We hope our latest edition of Health Matters – on the subject of “Reducing the burden of tuberculosis” – will help you and other health professionals by compiling key facts, figures and evidence of effective interventions.
Where we can, we’re also committed to answering your questions and taking on your feedback. In this blog we’ve published the answers to a number of Health Matters tuberculosis questions we received from professionals across the UK at the launch teleconference (podcast available here).
We’d love to hear from you at firstname.lastname@example.org.
Question 1 (Rising trend of TB cases in people with a social risk factor)
I’d really like to understand why there’s an increasing trend in the number of TB cases in those where there is a social risk factor. Do we know whether that is reflective of an actual increase in the proportion of cases with a social risk factor or could that be explained by an improvement in detection in those vulnerable groups?
With the reduction in the overall number of TB cases, we would expect to see a slight rise in the number of cases that are more complex and that have social risk factors, for example those who find it difficult to engage with health care and therefore get diagnosed late and so have a greater chance of transmitting their disease. So what we are seeing is not actually unexpected.
With a 30% reduction in the overall numbers of TB cases in 4 years complex cases will tend to come to the fore. We are therefore tackling this, and are producing a resource for under-served populations for publication in December to support TB control boards, CCGs and local authorities to meet the needs of TB patients with social risk factors.
Question 2 (Dealing with the homeless)
As a CCG lead, in the Health-matters content, you talk about what CCGs should be doing. My question is about the homeless. In my area we have a homeless group who manage to ‘capture’ all the homeless in our city and do actively pursue testing for tuberculosis and HIV. However we have a large number of CCGs who have an extremely low number of TB cases but they may have a homeless population which isn’t currently being ‘captured’ by a specialist healthcare team. How can we help them to put strategies in place when CCGs have constraints and other draws on their finances to develop commissioned services?
The under-served population resource that we are publishing in December has a whole chapter on homelessness and TB. It contains a number of recommendations, resources and pathways that are being used successfully around England in addition to examples of good practice for consideration.
Question 3 (child poverty strategy and TB)
We are in the process of putting in place a child poverty strategy and I’m really pleased to see the information within Health Matters around the correlation between deprivation and the prevalence of TB and how it’s a barometer for health inequalities. The information you’ve presented today is actually very interesting and very applicable to what we’re trying to do in my area. We do have a large migrant population coming in and we know that most of the cases of TB in England are in the non-UK born population. What are your views on the risks for children and babies who are not vaccinated?
There is very clear guidance on who to prioritise for BCG vaccination. It includes children from countries that have high incidence of TB (40 out of 100,000 or greater). There is clear guidance again in terms of the current situation of the limited supply of BCG vaccine and this is to prioritise children who are at highest risk of exposure of TB. This would be children living in areas of the country where TB rates are high, those from high incidence countries and those with a parent or grandparent born in a high incidence country. Further information on the BCG supply situation and priority groups is in the June version of “Vaccine update” which is available on the PHE Web site.
It is accepted that BCG vaccine protects against the most severe forms of active TB in young children. It is important to note however, that BCG vaccination plays a small part in the prevention and control of TB. The most effective way to prevent the spread of TB is by diagnosing it as soon as possible, providing correct treatment for people with active TB, and preventative antibiotic treatment of young children who have been exposed to an infectious case of TB until they are confirmed not to be infected.
Question 4 (Should TB teams commission housing allocation?)
There is a phrase in your guidance that says, “Local authorities are encouraged to ensure commissioning of appropriate access to housing and social care support that enables patients to complete treatment” which I think is brilliant.
I have just come from a meeting with a charity that is working with homeless people on a variety of multiple health problems. Local authorities are under enormous pressure. There was a clear call within my meeting this morning for health clinicians to be able to commission housing. Not just to ensure there is commissioning within local authorities, but to commission housing allocation themselves as a health need.
Have you got any thoughts on whether you can anticipate that coming into the system at some point, recognising the multiple problems that homeless people face?
That’s quite a large question. Currently if someone who is homeless and has TB is in hospital and is fit for discharge, then a multi-stakeholder discussion on how to house them takes place with local authority, CCG, clinical teams and others.
Where a person has no recourse to public funds, NICE guidance does suggest that there should be a discussion between local authority and CCG to try and find a solution. CCGs are looking at this pragmatically as it is more expensive to keep someone in hospital than house them in the community. There have been examples where the local authority has provided the accommodation but it has been funded by the CCG. Housing that is provided by local authorities can be as much as 10 times cheaper than a hospital stay. This is an area that needs some more work.
Question 5 (How has the number of TB cases been driven down)
There has been a 30% decrease in TB numbers since 2011. This clearly is good news for public health. To what would you attribute this decrease?
There are a number of reasons for this. The main one is changing patterns of immigration. As the countries from which people come to the UK change, we see this reflected in the country of origin of our TB cases. In many countries TB numbers and rates are declining which in turn reduces the number of cases seen in the UK.
Secondly, we now have UK pre-entry screening for TB and last year this identified 382 TB patients prior to arrival in the UK who would have come into the UK and been diagnosed here. Instead they were treated in their home country and once treated were able to obtain a UK entry visa. This is a method that the US and Australia and others have been using for a while.
The third reason is improved TB control in England where we have been working hard to implement the Collaborative Strategy for England.
Question 6 (Multi-drug resistance in migrants from Eastern Europe)
I’m a TB physician. My question concerns the absence of the word “resistance” in the short version of your document. This concerns me a bit because I think resistance of the tuberculosis strain, particularly multi-drug resistance and even worse, extensive drug resistance is relatively common now in some parts of the country, particularly the east of England where we see a lot of Eastern European migrants coming to the country. Should we tackle the risks in this particular group, particularly in arrivals from Romania and the Baltic states?
We do mention the problem of multi-drug resistance in the long version of this edition of Health Matters. One of the reasons we haven’t put it in the short version is that the rate of MDR TB, in 2015, was 1.6% and has been relatively stable over the last few years as has our cases of mono- drug resistance.
However, it is absolutely an issue because the cost of treating these cases is up to 50 times higher. We have a very big push within PHE and within government to try to contain our resistant strains of bacteria. One example of work that PHE is undertaking is that with the British Thoracic Society to enhance the BTS MDR-TB Advisory Service. The launch of this enhanced service will be in 2017.
Question 7 (Danger of finger-pointing at ethnic groups)
My concern is around improving access and tackling TB in underserved populations. I’m worried that if we’re painting this almost like an immigration issue and it could lead to finger pointing. We know that anyone can get TB and it’s not because people are from a particular ethnicity that they get TB.
Will Public Health England be investing in training and resourcing people in the different communities in the country, to raise awareness of TB and help reduce this fear of the unknown, as was done with HIV and AIDS?
We agree that this is not an immigration issue. This is however, about trying to treat patients who have active TB or latent TB and are greater risk of developing TB. We are talking here about training, resourcing and awareness-raising. This Health Matters resource links to new and updated information on the TB Alert web site, where information leaflets and a slide set can be downloaded for use by TB nurses to raise TB awareness locally. There are a number of new resources on the Health-Matters web site and also on TB Alerts; so I would encourage you to use these. We are trying to use a recently produced video with Emma Thompson to raise TB awareness in primary care and beyond. It shows Emma Thompson and her son Tindy discussing TB and their experience of it in their family.
In addition, NHS England is sponsoring the production of a number of posters that can be used in GP surgeries and these are about to be sent out to GP surgeries, through the regions, in the next week or two.
Question 8 (TB strategy and family members)
When it comes to the new Collaborative TB Strategy and the LTBI programme, we are faced with situations where new migrants come in as families and because the LTBI project has a screening age limit of 16 to 35 years, children and older family members are not always eligible for screening. Is this going to be reviewed before 2019?
The resources that were put forward by NHS England in 2015 to support the TB Strategy’s LTBI programme were based on the old NICE Guidance. NHS England is currently reviewing this now that the 2016 edition of NICE Guidance has been released.
In terms of family members, if you think they are at risk of TB then they should be referred as part of standard contact tracing to the local TB service.
Question 9 (Working with immigrants and TB strategy)
I work within a health integration team predominately working with CCGs. One of my concerns is that we no longer have access to flag four data. When looking at people coming into the area, we used to be well informed about the under-served population and had a really good screening programme. We don’t have access to that information now due to a tendering process and a change to the service.
We are very aware that this is an issue. England’s seven TB control boards have raised this with us on behalf of you and others. We have been negotiating with NHS Digital to try and access flag 4 data (data that indicates if a person is newly arrived in the UK and has registered with a GP) so that the latent TB screening programme can continue to run in areas where they have lost access to flag 4 data. We are quite hopeful that we will be able to access this data probably within the next few months. We will keep you and your TB control board updated on this.
Question 10 (Including TB within national public health awareness events to reduce stigma)
My question is if we could have a single calendar for the year of events that link in with the ethnic minority? We have World TB Day on 24th of March and I think we could link into some other dates such as World Immunization Week and that sort of thing.
As you rightly point out, 24th of March is WHO World TB Day and we tend to use that as the hook on which to organise quite a large number of events. But that’s not to exclude having other local events to raise awareness of TB, or using local celebrations that are relevant to particular ethnic groups or migrant groups. It’s a thought and we need to consider this further.
Question 11 (Use of BCG for close contacts of TB cases)
My question relates to BCG vaccination during the current shortages. No mention has been made within the guidance provided in relation to the vaccination of close contacts of cases of pulmonary TB. Should we be vaccinating them following a negative screen?
Yes, close contacts of cases of Pulmonary TB, who are under 16 years of age, BCG naïve and have a negative tuberculin test should be offered the BCG vaccination, particularly neonates and young children who have had significant exposure to infectious TB. They should be followed-up in line with the 2016 NICE TB guidance.]
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