Dr. Alistair Story, University College London Hospitals

Infectious Disease | Tuberculosis

Battling tuberculosis in the time of COVID-19

28 July 2020

All local recommended safety guidelines followed at the time of interview.

People experiencing homelessness have extremely high exposure rates to airborne diseases. Dr. Alistair Story is putting tuberculosis (TB) – the world’s deadliest airborne infectious disease – back on the public healthcare radar by bringing treatments to susceptible communities knowing that a disruption in TB testing would have major consequences.

The homeless population in the UK and London has been rapidly increasing over the last decade. To meet their basic needs, most homeless are forced to share communal air space in clustered areas, which can provide the ideal breeding ground for airborne diseases. Counted as the deadliest infectious disease globally, tuberculosis is a major public health concern, particularly in large urban centers where hostels shared by rough sleepers are often the only option for food and shelter.

To reach this susceptible part of UK’s population, Dr. Alistair Story operates Find&Treat – a mobile health unit service across London run by University College London Hospital (UCLH). He and his team initially began the service to find and treat tuberculosis in populations struggling to gain access to mainstream health services. “TB is the single leading killer for many. The leading infectious agent on this planet. And the death rate from TB, the number of preventable deaths that have occurred from tuberculosis in the time that we’ve been seeing a pandemic of COVID-19, is an order of magnitude higher than the number of people who have died from COVID. But no one’s talking about that,” says Story.

“The number of preventable deaths that have occurred from tuberculosis in the time that we’ve been seeing a pandemic of COVID is an order of magnitude higher than the number of people who have died from COVID.” Dr. Alistair Story runs the Find&Treat service to reach this susceptible population in London and explains the importance of testing for both COVID-19 and TB, a respiratory disease that has been "killing us since the dawn of time" while the world’s focus is on coronavirus.
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If you are going to ask the population to stay at home, what does that mean if you haven’t got one?
Dr. Alistair Story, Clinical Lead, University College London Hospitals, Find&Treat Service

Communal air spaces – a high-risk environment

TB is more prevalent in London than any other capital in the developed world, a city that has seen the homeless population double over the last decade. Although a person might not actually have the coronavirus, individuals with a cough are being tested for it by default – while TB often remains overlooked. “People just don’t include TB as a differential diagnosis, whereas for us, it’s TB until proven otherwise,” says Story. With COVID-19 on the global radar, TB has been pushed even further into the background, although it’s still very real for the millions who suffer from this stealthy disease.

Not surprisingly, the highest risk of resistant TB is found in those areas of society that are least able to access diagnostics and adhere to treatment. For individuals without ready access to the medical care required to make an early diagnosis, symptoms can be overlooked or simply ignored by both patient and doctor, leading to widespread disease transmission. “All these groups have very clearly demonstrated increased risk of TB, and TB is an airborne disease. And if they're at an increased risk of TB, they’re at increased risk of COVID-19. Bottom line,” says Story.

Tuberculosis has taught the Find&Treat team many lessons, including where outbreaks of infectious diseases are likely to occur – so when the coronavirus pandemic started gaining momentum, they were armed with solutions. “We’ve been learning the hard way for nearly 20 years about how to control an airborne communicable disease, in this instance, on the streets. So, we sort of had a little bit of experience in terms of what might be necessary for our client group when we saw COVID on the horizon,” says Story.

Dr. Alistair Story
Dr. Alistair Story, who is based at University College London Hospital (UCLH), has set up a mobile health unit service - Find&Treat – which is now one of the most vital agencies involved in preventing, controlling and treating TB in London. Their mobile health unit is making a real difference to Londoners’ health, especially in the ongoing campaign to diagnose and treat TB among homeless populations, with the ultimate goal to eradicate homelessness.
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We’ve been learning the hard way for nearly 20 years about how to control an airborne communicable disease, in this instance, on the streets.
Dr. Alistair Story, Clinical Lead, University College London Hospitals, Find&Treat Service

People not pathogens

As the COVID-19 outbreak was ramping up in London and the UK, the Find&Treat team knew that with the right set-up, they could help curb the spread of COVID-19 and, while doing so, find and treat more TB patients. Their first course of action was to shut down communal shelters and move the population into a safer space. After identifying people who showed symptomatic signs of infection, the team set up a “COVID care facility” at a hotel near City Airport together with Médecins Sans Frontières (MSF) International – all within 24 hours. They then managed to commandeer a number of hotel facilities and move people from the shelters into the empty hotels where each person had their own room and bathroom. “I think it's quite clear that we cannot return to communal air spaces for homeless people in the near future. We must be providing people with the dignity of their own front door, their own room, and their own bathroom.” In the face of a lockdown, “If you are going to ask the population to stay at home, what does that mean if you haven’t got one,” says Story with conviction.

In fact, the team’s approach has been quite successful in preventing explosive outbreaks around London. When they first started screening for COVID-19, three to four percent of the population was testing positive – a number much higher than among the general population. With the backing of the Greater London Authority (GLA), Find&Treat had created the capacity to help protect one of the UK’s most marginalised groups by getting 14 facilities across London on board to provide each individual with their own room and bathroom. Creating this minimum standard of provision for homeless people showing COVID-19 symptoms was what enabled the team to prevent further outbreaks. According to even the most conservative parameters, Story estimates that his team has prevented hundreds of deaths and many more infections in the UK through their work.

Both Tuberculosis and COVID-19 are airborne pathogens that cause respiratory symptoms, fever and weakness. One major difference, however, is the speed of onset: TB can remain latent in the lungs for weeks or even years, while COVID-19 symptoms can occur within a few days. While the data regarding COVID-19 is changing daily, tuberculosis has been around for hundreds of years, providing reliable data of affected individuals. In 2018 alone, 1.5 million people died from TB, equalling more than 4,000 deaths a day. Adequate testing and treating has proven the most effective model to help curb the spread of both of these highly infectious airborne pathogens.
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It is now completely within our grasp to redouble our efforts to find social and technological solutions to TB. We can do it with COVID. We can do it for TB.
Dr. Alistair Story, Clinical Lead, University College London Hospitals, Find&Treat Service

Redoubling efforts

Story sees the COVID-19 outbreak as an opportunity to identify – and treat – more TB cases, which would have otherwise gone undiagnosed. “It's ironic, but it's been quite good for TB detection in our population group, as we’ve been actively looking for people with respiratory symptoms who are in need of diagnostic investigations,” he says. Tuberculosis is still highly present in London and the team has been finding a lot more cases recently through the current set-up. “TB is there. It never went away.”

“The reality is TB has been killing us since the dawn of time, in millions, and it begs the question: is it technologically insurmountable, or is there a bit of a lack of will and investment?” says Story. “When you think about the progress we've made scientifically, and therapeutically, and socially in terms of thinking about how we're going to actually live with COVID-19, it is a testimony to human achievement, but it shines a really bright light on what we’ve failed to do with TB.”

For him, containing airborne diseases within marginalized populations is the medium, eradicating homelessness is the ultimate goal. “We need a different approach. It comes down to outreach. It comes down to taking the model to people.” Almost half of the team lived the experience of being homeless and they now work for Find&Treat. “So they’ve lived and breathed TB,” says Story. “They're an amazing resource to actually understand how to engage with people, how to get them on site, and more importantly, how to see them not just as a kind of passive recipient of a service, but as an active participant in a service and a resource, a resource to controlling TB and COVID in their own right.”

Although COVID-19 and TB are here to stay for the foreseeable future, Dr. Story’s mobile health unit service continue fighting the good fight – and are seeing positive results. “It is in all our interests to get rid of TB because we share the same air. It is now completely within our grasp to redouble our efforts to find social and technological solutions to TB. We can do it with COVID. We can do it for TB.”

Sharing communal air space in clustered areas, high influx of people moving between crowded night shelters and day centers, substance abuse, HIV infection, malnutrition and lack of access to medical care required to make an early diagnosis all strongly contribute to disease spread among an already vulnerable homeless population. Due to the many risk factors, underprivileged populations living on the streets are even more susceptible to TB and other diseases, which can easily run rampant amongst this important risk group. Dr. Alistair Story and his Find&Treat team have prevented countless outbreaks in the community through early detection.
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