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TUBERCULOSIS IN SURREY: HEALTH NEEDS ASSESSMENT
Dr Liz Brutus
Specialty Registrar Public Health
Public Health Department
Aug 09
Executive summary
Purpose of the document
The strategic aim of this work is to improve the prevention and treatment of tuberculosis (TB) in
Surrey in line with the recommendations outlined by the Chief Medical Officer in 2004 and the
guidance detailed in the NICE Clinical Guidelines and using guidance provided by the DH TB
Commissioning Toolkit.
The long-term goal is a reduction and ultimately, the elimination of TB in Surrey.
The immediate goals of Surrey’s TB programme are to:
1. Reduce the risk of people being newly infected with TB in Surrey
2. Provide high quality treatment and care for all people with TB
3. Maintain low levels of drug resistance, particularly, multi-drug resistant (MDR) TB
Introduction and statement of the problem
Surrey has approximately 80 – 90 cases of TB each year (which equates to an incidence of TB of
9.4/100,000). Surrey is defined as an area of low TB incidence (ie less than 40 cases a year per
100,000) however, like the national picture, this average rate hides pockets of considerably higher
incidence. Rates of TB in Surrey have varied over time without any clear trend but nationally, rates
still appear to be increasing although slowly.
What is TB?
Tuberculosis (TB) is a communicable disease and both worldwide and in the UK, it is considered a
notifiable disease. The onset of TB is insidious. Primary infection is usually asymptomatic. The
presentation of secondary infection is variable and often non-specific. A high index of suspicion in
patients from particular risk groups is essential to make a diagnosis.
Incidence
TB tends to occur in working-age adults aged 20-44 who have been born overseas and tends to be
associated with more urban areas. For example, Woking Borough has the highest incidence of TB
and not surprisingly, Ashford & St Peter’s Hospitals see the largest proportion of Surrey residents
with TB. New entrants are particularly at risk of developing active TB which usually occurs within
the first 5 years of entry to the UK.
A concern for Surrey is the number of undiagnosed cases of TB which is most likely related to the
lack of awareness amongst health care professionals, especially in Primary Care and amongst the
public. Diagnosis, when it is made, is often slow and this is both detrimental for the individual with
TB and the wider public health.
Surveillance
Surveillance is carried out by the Health Protection Agency (and its local office within Surrey, the
SSHPU) and relies on the monitoring of a variety of sources including laboratory reports and
treatment outcomes but the mainstay of surveillance is enhanced TB surveillance. This is a
national programme that relies on statutory notification from clinicians. Within Surrey, there are
concerns that this system is not being adhered to as closely as it should which undermine the
integrity of the information available to assess the impact of TB on the Surrey population.
Guidance on surveillance is provided in the TB Commissioning Toolkit.
Current services
The mainstay of routine TB care is provided by chest physicians and TB nurses within Surrey’s
acute trusts and the Community TB Nurses provided by Surrey Community Health. However,
there are complex relationships that exist between Surrey PCT, Surrey HPU and other
stakeholders. To date, these relationships have existed implicitly but increasingly, more explicit
contractual agreements are needed to formalise the obligations and responsibilities that each
organisation owes each other and their common patients.
2
Laboratory services
Laboratory support for TB is provided through the acute trusts’ microbiology departments who each
completed a survey of service provision. There is currently some debate regarding the advantages
and disadvantages of centralising TB laboratory services within Surrey. Recommended laboratory
standards are prescribed by the TB Commissioning Toolkit. Funding for the more expensive
quantiferon tests remains a potential bone of contention.
Current provision of TB care for people with or suspected to have TB
TB services are largely centred on acute trusts where confirmation of diagnosis, treatment initiation
and monitoring are largely provided. Response to treatment and associated patient welfare is
mainly monitored by TB Nurses.
Recent NICE guidance is available to guide the management of those with or at risk of TB. Audit
of clinical standards is not occurring regularly within Surrey so it would be difficult to formally
assess how closely NICE guidance is being implemented.
A significant clinical governance challenge in Surrey, due to its low incidence of TB, is clinicians’
familiarity and expertise in diagnosing and managing TB – both latent and active TB. This is a
particular risk for the management of children where the numbers at individual acute trusts are
particularly low. Similarly, GPs remain a significant gatekeeper to the TB service but in Surrey,
their awareness and familiarity with TB is falling and this presents a risk to the timely referral of
patients with TB into TB services.
Surrey PCT Community TB Nurses
Community TB Nurses are provided by Surrey Community Health (the provider arm of Surrey
PCT). The team consists of approximately 2.4 FTE however, only 0.8 FTE is Band 7, the usual
grade for a TB Nurse Specialist. This team is stretched thin over a large geographical area and
historically, the east and south-west of Surrey have had less TB Nurse support for tasks such as
contact tracing and domiciliary visits to ensure treatment adherence over the 6 months of a
patient’s typical treatment. Clinical supervision and continuing professional development have
been similarly patchy and present a potential risk to clinical governance.
TB Control – Screening for TB
In general, screening for TB is provided on an opportunistic and ad hoc basis, usually in response
to either a single case or a TB incident. Active case-seeking and education amongst higher-risk
groups, such as among BME, prisoners or the homeless has suffered due to the lack of TB Nurse
capacity and PCT strategy for TB management. The management of New Entrants remains a
challenge for the PCT, Port Health and the HPU, largely related to the lack of clarity regarding the
general coordination of screening in the county.
Managing tuberculosis incidents and outbreaks
TB Incidents have most commonly occurred in schools and health and social care settings. They
become complex due to a combination of factors; the speed of response and the level of
coordination required from multiple stakeholders, managing public anxiety and contractual issues
regarding responsibility (and payment) for different incident tasks. Recent outbreaks have
highlighted the need for a standard operating procedure, agreed by the key agencies, to most
effectively manage these incidents.
TB Prevention – BCG immunisation
Since 2005, BCG immunisation is no longer routinely offered to all children but is targeted to
people most at risk of TB. Within Surrey, the responsibility for BCG has fallen within the remit of
either TB Community Nurses or the PCT Immunisation Teams. This is dependent on geographical
location and has prevented a Surrey-wide approach. Current over-stretch of the TB Community
Nurse team requires that this provision is urgently reviewed.
3
Patient views of TB services
A patient survey of TB patients was completed in Jun-Jul 09. 13 people (of 40) responded, of
whom the majority were non-British-born Asian or African. Generally, patients were happy with the
service provided, the information received and they felt they were treated with respect. On
average, it took 13 weeks from the onset of symptoms for GPs to refer patients to secondary care.
Patients also reported there was a lack of information and knowledge about TB in primary care.
These results are supported by survey results from other PCT areas.
Effectiveness of services and funding
Surrey has a TB Clinical Network which meets twice per year however, the attendance, especially
from chest physicians from all the acute trusts within Surrey has been patchy. This can make it
difficult to agree pathways of care for patients.
Funding of acute TB services is mostly provided by the national Payment by Results ‘Tariff’
however, due to a lack of service level agreements between the PCT (both provider and
commissioning arms) and acute trusts, there is a lack of clarity regarding the delineation of
responsibility for community-based services such as domiciliary visits and incident management.
Options and models of care
Programme budgeting is a financial tool that can be used to compare patient outcomes against
actual health care funding for different disease areas. It has been used to compare Surrey which
has slightly worse TB outcomes than, for example, Berkshire West PCT although they spend
similar amounts of money.
Key options for TB services are whether to be based in acute trusts reaching out to the community
or vice versa, ie based in the community but reaching in to acute trusts. In either scenario, it is
vital that physicians managing TB patients and TB Nurses must work closely together to bridge the
divide between hospital and community to optimise TB patients’ outcomes. The PCT is key to
commissioning high quality TB services through planning, finance and information management
and a care pathway focus.
Key recommendations
A large number of recommendations have been made in the course of compiling this needs
assessment, however the five key ones for Surrey are:
1. Increase awareness of TB amongst GPs in order to speed up diagnosis.
2. Improve TB notifications from acute trust clinicians to the Surrey Health Protection Unit in
order to improve surveillance (and therefore target those most at need) and ensure
activation of the Community TB Nurse response to new patients with TB.
3. Develop the relationships between the Community TB Nurse team and the hospital-based
chest physicians.
4. Agree Surrey-wide patient pathways (for both adults and children) including screening and
management of those with or suspected to have TB.
5. Formalise the contractual relationships between the key stakeholders for both routine
management and for TB incident management eg through service level agreements and
standard operating procedures.
4
Contents
1
Purpose of document
2
Introduction and statement of the problem
3
What is TB?
3.1
Notifiable disease
3.2
Cause of tuberculosis
3.3
Types of infection
3.4
Symptoms
3.5
Diagnosis
4
Incidence
4.1
by borough
4.2
By hospital
4.3
By age
4.4
Trends over time
4.5
Undiagnosed TB cases
4.6
Incidence in new entrants
5
Surveillance
5.1
Routine data sources
5.2
Local data collection and databases
5.3
Special groups
5.4
Standards for surveillance
5.5
Summary of data systems and TB surveillance
6
The core TB service and inter-relationships with other stakeholders
6.1
Inter-relationships
6.2
The core Surrey TB service
7
Laboratory services
7.1
Current service provision
7.2
Recommended TB service laboratory standards
7.3
Use of laboratory services in latent TB screening
7.4
Funding of gamma-interferon tests
8
Current provision of TB care for people with or suspected to have TB
8.1
Overview
8.2
Role of GPs and primary health care professionals
8.3
Managing TB patients within two weeks
8.4
Acute adult services
8.5
Acute paediatric services
8.6
Prescribing anti-TB treatment
8.7
Management of multiply-drug resistant TB (MDRTB)
9
Community TB nurse team
9.1
Overview and responsibilities
9.2
Staffing
9.3
Distribution and capacity of the Community TB Team
9.4
Clinical supervision and continuing professional development
5
10 TB control – Screening for TB
10.1 Contact tracing
10.2 Higher risk groups
10.3 BME
10.4 Port Health and the care of new entrants
10.5 Asylum seekers, refugees and ‘illegal’ new entrants
10.6 TB in prisons
10.7 Street homeless
10.8 People living with HIV/AIDS
10.9 Occupational risk groups
11 Managing TB incidents
12 TB prevention – BCG immunisation
13 Patient views of TB services
13.1 Surrey PCT TB Patient Survey results - 2009
13.2 General results from other areas’ patient surveys
14 Effectiveness of services and funding
14.1 Surrey TB Clinical network and TB leads
14.2 Use of audit
14.3 Funding of acute and community TB services
15 Options and models of care
15.1 Using programme budgeting to compare outcomes in other areas with money spent
15.2 Comparison with services in other areas
15.3 Key elements of a comprehensive service
15.4 PCT commissioning responsibility
16 Summary of recommendations
Acknowledgements
Appendices
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Summary of NICE guidance for the diagnosis of TB
Laboratory services in Surrey – questionnaire and result
Analyses of New Entrants to Surrey during the period 01/01/07 to 20/09/08
Dr Kevin Carroll, CCDC, Surrey and Sussex Health Protection Unit
Standards for surveillance
Standards and criteria for effective laboratory diagnosis of (active) Mycobacterium
tuberculosis infection
TB Patient Survey Results - Jun 09
6
1. Purpose of document
The strategic aim of this work is to improve the prevention and treatment of tuberculosis (TB) in
Surrey in line with the recommendations outlined by the Chief Medical Officer in 20041 and the
guidance detailed in the NICE Clinical Guidelines2.
The long-term goal is a reduction and ultimately, the elimination of TB in Surrey.
The immediate goals1 of Surrey’s TB programme are to:
4. Reduce the risk of people being newly infected with TB in Surrey
5. Provide high quality treatment and care for all people with TB
6. Maintain low levels of drug resistance, particularly, multi-drug resistant (MDR) TB
2. Introduction and statement of the problem
Although the incidence of TB now appears to be stabilising across the UK, the rate is still too
high1,3. Latest data (2006) show the national incidence was 14.0/100,000 and South East regional
incidence was 8.6/100,000. The incidence of TB across Surrey was 9.4/100,0004 but like the
national picture, this average rate hides pockets of considerably higher incidence. Areas with
higher incidence are associated with larger proportions of people from BME groups, new entrants
and with social deprivation. For example, in Surrey, there is a much higher incidence of TB in
Woking and Spelthorne than in Mole Valley. However, in general, Surrey is considered to be a
‘low –incidence’ area especially in comparison to London where almost 40% of the nation’s people
with TB live. (Low incidence is defined as an incidence of TB cases less than 40 per 100,0002.)
It is reported by service providers in Surrey that historically, TB services locally have developed in
an uncoordinated way, often with limited resources. This was largely understood to be a function
of the relatively low incidence of TB however recent publications1,2,3,4 have recognised the
importance of managing TB to high standards regardless of the prevailing incidence. Poor
prevention and treatment of TB presents various risks to Surrey PCT. For example, it costs more
(approximately £50,000 -70,000) to treat someone with drug-resistant TB (which results from
inadequate initial treatment) than uncomplicated TB (approximately £5,000)5. Additionally, there
may be risks to Surrey PCT’s reputation and medico-legal risks where clinical pathways fail to
comply with recommended clinical guidance and the population’s health is put at risk.
TB is a notifiable disease. Left untreated, a person with TB with infectious TB of the lungs infects
on average 10-15 people every year. The risk of a contact acquiring infections depends on the
nature and duration of their exposure.
Over the last two decades, tuberculosis has re-emerged as a public health problem in the UK. Its
re-emergence has been marked by a significant change in its epidemiology. Tuberculosis now
largely affects population subgroups such as ethnic minorities, non-UK born individuals, the
homeless and problem drug users6,7. The highest burden largely affects deprived communities8.
As such, tuberculosis can be seen as a symptom of health inequalities.
1
Stopping Tuberculosis in England: An action plan from the Chief Medical Officer. Oct 2004. DH.
Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. 2006.
NICE. Available at: http://www.nice.org.uk/nicemedia/pdf/CG033niceguideline.pdf
3 Tuberculosis in the UK: Annual report on tuberculosis surveillance in the UK 2008. 2008. HPA.
4 Surrey PCT. Joint Strategic Needs Assessment. 2008.
5
Tuberculosis prevention and treatment: a toolkit for planning, commissioning and delivering high-quality services in
England. DH 2006. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_075621
6 French CE, Antoine D, Gelb D, Jones JA, Gilbert RL, Watson JM. Tuberculosis in non-UK-born persons,
England and Wales, 2001-2003. Int J Tuberc Lung Dis. 2007;11(5):577-84.
7 Story A, Murad S, Verheyen M, Roberts W, Hayward AC. Tuberculosis in London - the importance of homelessness,
problem drug use and prison. Thorax 2007;62:667-671.
2
7
Strategically, therefore, improved prevention and management of TB also fits with the PCT’s
strategy to address health inequalities in Surrey.
National policy drivers
Surrey PCT is committed to good TB practices as set down in:

The CMO Action Plan (Stopping Tuberculosis in England): published in Oct 04 by the
Department of Health. It highlighted ten action areas including both case management and
public health priorities. It had no funding and there was limited interest from Strategic
Health Authorities (SHAs) to drive the plan forward.

The NICE guidelines (Tuberculosis: clinical diagnosis and management of tuberculosis and
measures for its prevention and control); published in 2006 by the Royal College of
Physicians. It covered TB treatment in more detail (having developed the British Thoracic
Society’s guidelines for best practice) and provided the evidence for a variety of
interventions. It also came with no funding to implement change.

The TB Commissioning Toolkit (Tuberculosis prevention and treatment: a toolkit for
planning, commissioning and delivering high quality services in England): published in Jun
07 by the Department of Health. This document outlined a commissioning plan for PCTs,
with reference to payment by results (PbR) and local service specifications and
agreements.

The Health Act 2006: The Code of Practice will help NHS bodies to plan and implement
how they can prevent and control health care associated infections.
Local strategic context
 Surrey PCT Strategic Commissioning Plan9 (awaiting ratification): Goal 1 of the Strategic
Commissioning Plan is to improve the health and quality of life for (Surrey’s) population,
reducing the gap in health inequalities. TB disproportionately affects the most vulnerable
members of the population, exacerbating health inequalities.
8
French CE, Kruijshaar ME, Jones JA, Abubakar I. The influence of socio-economic deprivation on tuberculosis
treatment delays in England, 2000-2005. Epidemiol Infect. 2008;8:1-6.
9 NHS Surrey Strategic Commissioning Plan 2008-13. (Awaiting ratification – Apr 09)
8
3. What is TB? Subcategories of disease
3.1
Notifiable disease
Tuberculosis (TB) is a communicable disease and both worldwide and in the UK, it is considered a
notifiable disease. Doctors have a legal duty to report cases of both TB and suspected TB under
the Public Health (Control of Diseases) Act 1984 and the Public Health (Infectious Diseases)
Regulations 1988 even if this breaches an individual’s confidentiality for the benefit of the public
good.
The risk of a contact acquiring infections depends on the nature and duration of their exposure.
Table 1: TB risk from contact with an infected (pulmonary TB) person
Nature of contact*
Risk of infection
None known
1 in 100,000
Casual social contact
1 in 100,000
School, workplace
1 in 50 to 1 in 3
Bar, social club
Up to 1 in 10
Dormitory
1 in 5
Home
1 in 3
Nursing home
1 in 20
Source: New England Journal of Medicine 2003; 348:1256-66
* The duration of exposure is another major factor in interpreting these data
3.2
Cause of tuberculosis
TB is caused by bacteria of the Mycobacterium tuberculosis complex (M. tuberculosis, M. bovis or
M. africanum). It is most commonly spread by inhalation of infected droplets containing
mycobacteria.
3.3
Types of infection
Primary infection: When Mycobacterium tuberculosis is first encountered (primary infection), the
immune system attempt to control infection. Some organisms may spread via the lymphatics or
bloodstream to distant sites, forming small granuloma (tubercles). The tubercles may heal
spontaneously or calcify and persist in an otherwise healthy individual. Only a small proportion of
patients develop overt tuberculosis or further disease.
Miliary TB: This occurs when primary infection is not adequately contained and invades the
bloodstream resulting in severe disease.
Secondary TB: This is due to subsequent reactivation of semi-dormant Mycobacterium
tuberculosis and is usually precipitated by impaired immune function such as malnutrition, coexisting illnesses such as AIDS or immunosuppressive therapy. (Reactivation usually occurs in the
apex of the lungs and can spread locally or to distant sites.)
3.4
Symptoms10
The onset of TB is insidious. Primary infection is usually asymptomatic. The presentation of
secondary infection is variable and often non-specific. A high index of suspicion in patients from
particular risk groups is essential to make a diagnosis. TB can affect all organs and body systems.
Extra pulmonary TB being more common in children or the immunosuppressed:
10
Kumar P and Clark M. Respiratory Disease. In Clinical Medicine, Fourth Edition (1999), pp 745-827. London: WB
Saunders.
9








General symptoms: fatigue, malaise, fever, weight loss, anorexia, failure to thrive, PUO
(pyrexia of unknown origin).
Pulmonary: Respiratory TB accounts for 60% of cases in the UK. Symptoms include
chronic, productive cough with purulent ± bloodstained sputum. May result in lobar
collapse, bronchiectasis, pleural effusion, pneumonia.
Genitourinary: The commonest site outside the lungs often presents with "sterile" pyuria.
There may be kidney lesions, salpingitis, abscesses and infertility in females and swelling
of the epididymis in males.
Musculoskeletal: arthritis, osteomyelitis and abscess formation, particularly in the spine
(Pott's disease).
Central Nervous System: tuberculous meningitis and tuberculomas.
Gastrointestinal: mainly ileocaecal lesions but occasional peritoneal spread causes ascites.
Lymph nodes: hilar, paratracheal or superficial node involvement. Palpable nodes may be
initially tender, firm and discrete but later matted and suppurative with discharging sinuses.
Skin: Erythema nodosum (represents an early immunological response to infection),
erythema induratum.
3.4
Diagnosis
3.4.1 Use of chest xrays
Chest xray (CXR) is essential even in non-pulmonary disease as there may have been pulmonary
infection.

Primary TB usually appears as a central apical portion with a left lower-lobe infiltrate or
pleural effusion.

Reactivated TB - there is no pleural effusion and lesions are apical in position.

Severe disease with poor immune response can produce a picture like millet seeds over
the CXR. Hence the name miliary tuberculosis.

Pulmonary TB is unlikely with a normal CXR.

Even patients with non-pulmonary disease may have CXR findings due to initial lung
infection.
In
addition,
other
infections
may
mimic
CXR
appearance.
Typical appearances of TB on CXR include:
o Patchy or nodular shadows in the upper zones, loss of volume, fibrosis ±
cavitation
o Uniform 1-10mm shadows throughout the lung in miliary TB
3.4.2 Microbiological investigation
Firm diagnosis rests on isolating the infecting organism and subsequent sensitivity testing can be
used to guide antibiotic therapy. Isolation of the organism can be difficult.
Possible specimens include:
 Sputum
 Early morning urine
 Biopsy material
Samples are analysed by microbiology services using the following initial tests:
 Staining with Ziehl-Nielson (ZN) stain and rapid direct microscopy for acid/ alcohol fast
bacilli.
 Culture on which can take 4-8 weeks due to slow bacterial growth.
10
Antibiotic sensitivity cultures take a further 3-4 weeks. Rapid detection of rifampicin resistance from
cultured M. tuberculosis is now possible using molecular techniques. Results are fairly accurate
and allow appropriate treatment to begin more promptly but results must still be confirmed with
conventional techniques.
Tuberculin skin tests eg Mantoux, are rarely used in the diagnosis of tuberculous disease but can
detect previous exposure to the organism (or BCG vaccination) by provocation of a well
established, cell-mediated immune reaction.
More sophisticated methods for investigation are available, for example, genotypic methods such
as DNA sequencing and polymerase chain reaction (PCR) and immunodiagnostic tests such as
gamma interferon testing. However, their exact role in management continues to be debated11.
Summary of the NICE guidance for diagnosis is available in Appendix 1.
11 11
Tuberculosis prevention and treatment: a toolkit for planning, commissioning and delivering high-quality services in
England. DH 2006. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_075621
11
4. Incidence
The total population of Surrey PCT is approximately 1.1 million. It is defined as an area of low TB
incidence (ie less than 40 cases a year per 100,000). Incidence is calculated from formal TB
notifications completed by clinicians.
4.1
By borough
The table and chart below shows the TB incidence rate by borough across Surrey between 2004
and 2008. (The 2004-2006 data is the 3 year average.) Last year, in 2008, 86 cases were
notified to the Surrey and Sussex Health Protection Unit for Enhanced TB Surveillance (ETBS).
This reflects a rate of 8 per 100,000. Of these, the majority were working-age adults aged 20 to 44
years who had been born overseas.
TB is not experienced uniformly across the UK. It is associated with more urban areas with greater
ethnic diversity and more commonly affects those living with greater levels of deprivation and the
same holds true in Surrey. For example, Woking Borough has the highest incidence of TB while
the lowest rates are seen in Waverley and Tandridge boroughs.
Chart 1: New notifications of TB per 100,000 population 2004 - 2008
30
25
20
15
10
5
0
2004-06 crude average
2007
Waverley
Surrey
Heath
Guildford
Tandridge
Reigate and
Banstead
Mole Valley
Epsom and
Ewell
Woking
Spelthorne
Runnymede
2008
Elmbridge
Notifications per 100,000
population
New notifications of TB per 100,000 population 2004 - 2008
Table 2: Notifications of TB by borough between 2004 and 2007
Surrey Local
Authority
Elmbridge
Runnymede
Spelthorne
Woking
Epsom and Ewell
Mole Valley
Reigate and
Banstead
Tandridge
Guildford
Surrey Heath
Waverley
TOTAL
Population
(Exeter
2006)
133,175
69,890
93,364
99,756
70,523
85,545
123,210
75,937
134,692
85,421
121,131
1,092,644
Averaged
notifications
received
2004-2006
/100,000
5
6
12
17
7
0
Total
number of
notifications
received
2007
4
4
8
9
6
4
5
3
5
9
4
8
0
10
4
4
61
Source: Surrey and Sussex Health Protection Unit
12
Notifications
received
2007/100,000
3
6
9
9
9
5
Total
number of
notifications
received
2008
7
6
8
26
4
4
Notification
s received
2008 /
100,000
5
9
9
26
6
5
6
0
7
5
3
6
10
3
7
10
1
86
8
4
5
12
1
8
Chart 2: Distribution of TB cases in Surrey by local authority
Source: Surrey and Sussex Health Protection Unit
4.2
By hospital
Much of TB management centres on the hospital providers which mirror the experience of TB
within the neighbouring boroughs. In 2008 in Surrey, St Peter’s Hospital saw 45% (39 patients),
the largest proportion of Surrey residents with TB. The 2nd largest group of Surrey residents, 21%
(18 patients) were seen at various London hospitals. These patients were notified to the Surrey
Health Protection Unit from the London TB Network and therefore relied on accurate notification to
monitor this more disparate group of patients as there is no alternative means of cross-referencing
data outside of Surrey.
Chart 3: Pie chart showing the distribution of TB notifications by hospital - 2008
Pie chart showing the distribution of TB
notifications by hospital - 2008
East Surrey Hospital
18
21%
6
7%
Epsom General
Hospital
6
7%
10
12%
7
8%
Frimley Park Hospital
Royal Surrey County
Hospital
St. Peter's Hospital
(Chertsey)
Non-Surrey hospitals
39
45%
Data source: Surrey and Sussex Health Protection Unit
Less Surrey residents were seen at the other 4 Surrey hospitals. 7% (6 patients) each were seen
at East Surrey Hospital and Epsom Hospitals. Frimley Park Hospital saw 12% (10 patients) of
Surrey residents while Royal Surrey County Hospital (RSCH) saw 8% (7 patients). However, due
13
to their geographical positions on the Surrey county borders, all of the hospitals except RSCH, see
a large proportion of patients drawn from outside of Surrey and who may also come from areas of
higher TB incidence. Due to its location near the centre of Surrey, RSCH sees predominantly
Surrey residents. As a result, Surrey TB notifications for RSCH reflect approximately total
numbers of TB cases seen at the hospital although it is possible there may be more cases of TB
not ‘known to the system’ due to incomplete notification.
The DH TB Commissioning Toolkit guidance recommends the following:

“In lower incidence areas seeing few cases, the diagnostic service would normally be
provided by a respiratory physician. If TB is confirmed, the patient is best managed by, or in
conjunction with, a clinician (a respiratory physician or appropriately trained infectious
disease physician) who sees at least 10 confirmed cases per year.

In some low-incidence areas there may not be one clinician who sees this number alone,
even though the total number seen in a particular hospital is 10 or more. If this is the case,
then the alternatives are for all TB cases to be transferred to the care of the TB lead
clinician (see below) or for management to be discussed on a multidisciplinary team basis,
as with cancer cases. We further recommend that, in low-incidence areas, there is
discussion of cases between hospitals on a multidisciplinary team basis, in order to pool
experience and optimise management.”
Based solely on Surrey notifications, RSCH clinicians see below this recommended minimum TB
caseload.
The acute trusts do not generally collect specific data regarding how many cases of TB individual
consultants see.
4.3
By age
The two main age groups affected by TB, both nationally and in Surrey, are the 20 to 44 year olds
and the over 70 year olds. However, it is important to remember that TB can affect any age.
The 20 to 44 year old group comprise mainly new entrants who have arrived from countries with
higher rates of TB. (See later for detailed section on TB in new entrants.) The older age group
who develop TB are a mixed group of UK- and overseas-born. Many are suffering a re-activation of
past TB which is related to co-existing illness and immuno-compromise that have developed in
later life. For example, it is for this reason that patients who may be considered for anti-TNF
medication, often used to treat certain rheumatological disorders, require TB screening prior to
commencing treatment.
Chart 4: Age profile of TB notifications in Surrey (2008)
14
Age profile of TB Notifications in Surrey (2008)
20
18
16
Notifications
14
12
10
8
6
4
2
0
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
Source: Surrey and Sussex Health Protection Unit
50-54
55-59
60-64
65-69
70-74
75-79
80+
Age range
Across Surrey, the total number of children with TB is small and the number fluctuates greatly over
time. This has implications for clinical governance due to the low experience that any single
paediatric unit in Surrey can gain and maintain.
Recommendation: The DH Commissioning Toolkit recommends that where Paediatric Units have
a caseload of fewer than 10 new cases of active TB per year, they are recommended not to treat a
TB case without liaison with their adult TB colleagues and similarly, that adult TB clinicians are
recommended not to treat childhood TB without involvement of the paediatric services.
4.4
Trends over time
Based on the number of formal TB notifications, at a national level, incidence of TB is starting to
level off after a steady increase between 1980’s and 2006. In Surrey, due to the small numbers, it
is less easy to interpret the trends, as there is a natural fluctuation from one year to the next.
Chart 5: TB notified in Surrey PCT by calendar year
TB notified in Surrey PCT by calendar year
150
Number of cases
125
100
75
50
25
0
2001
2002
2003
2004
2005
Source: Surrey and Sussex Health Protection Unit
Year
15
2006
2007
2008
4.5
Undiagnosed TB cases
Additional caveats to interpreting the current trends of TB in Surrey relate to the lack of reliable
data associated with inconsistent TB notification and the lack of active screening in various
subgroups of the population, known to be at higher risk of TB.
For example, Chart 6 shows the actual and predicted rates of TB for Surrey, East Sussex and
West Sussex. Predicted rates have been estimated from the application of the national incidence
of TB in different ethnic groups applied to the ethnicity breakdown of each borough population.
With the exception of Surrey Heath, the other ten Surrey boroughs have lower actual rates of TB
than would be expected according to the ethnic makeup of the borough. Table 3 quantifies the
difference in rates and numbers of people suffering from TB.
Overall in Surrey, in 2006, 91 cases were actually diagnosed however, 169 cases were predicted.
This represents approximately 78 more cases than were actually seen. Had the predicted cases
presented to the Surrey, TB services, there could have been 86% more demand than was actually
experienced.
Predictions vary according to various other socio-economic and demographic factors however, it is
probably reasonable to say that there are several undiagnosed patients with TB in Surrey who are
suffering unnecessarily from treatable TB disease and who also pose a health risk to the wider
population.
Chart 6: TB rates in Surrey, East and West Sussex 2006
TB Rates Surrey, East and West Sussex 2006
WEST SUSSEX
SURREY
EAST SUSSEX (INC BR & HOVE)
Worthing District (B)
Mid Sussex District
Horsham District
Crawley District (B)
Chichester District (B)
Arun District (B)
Adur District
Woking District (B)
Waverley District (B)
Tandridge District
Surrey Heath District (B)
Spelthorne District (B)
Runnymede District (B)
Reigate and Banstead District (B)
Mole Valley District
Guildford District (B)
Epsom and Ewell District (B)
Elmbridge District (B)
Wealden District
Rother District
Lewes District
Hastings District (B)
Eastbourne District (B)
The City of Brighton and Hove (B)
Predicted rate
Actual rate
0
5
10
15
20
Rate per 100000
Source: Surrey and Sussex Health Protection Unit
16
25
30
35
Table 3: Surrey boroughs and difference between expected and actual numbers of people with TB
2006
Elmbridge District (B)
Runnymede District
(B)
Spelthorne District (B)
Woking District (B)
Epsom and Ewell
District (B)
Mole Valley District
Reigate and Banstead
District (B)
Tandridge District
Guildford District (B)
Surrey Heath District
(B)
Waverley District (B)
Totals
Borough
population
(Exeter
2006)
133,175
Actual
rate /
100,000
9.4
Actual
number
of
cases
13
Predicted
rate /
100,000
16.4
Predicted
number
of cases
22
Difference
between
predicted vs
actual
number of
cases
9
%
difference
between
predicted
vs actual
cases
74%
69,890
93,364
99,756
6.2
12.2
16.7
4
11
17
15.3
17.4
22.8
11
16
23
6
5
6
145%
42%
37%
70,523
85,545
8.7
5.0
6
4
21.4
11.2
15
10
9
5
145%
126%
123,210
75,937
134,692
4.7
1.2
6.1
6
1
8
15.6
13.5
13.4
19
10
18
13
9
10
234%
990%
121%
85,421
121,131
1,092,644
18.4
4.3
16
5
91
14.2
10.9
12
13
169
-4
8
78
-23%
155%
86%
Recommendations
1. There should be active case seeking in groups known to be at higher risk of TB.
2. Using the enhanced TB surveillance (ETBS) process, improve formal notification of people
with TB who are ‘known’ to TB services.
3. Consider annual audit between laboratories and HPU in order to triangulate the
notifications of TB cases (and ensure de-notification as appropriate). See p18 recommendation (4).
4.6
Incidence in new entrants
A detailed review of the incidence of TB in New Entrants and the rationale for a proposed change
in screening is at Appendix 2.
In summary, during the 18 months of a study conducted by Surrey and Sussex Health Protection
Unit (2006-07), there were 4004 new entrants to Surrey from countries with an incidence of TB >40
per 100,000 (approximately 2500 new entrants to Surrey annually). 89% of these were
successfully screened by CXR at Port of Entry or after they had arrived in Surrey. Of these
migrants, 83% were under 36 yrs of age.
Of the 4004 new entrants who were screened at the Port of Entry or referred by the HPU for
screening by chest X-ray, 62 individuals were subsequently referred for further investigations of
abnormal chest X-ray findings. The outcome of the referrals is unknown but as far as is known,
there have been no new active cases of TB detected by the current system of CXR at Port of Entry
or shortly after entry although one individual is known to have been commenced on
chemoprophylaxis. The TB specialist nursing service in Surrey now informs the HPU of new
entrant referrals who do not subsequently present for assessment.
Instead, the vast majority of cases of TB develop in new entrants within the first 5 years after entry
to the UK which is likely to be due to factors such as socio-economic deprivation associated with
being an immigrant in the UK.
17
5.
Surveillance
Surveillance is the process of systematic collection, collation and analysis of data with prompt
dissemination to those who need to know, for relevant action to be taken12
Aim of tuberculosis (TB) surveillance
To provide the information required in Surrey to:
 identify outbreaks
 monitor trends
 inform policy
 inform development of services
 monitor the success of the Tuberculosis programme
In Surrey, the Surrey and Sussex Health Protection Unit (SSHPU) are responsible for surveillance.
Current data sources used for TB surveillance in Surrey
5.1
Routine data sources
5.1.1 Statutory notification of Infectious diseases (NOIDS) forms
Clinicians have a statutory duty to report all suspected or clinically diagnosed tuberculosis cases to
the Proper Officer, usually the Consultant in Communicable Disease Control (CCDC). This
information is used to monitor the trend in the incidence of tuberculosis in England and Wales, and
locally to initiate control measures. The prime purpose of this system is speedy detection of
possible outbreaks and epidemics. If diagnosis of tuberculosis is later proved incorrect they should
be de-notified. Bacteriological confirmation of diagnosis may take weeks. In practice, instead of
NOIDS forms, clinicians tend to complete the Enhanced TB Surveillance (ETBS) forms.
5.1.2 Laboratory reports
Laboratory reports are sent on a voluntary basis to SSHPU by all 5 acute trusts in both paper form
and in an electronic form on the ‘CoSurv’ database. Clinical data is very limited so the reports act
more as a prompt to check the patient is known to the TB Community Service. Unfortunately, the
Co-Surv database cannot be interrogated which limits its broader usefulness.
5.1.3 Death certificate data
The Office for National Statistics (ONS) publishes data on deaths and of residents in England and
Wales annually. Causes of death, including tuberculosis, are included in death registration
information required for all deaths.
5.1.4 Tuberculosis incident and outbreak surveillance (TBIOS)
TBIOS is a passive system of national tuberculosis incidents and outbreaks surveillance (TBIOS)
in England and Wales which is established at the HPA Centre for Infections to inform the evidencebase for the purpose of public health management of such events. Reports are obtained from a
number of sources including regional health bulletins, news reports, prisons surveillance however
patient identifiable information is not included in the database.
In reality, TBIOS has had little impact in Surrey because there are no routine reports ‘back to the
field’
5.1.5 Enhanced TB surveillance in England, Wales and Northern Ireland (ETBS)
The minimum dataset includes notification details, demographics, clinical and microbiological
information on cases of tuberculosis reported by the clinicians to the local co-ordinators, then via
HPA Regional Units to CfI in Colindale. ETBS provides an annual corrected analysis of reports by
age, sex, and ethnic group, country of birth, site of disease and region of residence.
12
World Health Organisation. Protocol for the assessment of national communicable disease surveillance and response
systems. Guidelines for Assessment Tests. WHO Geneva. 2001. www.who.int/emc
18
Completion of ETBS forms is patchy across Surrey. ASPH routinely completes these forms. ESH
does not complete them at all. The other 3 hospitals, FPH, RSCH and SASH complete these
forms irregularly. Successful completion of ETBS appears to correlate with the availability of a
Community TB nurse as these forms are increasingly completed by them.
Approximately, 21% of Surrey patients were not seen in Surrey hospitals. They were all seen at
London hospitals where ETBS forms were completed for the London TB Registry. These
notifications were then passed to SSHPU. It is not otherwise possible to know the numbers of
patients treated outside of Surrey.
It is reported by some clinicians that there is some confusion regarding the timing of notification of
TB since not all suspected cases actually result in confirmed disease. For example, a proportion of
suspected cases may be diagnosed with an aytpical mycobacterium. Equally, a small proportion of
cases may be strongly clinically suspected as having TB but microbiological evidence is not
available.
To manage the ETBS data, the Health Protection Agency (HPA) has a web-based database, ETS.
It acts as a store of ETBS data however it has various limitations which reduce its practical
usefulness. For example, on the ETS database, clinical outcomes such as ‘death’ or ‘transfers out’
cannot be updated if they occur within 6 months of treatment starting. There is no opportunity to
record the dual diagnosis of HIV. Additionally, ETS cannot be used ‘in the field’ eg in hospital
outpatient clinics, by the TB Nurses for their real-time clinical case load eg managing cases and
contacts. As a result, it tends to present an administrative burden as data must also be entered
on ETS in addition to clinical records. In response to this, the CCDC, Kevin Carroll, has developed
a separate database – see later.
5.1.6 Treatment outcome surveillance (TOS)
Treatment outcome surveillance is part of the ETBS in England, Wales and Northern Ireland. It is
an essential tool in determining the effectiveness of the national effort to control tuberculosis, by
providing information on the proportion of patients who either completed treatment, died, were still
on treatment after one year, had treatment stopped, were transferred out or who were lost to follow
up prior to finishing treatment.
The completion of TOS forms in Surrey, like ETBS forms, is similarly patchy. ASPH routinely
completes these forms. ESH does not complete them at all. The other 3 hospitals, FPH, RSCH
and SASH complete these forms irregularly.
5.1.7 United Kingdom Mycobacterial Network (MycobNet)
Information of all cases of tuberculosis confirmed by culture at the reference Centres is collected at
CfI. Information includes species (M tuberculosis, M bovis and M africanum), drug sensitivity
results and some demographic and clinical data. Information produced through MycobNet is used
to monitor trends in drug sensitivity, and is the basis of surveillance of M bovis. MycobNet provides
an annually corrected analysis of mycobacterium complex isolates by drug sensitivities, age, sex,
region and previous history of tuberculosis.
5.2
Local data collection and databases
In SSHPU, there are two other databases – HPZone and the SSHPU local TB database.
5.2.1 HPZone
HPZone is a regional HPA database, currently used by both Surrey and Sussex HPUs. It is used
in the day-to-day management of both individual cases and outbreaks of all communicable
diseases and other health protection problems. For TB, it tends to be used most to manage TB
outbreaks or incidents and initial registration of cases (rather than their ongoing management by
the acute trusts / community TB nurses).
19
5.2.2 SSHPU local TB database
SSHPU local TB database has been designed to allow day-to-day case management by the
Community TB Nurses with the primary aim of producing a single tool that is useful for both clinical
care and surveillance while minimising the administrative burden of data inputing. It allows linking
of cases, contact tracing and interrogation in order to be able to produce reports.
5.3
Special groups
There is currently no separate surveillance system in place for TB monitoring of prisons or the
homeless however, data on new entrants is collected. Port Health inform SSHPU of new entrants’
arrival and an initial TB risk assessment is entered on the New Entrant database.
5.4
Standards for surveillance
The DH TB Commissioning Toolkit13 specifies the standards for national surveillance of TB. See
appendix 5. It should also be useful to monitor performance of TB services. Standards relate to
the following areas which are detailed more specifically in the Toolkit:







Reporting of new cases by clinical teams / local TB services
Collection and forwarding of information on reported cases by HPA local and regional
services
Treatment outcomes
Microbiology results
Molecular strain typing
Feedback and reports
Audit trail
5.5
Summary of data systems and TB surveillance in Surrey
Overall, the surveillance of TB in Surrey is fragmented and very much dependent on the good will
of a few individuals at the different hospitals. Amongst its Surrey peers, ASPH appears
consistently to be more committed to the importance and practicalities of TB surveillance. There is
no single-best database. The national ETS database (HPA) is already out of date and requires
cross-referencing with other databases eg Co-Surv and HPZone to optimise accuracy.
Recommendations
1. Acute Trusts must ensure compliance with statutory reporting of both suspected and
confirmed TB cases as part of the legal requirement of clinicians.
2. SSHPU and clinicians should work together to increase understanding of the ETBS system
which is the main method for clinicians to notify TB cases to the SSHPU.
3. Use the TB Commissioning Toolkit standards to audit performance of TB services. See p15
Recommendation (3).
4. Consider requesting that future versions of the ETBS form include TB ‘risk groups’.
13
Tuberculosis prevention and treatment: a toolkit for planning, commissioning and delivering high-quality services in
England. DH 2006. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_075621
20
Current services
6
The core TB service and inter-relationships with other stakeholders
6.1
Inter-relationships
In Surrey, TB services interact (or could interact) with various different services and agencies as
detailed in chart 7 below.
Chart 7: Key relationships and stakeholders to core TB Services
Mental
health
services SABP
Health of
Homeless
Prison
health
Outbreak
management
- HPU
TB SERVICES
DAAT
HIV
services
Port
Health
Mother
and
child
health
Immunisations
Occupational
health
Health of
New
Ne
entrants
w
Abbreviations:
SABP – Surrey and Borders Partnership Mental Health Trust
DAAT – Drugs and Alcohol Team
HPU – Health Protection Unit
6.2
The core Surrey TB Service
The core Surrey TB service consists of various independent and semi-independent organisations
that Surrey PCT works with to provide health care for the benefit of its population.



The Community TB Nurse Team (provided by Surrey PCT’s provider arm, Surrey
Community Health)
The Acute Trusts:
ASPH – Ashford and St Peter’s Hospitals NHS Trust
ESH – Epsom and St Helier Hospitals NHS Trust
FPH – Frimley Park Hospital NHS Foundation Trust
RSCH – Royal Surrey County Hospital NHS Trust
SASH – Surrey and Sussex Hospitals NHS Trust
Surrey and Sussex Health Protection Unit
The relationships between each element of the core service have evolved over time, particularly
regarding both the clinical and financial responsibility for services users’ care. Many of the
agreements in place at present are implicit but where the relationship has changed over time, there
is now some tension at times.
Part of the challenge of this health needs assessment will be to make more explicit the boundaries
of the different relationships so that there is greater clarity over duties and responsibilities for our
common patients. However, the PCT has a duty to commission appropriate services and where
21
this is not covered by the Payment by Results ‘Tariff’, there should be a service level agreement
(SLA) in place to specify the detail. (See section 15.4).
7
Laboratory services
7.1
Current service provision
Laboratory support for the management of TB in Surrey is provided through general microbiology
departments at ASPH, SASH, the Partnership Laboratory of RSCH and FPH and the HPA-regional
laboratory hosted by ESH.
A questionnaire was sent to all the laboratories requesting information about the TB services
provided and for their opinions of how TB laboratory services could be provided for Surrey
residents in the future. Laboratories for 4 of the five Acute Trusts have responded and the
response from Epsom & St Helier Acute Trust is awaited. The questionnaire and results are
detailed at Appendix 4.
At ASPH, SASH and the Partnership Laboratory of RSCH and FPH, microscopy is performed daily
on Monday to Friday while a weekend service is available on request. Culture is provided in house
at each of the 3 laboratories although PCR and gamma-interferon testing are routinely sent away,
mainly to London acute trusts. A large proportion of this work is sent to the Mycobacterium
Reference Laboratory at The London Hospital.
Looking ahead, ASPH, SASH and the Partnership Laboratory agreed that TB services may be
better served by a central Surrey laboratory that was able to perform all the culturing and
dependent on volume of workload, perhaps, PCR and gamma interferon testing. The ‘basic’ task
of TB microscopy could also be centralised but only if transport was sufficiently reliable both inand out-of hours to provide a timely response to clinicians. It was generally agreed that
identification and sensitivity testing be left to a Mycobacterium Reference Laboratory.
7.2
Recommended TB service standards
The DH TB Commissioning Toolkit14 details the recommended methodologies and criteria to
ensure the rapid, accurate diagnosis of active TB. With the needs and expectations of patients
and their clinicians in mind, it also addresses:
 Supporting the early confirmation of appropriate treatment;
 Instigating suitable measures to reduce transmission; and
 Providing timely evidence to help identify and investigate possible outbreaks.
It provides specific recommendations and standards regarding the management of microbiological
samples, culture, isolation and identification with particular attention to the time-scale involved in
getting test results and the communication of those results to the relevant parties.
These
standards are detailed in Appendix 6.
It has not been possible for this health needs assessment to investigate how closely Surrey’s
laboratories conform to the standards specified.
14
Tuberculosis prevention and treatment: a toolkit for planning, commissioning and delivering high-quality
services in England. DH 2006. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_075621
22
7.3
Use of laboratory services in latent TB and screening: Tuberculin skin test (TST) vs
gamma-interferon test
In asymptomatic persons exposure to, and potential infection with tuberculosis is demonstrated by
a positive tuberculin skin test (TST) or more recently from a positive blood based immunological
test (gamma-interferon test).
Those with a strongly positive TST are considered as having been infected with tuberculosis. TSTs
are cheap and relatively easy to perform but, they have to be interpreted within a certain time
scale. Patients who do not return or delay returning will have either no results or an inaccurate
one. False positives may be a result of BCG vaccine or people being sensitised with opportunistic
environmental mycobacterial, severe infection, ie miliary tuberculosis may result in a negative skin
test.
The new interferon-gamma tests will only react to mycobacterium tuberculosis and to a few
species of environmental mycobacteria, they do not react to BCG protein. NICE recommend an
initial TST, followed, if positive, by an interferon-gamma test to confirm positivity. (Economic
modelling of the 2 tests provided most support, on the grounds of cost effectiveness, for this 2
stage approach.)
Gamma-interferon tests are considerably more expensive than TSTs – at approximately £40 per
test. However, these costs must be offset by the benefit of less false positive TB testing. This is
important when the costs of chemoprophylaxis - providing and monitoring treatment and the risk of
its potential harms, are considered.
7.4
Funding of gamma-interferon tests
In Surrey at present, screening occurs on an ad hoc basis, usually as a result of an incident.
Those who are offered screening do not pass via their GPs and therefore associated investigations
are not funded directly under GPs’ budgets. In the past, many of the gamma-interferon tests (and
the associated courier costs) were ‘swept up’ under the acute trusts’ microbiology department
budgets however, an increasing awareness of this ‘funding loophole’ and an increase in absolute
numbers of tests ordered (as a results of growing clinical use of the test)) has resulted in tension
over who should pay.
According to the DH Commissioning Toolkit15, while laboratory investigations for a person referred
to secondary care for suspected with TB falls within the Tariff, screening activities, such as contact
tracing and incident management, are not funded by Payment by Results (PbR) and therefore,
there should be a local service agreement agreed between the PCT, Community provider and
acute trusts. An example of a Service Level Agreement (SLA) is available in the Toolkit.
Recommendations:
1. The PCT (Commissioning), PCT (Provider) and Acute Trusts should agree a local service
agreement which includes contact tracing, screening and the associated costs of
investigations such as gamma interferon tests, mantoux, chest xrays etc.
2. Acute Trusts should audit TB laboratory standards (with reference to the standards detailed
in Appendix 6) to establish a baseline and to be able to quantify any future progress made.
(Ultimately, this will need to be part of the PCT-Acute Trust service level agreement and
service specification.)
15
Tuberculosis prevention and treatment: a toolkit for planning, commissioning and delivering high-quality services in
England. DH 2006. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_075621
23
8
Current provision of TB care for people with or suspected to have TB
8.1
Overview
TB services are largely centred on the acute trusts. Diagnosis, treatment initiation and monitoring
are provided at the acute trusts however, much of the response to treatment and associated
patient welfare is mainly monitored by either a hospital-employed or community (PCT-employed)
TB Nurse.
Current guidance recommends that all patients with TB should have a named case worker who
can help the patient through their long treatment. In reality, in most cases locally, this function is
provided by either the community or hospital TB nurse.
Current NICE16 guidance details the recommended treatment for individuals suspected of or
diagnosed with TB and it is expected that clinicians would manage patients in line with these
recommendations except in patient-specific circumstances.
It has proved difficult to assess quality of clinical care received by Surrey patients with TB because
of the general lack of audit of NICE guidelines in acute trusts.
Similarly, there is a dearth of outcome monitoring for patients. Anecdotally, most Surrey patients
appear to complete treatment within the expected timeframe and rarely default from treatment
however, few data are actually collected to support this view despite the formal HPA surveillance
process in place.
Recommendations:
Surrey PCT should work with the Acute Trusts to ensure that the following is agreed as part of the
service level agreement for TB service provision.
1. Acute Trusts should conduct regular audit of the management of their patients with TB in
order to ensure compliance with current NICE guidance. This should be linked through
each acute trust’s Clinical Governance Committee and be part of the recommendations
made to the Acute Trust Board.
2. Acute Trust physicians should complete outcome monitoring as part of their contribution to
routine surveillance. (See surveillance recommendations p18.)
3. All patients should have a named case worker and know how to contact them for advice.
(As this is a capacity issue, please see the section on TB Nurses p28-29.)
8.2
Role of GPs and primary care health care professionals
Diagnosis of TB is almost never confirmed in general practice and diagnosis and treatment of TB
are best provided by specialist services.
TB is best diagnosed and managed by experienced specialists17. While primary care clinicians may
suspect a diagnosis of TB, a formal diagnosis including treatment and care plans is best made by
specialist service providers. Primary care does have an important role in providing support to the
patient through the treatment period;
Recommendations:
1.
Ensure that GPs and other primary and community care staff are aware of the
symptoms and signs of TB, local TB services and local arrangements for referring
patients with suspected TB including the need for urgent referrals. (See Section 8.3)
2.
Consider linkage with GP tutors to incorporate TB as part of core GP continuing
professional development (CPD) on health protection.
16
Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. 2006.
NICE. Available at: http://www.nice.org.uk/nicemedia/pdf/CG033niceguideline.pdf
17
Tuberculosis prevention and treatment: a toolkit for planning, commissioning and delivering high-quality
service sin England. DH. 2007.
24
8.3
Managing TB patients within two weeks
The CMO’s Stop TB Action Plan recommends that all patients have access to secondary care
diagnostic and treatment teams within two weeks. Where there is strong clinical suspicion on the
part of the GP of active infectious TB, most services will aim to assess the patient within two days.
According to the DH TB Commissioning Toolkit, TB may be excluded from the choice requirement
(Choose and Book) on the grounds that it is a rapid access service. In this way, a well-organised,
integrated community TB service is able to justify exemption on the same grounds as maternity or
mental health services. Consequently, it is not necessary for TB services to be provided within the
Choose and Book framework. However, all efforts should be made to ensure that, where practical,
patients have the opportunity to negotiate a mutually convenient appointment.
In Surrey, patients are generally seen swiftly in secondary care and within the recommended timescale, however, this is usually done by creating ‘extras’ on an already full outpatient list.
Recommendations:
1. Ensure that those administering the allocation of appointments for patients with suspected
TB are aware of the 2 week guidance. (GPs may wish to consider annotating referral
letters with a notice highlighting the urgency as is done with the management of cancer
where the ‘2 week rule’ is flagged routinely.)
2. Consider whether there are alternative means of streamlining the patient pathway, for
example by establishing clinics that integrate multiple aspects of the TB service eg
screening and ‘routine‘ outpatient care.
8.4
Acute adult services
There is a named TB lead adult physician at each of Surrey’s 5 acute trusts. All the TB leads are
adult respiratory physicians. ASPH is the only acute trust to run a TB clinic that is separate from
the general respiratory outpatients.
Hospital-based TB Nurses
At ASPH, there is a TB nurse, part-funded by Surrey Community Health and part-funded by ASPH,
who works alongside the hospital TB physicians and provides support to patients both at the
hospital and in their homes. She also provides any contact tracing generated by the patient and
deals with ward referrals.
FPH have a trust-employed TB nurse who looks after Surrey patients, however the service does
not include home visits or community contact tracing beyond the immediate family.
SASH does not have a hospital-based TB nurse who provides care or contact tracing for Surrey
residents. (However, there is a PCT-employed TB nurse who provides a full community and
hospital service for West Sussex residents.) RSCH has no hospital-based TB nurse.
For both SASH and RSCH, patient support and community contact tracing is provided by the
Community TB Nurse but must be initiated by TB notification – see Section 9. (A similar
arrangement existed for ESH Surrey patients until Jan 09 when the new trust-employed TB nurse
started.) In reality, since formal TB notification is known to be patchy, it is possible that some
patients may not benefit from the services of a community-based TB nurse including extended
contact tracing as required.
Inpatient facilities
Of the acute trusts, only SASH has a specific hospital policy on the management of someone with
TB however the lead TB physician is known in all the acute trusts and in-house referrals can be
made to either the lead TB physician or the hospital-based TB Nurse.
25
Isolation facilities for the care of a patient with suspected pulmonary TB are available at all of the
acute trusts however, specialist negative pressure rooms are only available at FPH.
Recommendations:
1. Ensure that all cases of TB are notified formally to SSHPU in order to trigger the
Community TB nurse service. (See Surveillance Section 5.)
2. Review the provision of TB nurses across the county in order to provide high quality TB
service for all regardless of geographical location. (See TB Nurse Section 9)
8.5
Acute paediatric services
There are very few children in Surrey who are found to have TB. This presents a significant
clinical governance challenge in the high quality management of TB in such a low incidence area,
to ensure that clinicians have adequate experience to manage cases appropriately. Children
suspected of having TB are usually the ‘contact’ of an adult close to them such as a parent or
teacher and their TB is often detected through contact tracing or outbreak/incident management.
Children who fall into the category of ‘latent’ TB (who are then treated with chemoprophylaxis)
frequently fall ‘between stools’ in Surrey as the current TB Service manages adults better.
Surrey hospital practice
Both Royal Surrey County Hospital and Frimley Park Hospital routinely refer children found to have
TB to tertiary centres in London (for example, the Royal Brompton Chest Hospital) for their
subsequent TB management.
Children with TB at Ashford and St Peter’s Hospital and Surrey and Sussex Hospital are managed
in-house by paediatricians who see relatively large numbers of children suspected of having TB
and this is related to the demographic profile of both hospitals’ local ‘catchment’ area.
Epsom Hospital tends to refer children with suspected TB to the lead paediatrician for TB at Queen
Mary’s Childrens Hospital (co-located with St Helier’s Hospital, Sutton).
Common themes
1. Taking over care of children with TB diagnosed overseas: A common problem at all the
hospitals is that although new diagnoses may be few, the Paediatricians end up taking over
the care of children whose TB treatment has been started overseas. It can be near
impossible to confirm microbiological diagnosis as, is common in many cases of TB in
children, no specimen was originally collected and treatment was started empirically.
2. Treating ‘well-looking’ children: It can be difficult to ensure compliance with treatment over
its long duration in children who look well. Parents may feel anxious to give treatment with
its risk of adverse effects or simply forget as the imperative to treat goes. This is
particularly the case with latent TB which is more common in children.
3. Liaison with Community Paediatricians is becoming increasingly difficult (and is likely to
remain so for the foreseeable future) as it is reported there is a relative recruitment crisis for
Community Paediatrics. This contributes to the loss of experience (and confidence) of
GPs and other community healthcare professionals in detecting, diagnosing and managing
TB in the community.
Recommendations:
1. Agree a Paediatric patient pathway (after cost-benefit analysis) to facilitate high quality care
for children in Surrey with either latent or active TB. (This should take into account the
26
particularly low incidence of TB in Surrey children but allow for those affected to still receive
high quality care.)
2. Ensure raised awareness of both public and health care professionals for the possibility of
TB in children, especially amongst communities at greater risk of TB.
(See
recommendations for GP awareness on p22).
3. Ensure that parents and guardians of children – and the children themselves – understand
the importance of adherence with TB treatment and have sufficient appropriate information
to inform their decisions.
8.6
Prescribing anti-TB treatment
The NHS (Charges for Drugs and Appliances) Regulations 2000 (the Charges Regulations)18 were
amended in September 2007 to allow medication for the treatment of tuberculosis to be provided
free of charge in TB clinics or via a patient group direction.
Regulations 5 (supply of drugs by HAs, NHS Trusts and PCTs) and 6A (supply of drugs under
patient group directions) of the The National Health Service (charge for Drugs and Appliances) and
(Travel Expenses and Remission of Charges) were amended as follows:
“No charge shall be made and recovered under this regulation from a patient who is accepted by
the person supplying the drug as suffering from tuberculosis in respect of any drug supplied to that
patient for the treatment of tuberculosis”
TB services and hospital pharmacies should ensure that drugs supplied to treat TB should be free
of prescription charges for patients attending TB clinics or treated under a patient group direction.
FP10 forms (GP and Community prescriptions) cannot be used under this arrangement. It was
recommended that if prescribing in the community was required, a patient group directive (PGD)
might be easier to use.
The Surrey Community TB Nurse team has confirmed that patients receive their medications free
of charge from their hospital when they attend their outpatient appointment. Problems occasionally
arise when patients mislay medication or run out before their next appointment. There is currently
no patient group directive in Surrey which in situations like this, can complicate patients’ care. At
present, in such a situation, the TB Community Nurses will ask a ‘willing’ consultant at the local
hospital to provide a prescription at short notice and without seeing the patient.
Recommendation: Consider the introduction of a Patient Group Directive for Community TB
nurses to minimise disruption of a patient’s adherence to treatment in the event of medication
issues in between outpatient appointments.
8.7
Management of multiply-drug resistant tuberculosis (MDR-TB)
There are currently no cases of MDR-TB in patients being treated in Surrey however, health
professionals need to be aware of the possibility of this.
NICE recommend that a risk assessment for drug resistance should be made for each patient with
TB, based on the risk factors listed below:
 history of prior TB drug treatment; prior TB treatment failure
 contact with a known case of drug-resistant TB
Supply of TB drugs to patients – changes to regulations and advice on implementation. Available at:
http://www.dh.gov.uk/en/Publichealth/Communicablediseases/Tuberculosis/DH_078136
18
27





birth in a foreign country, particularly high-incidence countries7
HIV infection
residence in London
age profile, with highest rates between ages 25 and 44
male gender.
NICE recommend:
1. The TB service should consider the risk assessment for drug resistance and, if the risk is
regarded as significant, urgent molecular tests for rifampicin resistance should be
performed on smear-positive material or on positive cultures when they become available.
2. Response to treatment should be closely monitored in patients at increased risk of drug
resistance. If there is no clinical improvement, or if cultures remain positive after the 4th
month of treatment (‘treatment failure’), drug resistance should be suspected and treatment
reviewed with a clinician experienced in the treatment of MDR TB.
3. The options for organising care for people with MDR TB should be discussed with clinicians
who specialise in this. While the views of the patient should be sought and taken into
account, and shared care should be considered, in Surrey, this is very likely to require a
tertiary referral.
28
Table 4 showing the current distribution of Acute Trust TB services in Surrey
ASPH
ESH
FPH
RSCH
SASH
6
10
7
6
7%
?
Also treats London
borough patients
12%
?
Also treats Hampshire
& Berkshire patients
8%
?
Also treats Hounslow
patients
7
Only Surrey patients
2
Dr Wood*
Dr Nordstrom
Yes
Alison Byers
Funded by Surrey
Community Health and
ASPH
2
Dr Cooke*
Dr Rahman
Yes
Proseetha Pradesh
ESH-employed
(Newly appointed for
Surrey patients)
3
Col Hoad*
Dr Knight
Dr Ho
2
Dr McAllister*
Dr Alexander
7%
?
Also treats West Sussex
patients
2
Dr Jenkins – for Surrey
(Dr Acharya* – for West
Sussex ie The bulk of TB
work at SASH))
Yes
Pam Hoad
FPH-employed
No
Covered by Surrey
Community Health TB
Community Nurse
No
Covered by Surrey
Community Health TB
Community Nurse
Yes
To start shortly
Dr Richard Chivas
St Mary’s Children’s
Hospital
No
No
No
No specific TB lead
Dr Godden (Respiratory
Paediatrics)
Dr Hussain
Number of Surrey
patients with TB 2008
% of total Surrey
patients
Total No TB patients
seen at acute trust
No of Chest
Physicians treating TB
patients
* Trust TB lead
TB Nurse working at
hospital for Surrey
patients?
Domiciliary visits done
by hospital-based TB
nurse?
Paediatric TB lead
39
45%
Dr Diab Hadad
29
9
Surrey PCT Community TB Nurses
9.1
Overview
In general in the UK, the management of suspected and actual TB is mainly provided in secondary
care and this is no different in Surrey. Most patients with TB are treated on an outpatient basis
with few requiring inpatient facilities. While the five acute trusts in Surrey manage much of the
diagnosis and initial management of patients with suspected or actual TB, the ‘glue’ that holds the
TB service together is the Surrey Community Health (Surrey PCT provider arm) Community TB
Nurse Team.
Community TB Nurses are theoretically involved in the following activities:
 Referrals from GPs for patients with suspected TB
 Liaising with the acute trusts to ensure that patients on TB treatment are monitored
appropriately
 Domiciliary visits to ensure treatment adherence
 Contact tracing
 BCG clinics
 Outbreak / incident management eg screening questionnaires, risk assessment including
referrals for further diagnostic tests, managing the ‘worried well’
 Liaison with the Health Protection Unit to ensure formal notification
 Surveillance
 New entrant screening
 Health education
o Raising TB awareness for HCPs
o Raising TB awareness for the public
9.2
Staffing
Surrey Community Health administer the TB Community Nurse Team as part of the Children’s
Services.
For some considerable time, the Surrey Community Health TB service was run by a single Band 7
nurse working 0.8FTE. Since Summer 2008, a 2nd TB nurse (Band 6) has joined, also providing
0.8FTE. In January 2009, a 3rd TB nurse (Band 5, working 0.8FTE) joined the team.
Band 7 nurses and above can work autonomously and make independent TB assessments
including referrals for diagnostic tests such as xrays and tuberculin skin testing (although this often
depends on the referral protocols for each individual acute trust). A Band 7 TB nurse should also
be able to refer patients to a secondary care consultant. In contrast, Band 6 and Band 5 nurses
have respectively less clinical autonomy which therefore limits the breadth of work that they can
provide unsupervised.
The DH TB Commissioning Toolkit recommends that outside London, there should be 1 FTE TB
Nurse for every 50 notifications. While the nurse banding is not specified, the assumption is for a
Band 7 nurse, which would reflect the more autonomous and specialist nature of TB nursing.
9.3
Distribution and capacity of the Community TB Team
Surrey Community Health is commissioned by Surrey PCT to provide community TB services
throughout Surrey, including the area usually covered by Central Surrey Health, the other main
community provider in Surrey.
Across Surrey, the Community TB Service is expected to provide different elements of service
complementary to the service provided by the Acute Trust of the area. For example, at Frimley
Park Hospital, while patients with TB can attend the hospital-employed TB nurse at the hospital,
there is no domiciliary service provided. Community TB work in the Frimley Park locality, for
example, contact tracing, outbreak management or new entrant screening is picked up by
30
Community TB Team. In contrast, at Ashford and St Peter’s Hospital, due to the large proportion
of Surrey patients with TB, the Community Team have allocated one of their nurses to the full-time
care of this locality’s population. This results in both community and hospital-related TB work
being completed by a single TB nurse that patients can come to know and trust.
Currently, the capacity of Surrey’s TB nurse specialist team is limited to management of patients
on anti-TB medication, their contact tracing and outbreak management as is immediately
necessary. Fortunately, anecdotally, the vast majority of patients in Surrey are reported as largely
adherent to treatment regimens without direct observation of treatment (DOTS) and there are
currently no patients in Surrey with multiply-drug resistant TB (MDRTB) that would require
enhanced management. The current capacity of the TB Community Nurse Team would not
adequately allow enhanced patient case management in the event of more patients needing DOT.
There is currently no formal administrative support for the TB Community Nurse Team and they
are therefore responsible for administrative work such as sending out patient appointments,
chasing patients who DNA (do not attend) and inputting patient details on their new database.
9.4
Clinical supervision and continuing professional development
As local specialists in the field of TB nursing, it is more difficult for the TB Community Nurses to be
adequately clinically supervised by their own line management and there are no formal
arrangements for clinical supervision within the existing TB service.
Possible options for clinical supervision would include one of the TB leads at an Acute Trust or a
Consultant in Communicable Disease Control (CCDC) at Surrey and Sussex Health Protection
Unit.
As the management of TB evolves over time, it is important that Surrey’s Community TB nursing
team have sufficient capacity to allow them time for both clinical supervision and continuing
professional development (CPD).
Recommendations:
1. Surrey PCT should commission Surrey Community Health to ensure adequate and
appropriate provision of TB Nurse specialists in line with current guidance (both quantity of
FTE staff and appropriate banding). However, this may involve devolving certain services
to non-TB health care professionals eg BCG immunisation. (See BCG Section p40)
2. Ensure adequate administrative support in order to free TB Community Nurses to expand
their clinical work. (This expansion includes tasks such as active case finding in high risk
groups and raising awareness of TB in Surrey.)
3. Surrey Community Health should ensure that TB Community Nurses are suitably clinically
supervised to ensure that high quality patient care is maintained as part of good clinical
governance.
4. Surrey PCT should clarify the role of Central Surrey Health in TB, especially in TB incident
management.
31
10
TB Control - Screening for TB
In Surrey, screening for TB is provided on an opportunistic and ad hoc basis, most often in
response to contact tracing for a known patient with TB and less commonly, to TB outbreaks.
As discussed previously, the capacity of the TB Nurse Team has limited their ability to actively
case-seek in higher risk groups of the Surrey population, such as through outreach to BME
communities, in the five Surrey prisons, the homeless and people with drug and alcohol problems.
On average, it has been estimated that each index case of TB results in 6.5 contacts19 that must
be followed up and investigated. This work is often ‘invisible’ as the focus tends to be on the
number of actual TB notifications.
Recommendation: Consider developing Surrey TB service to provide active case finding for TB
through outreach to higher risk groups.
10.1 Contact tracing
Contact tracing in Surrey is conducted by both the community and the hospital-based TB nurses in
line with current NICE guidance and with advice from the Surrey and Sussex Health Protection
Unit.
The NICE guidance summarises guidance to deal with contact tracing in the following
circumstances:
 Household and close contacts
 Cases in schools
 Cases in community childcare
 Cases in hospital inpatients
 Cases on aircrafts
 Cattle to human transmission
10.2
Higher risk groups
The population groups considered to be at higher risk of TB are:
 BME
 New entrants from countries with high TB incidence (ie over 40 per 100,000 population)
 Asylum seekers, refugees and illegal new entrants
 Prisoners
 Street homeless
 People with drug and alcohol problems
 Occupational risk groups eg healthcare workers
It is important that TB resources are directed at these groups in order to most effectively use
resources, particularly in Surrey’s low TB incidence environment.
10.3 BME
There are currently no reported BME community awareness programmes for TB in Surrey. The
Surrey PCT BME Development Worker has been involved with individuals with TB and has acted
in an advocacy role on an individual basis but the work on TB has been opportunistic and ad hoc
rather than through a systematic programme of health promotion.
19
Ansari S et al. Refine tuberculosis contact tracing in a low incidence area. Respiratory Medicine 1998;
92(9):1127-1131.
32
A health needs assessment for BME groups is planned by Surrey PCT to address general health
needs but especially those conditions that disproportionately affect BME populations such as
coronary heart disease, stroke, diabetes and tuberculosis.
There are anecdotal reports of concern amongst BME groups about the risk of stigma and as a
result, conditions such as mental illness and tuberculosis are often hidden by families.
There is a targeted BCG immunisation programme since 2005 but anecdotal reports suggest that
this is not as widely known to both BME communities and their health care professionals as would
be hoped.
Recommendations
1. Surrey PCT should consider completing a BME Health Needs Assessment.
2. Increase (and maintain) awareness of TB, including through the media and community
groups, and develop initiatives to support local awareness-raising among high risk groups.
3. Increase awareness and availability of BCG clinics eg Via Health Visitors, Practice nurses
and via primary schools in targeted areas.
10.4 Port Health and the care of new entrants
Surrey and Sussex Health Protection Unit have completed a study of the screening of new entrants
in Surrey. The results are detailed in Appendix 2.
The UK has had a policy of screening entrants from high-risk countries for several years now
through the ‘Port of Arrival’ scheme (Hogan et al 2005). New arrivals from high-incidence countries
(40/100,000 or over) who are intending to stay for six months or more are identified by immigration
staff and referred for initial clinical and radiographic assessment at port health control units. Local
consultants in communicable disease are then notified of the results for people moving into their
area and are expected to organise appropriate follow-up.
In addition to the Port of Arrival scheme, the Home Office has more recently introduced a TB
screening system for asylum seekers at fast-track induction centres20
In Surrey, a small number of new entrants, identified by Port Health (usually from either Gatwick or
Heathrow Airports) are notified to the Surrey & Sussex Health Protection Unit (SSHPU) who in
turn, notify the Community TB Nurses to arrange screening. However, the process is widely
recognised as failing for a variety of reasons:
a. High risk new entrants do not always receive a chest xray at their Port of Entry and the
responsibility for this is shifted from Port Health to SSHPU. However, SSHPU are not
responsible for individual patient care and have no direct means of referral into secondary
care eg for chest xrays, therefore, the SSHPU relies on the new entrant registering with a
GP.
b. Communication between Port Health and SSHPU is reported as being inconsistent; not
every new entrant identified as higher risk for TB is thought to be referred to the SSHPU.
c. New entrants identified by Port Health are not yet registered with a GP and some may have
difficulties doing so. GPs act as a formal gateway both to the Acute and Community
elements of the TB service. Therefore, without GP registration, there is no means for the
Acute Trusts to recoup costs of managing new entrants referred to them informally from the
TB Community Nurse service. (Therefore, there is no separate healthcare funding for
these New Entrants who are not formally registered with a GP. As a result, even if
20
NICE. Clinical Guidance 33 (Full version). Appendix D. Available from:
http://www.rcplondon.ac.uk/pubs/books/TB/TBappendices.pdf
33
accepted by the TB Community Nurses for TB care, the Acute Trusts bear the costs of
managing suspected and confirmed cases of TB, rather than the PCT.
Recommendations
1.
Surrey PCT, Surrey and Sussex Health Protection Unit and the Port Health at Heathrow
and Gatwick airports should work together to improve the new entrant referral process
including for example:
a. GP registration
b. Referral to a Health Visitor for Under 5’s
2.
Surrey PCT should work with Surrey GPs to facilitate prompt GP registration for new
entrants.
3.
New Entrant health screening: Surrey PCT should consider a locally enhanced service
(LES) agreement with GPs to provide holistic health screening targeted at specific
needs of new entrants based on the recommendations of a New Entrant Health Needs
Assessment.
4.
New Entrant Health Care Needs Assessment (HCNA). Surrey PCT should consider
completing an HCNA in order to understand the potentially diverse health needs of New
Entrants. There is likely to be an increased need for health care related to
immunisations and reproductive, mental, nutritional and dental health.
10.5 Asylum seekers, refugees and ‘illegal’ new entrants
It is not clear how many asylum seekers, refugees or illegal new entrants may be living in Surrey at
any one time however, it is known that London is a popular destination for many people in this
situation and there is likely to be ‘spill over’ into Surrey.
There are also Home Office Detention Centres near Gatwick Airport and Heathrow Airport which
border Surrey to the east and west respectively.
Many of the countries that asylum seekers arrive from have a high incidence of TB however, it is
also likely that there may be a ‘healthy migrant’ effect that mitigates their initial TB risk. (The
‘healthy migrant effect’ suggests that it is often the healthier people who leave their country of
origin and therefore, are not fully representative of the relatively poorer health of their country and
of those that stayed.) In fact, as detailed in the section on New Entrants, it is often as a result of
migration to the UK and the higher risk of living in poverty, without access to their previously
supportive social networks and access to healthcare, that migrants become ill.
Entitlement to NHS treatment
The Department of Health recently issued guidance in Nov 08 regarding entitlement to NHS
treatment. It details the extent to which asylum seekers, refugees and failed asylum seekers may
access both primary and secondary care. It is considered by many to be complex and fairly
difficult to interpret, particularly in the case of ‘failed’ asylum seekers. It is likely that both new
entrants and health care staff (especially reception administrative staff) may not be fully aware of
their entitlements which may hinder access to timely TB care. Detailed guidance is available on
the DH website21. No specific reference is made regarding the care of new entrants with
suspected TB who are considered to be ‘illegal’.
It is important to highlight that regardless of entitlement, the guidance states:
21
http://www.dh.gov.uk/en/Healthcare/International/AsylumseekersAndrefugees/index.htm
34
“Certain services are exempt from charges for everyone. This includes treatment provided solely in
an Accident and Emergency Department, treatment of certain specified communicable diseases
(although prescription charges may be payable unless exempt) and compulsory mental health
treatment.”
Tuberculosis is one of the specified communicable diseases referred to. Prescription charges are
not payable for prescriptions issued from a hospital (or through a patient group directive) as
detailed in Section 6.3.6.
Welfare support and advice
Surrey County Council’s HIV Liaison Coordinator provides advice about services (health, social
and non-governmental) and welfare support for new entrants (including asylum seekers and
refugees) who are HIV positive. There are a number of patients with TB co-morbidity who fall
within this provision, however, the social welfare of asylum seekers with TB but without HIV
becomes the responsibility of the 11 individual borough councils. However, certain patients with
TB, for example, those with only limited leave to remain in the UK, may have ‘no recourse to public
funds’ and not be eligible to apply for statutory support. The numbers of patients in Surrey
anticipated to be in this category are likely to be small however, they potentially raise difficult moral
and potentially ethical issues for health care workers.
Anecdotally, none of the patients currently receiving care under the TB service in Surrey is thought
to be destitute however, given some of the factors associated with TB and the challenges
experienced by many new entrants in registering for health care, it is quite possible that some
patients may be suffering financial hardship in silence and might benefit from some social welfare
support. This is important, not only morally, but clinically. In addition to anti-tuberculous
medication, patients with TB should have adequate housing and good nutrition in order to aid
physical recovery, optimise compliance with treatment and reduce the likelihood of TB
transmission to others.
Recommendations
1. Surrey PCT should inform all GP surgeries of the guidance relating to entitlement to NHS
services for asylum seekers, refugees and other categories of new entrants to the UK. It is
important that the message about the universal free access to anti-tuberculosis treatment is
understood.
2. The TB Nurses should have sufficient knowledge of entitlement to NHS treatment and how
to access social welfare support in order to provide signposting for patients with TB who
may also be suffering social hardship.
35
10.6 TB in Prisons
There are five prisons in Surrey. They cater for 1133 female prisoners and 1622 male prisoners, a
total of 2755 people. HMP Bronzefield is a private prison while the other four are run by the Prison
Service and their healthcare is now the responsibility of Surrey PCT.
Table 4: Prisons in Surrey - operational capacity, category and prisoner ethnicity.
Prison
Operational Male /
capacity
female
Category
HMP Send
280
Female
HMP Bronzefield
Female
HMP High Down
465 +
12 Mother &
Baby Unit
360 +
16 Juvenile
Unit
1105
Male
Closed
Training
prison
Closed
(Private
prison)
Closed
Training
prison
Category B
HMP Coldingley
517
Male
Category C
All prisons
1133
1622
2755
Female
Male
Total
HMP Downview
Female
Average
monthly
throughput
240 per
month
High
turnover
Ethnicity
White British 65%
White other 6%
BME 29%
Not known
White British 28%
White other 11%
BME 61%
White British 56%
White other 8%
BME 36%
White British 53%
White other 7%
BME 40%
Surrey prisons health need assessments
Surrey PCT is currently undergoing a programme of health needs assessments of its prisons as it
is acknowledged that in addition to the usual spectrum of health problems, there are various
medical conditions that prisoners are more at risk of and which may also be caused or exacerbated
by the prison environment.
Prisoners’ risk of TB
Prisoners are at increased risk of TB for a variety of reasons. These include pre-imprisonment
socioeconomic factors such as homelessness, lower socioeconomic status and higher
unemployment, co-morbidities such as HIV, poor nutrition and drug and alcohol use. In addition,
environmental conditions in prisons may facilitate transmission of TB infection, such as
overcrowding, poor hygiene and inadequate ventilation.
Story et al (2007) estimated that there was a prevalence rate of 208 per 100,000 London prisoners
compared to an England prevalence of 15.5 per 100,000 population. While several demographic
factors may be different between the general population of London versus the Surrey population,
within the prison system, the differences may not be as marked. This is related to the
overcrowding in the prison service and Surrey’s close proximity to London which means that
Surrey prisons often receive prisoners from around the South East and London. As a result, it may
not be an unreasonable assumption that the rate of TB in London prisons may be much different
from in Surrey prisons.
Lower incidence than expected
In recent years, there have only been known to be approximately 1 or 2 prisoners receiving
treatment for TB per year. However, this is surprising given the risk factors mentioned previously,
the increasing proportion of prisoners known to come from higher TB risk countries and the high
36
proportion of prisoners who are of BME ethnicity and who may therefore be at increased risk of TB
due to either their country of birth or of their parents’ / grandparents’ countries of birth. Care must
be exercised when calculating expected numbers of prisoners with TB because the Surrey prison
population is small, but based on Story’s rate of 208/100,000 prison population, one would expect
to see between 5 and 6 prisoners with TB at any one time in Surrey prisons.
The lower than expected numbers of prisoners with TB may be due to a number of factors:




Small overall numbers of prisoners which obscures the natural variation in TB incidence.
Enhanced surveillance forms do not routinely record ‘Prisoner’ status (unless completed
within the ‘Occupation’ section) which could theoretically be missing prisoners with TB.
(However, this is unlikely because the overall number of patients with TB is small enough
that TB Community Nurses are informally aware of most patients with TB in Surrey.)
Inadequate detection of TB in the prison service relating to, for example, inadequate TB
contact tracing, health screening on prison entry or the prisoner’s presentation to health
services.
Inadequate continuity of medical care for prisoners known to have TB. It is known that
prisoners who may have been diagnosed with TB in one prison (and even have started
treatment) may not have their management continued when they transfer to another prison.
Recommendations:
NICE22 has issued guidance on the prevention of TB in prisons and these are all relevant for
prisons in Surrey:
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.
2. Prisoners should be screened for TB by:
a. a health questionnaire on each entry to the prison system then
b. for those with signs and symptoms of active TB, a chest X-ray, and three sputum
samples taken in 24 hours for TB microscopy, including a morning sputum sample.
3. All prisoners receiving treatment for active or latent TB should receive directly observed
treatment (DOT).
4. Prison medical services should have liaison and handover arrangements to ensure
continuity of care before any prisoner on TB treatment is transferred between prisons.
5. If a prisoner is being treated for active or latent TB, the prison medical services should draw
up as early as possible a contingency plan for early discharge, which could happen directly
from a court appearance. This plan should include firm arrangements for clinical follow-up
and treatment monitoring in the intended district of residence, and should take into account
that there may not be a fixed residence arranged for the prisoner after release. The
prisoner should be given contact details for a named key worker, who will visit and monitor
the prisoner after release and liaise between services involved.
6. Prison service staff and others who have regular contact with prisoners (for example,
probation officers and education and social workers) should have pre- and on-employment
screening at the same level as for healthcare workers with patient contact.
22
Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. 2006.
NICE. Available at: http://www.nice.org.uk/nicemedia/pdf/CG033niceguideline.pdf
37
10.7 Street homeless
It is estimated that there are probably less than 100 people sleeping on the streets in Surrey. For
example, approximately 15 – 20 rough sleepers use night hostels each in Guildford and Woking
however, there are likely to be some who remain on the street.
While the situation in Surrey is likely to be different, it may be useful to understand the picture seen
in London. Analysis23 of the data available in London suggests that the main groups still on the
streets are:
 a continuing flow of ‘new’ rough sleepers
 entrenched rough sleepers resistant to service provision
 migrants without recourse to public funds, including Eastern Europeans not in work
(estimated to account for at least 15% of rough sleeping in London)
Rough sleepers in London tend to:
 be predominantly male (88%) and usually white (77%), though more likely to be from ethnic
minorities than 10 years ago
 usually aged between 25 and 45 years (only 7% under 25, 28% over 45)
 have a range of support needs (48% alcohol, 41% drugs, 35% mental health)
 often have an institutional history – 39% have been in prison (though not necessarily
recently), 12% in care and 5% in the armed forces.
Recommendations:
The recommendations issued by NICE in the management of street homeless are useful for
Surrey:
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.
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.
10.8 People living with HIV/AIDS
HIV/AIDS is well-established as a risk factor for TB. In the UK, it is estimated that approximately
3% of people diagnosed with TB also have HIV/AIDS; from a global perspective, particularly in
Africa and parts of Asia, the proportion is much higher. As such, this co-morbidity is increasingly
common in new entrants.
It is therefore important that patients presenting with one infection, should be offered screening for
the other in line with UK national guidelines for HIV testing24. Across the country, including
Surrey, HIV services are better developed than those for TB and therefore, patients with HIV are
more likely to be offered additional screening for TB. The reverse is less consistent, ie patients
who present with TB are not consistently offered HIV testing with its attendant need for pre-test
counselling. Some clinicians, including physicians and both community and hospital-based TB
nurses feel less confident to raise the issue of HIV/AIDS with their patients with TB.
23
Rough Sleeping 10 years on. From the streets to independent living and opportunity. Discussion paper. Apr 08.
Department for Communities and Local Government. Available from:
http://www.communities.gov.uk/documents/housing/doc/Disscussionpaper.doc
24 UK National Guidelines for HIV Testing 2008. BHIVA (British HIV Association.) Available at:
http://www.bhiva.org/files/file1031097.pdf
38
Despite this, there are good links between HIV and TB services in Surrey and clinicians feel able to
refer patients between services as appropriate.
It is also important to remember that standard TB screening, eg with use of the Mantoux tuberculin
skin test, is much less accurate in people with HIV/AIDS. In this situation, alternative testing using
an interferon test eg T-spot, is preferable.
Recommendations
1. Health care professionals providing TB or HIV/AIDS services should routinely coordinate
screening tests for the other infection (ie HIV or TB respectively) for their patients,
especially if other risk factors are present. This may involve referral to the other service or
with sufficient appropriate training, the screening may be provided within the original
service.
For example, a patient with TB should routinely be offered HIV testing. HIV testing may
occur after referral to the HIV/AIDS service or from a TB physician or nurse who has
undergone sufficient and appropriate training to deliver the pre- and post-test counselling
required.
2. Interferon tests should be used to screen for TB in someone known or suspected as having
HIV/AIDS (rather than relying on Mantoux tests).
10.9 Occupational risk groups
Occupational health assessment is the responsibility of the employer and as such, does not fall
within the immediate remit of Surrey’s core TB service. However employees, who are found, at
occupational screening to be at higher risk of TB, should be referred into the TB Service as for any
individual requiring further investigation for suspected TB.
The Department of Health’s ‘Green Book’ (Immunisation against Infectious Disease) details the
occupational groups where people are more likely than the general population to come into contact
with someone with TB:






Healthcare workers who will have contact with patients or clinical materials
Laboratory staff who will have contact with patients, clinical materials or derived isolates
Veterinary and staff such as abattoir workers who handle animal species known to be
susceptible to TB, e.g. simians
Prison staff working directly with prisoners
Staff of care homes for the elderly
Staff of hostels for homeless people and facilities accommodating refugees and asylum
seekers
Unvaccinated, tuberculin-negative individuals aged under 35 years in these occupations are
recommended to receive BCG. There are no data on the protection afforded by BCG vaccine when
it is given to adults aged 35 years or over. Since not all healthcare workers are at an equal risk of
TB, there should be a clinical risk assessment when the use of BCG is being considered for a
healthcare worker over 35 years of age.
39
11
Managing tuberculosis incidents and outbreaks
A tuberculosis incident is defined as where potential transmission of tuberculosis to non-household
contacts is identified, warranting wider public investigation beyond routine contact tracing. This
includes potential, suspected or confirmed tuberculosis transmission in:





An educational setting involving a child, student or member of staff
A prison, reception centre or detention setting
A healthcare setting involving a patient or a health care worker
Exposure of passengers or staff on an aircraft
Where a patient or member of the public necessitates public health action, such as
applications made under the Public Health (Control of Diseases) Act, 1984
Tuberculosis outbreaks are a subset of incidents, where two or more linked cases of tuberculosis
have occurred in non-household contacts.
In general, in Surrey, it is the Surrey and Sussex HPU who are alerted of possible TB incidents /
outbreaks and they would lead on its management. Initial actions often include convening an
incident meeting with the key stakeholders.
The stakeholders usually include, as a minimum:
 The school / nursing home / organisation affected
(If a state school, Surrey CC may send a representative from the Schools Department)
 Surrey and Sussex HPU
 Community TB Nurse
 Acute trust Treating Physician +/- Microbiologist
 Surrey PCT
Logistics of outbreak management
TB incidents and outbreaks tend to be highly time-consuming and labour intensive because of the
often high numbers of people requiring screening. They also have highlighted shortcomings of the
current IT system in place.
Large numbers are assessed for their risk (using questionnaires) and for many, Mantoux testing is
completed. A proportion of people will need further investigation, such as using chest xray or
gamma interferon testing and of these, a proportion will need referral to secondary care and TB
treatment.
There have been a number of incidents in Surrey over the last few years. The results of these
incidents are detailed in Table 5 (below). The majority have involved primary schools and health
care settings. The volume of work is not routinely monitored however, approximate numbers of
people affected by TB incidents are detailed below. Incidents can disrupt the TB service because
of their sudden and unpredictable impact on work-load, the requirement for prompt risk
assessment and also for their potential to create varying degrees of public alarm that must be
managed. They present a risk to all the organisations involved, largely due to the potential risk to
reputation.
In addition, since Spring 2009, there have been a number of TB incidents in schools which have
resulted in the screening of large numbers of children. While the exact results have yet to
confirmed, the key issues have been similar to previous incidents and highlight the importance of
having a standard operating procedure for coordinating these incidents amongst the key agencies
involved.
40
Table 5: Approximate number of people screened by Surrey Community TB nurses for TB
(excluding ‘in-house’ screening conducted by Acute Trusts and Surrey and Borders Partnership
Trust) between 2006 and Spring 2009.
Outbreak / Incident
management
Total number affected
Incident meetings /
visits
Questionnaires
Mantoux tests
Chest xrays
Gamma interferon
tests
BCG immunisation
Referrals to secondary
care
Treated for TB
Number
involved
2006
181
13
Number
involved
2007
186
13
Number
involved
2008
539
17
Number involved
2009
(to Spring 2009)
152
10
181
181
181
80
72
63
37
6
61
13
36
29
66
136
21
1
3? Or 10
34
85
0
90
116
15
7
9
2
0
Areas of conflict
Recent TB incidents have accentuated points of conflict arise due to lack of clarity regarding:
 Responsibility for specific tasks of stakeholders eg Surrey and Sussex HPU vs Acute
Trusts vs Community providers vs PCT is not always clear.
 Funding for large numbers of (or higher cost) consumables:
o Interferon tests
o Patient information leaflets (TB Alert)
o Stationery and stamps
 Cross-boundary issues between community providers ie Surrey Community vs Central
Surrey Health. (For example, Central Surrey Health (community provider) are not
contracted to provide TB services even for patients in their geographical boundaries)
Linking TB cases
Increasingly, more sophisticated laboratory techniques are available, such as DNA fingerprinting
and molecular typing however, they are not currently routinely used in all outbreaks.
Recommendations
1. Agree Surrey standard operating procedure for managing TB incidents in Surrey and alert
key stakeholders.
2. Plan for ‘surge capacity’ to better manage outbreaks / incidents especially regarding the
funding of extra resources eg gamma interferon testing.
(A possible solution is establishing a contingency fund above and beyond an agreed
‘normal’ expected annual workload – based on previous years’ outbreak experience.)
3. Increase administrative support available for Community TB Nurses.
4. Ensure an effective IT system is in place that allows outbreaks, especially cases and
contacts, to be correctly recorded.
5. Surrey PCT/SSHPU need to liaise with the relevant employers/regulatory authorities to
confirm the occupational health BCG provision for higher risk facilities eg schools,
nurseries, prisons etc.
41
12
TB Prevention - BCG immunisation
Since the abolition of universal school age BCG vaccination in 2005, the DH has recommended
that all 0-15 year olds are screened for high risk TB status and offered BCG vaccination if
appropriate.
While the targeted programme is generally well-accepted by individuals and communities
assessed to be at higher risk of TB, there is also the risk of causing offence and potentially
stigmatising targeted individuals. In many countries, TB has negative connotations which may be
difficult to overcome.
Ashford and St Peter’s Hospital Trust is the only acute trust in Surrey to routinely offer BCG
vaccination to neonates and this is administered in the Maternity Unit. Surrey and Sussex
Hospitals (SASH) do not routinely provide this in the Maternity Unit however, there is now an active
BCG immunisation service in the surrounding area that is well attended by women and their babies
from the local BME community.
BCG clinics are run in a variety of locations around Surrey however, staffing levels limit regularity
of clinics and there are occasionally last-minute cancellations due to staff non-availability.
Historically, the PCT funded GPs to provide BCG but when this service shifted to Surrey
Community Health provision, the funding did not shift accordingly.
Currently, apart from the East Surrey locality BCG clinics, BCG delivery is coordinated (and often
provided) by the TB Community Nurse team. The TB Community Nurse team have attempted to
train other health care professionals in BCG vaccination but this is has not consistently resulted in
course attendees actually going on to run BCG clinics alone. For the time being, TB nurses
continue to administer the bulk of BCG in Surrey and are drawn away from TB management,
contact tracing and screening.
Table 6: Surrey Community Health BCG clinics in Surrey as at Jan 09
Locality
Clinic
North West
Shepperton Health
Centre
Maybury Centre
South West Guildford – Jarvis
Centre
East
Camberley Children’s
Centre / Berkshire
Road Clinic
East Surrey Hospital
Number of
clinics per
month
2
2
3
(To reduce to
2 – Jan 09)
2
1
Age of those
attending
Comments
0 – 16
>6yrs – Mantoux
<6yrs – BCG only
0 – 16
>6yrs – Mantoux
<6yrs – BCG only
0 – 16
>6yrs – Mantoux
<6yrs – BCG only
0 – 16
>6yrs – Mantoux
<6yrs – BCG only
BCG Baby clinic –
well attended
>6 Catchup clinic –
poorly attended
Lead by TB
Community
Nurses
Lead by TB
Community
Nurses
Lead by TB
Community
Nurses
Lead by TB
Community
Nurses
Run by Surrey
Community Health
Immunisations
Team
Recommendations:
1. Considering fully moving the responsibility of BCG vaccination delivery to local
immunisation teams / primary care (rather than diverting the scarce TB Nurse resources
from TB work that can only be done by a TB-trained nurse).
2. Continue to target schools with high proportions of pupils at higher risk of TB eg BME
communities, to raise awareness of the Targeted BCG programme but while remaining
sensitive to the risk of stigmatising individuals and communities.
3. Encourage working between the Immunisation Team and BME Community Development
worker to facilitate culturally-sensitive targeted health promotion materials on BCG (and
other relevant health subjects).
4. Surrey PCT’s Immunisation and Vaccines Committee should review provision of BCG
immunisation in Surrey to ensure that only those targeted to receive BCG actually receive
it.
5. Acute trusts should review their Maternity Unit policy regarding neonatal BCG immunisation
for babies at higher risk of TB.
43
13
Patient views of TB services
13.1 Surrey PCT TB Patient Survey results - 2009
A survey of the views of Surrey PCT patients with TB was carried out in June – July 2009. Forty
paper copies of the survey (in English) were sent to TB nurses across the county who agreed to
distribute them to their patients currently in treatment. 13 surveys were returned – approximately
33% response rate. The questions and their results are detailed in Appendix 6.
Who replied?
In summary, 8/13 were aged 18-40 years and 10/13 were female. 7/13 were non-British born
Asians and 4/13 were non-British born Black Africans. (The remaining 2 were White British people
investigated for TB prior to starting chemotherapy for cancer.)
How long for patients to be referred to TB Services?
5 people quantified the time it took for their GP to diagnose and refer them to TB Services and the
average time from first presentation of symptoms to when they were seen in secondary care was
13 weeks.
Language and information issues
While 9/13 people stated that English was not their first language, only 2 needed help to
understand their health professional and a family member was asked to help. Most had received
written information and were happy with it in English. All respondents felt they understood their TB
but approximately one third of the respondents would have liked more information, often about
whether their TB was eradicated and if it might recur.
Transport
9/13 respondents attended the hospital by car with the others using a combination of public
transport. 4/9 said that travelling to another hospital for their treatment would not be a problem
however 5/9 respondents would find it either quite or very difficult. Comments about travel mainly
related to the cost (eg fares or car parking) or the time lost for those that worked.
Overall feeling for Surrey TB Services
All 11 who responded to the question regarding respect considered they were treated with respect
with only 1 person feeling they could have been treated any better. Patients particularly
appreciated when their TB Nurse helped them out by bringing medicine to their homes. 7/9
respondents to the question of satisfaction were either very or sufficiently satisfied with their TB
care with only 1/9 people not satisfied and 1 person not being able to remember.
Several of the general comments referred to dissatisfaction with the time it had taken for their GPs
to suspect their TB and for the lack of information on TB available in primary care. Worryingly,
one patient had been told by her GP that ‘we don’t have TB in our village’.
13.2 General results from other areas’ patient surveys
The Surrey PCT survey findings are based on the responses of only 13 people however, they are
not dissimilar from findings from other area’s patient surveys as outlined in Sections 13.2.1 –
13.2.5.
13.2.1 Poor general awareness of tuberculosis amongst health care professionals
Patients have reported that it takes a long time to be referred from primary care to the TB service
but that once they are referred, their subsequent management occurs quickly. Patients report
having to see either the same health care professional (HCP) several times before tuberculosis is
raised as a possible diagnosis or that they need to see multiple primary care HCPs before they are
referred.
44
13.2.2 Public/community awareness of TB
Some patients have reported that their families and friends know little about TB and this can cause
great anxiety and a degree of shame because there is still some stigma about the diagnosis.
Similarly, there is a wider community anxiety which often stems from inadequate information
related to the health protection aspects of TB. This can manifest itself in over-reactions from for
example, schools (staff and other parents) who are overly anxious about the need for exclusion
any other public health measures.
Additionally, extra care may be required to inform the general public about TB to prevent this
becoming a wider issue relating to racism or jingo-ism in view of the greater proportions of BME
groups and new entrants affected by TB.
13.2.3 Cultural and language issues
TB disproportionately affects BME and new entrants and other issues are reported to affect
individuals and families affected by TB. These include:
1. Language: English may not be the first language and some individuals may struggle to
communicate either verbally or through written media or both. While written information
may be available in other languages, TB Services need to be aware that this may still be an
issue if literacy in that language is a problem.
Anecdotally, formal translation services are rarely used in Surrey and instead, patients’
relatives provide this service informally. However, it is important to realise that this can
bring about its own problems if the translation is modified and the patient cannot express
themselves fully or accurately.
2. Cultural differences: It is important to understand that that differences in culture may affect
the way in which the TB services are delivered and their acceptability to the service user.
For example, women in some cultures may find it embarrassing or unacceptable to see a
male doctor. Similarly, it has been reported that some women with TB may be reluctant to
present themselves for medical care if they are worried that their ability to care for their
families may be impaired. Other examples of possible cultural differences may relate to
some patients being reluctant to take medication while fasting.
13.2.4 Availability of info leaflets / material appropriate for children
In Surrey, the vast majority of people with TB, are adults however, there are a small number of
children affected by TB each year. Some families may wish to have information about TB available
in a more child-friendly format to aid explanation.
13.2.5 Access to care
Both patients and staff have raised issues regarding equity of access to health care. These
include issues relating to knowledge of the services available to them, geographical access and
affordability of ‘low ticket’ items such as transport to and from health services.
TB
disproportionately affects those who may have less disposable income and many find these
‘hidden charges’ of NHS healthcare difficult to afford.
While many of the people who are seen by Surrey TB Services, either for treatment or for
screening, appear to have knowledge of the NHS and how to access care, there are likely to be a
proportion, particularly new entrants, who may be less familiar with ‘the system’. It can be
bewildering to attend a busy GP surgery or hospital, particularly if you don’t speak English well or
are not familiar with what the costs might be or your general rights to health care.
45
Recommendations
1. Raise awareness of TB amongst both primary care health care professionals (especially
amongst GPs) and communities, specifically targeting awareness in the higher incidence
areas and those areas where incidence is expected to be higher than is currently
experienced.
2. Ensure that staff who work with TB Service users are able to provide information about how
they can access NHS health care or signpost to other resources eg Patient Advisory
Liaison Service (PALS) and /or the Department of Health leaflet introducing NHS services.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida
nce/DH_4122587
3. Ensure there is information available for patients about state help with costs such as travel,
prescription charges etc and that service users are alerted to the possible options available
to them.
4. Ensure access to information about TB suitable for the specific user eg child-centred,
appropriate language etc. (The charity, TB Alert, charges a small fee to PCTs for use of
their well-written information leaflets.)
46
14
Effectiveness of services and funding
14.1 Surrey TB Clinical Network and TB Leads
The CMO’s Stop TB Action Plan recommended that every PCT have a designated TB co-ordinator
and that Acute Trusts identify a TB lead. The aim is to create a strongly led, well-coordinated and
adequately resourced local TB programme so that all those working to deliver the programme have
a clear focus on what needs to be achieved and the best practice for doing so.
The Surrey TB Clinical Network has been established for approximately 1-2 years and meets every
six months. It is gradually gaining momentum however attendance, particularly from several Acute
Trust TB leads, has been patchy. It is hoped that in time, the TB Clinical Network might become
more of a resource for clinicians to share and develop good practice in Surrey.
14.2 Use of audit
Despite publication of NICE guidelines to help shape clinical management of patients with or
suspected of having TB, there is little evidence of audit of the care of these patients in the acute
trusts.
During the drafting of this health needs assessment, it has proved difficult to establish a baseline of
care currently being provided because so little data is routinely collected by providers.
14.3 Funding of acute and community TB services
Most of the acute trust provision for the management of patients either with TB or suspected as
having TB, is funded under the Payment by Results (PbR) ‘Tariff’ in the same way that any
outpatient management is funded. It is therefore expected that for these individuals, registered
with NHS GPs, all relevant diagnostic tests and treatment would be covered by either inpatient or
outpatient Tariff. For example, allowance has been made under PbR for monthly follow up over
the usual 6 months of treatment, attracting a separate outpatient appointment Tariff for each visit.
For pragmatic reasons, in order to expedite the care of a patient suspected to have TB, the current
TB Community service often appears to have been ‘short-cutting’ the formal secondary care
referral process. GPs, if the actually patient is registered, may be bypassed which can then cause
some confusion about who is ultimately responsible for the funding of investigations used to
diagnose the patient. Is it the PCT or Acute Trust that foots the bill? This is a particular problem for
individuals detected as being at risk of TB who have been identified by contact tracing, outbreak
management screening and new entrant screening. Planning ahead, in the event that active TB
case finding, for example in high risk groups, were to be developed, the ‘system’ may be at further
risk of being ‘short-cut’.
The Tariff does not cover any community services such as home visits, telephone support or
directly observed treatment (DOT) in the community. These community services are vital to
facilitate a patient-centred approach which is considered key to increasing adherence to
treatment25. (Ultimately, treatment adherence is important to ensure that the incidence of drugresistant strains of TB does not increase and hinder the control of TB in the population.)
Additionally, funding for outbreak management is a significant bone of contention in Surrey. As
discussed in the section on outbreak management, these incidents are labour-intensive to manage
and can consume large volumes of consumables. In addition, since NICE guidance recommended
the increased use of the more costly interferon tests, further pressure has been put on budget
allocations, which by their very nature, can be difficult to predict.
25
Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. 2006.
NICE.
47
The DH TB Commissioning Toolkit recommends that local agreements are drawn up between
PCTs, Acute Trusts and Community providers in order to agree the details of the services that are
to be provided by each party.
Recommendations:
1. Agree patient pathway with stakeholders in line with best evidence.
2. Establish local service level agreements between PCT and Acute Trusts to ensure
appropriate funding of the different elements of TB care including both Tariff and Non-tariff
services.
3. Consider the establishment of an ‘Outbreak contingency fund’ which could provide
insurance over and above a pre-agreed level of annual outbreak management.
4. Clarify responsibility with key stakeholders for different components of TB service eg
Management of contact tracing, screening (active case finding), BCG immunisation etc.
48
15
Options and Models of care
The DH TB Commissioning Toolkit highlights the principle underpinning TB services in areas of low
TB incidence is that the care of the individual patient presenting in that area must be delivered to
the same overall standard as that which the patient would receive if diagnosed in an area where
TB is more common. In essence, this may be either hospital out-reach or community in-reach.
The models by which the responsibilities for care of a TB patient are fulfilled may differ depending
on other local factors. The options available include employing:
 A specialist nurse with responsibilities additional to those for TB (eg Also managing
asthma, chronic obstructive pulmonary disease)
 Specialist TB nurse(s) but shared between neighbouring trusts
 Specialist TB nurse(s) covering several trusts but employed by eg the local Health
Protection Unit (HPU)
15.1 Using programme budgeting to compare outcomes in other areas with money spent
Programme budgeting is a tool being developed nationally that allows some comparison of clinical
outcomes against expenditure for a given health disease category. At present, TB falls within the
‘Infectious Disease’ programme budgeting category however, the total budget is predominantly
spent on care for HIV/AIDS.
It is also possible to compare Surrey against all PCTs in England or its Strategic Health Authority
neighbours. Ideally, it is best to compare Surrey with PCTs which are more similar from a socioeconomic and demographic perspective. The ONS has grouped such similar PCTs as ‘clusters’.
The ONS cluster that provides the most similar comparator group for Surrey is the ‘Prospering
Southern England’ cluster. This consists of the following PCTs:
 Buckinghamshire PCT
Berkshire West PCT
 Cambridgeshire PCT
Mid Essex PCT
 Oxfordshire PCT
West Hertfordshire PCT
 West Kent PCT
At present, programme budgeting is a fairly blunt tool. For example, the Infectious Disease
programme budgeting category (PBC) includes the funding of healthcare directed at HIV/AIDS
which involves costly treatments and it is not possible to accurately separate out the expenditure
for TB. However, it has been possible to exclude HIV/AIDS treatments to give an ‘Other Infectious
Disease’ subgroup although this still includes large amounts of expenditure such as pneumonia.
Despite these shortcomings, it is still useful to compare Surrey PCT’s ONS cluster peers in order to
identify good practice and different ‘ways of doing business’ that improve outcomes and make
better use of health resources.
Comparing years of life lost (YLL) due to mortality from TB by total health spend on ‘other
infectious disease’
Surrey PCT has relatively low YLL but is a relatively high spender to achieve that in comparison to
Cambridgeshire PCT which spends less for similar patient outcomes.
Surrey PCT
Cambridgeshire PCT
49
Comparing years of life lost (YLL) due to mortality from TB by deprivation levels
In general, tuberculosis and its complications are associated with deprivation – as demonstrated in
the graphs below. Surrey PCT and Berkshire West PCT have similarly low levels of deprivation.
Despite this similarity, in comparison to Berkshire West, Surrey has relatively worse patient
outcomes with slightly higher YLL to TB deaths.
Surrey PCT
15.2
Berkshire West PCT
Comparison with services in other areas
15.2.1 Berkshire West
Berkshire West PCT currently have no reported PCT TB lead and have not completed a recent TB
health needs assessment or service review. TB service provision is largely driven from the acute
trust, Royal Berkshire Hospital, which serves much of West Berkshire’s population.
There are 2 TB Specialist Nurses (both Band 7) who provide 30hours and 37.5hours per week.
Although employed by Royal Berkshire Hospital Acute Trust, they see patients both from Royal
Berkshire Hospital and from a wider geographical catchment area (where patients have a choice of
acute trust for follow-up).
The TB nurses work fairly autonomously. They run their own clinics and lists, can order
diagnostics (such as chest xrays and T-spot blood tests), can review the hospital pathology results
system and are able to prescribe using patient group directives (PGDs). (The TB nurses are also
being encouraged to complete their nurse prescribing course for more autonomous prescribing.)
There is a close working relationship with the Royal Berkshire Hospital chest physicians and
hospital physicians of other specialties. West Berkshire GPs are less familiar with the referral
50
system but will often call the TB nurses for advice. In general, patients are seen within a few days
of referral.
Berkshire West PCT have a designated New Entrant nurse (who works at a nurse-run clinic
providing primary care for typically ‘hard-to-reach groups eg homeless). The TB nurses work
closely with the New Entrant nurse to provide specialist TB advice and expertise.
The TB nurses provide domiciliary visits if they are required and currently provide most of the BCG
immunisation however, other healthcare professionals eg midwives and school nurses, are being
trained up at present to provide BCG.
In summary, the Berkshire West TB nurses thought that their service worked well for 3 main
reasons:
1. Close working relationship with Chest Physicians
2. Flexibility to manage patients who may have difficulties in adhering to strict clinic times
3. The TB nurses were employed by the acute trust which facilitates the use of diagnostic
tests and a closer working relationship
15.2.2 West Sussex
There was no reported specific PCT TB lead however, the PCT employs two (Band 7) TB nurse
specialists and a TB administrator who are based at Crawley and Horsham Hospital. The 2 nurse
specialists work 22.5hours and 37.5hours per week respectively. Between them, they cover the
wide geographical area of West Sussex however, this does not include either Worthing or Brighton
which both have their own TB nurse specialists. Home visits are available as a ‘last resort’ and
instead, patients are encouraged to attend one of the three clinics (Crawley and Horsham Hospital,
Haywards Heath and Chichester) available across the county.
15.2.3 Cambridgeshire
There are 2 TB nurse specialists (both Band 7) who are employed by Addenbrookes Hospital
Acute Trust. They work 22hours and 17.5hours per week respectively. A 3rd TB nurse specialist
(Band 7) employed by Cambridgeshire PCT, works from Hinchingbrook District Hospital for
15hours per week. There is a formal service level agreement between the hospital and the PCT
for this arrangement.
The specialist nurses are able to order diagnostic tests, review results and run clinics but do not
currently prescribe TB medication however, there is a PGD for BCG immunisation. There is a
close working relationship between the TB nurse specialists and chest physicians.
There is no allocated administrative support at either site however any clinic letters are typed up by
the chest physicians’ secretarial support. Due to the wide geographical area, home visits are
discouraged but DNA rates (despite use of Choose and Book for appointments) are approximately
30-50% on both sites.
The Cambridgeshire TB nurses recommended the following:
 Awareness of TB is raised amongst GPs
 Close working between chest physicians and TB nurses
Recommendations
1. Review the model for TB nurse provision within Surrey.
2. TB nurse specialists should be a Band 7 to ensure both recruitment and retention.
3. Review the scope of autonomy available for the TB nurse specialists at each
hospital eg Use of diagnostic tests, access to test results, prescribing etc.
4. TB nurses and chest physicians should work together to ensure a close working
relationship to optimise patient care.
51
15.3 Key elements of a comprehensive TB service
In line with the recommendations from the DH’s TB Commissioning Toolkit, commissioning TB
services needs to go beyond simply the treatment of active TB cases, as referenced by the full
NICE guidelines and the TB action plan.
A comprehensive TB service addresses:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
rapid access to specialist services if GPs suspect TB;
prompt identification of non-TB patients;
TB diagnostic services in hospitals (as opposed to primary care);
case management of TB patients;
ward visits to TB patients;
tuberculin skin testing for ward patients;
contact tracing of individuals exposed to TB;
inpatient beds for TB patients requiring hospitalisation;
negative pressure facilities;
quality-assured and timely TB microbiology services;
inpatient infection control services;
provision and management of long-term isolation facilities;
standardised outcome real-time monitoring;
performance monitoring;
advisory work/expert opinion/advice;
staff training;
multidisciplinary TB clinics;• occupational health assessment of TB risk among healthcare
workers;
community infection control services;
community home visiting;
managed access to social care and support;
hospital and community TB clinics responsive to patient need;• outreach work;
directly observed therapy (DOT);
new entrant services;
locally targeted health promotion and awareness raising;
protection of public health;
reactive outbreak case detection/monitoring;
coherent service provision with the prison and custody sector;
reference laboratories; and
surveillance.
15.4 PCT commissioning responsibility
According to the DH’s TB Commissioning Toolkit, Surrey PCT is responsible for planning, finance
and information management and ensuring a care pathway focus for TB services as detailed
below:
Planning
 Carry out needs assessment
 Set up and operate governance arrangements
 Local forward planning
 Ensure that choice operates at an appropriate level
 Partnership planning with local authority and other stakeholders
 Maintain links with advisory bodies (eg Expert Patient Forum, TB Network)
52

Liaise and co-operate with health protection unit
Finance and information management
 Set practice budgets
 Ensure financial stability
 Manage claims and disputes
Care pathway focus
 Ensure that local care pathways meet the needs of patients
 Support Expert Patient schemes
 Survey patient satisfaction
 Ensure that the majority of complaints are managed at local level
In addition, as part of its over-arching responsibility, as discussed in Section 6.2, Surrey PCT
needs to make more explicit the boundaries of the different relationships with key stakeholders so
that there is greater clarity over duties and responsibilities for our shared patients. The PCT has a
duty to commission appropriate services and where services are not covered by the Payment by
Results ‘Tariff’, there should be a service level agreement (SLA) in place to specify the detail.
53
16. Summary of recommendations by suggested lead organisation
The table below summarises the recommendations, collated from each section of the document
but ordered according to the organisation considered best placed to lead the implementation of the
recommendation.
Section in
Needs
Assessment
Owner / lead
organisation
14.3
15.1.3
4.5
All
All
All
10
14.3
All
All
Consider whether there are alternative means of streamlining the patient
pathway, for example by establishing clinics that integrate multiple aspects of the
TB service eg screening and ‘routine‘ outpatient care.
8.3
All
Agree a Paediatric patient pathway to facilitate high quality care for children in
Surrey. (This should take into account the particularly low incidence of TB in
Surrey children but allow for those affected to still receive high quality care.)
15.1.3
All
10.7
All
13.5
All
13.5
All
13.5
All
13.5
All
8.1
Acute
4.5
Acute
5.5
Acute
8.4
Acute
TB Health Needs Assessment - Summary of recommendations
Recommendations for all stakeholders - TB Clinical Network
Clarify responsibility with key stakeholders for different components of TB service
eg Management of contact tracing, screening (active case finding), BCG
immunisation etc.
Review the model for TB nurse provision within Surrey.
There should be active case seeking in groups known to be at higher risk of TB.
Consider developing Surrey TB service to provide active case finding for TB
through outreach to higher risk groups.
Agree patient pathway with stakeholders in line with best evidence.
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.
Ensure that staff who work with TB Service users are aware of some of the
potential cultural differences and are able to be sensitive to them.
Ensure that staff who work with TB Service users are able to provide information
about how they can access NHS health care or signpost to other resources eg
Patient Advisory Liaison Service (PALS) and /or the Department of Health leaflet
introducing NHS services. (Check at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_4123594 website not available at the time of writing)
Ensure there is information available for patients about state help with costs such
as travel, prescription charges etc and that service users are alerted to the
possible options available to them.
Ensure access to information about TB suitable for the specific user eg childcentred, appropriate language etc. (The charity, TB Alert, charges a small fee to
PCTs for use of their well-written information leaflets.)
Recommendations for Acute Trusts
Surveillance
Acute Trust physicians should complete outcome monitoring as part of their
contribution to routine surveillance.
Using the enhanced TB surveillance (ETBS) process, improve formal notification
of people with TB who are ‘known’ to TB services.
Acute Trusts must ensure compliance with statutory reporting of both suspected
and confirmed TB cases as part of the legal requirement of clinicians.
Ensure that all cases of TB are notified formally to SSHPU in order to trigger the
Community TB nurse service.
54
Recommendations for Acute Trusts continued
Clinical
The DH Commissioning Toolkit recommends that where Paediatric Units have a
caseload of fewer than 10 new cases of active TB per year, they are
recommended not to treat a TB case without liaison with their adult TB
colleagues and similarly, that adult TB clinicians are recommended not to treat
childhood TB without involvement of the paediatric services.
4.3
Acute
Ensure that parents and guardians of children – and the children themselves –
understand the importance of adherence with TB treatment and have sufficient
appropriate information to inform their decisions.
8.5
Acute
and
SCH (TB)
8.7
Acute
8.7
Acute
10.8
Acute
8.7
Acute
Health care professionals providing TB or HIV/AIDS services should routinely
coordinate screening tests for the other infection (ie HIV or TB respectively) for
their patients, especially if other risk factors are present. This may involve
referral to the other service or with sufficient appropriate training, the screening
may be provided within the original service.
Eg A patient with TB should
routinely be offered HIV testing. HIV testing may occur after referral to the
HIV/AIDS service or from a TB physician or nurse who has undergone sufficient
and appropriate training to deliver the pre- and post-test counselling required.
Acute trusts should review their Maternity Unit policy regarding neonatal BCG
immunisation for babies at higher risk of TB
Audit
Acute Trusts should conduct regular audit of the management of their patients
with TB in order to ensure compliance with current NICE guidance.
Use the TB Commissioning Toolkit standards to audit performance of TB
services.
10.8
Acute
and
SCH (TB)
12
Acute
8.1
Acute
5.5
Acute
Acute Trusts should audit TB laboratory standards (with reference to the
standards detailed in DH TB Commissioning Toolkit) to establish a baseline and
to be able to quantify any future progress made.
Acute Trust administration
7.4
Acute
Ensure that those administering the allocation of appointments for patients with
suspected TB are aware of the 2 week guidance. (GPs may wish to consider
annotating referral letters with a notice highlighting the urgency as is done with
the management of cancer where the ‘2 week rule’ is flagged routinely.)
The role of TB Nurses within Acute Trusts
TB Nurses and Chest Physicians should work together to ensure a close working
relationship to optimise patient care.
8.3
Acute
15.1.3
Acute & SCH
(TB)
The options for organising care for people with MDR TB should be discussed
with clinicians who specialise in this. While the views of the patient should be
sought and taken into account, and shared care should be considered, in Surrey,
this is very likely to require a tertiary referral. (NICE)
Response to treatment should be closely monitored in patients at increased risk
of drug resistance. If there is no clinical improvement, or if cultures remain
positive after the 4th month of treatment (‘treatment failure’), drug resistance
should be suspected and treatment reviewed with a clinician experienced in the
treatment of MDR TB. ( NICE)
Interferon tests should be used to screen for TB in someone known or suspected
as having HIV/AIDS (rather than relying on Mantoux tests).
TB Physicians should consider the risk assessment for drug resistance and, if
the risk is regarded as significant, urgent molecular tests for rifampicin resistance
should be performed on smear-positive material or on positive cultures when
they become available. (NICE)
Consider the introduction of a Patient Group Directive for Community TB nurses
to minimise disruption of a patient’s adherence to treatment in the event of
medication issues in between outpatient appointments.
Review the scope of autonomy available for the TB nurse specialists at each
hospital eg Use of diagnostic tests, access to test results, prescribing etc.
55
8.6
15.1.3
Acute and
SCH (TB)
Acute and
SCH (TB)
Recommendations for HPU
Agree Surrey protocol for managing TB incidents in Surrey and alert key
stakeholders.
Increase use of the TB surveillance system to monitor TB incidence and help
target interventions in higher-risk groups eg BME groups, new entrants,
prisoners and homeless people.
SSHPU and clinicians should work together to increase understanding of the
ETBS system which is the main method for clinicians to notify TB cases to the
SSHPU.
Ensure an effective IT system is in place that allows outbreaks, especially cases
and contacts, to be correctly recorded.
Surrey PCT, Surrey and Sussex Health Protection Unit and the Port Health at
Heathrow and Gatwick airports should work together to improve the new entrant
referral process including for example: GP registration, Referral to a Health
Visitor for Under 5’s
11
HPU
HPU
5.5
HPU
Acute
11
HPU& SCH
10.4
HPU & PCT
Surrey PCT/SSHPU need to liaise with the relevant employers/regulatory
authorities to confirm the occupational health BCG provision for higher risk
facilities eg schools, nurseries, prisons etc.
11
and
HPU & PCT
PCT
PCT working with Primary Care
Ensure that GPs and other primary and community care staff are aware of the
symptoms and signs of TB, local TB services and local arrangements for
referring patients with suspected TB.
The PCT should consider linkage with GP Tutors to incorporate TB as part of
core GP continuing professional development (CPD) on health protection.
Surrey PCT should work with Surrey GPs to facilitate prompt GP registration for
new entrants.
Surrey PCT should inform all GP surgeries of the guidance relating to entitlement
to NHS services for asylum seekers, refugees and other categories of new
entrants to the UK. It is important that the message about the universal free
access to anti-tuberculosis treatment is understood.
Raise awareness of TB amongst both primary care health care professionals and
communities, specifically targeting awareness in the higher incidence areas and
those areas where incidence is expected to be higher than is currently
experienced.
Ensure raised awareness of both public and health care professionals for the
possibility of TB in children, especially amongst communities at greater risk of
TB.
Increase awareness and availability of BCG clinics eg Via Health Visitors,
Practice nurses and via primary schools in targeted areas.
PCT Prison Health
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.
Prisoners should be screened for TB by: a) a health questionnaire on each entry
to the prison system then b) for those with signs and symptoms of active TB, a
chest X-ray, and three sputum samples taken in 24 hours for TB microscopy,
including a morning sputum sample.
All prisoners receiving treatment for active or latent TB should receive directly
observed treatment (DOT).
Prison medical services should have liaison and handover arrangements to
ensure continuity of care before any prisoner on TB treatment is transferred
between prisons.
56
8.2
PCT
8.2
PCT
10.4
PCT
10.5
PCT
13.5
PCT & HPU
8.5
PCT & HPU
10.3
PCT & SCH
10.6
PCT
10.6
PCT
10.6
PCT
10.6
PCT
Prisons
and
PCT recommendations continued
PCT Prison Health continued
If a prisoner is being treated for active or latent TB, the prison medical services
should draw up as early as possible a contingency plan for early discharge,
which could happen directly from a court appearance. This plan should include
firm arrangements for clinical follow-up and treatment monitoring in the intended
district of residence, and should take into account that there may not be a fixed
residence arranged for the prisoner after release. The prisoner should be given
contact details for a named key worker, who will visit and monitor the prisoner
after release and liaise between services involved.
Prison service staff and others who have regular contact with prisoners (for
example, probation officers and education and social workers) should have preand on-employment screening at the same level as for healthcare workers with
patient contact.
PCT Contracts
The PCT (Commissioning), PCT (Provider) and Acute Trusts should agree a
local service agreement which includes screening and associated cost of
investigations such as gamma interferon tests.
PCT
Prisons
and
10.6
HPU
Prisons
and
10.6
7.4
PCT
Surrey PCT should work with the Acute Trusts and TB Nurses to ensure that as
part of the service level agreement for TB service provision, all patients should
have a named case worker and know how to contact them for advice.
Surrey PCT should commission Surrey Community Health to ensure adequate
and appropriate provision of TB Nurse specialists in line with current guidance
(both quantity of FTE staff and appropriate banding).
Surrey PCT should clarify the role of Central Surrey Health in TB, especially in
TB incident management.
New Entrant health screening: Surrey PCT should consider a locally enhanced
service (LES) agreement with GPs to provide holistic health screening targeted
at specific needs of new entrants based on the recommendations of a New
Entrant Health Needs Assessment.
Establish local service level agreements between PCT and Acute Trusts to
ensure appropriate funding of the different elements of TB care including both
Tariff and Non-tariff services.
Consider the establishment of an ‘Outbreak contingency fund’ which could
provide insurance over and above a pre-agreed level of annual outbreak
management.
Plan for ‘surge capacity’ to better manage outbreaks / incidents especially
regarding the funding of extra resources eg gamma interferon testing. (A
possible solution is establishing a contingency fund above and beyond an agreed
‘normal’ expected annual workload – based on previous years’ outbreak
experience.)
PCT Needs Assessments & Policy
Surrey PCT should consider completing a BME Health Needs Assessment.
Increase (and maintain) awareness of TB, including through the media and
community groups, and develop initiatives to support local awareness-raising
among high risk groups.
New Entrant Health Care Needs Assessment (HCNA). Surrey PCT should
consider completing an HCNA in order to understand the potentially diverse
health needs of New Entrants. There is likely to be an increased need for health
care related to immunisations and reproductive, mental, nutritional and dental
health.
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.
57
PCT
9.4
PCT
9.4
PCT
10.4
PCT
14.3
PCT
14.3
PCT
11
PCT
10.3
PCT
10.3
PCT
10.4
PCT
10.7
PCT
Surrey PCT’s Immunisation and Vaccination Committee should review provision
of BCG immunisation in Surrey to ensure that only those targeted to receive
BCG actually receive it.
Ensure availability of translation services at all stages of the patient pathway and
the availability of information in different languages.
12
PCT
13.5
PCT
Considering fully moving the responsibility of BCG vaccination delivery to local
immunisation teams / primary care (rather than diverting the scarce TB Nurse
resources from TB work that can only be done by a TB-trained nurse).
12
SCH
Target schools with high proportions of pupils at higher risk of TB eg BME
communities, to raise awareness of the Targeted BCG programme but while
remaining sensitive to the risk of stigmatising individuals and communities.
12
PCT
SCH
12
PCT and
SCH
9.4
11
SCH
SCH
Surrey Community Health
Immunisations
Encourage working between the Immunisation Team and BME Community
Development worker to facilitate culturally-sensitive targeted health promotion
materials on BCG (and other relevant health subjects).
TB Nurses
Ensure adequate administrative support in order to free TB Community Nurses to
expand their clinical work. (This expansion includes tasks such as active case
finding in high risk groups and raising awareness of TB in Surrey.)
Increase administrative support available for Community TB Nurses.
All patients should have a named case worker and know how to contact them for
advice. (As this is a capacity issue, please see section 9 on TB nurses.)
Review the provision of TB nurses across the county in order to provide high
quality TB service for all regardless of geographical location.
Surrey Community Health should ensure that TB Community Nurses are suitably
clinically supervised to ensure that high quality patient care is maintained as part
of good clinical governance.
TB nurse specialists should be a Band 7 to ensure both recruitment and
retention.
58
8.1
and
SCH
8.4
PCT & SCH
9.4
SCH
15.1.3
SCH
Acknowledgements
Thanks to the following people who provided extensive information about TB Services in Surrey:
Dr Kevin Carroll – CCDC, Surrey and Sussex Health Protection Unit
Nigel Bainton – Data Manager, Surrey and Sussex Health Protection Unit
Deborah Hepburn – TB Clinical Nurse Manager, Surrey Community Health
59
Appendix 1
Summary of NICE guidance for the diagnosis of TB
The full NICE guidance: Tuberculosis: Clinical diagnosis and management of tuberculosis, and
measures for its prevention and control. 2006. NICE.
Available at: http://www.nice.org.uk/nicemedia/pdf/CG033niceguideline.pdf
NICE guidance sets out the following advice when diagnosing active TB:

Respiratory TB:
o CXR and if this suggests TB, arrange further tests.
o Send at least 3 spontaneous sputum samples for culture and microscopy
(including one early morning sample).
o If spontaneous sputum samples are not possible then consider bronchoscopy
and lavage or, in children, gastric washings.
o Take samples before starting treatment or within 7 days of starting.
o Start treatment without culture results if there are clinical signs and symptoms
of TB and complete treatment even if the culture results are negative.
o Send autopsy samples for culture if respiratory TB suspected.

Non-respiratory TB:
o Discuss the advantages and disadvantages of biopsy and needle aspiration
with the patient.
o Send samples in a dry pot for TB culture. These may be lymph node biopsies,
aspirated pus or any other samples.
o Start drug treatment, if the histology and clinical picture are consistent with TB,
before culture results are available.
o Continue treatment even if culture results are negative.
o CXR should be done for coexisting respiratory TB in all patients with nonrespiratory TB. Other investigations should also be considered.

Laboratory tests:
o Only perform rapid diagnostic tests on primary specimens when:
 Rapid confirmation of Tb would alter care of the patient.
 Before conducting large contact-tracing initiatives.
o If clinical signs and test results suggest TB meningitis, start treatment even
when rapid test results are negative.
o If risk assessment suggests MDR TB then:
 Do rapid diagnostic tests for rifampicin resistance.
 Start infection control measures and treat the MDR TB whilst
awaiting test results
60
Appendix 2
Laboratory services in Surrey - 2008
ASPH
ESH
FPH-RSCH
SASH
Do you provide a diagnostic TB Service?
Yes
Yes
Yes
Yes
How many TB microscopies did you perform in
2008?
How many were positive?
1521
707
3150
1357
45 (3.0%)
14 (2.0%)
34 (1.1%)
68 (5.0%)
How many times a week do you usually do TB
microscopy?
Do you provide a TB microscopy on call service?
Daily Mon - Fri
Daily Mon - Fri
Daily Mon - Fri
Yes
Yes
Yes
Daily Mon Fri
Yes
Do you provide TB microscopy at weekends?
Yes – on request
Yes – on request
Yes – on request
Yes – on
request
How many specimens did you culture for
mycobacteria in 2008?
How many were positive for MTB?
795
3272
2147
10 (1.3%)
50
(1.5%)
45
(2.1%)
How many were positive for Mycobacteria other
than TB?
What culture method do you use i.e. TBbactec/LJ
slopes/liquid media?
What percentage were contaminated?
27 (3.4%)
60
(1.8%)
25
(1.2%)
TB bacTalert + LJ slope
TB bacTalert
4.7%
4%
Culture
Liquid - MGIT
Liquid culture
+ LJ slope
Idenfication and sensitivity testing
Do you do this in house?
If not, who do you send to for ID and sensitivity?
No
London Myco Ref
Laba
No
No
No
The Brompton
37
110
London Myco
Ref Laba
55
No
No
No
No
London Myco Ref
Laba
London Myco Ref Laba
The Brompton
8
72
London Myco
Ref Laba
20
7
55
No
Not currently but
Immunology Dept would
like to start service
No
No
Quantiferon – The
Londona
Tspot - Oxfordb
Oxfordb
Quantiferon – St
Barts
Tspot - Oxfordb
610
Chelsea &
Westminster
30
How many isolates in 2008 did you do or send
away for ID and sensitivity testing?
London Myco Ref Lab
a
Newer testing methods
Do you perform rapid PCR based detection test in
house?
If not who do you send PCR based tests to?
How many PCR based tests did you do/send away
in 2008?
How many of these were positive?
Do you perform any interferon-gamma based (IFNy) test in house?
(76.4%)
If so which one
Do you send away blood for (IFN-y) testing and if
so where and which test
How many interferon based assays did you
perform/send away in 2008?
5 (Does not include Occ
Health samples sent
directly)
Service development ideas
How do you feel the TB services should be
provided in Surrey?
If a centralised service was to be developed on 1-2
sites would you want it to provide an extended
range of tests such as PCR and interferon-gamma
based assays?
Do you think any TB investigations would need to
remain on site and if so what?
Consider
centralising
Central culture and
possibly PCR. Not
gamma-interferon
tests.
Microscopy – unless
transport improves
Adapted from Hampshire PCT TB Review 2006
a
b
– Mycobacterium Reference Laboratory, The London Hospital
- Oxford Immunotec
Resource adequately and
maintain on current sites
No benefit since MRU
provides a good service.
Consider
centralising
Yes
Current service provides
rapid results and
maintains skills. TB work
is part of the investigation
carried out for many
routine samples and
should not be divorced
from the routine work.
Possibly
microscopy unless
good transport.
Consider
centralising
Yes but will
depend on
numbers to
be viable.
Microscopy &
liquid / slope
culture
Appendix 3
Analyses of New Entrants to Surrey during the period 01/01/07 to
30/09/08
Dr Kevin Carroll, CCDC, Surrey and Sussex Health Protection Unit
Background
Nationally and also in Surrey most cases of Tuberculosis (TB) are diagnosed in individuals who
were born in countries where the incidence of Tuberculosis is high. The rate of TB is also higher in
individuals born in this country but whose families originate from these countries (see Table 1).
This observation has determined the UK policy of screening for TB at the Port of entry.
Table 1
Currently
a
new
entrant
proposing to stay in the UK for 6
months or longer and who
originates from a country where
the rate of TB (WHO rates) is
>40 per 100,000 is identified by
immigration officers and usually
screened for TB by a single
Chest X-ray. Occasionally new
entrants presenting a recent
CXR or entering under special
programmes, or who are
pregnant or children are exempt
from this requirement.
The Surrey Office of the HPU on
behalf of Surrey PCT receives
information about these New
Entrants from the Port Health
Medical Units. For all new
entrants notified to the HPU a letter is sent to the new entrant at the address given on the Port
Health form. The letter informs them about the procedure to register with a GP practice and
encloses a return slip to inform the HPU of the GP details when registered. Individuals who were
not screened by CXR at the Port of Entry are sent a CXR form for their local hospital and the report
is returned to the HPU (with the exception of East Surrey Hospital). The HPU informs the patient or
(GP if already known) of the result by letter. If the screening reveals abnormalities on the CXR the
individual is referred by the HPU to the TB nursing service or directly to the nearest chest clinic for
further assessment.
Figure 1
The screening of new entrants is currently under
review nationally. NICE has recommended that new
entrant screening should be carried out as described
in algorithm opposite (see Figure 1). The chest X-ray
is still recommended as the first step, however for
certain categories further screening using the
Mantoux skin test and Interferon gamma test are
recommended. The intention is to identify those who
have latent TB and who are therefore most likely to
benefit from chemoprophylaxis to prevent progression
of latent infection to active disease.
National data and also that from the Surrey Enhanced
TB Surveillance database (see Figure 2) confirms that
most new entrants who develop TB do so within 10 years of first entering the UK. The majority of
new entrants to Surrey from high incidence countries are under the age of 36 yrs (83% of new
entrants, see Figure 3).
Figure 2
Figure 3
New entrants to Surrey under 36 yrs of age during the period 01/01/07 to 30/09/08
from Countries with rates of TB >40 per 100000
Group
Number
%
All new entrants under 36 yrs of age from countries
with T rates > 40 per 100000
All new entrants under 36 yrs of age and from
countries with TB rates > 150 per 100000
All new entrants under 36 yrs of age and from
countries with TB rates > 200 per 100000
All new entrants from countries with T rates > 40
per 100000
3310
82.7
2270
56.7
1001
25.0
4004
100
New entrants to Surrey with Chest X-ray performed or accepted at the Port of
Entry during the period 01/01/07 to 30/09/08 from Countries with rates of TB >40
per 100000
Group
Number
%
Aged 11 to 36 yrs of age and from countries with TB
rates > 40 per 100000
Aged 11 to 36 yrs of age and from countries with TB
rates > 150 per 100000
Aged 11 to 36 yrs of age and from countries with TB
rates > 200 per 100000
Aged >10 yrs of age and from countries with TB rates
> 40 per 100000
All new entrants from countries with TB rates > 40
per 100000
2330
69.3
1621
48.2
673
20.0
2877
85.5
3364
100
New entrants to Surrey who did not have a Chest X-ray performed at the Port of
Entry during the period 01/01/07 to 30/09/08 from Countries with rates of TB >40
per 100000
Group
Aged 11 to 36 yrs of age
and from countries with TB
rates > 40 per 100,000
Aged 11 to 36 yrs of age
and from countries with TB
rates > 150 per 100,000
Aged 11 to 36 yrs of age
and from countries with TB
rates > 200 per 100,000
Aged >10 yrs and from
countries with TB rates >
200 per 100,000
New entrants from
countries with TB rates >
40 per 100,000 who did
not have CXR done at
Port of Entry
468
148 (30.8)
Registered with
GP (informed
HPU)
120 (24.9)
296
95 (32.1)
74 (25.0)
177
56 (31.6)
41 (23.2)
628
208 (33.2)
169 (26.7)
635
211 (33.2)
169 (26.7)
Number
CXR done
(%)
New Entrants By Country of Origin and Incidence Rate of TB (if > 100 per 100000) (N=3008)
Country
Swaziland
South Africa
Namibia
Zimbabwe
Zambia
Botswana
Cambodia
Rwanda
DR Congo
Togo
Kenya
Ethiopia
Malawi
Uganda
Tanzania, UR
Nigeria
Chad
Haiti
Philippines
Angola
Senegal
Gambia
Sudan
Indonesia
Bangladesh
Tajikistan
Ghana
Bolivia
Cameroon
Pakistan
Nepal
Niger
Viet Nam
Myanmar
India
Peru
Afghanistan
Lao PDR
Thailand
Moldova, Republic of
Solomon Islands
Kazakhstan
Ecuador
Uzbekistan
Russian Federation
Ukraine
Malaysia
Total
TB rate per 100000 pop
1155
940
767
557
553
551
500
397
392
389
384
378
377
355
312
311
299
299
287
285
270
257
242
234
225
204
203
198
192
181
176
174
173
171
168
162
161
152
142
141
135
130
128
121
107
106
103
Number
1
661
6
39
10
4
2
2
2
1
18
8
7
10
1
157
1
1
249
1
1
4
3
13
53
1
16
2
3
194
212
1
21
8
1026
8
12
1
90
3
1
4
5
1
89
16
118
3088
%
0
16.5
0.1
1
0.2
0.1
0.1
0.1
0.1
0
0.4
0.2
0.2
0.2
0
3.9
0
0
6.2
0
0
0.1
0.1
0.3
1.3
0
0.4
0.1
0.1
4.8
5.3
0
0.5
0.2
25.6
0.2
0.3
0
2.2
0.1
0
0.1
0.1
0
2.2
0.4
2.9
Cumulative %
0
16.5
16.7
17.7
17.9
18
18.1
18.1
18.2
18.2
18.6
18.8
19
19.3
19.3
23.2
23.2
23.3
29.5
29.5
29.5
29.6
29.7
30
31.3
31.4
31.8
31.8
31.9
36.7
42
42.1
42.6
42.8
68.4
68.6
68.9
69
71.2
71.3
71.3
71.4
71.5
71.6
73.8
74.2
77.1
77.1
Discussion
During the 18 months of this study there were 4004 new entrants to Surrey from countries with an
incidence of TB >40 per 100000 (approximately 2500 new entrants to Surrey annually) 89% of
these were successfully screened by CXR at Port of entry or after they had arrived in Surrey. Of
these migrants 83% were < 36 yrs of age. If screened according to the NICE guidance they would
be considered for chemoprophylaxis if there was evidence of latent disease ie positive Mantoux
and interferon gamma test results. The performance of the screening programme is unknown,
although overall about 33% of migrants who are sent CXR forms after arriving in Surrey present for
radiography and about 27% inform the HPU that they have registered with a GP.
Of the 4004 new entrants who were screened at the Port of Entry or referred by the HPU for
screening by chest X-ray, 62 individuals were subsequently referred for further investigations of
abnormal chest X-ray findings. The outcome of the referrals is unknown but far as is known there
have been no new active cases of TB detected by the current system of CXR at Port of Entry or
shortly after entry, but one individual is known to have been commenced on chemoprophylaxis.
The TB specialist nursing service in Surrey now informs the HPU of new entrant referrals who do
not subsequently present for assessment.
There is currently considerable debate concerning the most cost effective model for new entrant
screening. There appears to be a consensus that the model of a one off CXR currently used is no
longer appropriate because most cases of TB in new entrants are not identified on arrival, but
develop after arrival and within 10 yrs of entering the UK. A review of the effectiveness of the
current national system is currently underway. With the development of the interferon gamma tests
and the NICE guidance there is the opportunity to screen for latent disease in the < 36 yr olds (the
age group from epidemiological studies most likely to progress to active disease) and to offer them
chemoprophylaxis. However this has considerable resource implications particularly with respect to
the supervision of the treatment by already over stretched TB services.
At least one PCT in England has adopted a targeted screening strategy in which all new entrants
from countries with an incidence of > 200 per 100,000 are offered screening using a gamma
interferon test only and if found to be positive are assessed for active disease and offered
chemoprophylaxis as appropriate, for age and other risk factors eg HIV status. If this approach
were to be adopted in Surrey about 800 new entrants of all ages would be eligible annually. If it
were targeted to those under 36 yrs of age, about 640 individuals would be eligible for screening
annually.
There is no national policy statement as to the preferred model for such a screening strategy, but
NICE does suggest that TB screening as well as screening for other infectious diseases eg HIV,
hepatitis B and C and immunisation status could be offered in primary care and form part of the
new patient registration process. The challenge would then be to encourage new entrants to
register with a GP.
Appendix 4
Standards for surveillance
Taken from: Tuberculosis prevention and treatment: a toolkit for planning, commissioning and
delivering high-quality services in England.
DH 2006.
pp 37 – 39.
Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH
_075621
Reporting new cases by clinical teams/local TB services (case definitions are given on page
39 of the DH TB Toolkit)
 All cases should be reported by the clinical team to the local health protection unit.
 At least 95% of cases should be reported within two weeks of diagnosis or decision to treat
with a full course of anti-TB drugs.
 At least 95% of reported cases should include complete data for the key variables (see
appendix on page 40 for the key variables).
 At least 95% of all originally notified cases of TB that are subsequently denotified, should
be reported within two weeks of the date of the non-TB diagnosis.
Collection and forwarding of information on reported cases by HPA Local and Regional
Services
 All cases reported by clinical teams/local TB services to HPA Local and Regional Services
(LaRS) should be forwarded to HPA Centre for Infections (CfI) within three months of the
date of diagnosis or decision to treat.
 Treatment outcome (see appendix on page 39 for categories)
 Outcome of treatment should be reported on at least 95% of all cases reported as incident
cases by the clinical team to the local health protection unit within three months of the oneyear anniversary of the date of diagnosis or start of treatment.
 The outcome of treatment in all cases reported by clinical teams should be forwarded by
HPA LaRS to HPA CfI within four months of the one-year anniversary of the date of
diagnosis or start of treatment.
Microbiology results
 Mycobacteriology reference laboratories should report the results of species identity and
drug susceptibility on all isolates, within one working day of the result being available, to the
source primary diagnostic laboratory.
 Mycobacteriology reference laboratories should, simultaneously, report the results of
species identity and drug susceptibility on all isolates, within one working day of the result
being available, to MycobNet.
 The primary diagnostic laboratory should report the results of all new sputum smears
positive for mycobacteria to the clinical team and local health protection unit (according to
local arrangements) within one working day of the results being available.
 The primary diagnostic laboratory should report the results of all new positive mycobacterial
cultures (identified as MTBC complex by the reference laboratory) to the clinical team and
local health protection unit (according to local arrangements) within one working day of the
results being available.
Molecular strain typing
 The mycobacteriology reference laboratories should report the results of molecular strain
typing on all isolates, within one week of the result being available, to the national strain
typing database (as well as the source primary diagnostic laboratory).
Feedback and reports
 HPA local, regional and national surveillance units/centres have a responsibility to produce
timely reports to be distributed locally to inform appropriate action. Surveillance data
collected within a given calendar year must be reported back within the subsequent year.
 Quarterly reports using provisional data should be produced within six months of the
quarter in which a case is reported.
 Annual reports of finalised data should be available before the end of the following calendar
year.
 Information should be provided by the HPA to commissioners, acute trusts, PCTs and the
Department of Health to support commissioning and planning of TB services in a timely
manner.
Audit trail
 All health protection units and the national surveillance centre should be able to show that
they are achieving the standards outlined in this document for all cases reported within the
geographical areas for which they are responsible.
 NHS trusts and SHAs should monitor compliance with the standards outlined through local
TB networks in collaboration with the HPA.
Appendix 5
Standards and criteria for effective laboratory diagnosis of (active) Mycobacterium
tuberculosis infection
Taken from: Tuberculosis prevention and treatment: a toolkit for planning, commissioning and
delivering high-quality services in England.
DH 2006.
pp 30 – 36.
Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH
_075621
This section is intended for microbiologists and histopathologists working to diagnose active TB via
the use of appropriate laboratory tests.
PCTs might find this section useful for background reference when considering appointing
laboratory providers as part of effective local TB commissioning.
Introduction
This section of the toolkit recommends methodologies and criteria to ensure the rapid, accurate
diagnosis of active TB. With the needs and expectations of patients and their clinicians in mind, it
also addresses:
•
supporting the early confirmation of appropriate treatment;
•
instigating suitable measures to reduce transmission; and
•
providing timely evidence to help identify and investigate possible outbreaks.
Many microbiology laboratories only perform certain investigations because confirmation of
identity, antimicrobial susceptibility testing and molecular typing can only be done at a few
specialist centres. However, best practice requires all laboratories to meet the appropriate criteria
for the procedure(s) they undertake. Time guidelines are indicated on the basis of microbiology
services being provided six days each week, with local arrangements for public holidays to
minimise delays.
The criteria discussed in this section are designed to complement the information and
recommendations published in other national guidance documents. It is recommended that they
are read in conjunction with the guidelines on tuberculosis issued in March 2006 by NICE and the
National Standard Method (Bacteriology Standard Operating Procedure (BSOP) 40) for the
microbiological investigation of specimens of Mycobacterium species issued by the Standards and
Evaluations Unit of the HPA. See links listed below.
NICE guidelines on tuberculosis
http://guidance.nice.org.uk/CG33/quickrefguide/pdf/English
http://guidance.nice.org.uk/CG33/guidance/pdf/English
www.nice.org.uk
The National Standard Method (BSOP 40)
www.hpa-standardmethods.org.uk/documents/bsop/pdf/bsop40.pdf
www.evaluations-standards.org.uk
Types of sample
Laboratories undertaking mycobacterial work should be prepared for the examination of a wide
variety of specimen types, including:
•
sputum or other respiratory samples;
•
cerebrospinal fluid, spinal/paraspinal/intracerebral material;
•
gastric washings;
•
lymph node or other tissue samples or tissue fluids;
•
•
•
blood or bone marrow (taken into mycobacterial culture medium);
bone; and
urine.
Number of samples
For sputum, three fresh, purulent samples (ideally 5ml or greater) from the lower respiratory tract
should be collected at intervals of 8–24 hours, including at least one early morning sample. Most
other specimen types will be single samples except for gastric washings and urine. For patients
with sputum initially positive for M. tuberculosis complex (MTBC), repeat sputum specimens (if
available) should be sent monthly until at least one is reported as culture-negative for MTBC.
Documentation
Full personal identification and clinical details are provided with the samples. This is required to
comply with local specimen labelling policies and minimum data set requirements in accordance
with trust policy and Clinical Pathology Accreditation standards.
Transfer to the laboratory
Ideally, specimens need to be received in the laboratory within one working day (48 hours
maximum) of collection. This is necessary to prevent increased overgrowth by commensal flora
and the possible deterioration of mycobacterial cell walls, which may not impact on viability but can
lead to the failure to retain stain and risk a false negative smear test. For the same reason,
laboratories that do not perform any mycobacteriological investigations on site are required to
transfer specimens to their processing laboratory within one working day.
For information on the transport of potentially infected clinical samples, see ‘Transport of samples
and cultures’ on page 33 of the DH TB Commissioning Toolkit.
Initial investigations
Microscopy – auramine fluorescent staining
It is recommended that at least a six-day service is provided for smear examination on appropriate
samples during the normal working day. Out-of-hours smear testing for M. tuberculosis may
compromise quality guidelines. Risk assessment of the patient with suspected TB needs to
assume the patient is infectious.
For optimum clinical and public health management, microscopy should be performed and the
result issued within one working day of receipt of the specimen by the processing laboratory. Any
new positive results need to be telephoned through as soon as possible to a member of the clinical
team responsible for the patient’s care.
It is also recommended that the lead TB nurse, lead clinician for TB and the CCDC are also
informed within one working day, in line with locally agreed arrangements to ensure that:
 the person with confirmed TB is told in a timely fashion by someone with appropriate
expertise; and
 suitable public measures can be instigated.
Laboratories accredited for this work will have an internal quality control (IQC) programme in place
and show satisfactory performance in an external quality assurance (EQA) proficiency scheme. To
achieve this, laboratory staff need to maintain proficiency in interpretation of smears through
continuing professional development (CPD) and peer review (for example, by an interpretative
quality assurance programme).
Molecular tests for MTBC may be used in appropriate
circumstances; see ‘Molecular fingerprinting/typing’ on page 34.
Culture, isolation and identification
To meet internationally accepted criteria, the culture, isolation and identification in 90% of cases
need to be completed within 21 days of the source laboratory receiving a specimen. (Although
most non-tuberculous species will grow in this time, some are slower, eg M. malmoense, M.
xenopi. Definitive identification of some of these species may also be more protracted.)
Culture
In order to meet the 21-day criteria for speed and sensitivity:*
 Automated liquid culture needs to be done on all samples being processed for
mycobacterial culture (by arrangement with other laboratories if necessary).
 This is required to be set up within one working day of receipt of the specimen (six-day
service).
 Conventional solid culture also needs to be set up on at least one sample of each suitable
specimen type received for mycobacterial investigation (see BSOP 40). This is required for
some MTBC isolates and other Mycobacterium species that do not grow well in liquid
culture.
Positive cultures
Acid-fast bacilli isolates (liquid or solid culture) for identification and susceptibility testing go to the
appropriate regional centre for mycobacteriology (RCM) within one working day of the culture
becoming positive. However, if the mycobacterial growth indicator tube (MGIT), BD culture system
is used, consideration may be given (in conjunction with the RCM) to incubating cultures for a
further 48 hours before despatch to achieve suitable biomass.
To maintain the quality of the sample, and for safety reasons, the culture needs to reach the
regional centre within one working day of despatch (for information on transport, see page 33). At
least one acid-fast bacilli isolate from each new patient needs to be identified to complex/species
level, and suitable susceptibility tests performed if identified as MTBC. Repeat AFB isolates from
the same patient need to be identified and susceptibility tests performed if cultured from a
specimen taken three months or more after a previously referred MTBC isolate.
Identification
To facilitate timely initiation of clinical treatment and public health measures:
 A nucleic acid amplification test (NAAT) or a hybridisation gene probe for MTBC needs to
be done within one working day of a culture being shown to be positive or within one
working day of receipt of a positive culture by the RCM.
 As necessary, other hybridisation probes and phenotypic identification tests will be done in
the RCM.
Reporting
Similarly the RCM needs to report receipt of the isolate and initial identification results to the
source laboratory within one working day. The source laboratory then needs to inform a member of
the clinical team responsible for the patient’s care, and ensure that the lead TB nurse, the lead
clinician for TB and the CCDC are informed of new positive culture results and identification results
from the RCM. This should also be done within one working day of the results being received, in
line with locally agreed arrangements.
* Health Technology Assessment 2007, Volume 11 No. 3 concludes: ‘fully automated liquid culture
methods were superior to culture on solid media, in terms of their speed and precision’.
Laboratory facilities and expertise
 Safety: all culture work in primary diagnostic laboratories and RCMs needs to be done in a
containment level 3 facility which has Health and Safety Executive approval for the
purpose; has a contingency plan for containment in the case of accidental dispersal; and
has a continuity plan for service support in the event of containment level 3 facility closure.
 To maintain reliable services of appropriate quality, those commissioning TB diagnostic
services are strongly advised to use laboratories accredited for mycobacteriology culture,
with an IQC programme in place, and which show satisfactory performance in an EQA
proficiency scheme for every level of service provided, ie microscopy, culture, identification
and susceptibility testing. In addition, the laboratory needs to maintain sufficient throughput
to sustain competence levels.
 Consultant medical microbiologists/clinical scientists and biomedical scientists in
laboratories providing M. tuberculosis culture are required to maintain their expertise and
competence in laboratory testing – and also in the provision of advice on diagnosis,
management and infection control aspects of TB through an appropriate programme of
CPD.
Details of laboratory procedures for processing individual specimen types are given in the National
Standard Method (BSOP 40), available at:
www.hpa-standardmethods.org.uk/documents/bsop/pdf/bsop40.pdf
Transport of samples and cultures
Patient samples
Patient samples need to be transported by a system conforming to the requirements for potentially
infected samples (and routine for general bacteriology samples).
Positive cultures
Under current international transport regulations, these are category A cultures. However, an
exemption clause allows them to be transported as category B material for clinical and diagnostic
purposes if transported by road or rail. These cultures are assigned to UN 3373 (diagnostic or
clinical specimens) and need to bear the marking ‘diagnostic specimens’ or ‘clinical specimens’,
and be packed to packing instructions P650. Substances packed and marked in accordance with
packing instructions P650 are not subject to any other requirements in the regulations – thus there
is no requirement for additional transportation documentation. Such specimens should not be
transported via Royal Mail because any mail may be transported by air, which carries additional
requirements.
Susceptibility testing
Results
To fulfil internationally accepted criteria, the results of susceptibility tests to primary therapeutic
agents are required to be made available within 30 days of the initial receipt in the source
laboratory of a clinical sample from which MTBC is isolated for at least 95% of specimens.
For each new patient case, the primary agents to be tested are isoniazid, rifampicin, pyrazinamide
and ethambutol with test results ideally available within 14 days of receipt of the isolates by the
RCM and reported to the source laboratory within one working day. If a new isolate of MTBC is
found to be resistant to isoniazid or rifampicin, it is recommended that this information is
telephoned by the RCM to the source laboratory.
To enable appropriate clinical and public health action, the source laboratory needs to inform a
member of the clinical team responsible for the patient’s care within one working day of the results
being received, in line with locally agreed arrangements. Similarly, the source laboratory should
also inform the lead TB nurse, the lead clinician for TB and the CCDC of the results.
Molecular detection
Molecular detection of resistance gene markers for rifampicin is useful in identifying possible MDR
TB (see NICE guidance – http://guidance.nice.org.uk/CG33). It is recommended that the specimen
or isolate should be sent within one working day of the test being agreed between the source
laboratory and the RCM or another testing laboratory, and that those results (including the
confirmation of the presence of MTBC) are available within three working days of receipt of the
specimen or isolate at the testing laboratory. It is recommended that susceptibility testing is done in
an RCM with appropriate accreditation, IQC and EQA in place.
Resistant isolates
If a previously unknown MTBC isolate is shown to be resistant to rifampicin or two other primary
agents, further tests need to be performed to guide appropriate treatment. Agents tested would
usually include a fluoroquinolone, amikacin, capreomycin, streptomycin, ethionamide, cycloserine,
para-amino salicylic acid and a macrolide.
Ideally, these ‘second’ or ‘third’ line results are reported to the source laboratory within 30 days of
the resistance to the primary agents being identified.
The RCMs will provide the facility for testing other (including novel) agents as appropriate.
The laboratory requirements are set out in ‘Laboratory facilities and expertise’ on page 33.
Molecular fingerprinting/typing
Many public health specialists and clinicians agree that, for optimal public health management of
TB in the community, all new isolates of MTBC should undergo 15-loci mycobacterial interspersed
repetitive units – variable number tandem repeats (MIRU-VNTR) typing and the results entered in
the national database within 21 days of receipt of the isolate at the RCM for at least 95% of
isolates. Other molecular techniques may be used for particular investigations as appropriate. The
most appropriate facilities for these tests are at an RCM, and it is recommended that:
 the results are reported to the source laboratory within one working day of the test being
done; and
 the source laboratory ensures that that local arrangements are in place to inform the clinical
team, the lead TB nurse, the lead clinician for TB and the CCDC of the results within one
working day of them being received.
Reporting to the HPA surveillance system
To enable comprehensive public health surveillance and monitoring, the laboratory that first
isolates M. tuberculosis from a sample should report this to the HPA as part of CoSURV reporting
to the Communicable Diseases Report (CDR). The RCM will also report to the CDR all positive
cases within one working day of confirming the positive results.
The RCM will report culture details including susceptibility results to the Mycobacterial Surveillance
Network (MycobNet) within one working day of the report being sent to the source laboratory.
Direct nucleic acid amplification tests for detection of M. tuberculosis
This is not part of the routine investigation of samples for M. tuberculosis but may be considered
where there is a high suspicion of infection and a definitive diagnosis of M. tuberculosis is deemed
urgent in clinical terms or for health protection purposes (see NICE guidance –
http://guidance.nice.org.uk/CG33).
This test could be arranged between the requesting clinician and a suitably experienced local
medical microbiologist, clinical or biomedical scientist who will liaise with the RCM or other
laboratory providing the service. Good practice would be availability of the result within three
working days of receipt of the sample by the testing site laboratory.
Immunodiagnostic tests
Debate continues on the use of interferon-gamma tests and the NICE guidelines contain
recommendations on their use. Further information on the microbiological aspects is provided in
Annex 5.
There is currently no evidence that interferon-gamma tests are cost-effective in diagnosis of active
TB but may be useful in diagnosis of latent TB. The HPA is developing further advice on use of
interferon-gamma tests in the form of frequently asked questions. They are expected to be
published later in 2007.
Histopathology of lymph nodes and other tissue samples taken at biopsy or autopsy
This summary guidance should be read in conjunction with current histopathology and autopsy
guidance.
Tissue biopsies
It is recommended that:
 results are reported within three working days (or four, if extended fixation is indicated on
safety grounds) of receiving the sample when TB is suspected clinically, or as soon as
detected when discovered unexpectedly and the pathologist considers it
clinicopathologically urgent;
 when biopsy samples of tissue clinicoradiologically suspected to be TB are taken, including
samples analysed by perioperative frozen section, arrangements are in place for part of it to
be sent to microbiology for culture. This may be the clinician’s or the pathologist’s
responsibility, according to local protocols;
 once the clinical team responsible for the patient’s care has been given the diagnosis of TB,
 locally agreed arrangements ensure that the lead TB nurse, the lead clinician for TB and
the
 CCDC are informed of the results as soon as is feasible;
 cytopathology laboratories receiving material for diagnosis of M. tuberculosis infection liaise
with their microbiology laboratory, as described for biopsy samples (second bullet, above);
and
 histopathology and cytopathology samples of fresh TB tissue are handled according to
standard safety conditions until they are fixed and non-infectious (ie in a ventilated cabinet).
Autopsy tissues
It is recommended that:
 If M. tuberculosis infection is suspected before or during autopsy:
 the autopsy is performed according to infection containment protocol;
 fresh samples of potentially infected tissues should be sent for
microbiological investigation; and
 when a diagnosis of TB is made through autopsy alone, the histopathologist reports the
case to the local microbiology laboratory, which can inform the CCDC.
General considerations
Histopathologically, the diagnosis of TB is a continuum ranging from certain mycobacterial infection
(ie acid-fast bacillus positive, in the appropriate cellular context) consistent with TB, to granulomas
and/or necrosis, without evident acid-fast bacilli – consistent with TB, but also with other infectious
and non-infectious conditions.
It is recommended that in reporting suspected TB samples, the pathologist conveys the degree of
confidence in such a diagnosis, in order to aid clinical management, including consideration of
empirical therapy. This is correlated with available microbiology results.
A polymerase chain reaction (PCR) of formalin-fixed, paraffin-embedded material is not reliable for
diagnosing infection with M. tuberculosis (ie not sensitive or specific enough), and there are
currently no CE-marked commercial kits available.
Audit trail
To fulfil accreditation requirements, all laboratories involved in the provision of diagnostic services
for TB need to be able to show that they fulfil the criteria listed above for timeliness and
completeness of reporting and quality assurance in reports for commissioners, SHA performance
managers, the Healthcare Commission and Clinical Pathology Accreditation (CPA UK Ltd).
Appendix 6
TB Patient Survey Results - Jun 09
Total number – 13 responses
Patient information
Please mark
with X
1) What age are you?
Under 18
18 to 40
41 to 64
over 65
9
3
2
Please mark
with X
2) Are you?
Male
Female
3
10
3) Which of the following best describes your ethnic origin?
Asian
Indian
5
Pakistani
1
Bangladeshi
Any other Asian
1
White
British
2
Please mark with X
Sri Lankan
Tamil
British Asian
Any other white non
European
Any other white European
background
Irish
Polish
Black
Black Caribbean
Black African
4
Black British
Any other Black background
Mixed
White & Black Caribbean
White & Black African
White & Asian
Any other mixed background
Chinese
Gypsy
Arabic
Japanese
Any other background
Other
4) Which hospital are you being treated at for your tuberculosis?
Please mark with X
St Peter’s Hospital, Chertsey
East Surrey Hospital, Redhill
Epsom Hospital, Epsom
Frimley Park Hospital, Frimley
Timing of treatment
5) When did you start treatment at the
hospital?
Month
4
1
1
1
Royal Surrey County
Hospital, Guildford
Other hospital?– please
hospital
4
write name of
Year
6) If you told a family doctor (GP) or practice nurse about your symptoms, approximately how many
weeks did it take before you were sent to the hospital for assessment for tuberculosis?
Number of weeks…1 / 28/ 8/ 14/ 13 (5
responses)
Average
12.8wk
Language
7) Is English your first language (mother
tongue)?
Yes
No
Please
mark
with X
3
10
8) Do you need help to understand the TB
doctor or nurse?
Yes
No
9) If you need help to understand English, who
do you ask for that help?
Family member
Friend
Professional translator
Other
Please
mark
with X
2
10
Please
mark
with X
3
Understanding your TB
10) Overall do you feel you understand
enough about your TB?
Yes
Yes but would like to know more
No
Don't know
11) What things do you already know about
TB?
How to take my medication
How long I need to be treated
How I got TB
If my TB can spread to other people
If my TB affected my job
Please
mark
with X
9
4
Please
mark
with X
12
11
6
7
5
12) What extra information would you like to know about TB?
Comments
Had TB while pregnant: What impact TB will have on baby?
How long does treatment take?
Is there any way of preventing TB?
Why does TB keep coming back?
Has taken patient but is TB truly gone?
13) Have you received any written information
about TB?
Yes
No
Please mark
with X
8
5
14) If English is not your first language
(mother tongue), have you been offered written
information in another language?
Yes
No
Please mark
with X
2
6
15) If you are looking after a child with TB,
would you like your child to have different
information in a way that they can understand?
Yes
No
Please mark
with X
2
2
Transport
16) How do you get to the hospital most of the
time?
Car
Bus
Train
Walk
Cycle
Other
Please mark
with X
9
4
2
2
0
0
17) If you had to travel to another hospital in
Surrey, would this be difficult for you?
Very difficult
Quite difficult
No problem
Comments re Transport
As long as TB Clinic is close to public transport
Please mark
with X
2
3
4
Concerned about changing job and finding time to travel to clinic from new location - Feel fine now so might
stop treatment.
Insufficient money to pay travel fares
Relied on husband to drive so he had to miss work
Your overall feeling for the TB services in
Surrey
18) Overall do you feel the TB health staff
Please mark
treat you with respect?
with X
Yes – they treat me with respect
10
Yes but they could do better
1
No – they don’t treat me with respect
Don't know / can't remember
Comments
Appreciated TB Nurse support and help re medicine to home
Felt that St Peter's Clinic were lazy eg Delay to testing family with Mantoux
Really appreciated the respect from TB Nurses and bringing medicine home.
19) Overall do you feel satisfied with your TB
care?
Very satisfied
Satisfied
Not satisfied
It is terrible
Don't know / can't remember
Comments
Please mark
with X
5
2
1
1
GP needs more awareness and education
Diagnosed by Oncology Team prior to starting treatment
Unhappy with GP and slow diagnosis
Appreciated the patient survey and chance to give opinion
Diagnosis is unclear so not happy with lack of clarity
GP was slow to diagnose and limited information available until into 'TB system' - Would like more info at GP
level.
Felt that while TB nurses were very good, they were overstretched.
Grateful to Hospital team and TB nurses but disappointed that GP told her 'We do not have TB in our village'
despite GP being told she was a new entrant (from a high-risk country)!