Tackling tuberculosis among hard-to-reach groups
Tuberculosis hit the headlines back in 2009, when cases of the infectious airborne disease reached their highest levels in the UK for 30 years.
Just over 9,150 people were found to have the disease according to the Health Protection Agency (HPA), prompting calls for more work to alert the public, and health profession, to the possibility of TB.
Although TB is a preventable and treatable condition, if left untreated, it can be life threatening and accounts for around 300 deaths a year.
Delayed diagnosis and incomplete TB treatment can cause it to spread within the community and also result in drug resistant forms of the disease that are harder to treat.
The number of cases of TB decreased in 2010 down to 8,483, but now provisional figures from the HPA show that the disease may be on the rise again.
Cases of TB in the UK have increased by 5 per cent to 9,042 in 2011.
But Professor Ibrahim Abubakar, Head of the TB section at the HPA, cautions: "We have observed a slight increase in the numbers this year but from studying the data patterns it seems TB may actually be stabilising overall.
“We have not yet reached the 2009 peak when 9,153 new cases were reported, so it is important to interpret this increase with caution.”
Nevertheless, the latest figures serve as a wakeup call and highlight that there is still much work to be done before the disease is fully under control.
Proactively find cases of TB
To help drive down rates of the disease, NICE has published its second piece of guidance on TB which focuses specifically on hard-to-reach groups. This follows on from a 2011 updated clinical guideline on diagnosis and management of TB.
“This new guidance covers prisoners, homeless people, drug users and vulnerable migrants,” says Professor Mike Kelly, Director of Public Health at NICE.
“The greatest concentration of hard-to-reach groups is in London, followed by our other big cities such as Manchester, Glasgow and Birmingham.
“But generally wherever you get social problem factors like poor nutrition, poor access to healthcare, homelessness, and problem drug use then that's where TB can be found.”
The new guidance, which coincides with World TB Day, recommends that commissioners of TB control programmes adopt a more proactive approach to finding active TB.
“It's the opposite of services waiting for people with TB to turn up to be treated,” adds Professor Kelly.
“This could be done with homeless groups by using mobile X-ray teams in places where they congregate, such as homeless day centres, rolling shelters, hostels and temporary shelters.
“Introducing incentives in these places like a meal or a hot drink can help encourage people to come along for a test.”
The guidance also recommends that prisons use static digital X-ray facilities to X-ray all new prisoners entering the establishment including those being transferred from elsewhere for active TB, if they have not received a chest X-ray in the last 6 months.
The guidance recommends that Public Health England and commissioners ensure TB prevention and control programmes set up multidisciplinary TB teams to provide all TB services.
Multidisciplinary teams should include at least one TB case manager with responsibility for planning and coordinating the care of hard-to-reach people, and include an appropriate range of clinical specialties including paediatrics, infection control and respiratory medicine.
NICE says that multidisciplinary teams should be able to provide rapid access TB clinics for hard-to-reach groups, and have the resources to provide a continuous service throughout the year.
They should also have access to funds that can be used flexibly to improve adherence to treatment among hard-to-reach groups. For example, funds could be used to provide transport to clinics, to provide incentives for treatment, or for paying outreach workers or community services to support directly observed therapy.
The multidisciplinary teams should also have the resources to provide ongoing TB awareness-raising activities for professional, community and voluntary groups that work with hard-to-reach groups.
As well as helping to drive down cases of TB among hard-to-reach groups, this latest guidance offers an excellent opportunity for commissioners to make some substantial cost savings - at a time when budgets are being squeezed.
“As TB is an infectious disease, one case infects other cases. It costs about £15,000 to treat one hard-to-reach complex case, but by preventing one case of TB we are preventing that person from going on to infect 10 to 15 other people,” explains Professor Kelly.
“So multiple £15,000 by 15 people and you see that there is an opportunity for real cost savings.”
Listen to a podcast with Professor Kelly exploring the guidance in further detail and explaining how the recommendations can be put into practice.
23 March 2012