the barriers to health are torn down, people are empowered to engage.