Lessons learnt from managing a complex tuberculosis case: treating a client with tuberculosis whose social and economic situation is poor and lifestyle risky presents a public health nurse with some major challenges.

Tuberculosis is a disease that continues to cause problems worldwide--numbers of infected people in New Zealand continue to be higher than in Australia. It is often associated with overcrowded living conditions, poor nutrition, poverty, alcohol and substance abuse, factors that can complicate the management of a TB case and present major challenges for a public health nurse (PHN). The case of Mr D, a Maori make in his 20s who was diagnosed with smear positive pulmonary TB, illustrates the nature of the problems that can be encountered from presentation of symptoms to diagnosis, and then to the completion of nine months of treatment. It does not touch on the many hours spent finding and working with his contacts and their treatment.

I met Mr D in late 2004 in the isolation unit. He was a tall, very thin young man, obviously image-conscious, wearing a cap, baggy trousers, a hooded sweatshirt and sunglasses with his cell phone close at hand. He presented with a two- to three-year history of cough with green, brown phlegm. He was seen by his GP in 2003 with a productive cough and muscular pain, diagnosed with bronchitis, given antibiotics, which he did not collect, and advised to return if he did not improve. Despite his continuing cough, his next visit to his GP was 15 months later when he presented with a Long history of night sweats, a 20 kilogram weight loss, shortness of breath when walking short distances and overwhelming fatigue.

His chest x-ray was consistent with TB, with a large cavity in the right upper apex. His sputum smear was positive and his sputum culture became positive after three days. This indicated he had an extremely high level of infectivity.

The initial interview showed that Mr D did not understand his situation, why he was in isolation and what this meant for himself and his visitors. His concentration was poor. I had to work hard to keep him focused on what we needed to cover and explained the issues several times. Confidentiality was an issue, because he feared he was in danger of being beaten if his friends--particularly the people he associated with one day a week at the Community Probation Service--learned of his diagnosis.

Because of his illness he had failed to report to the Probation Service for some weeks and a warrant had been issued for his arrest. This was a huge concern and was the first thing I sorted out for him. I found myself involved with the justice system on many occasions throughout his treatment.

As our relationship developed, I realised that Mr D had some characteristics which were protective, enabling him to survive, and others that worked against him, adversely affecting his health and influencing the issues needing to be addressed throughout his treatment.

Resilient characteristics

Mr D was a likeable, social person with a great sense of humour who related well to children. He always intended to do good even though he was easily misted. He was resilient and was able to manipulate most situations to his advantage. He knew how to access and use health and government systems when it was useful to him. He had a lifelong history of poorly controlled asthma with a chronic cough which caused some difficulties with his initial diagnosis.

Mr D often lied, stretching the truth to enhance his image. But honesty and trust were crucial to our working relationship and his lies often complicated our journey. He was a binge drinker and a regular user of cannabis and methamphetamine. When using methamphetamine his personality would change and, on those occasions, I did not feel safe with him. He had been in prison on a drug-related charge several years prior to his diagnosis.

Several of the socio-economic factors regarded as health determinants are reflected in his case. Income and poverty, among the most important determinants of health, are closely associated with employment and basic population-based services, such as water, electricity and transport. (1) Mr D was on the unemployment benefit, which was often stopped because he did not attend appointments with his WINZ case worker. He then did not have the money for transport to meet the case worker or for food and bills, including electricity and his cell phone. There is good evidence that unemployment is detrimental to both physical and mental health, because employment provides income, social status, social contact and regular activity. It also improves self-esteem. (1) Mr D spent his days "hanging out" He had never been employed. He complained of being lonely and bored and did not appear to have the self-confidence to apply for work.

Family background

Education is strongly related to occupation and income. Literacy skills are critical for coping effectively in society. (1) In his early childhood, Mr D's family were transient. Consequently he attended five primary schools and was expelled from two high schools. He never completed his high school education.

Good levels of social support enhance health. People with strong family and community ties have better health than those who are socially isolated. (1) Mr D came from a large family. His parents separated when he was at primary school His mother moved to another city and struggled to cope with all of her children. Even now she has limited contact with them. They do not know how to contact her and she contacts them when she is able.

Culture refers to accepted patterns and behaviours within identified groups in society. (1) Mr D mixed with young people who were associated with gangs, drugs, alcohol and violence. His father had been a leader within one of the local gangs.

Housing involves the quality of accommodation, its location and overcrowding. (1) After Mr D left home he led a transient lifestyle, staying with friends and extended family. He never had his own home. When I met him he was living in a boarding house.

For Mr D to complete nine months of TB treatment successfully, it was essential our relationship allowed him to feel good about himself, genuinely cared for, and listened to with boundaries that were flexible and constantly being renegotiated. Working with people who are diagnosed with TB is unique because the extensive contact tracing enables the nurse to establish a relationship with most people involved in the client's life. This allows the nurse to have a good knowledge of the client's networks and support, which in this case was another reason for the successful completion of treatment.

The main issues addressed in Mr D's case were his management of his hospital isolation and then home isolation, inappropriate housing, poor nutrition, finances, liaison with the justice system, his alcohol and drug abuse, the safety of the nurse, compliance with medication and management of the daily observed therapy (DOT). Nurses working with TB cases work under the Tuberculosis Act 1948, which states that people must take their medication. DOT involves the nurse delivering the medication and ensuring the client swallows it correctly. The TB medication is broken down by the liver and therefore it is recommended that patients avoid alcohol while taking it.

Generally after two weeks of TB treatment we can assume that clients are no longer infectious but, in cases with high levels of infectivity, this can take much longer. In Mr D's case this took approximately eight weeks.

Managing client's isolation

Managing the home and hospital isolation was difficult because of Mr D's Lifestyle, smoking and drug and alcohol habits. During his hospital stay he spent hours outside smoking, which frustrated the ward nurses. He had many visitors who did not always wear masks and often turned up very late at night. After ten days in hospital isolation he disappeared and went to a party with his friends. I was contacted by the ward, and with the help of his friends, found him and returned him to the isolation unit. This emphasised to Mr D very early in his treatment that protecting the public from infectious patients is paramount and that, as health professionals, we were serious about treating him and that we cared about him.

There was never going to be an ideal place to manage his isolation, because of the difficulties the ward staff faced and the risk to other patients. After three weeks' hospital treatment, he was discharged home to the boarding house. He was advised to wear a mask whenever he left his room; a microwave was provided for heating his meals; and he was allowed to socialise with his friends outside. Later we helped him get his first home, a flat situated near his friends.

Negotiating treatment times

It is important that the TB medication is taken daily for the first two months; for the remaining treatment it can be given in larger doses twice weekly. It was decided to set firm boundaries around medication management from the very beginning. The first morning after Mr D's hospital discharge I visited him at home with the local Medical Officer of Health and a contract which would oblige him to be home every day between 8 and 9 am and to take his medication. He refused to sign the contract, because he felt it would be impossible to always be at home, but he could promise to always have his cell phone switched on so I could phone each day to establish his whereabouts. Mostly, if the cell phone battery had not gone flat or he had not lost his cell phone, this arrangement worked well. When his cell phone was not working, I would contact his friends or his sister who could tell me his whereabouts. I medicated him in many settings--the beach, his friends' flats, the local district court cell, at court, at parties.

He quickly understood the potential combined effect of alcohol and the TB medication on his liver, most often substituting alcohol with drugs. He managed to do this for several months until he succumbed to pressure from his peers. During this time he was on twice-weekly medication, which was administered Monday and Thursday mornings. Wednesday was benefit day and in the evening he would often binge on alcohol. Thursday mornings then became problematic because he would try to avoid taking the medication by not answering the door or cell phone. On two occasions he admitted pretending to take his medication and throwing it away because he was worried about the effect it would have on his liver after heavy drinking sessions the night before. These were the only doses he missed in his treatment. Once we identified this as an issue we administered the Thursday dose late in the afternoon.

Maintaining personal safety

There were many occasions when I felt unsafe, particularly when Mr D had been bingeing on alcohol or drugs. I would then leave the flat and return later. As a team we often discussed this issue and we decided I would always phone Mr D before visiting to assess the situation. If in doubt, I visited with another nurse or met in a neutral place Like the beach. I always carried a cell phone and let another team member know where I was.

Mr D completed nine months of treatment. Eight other people were diagnosed with TB as a result of their contact with him, three of them young children. Of the 117 people screened, 29 had positive mantoux tests and 15 were given Isoniazid treatment for latent TB. Many of these required DOT to ensure they completed the treatment. We helped two other family members move into more suitable accommodation.

In contrast to Mr D is the case of another TB client I dealt with who had a similar chest x-ray, sputum smear and culture result. This client was in good employment, owned his own home and car, was married with good support from family and friends. He presented to his GP as soon as he developed a cough and felt unwell Because there was limited improvement with the introduction of the antibiotics, a chest x-ray was done and TB was diagnosed within a month of symptom development. The treatment was uncomplicated for this client, no further TB cases were identified and, out of the 79 people screened, only two required Isoniazid treatment. Mr D's case was challenging and taught me many lessons. I learned the importance of putting aside my own values and seeing the good in someone else's; of emphasising the good points in people who have been faced with negative messages throughout their lives. I learned relationships need to have boundaries and take time to develop. I learned never to judge, to be patient and flexible, and to let the patient lead the way. I learned that people learn differently and that persistently reiterating health messages is important--when the time is right, the client will take on board the information you are trying to give. Finally, I learned to appreciate the strength and support of a good nursing team and to maintain a sense of humour.

* Some details have been changed to protect patient confidentiality.

1) National Health Committee. (1998) The Social, Cultural and Economic Determinants of Health in New Zealand: Action to Improve Health. Wellington: Ministry of Health.

Andrea Vause, RN, BN, is a public health nurse working for regional public health in Lower Hutt. This article is based on a presentation she gave at the National Navigating Futures Tuberculosis Conference in March 2006 in Wellington.