Quality statement 1: Latent tuberculosis testing for people from high-incidence countries

Quality statement

People aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of tuberculosis (TB), are tested for latent TB infection when they register with a GP.

Rationale

Detecting latent TB infection in recent arrivals to the country is beneficial because they have a higher relative risk of progression to active, potentially infectious TB than the general population. The highest burden of TB disease and the largest proportion of new entrants from high incidence countries are aged 16 to 35 years. Early detection can lead to treatment of latent infection before it progresses to active disease. This can prevent onward transmission and the associated harms and costs of active TB.

Quality measures

Structure

a) Evidence of local arrangements to identify people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, when they register with a GP.

Data source: Local data collection.

b) Evidence of local arrangements to ensure that people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, are tested or referred for testing for latent TB infection when they register with a GP.

Data source: Local data collection.

Process

Proportion of people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, who are tested for latent TB infection when they register with a GP.

Numerator – the number in the denominator who are tested for latent TB infection.

Denominator – the number of people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, registering with a GP.

Data source: National data is collected in the Public Health England's Database for the national latent tuberculosis screening programme in new migrants from high-incidence countries. The data collection includes patient-level data about those people who have been offered screening and those who have taken up the screening.

Outcome

TB incidence.

Data source: National and regional data on TB incidence in England are collected in Public Health England's TB Strategy monitoring indicators.

What the quality statement means for different audiences

Service providers (general practices) have systems in place to identify people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, when they register with the practice. They should ensure that the people identified have latent TB infection testing.

Healthcare professionals (such as GPs and nurses) test for latent TB infection in people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, when they register with a GP. If the practice cannot perform the test, they should refer to the person to a service where it can be done.

Commissioners (NHS England and clinical commissioning groups) ensure that they commission primary care services that identify people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB. They should ensure that these primary care services provide or facilitate testing for latent TB infection for the people identified.

People aged 16 to 35 years who have come to England within the past 5 years from a country where there are a high number of TB cases have a test to find out if they have TB.

Source guidance

Tuberculosis (2016) NICE guideline NG33, recommendation 1.2.3.1

Definitions of terms used in this quality statement

Five years

The time period of 5 years is based on Public Health England's Collaborative tuberculosis strategy for England: 2015 to 2020 and consensus of expert opinion.

High incidence of TB

The Collaborative tuberculosis strategy for England: 2015 to 2020 defines this as countries with an estimated TB incidence rate of more than 150 cases of TB per 100,000 people per year.

Public Health England lists countries and their estimated TB incidence in Tuberculosis (TB) by country: rates per 100,000 people. People who were born in, or have spent more than 6 months in a high-incidence country, should be tested.

[Adapted from the Collaborative tuberculosis strategy for England: 2015 to 2020 and Latent TB testing and treatment for migrants: a practical guide for commissioners and practitioners]

Testing for latent TB infection

There are 2 types of test that can be used to diagnose latent TB infection. The Mantoux test should be used as the initial diagnostic test. It is a type of tuberculin skin test in which tuberculin is injected into the skin. The injection site is examined for signs of an immune response after 2 to 3 days.

If Mantoux testing is unavailable the interferon-gamma release assay (IGRA) test should be used. This is a blood test used to diagnose latent TB based on the response of white blood cells to TB antigens.

[Adapted from NICE's full guideline on tuberculosis (glossary) and recommendation 1.2.3.1]

Equality and diversity considerations

When offering testing to people who have arrived in the country within the past 5 years, healthcare professionals should be aware that people in this group may not speak or read English or have English as their first language. They should have access to an interpreter or advocate if needed.