Identification of Refugees at Risk of Drug-Resistant TB

A Case Study

Rates of Tuberculosis (TB), and drug-resistant TB in Ukraine are much higher than the UK. The humanitarian crisis in Ukraine prompted the arrival of refugees into the UK, but the UK faced public health concerns because the UK no longer routinely vaccinates against TB. An emergency response to rapidly identify and screen Ukrainian refugees for TB was needed…

The outcomes from this case study:
Rapidly developed, rapidly implemented
The guideline and supporting resources were developed rapidly, in time for the first wave of refugees to arrive in Wales.
Coordinated national data collection
A national data collection effort, recording the screening of all refugees at risk of drug-resistant TB arriving in Wales.
Informing service provision
The information collected during the audit helped coordinate healthcare provision and policy.
Protecting both refugees at risk of TB, and local communities
This programme helps protect individuals with drug-resistant TB who are at risk of poorer health outcomes, and local communities who are at risk of transmission of infection.

Background to the project

Asylum seekers and refugees are at high-risk of reactivation of Tuberculosis. Early screening, particularly to detect active TB, is vital to exclude ongoing transmission and ensure treatment success.
Ukraine has one of the highest rates of Multi Drug-Resistant Tuberculosis in the world. The humanitarian crisis in Ukraine prompted the arrival of refugees into the UK, resulting in an impending public health crisis, both for:  
  • Individuals with MDR-TB who are at risk of poorer health outcomes due to delays in diagnosis and initiation/ disruption of treatment
  • And local communities who are at risk of transmission of infection
Following the success of the COVID hospital guideline, successfully implemented using ICST’s Emergency Implementation Science Methodology, ICST were asked to produce and implement the following innovations:  
  • A guideline for designated TB teams within each health board, for identification, screening, assessment and management of refugees
  • A national data collection effort, recording the screening of all refugees at risk of drug-resistant TB arriving in Wales, to help coordinate healthcare provision and policy

The journey of success:

Innovation development, under time pressure
The early stages of the implementation process ensures that the product is prepared for the new environment, and that the environment is prepared to receive this product.
Establishing the teams
Identification of those who would be involved in the development of the innovations (the innovation team), the team who would oversee the governance of the process and content (the governance team) and the team that would oversee the implementation of the innovation into the system (the implementation team).
Alignment and awareness campaign
As part of ICST’s implementation methodology, the active alignment of key stakeholders, or people with influence in the system, is key to ensure that there are no barriers to implementation. In doing so, ICST supported NHS Wales to run awareness campaigns prior to the launch of the NHS Wales Toolkit for the identification and screening of refugees at risk of Drug-resistant TB, to ensure that every specialist TB team were aware of this new process.

Ongoing implementation success:

Continuous optimisation of the toolkit
Throughout the implementation, ICST monitors the uptake and engagement of the innovation, as well as survey data and feedback from the audience. The findings from this help inform further development work, ensuring that the innovations continue to be optimised for the audience. One such finding, suggested that the data collectors who were entering data into the audit forms, were confused about the different categories of patient outcome (e.g. Latent TB infection, Non-Pulmonary active TB). The form was updated to ensure that the definitions were clear and without ambiguity.
Active implementation work
During active implementation, ICST leads the implementation team towards implementation success, monitoring a whole range of proven implementation factors (we call them Enablers), to ensure that the value is realised for this implementation project.

Barriers overcome

Short timeline for development
The arrival of refugees into the UK from Ukraine happened rapidly, with a scheme to identify host families to support their arrival.
The process needed to be agreed, and the guideline published and implemented within a matter of days, to ensure that families and refugees were protected from active TB infection.
Making the complex simple
It was important that the categorisation system of people at risk of TB was really simple, and the subsequent management pathways were clear and straightforward.
It was clear that there were four distinct categorisations, which were clearly represented in the pathway.
Staggered implementation
The arrival of refugees in different areas of Wales was staggered, and therefore the implementation of the guideline was more urgent in those healthboards with the earlier arrivals.
This was identified, and the implementation process was coordinated to ensure that those frontline teams were aware promptly.

”It’s a simple pathway. Once those people are identified, and are fed into the expert teams who know how to manage tuberculosis, we will be successful.”


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