Tackling tuberculosis among hard-to-reach groups

Targeted action is needed to prevent the spread of tuberculosis (TB) and ensure treatment success among patients who have difficulty recognising symptoms, accessing health services and taking medication. The patients who are hardest to reach through traditional hospital based TB services include people with drug or alcohol addiction, homeless people, prisoners and some migrant communities.

In new draft guidance, available from today (8 September) for consultation, NICE recommends strengthening efforts to find patients early and providing intensive clinical and social support to help patients complete TB treatment.

TB is a serious infectious airborne disease which is spread by simply breathing. Left untreated TB can be fatal. However the disease is curable in virtually in all cases, provided patients are diagnosed early and take a six month minimum course of medication. 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.

Following infection, most people's immune systems can control the infection so that the bacteria do not cause them to become ill. This is known as ‘latent' tuberculosis. However, in around 10 percent of those who become infected, the bacteria multiply and cause ‘active' tuberculosis which can make them ill. If this disease affects the lungs, it can be spread to others.

Existing TB services provide excellent care for the majority of TB cases who live in household settings, readily seek medical help and take TB treatment. At least one in ten of all TB cases nationally, however, have social risk factors which can lead to delayed diagnosis and incomplete treatment with serious consequences. These factors include poor nutrition, poor access to healthcare, homelessness, problem drug use and imprisonment.

The new draft guidance recommends commissioners of TB control programmes adopt a more proactive approach to finding active TB among homeless groups by using mobile X-ray teams in places where they congregate. For example, homeless day centres, rolling shelters, hostels and temporary shelters.

Prisons which have static digital X-ray facilities should also X-ray all new ‘receptions' (including transfers) for active TB, if they have not received a chest X-ray in the last 6 months.

Further measures to improve detection of TB include incorporating testing for TB among hard-to-reach migrants within larger health programmes for new entrants. This should help detect and treat TB earlier, preventing it from developing further, and spreading to other people.

In addition, all hard-to-reach TB patients should receive community based clinical and social support co-ordinated by their TB case worker. Support will include directly observing every dose of treatment and providing practical help with housing, addiction and other unmet health and social care problems.

Although TB is much less common since antibiotics were introduced, it remains an important public health issue. In 2009, 9,040 cases of TB were reported in the UK. Most of these occurred in urban centres, with over one-third of cases in London. While most people with TB were born outside the UK, the highest risk of disease is among homeless people, prisoners and problem drug users.

Professor Mike Kelly, Director of Public Health, said: “TB is a serious public health issue. If left untreated, active TB can be fatal. We also know that one untreated person with pulmonary TB can infect around 10-15 people every year.

“This draft guidance recommends new ways in which we can help tackle TB among hard-to-reach groups who are most at risk. Evidence shows relying on these groups to present themselves to health services doesn't work, and we need to adopt a more proactive approach to identify and treat this disease.

“TB is curable, so it's vital to identify it as quickly as possible and provide effective treatment to stop it getting worse, or spreading to others. We actively encourage anyone with an interest in this condition to contribute to our consultation on these draft recommendations.”

Anyone wishing to submit comments on this draft guidance is invited to do so via the NICE website,, until 3 November 2011. Final guidance is expected in March 2012.


Notes to Editors

About the guidance

  1. The draft guidance will be available from Thursday 8 September at
  2. This guidance is for NHS and other policy makers, commissioners, managers and practitioners who have a direct or indirect role in, and responsibility for, identifying and managing TB. This includes those working in local authorities, the criminal justice system, drug and alcohol services and the wider public, private, voluntary and community sectors
  3. This draft guidance is out for consultation with stakeholders for comment. Consultation will take place until 3 November 2011. Final guidance will be published in March 2012 once this process has been completed. NICE has not yet issued final guidance to the NHS, local authorities and the wider public, private, voluntary and community sectors.

This page was last updated: 07 September 2011

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