4. TUBERCULOSIS INTRODUCTION Tuberculosis (TB) is an infectious, notifiable disease (meaning there is a requirement by law to report it to government authorities) caused by the bacterium Mycobacterium Tuberculosis. TB is present in many parts of the world and particularly Africa and South East Asia (1). In the 1930s, TB was one of the leading causes of death in the UK. After falling steadily, the number of TB notifications in England and Wales has increased over the past 20 years. The main underlying factor in this rise has been infection in people born outside the UK. Most people infected with TB do not go on to have active disease, although a few will develop a dormant disease which may be reactivated as they get older. TB is curable with a full course of treatment. Good management of TB involves early diagnosis, rapid identification of the strain and completion of the course of treatment. WHICH GROUPS ARE MOST AFFECTED? TB is concentrated in deprived communities in cities and predominantly affects BME and non-uk born groups, homeless people and problem drug-users (2). Age In London TB is more common in younger adults aged 15-44 years and peaks in the 25-34 age group (3). Place of birth, migration and ethnicity Over 80% of cases of TB in North Central London are in BME groups, with the highest incidence in Black African and Indian groups. Increasing rates of TB in people born outside the UK reflect the rising numbers of migrants arriving from high incidence areas (4). The majority of people with TB who are born abroad do not arrive with active TB but develop TB within one to five years after entry to the UK. Homeless, prisoners and substance users People who are homeless, have prison experience or are misusing drugs or alcohol have a higher prevalence of TB. These groups are often infectious, drug resistant, poorly adherent 1
to treatment and difficult to follow-up. Despite their relatively low numbers, they have a significant impact on TB service workloads (5). People with weakened immune systems People with compromised immune systems have increased risk of developing active TB after infection and are more likely to have poorer outcomes. The association of TB with HIV is important. HIV infection increases the risk of progression from inactive to active TB which, if untreated, is more likely to progress to severe disease and death (6). THE ISLINGTON PICTURE Incidence of TB is high in London, accounting for about 40% of notifications in England (3). Islington has a higher incidence of TB than North Central London and London as a whole. There has been a downward trend in TB cases in Islington over recent years. Figure 4.1: TB incidence rates for Islington, North Central London and London 1982 2008 70 Islington NCL London TB incidence rates per 100,000 population 60 50 40 30 20 10 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 Year Source: London TB Register (LTBR), HPA London 2
Table 4.1: Incidence of TB per 100,000 population for Islington, North Central London, London and England and Wales, 2002 2008 TB rates 2002 2003 2004 2005 2006 2007 2008 Islington 57.5 51.3 47.4 47.6 52.7 51.9 50.3 NCL 45.3 43.3 41.0 43.7 45.8 36.8 39.5 London 40.6 41.4 42.3 46.7 44.8 43.2 44.3 E&W 13.4 13.5 14.1 15.5 15.5 15.2 14.2 Source: London TB Register (LTBR), HPA London Within Islington there is considerable geographical variation in the incidence of TB. Figure 4.2: TB notification rates per 100,000 population by ward, Islington, 2008 Rate per 100,000 72.2 to 101.1 53.3 to 72.2 46 to 53.3 25.7 to 46 16.7 to 25.7 Source: North Central London TB Commissioning Group. Mapping by NHS Haringey Public Health 3
Figure 4.3 shows that in Islington between 2003 and 2008 there was an increase in the proportion of cases of Black African ethnicity and a decrease in cases of Indian ethnicity, while in North Central London as a whole the opposite was true. Figure 4.3: TB notifications in North Central London and Islington by ethnicity, 2003 and 2008 60.0 Percentage of TB notifications 50.0 40.0 30.0 20.0 10.0 NCL 2003 NCL 2008 Islington 2003 Islington 2008 0.0 Bangladeshi Black African Black Caribbean Black Other Chinese Indian Other Pakistani Unknown White Ethnic group Source: London TB Register (LTBR), HPA London Multi-Drug Resistant TB Resistance to first-line drug treatment for TB is low in the UK and alternative drug treatment options are available (7). TB control requires early and accurate diagnosis followed by completion of treatment in order to mitigate the development of drug-resistant strains of the bacteria. In multiple-drug resistant (MDR) TB the bacteria are resistant to at least Rifampicin and Isoniazid, the two most powerful TB drugs. Across North Central London, the total proportion of cases that are multi-drug or Isoniazid resistant is very small and mostly associated with an outbreak of Isoniazid-resistant TB in North Central London which mainly affected Enfield and Haringey residents (8). 4
SERVICES CURRENTLY PROVIDED IN ISLINGTON Vaccination Neonatal BCG vaccination is routinely offered on a universal basis to all babies resident in Islington, in line with Department of Health guidance for areas with a high incidence of TB. There is targeted vaccination of under 16 year olds within school, deemed to be at increased risk of TB. BCG is also offered to adults in high risk groups, such as new entrants to the UK from high prevalence areas and healthcare workers. Screening The Port Health Authority screens new entrants to the UK from high incidence areas who plan to stay in the UK for more than 6 months (5). A mobile X-ray screening unit provides a targeted screening service to hostels, drug and alcohol service units and refugee centres. Based on the success of the mobile screening unit at detecting TB in prisoners, five London prisons have successfully bid for static digital x-ray facilities, with installation at Pentonville Prison in 2009 (3). Screening is offered to close contacts of newly diagnosed individuals with infectious TB. Treatment Outpatient TB services are provided by one team working across five hospital sites in the North Central London sector. Co-ordination of the service in this way has enabled an increase in staff establishment, and the development of a multi-disciplinary team to better support people with TB. All new patients are risk assessed for likely treatment compliance. Directly observed treatment (DOT) is offered where appropriate. DOT involves observing a patient to ensure they take their medication in the right combination and for the correct duration. The Find and Treat multidisciplinary team locate and re-engage patients who have been lost to follow-up, support DOT and link patients with allied support services in the community. Inpatient TB services are provided at Barnet and Chase Farm Hospitals, North Middlesex Hospital, Royal Free Hospital, UCLH and The Whittington Hospital. 5
Pentonville prison has a specialist TB nurse post funded by the Department of Health to improve the TB pathway across all London prisons (3). Treatment completion rates for 2007/08 notifications of TB were above the London target of 85% for all PCTs in North Central London (9). The North Central London boroughs jointly fund out-patient and community TB services. In 2008/9 Islington s contribution to this was 256,305. A recent review realigned payments by PCTs to reflect the number of TB notifications for each borough to make contributions by each PCT more equitable. As a result in 2009/10 Islington s spend was reduced to 147,885. In-patient care is paid for separately. NATIONAL DRIVERS FOR SERVICE PROVISION In 2004 the Chief Medical Officer (CMO) produced a National TB Action Plan (10) outlining ten actions to bring TB under control in England, including partnership working, improvements to the organisation of care and raising awareness of TB. In 2006 the National Institute for Health and Clinical Excellence (NICE) produced guidance for the clinical diagnosis and management of TB and measures for its prevention and control. This includes a care pathway and key priorities for implementation (11). The Department of Health produced a TB Commissioning Toolkit in 2007 to support the implementation of the guidance from the CMO and NICE (12). A key recommendation of this was for commissioning and performance management of TB services to be restructured at both regional and sector levels. As a result the London TB commissioning unit, London TB Commissioning Board and London TB Clinical Reference Group were established in 2009 and support the following: Needs assessment. Strategic review of service configuration and planning. Performance management of PCT and TB services. Provider workforce development. Strengthening of communications. Cross-boundary working. Dissemination of good practice. 6
North Central London has a collaborative commissioning group which is supported by the London TB Commissioning Unit. This group engages the PCTs within the sector to secure investment, improve TB service delivery and patient care. This is the model which other London sectors are working towards (3). PROGRESS SINCE LAST YEAR S JSNA Progress has been made on the recommendations made in last year s JSNA. The quality of data collection has much improved. Early and prompt diagnosis has been improved through work with Occupational Health departments to review TB policies in line with NICE guidance. Awareness raising sessions were held with trainee health advocates and through community events and social marketing across the sector. Care pathways have been taken forward as part of the London TB Strategy to ensure patient experience is standardised across London. Targeted work with communities with very high rates of TB, such as the Somali community, has been undertaken. The contact tracing database is now part of the national TB database and due for implementation in 2010. OPPORTUNITIES FOR DEVELOPMENT The World Health Organisation Millennium Development Goal for TB is to halve the London 1990 TB rate by 2015. In 1990 the London TB rate was 23.4 per 100,000 population and in 2008 it was 44.3. The ambitious target for the London TB Commissioning Unit is to achieve 11.7 per 100,000 population in the next six years by commissioning effective TB services. The North Central London sector is a national leader in terms of service provision and is piloting projects to improve TB service provision and the TB patient s experience, for example through the Find and Treat team. Although excellent work is well established, challenges remain. Care pathways are being developed for London and these need to be embedded in local practice. Awareness raising activity with high-risk population groups, such as the Somali community, has been ongoing for a number of years but is not having the anticipated impact on reducing TB. New approaches are needed to work with high-risk groups and tackle stigma. There are ongoing challenges in securing patient representatives to input into TB service development in North Central London. 7
RECOMMENDATIONS Conduct a needs assessment to gain a better understanding of the requirements of a TB service Achieve the London TB targets covering elements such as diagnostics, waiting times and treatment completion. Review paediatric TB services in North Central London to reduce the number of paediatric service providers from five to two, in order to concentrate care in specialist centres. Review provision of adult TB services in North Central London in line with World Class Commissioning standards. Implement the DOT project by funding a team to improve treatment compliance and patient support. REFERENCE LIST (1) World Health Organisation. Global tuberculosis control: surveillance, planning, financing 2008. (2) Health Protection Agency Centre for Infections. Tuberculosis in the UK: annual report on tuberculosis surveillance in the UK. 2008. (3) Health Protection Agency London and NHS. Tuberculosis in London 2007. 2009. (4) Health Protection Agency Centre for Infections. Migrant health: infectious diseases in non-uk born populations in England, Wales and Northern Ireland. A baseline report. 2006. (5) Health Protection Agency Centre for Infections. Migrant health: infectious diseases in non-uk born populations in England, Wales and Northern Ireland. A baseline report. 2006. (6) Lienhardt C, Rodrigues LC. Estimation of the impact of the human immunodeficiency virus infection on tuberculosis: tuberculosis risks revisited? 1997(1):pp. 196-204. (7) Health Protection Agency Centre for Infections. Tuberculosis in the UK: annual report on tuberculosis surveillance in the UK. 2008. (8) Altass L. Tuberculosis in North Central London. Annual Report for 2007. 2008. (9) Altass L. Data downloaded from the London TB Register. 2009. (10) Department of Health. Stopping tuberculosis in England: An action plan from the Chief Medical Officer. 2004. (11) National Institute for Health and Clinical Excellence (NICE). Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. 2006. 8
(12) Department of Health. Tuberculosis prevention and treatment: a toolkit for planning, commissioning and delivering high quality services in England. 2007. FURTHER INFORMATION Global tuberculosis control: surveillance, planning, financing. World Health Organisation. Geneva. 2008 http://www.who.int/tb/publications/global_report/2008/pdf/fullreport.pdf Tuberculosis in the UK: annual report on tuberculosis surveillance in the UK. Health Protection Agency Centre for Infections. 2008 http://www.hpa.org.uk/webw/hpaweb&hpawebstandard/hpaweb_c/122526888596 9?p=1262704891708 Tuberculosis in London 2007: A report from HPA London and NHS London. Health Protection Agency London and NHS. 2009 http://www.london.nhs.uk/publications/tools-and-resources/public-health-- tuberculosis-in-london-2007 9
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