Boston - an eye-opening experience

Forum committee member Sue Dart writes.

As part of the RCN TB Nurses Travel and Research Award, I travelled to Boston, USA in April 2008, to observe TB management in Massachusetts. Below are a few immediate impressions that I came away with:

  • Numbers of TB cases were small: in 2007, of the 224 cases of TB (3.53 per cent per 100,000) in Massachusetts, 49 of those cases (8.3 per cent per 100,000) were within the inner city of Boston. A large part of the work is now centred on providing prophylaxis, which they offer to anyone with a positive mantoux, regardless of age.
  • TB cases in Massachusetts have a similar profile to those in the UK: the majority of patients are not born in the USA; and in Boston itself, at least 18 per cent of those diagnosed with TB were classified as homeless.
  • There was provision of a flexible service to the homeless: providing both treatment and prophylaxis. One 200-bedded shelter I visited also had a health clinic on site, open seven days a week. All new users of the centre were given a skin test and symptom check and any positive results were referred to the TB clinic that was held two evenings a month on site. Compliance rates with prophylaxis were reported as good, and staff attributed this to a good working relationship with the TB doctor and nurse and with having the clinic on site; this kept TB management at the forefront for staff and clients alike.
  • Visiting the Lemuel Shattuck Hospital and its dedicated TB unit that provides support for TB patients either with complex medical disease or for those with adherence issues was a positive experience. The unit is rarely used to detain patients forcibly, but the staff who I spoke to said that having such a unit was a benefit and it was often used as a stepping stone for patients with complex social needs.
  • The benefit of centralised management was clear: In Boston, TB management is the responsibility of the Department of Public Health and the Division of Tuberculosis Prevention and Control. Whilst no system is completely without difficulties, it did seem that having one controlling body created a system in which there were clear lines of responsibility and accountability.