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PH37: Identifying and managing tuberculosis (TB) in hard-to-reach groups

Professor Mike Kelly, Director of Public Health at NICE, discusses the new public health guidance on identifying and managing TB in hard-to-reach groups.

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This podcast was added on 23 Mar 2012

Podcast transcript

Professor Mike Kelly, Director of Public Health at NICE, discusses the new public health guidanceon tuberculosis (TB) among hard-to-reach groups.  

Hello and welcome to this podcast from NICE. This month sees the launch of new public health guidance on tuberculosis (TB) among hard-to-reach groups. Joining me to discuss this guidance is Professor Mike Kelly, who is the director of public health at NICE.

Q1: “So Mike, if we can just start by identifying who is in these hard-to-reach groups.”

MK: “Well the main groups identified in the guidance are prisoners, homeless people, drug users and vulnerable migrants.”

Q2: “Why are these hard to reach groups more likely to be infected with tuberculosis?”

MK: “Well until the middle, towards to end of the last century, TB was quite a common problem affecting many thousands of people in the country.

“With the introduction of the BCG vaccine in 1953, along with better sanitation and effective antibiotics, this resulted in the disease becoming a significantly less important problem.

“So nowadays the condition is much less common in the general population. So in 2010, for example, there were only 8,483 reported cases and incidences of 13.6 per 100,000 of the population.

“However, it does remain a problem in certain subgroups of the population. TB is an airborne disease which is spread by things like breathing, coughing, sneezing and is caught by being in close proximity to someone who is infected. But anyone can actually still catch TB.

“That said, your risk of becoming infected is influenced by a range of social and other factors. And these social and other factors are the ones that make you vulnerable and hard-to-reach groups are much more vulnerable to infection than the rest of the population.

“So the factors that are linked to these things are poor nutrition, poor access to healthcare, homelessness, problem drug use and imprisonment. All these things exert a negative impact on individuals and their general health and may also bring them into close contact with people who have already got TB.

“Social factors are all associated with the transmission of the disease and they are also associated with negative treatment outcomes. So once people become infected, they are infected for longer, the disease becomes more entrenched and they become difficult to treat. Their chances of infecting other people becomes greater as a consequence of that.

“So TB is associated with a chaotic lifestyle, poorer low housing, poor general health, existing possibly untreated other health conditions, substance misuse and contact with others who are likely to be infected. 

“This means that certain subgroups of the population for whom one or more of these factors are an issue are more at risk of getting TB than everyone else.

“And once they have caught it, people with one or more of these risk factors are the ones that are likely to find to harder to access health services so are unlikely to make use of them. Or at least until they are very, very sick.

“This means that in turn they are less likely to be diagnosed early, less likely to complete treatment and we can deduce that they are more likely to transmit the problem onto others.

Q3: “Where are we most likely to find hard to reach groups? Are they going to be in the major cities or spread evenly across the country?”

MK: “The greatest concentration of hard to reach groups is in London, followed by our other big cities such as Manchester, Glasgow and Birmingham.  But wherever you get social problem factors then that’s where the problem will be found.

Q4: “Now this new piece of guidance recommends taking a more pro-active approach to finding active TB. What does this involve and how will it be done in practice?”

MK: “Well it’s the opposite of services waiting for people with TB to turn up to be treated and the guidance recommends a number of things to do that.

“First of all, local areas should you multidisciplinary teams to manage all TB cases in their area, not just the hard-to-reach ones. Some places do this already, but for those areas that don’t do that we are recommending that they think about organising their resources, maybe sharing some of those resources with other local areas nearby and ensuring that TB patients in the area have access to all relevant skills, including clinicians, TB nurses and social workers to manage the cases more effectively.

Second, that local areas should carefully assess the levels of TB and the risk of TB and plan their work and their services accordingly.

Third, local teams should regularly review all cases of TB in their area, especially the hard-to-reach cases, and look at what went well and what could be improved.

“And also where cases weren’t picked up early, what can be learnt from that. What were the things that were going on which led to the person either not being picked up or dropping out and that sort of thing.

“Next, that they use active case finding methods. Getting out there and trying to find the people who are already infected with TB by using mobile x-ray units or by taking screening and testing opportunities to the places where people who are homeless meet and stay.

“Perhaps introduce incentives in these places like a meal or a hot drink.  We know that these things can help encourage people to come along for a test.

“People in prisons or immigration removal centres should be screened for TB within 48 hours of arrival and the identified cases should be reported immediately to the local multidisciplinary team and local public health England health protection unit within one day.

“People who are found to have TB should be given a case manager straightaway. It’s about early pick up, early identification.

“And finally, that primary care services ensure that they work to register vulnerable migrants and they work with local community organisations to encourage the use of primary care and TB screening.”

Q5: “Now we have mentioned people in the community and in primary care, is there anyone else that you think should be following this guidance?”

MK; “Well the guidance is for commissioners and providers of TB services in primary and secondary care but also for local authorities and other statutory organisations that work in one way or another with hard-to-reach groups.

“With the move of public health function into local authorities from the 1 April 2013, subject to legislation, the local authorities will be able to play an integrating role in certain circumstances because of course they are responsible for some of the other services that sit alongside the medical ones.

“And of course the guidance will be of interest to people with TB and perhaps the general public too.”

Q6: “Now this new piece of guidance will sit alongside existing guidelines from NICE which look at identifying, preventing and treating people with TB. How will they complement each other?”

MK: “Well the existing clinical guideline, published in 2006 and then updated in 2011, covers the identification, treatment and management as you say but in the general population.

“The new guidance cross references this where relevant but the recommendations in the new guidance provide additional information to the clinical guideline specifically for those working with hard-to-reach groups. So it’s an add-on to the existing guideline about these particular groups in the population.”

Q7: “In this age of austerity cuts, why should commissioners put this latest guidance into practice? As well as major health benefits, are there any long term saving that can be made?”

MK: “Yes, because it is an infectious disease, so one case infects other cases. So you are not just preventing one case but all the other cases that would have been infected as a consequence of the transmission.

“So when you do the arithmetic, it’s really very simple. One hard-to-reach complex TB case costs about 15,000 to treat. One infected person who isn’t in treatment and is not in contact with services is likely to infect 10 to 15 other people.

“So you can see that if we stop the infection in one person then we are preventing an infection in 10 to 15 other people and you multiply out the 15,000 and you can see that it’s a cost saving opportunity.”

Professor Kelly, thank you very much for your time.

23 March 2012

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This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.

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This page was last updated: 19 September 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.