Guidance

Tuberculosis: applying All Our Health

Published 1 April 2015

This guidance was withdrawn on 24 July 2019

This page has been withdrawn as it is out of date. See Tuberculosis (TB): diagnosis, screening, management and data for the latest information on TB.

Introduction

Tuberculosis (TB) is an infectious disease caused by bacteria belonging to the Mycobacterium tuberculosis complex. TB usually affects the lungs but can also affect any other area of the body.

Only some people with TB in the lungs or larynx are infectious to other people. TB is curable with a combination of specific antibiotics, treated for at least 6 months in people with fully sensitive strains of TB. If left untreated, one person with active pulmonary TB may infect as many as 10 to 15 people every year.

In the UK, around 8,000 cases of TB are currently reported each year. Most cases occur in major cities, particularly in London.

Good public health measures are essential for effective TB control. The Collaborative tuberculosis strategy for England, 2015 to 2020 was launched by the Public Health Minister, Jane Ellison on 19 January 2015. The report brings together best practice in clinical care, social support and public health to strengthen TB control. It aims to achieve a year-on-year decrease in incidence, a reduction in health inequalities and, ultimately, the elimination of TB as a public health problem in England.

Facts about tuberculosis

The Tuberculosis in England 2015 report states that in the past 3 years there has been a year-on-year decline in the number of TB cases in England, down to 6,520 in 2014, a rate of 12.0 per 100,000. Despite this decline, the number of TB cases in England is still unacceptably high.

The recent reduction in TB cases is mainly due to a reduction in cases in the non-UK born population, which make up nearly three-quarters of all TB cases in England. This reduction is likely to reflect recent declines in the number of migrants from high TB burden countries and the impact of pre-entry TB screening.

86% of non-UK born cases are now notified more than 2 years after entering the UK, and are likely to be due to reactivation of latent TB infection. The roll out of latent TB testing and treatment, and further strengthening of TB services is needed to sustain the decline in non-UK born cases.

There has been no downward trend in the incidence of TB in the UK born population in the past decade, with a rate of 3.9 per 100,000 in 2014. 15% of cases in the UK born population had at least one social risk factor, and 38% were from minority ethnic groups.

There is some evidence of a recent reduction in transmission of TB in England, with a decline in TB incidence in UK born children in the past 6 years. More substantial reductions in transmission will require improvements in early diagnosis, contact tracing and further improvements in treatment completion.

The average delay from symptom onset to treatment start is unacceptably long and increasing; nearly one-third of pulmonary TB cases had a delay of more than 4 months in 2014. Reducing this delay requires:

• improved awareness in affected communities and among health professionals
• improved access to high quality services

Nearly 1 in 10 TB cases in 2014 had at least one social risk factor, with no reduction in the number of cases with social risk factors over the past 5 years. A higher proportion of those with social risk factors have drug resistant TB and worse TB outcomes. This highlights the added importance of tackling TB in this group, including through targeted outreach services.

Core principles for healthcare professionals

Healthcare professionals should:

• know the needs of individuals, communities and population and the services available
• think about the resources available in health and wellbeing systems
• understand specific activities which can prevent, protect, and promote

Interventions

Population level

Healthcare professionals should be aware of the interventions at population level, which include:

• reading the Collaborative TB strategy for England, 2015 to 2020 to review the 10 evidence-based areas for action
• reading the latest TB strategy update (PDF, 500KB, 6 pages) and subscribing to receive future updates
• finding out how your area is performing against other localities by using the TB strategy monitoring indicators tool which provides interactive maps, graphs and tables to support local areas assess their local TB service need and can be used to help develop local action plans

Community level

Community health professionals and providers of specialist services can have an impact by:

• being aware of the signs and symptoms of TB to initiate early diagnosis and treatment to prevent transmission of infection to the wider population and reducing health and social inequalities
• knowing your local TB team and the referral pathway including details of who to refer to and how
• having a high-level awareness of TB among the vulnerable communities; the rate of TB in the non-UK born population is 15 times higher than in the UK born population, and 72% of cases are non-UK born
• helping to promote community-based awareness activities
• knowing the eligibility criteria for BCG immunisation and who is responsible for BCG provision: see tuberculosis: the green book, chapter 32
• improving BCG uptake by ensuring eligible infants and young children are promptly vaccinated after birth or at the earliest opportunity

Family and individual level

Healthcare professionals can have an impact on an individual level by:

• knowing who TB primarily affects, how it is transmitted, the signs and symptoms and how and who to refer to if you suspect someone may have TB or has been exposed to a case of TB
• reducing inequalities; regardless of a person’s status in the UK everyone is entitled to free treatment for TB, including free hospital care
• understanding your local epidemiology; TB disproportionately affects underserved groups and other at high-risk groups but be aware that TB can also occur in people without obvious risk factors
• ensuring a positive outcome for the individual and minimising public health implications; early diagnosis and patient-centred treatment and social support are essential elements to reduce onward transmission of the disease and prevent infection in others
• providing patient information materials available from TB Alert to raise awareness among your patients
• accessing online TB training for primary care clinicians
• identifying babies eligible for vaccination, in line with tuberculosis: the green book, chapter 32 before birth; ideally through antenatal services and discussing neonatal BCG vaccination for any baby at increased risk of TB with the parents or legal guardian

Measuring outcomes

There are two TB indicators in the Public Health Outcome Framework (PHOF):

• 3.05ii – treatment completion for TB
• 3.05ii – incidence of TB

The PHOF also contains a number of indicators that are indirectly related to TB, including those that focus on:

• increased healthy life expectancy
• reduced differences in life expectancy
• healthy life expectancy between communities

Other important indicators

The new online TB strategy monitoring indicators tool allows easy access to local information about the important TB monitoring indicators for the Collaborative TB strategy for England, 2015 to 2020. Users can see how their areas are performing against other localities and to track their performance over time. The interactive maps, graphs and tables can be used to support local areas to assess their local TB service needs, develop their local TB action plans and monitor their progress.

Examples of good practice

The Royal College of Nursing has developed good practice information about TB case management and cohort review (PDF, 1.69MB, 48 pages).

Latent TB testing and treatment for migrants is a practical guide for commissioners and practitioners.

Tackling tuberculosis: local government’s public health role is a useful guide to the local authorities role in the prevention, detection and treatment of TB.

Tuberculosis screening covers screening and early detection methods, for professionals working with at-risk populations in the UK.

Defining a model for a gold standard for a TB MDT group and associated networks (PDF, 1.27MB, 19 pages) describes good practice in developing a multi-disciplinary team approach to the management of TB.

Transition: getting it right for young people: improving the transition of young people with long-term conditions from children’s to adult health services provides good practice in managing young people with long-term conditions when they have to move between children’s and adult’s services.

Healthcare professionals should follow the Mental Capacity Act Code of Practice.

The code of practice gives guidance to people who:

• work with people who can’t make decisions for themselves
• care for people who can’t make decisions for themselves

Guidance

NICE guidelines

Tuberculosis (NG33) 2016 covers preventing, identifying and managing latent and active TB in children, young people and adults. It aims to improve ways of finding people who have TB in the community and recommends treating everyone under 65 with latent TB. It describes how TB services should be organised, including the role of the TB control board.

Tuberculosis pathway makes recommendations on the prevention, diagnosis and management of latent and active TB, including both drug-susceptible and drug-resistant forms of the disease.

Behaviour change: individual approaches (PH49) covers individual-level interventions aimed at changing health-damaging behaviours among people aged 16 or over.

Behaviour change: general approaches (PH6) for effective interventions is aimed at those responsible for helping people to change their behaviour to improve their health.

NICE guidance summary for public health outcome domain 3: health protection contains evidence-based public health nursing and midwifery information on TB services.