Update information

June 2019: Recommendation 1.6.1.8 has been amended to add in more detail about the meaning of contacts.

November 2018: Recommendation 1.1.3.16 on BCG vaccinations for healthcare workers and other NHS employees was updated after a surveillance review.

May 2016: Recommendation 1.2.1.1 was clarified to reflect the sequencing of tests. Reference to IGRA status was removed from recommendations 1.1.3.13; 1.1.3.16-18; 1.1.4.6; 1.1.4.8 and 1.6.1.4.

February 2016: Recommendation 1.1.3.4 has been amended to clarify that the recommendation is about assessing risk for and vaccinating the baby.

January 2016: This guideline was published. It is an update of NICE guideline CG117 (published March 2011) and replaces it. It also incorporates and adapts NICE guideline PH37 (published March 2012).

Through the scoping process we work with stakeholders to identify, prioritise and agree areas of the guideline to update. This means that areas outside the scope were not reviewed during this update and the recommendations may not reflect current practice. Areas that have not been reviewed in this update may be addressed 2 years after publication, when NICE next considers updating this guideline. NICE may undertake an update of discrete areas of the guideline if new and relevant evidence is published.

Recommendations are marked as:

  • [new 2016] if the evidence has been reviewed and the recommendation has been added or updated

  • [2016] if the evidence has been reviewed but no change has been made to the recommended action

  • [2006] if the evidence has not been reviewed since 2006

  • [2006, amended 2011] or [2011] if the evidence has not been reviewed since 2006

  • [2012] if the evidence has not been reviewed since 2012

  • [2006, amended 2011, amended 2016] or [2011, amended 2016] if the evidence has not been reviewed since 2011, but either changes have been made to the recommendation wording that change the meaning or NICE has made editorial changes to the original wording to clarify the action to be taken (see below).

  • [2006, 2012, amended 2016] or [2012, amended 2016] if the evidence has not been reviewed since 2012, but either changes have been made to the recommendation wording that change the meaning or NICE has made editorial changes to the original wording to clarify the action to be taken (see below).

Recommendations from NICE guideline CG117 that have been amended

Recommendations are labelled [2011, amended 2016] and [2006, amended 2011, amended 2016] if the evidence has not been reviewed but either:

  • changes have been made to the recommendation wording that change the meaning, or

  • NICE has made editorial changes to the original wording to clarify the action to be taken.

Recommendation in 2011 guideline

Recommendation in current guideline

Reason for change

1.1.1.1 Offer Mantoux testing in line with the Green Book to diagnose latent TB in people who are:

  • household contacts (aged 5 years and older) of all people with active TB

  • non‑household contacts (other close contacts for example, in workplaces and schools)

1.1.1.2 Consider interferon‑gamma testing for people whose Mantoux testing shows positive results, or in people for whom Mantoux testing may be less reliable, for example BCG‑vaccinated people.

1.2.1.1 Offer Mantoux[a] testing to diagnose latent TB in adults aged 18 to 65 who are close contacts of a person with pulmonary or laryngeal TB.

  • If the Mantoux test is inconclusive, refer the person to a TB specialist.

  • If the Mantoux test is positive (an induration of 5 mm or larger, regardless of BCG history), consider an interferon‑gamma release assay.

  • If either is positive, assess for active TB (see sections 1.3.1, 1.3.2, 1.3.3 and 1.3.5); if this assessment is negative, offer them treatment for latent TB infection (see section 1.2.4 and 1.2.5). [2011, amended 2016]

1.2.2.1 Only consider using interferon‑gamma release assays alone in children and young people if Mantoux testing is not available or is impractical. This includes for example, situations in which large numbers need to be tested (see section 1.6.4 and recommendation 1.2.3.2). [2011, amended 2016]

1.2.2.4 If a child aged between 4 weeks and 2 years has been in close contact with people with smear‑positive pulmonary or laryngeal TB who have not had at least 2 weeks of anti‑TB treatment:

  • Assess for active TB.

  • Start treatment for latent TB (see section 1.2.4 and 1.2.6) and carry out a Mantoux test.

  • If the Mantoux test is inconclusive, refer the child to a TB specialist.

  • If the Mantoux test is positive (5 mm or larger, regardless of BCG history), reassess for active TB; if this assessment is negative, complete treatment for latent TB.

  • If the Mantoux test is negative, continue treatment for latent TB, reassess for active TB after 6 weeks and repeat the Mantoux test:

    • if the Mantoux test is negative, consider an interferon‑gamma release assay

    • if the interferon‑gamma release assay is negative, treatment for latent TB may be stopped; give a BCG vaccination if the child has not already had one

    • if either test is positive, reassess for active TB; if this assessment is negative, complete treatment for latent TB.

The guidance for children has been updated by new evidence reviews and economic analyses.

The upper age‑limit for offering treatment for latent TB – and by relation to offer testing to diagnose latent TB – has been added. This was previously 35 years, but has been increased to 65 years. Although evidence on contact‑tracing in adults of different ages was not reviewed as part of the 2016 update, the age threshold for testing is directly dependent on evidence of the benefits, harms and costs of treating latent TB. The committee has reviewed this evidence and concluded that people should be offered treatment up to the age of 65 years. Therefore, it is necessary to amend this recommendation to reflect the revised upper age‑limit for treatment.

Although not amended by a new review, the committee felt strongly that the threshold for test positivity in healthcare workers should be brought in line with both international guidance and the other recommendations in this section. The previous threshold for test positivity of 6 mm from the 2011 guideline (taken from the Department of Health's The Green Book) is inconsistent with the new recommendations, which opted for a threshold of 5 mm, as well as with the new clinical‑ and cost‑effectiveness reviews and the new health economic modelling on which these were based. This is particularly an issue given that the 2011 recommendations were consensus‑based, not driven by evidence. See the full guideline for further information.

1.1.1.9 In an outbreak situation when large numbers of people may need to be screened, consider a single interferon‑gamma test for people aged 5 years and older.

1.2.3.2 In an incident situation when large numbers of people may need to be screened, consider a single interferon‑gamma release assay for people aged 18–65 years. For children and young people, follow recommendations 1.2.2.1 to 1.2.2.6. [2011, amended 2016]

The upper age‑limit for offering treatment for latent TB – and by relation to offer testing to diagnose latent TB – has been added. This was previously 35 years, but has been increased to 65 years. Although evidence on contact‑tracing in adults of different ages was not reviewed as part of the 2016 update, the age threshold for testing is directly dependent on evidence of the benefits, harms and costs of treating latent TB. The committee has reviewed this evidence and concluded that people should be offered treatment up to the age of 65 years. Therefore, it is necessary to amend this recommendation to reflect the revised upper age‑limit for treatment.

The committee considered the substantial resource implications inherent in the potential widespread use of IGRA testing, particularly in children who would require multiple appointments and blood taken in a children's hospital (thereby raising costs). Testing for children has been reviewed as part of the 2016 update; the recommendation has therefore been updated to reflect the new findings.

1.1.1.16 Offer an interferon‑gamma test to new NHS employees who have recently arrived from high‑incidence countries or who have had contact with patients in settings where TB is highly prevalent.

1.2.1.7 Offer an interferon‑gamma release assay to new NHS employees who have had contact with patients in settings where TB is highly prevalent.

  • If the interferon‑gamma release assay is positive, assess for active TB; and

  • if this assessment is negative, offer them treatment for latent TB infection. [2011, amended 2016]

The part of the recommendation for new NHS employees who have recently arrived from high‑incidence countries has been amended to be consistent with the new recommendation on the diagnosis of latent TB in new entrants from high‑incidence countries, which is based on a new evidence review and economic model. The part of the recommendation for new NHS employees who have had contact with patients in settings where TB is highly prevalent remains unchanged.

1.1.1.18 Offer people from hard‑to‑reach groups a single interferon‑gamma test.

1.2.3.3 Offer people younger than 65 years from under-served groups a single interferon‑gamma release assay. [2011, amended 2016]

For changes to similar recs in PH37 see recommendation 12 in recommendations from NICE guideline PH37 that have been amended

The upper age‑limit for offering testing to diagnose latent TB was previously 35 years, but has been increased to 65 years. Although evidence on contact‑tracing in adults of different ages was not reviewed as part of the 2016 update, the age threshold for testing is directly dependent on evidence of the benefits, harms and costs of treating latent TB. The committee has reviewed this evidence and concluded that people should be offered treatment up to the age of 65 years. Therefore, it is necessary to amend this recommendation to reflect the revised upper age‑limit for treatment.

1.1.2.1 … multiple sputum samples (at least three, with one early morning sample) should be sent for TB microscopy and culture for suspected respiratory TB before starting treatment if possible or, failing that, within 7 days of starting

1.3.2.2 Send multiple respiratory samples (3 deep cough sputum samples, preferably with 1 early morning sample) for TB microscopy and culture. [2016]

  • This should be before starting treatment if possible or, failing that, within 7 days of starting treatment in people with life‑threatening disease. [2006, amended 2016]

  • Obtain spontaneously‑produced, deep cough sputum samples if possible, otherwise use:

    • 3 gastric lavages or 3 inductions of sputum in children and young people (see recommendation 1.5.1.10), or

    • induction of sputum or bronchoscopy and lavage in adults (see recommendation 1.5.1.10). [2006, amended 2016]

  • Laboratory practices should be in accordance with the UK's Standards for Microbiology Investigations. [new 2016]

The committee felt that the recommendation needed clarifying with regards to the desired type of respiratory sample.

Furthermore, they felt that it was more important to obtain good diagnostic samples than rushing to start treatment, unless the patient had disease severe enough to be life‑threatening.

1.1.2.1 … spontaneously produced sputum should be obtained if possible; otherwise induction of sputum or bronchoscopy and lavage should be used

1.3.2.2 … Obtain spontaneously‑produced, deep cough sputum samples if possible, otherwise use:

  • induction of sputum or bronchoscopy and lavage in adults… [2006, amended 2016]

Recommendation reworded for clarity. Children have a separate recommendation, based on evidence reviewed for the 2016 update.

1.1.2.1 … samples should be sent for TB culture from autopsy samples if respiratory TB is a possibility.

1.3.2.3 Send samples for TB culture from autopsy samples if pulmonary or laryngeal TB is a possibility. [2006, amended 2016]

Recommendation reworded for clarity around specific forms of TB. Converted into a stand alone recommendation for emphasis.

1.1.2.2 … if non‑respiratory TB is a possibility, part or all of any of the following samples should be placed in a dry pot (and not all placed in formalin) and sent for TB culture:

  • lymph node biopsy

  • pus aspirated from lymph nodes

  • pleural biopsy

  • any surgical sample sent for routine culture

  • any radiological sample sent for routine culture

  • histology sample

  • aspiration sample

  • autopsy sample

1.3.5.2 Do not place part or all of any of the samples in formalin (or other fixative agent) when sending for TB culture. [2006, amended 2016]

The recommendation was previously a bullet point housed alongside a number of other recommendations for diagnosing non‑pulmonary TB; it was felt that having standalone recommendations was clearer. The group also felt that the type of fixative agent to be avoided should not be restricted to formalin alone, and that the type of sample that should not be placed in such a fixative agent should include all samples sent for culture, not just those previously listed. These changes were consensus‑based, as was the original recommendation.

1.1.2.1 … the standard recommended regimen should be continued in patients whose subsequent culture results are negative

1.1.2.2 … the appropriate drug regimen should be continued even if subsequent culture results are negative.

1.3.1.3 Consider completing the standard recommended regimen (see recommendations 1.3.7.2 and 1.3.7.3), even if subsequent culture results are negative. [2006, amended 2016]

Recommendation reworded for clarity: we changed the verb to 'consider' to reflect the strength of the evidence, and combined the recommendations for pulmonary and non‑pulmonary TB.

1.1.2.2 … microbiology staff should routinely perform TB culture on the above samples (even if it is not requested)

1.3.1.1 If TB is a possibility, microbiology staff should consider carrying out TB culture on samples, even if it is not requested. [2006, amended 2016]

The committee felt that the recommendation needed refining to reflect their view of current best practice.

1.2.1.4 A thrice‑weekly dosing regimen should be considered for patients receiving directly observed therapy (DOT).

1.2.1.5 A twice‑weekly dosing regimen should not be used for the treatment of active TB.

1.3.7.10 Do not offer anti‑TB treatment dosing regimens of fewer than 3 times per week. [2006, amended 2016]

1.3.7.11 Offer a daily dosing schedule to people with active pulmonary TB. [2006, amended 2016]

1.3.7.13 Consider 3 times weekly dosing for people with active TB only if:

  • risk assessment identifies a need for directly observed therapy and enhanced case management (see section 1.7) and

  • daily directly observed therapy is not possible. [2006, amended 2016]

New evidence for adults not reviewed for the 2016 update; new evidence was reviewed for children. It was decided that a minimum of 3 times weekly dosing was still desirable, though daily dosing remains the preferred option if resource constraints relating to the need for directly observed therapy and enhanced case management are not preventing it. The rationale is essentially that: 1) 3 times weekly dosing is only considered appropriate (that is, the patient is not at risk of receiving 'inadequate' treatment) when DOT and enhanced case management are performed, and 2) that if possible daily dosing would still be the preferable option, but given the situation in which a need for DOT has been identified but it cannot (e.g. for resource reasons) be performed daily, then 3 times weekly DOT may be considered.

Although prescription of a once‑weekly regimen would be unlikely, the committee felt that rewording 1.2.1.5 such that twice‑ and once‑weekly regimens were explicitly excluded was useful. This is supported by the evidence reviews.

1.2.2.2 Unless there is a clear clinical or socioeconomic need, such as homelessness, people with TB at any site of disease should not be admitted to hospital for diagnostic tests or for care.

1.5.1.5 Unless there is a clear clinical or public health need, such as homelessness, people with suspected infectious or confirmed pulmonary TB should not be admitted to hospital for diagnostic tests or for care. [2006, amended 2016]

The committee felt that the recommendation needed refining to reflect their view of current best practice.

1.3.1.2 Clinicians prescribing treatment for active meningeal TB should consider as first choice:

  • a daily dosing schedule

  • using combination tablets.

1.3.2.1 For patients with active peripheral lymph node tuberculosis, the first choice of treatment should:

  • be the standard recommended regimen

  • use a daily dosing schedule

  • include combination tablets.

1.3.3.2 Clinicians prescribing treatment for active bone and joint tuberculosis should consider as first choice:

  • a daily dosing schedule

  • using combination tablets.

1.3.5.1 For patients with active pericardial TB, the first choice of treatment should:

  • be the standard recommended regimen

  • use a daily dosing schedule

  • include combination tablets.

1.3.6.1 For patients with disseminated (including miliary) TB, the first choice of treatment should:

  • be the standard recommended regimen

  • use a daily dosing schedule

  • include combination tablets.

1.3.7.1 For patients with:

  • active genitourinary TB, or

  • active TB of any site other than:

  • respiratory system

  • CNS (typically meninges)

  • peripheral lymph nodes

  • bones and joints

  • pericardium

  • disseminated (including miliary) disease

the first choice of treatment should:

  • be the standard recommended regimen

  • use a daily dosing schedule

  • include combination tablets.

1.3.7.10 Do not offer anti‑TB treatment dosing regimens of fewer than 3 times per week. [2006, amended 2016]

1.3.7.12 Consider a daily dosing schedule as first choice in people with active extrapulmonary TB. [2006, amended 2016]

1.3.7.13 Consider 3 times weekly dosing for people with active TB only if:

  • risk assessment identifies a need for directly observed therapy and enhanced case management (see section 1.7) and

  • daily directly observed therapy is not possible. [2006, amended 2016]

A review for dosing frequency in children was done, though no new evidence was found. New evidence for duration of treatment for TB in extrapulmonary sites was also reviewed. Although re‑worded for clarity, the standard recommended regimens remained unchanged.

New evidence for dosing frequency in adults was not reviewed for the 2016 update, nor were the evidence or recommendations for the use of combination tablets.

It was decided that a minimum of 3 times weekly dosing was still desirable, though daily dosing remains the preferred option if resource constraints relating to the need for directly observed therapy and enhanced case management are not preventing it. The rationale is essentially that: 1) 3 times weekly dosing is only considered appropriate (that is, the patient is not at risk of receiving 'inadequate' treatment) when DOT and enhanced case management are performed, and 2) that if possible daily dosing would still be the preferable option, but given the situation in which a need for DOT has been identified but it cannot (e.g. for resource reasons) be performed daily, then 3 times weekly DOT may be considered.

1.8.4.4 Clinicians conducting contact tracing in a school should consider extending it to include children and teachers involved in extracurricular activities, and non‑teaching staff, on the basis of:

  • the degree of infectivity of the index case

  • the length of time the index case was in contact with others

  • whether contacts are unusually susceptible to infection

  • the proximity of contact.

1.6.1.17 Consider extending contact tracing in schools to include children and teachers involved in extracurricular activities, and non‑teaching staff, on the basis of:

  • the degree of infectivity of the index case

  • the length of time the index case was in contact with others

  • whether contacts are unusually susceptible to infection

  • the proximity of contact. [2006, amended 2016]

Recommendation changed to allow these actions to be completed by both clinical and non‑clinical staff.

1.7.2.3 In areas with a low incidence of TB, primary care organisations should offer BCG vaccination to selected neonates who:

  • were born in an area with a high incidence of TB, or

  • have one or more parents or grandparents who were born in a high‑incidence country, or

  • have a family history of TB in the past 5 years. [2006]

1.1.3.10 In areas with a low incidence of TB (see Public Health England's TB rate bands, published in their Annual Report), primary care organisations should offer BCG vaccination to selected neonates who:

  • were born in an area with a high incidence of TB or

  • have 1 or more parents or grandparents who were born in a high‑incidence country or

  • have a family history of TB in the past 5 years. [2006, amended 2016]

Recommendation reworded for clarity and to ensure currency with changing data from Public Health England's TB rate bands in annual reports.

1.7.3.1 Routine BCG vaccination is not recommended for children aged 10–14.

  • Healthcare professionals should opportunistically identify unvaccinated children older than 4 weeks and younger than 16 years at increased risk of TB (see section 1.6.1) who would have qualified for neonatal BCG and provide Mantoux testing and BCG (if Mantoux negative).

  • This opportunistic vaccination should be in line with the Chief Medical Officer's advice on vaccinating this age group following the end of the school‑based programme.

1.1.3.11 Routine BCG vaccination is not recommended for children aged 10–14 years.

  • Healthcare professionals should opportunistically identify unvaccinated children older than 4 weeks and younger than 16 years at increased risk of TB (see section 1.2.2) who would have qualified for neonatal BCG and provide Mantoux testing and BCG vaccination (if Mantoux‑negative).

  • This opportunistic vaccination should be in line with the Green Book. [2006, amended 2016]

This recommendation was amended to reflect current sources of information and guidance.

1.7.4.1 BCG vaccination should be offered to Mantoux‑negative new entrants who:

  • are from high‑incidence countries, and

  • are previously unvaccinated (that is, without adequate documentation or a characteristic scar), and

  • are aged:

    • younger than 16 years, or

    • 16 to 35 years from sub‑Saharan Africa or a country with a TB incidence of 500 per 100,000.

1.1.3.13 Offer BCG vaccination to new entrants who are Mantoux‑ or interferon-gamma release assay‑negative who:

  • are from high‑incidence countries, and

  • are previously unvaccinated (that is, without adequate documentation or a BCG scar), and

  • are aged:

    • younger than 16 years, or

    • 16–35 years from sub‑Saharan Africa or a country with a TB incidence of 500 per 100,000 or more. [2006, amended 2016]

Merged to reduce repetition.

The recommendation has also been updated to accommodate the inclusion of interferon‑gamma release assays in the guidance for the diagnosis of latent infection. Specifically, now a negative Mantoux test or a negative interferon‑gamma release assay might indicate the need to offer vaccination.

1.7.5.1 BCG vaccination should be offered to healthcare workers, irrespective of age, who:

  • are previously unvaccinated (that is, without adequate documentation or a characteristic scar), and

  • will have contact with patients or clinical materials, and

  • are Mantoux (or interferon‑gamma) negative.

Offer BCG vaccination to healthcare workers and other NHS employees who have contact with patients or clinical specimens, irrespective of age, who:

  • are previously unvaccinated (that is, without adequate documentation or a BCG scar) and

  • are Mantoux‑ (or interferon‑gamma release assay‑) negative (see section 1.2.1). [2006, amended 2016]

Recommendation reworded for clarity.

1.7.6.1 BCG vaccination should be offered to Mantoux‑negative contacts of people with respiratory TB (see section 1.8.1 for details of contact tracing) if they are previously unvaccinated (that is, without adequate documentation or a characteristic scar) and are:

  • aged 35 or younger

  • aged 36 and older and a healthcare or laboratory worker who has contact with patients or clinical materials.

1.1.3.17 Offer BCG vaccination to Mantoux‑ (or interferon‑gamma release assay‑) negative contacts of people with pulmonary and laryngeal TB (see section 1.2.3) if they:

  • have not been vaccinated previously (that is, there is no adequate documentation or a BCG scar) and

  • are aged 35 years or younger or

  • are aged 36 years and older and a healthcare or laboratory worker who has contact with patients or clinical materials. [2006, amended 2016]

The recommendation has been updated to accommodate the inclusion of interferon‑gamma release assays in the guidance for the diagnosis of latent infection. Specifically, now a negative Mantoux test or a negative interferon‑gamma release assay might indicate the need to offer vaccination.

1.7.7.1 BCG vaccination should be offered to previously unvaccinated, Mantoux‑negative people aged 35 or younger in the following groups at increased risk of exposure to TB, in accordance with the Green Book:

  • veterinary and other staff such as abattoir workers who handle animal species known to be susceptible to TB, such as simians

  • prison staff working directly with prisoners

  • staff of care homes for elderly people

  • staff of hostels for homeless people and facilities accommodating refugees and asylum seekers

  • people going to live or work with local people for more than 1 month in a high‑incidence country.

1.1.3.18 Offer BCG vaccination to previously unvaccinated, Mantoux‑ or interferon‑gamma release assay‑negative people aged 35 years or younger in the following groups at increased risk of exposure to TB, in accordance with the Green Book:

  • veterinary and other staff such as abattoir workers who handle animal species known to be susceptible to TB, such as simians

  • prison staff working directly with prisoners

  • staff of care homes for older people

  • staff of hostels for people who are homeless and facilities accommodating refugees and asylum seekers

  • people going to live or work with local people for more than 3 months in a high‑incidence country. [2006, amended 2016]

The recommendation has been updated to accommodate the inclusion of interferon=gamma release assays in the guidance for the diagnosis of latent infection. Specifically, now a negative Mantoux test or a negative interferon‑gamma release assay might indicate the need to offer vaccination.

Additionally, the time threshold for people going to live or work with local people in a high‑incidence country has been updated to 3 months, to bring it in line with the Green Book.

1.9.1.7 If a new employee from the UK or other low‑incidence setting, without prior BCG vaccination, has a positive Mantoux and a positive interferon‑gamma test, they should have a medical assessment and a chest X‑ray. They should be referred to a TB clinic for consideration of TB treatment if the chest X‑ray is abnormal, or for consideration of treatment of latent TB infection if the chest X‑ray is normal.

If a new employee from the UK or other low‑incidence setting, who has not had a BCG vaccination, has a positive Mantoux test and a positive interferon‑gamma release assay, they should have a medical assessment and a chest X ray. They should be referred to a TB clinic to determine whether they need TB treatment if the chest X ray is abnormal, or to determine whether they need treatment of latent TB infection if the chest X ray is normal. [2006, amended 2011, amended 2016]

Recommendation reworded for clarity.

1.9.1.8 If a prospective or current healthcare worker who is Mantoux negative (less than 6 mm) declines BCG vaccination, the risks should be explained and the oral explanation supplemented by written advice. If the person still declines BCG vaccination, he or she should not work where there is a risk of exposure to TB. The employer will need to consider each case individually, taking account of employment and health and safety obligations.

1.1.4.8 If a prospective or current healthcare worker who is Mantoux‑ (or interferon‑gamma release assay‑) negative (see recommendations 1.2.1.5 to 1.2.1.8) declines BCG vaccination, explain the risks and supplement the oral explanation with written advice. If the person still declines BCG vaccination, he or she should not work where there is a risk of exposure to TB. The employer will need to consider each case individually, taking account of employment and health and safety obligations. [2006, amended 2016]

The recommendation has been updated to accommodate the inclusion of interferon‑gamma release assays in the guidance for the diagnosis of latent infection. Specifically, now a negative Mantoux test or a negative interferon‑gamma release assay might indicate the need to offer vaccination.

1.8.1.2 Screening should be offered to the household contacts of any person with active TB, irrespective of the site of infection. Household contacts are defined as those who share a bedroom, kitchen, bathroom or sitting room with the index case. Screening should comprise:

  • standard testing for latent TB for those aged 35 or younger, and consideration of BCG or treatment for latent TB infection once active TB has been ruled out

  • interferon‑gamma test 6 weeks after the Mantoux test, and consideration of BCG or treatment for latent TB infection once active TB has been ruled out, for those who:

    • are previously unvaccinated and

    • are household contacts of a person with sputum‑smear‑positive TB and

    • are Mantoux negative (less than 6 mm)

  • chest X‑ray (if there are no contraindications) for those older than 35, possibly leading to further investigation for active TB.

1.6.1.2 Offer screening to the close contacts of any person with pulmonary or laryngeal TB. [2006, amended 2016]

The committee has revised this recommendation – which previously referred to 'all people with active TB' – to limit testing to contacts of people with potentially infectious TB.

1.8.1.2 Screening should be offered to the household contacts of any person with active TB, irrespective of the site of infection. Household contacts are defined as those who share a bedroom, kitchen, bathroom or sitting room with the index case. Screening should comprise:

  • standard testing for latent TB for those aged 35 or younger, and consideration of BCG or treatment for latent TB infection once active TB has been ruled out

  • interferon‑gamma test 6 weeks after the Mantoux test, and consideration of BCG or treatment for latent TB infection once active TB has been ruled out, for those who:

    • are previously unvaccinated and

    • are household contacts of a person with sputum‑smear‑positive TB and

    • are Mantoux negative (less than 6 mm)

  • chest X‑ray (if there are no contraindications) for those older than 35, possibly leading to further investigation for active TB.

1.6.1.4 In asymptomatic close contacts younger than 65 years, consider standard testing for latent TB (see sections 1.2.1 to 1.2.3), followed by consideration of BCG vaccination (see section 1.1.3) or treatment for latent TB infection (see sections 1.2.4 to 1.2.6) once active TB has been ruled out for people who:

  • are previously unvaccinated and

  • are contacts of a person with smear‑positive pulmonary or laryngeal TB and

  • are Mantoux[a]‑ or interferon‑gamma release assay‑negative. [2006, amended 2016]

1.6.1.5 In asymptomatic close contacts older than 65 years, consider a chest X‑ray (if there are no contraindications), possibly leading to further investigation for active TB. [2006, amended 2016]

The committee felt that a distinction between symptomatic – that is, those who are more likely to have active disease, who should therefore proceed more quickly to diagnosis for active disease – and asymptomatic contacts.

Furthermore, the upper age‑limit was raised. Although evidence on contact‑tracing in adults of different ages was not reviewed as part of the 2016 update, the age threshold for testing is directly dependent on evidence of the benefits, harms and costs of treating latent TB. The committee has reviewed this evidence and concluded that people should be offered treatment up to the age of 65 years. Therefore, it is necessary to amend this recommendation to reflect the revised upper age‑limit for treatment.

Further guidance has been added on the type of X‑ray that should be performed. This was done to improve clarity and consistency within the guideline.

The committee also amended the contact terminology for clarity, and to ensure it reflected current practice.

1.8.1.3 For people with sputum‑smear‑positive TB, other close contacts should be assessed. These may include boyfriends or girlfriends and frequent visitors to the home of the index case. Occasionally, a workplace associate may be judged to have had contact equivalent to that of household contacts, and should be assessed in the same way.

1.6.1.4 In asymptomatic close contacts younger than 65 years, consider standard testing for latent TB (see sections 1.2.1 to 1.2.3), followed by consideration of BCG vaccination (see section 1.1.3) or treatment for latent TB infection (see sections 1.2.4 to 1.2.6) once active TB has been ruled out for people who:

  • are previously unvaccinated, and

  • are contacts of a person with smear‑positive pulmonary or laryngeal TB, and, and

  • are Mantoux‑ or interferon‑gamma release assay‑negative. [2006, amended 2016]

1.6.1.5 In asymptomatic close contacts older than 65 years, consider a chest X ray (if there are no contraindications), possibly leading to further investigation for active TB. [2006, amended 2016]

The committee amended the contact terminology for clarity, and to ensure it reflected current practice. The detail provided in the CG117 recommendation has been moved to the glossary definition.

1.8.1.5 The need for tracing casual contacts of people with TB should be assessed if:

  • the index case is judged to be particularly infectious (for example, evidenced by transmission to close contacts), or

  • any casual contacts are known to possess features that put them at special risk of infection.

1.6.1.7 Assess the need for tracing social contacts of people with pulmonary or laryngeal TB if:

  • the index case is judged to be particularly infectious (for example, evidenced by transmission to close contacts) or

  • any social contacts are known to possess features that put them at high risk of going on to develop active TB. [2006, amended 2016]

The committee has revised this recommendation – which previously referred to 'all people with active TB' – to limit testing to contacts of people with potentially infectious TB. Additionally, the recommendation has been edited to be in the active voice, rather than passive.

The committee also amended the contact terminology for clarity, and to ensure it reflected current practice.

1.8.3.1 Following diagnosis of TB in an aircraft traveller, contact tracing of fellow passengers should not routinely be undertaken.

1.6.1.9 After diagnosis of TB in an aircraft traveller, do not routinely carry out contact tracing of fellow passengers. [2006, amended 2016]

Recommendation reworded for clarity.

1.8.3.2 …The CCDC should provide the airline with 'Inform and advise' information to send to passengers seated in the same part of the aircraft as the index case.

1.6.1.11 The consultant in communicable disease control or health protection should provide the airline with 'inform and advise' information to send to passengers seated in the same part of the aircraft as the index case. [2006, amended 2016]

Recommendation reworded for clarity.

1.8.4.1 Following diagnosis of TB in a school pupil or member of staff, the consultant in communicable disease control should be prepared to explain the prevention and control procedures to staff, parents and the press. Advice on managing these incidents and their public relations is available from the Health Protection Unit.

1.6.1.14 After diagnosis of TB in a school pupil or member of staff, the consultant in communicable disease control or health protection should be prepared to explain the prevention and control procedures to staff, parents and the press. Advice on managing these incidents and their public relations is available from the Public Health England health protection team and the local authority. [2006, amended 2016]

Recommendation reworded to be current with new policy

1.8.5.1 When an adult who works in childcare (including people who provide childcare informally) is diagnosed with sputum‑smear‑positive TB, management is as for contact tracing (see section 1.8.1)

1.6.1.20When an adult who works in childcare (including people who provide childcare informally) is diagnosed with smear‑positive TB, follow recommendations 1.6.1.1 to 1.6.1.8. [2006, amended 2016]

Recommendation reworded for clarity around smear positive status

1.8.6.1 Following diagnosis of TB in a hospital inpatient, a risk assessment should be undertaken. This should take into account:

  • the degree of infectivity of the index case

  • the length of time before the infectious patient was isolated

  • whether other patients are unusually susceptible to infection

  • the proximity of contact.

Contact tracing and testing should be carried out only for patients for whom the risk is regarded as significant

1.6.1.21 If TB is diagnosed in a hospital inpatient, do a risk assessment. This should take into account:

  • the degree of infectivity of the index case

  • the length of time before the infectious patient was isolated

  • whether other patients are unusually susceptible to infection

  • the proximity of contact. [2006, amended 2016]

Recommendation reworded for clarity.

1.8.6.3 If patients were exposed to a patient with sputum‑smear‑positive TB for long enough to be equivalent to household contacts (as determined by the risk assessment), or an exposed patient is known to be particularly susceptible to infection, they should be managed as equivalent to household contacts (see section 1.8.1)

1.6.1.24 If patients were exposed to a patient with smear‑positive TB for long enough to be equivalent to close contacts (as determined by the risk assessment), or an exposed patient is known to be particularly susceptible to infection, manage their TB risk in the same way as close contacts. [2006, amended 2016]

Recommendation reworded for clarity around smear positive status.

In cases of doubt when planning contact tracing after diagnosing sputum‑smear‑positive TB in an inpatient, further advice should be sought from the regional or national Health Protection Agency or people experienced in the field.

1.6.1.26 In cases of doubt when planning contact tracing after diagnosing smear‑positive TB in an inpatient, seek further advice from the local or national Public Health England or Wales unit or people experienced in the field. [2006, amended 2016]

Recommendation reworded for clarity around smear positive status.

1.8.7.2 Assessment for, and management of TB in new entrants should consist of the following.

  • Risk assessment for HIV, including HIV prevalence rates in the country of origin, which is then taken into account for Mantoux testing and BCG vaccination.

  • Assessment for active TB if interferon‑gamma test is positive; which would include a chest X‑ray.

  • Treatment for latent TB infection for people aged 35 years or younger in whom active TB has been excluded, with a positive Mantoux test inconsistent with their BCG history, and a positive interferon‑gamma test.

  • Consideration of BCG for unvaccinated people who are Mantoux negative.

  • 'Inform and advise' information for people who do not have active TB and are not being offered BCG or treatment for latent TB infection.

1.6.2.1 Assess and manage TB in new entrants from high incidence countries who present to healthcare services as follows:

  • assess risk of HIV, including HIV prevalence rates in the country of origin, and take this into account when deciding whether to give a BCG vaccination

  • offer testing for latent TB (see sections 1.2.1 to 1.2.3)

  • assess for active TB if the test for latent TB is positive (see sections 1.3.1 to 1.3.5)

  • offer treatment to people aged 65 years or younger in whom active TB has been excluded but who have a positive Mantoux test or a positive interferon‑gamma release assay for latent TB infection (see sections 1.2.4 to 1.2.6)

  • consider offering BCG for unvaccinated people who are Mantoux negative or interferon‑gamma release assay‑negative (see section 1.1.3)

  • give 'inform and advise' information to people who do not have active TB and are not being offered BCG or treatment for latent TB infection (see section 1.1.2). [2006, amended 2011, amended 2016]

The committee added 'from high incidence countries who present to healthcare services as follows' for greater clarity of the target population.

Instead of giving recommendations on the diagnosis of latent TB infection here – which would duplicate recommendation 1.2.1.11 – the group preferred to keep this strictly about the process of case‑finding. This mirrors the approach taken to evaluation of active disease in bullet 3 (no clinical instructions given, these are simply cross referenced) and treatment of latent infection in bullet 4 (again, no clinical instructions given, these are simply cross referenced).

Furthermore, the upper age‑limit was raised. Although evidence on contact‑tracing in adults of different ages was not reviewed as part of the 2016 update, the age threshold for testing is directly dependent on evidence of the benefits, harms and costs of treating latent TB. The committee has reviewed this evidence and concluded that people should be offered treatment up to the age of 65 years. Therefore, it is necessary to amend this recommendation to reflect the revised upper age‑limit for treatment.

The wording was also amended such that clinicians are asked to 'offer' testing and treatment for latent TB and BCG. This is to better reflect the fact that no one in England and Wales has the power to force new entrants to accept testing or treatment for latent TB.

Finally, the recommendation has been updated to accommodate the inclusion of interferon‑gamma release assays in the guidance for the diagnosis of latent infection. Specifically, now a negative Mantoux test or a negative interferon‑gamma release assay might indicate the need to offer vaccination.

1.8.7.4 Any healthcare professional working with new entrants should encourage them to register with a GP.

1.6.2.2 Primary care services should support local, community‑based and voluntary organisations that work with vulnerable migrants to ensure they:

  • register with a primary care provider

  • know how to use NHS services (emergency or primary care).

Recommendation merged with a related recommendation from Identifying and managing tuberculosis among hard-to-reach groups.

1.8.8.1 Active case finding should be carried out among street homeless people (including those using direct access hostels for the homeless) by chest X‑ray screening on an opportunistic and/or symptomatic basis. Simple incentives for attending, such as hot drinks and snacks, should be considered.

1.6.2.5 Multidisciplinary TB teams should consider using simple incentives, such as providing hot drinks and snacks, to encourage people to attend for testing. [2006, amended 2012, amended 2016]

Recommendation merged with a related recommendation from Identifying and managing tuberculosis among hard‑to‑reach groups.

1.8.8.2 Healthcare professionals working with people with TB should reinforce and update education about TB, and referral pathways, to primary care colleagues, social workers and voluntary workers who work with homeless people.

1.1.1.1 Multidisciplinary TB teams (in collaboration with Public Health England, primary care, the voluntary sector and Health Education England) should identify and support an ongoing TB education programme for local professionals in contact with the general public, and at‑risk groups in particular. This includes, for example, staff in emergency departments, GPs and wider primary care staff, people who work in housing support services, staff who support migrants and those working in walk‑in centres, hostels, substance misuse projects and prisons. [2012, amended 2016]

Recommendation merged with a recommendation 5 from Identifying and managing tuberculosis among hard-to-reach groups.

1.9.1.4 Employees who will be working with patients or clinical specimens and who are Mantoux negative (less than 6 mm) should have an individual risk assessment for HIV infection before BCG vaccination is given.

1.9.1.6 Employees of any age who are new to the NHS and are from countries of high TB incidence, or who have had contact with patients in settings with a high TB prevalence should have an interferon‑gamma test. If negative, offer BCG vaccination as with a negative Mantoux result. If positive, the person should be referred for clinical assessment for diagnosis and possible treatment of latent infection or active disease.

1.1.4.5 Employees who will be working with patients or clinical specimens and who are Mantoux‑ or interferon‑gamma release assay‑negative (see section 1.2.1) should have an individual risk assessment for HIV infection before BCG vaccination is given. [2006, amended 2016]

1.2.1.5 Offer a Mantoux test to new NHS employees who will be in contact with patients or clinical materials, if the employees:

  • are not new entrants from high‑incidence countries and

  • have not had BCG vaccination (for example, they are without a BCG scar, other documentation or a reliable history).

If the Mantoux test is positive, offer an interferon‑gamma release assay. If this is positive, assess for active TB; if this assessment is negative, offer them treatment for latent TB infection. [2011, amended 2016]

Although not updated by a new review, the committee felt strongly that the threshold for test positivity in healthcare workers should be brought in line with both international guidance and the other recommendations in this section. The previous threshold for test positivity of 6 mm from is inconsistent with the new recommendations, which opted for a threshold of 5 mm, as well as with the new clinical‑ and cost‑effectiveness reviews and the new health economic modelling on which these were based. This is particularly an issue given that the 2011 recommendations were consensus‑based, not driven by evidence. For this reason, the recommendation now simply references the recommendations on the diagnosis of latent TB infection.

See section 4.1.3.4 of the full guideline for further information.

The recommendation has also been updated to accommodate the inclusion of interferon‑gamma release assays in the guidance for the diagnosis of latent infection. Specifically, now a negative Mantoux test or a negative interferon‑gamma release assay might indicate the need to offer vaccination.

1.9.3.1 Healthcare workers providing care for prisoners and remand centre detainees should be aware of the signs and symptoms of active TB. TB services should ensure that awareness of these signs and symptoms is also promoted among prisoners and prison staff.

1.1.1.1 Multidisciplinary TB teams (in collaboration with Public Health England, primary care, the voluntary sector and Health Education England) should identify and support an ongoing TB education programme for local professionals in contact with the general public and at‑risk groups in particular. This includes, for example, staff in emergency departments, GPs and wider primary care staff, people who work in housing support services, staff who support migrants and those working in walk‑in centres, hostels, substance misuse projects and prisons. [2012, amended 2016]

Recommendation merged with recommendation 5 from Identifying and managing tuberculosis among hard-to-reach groups.

1.4.3.3 TB services should consider the following interventions to improve adherence to treatment for active or latent TB if a patient defaults:

  • reminder letters in appropriate languages

  • health education counselling

  • patient‑centred interview and health education booklet

  • home visits

  • patient diary

  • random urine tests and other monitoring (for example, pill counts)

  • information about help with paying for prescriptions

  • help or advice about where and how to get social security benefits, housing and social services. [2006]

1.7.2.2 Multidisciplinary TB teams should implement strategies for active and latent TB to encourage people to follow the treatment plan and prevent people stopping treatment early. These could include:

  • reminder letters, printed information, telephone calls, texts and apps using an appropriate language [2006, amended 2016]

  • health education counselling and patient‑centred interviews [2006, amended 2016]

  • tailored health education booklets from quality sources (see recommendation 1.1.2) [2006, amended 2016]

  • home visits [2006]

  • random urine tests and other monitoring (for example, pill counts) [2006]

  • access to free TB treatment for everyone (irrespective of eligibility for other NHS care) and information about help with paying for prescriptions [2006, 2012, amended 2016]

  • social and psychological support (including cultural case management and broader social support) [new 2016]

  • advice and support for parents and carers [new 2016]

  • incentives and enablers to help people follow their treatment regimen. [new 2016]

TB services changed to MDTB team to reflect specific group responsible

More descriptive text requested by the committee explaining why action should be taken.

To reflect increased options and technological advances.

To remove duplication and reflect new recommendations on information for the public and quality assurance and changes in the adherence section.

Patient diary removed – committee considered outdated.

Random urine tests removed – committee considered inappropriate and does not happen in practice.

TB treatment is free to all added to information on prescription charges

Social and psychological support, cultural case management, incentives and enablers added to reflect evidence.

[a] At the time of publication (January 2016) the BNF states: 'The Mantoux test is recommended for tuberculin skin testing, but no licensed preparation is currently available. Guidance for healthcare professionals is available at www.dh.gov.uk/immunisation.'

Recommendations from NICE guideline PH37 that have been amended

Recommendations are labelled [2012, amended 2016] if:

  • The evidence has not been reviewed, but a change has been made to clarify roles or actions in the original recommendation, extrapolate to the whole population, or where system changes such as establishment of TB control boards have been reflected

  • NICE has made editorial changes to the wording to clarify the action to be taken, but where there is no change of meaning to the original recommendation.

Recommendation in 2012 guideline

Recommendation in current guideline

Reason for change

Recommendation 1 Strategic oversight and commissioning of TB prevention and control activities

1.8.1 Strategic oversight and commissioning of TB prevention and control activities

The NHS Commissioning Board, in partnership with Public Health England, should take responsibility for national oversight of TB prevention and control activities

1.8.1.1 Public Health England, in partnership with NHS England, should take responsibility for national oversight of TB prevention and control activities. This includes setting up TB control boards (see section 1.8.2). [2012, amended 2016]

This change reflects the change in name of NHS commissioning board to NHS England, and the establishment of TB control boards, which is a new system change.

Public Health England and commissioners should ensure the TB prevention and control programme targets all ages, including children. In addition, it should cover all aspects of TB prevention and control as follows:

  • active case‑finding (contact investigations and screening of high‑risk groups)

  • awareness‑raising activities

  • diagnostic and treatment services

  • standard and enhanced case management (including the provision of directly observed therapy)

  • ◦ finding those lost to follow‑up and encouraging them back into treatment

  • identification and management of latent infection

  • immunisation

  • incident and outbreak control

  • cohort review (see recommendation 3)

  • monitoring and evaluation

  • the gathering of surveillance and outcome data

1.8.1.3 Clinical commissioning groups and local authority public health teams working in partnership with Public Health England and NHS England should consider collaborative commissioning arrangements through TB control boards. This could, for example, include working with 1 or more clinical commissioning groups to cover a major metropolitan district, region or TB control board area taking into account:

  • local TB incidence

  • local at‑risk populations and their movements across different geographical areas

  • existing service configurations for organisations involved in TB prevention and control

  • the need to share services, such as mobile X‑ray facilities, and outreach incident teams across different geographical areas. [2012, amended 2016]

This change reflects who is responsible for the decision making and the establishment of TB control boards, which is a new system change, and to further clarify the recommendation.

In addition the bullet list has been reduced to reduce duplication with TB control board roles and responsibilities in the next section of recommendations.

Public Health England and commissioners should ensure TB prevention and control programmes are led by a director of public health or another nominated public health consultant. The lead should ensure a comprehensive prevention and control programme is commissioned to support the level of need (see recommendation 2).

1.8.1.5 An executive director of local commissioning groups, working with the local director of public health or another nominated public health consultant, should lead implementation of the programme in their locality. The lead should ensure a comprehensive prevention and control programme is commissioned to support the level of need (see section 1.8.5) and that they work with the control board regularly. [2012, amended 2016]

This change reflects the establishment of TB control boards, and the need to consider who on a wider geography may need to be involved.

Public Health England and commissioners should ensure TB prevention and control programmes set up multidisciplinary TB teams to provide all TB services (see recommendation 4)

1.8.1.6 Working together through TB control boards and local networks, commissioners, local government and Public Health England should ensure TB prevention and control programmes set up multidisciplinary TB teams to provide all TB services (see section 1.8.7). They should ensure that local strategy and service commissioning focuses on an end-to-end pathway. [2012, amended 2016]

This change reflects the establishment of TB control boards, and other groups or specific commissioners who need to consider TB service requirements. In addition it reflects the need to consider the service as a whole from a prevention to cure perspective.

Public Health England and commissioners should ensure the TB prevention and control programme is informed by relevant NICE guidance and developed in collaboration with relevant clinical services. It should also be informed by the standard minimum data set collected through local needs assessment and service audit (see recommendation 2).

1.8.1.7 Working together through TB control boards, commissioners and Public Health England should ensure the TB prevention and control programme is informed by relevant NICE guidance and developed in collaboration with clinical services. It should also be informed by the standard minimum data set collected through local needs assessment and service audit. [2012, amended 2016]

This change reflects the establishment of TB control boards.

Public Health England and commissioners should ensure the TB prevention and control programme targets all ages, including children. In addition, it should cover all aspects of TB prevention and control as follows:

  • active case‑finding (contact investigations and screening of high‑risk groups)

  • awareness‑raising activities

  • diagnostic and treatment services

  • standard and enhanced case management (including the provision of directly observed therapy)

  • finding those lost to follow‑up and encouraging them back into treatment

  • identification and management of latent infection

  • immunisation

  • incident and outbreak control

  • cohort review (see recommendation 3)

  • monitoring and evaluation

  • the gathering of surveillance and outcome data.

1.8.1.8 Working together through TB control boards, commissioners and Public Health England should ensure the TB prevention and control programme targets all ages, including children, and covers all aspects of TB prevention and control (see recommendations 1.8.2.1 and 1.8.2.2), including but not limited to:

  • active case finding (contact investigations and identifying latent TB in high‑risk groups)

  • awareness‑raising activities

  • standard and enhanced case management (including providing directly observed therapy and free treatment)

  • finding those lost to follow‑up and encouraging them back into treatment

  • incident and outbreak control

  • monitoring, evaluating and gathering surveillance and outcome data. [2012, amended 2016]

This change reflects the establishment of TB control boards, which is a new system change. Additional wording on what the responsibilities of TB control boards are has been added for clarification.

Public Health England and commissioners should ensure TB prevention and control programmes take account of the need to work with other programmes targeting hard‑to‑reach groups (including those in the voluntary sector). Examples include programmes focused on: the health of asylum seekers and refugees, vulnerable children, homelessness and housing, offenders and substance misusers.

1.8.1.9 Working together through TB control boards, commissioners, Public Health England and the voluntary sector should ensure TB prevention and control programmes take account of the need to work with other programmes targeting specific high‑risk groups, such as those who are under-served. Examples include programmes focused on the health of asylum seekers and refugees, under-served children, homelessness and housing, offenders and people who misuse substances. [2012, amended 2016]

This change reflects the establishment of TB control boards, which is a new system change, and ensures the voluntary sector's role is clear.

Recommendation 2 Local needs assessment

1.8.5 Local Needs Assessment

Directors of public health and others who lead TB prevention and control programmes should use cohort review (see recommendation 3) and other methods to collect data on the following, to inform local needs assessment:

  • Number of annual notified TB cases (see Enhanced TB surveillance on the Health Protection Agency website).

  • Size, composition (for example, age and ethnicity) and distribution of local at‑risk groups.

  • Indices of social deprivation.

  • Local statutory and non‑statutory services working with these groups.

  • Organisation of local TB services, including the composition and capacity of the local multidisciplinary TB and location of services.

  • Numbers requiring enhanced case management (see recommendation 15).

  • Numbers receiving directly observed therapy from the start, or at any point during, treatment (see Enhanced TB surveillance on the Health Protection Agency website).

  • Evidence of recent transmission (for example, using DNA fingerprinting or surrogate markers such as number of cases in under 5s).

  • Completeness and yield of contact investigations. This includes: proportion of sputum‑smear‑positive cases with none, five or more contacts identified; proportion of identified contacts clinically assessed; and proportion of contacts with latent TB infection who successfully complete treatment. (See also recommendation 13.)

  • Active case‑finding initiatives.

  • Treatment outcomes for everyone grouped according to social risk factors and by the use of directly observed therapy (including rates of loss to follow‑up and treatment interruptions – see Enhanced TB surveillance on the Health Protection Agency website and recommendation 13).

  • Local education and awareness‑raising programmes for hard‑to‑reach groups and professionals working with them.

  • Views and experience of TB patients and the services working with them

1.8.5.4 Directors of public health and TB control boards should use cohort review (see section 1.8.6) and other methods to collect data on the following, to inform local needs assessment:

  • Number of annual notified TB cases (see Public Health England's enhanced TB surveillance data and annual 'suite of indicators').

  • Size, composition (for example, age and ethnicity) and distribution of local at‑risk groups.

  • Indices of social deprivation.

  • Local statutory and non‑statutory services working with these groups.

  • Organisation of local TB services, including the composition and capacity of the local multidisciplinary TB team(see the results of local audit) and location of services. This may also include data to support evaluating the need for integrated TB/HIV services including joint clinics.

  • Numbers needing enhanced case management (see section 1.7)

  • Numbers receiving directly observed therapy from the start of, or at any point during, treatment (see Public Health England's enhanced TB surveillance data).

  • Evidence of recent transmission (for example, using DNA fingerprinting or surrogate markers such as number of cases in children under 5 – See UK TB strain-typing database and local incident and outbreak reports).

  • Completeness and yield of contact investigations. This includes: proportion of sputum‑smear‑positive cases with 0, 5 or more contacts identified; proportion of identified contacts clinically assessed; and proportion of contacts with latent TB infection who successfully complete treatment (see section 1.6 and 1.8.6).

  • Active case‑finding initiatives, incident contact investigations and identification of latent TB infection in high‑risk groups.

  • Treatment outcomes for everyone grouped according to social risk factors and by the use of directly observed therapy (including rates of loss to follow‑up and treatment interruptions – see Public Health England's enhanced TB surveillance data).

  • Local education and awareness‑raising programmes for under‑served groups, professionals and practitioners working with them.

  • Views and experiences of people with TB, carers and the services working with them. [2012, amended 2016]

This change reflects the establishment of TB control boards, which is a new system change, and also adds clarification.

In addition the need for data on HIV or other topics have been added support the addition of the recommendation on integration of TB‑HIV clinical in the strategic oversight recommendations or other downstream recommendation changes.

Directors of public health should provide TB prevention and control programme commissioners (see recommendation 1) with local needs assessment information on an annual basis

1.8.5.2 Directors of public health should provide commissioners of TB prevention and control programmes and TB control boards with local needs assessment information annually using data provided by Public Health England.[2012, amended 2016]

This change reflects the establishment of TB control boards.

Directors of public health should ensure TB is part of the joint strategic needs assessment in areas of high need

1.8.5.1 Directors of public health, in discussion with local health protection teams, should ensure that TB is part of the joint strategic needs assessment. [2012, amended 2016]

To support decision making as health protection teams can provide the relevant information to support this.

Commissioners of TB prevention and control programmes should ensure services reflect the needs of their area, as identified by needs assessment

1.8.5.3 Commissioners of TB prevention and control programmes should ensure services reflect the needs of their area, identified by needs assessment. Health and wellbeing boards should ensure that local TB services have been commissioned based on local needs identified through needs assessment. [2012, amended 2016]

This change reflects the role of health and wellbeing boards as a result of the Health and Social Care Act.

Recommendation 3 Cohort review

1.8.6 Cohort review

TB prevention and control programme leads should initiate, audit and evaluate cohort reviews within their commissioning area. Quarterly cohort review meetings should take place in the area covered by the programme.

1.8.6.1 TB control boards and prevention and control programme leads should initiate, audit and evaluate cohort reviews in their commissioning area. Quarterly cohort review meetings should take place in the area covered by the programme. Combine these meetings with others if possible, or use technology to make it easier for clinicians and case managers to attend. [2012, amended 2016]

This change reflects the establishment of TB control boards, resulting from the National TB strategy. It also adds clarification on how the cohort review meetings can more easily be implemented in practice.

TB case managers should present standardised information on each case, including: demographic information, status (clinical, laboratory, radiology), adherence to treatment and the results of contact investigations.

TB case managers and key allied professionals from the TB prevention and control programme should attend cohort review meetings. Either a paediatrician with training and expertise in TB management, or a paediatric infectious disease specialist, should be present when cases of children with TB are presented

1.8.6.2 TB case managers should present standardised information on each case, including: demographic information, HIV test results, pre‑treatment and ongoing status (clinical, laboratory, radiology), adherence to treatment and the results of contact investigations. [2012, amended 2016]

1.8.6.3 TB case managers and key allied professionals from the TB prevention and control programme should attend cohort review meetings. This could include the lead clinician (who may or may not be the case manager). Either a paediatrician with experience and training in the treatment of TB or a general paediatrician with advice from a specialised clinician should be present when cases of children with TB are presented. [2012, amended 2016]

Clarification on what may be useful and to extrapolate to all people with TB.

The chair of the cohort review should be neutral, that is, they should not work for any of the TB services included in the review. Examples of possible chairs include the director of public health, a specialist physician from a different geographical area, or a representative from the local Public Health England unit

1.8.6.4 The chair of the cohort review should not work for any of the TB services included in the review. Examples of possible chairs include a public health consultant, a specialist physician or a senior TB nurse, preferably from a different geographical area. Alternatively the chair could be a representative from the local Public Health England health protection team or the TB control board. [2012, amended 2016]

Examples added to support implementation.

Public Health England units, in conjunction with the TB prevention and control programme lead, should collate and then present cohort review data on TB treatment and the outcome of contact investigations at the review meetings. In addition, progress towards national, regional and local service targets should be presented

1.8.6.5 Multidisciplinary TB teams, in conjunction with Public Health England units, should collate and present cohort review data on TB treatment and the outcome of contact investigations at the review meetings. In addition, progress towards national, regional and local service targets should be presented. [2012, amended 2016]

Reflect that it is the MDTB teams who are the primary actor and to account for the establishment of TB control boards.

Those participating in a cohort review should review the results and evaluate local services

1.8.6.8 People participating in a cohort review should review the results and evaluate local services (for example, auditing adverse outcomes, rates of culture confirmation, treatment completion rates or time to diagnosis). [2012, amended 2016]

Examples added to support implementation and aid clarity.

TB prevention and control programme leads should ensure outputs from the cohort review feed into the needs assessment for TB services. These leads should attend the cohort review at least once a year

1.8.6.6 TB control boards, directors of public health and local public health consultants should ensure outputs from the cohort review feed into the needs assessment for TB services. TB control board directors should attend the cohort review at least once a year. [2012, amended 2016]

This change reflects the establishment of TB control boards, and to reflect the other primary actors for delivery of this recommendation due to other changes in the system as a result of the Health and Social Care Act.

TB case managers should feed back promptly to MDTB teams on issues identified as a result of cohort review. The chair of the cohort review should feed back to commissioners via needs assessment

1.8.6.7 TB case managers should feed back promptly to multidisciplinary TB teams on issues identified as a result of cohort review. The results of the cohort review should be collated locally and agreed by the chair before being fed back to TB control boards, commissioners and health and wellbeing boards regularly and via needs assessment. [2012, amended 2016]

This change reflects the establishment of TB control boards, who have a responsibility to monitor the cohort review process as part of their work it also supports implementation, by providing additional detail on which elements of the process are relevant for different people.

Recommendation 4 Commissioning multidisciplinary TB support for hard‑to‑reach groups

1.8.7 Commissioning multidisciplinary TB support

Have the skills and resources to manage those who are not from hard‑to‑reach groups. (One whole‑time equivalent case manager is recommended per 40 incident cases requiring standard management.)

1.8.7.1 Commissioners should ensure multidisciplinary TB teams:

  • Have the skills and resources to manage the care of people with active TB who are not from under‑served groups. [2012, amended 2016]

Clarification added to highlight that this recommendation applies to all those with active TB and not latent TB.

Include at least one TB case manager with responsibility for planning and coordinating the care of hard‑to‑reach people. (One whole‑time equivalent case manager is recommended per 20 incident cases requiring enhanced case management

1.8.7.1…

  • Include at least 1 TB case manager with responsibility for planning and coordinating the care of under‑served people and those with active TB who receive enhanced case management. [2012, amended 2016]

Clarification added to highlight that this recommendation applies to all those with active TB.

The recommendation has also been revised to take account of the fact that responsibility for setting staffing levels advice has now transferred to NHS Improvement.

Include an appropriate range of clinical specialties including paediatrics, infection control and respiratory medicine

1.8.7.1…

  • Include a range of clinical specialties in the multidisciplinary TB team, including paediatrics, infection control and respiratory medicine. [2012, amended 2016]

Small change to wording added for clarification.

Can provide rapid access TB clinics for hard‑to‑reach groups.

1.8.7.1…

  • Can provide rapid access TB clinics for all cases, including under‑served groups. [2012, amended 2016]

All cases added to highlight that this recommendation applies to all cases of TB. PH37 was limited in scope to only those who were deemed 'hard‑to‑reach', however the committee discussed that had the scope of PH37 been broader this recommendation would still have been made as it applies to all cases.

Have the resources to provide a continuous service throughout the year

1.8.7.1…

  • Have the resources to provide a continuous service throughout the year, ensuring the TB service accounts for the following to manage continuity of care:

    • planned absence (for example, professional development, mandatory training, annual, maternity or paternity leave)

    • unplanned absence (such as sickness absence). [2012, amended 2016]

Amended to clarify meaning and aid implementation.

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. Funds may also be used to provide accommodation during treatment (see recommendation 14).

1.8.7.1…

  • Have access to funds through local government and clinical commissioning groups that can be used flexibly to improve adherence to treatment among under‑served groups. For example, funds could be used to provide transport to clinics, to provide support or enablers for treatment, or for paying outreach workers or community services to support directly observed therapy. Funds may also be used to provide accommodation during treatment (see section 1.8.11). [2012, amended 2016]

This recommendation has been amended to reflect the role of local government and clinical commissioning groups and give clear actions for groups who the committee consider are accountable for delivering the recommendations.

Changed to 'enablers' as incentives may be considered unethical in this recommendation.

Have the resources to provide ongoing TB awareness‑raising activities for professional, community and voluntary (including advocacy) groups that work with hard‑to‑reach groups

1.8.7.1…

  • Have the resources to provide ongoing TB awareness‑raising activities for professional, community and voluntary (including advocacy) groups that work with populations at high risk of TB (see section 1.1.1). These resources could be financed by local government or clinical commissioning groups. [2012, amended 2016]

Recommendation extrapolated to all people with TB not just under‑served groups.

Recommendation 5 Raising and sustaining awareness of TB among health professionals and those working with hard‑to‑reach groups

Among health professionals and those working with at‑risk groups

MDTB teams should identify and support an ongoing TB education programme for local professionals in contact with hard‑to‑reach groups. This includes, for example, staff in accident and emergency departments, GPs, staff who support vulnerable migrants and those working in walk‑in centres, hostels, substance misuse projects and prisons

1.1.1.1 Multidisciplinary TB teams (in collaboration with Public Health England, primary care, the voluntary sector and Health Education England) should identify and support an ongoing TB education programme for local professionals in contact with the general public and at‑risk groups in particular. This includes, for example, staff in emergency departments, GPs and wider primary care staff, people who work in housing support services, staff who support migrants and those working in walk‑in centres, hostels, substance misuse projects and prisons. [2012, amended 2016]

Reflects system changes and additional groups with a role. Extrapolated to the general public from hard‑to‑reach groups.

MDTB teams should ensure the education programme increases other professionals' awareness of the possibility of TB disease and reduces the stigma associated with it. The programme should include detail on the:

  • Causes of TB, how it is transmitted and the signs and symptoms.

  • Lifestyle factors that may mask symptoms.

  • Local epidemiology, highlighting at‑risk, hard‑to‑reach groups.

  • Principles of TB control: early diagnosis and active case‑finding; how to support treatment (including directly observed therapy); drug resistance; awareness of drug interactions; and contact investigations following diagnosis of an active case.

  • Importance of adhering to treatment.

  • Fact that treatment is free for everyone.

  • Social and cultural barriers to accessing health services (for example, fear of stigma and staff attitudes).

  • Local referral pathways, including details of who to refer and how.

  • Role of allied professionals in awareness‑raising, identifying cases and helping people complete treatment.

  • Misinformation which causes fear about TB, including concerns about housing people with the condition

1.1.1.2 Multidisciplinary TB teams should ensure the education programme increases other professionals' awareness of the possibility of TB and reduces the stigma associated with it. The programme should include detail on:

  • causes of TB, how it is transmitted, and the signs and symptoms

  • lifestyle factors that may mask symptoms

  • local epidemiology, highlighting under-served groups, other high-risk groups and the fact that TB also occurs in people without risk factors

  • principles of TB control:

    • early diagnosis and active case‑finding

    • how to support treatment (including directly observed therapy)

    • drug resistance

    • awareness of drug interactions (including factors such as effect on contraception efficacy)

    • contact investigation after diagnosing an active case

    • the importance of adhering to treatment

    • treatment for TB is free for everyone (irrespective of eligibility for other NHS care)

    • social and cultural barriers to accessing health services (for example, fear of stigma and staff attitudes)

    • local referral pathways, including details of who to refer and how

    • the role of allied professionals in awareness‑raising, identifying cases and helping people complete treatment

    • misinformation that causes fear about TB, including concerns about housing people with the condition

    • the best ways to effectively communicate all the above topics with different groups. [2012, amended 2016]

Amended to improve implementation and reduce risk that it is not just seen as a health need in under‑served or migrant groups.

Also reflects need for tailoring to meet people needs.

Statutory, community and voluntary organisations and advocates working with hard‑to‑reach groups should disseminate information on TB education and awareness training to all frontline staff. (They should get information on this from the local MDTB team.)

1.1.1.3 Statutory, community and voluntary organisations and advocates working with the general public, and under‑served and high‑risk groups in particular, should share information on TB education and awareness training with all frontline staff. (They should get information on this from the local multidisciplinary TB team.) [2012, amended 2016]

Extrapolated to the general public from hard‑to‑reach groups.

Where possible, statutory, community and voluntary organisations should ensure peers from hard‑to‑reach groups with experience of TB contribute to, or lead, awareness‑raising activities. (Peers who lead such activities will need training and support.)

1.1.1.4 If possible, statutory, community and voluntary organisations should ensure peers from under‑served groups and anyone else with experience of TB contribute to, or lead, awareness‑raising activities. (Peers who lead such activities will need training and support.) [2012, amended 2016]

Extrapolated to the general public from hard‑to‑reach groups.

Recommendation 6 Raising and sustaining awareness of TB among hard‑to‑reach groups

Among at‑risk groups

MDTB teams should help professionals working in relevant statutory, community and voluntary organisations to raise awareness of TB among hard‑to‑reach groups. These professionals should be able to explain that treatment is free and confidential for everyone (irrespective of immigration status). They should also be able to provide people with details on:

  • How to recognise symptoms in adults and children.

  • How people get TB.

  • The benefits of diagnosis and treatment (including the fact that TB is treatable and curable).

  • Location and opening hours of testing services.

  • Referral pathways, including self‑referral.

  • Where relevant, the potential interaction of TB medication with other drugs, for example, oral contraceptives and opioids (especially methadone) and HIV treatment.

  • TB/HIV co‑infection.

  • How to address the myths about TB infection and treatment (for example, to counter the belief that TB is hereditary).

  • How to address the stigma associated with TB.

  • The risk of vulnerable migrants from high‑incidence countries developing active TB – even if they have already screened negative for it

1.1.1.5 Multidisciplinary TB teams should help professionals working in relevant statutory, community and voluntary organisations to raise awareness of TB among under‑served and other high‑risk groups. These professionals should be able to explain that treatment for TB is free and confidential for everyone (irrespective of eligibility for other NHS care). They should also be able to provide people with details of:

  • how to recognise symptoms in adults and children

  • how people get TB

  • the benefits of diagnosis and treatment (including the fact that TB is treatable and curable)

  • location and opening hours of testing services

  • referral pathways, including self‑referral

  • the potential interaction of TB medication with other drugs, for example, oral contraceptives and opioids (especially methadone) and HIV treatment

  • TB/HIV co‑infection

  • how to address the myths about TB infection and treatment (for example, to counter the belief that TB is hereditary)

  • how to address the stigma associated with TB

  • the risk of migrants from high‑incidence countries developing active TB – even if they have already screened negative for it

  • contact tracing. [2012, amended 2016]

Extrapolated to other high‑risk groups such as those who are immuno‑compromised and to support all aspects of TB prevention and control.

MDTB teams and others working with hard‑to‑reach groups should use high quality material to raise awareness of TB. The material should be current, culturally and linguistically appropriate and available in a range of media formats (that is, not just in a written format). This material should be modified to meet the specific needs of the audience, if necessary

1.1.1.6 Multidisciplinary TB teams and others working with at‑risk groups should use high quality material to raise awareness of TB (see section 1.1.2). [2012, amended 2016]

A new section has been written on what good information looks like and this has been cross‑referenced here.

MDTB teams and others working with hard‑to‑reach groups should include information on TB with other health‑related messages and existing health promotion programmes tailored to the target group

1.1.1.7 Multidisciplinary TB teams and others working with the general public, and with under‑served and other high‑risk groups in particular, should include information on TB with other health‑related messages and existing health promotion programmes tailored to the target group. [2012, amended 2016]

Extrapolated to the general public from hard‑to‑reach groups.

MDTB teams should work in partnership with voluntary organisations and 'community champions' to increase awareness of TB among hard‑to‑reach groups at risk of infection. Where possible, peers from these groups who have experience of TB should contribute to awareness‑raising activities

1.1.1.8 Multidisciplinary TB teams should work in partnership with voluntary organisations and 'community champions' to increase awareness of TB, in particular among under‑served groups at risk of infection but also in the general population. If possible, peers who have experience of TB should contribute to awareness‑raising activities and support people in treatment. [2012, amended 2016]

Extrapolated to the general public from hard‑to‑reach groups.

Recommendation 8 Identifying and managing active TB in prisons or immigration removal centres: organisational factors

1.8.10 Identifying and managing active TB in prisons, custody suites or immigration removal centres: organisational factors

MDTB teams, prison and immigration removal centre healthcare services should have named TB liaison leads to ensure they can communicate effectively with each other

1.8.10.1 Multidisciplinary TB teams, prisons, custody suites and immigration removal centre healthcare services should have named TB liaison leads to ensure they can communicate effectively with each other. [2012, amended 2016]

Amended to include an additional high‑risk setting.

Prison and immigration removal centre healthcare services should develop a TB policy by working with the MDTB team and the local Public Health England unit

1.8.10.2 Prison, custody suites and immigration removal centre healthcare services should develop a TB policy by working with the TB control board and multidisciplinary TB team and the local Public Health England health protection team. [2012, amended 2016]

This recommendation has been amended to reflect the role of TB control boards.

MDTB teams, in conjunction with prison and immigration removal centre healthcare services, should agree a care pathway for TB to ensure any suspected or confirmed cases are reported to, and managed by, the MDTB team

1.8.10.3 Multidisciplinary TB teams, in conjunction with prisons, custody suites and immigration removal centre healthcare services, should agree a care pathway for TB. This is to ensure any suspected or confirmed cases are reported to, and managed by, the multidisciplinary TB team. [2012, amended 2016]

High‑risk setting added.

MDTB teams, in liaison with prison or immigration removal centre healthcare providers, should manage all cases of active TB. Investigations and follow‑up should be undertaken within the prison or immigration removal centre, wherever practically possible

1.8.10.4 Multidisciplinary TB teams, in liaison with prisons, custody suites or immigration removal centre healthcare providers, should manage all cases of active TB. Investigations and follow‑up should be undertaken within the prison or immigration removal centre if possible. [2012, amended 2016]

High‑risk setting added.

Recommendation 10 Managing active TB in prisons or immigration removal centres

1.5 Infection control

1.5.2 Non‑healthcare settings

Amended to enable improved incorporation and placement in the guideline.

Everyone with X‑ray changes indicative of active TB, and those with symptoms who are awaiting X‑ray, should be isolated in an individual room or cell. Prisoners and detainees should be retained on medical hold until they have:

  • proven smear negative and had an X‑ray that does not suggest active TB or

  • had a negative risk assessment for multi‑drug resistant (MDR)‑TB and completed 2 weeks of the standard treatment regimen.

1.5.2.2 In prisons or immigration removal centres, everyone with X‑ray changes indicative of active TB, as well as those with symptoms who are awaiting X‑ray, should be isolated in an adequately ventilated individual room or cell. Prisoners and detainees should be retained on medical hold until they have:

  • proven smear negative and had an X‑ray that does not suggest active TB or

  • had a negative risk assessment for multidrug‑resistant TB and completed 2 weeks of the standard treatment regimen. [2012, amended 2016]

"In prisons or immigration removal centres" inserted to clarify setting; "adequately ventilated" individual room or cell inserted to better reflect the committee's view of current best practice.

Recommendation 11 Identifying and managing active and latent TB: vulnerable migrants

1.6.2 Opportunistic case finding

Healthcare professionals, including primary care staff, responsible for screening new entrants should screen all vulnerable migrants who have not previously been checked, in line with NICE guidance on tuberculosis for new entrants. This is regardless of when they arrived in England. People born in countries with an incidence of more than 150 per 100,000 per year should be made a priority for latent TB screening when they arrive here.

1.6.2.3 Healthcare professionals, including primary care staff, responsible for testing new entrants should test all vulnerable migrants who have not previously been checked. This is regardless of when they arrived in England. People born in countries with an incidence of more than 150 per 100,000 per year should be made a priority for latent TB testing when they arrive here. [2012, amended 2016]

Recommendation reworded for clarity and in particular to avoid use of the the term 'screening'.

In areas of identified need (see recommendation 2), including major urban centres with a high incidence of tuberculosis, commissioners should:

  • Ensure there is a programme of active case‑finding using mobile digital radiography in places where homeless people and substance misusers congregate. (This includes: homeless day centres, rolling shelters, hostels and temporary shelters established as part of cold weather initiatives and venues housing needle and syringe programmes.)

  • Base the frequency of screening at any one location on population turnover.

  • Where local demand does not warrant a mobile X‑ray team, consider commissioning mobile X‑ray screening capacity from another area.

1.6.2.4 In areas of identified need (see section 1.8.5), including major urban centres with a high incidence of TB, commissioners should:

  • ensure there is a programme of active case‑finding using mobile X ray in places where homeless people and people who misuse substances congregate (this includes: homeless day centres, rolling shelters, hostels and temporary shelters established as part of cold weather initiatives and venues housing needle and syringe programmes)

  • base the frequency of screening at any 1 location on population turnover

  • where local demand does not warrant a mobile X ray team, consider commissioning mobile X ray capacity from another area. [2006, amended 2012]

Recommendation reworded for clarity and updated cross‑reference and terminology which now longer exists.

Recommendation 12 Identifying and managing latent TB: Substance misusers and prison populations

Diagnosing latent TB – under‑served groups

Commissioners of TB prevention and control programmes should ensure arrangements are in place to provide latent TB testing for substance misusers and prisoners.

Substance misuse services should provide clients aged under 35 with access to an interferon‑gamma release assays (IGRA) test for TB if they:

Live in a high incidence area[8].

Are likely to be involved with substance misuse or other support services on a regular basis (for example, for opioid substitution therapy). In such cases, support should be available for directly observed preventive therapy.

All prisoners receiving treatment for latent TB should have a named TB case manager. The case manager should be responsible for contingency planning for discharge from prison/detention.

In high incidence areas[8] (and at prisons which receive prisoners from high incidence areas), prison health services should offer IGRA testing for TB to inmates aged under 35 who are in regular contact with substance misuse or other support services, provided arrangements have been made for this support to continue after release. If the under‑35s test positive, directly observed preventive treatment (DOPT) should be arranged alongside the existing support.

Substance misuse services and prison health services should incorporate IGRA testing with screening for hepatitis B and C and HIV testing and refer prisoners and substance misusers with positive IGRA tests to local MDTB teams for further clinical investigations. The aim is to exclude active disease and assess their suitability for preventive treatment. For prisoners, these investigations should be undertaken within the prison wherever practically possible.

Where practical, MDTB teams should start directly observed preventive therapy for prisoners with latent TB who, on release, will also receive support from other services.

1.2.3.4 Substance misuse services with access to an interferon‑gamma release assay should provide testing for people younger than 65 years who misuse substances if they:

  • live in a high incidence area

  • are likely to be involved with substance misuse services or other support services on a regular basis (for example, for opioid substitution therapy), when support should be available for directly observed preventive therapy. [2012, amended 2016]

1.2.3.5 In high incidence areas (and at prisons that receive prisoners from high incidence areas), prison health services should offer an interferon‑gamma release assay test for TB to inmates younger than 65 years who are in regular contact with substance misuse services or other support services. This is provided arrangements have been made for this support to continue after release. [2012, amended 2016]

1.2.3.6 Substance misuse services and prison health services should incorporate interferon‑gamma release assay testing with screening for hepatitis B and C, and HIV testing. They should refer prisoners and people who misuse substances with positive interferon‑gamma release assay tests to local multidisciplinary TB teams for further clinical investigations. For prisoners, these investigations should be done in the prison if practically possible. [2012, amended 2016]

1.2.3.7 If the interferon‑gamma release assay is positive, assess for active TB (see sections 1.3.1 to 1.3.5); if this assessment is negative, offer them treatment for latent TB infection (see section 1.2.4 to 1.2.6). [2012, amended 2016]

For changes to similar recs in CG117 see recommendation 1.1.1.8 in Recommendations from NICE guideline CG117 that have been amended

The upper age‑limit for offering testing to diagnose latent TB was previously 35 years, but has been increased to 65 years. Although evidence on contact‑tracing in adults of different ages was not reviewed as part of the 2016 update, the age threshold for testing is directly dependent on evidence of the benefits, harms and costs of treating latent TB. The committee has reviewed this evidence and concluded that people should be offered treatment up to the age of 65 years. Therefore, it is necessary to amend this recommendation to reflect the revised upper age‑limit for treatment.

Recommendation 13 Contact investigations

1.6.3 Active case finding in under‑served groups

Amended to enable improved incorporation and placement in the guideline.

MDTB teams should, where available and appropriate, encourage peer educators to help with contact investigations when it involves hard‑to‑reach people who have complex social networks

1.6.3.3 Multidisciplinary TB teams should, if available and appropriate, encourage peer educators or TB programme support workers (see section 1.8.8) to help with contact investigations involving under‑served people who have complex social networks. [2012, amended 2016]

Amended to reflect guideline changes.

Local Public Health England units should consider using digital mobile radiography for active case‑finding in settings identified by social network analysis as places where people at risk congregate. They should also provide the necessary support so that MDTB teams can use strain‑typing and social network analysis to ascertain where transmission is occurring in the community. (Examples of transmission sites may include pubs, crack houses, hostels and day centres.) They should focus on active case‑finding in the settings identified.

1.6.3.4 Multidisciplinary TB teams in discussion with local Public Health England health protection teams should consider using digital mobile X ray for active case‑finding in settings identified by looking at social networks as places where under‑served people at risk congregate. They should also provide the necessary support so that multidisciplinary TB teams can use strain‑typing and social network analysis to ascertain where transmission is occurring in the community. (Examples of transmission sites may include pubs, crack houses, hostels and day centres.) They should focus on active case‑finding in the settings identified. [2012, amended 2016]

Recommendation reworded for clarity around use of multidisciplinary TB teams in discussion with local Public Health England teams and terminology around X‑ray.

MDTB teams should investigate all those who have been in contact with hard‑to‑reach children who have pulmonary or non‑pulmonary TB to identify the primary source of infection. If necessary, they should look beyond immediate close contacts to find the source

1.6.4.5 In all types of contact investigation scenario (active case finding, incident or outbreak investigations) multidisciplinary TB teams should investigate all those who have been in contact with children who have pulmonary or non‑pulmonary TB to identify the primary source of infection. If necessary, they should look beyond immediate close contacts to find the source. [2012, amended 2016]

Amended to reflect guideline changes and new recommendations.

Recommendation 14 Rapid‑access TB services

1.8.9 Rapid‑access TB services

MDTB teams should accept self‑referrals to TB clinics by people from hard‑to‑reach groups

1.8.9.3 Multidisciplinary TB teams should accept self‑referrals to TB clinics by people who suspect they have TB or have recently been in contact with someone with TB. [2012, amended 2016]

Amended to better reflect practice according to the committee and ensure all at risk can gain access quickly to reduce transmission risk to other people.

Healthcare professionals from statutory organisations should refer people to TB clinics promptly. They should also ensure the results from first line diagnostic tests (including a sputum smear and chest X‑ray) are available prior to the person seeing a physician. (Note: this should not delay the referral.)

1.8.9.5 Healthcare professionals should consider urgent referral to TB clinics for people with suspected active TB. They should also ensure the results from first‑line diagnostic tests (including a sputum smear and chest X‑ray) are available before the person sees a specialist. (Note: this should not delay the referral.) [2012, amended 2016]

Amended for clarity and to ensure referral was based on suspected 'active' TB for urgent referral. The committee suggested the term 'urgent referral' has a specific meaning in the healthcare community that was appropriate here for active TB.

MDTB teams should use specialist TB nurses to triage referrals, so that case management starts promptly

1.8.9.6 Multidisciplinary TB teams should have pathways to triage referrals, start investigations and collect clinical information before the person is seen by a physician. While triaging they should ensure everyone is given information about TB as part of the process (see section 1.1.2). This should include who the person should contact if they have any questions and how to access advice or information from support groups, national charities such as TB Alert and other sources such as local government, for example, public health or social care teams. [new 2016]

Expanded the recommendation for improved clarity and implementation support also incorporate some elements from other recommendation.

MDTB teams should ensure people who have a smear‑positive result are assessed within 24 hours. Others who are not smear‑positive should be seen as soon as possible – and no later than 5 working days after a referral. Where necessary, outreach services should be used for assessment

1.8.9.8 Multidisciplinary TB teams should ensure people who have a smear‑positive result or imaging features highly suggestive of smear‑positive TB (for example, evidence of cavitation on chest X‑ray) are assessed the next working day. This is so that case management and infection control procedures start promptly. [2012, amended 2016]

Amended for clarity and to split the recommendation (see below), and to say next working day which the committee consider is the best terminology to use here.

MDTB teams should ensure people who have a smear‑positive result are assessed within 24 hours. Others who are not smear‑positive should be seen as soon as possible – and no later than 5 working days after a referral. Where necessary, outreach services should be used for assessment

1.8.9.9 The multidisciplinary TB team should assess people who are not smear‑positive but have imaging that suggests pulmonary or laryngeal TB as soon as possible. This should be no later than 5 working days after a referral. [2012, amended 2016]

Amended for clarity, this is the second part of the split recommendation.

All those listed above should work together to agree a process for providing accommodation for homeless people diagnosed with active pulmonary TB who are otherwise ineligible for state‑funded accommodation. The process should detail the person's eligibility and ensure they are given accommodation for the duration of their TB treatment

1.8.11.2 Multidisciplinary TB teams, commissioners, local authority housing lead officers and other social landlords, providers of hostel accommodation, hospital discharge teams, Public Health England and the Local Government Association should work together to agree a process for identifying and providing accommodation for homeless people diagnosed with active pulmonary TB who are otherwise ineligible for state‑funded accommodation. This includes people who are not sleeping rough but do not have access to housing or recourse to public funds. The process should detail the person's eligibility and ensure they are given accommodation for the duration of their TB treatment. [2012, amended 2016]

Amended to include the 'list from above' in the original recommendation, and to clarify who will benefit, which would also otherwise be missing from the incorporation of this recommendation from the original guidance.

Commissioners of TB prevention and control programmes should fund accommodation for homeless people diagnosed with active TB who are otherwise ineligible for state‑funded accommodation. Health or public health resources should be used

1.8.11.3 Local government and clinical commissioning groups should fund accommodation for homeless people diagnosed with active TB who are otherwise ineligible for state‑funded accommodation. Use health and public health resources, in line with the Care Act 2014. [2012, amended 2016]

Amended to clarify the responsible commissioners and to reflect the changes in care legislation.

Recommendation 15 Enhanced case management

1.7.1 Improving adherence: case management including directly observed therapy

MDTB teams should, as soon as possible (and within 5 working days of a referral), allocate a named TB case manager to people who have TB and have been identified as hard‑to‑reach. They should also provide an individual care plan within the same timescale.

1.7.1.1 Allocate a named TB case manager to everyone with active TB as soon as possible after diagnosis (and within 5 days). The clinical team should tell each person who their named TB case manager is and provide contact details. [2006, 2012 amended 2016]

Recommendation reworded for clarity around access to TB case managers for all people with TB not just those identified as 'hard‑to‑reach'. Also clarified role of clinical team.

TB case managers should develop the care plan during a face‑to‑face discussion with the person. They should also involve representatives from other allied professionals and key workers from community organisations who work with the person. In addition, they should gain the person's consent to the plan and agree a review date.

The plan should:

  • State who will be observing treatment and where (if the person is having directly

  • observed therapy this should be provided at a location convenient to them).

  • Include actions to take in the event of losing contact with someone who is being treated

  • (for example, keeping details of people who might be able to help re‑establish contact).

  • Refer to, and be coordinated with, any other care plan already established for the person.

  • Define the support needed to address any unmet health and social care needs (for example, support to gain housing or other benefits, or to help them access other health services).

  • Explore appropriate ways that peers and voluntary organisations can provide support.

  • Include an obligation on the person to commit to TB treatment.

1.7.1.2 The TB case managers should work with the person diagnosed with TB to develop a health and social care plan, and support them to complete therapy successfully. The TB case manager should:

  • offer a risk assessment to every person with TB, to identify their needs and whether they should have enhanced case management including directly observed therapy

  • educate the person about TB and the treatment

  • develop an individual care plan after discussion with the person

  • gain the person's consent to the plan and agree a review date (for example, when moving from initiation to maintenance, or at each contact to ensure the person's needs are being met)

  • coordinate discharge planning, especially for people on directly observed therapy

  • involve representatives from other allied professions and key workers from all organisations who work with the person, if appropriate

  • explore appropriate ways that peers and voluntary organisations can provide support. [2006, 2012, amended 2016]

Recommendation reworded for clarity after amalgamation of previously separate clinical and public health guidelines.

TB case managers should undertake a risk assessment to identify whether the person should have directly observed therapy (DOT). DOT should be considered part of standard care, from the start of treatment, for all hard‑to‑reach children aged under 16. It should also be standard care for anyone who requests it and those who:

  • Do not (or have not in the past) adhered to treatment.

  • Have been treated previously for TB.

  • Have a history of homelessness, drug or alcohol misuse.

  • Are currently (or have previously been) in prison.

  • Have a major psychiatric, memory or cognitive disorder.

  • Are in denial of the TB diagnosis.

  • Have multi‑drug resistant TB.

  • Are too ill to administer the treatment themselves.

1.7.1.3 Offer directly observed therapy as part of enhanced case management in people who:

  • do not adhere to treatment (or have not in the past)

  • have been treated previously for TB

  • have a history of homelessness, drug or alcohol misuse

  • are currently in prison, or have been in the past 5 years

  • have a major psychiatric, memory or cognitive disorder

  • are in denial of the TB diagnosis

  • have multidrug‑resistant TB

  • request directly observed therapy after discussion with the clinical team

  • are too ill to administer the treatment themselves. [2012, amended 2016]

Recommendation reworded for clarity and recommendation on children has been separated out.

TB case managers should ensure the care plan identifies potential barriers to diagnosis and treatment (including fear of being stigmatised) and any support that may be required. It should also take account of cultural beliefs. The plan may include:

  • Demographic information (for example, age, nationality, place of birth, length of time in UK).

  • Current prescribing regimens.

  • Housing needs and living situation (see recommendation 16).

  • Substance use issues (drugs or alcohol).

  • Criminal justice issues.

  • The need for hepatitis B and C or HIV testing.

  • Other health issues (physical or mental).

  • Communication factors (for example, language and literacy level).

  • Ability to access treatment (mobility and transport needs).

  • Employment or entitlement to benefits.

  • Legal or immigration status (including risk of removal from, or relocation within, England).

  • Any 'enablers' or incentives to overcome the barriers to diagnosis or treatment.

1.7.1.6 TB case managers should ensure the health and social care plan (particularly if directly observed therapy is needed) identifies why a person may not attend for diagnostic testing or follow a treatment plan, and how they can be encouraged to do so. It should also include ways to address issues such as fear of stigmatisation, support needs and/or cultural beliefs, and may include information on:

  • demographics (for example, age, nationality, place of birth, length of time in UK)

  • all current prescribing regimens

  • housing needs and living situation, including looked‑after children

  • substance misuse (drugs or alcohol)

  • any contact with the criminal justice system

  • the need for hepatitis B and C or HIV testing (see recommendations 1.2.5.2, 1.2.5.3 and 1.2.6.1)

  • HIV status

  • other health conditions (physical or mental)

  • communication factors (for example, language and literacy levels)

  • ability to access treatment (mobility and transport needs)

  • employment or entitlement to benefits

  • legal or immigration status (including risk of removal or relocation within the UK)

  • any enablers or incentives to overcome anything that is stopping diagnosis or treatment. [2012, amended 2016]

Recommendation reworded for clarity and to provide additional information where appropriate.

The plan should:

  • State who will be observing treatment and where (if the person is having directly observed therapy this should be provided at a location convenient to them).

  • Include actions to take in the event of losing contact with someone who is being treated (for example, keeping details of people who might be able to help re‑establish contact).

  • Refer to, and be coordinated with, any other care plan already established for the person.

  • Define the support needed to address any unmet health and social care needs (for example, support to gain housing or other benefits, or to help them access other health services).

  • Explore appropriate ways that peers and voluntary organisations can provide support.

  • Include an obligation on the person to commit to TB treatment.

1.7.1.7 The health and social care plan should:

  • state who will be observing treatment and where (if the person is having directly observed therapy this should be provided at a location that is convenient and accessible to them, for example, at a methadone clinic) [2012, amended 2016]

  • include actions to take if contact with the person is lost (for example, keeping details of people who might be able to help re establish contact) [2012]

  • refer to, and be coordinated with, any other care plan already established for the person [2012]

  • define the support needed to address any unmet health and social care needs (for example, support to gain housing or other benefits, or to help them access other health or social care services) [2012, amended 2016]

  • include a commitment from the person to complete their TB treatment [2012, amended 2016]

  • be supported by frequent contact with any key workers who work with the person. [2006 amended 2011, amended 2016]

Recommendation reworded for clarity.

Recommendation 16 Accommodation during treatment

1.8.11 Accommodation during treatment

MDTB teams should assess the living circumstances of people with TB. They should work with allied agencies to ensure all those who are entitled to state‑funded accommodation receive it as early as possible during the course of their treatment.

1.8.11.1 Multidisciplinary TB teams should assess the living circumstances of people with TB. Where there is a housing need they should work with allied agencies to ensure that all those who are entitled to state‑funded accommodation receive it as early as possible during their treatment, for example, as a result of a statutory homelessness review and identified need. [2012, amended 2016]

Recommendation reworded for clarity.

ISBN: 978-1-4731-1587-3

  • National Institute for Health and Care Excellence (NICE)