TB Talks, S2: Episode 4 – What it Takes


In the final episode of this series, TB program staff reflect on their lessons from the outbreak, including what worked well, and what is still needed for TB elimination.

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Shivoan: Hello, I’m Shivoan Balakumar, and this is TB Talk; an audio series by the National Collaborating Centre for Infectious Diseases.

This is our fourth and final episode of our current season, A Community Outbreak Story – produced in partnership with NCCIH, the National Collaborating Centre for Indigenous Health, and NITHA — the Northern Intertribal Health Authority.

An in-depth look at a 2019 tuberculosis outbreak in a small northern First Nation in Saskatchewan, our series so far has heard the powerful stories of TB survivors. In this episode, we feature the voices of TB program staff: both what they’ve learned, and what they believe would finally rid First Nations of the disease.

Nnamdi: So part of our approach to the outbreak management within this community was, um, um, basically framed around the TB high-incidence strategy.

NARRATOR: Dr. Nnamdi Ndubuka is a Medical Officer of Health with NITHA.

Nnamdi: – And the high-incidence strategy basically revolve around, you know, early case detection, active case finding, active management of latent TB infection, and also enhanced surveillance, and finally some advocacy around determinants of health.

These were the major pillars of our response to this particular outbreak and we did see value in this because these were already ongoing strategy in other communities.  But we kind of taIlored this approach to this community based on the resources that is available and also based on the ability of the staff in the community to also have some ownership from a public health point of view.

NARRATOR: One key part of NITHA’s response was to foster community collaboration and partnerships.

Nnamdi: The response also was around community engagement; so we used the opportunity to ensure that the local leadership were pretty much informed about the ongoing investigation and outbreak management. And the Chief of Council and the Health Director were all on board to support the outbreak plan which was jointly developed with the community nurses. And they were able to also promote TB education each time they have the opportunity there in community gatherings, or any meetings where they find themselves, and had the opportunity to let community members know what TB’s all about and how they needed to prevent TB.

There are also surrounding communities that ensured collaboration from a public health perspective, which was really a good thing for us in terms of creating awareness of TB, helping to ensure that issues around stigma was adequately dealt with in those particular neighboring communities. The other thing that is helpful: developing outbreak teams as quickly as possible.  We did help mobilize additional capacity for this particular community in collaboration with the tribal council. So, our lessons from a prompt deployment of an outbreak management team that was multidisciplinary was really very, very paramount.

NARRATOR: With the community on board, a strategy in place, and a rapid outbreak response team developed, the wheels of the outbreak investigation were ready to touch ground; and who better to quarterback its early steps than Shirley Nelson, a First Nations NITHA Community TB Nurse.

Shirley: My role was to do the contact investigation. So when I come here I am checking to see who the contacts are, which are high, medium and low priorities. I’m doing TSTs (tuberculin skin tests) on the ones that are eligible for that. And I’m doing symptom enquiries. I’m doing risk factor enquiries and health risk factors. So I’m doing that with each of the contacts, okay? Anyone that’s having symptoms we’re getting sputum samples, doing those assessments.  I’m also checking the history on their charts, all the contacts to make certain I’m not TST-ing anyone that’s not eligible. And I’m checking to see if they have TB history. I’m checking all that information out too. 

What’s at stake is lives. People could die from TB. And with this trace here, we found TB before it got really contagious in some of the clients. And we found a few extra-pulmonary cases of TB, areas other than the lungs, where it’s most contagious.

NARRATOR: Finding and treating TB before it spreads isn’t a one-person job; it requires a strong and dedicated supporting cast – particularly, public health staff known as Community TB Workers. In the case of this outbreak, that lead TB Worker was a local community resident named Kelly. She was essential to the investigation and took on more than her share of responsibilities — and clients.

Kelly: There’s too many to name [laughing]. No, but uh, when we – when during this outbreak I didn’t have a nurse, I only had Shirley, so when Shirley wasn’t here I was doing the DOT and trying to stay organized with the numbers.

Shirley: When we get the initial call, she’ll go and weigh and measure all the gap kids – kids that are between zero and five years old. So they’re started on meds automatically without real, any assessments and that. Plus, she’s – when I’m not here — she’s collecting sputums on anyone that’s having any symptoms. We collect a lot of sputums. Oh god.

Kelly: Collecting sputums too sometimes is a challenge: they don’t always do them. So you just have to keep, like, repeating home visits until I get them done.

Shirley: So we get TB Control, the infectious doctors involved, to support us in that area.  So a lot is occurring in a short period of time. And when she says it’s too much to list, it is a lot of work and a lot of – she’s, like, doing all that plus travelling to and fro, you know, different households. And they don’t just go once to notify somebody that they have a TB appointment; she’s there about three or four times. And she’s actually there to pick them up too. It’s not just one reminder. It’s several reminders. And several times to go to the home visit to get them to see the specialist.

Kelly: And then also TB clinics. The outbreak started in December and our first clinic was in January. I think we had 22 show up for clinic. And it was only from 10 to 3. So we saw 22 people in five hours.

Shirley: Some challenges that Kelly addressed with regards to TB clinics, okay? Is the attendance. What she did was she prepared some awesome meals, and that was a good draw to bring people in.

Kelly: Usually a TB clinic is once every three months. But since December, we’ve had one a month. So I’m planning those, sending out invitations for our contacts. And then when we don’t have the x-ray technician, we’re planning to send them out for x-rays. Make sure they go. And then when they’re done their x-ray, I got to make sure they come to clinic to see the doctor.  Sending people out for x-rays is a challenge. That, and then working with transportation to get people to x-ray, to and from, without putting anybody else at risk for TB. So if I had to take out somebody that was high risk, then I would probably take them myself instead of putting them on a taxi. Or hire an extra driver who’s willing to go.

Shirley: Another key role she plays in the contact investigation: she knows the people in the community. She knows where we need to go. So she’s the person that’s taking us to the home, and she’s introducing us to the people we have to interview. And um, she has that relationship with uh, community members. So they’re more apt to open the door for her.

Kelly: The active cases they get frustrated and really impatient, but you just have to let them take their frustrations out on you. But not – like, I’m not going to let them abuse me, but just make it easy for them.

Shirley: I think she allows them to vent. She develops a really good relationship with them. They really trust her. That’s one thing with Kelly, she’s a strong advocate for the clients and the clients feel so comfortable with her. They would contact her anytime, really. And she always provided them support, bringing them to the clinic if needed at any time. She was there for them: treats them like one of her family members. Honestly.

Nnamdi: Part of the successes that we observed was around the use of TB workers. So, currently, the TB workers work in an expanded scope of practice: in other words, they don’t just deliver the meds but they’ve also been trained in providing some kind of education to these particular clients. Either those on active treatment or those on prophylactic medication.  

Shirley: In order to have a really successful program, you need to have a TB worker that’s really passionate about what they’re doing, okay? Very organized. Understands the whole rationale behind giving meds. And somebody who is approachable and that the clients feel at ease to come to if an issue presents. Somebody who has knowledge about community, the people, who the people hang out with, and anticipate the support that the clients may need.

Talia: It’s good and they really – they check up on us a lot. And when we were in the hospital, they came, stopped by and gave us some gift cards to help us. Yeah, they were good. I usually always talk to Kelly when I come here.  Like, open up to her, yeah.  She’s a lot of help.

Nnamdi: I think they have a lot of credit to take: so I think those TB Workers really are a backbone for our TB program.

NARRATOR: Drawing on local expertise and human resources is critical to NITHA’s TB outbreak response strategy. Yet their ultimate goal is not simply to contain TB, but to eliminate the factors which drive its spread.

Nnamdi: There is a  need to address some of the key issues around determinants and specifically housing. You know, crowding really promotes the spread of TB, so every effort that could be directed to us improving the state of housing on reserve will really make a difference in not just preventing but also eliminating TB as a disease.

Shirley: Definitely more housing: we’re just talking today with regards to one of the clients. She has three children and going to have a fourth one. She doesn’t have a house. And she’s going from home to home to home, right? So definitely addressing the housing issue.

One of the social determinants is food insecurity. Because there’s no grocery store here they have to go an hour and 20 minutes out of town to get their groceries and come back. And those on social assistance have to pay a portion of their small amount they get for groceries towards somebody driving them to that town to purchase groceries.

Kelly: A single person only gets 305 [dollars] a month. So if I was on welfare I would get 305 and then if I had three kids, I’d get an extra $25 each a month for those kids.

Shirley: To be healthy you need proper nutrition. And if you don’t have any food then you’re not getting the nutrients you need.

Kelly: Our clients that are on TB meds, we always give them snacks, try to be high in fat or tell them to try and eat something before they take their meds, so that their body better absorbs the medication without making them sick.

A dietician said that clients in the program would be eligible for a few extra dollars on their cheque. But I’m not sure how to go about that yet.

Shirley: We’re trying to figure that out.

Kelly: Yeah. That’s another thing too is, like, for that trying to get the extra funds for the client, without — I don’t like talking about people’s health information without permission. So it makes it harder to try and reach out for help.

Emergency funds would help our clients in situations. Extra funding for TB, if something – another outbreak like this happens. Because we did have a mom who couldn’t pay her power bill. She was let go from her job for being away for so long in the hospital. And for, like, our other client who was discontinued from school, who got by on gift cards for three months. They get caught in these situations because of TB and we don’t know where to get help. Something like that would help them a lot in the program.

NARRATOR: While doing what they can to advocate for improved living conditions, food security, and poverty alleviation, NITHA and their partners have forged ahead with several promising initiatives to keep TB care closer to home, and reduce disease burden in northern communities.

Nnamdi: Some of the innovative approaches that, um, we employed which I think also has the potential to eliminate TB is around the use of mobile technology. So we deployed portable chest x-ray de-device which was used by the mobile clinic to ensure that individuals travel just once and during that visit they do their chest x-ray and then they see the physician that same day. As compared to, you know, travelling twice before seeing the TB clinician.

I think that has helped to ensure that the care is client-centred and we’re respecting people’s time and also decreasing the stress of people travelling more than several hundred kilometres the first time to just take the x-ray.

NARRATOR: Another piece of the puzzle for the Authority: a proactive approach to ‘LTBI’ — latent tuberculosis infections, or what some people refer to as “sleeping TB”.

Nnamdi: From our experience here, the LTBI pool in the communities is one major source of new infections. So every effort to decrease that LTBI pool, has the potential to eliminate TB. By way of providing targeted prophylaxis to those that are at risk — for example, those that are diabetic, or those that have chronic renal conditions, or those that have immune-compromising conditions like HIV or AIDS — I think would really be helpful as a key strategy to eliminate TB in northern communities.

NARRATOR: A multi-pronged strategy, strong community partnerships, trained local staff, mobile technology, and a proactive approach: for NITHA, these are the critical components of an effective TB outbreak response. Combined with interventions to improve living conditions and community resiliency, it’s a potent formula for TB elimination in northern First Nations.

Shivoan: That was our fourth and final episode of TB Talk, season 2 – A Community Outbreak Story, narrated by Rick Harp. We’d like to thank our partners on this series — NCCIH, the National Collaborating Centre for Indigenous Health, and NITHA, the Northern Inter-tribal Health Authority. I’m Shivoan Balakumar: thanks for listening to NCCID’s TB Talk.

Music on this podcast is ‘Helmer Sprak’ by Blue Dot Sessions, via Creative Commons license (CC BY-NC 4.0). Learn more at https://www.sessions.blue/.

Production of this podcast has been made possible through a financial contribution from the Public Health Agency of Canada, but the views expressed here do not necessarily represent those of the Agency. The host organization of the NCCID is the University of Manitoba. Learn more at nccid.ca.