Tackling Tuberculosis

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1 Tackling Tuberculosis Local government s public health role 1. Courtesy of TB Alert

2 Introduction These FAQs on tuberculosis (TB) have been produced by the Local Government Association (LGA) and Public Health England (PHE) to address questions that councillors and officers in local government may have on TB and its burden in the UK. Responsibility for public health transferred from the NHS to local authorities in April 2013 under the wider shakeup of the health service. Local councils have a critical role in protecting the health of their population. What is TB? Tuberculosis (TB) is an infectious disease caused by bacteria belonging to the Mycobacterium tuberculosis complex. TB usually affects the lungs, but can affect other parts of the body, such as the lymph nodes (glands), the bones and the brain. Infection with the TB organism may not develop into TB disease. The vast majority of TB is curable with a combination of specific antibiotics, treated for at least six months. Tuberculosis (historically known as consumption ) used to be very common in England. For example, in the mid-1930s over 50,000 cases of TB were reported each year. These days it is not as common, but from 1990s-2005 the UK has seen a progressive increase in TB cases and the incidence has stabilised at a relatively high level since then. Over 8000 people still develop TB in England and Wales each year. How is TB spread? The TB bacteria are usually spread in the air. It is caught from close contact with another person who has TB of the lungs. The bacteria are released into the air when that person coughs or sneezes. Only some patients with TB in the lungs (pulmonary) are infectious to other people. Patients with sputum smear positive (or open TB of the lungs) are more likely to be infectious, but even then, you need close and prolonged contact with them to be at risk of being infected. Patients with infectious TB usually stop being infectious after a couple of weeks of treatment. When a person is infected with TB, their immune system usually manages to bring it under control and they enter into a state of latent TB infection (LTBI). People with LTBI do not have any signs or symptoms of TB and are not infectious to others. Only around one in 10 of people who acquire TB infection develop active TB. Around half of these people develop active disease within two years of acquiring the infection, and the remainder develop it later in life, often when their immune systems are weakened by age or other illnesses (such as HIV) or drugs. Symptoms and signs TB disease develops slowly in the body, and it usually takes several months for symptoms to appear. Because TB can affect almost any part of the body, the symptoms are extremely varied, however the most common symptoms may include: persistent cough sometimes with blood streaked sputum (phlegm or spit) loss of appetite weight loss fever 2 Tackling Tuberculosis

3 night sweats shortness of breath extreme fatigue and tiredness. TB treatment and drug resistance Modern anti-tb drugs are effective and in nearly all cases TB patients are not infectious and feel much better after the first two weeks of medication. Anti-TB drugs are prescribed in combination to reduce the risk of the TB bacteria becoming resistant to one or more of them. For this reason, patients are usually started on at least four different drugs. A course of anti-tb drugs lasts for at least six months because the medicine is most effective against bacteria that are awake and growing. Six months of anti-tb medication has been demonstrated as the most effective duration to ensure that the dormant bacteria are also killed and then cannot reactivate to cause TB disease in the future. It is vital that TB medication is taken as prescribed. Taking anti-tb medication in the wrong dose, intermittently or for too short a time can result in the development of drug resistance making the disease much harder to treat and significantly increasing the patient s risk of long term complications or death. TB patients, and children in particular, will require support to help them remember to take their medication as prescribed and to deal with the physical and social consequences of the disease. TB is still highly stigmatised and patients can feel isolated and find it difficult to communicate their problems Pre-entry screening In 2012 the UK Government announced a new pre-entry screening programme for TB. Following a pilot scheme, pre-entry screening is currently being introduced in countries with a high incidence of TB for migrants prior to applying for a UK visa for over 6 months. The screening includes a chest x-ray and symptom assessment. Individuals who are found to have active TB of the lungs must complete treatment before their visa is granted. By March 2014, 101 countries will carry out pre-entry screening of migrants, and TB x-ray screening at ports of entry (Heathrow and Gatwick airports) will close. Social risk factors Anyone can get TB, but it is difficult to catch. People are most at risk if they are living in the same house as someone with infectious TB of the lungs, or spend long periods of time sharing room air with such a person. The following people have a higher risk of being exposed to TB: those in very close contact with infectious people homeless populations people with a history of imprisonment people who are dependent on drugs or alcohol, or have a history of misuse/abuse country of origin being born or having lived in a country with a high incidence of TB. Drug resistant TB is an increasing problem, with around 7 per cent of cases in the UK having resistance to at least one first line antibiotic. The cost of treatment between fully sensitive TB and drug-resistant TB can vary from 1100 to over 100,000 respectively. Tackling Tuberculosis 3

4 Figure 1. Three-year average tuberculosis case rates by local area, UK TB Rate (per 100,000 population) Prevention In some high-risk groups, and especially among infants and young children at risk of exposure to TB, BCG vaccination can offer some protection against TB, particularly disseminated forms of the disease. However, outside these groups, BCG vaccination plays a limited role in TB control. The most important factors are early detection and diagnosis, especially of infectious cases, and treatment completion. Early case detection and prompt initiation of treatment reduces onward transmission of the disease. Completing a full course of appropriate treatment is vital to prevent the disease relapsing, to prevent the development of drugresistant strains of TB, to prevent prolonged infectiousness and preventable death. Identifying patients who have been recently infected through screening contacts and offering preventive treatment to those with LTBI also contributes to TB control. In hospitals and institutional settings, infection control measures to identify and isolate infectious cases are important. 4 Tackling Tuberculosis

5 A global picture Throughout the 19th and early 20th century, TB was rife in the cities of Europe and North America - London and New York were two of the worst affected cities. Reported cases in the UK and other industrialised nations declined rapidly last century but never went away. Today, an estimated one third of the world s population (over two billion people) is infected. Nine million people a year develop the active disease and in million people died from TB. Nearly all countries in the world are now affected by the global resurgence of TB caused primarily by increasing poverty and poor access to health services, migration and HIV. TB was declared a global health emergency by the World Health Organization in Figure 2. Trends in the annual number of cases of tuberculosis in the UK compared with the USA Dotted lines show projected numbers, assuming present annual percentage change continues for 2 more years. Data from PHE (UK) and CDC (USA). TB in the UK The UK now has one of the highest incidence rates of any Western European country, with 8,751 cases of TB reported in See Figure 3 for rates by UK local authorities. TB is very unequally distributed, with certain sub-groups, such as new migrants and those with social risk factors, disproportionally affected. Figure 3. Three-year average tuberculosis case reports and rates by top twenty upper tier local authorities, England, Public Health England. (see Annex 1 for full list) Upper tier local authority Average number of cases Rate (per 100,000 population) 1. Newham LB Brent LB Hounslow LB Ealing LB Harrow LB Leicester UA Slough Redbridge LB Tower Hamlets Hillingdon LB =11. Greenwich LB =11. Luton UA Waltham Forest LB Haringey LB Manchester MCD Blackburn with Darwen UA 17. Southwark LB Birmingham MCD Hackney LB Sandwell MCD London has the main burden of infection in 2012, with 3,426 cases - almost 40 per cent of the UK total, followed by the West Midlands with 12 per cent. As in previous years, almost three quarters of cases were in people born in countries where TB is more common. Of those born abroad, the majority of cases were from Tackling Tuberculosis 5

6 South Asia (60 per cent of non-uk born TB population) and sub-saharan Africa (22 per cent). Rates of TB have stabilised at around 14 cases per 100,000 since the mid-2000s, following the increase in incidence seen in the previous 2 decades. However, despite considerable efforts to improve prevention, treatment and control, TB incidence in the UK remains high compared to most other Western European countries. Figure 2 demonstrates that if the UK rates of TB continue increasing we will have more TB cases than the whole of the USA within 2 years. What is now needed to reduce the burden of TB? TB is one of Public Health England s (PHE) key priorities and one supported across local government. A collaborative strategy has been launched for consultation, and aims to bring together best practice in clinical care, social support and public health to strengthen TB control, and provide support to local clinical, preventive and social care services in the NHS, local government and wider health and social care system. Improve TB treatment completion and thus outcomes improve screening for LTBI improve BCG vaccination uptake reduce drug-resistant TB reduce TB transmission establish regular TB cohort review ensure an appropriate workforce available to deliver TB control. There is considerable evidence about what works for TB prevention, treatment and control including extensive published clinical and policy guidance. There is also clear evidence of the devastating consequences of failing to invest in TB services: disinvestment in services in New York in the 1970s and 1980s led to widespread community TB transmission, which required hundreds of millions of dollars of reinvestment to reverse. Many of the actions needed to eliminate the burden of TB require strengthened and more integrated local services which ensure consistent, evidence based prevention, treatment and support to patients, their families and other contacts, especially so because TB does not exist in isolation from other health and social concerns. PHE are determined to see a sustained reduction in TB, and will work tirelessly to support local partners in those areas where the burden is greatest. The following outcomes and indicators of success will, if achieved, deliver significant improvements in TB control: reduce TB incidence year on year reduce diagnostic delay improve high quality diagnostics improve support to underserved populations 2. Courtesy of TB Alert 6 Tackling Tuberculosis

7 Is there a role for council scrutiny? Some Councils have carried out scrutiny reviews focussing on services available for people with TB. Whilst access to services and quality are important topics, prevalence of TB within different communities (for example, migrant and transient communities), strategies to prevent the spread of disease are other ways to tackle this issue. Council scrutiny can play an important role bringing together public agencies and civil society organisations to establish the extent to which these issues are prevalent in local areas and to ask questions about planning for better outcomes from services. What can local authorities do? Drive improvements through overview and scrutiny committees and Health and Wellbeing boards. These boards have a role in oversight and challenge of the NHS commissioners to ensure that they achieve and sustain effective TB control. This could include identifying if indicators such as treatment completion rates are met. Local health service commissioners should prioritise the delivery of appropriate clinical and public health services for TB, especially in areas where TB rates are highest and for underserved groups, (Figure 3) and drive improvements in early diagnosis and appropriate treatment which are key to reducing TB levels in the UK. Promote local leadership at all levels such as local leadership through elected members, strategic leadership through the Health and Wellbeing Board and health leadership via clinical commissioning groups, wider NHS partners and public health teams. Consider appointing a senior coordinator role, perhaps from the public health team, and/or a sub-committee to take responsibility for the issue. Ensure a joined-up approach by fully involving other statutory agencies and council departments, such as social care, housing, education and benefits. They may consider appointing people within these areas to champion TB. Housing departments can work together with multidisciplinary TB teams, commissioners, and hostel accommodation providers to agree a process for providing accommodation to those who are otherwise ineligible for statefunded accommodation. Encourage and empower the voice of people affected by TB. These groups are important sources of support and role models for others, as well as their participation in commissioning decisions and the design of health programmes. Use TB cohort review and other methods to collect data to inform local needs assessment, and ensure TB is part of the joint strategic needs assessment in areas of high need. Facilitate appropriate access to information and services for underserved populations, such as homeless populations. Questions should be raised to determine whether screening, immunisation and treatment services reach out to diverse populations and are accessible to deprived or marginalised sections of the population. Assist with supporting an individual s social needs, which can improve treatment completion rates and include basic needs such as travel to clinics and sufficient nutrition to support medication, as well as providing accommodation during treatment. Review how third sector organisations can help improve access to services and patient support Ensure information about TB is cascaded into key teams for example Children s Services, Adult Services, Housing and Benefits, Citizen s Advice Tackling Tuberculosis 7

8 Annex 1 Three-year average tuberculosis report and rates by upper tier local authority, England, , Public Health England Upper tier local authority Average number of cases Rate (per 100,000 population, 95% CI) Barking and Dagenham LB ( ) Barnet LB ( ) Barnsley MCD ( ) Bath and North East Somerset UA ) Bedford UA ( ) Bexley LB ( ) Birmingham MCD ( ) Blackburn with Darwen UA ( ) Blackpool UA ( ) Bolton MCD ( ) Bournemouth UA ( ) Bracknell Forest UA ( ) Bradford MCD ( ) Brent LB ( ) Brighton and Hove (6.2-14) Bristol, City of UA ( ) Bromley LB ( ) Buckinghamshire (7.3-13) Bury MCD (6.2-16) Calderdale MCD ( ) Cambridgeshire ( ) Camden LB ( ) Central Bedfordshire UA ( ) Cheshire East UA ( ) Cheshire West and Chester UA (1-4.8) City of London ( ) Cornwall UA ( ) County Durham UA ( ) Coventry MCD ( ) Croydon LB ( ) Cumbria (2-5.4) Darlington UA (1-9.7) Derby UA ( ) Derbyshire ( ) Devon ( ) Doncaster MCD (4.6-11) Dorset ( ) Dudley MCD ( ) Ealing LB ( ) 8 Tackling Tuberculosis

9 Upper tier local authority Average number of cases Rate (per 100,000 population, 95% CI) East Riding of Yorkshire UA (1-4.7) East Sussex ( ) Enfield LB ( ) Essex ( ) Gateshead MCD ( ) Gloucestershire ( ) Greenwich LB ( ) Hackney LB ( ) Halton UA 0.7 #VALUE! Hammersmith and Fulham LB ( ) Hampshire ( ) Haringey LB ( ) Harrow LB ( ) Hartlepool UA ( ) Havering LB ( ) Herefordshire, County of UA ( ) Hertfordshire ( ) Hillingdon LB ( ) Hounslow LB ( ) Isle of Wight ( ) Isles of Scilly UA 0.0 #VALUE! Islington LB ( ) Kensington and Chelsea LB (17-33) Kent (6-8.8) Kingston upon Hull, City of UA (5.4-13) Kingston upon Thames LB ( ) Kirklees MCD ( ) Knowsley MCD (0.4-6) Lambeth LB ( ) Lancashire ( ) Leeds MCD ( ) Leicester UA ( ) Leicestershire ( ) Lewisham LB ( ) Lincolnshire (2.2-5) Liverpool MCD ( ) Luton UA ( ) Manchester MCD ( ) Medway UA ( ) Merton LB ( ) Middlesbrough UA ( ) Milton Keynes ( ) Newcastle upon Tyne MCD ( ) Newham LB ( ) Norfolk ( ) North East Lincolnshire UA (1-7.3) North Lincolnshire UA ( ) North Somerset UA (2-8.4) Tackling Tuberculosis 9

10 Upper tier local authority Average number of cases Rate (per 100,000 population, 95% CI) North Tyneside MCD ( ) North Yorkshire ( ) Northamptonshire (8-12.9) Northumberland UA ( ) Nottingham UA ( ) Nottinghamshire ( ) Oldham MCD ( ) Oxfordshire (7.9-13) Peterborough UA ( ) Plymouth UA ( ) Poole UA ( ) Portsmouth ( ) Reading ( ) Redbridge LB ( ) Redcar and Cleveland UA ( ) Richmond upon Thames LB ( ) Rochdale MCD ( ) Rotherham MCD ( ) Rutland UA ( ) Salford MCD ( ) Sandwell MCD ( ) Sefton MCD (2-7.2) Sheffield MCD ( ) Shropshire UA (1.6-6) Slough ( ) Solihull MCD ( ) Somerset ( ) South Gloucestershire UA ( ) South Tyneside MCD ( ) Southampton ( ) Southend-on-Sea UA (7-17.7) Southwark LB ( ) St. Helens MCD ( ) Staffordshire (3.1-6) Stockport MCD (3.8-10) Stockton-on-Tees UA ( ) Stoke-on-Trent UA ( ) Suffolk ( ) Sunderland MCD ( ) Surrey ( ) Sutton LB (11-23) Swindon UA ( ) Tameside MCD ( ) Telford and Wrekin UA (2.9-11) Thurrock UA ( ) Torbay UA (3.1-13) Tower Hamlets LB ( ) Trafford MCD ( ) 10 Tackling Tuberculosis

11 Upper tier local authority Average number of cases Rate (per 100,000 population, 95% CI) Wakefield MCD (3-8.3) Walsall MCD ( ) Waltham Forest LB ( ) Wandsworth LB ( ) Warrington UA (2-8.4) Warwickshire ( ) West Berkshire ( ) West Sussex ( ) Westminster, City of ( ) Wigan MCD ( ) Wiltshire UA (1.6-5) Windsor and Maidenhead ( ) Wirral MCD ( ) Wokingham ( ) Wolverhampton MCD ( ) Worcestershire ( ) York UA ( ) CI - confidence interval Rates calculated using 2011 ONS Census data Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS) Data as at July 2013 Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England Tackling Tuberculosis 11

12 Additional resources Tuberculosis in the UK: Annual report on tuberculosis surveillance in the UK, London: Public Health England, August HPAweb_C/ Collaborative Tuberculosis Strategy for England 2014 to 2019: For consultation. Public Health England, prepared by PHE s TB section (March 2014) InfectiousDiseases/Tuberculosis/1403TBstrategyconsultation2014/ Three-year average tuberculosis case reports and rates by upper tier local authority, England, Public Health England. HPAweb_C/ Tuberculosis rates by parliamentary constituency, England, HPAwebFile/HPAweb_C/ NHS Conditions Information, Case for Change: TB Services in London, London Health Programmes 2011 NICE Tuberculosis Guidance : clinical (www.nice.org.uk/guidance/cg117) and public health (www.nice.org.uk/guidance/ph37) guidance, and Local Government Briefing (www.nice.org.uk/advice/lgb11) Tuberculosis in London: Annual review (2012 data), 2013, Public Health England, October Reversing the tide of the UK tuberculosis epidemic. D Zenner, A Zumla, P Gill, P Cosford, I Abubakar The Lancet - October 2013 ( Vol. 382, Issue 9901, Pages ) DOI: / S (13) The Truth About TB - TB Alert s awareness programme Photos 1. and 2. Courtesy of TB Alert, Photographer: Zul Mukhida Figures Public Health England (2013) Three-year average tuberculosis case rates by local area UK Annual Report on Tuberculosis surveillance in the UK 2013 Slideset. Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS) Data as at July 2013 Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England PHE Centre for Infectious Disease Surveillance and Control, and Centers for Disease Control and Prevention (2013) Trends in the annual number of cases of tuberculosis in the UK compared with the USA Based on data from PHE (UK) and CDC (USA). Top twenty compiled from: Public Health England (2013) Three-year average tuberculosis case reports and rates by upper tier local authorities, England, Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England 12 Tackling Tuberculosis

13 Prepared by: Charlotte Roberts (PHE) and Paul Ogden (LGA) Acknowledgements: PHE: Ibrahim Abubakar, Paul Cosford, Lucy Thomas and Dominik Zenner and the Tuberculosis Section, Respiratory Diseases Department, Centre for Infectious Diseases Surveillance and Control. TB Alert: Mike Mandelbaum Rachel Dukes and Zul Mukhida LGA: Tim Gilling, Centre and Public Scrutiny, and Councillor Catherine McDonald, London Borough of Southwark Tackling Tuberculosis 13

14 Local Government Association Local Government House Smith Square London SW1P 3HZ Telephone Fax Local Government Association, May 2014 For a copy in Braille, larger print or audio, please contact us on We consider requests on an individual basis. L14-164

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