An attempt to improve Tuberculosis Screening of international students enrolling at University of Glamorgan in line with British Thoracic Society guidelines

A collaborative initiative between UOG Dept of Student Services Health Centre and Respiratory Unit Pontypridd and Rhondda NHS Trust

Summary

What we did:

Increased uptake of screening for TB from 8.3% to 97% by:

• Liaising with International Support Unit to target students during induction week.
• Utilising web/hard copy information to promote Health Centre registration and TB screening clinics.
• Including Health Centre registration/TB screening sessions in the international induction week programme.
• Promoting screening and giving individual appointments at Health Centre registration interviews.
• Collaborating with specialist TB nurses to provide clinics in the Health Centre on campus as required.
• Holding clinics which, in line with British Thoracic Society guidelines, offered heaf testing and referral for chest Xray and BCG if necessary.

• Government initiatives were encouraging an increase in overseas students in Higher Education.
• Glamorgan planned to expand its international recruitment. Many of the countries targeted were TB high risk areas.
• The World Health Organisation identified an increasing incidence of TB in the UK.
• During 2003 2 cases of TB were identified within the Glamorgan student population (see History).
• The Health Centre had previously relied on ad hoc presentation of international recruits for registration. This depended on individuals taking the initiative and was unreliable.
• The system for identifying health risks and potential cases of TB was time consuming, sporadic and attendance for screening was poor.
  

• Improved understanding of the importance of screening.
• 100% attendance for screening.
• Targeting of potential problems.
• Provision of a seamless service for referral.
  

When we did it:

Work began with planning in July 2004. The initial pilot was completed in December 2004 but following its success is set to continue.

What evidence is there to support our work:

TB Screening Figures

Outcomes

How has our work benefited patients:

1. We have reduced the risk of TB amongst individual international recruits and also other members of the University community.
2. There have been no reported cases of TB since 2003.
3. We have improved awareness not only of TB but also other health issues by increasing the attendance of international students at the Health Centre.

Taking it forward:

• The results have been disseminated within the University and NHS trust as an example of good practice. The National Public Health Service for Wales has been made aware of the effectiveness of our system.
• The collaboration and provision of flexible campus based clinics is to be extended next academic year to provide daily clinics at peak registration times in an attempt to achieve 100% attendance.
• It is planned to offer BCG vaccination on campus in future.
  

Further Details:

History

TB screening of incoming international students was never really successfully addressed at University of Glamorgan until 2004.

Efforts were made after 2 cases of TB during 2001 and 2002 to improve the situation. Following discussion between the TB specialist nurse involved with the cases and the Health Centre Manager specialist nurse sessions were booked in the Health Centre on campus. Appointments for all port of entry notifications were prepared by the respiratory unit and sent as a batch to the Health Centre. These were posted out from the Health Centre once students had registered and had a local address. Uptake however was low.

During 2003 two things happened. First, there was an unexpected (from a Health Centre perspective) 100% increase in international students registering. Second, a student from India presented at the Health Centre coughing up blood. He was admitted to hospital. He had been identified at port of entry as having a suspicious chest Xray but had failed to follow this up as instructed. This case highlighted the current inadequacy of port of entry screening.

TB requires an intensive 6 month course of antibiotic therapy. The student failed to comply with this on discharge from hospital so had to be readmitted for directly observed therapy for 2 months. Following this he was seen regularly in the Health Centre by the TB specialist nurse to ensure compliance.

Meanwhile close liaison between the Health Centre / TB nurse specialist / Accommodation staff and academic staff was required to:

• trace contacts among friends and students in the same corridor
• trace contacts in the same tutor group
• make presentations to both of the above groups to raise awareness of the disease, explain contact tracing procedures and also to allay anxiety.

Longer term results of this experience during 2003 were:

• a greatly increased collaboration with the International Support Unit (ISU)
• writing of international health information of 2 types:
     - Pre arrival information which was integrated into Health Centre web pages and the international first experience handbook which is sent out to new students.
     - During your stay information which is given by hand on registration in the Health Centre.
• writing of a non compliance amendment into the University's Communicable Illness Protocol.
• planning of much closer liaison between TB specialist staff and the HealthCentre and ISU as documented below.

TB screening appointment procedure 2004

1. ISU organised a pilot induction week for international students coming to UOG. Health Centre staff and TB nurses were involved in planning TB sessions to coincide with days when the students were required to be around on campus for other sessions like organising bank accounts and police registration. Close liaison was on going regarding numbers.
2. TB nurses were very flexible with planning of further sessions to accommodate both students requiring follow up screening and those arriving after the induction week. In all 10 sessions were held during term one between 20 September and 2 November.
3. International students were encouraged to register with the Health Centre as soon as possible after arrival through a variety of means including web and hard copy information and induction programme timetabling and word of mouth encouragement by ISU staff.
4. At the end of each new patient interview international students were given a TB clinic appointment attached to the 'looking after yourself during your stay' information sheet and asked by nursing staff to attend.
5. Sessions were very well attended and accommodated both new registrations and follow up visits requested by TB nurses.
6. Further sessions were planned as above to coincide with new international intakes during the academic year in January and April.

TB clinic sessions procedure

1. TB nurse fills in form with basic details.
2. Student's general health ascertained.
3. Check for /document presence of BCG scar.
4. Heaf test performed if no scar.
5. Follow up visit to read heaf 3 -10 days later (as recommended in Jenner E 1996 Bicentenary edition Immunisation against infectious diseases).
6. Heaf negatives offered BCG at RGH.
7. If no recent chest Xray/evidence of BCG and student is experiencing any of the signs and symptoms of TB Xray form written and directions to Dewi Sant Xray Dept given.
8. If any suspicion of TB or an abnormal Chest Xray chest physician appt at RGH offered asap.
9. If student coughing up sputum 1 sample of this is taken each day for 3 days for laboratory testing for AFB (acid fast bacilli).
10. All students to be given information about signs and symptoms of TB and advised to visit HC/GP if worried .

Reasons for heafing:

Contact of smear positive TB
Scar difficult to distinguish
Either of above with poor h/o vaccination

Reasons for chest Xray:

Pre-guideline changes for port entry screening
Suspicious CXR at port of entry
Grade 3 Heaf

Reasons for referring to consultant:

1 suspicious CXR
1 Grade 3 Heaf

Althea Sharp, Nurse Manager University of Glamorgan Health Centre
Rhian Williams & Kath Bruce. Respiratory Nurse Specialists Pontypridd and Rhondda NHS Trust

January 2005