Download management, control and prevention

Tuberculosis:
management, control and prevention
Developed by:
In partnership with:
The Truth About TB is a national programme that
raises public and professional awareness of
tuberculosis.
This training resource has been developed by TB
Alert, the national tuberculosis charity, in
partnership with NHS England and Public Health
England.
www.thetruthabouttb.org
Aims and objectives
Aim: to recognise how TB
We will cover:
presents and to enhance early • epidemiology
diagnosis and treatment
• aetiology and pathogenesis
through prompt referral to TB
• risk factors
Specialist Services.
• early diagnosis
• the impact of delay in
Objectives: To provide an
overview of the identification, diagnosis
prevention and treatment of • treatment of TB
Tuberculosis (TB) in your area • LTBI testing and treatment
of clinical practice.
• role of TB Specialist Services.
www.thetruthabouttb.org
What is tuberculosis?
• TB is a bacillus, meaning rod shaped bacteria; it
is from the genus mycobacteria.
• TB most usually affects the lungs but it can
affect other parts of the body.
• Only TB of the lungs or throat is infectious.
• TB is an airborne disease which can be cured.
• TB is transmitted to others when a person with
infectious TB coughs, talks, sings, laughs or
sneezes.
• TB is a notifiable disease under Public Health
(Control of Disease) Act 1984.
• TB incidence is decreasing globally, and has
decreased in the UK since 2011.
www.thetruthabouttb.org
Epidemiology of TB
www.thetruthabouttb.org
TB notifications and rate, England, 2000-2014
Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS). Data as at: March 2015. Prepared by: TB Section,
National Infection Service, PHE
www.thetruthabouttb.org
TB notifications and rate by PHE Centre, England, 2000-2014
Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS). Data as at: March 2015. Prepared by: TB Section,
National Infection Service, PHE
www.thetruthabouttb.org
Three-year average tuberculosis case rates by
local authority, England, 2012-2014
Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS). Data as at: March 2015.
Prepared by: TB Section, National Infection Service, PHE
www.thetruthabouttb.org
TB notifications and rates by place of birth, England,
2000-2014
Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS). Data as at: March 2015. Prepared by: TB Section,
National Infection Service, PHE
www.thetruthabouttb.org
Most frequent countries of birth for TB notifications and
time, in years, between UK entry and notification (for
non-UK born cases), England, 2014
Country of birth
United Kingdom
India
Pakistan
Somalia
Bangladesh
Nepal
Nigeria
Philippines
Zimbabwe
Afghanistan
Romania
Eritrea
Kenya
Sri lanka
Poland
Others (each <1%)
Total
Cases no.
1,774
1,288
791
230
207
168
118
111
107
96
88
83
81
78
70
1,007
6,297
Cases %
28.2
20.5
12.6
3.7
3.3
2.7
1.9
1.8
1.7
1.5
1.4
1.3
1.3
1.2
1.1
15.8
100.0
Median time since entry
7 (3 -14)
10 (3 -25)
10 (3.5 -14.5)
8 (4 -19)
4 (3 -9)
7 (2 -17)
9 (4 -13)
11 (9 -12)
8 (4.5 -13)
1 (0 -6)
3 (0 -8)
19 (8 -41)
11 (4 -15)
6 (2 -8)
8 (3 -16)
9 (3 -20)
Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS). Data as at: March 2015.
Prepared by: TB Section, National Infection Service, PHE
www.thetruthabouttb.org
Local epidemiology
2013
Total notifications
Incidence (n/100,000)
UK born (%)
Non-UK born (%)
Pulmonary disease
Extra-pulmonary disease
www.thetruthabouttb.org
2014
Local epidemiology
ADD a local map showing the local burden of TB – possibly
by LSOA (available from PHE’s Field Epidemiology Service)
www.thetruthabouttb.org
Aetiology, pathogenesis and
transmission of TB
www.thetruthabouttb.org
Droplet nuclei
containing TB bacilli
are inhaled, enter
the lungs, and travel
to the alveoli.
TB bacilli multiply in
the alveoli.
www.thetruthabouttb.org
A small number of TB bacilli enter the
bloodstream and spread throughout
the body. The bacilli may reach any
part of the body.
Within 2-10 weeks, the immune
system produces immune cells
called macrophages that surround
the TB bacilli. The cells form a hard
shell called a granuloma that keeps
the bacilli contained and under
control (latent TB infection).
www.thetruthabouttb.org
If the immune system cannot
keep the bacilli under control,
the bacilli begin to multiply
rapidly (TB disease). This
process can occur in different
places in the body, such as
the lungs, kidneys, brain, or
bone.
Of those infected:
• 5% will progress to disease usually in the first two years
• 5% will progress to disease some time in their lifetime
www.thetruthabouttb.org
Risk factors for TB
www.thetruthabouttb.org
Poor housing
Smoking
Low income
Homelessness
Risk
factors
Vitamin D deficiency
Poor nutrition
Overcrowding
Cultural / language barriers
Lack of resources
and information
Immunosuppression, secondary
to disease or medications
Children
People with co-morbidities: diabetes,
immunosuppressive disorders
Asian / African groups
New immigrants, refugees
Vulnerable
groups
Known TB contacts
People with co-infection: HIV, Hep B, Hep C
www.thetruthabouttb.org
Older people
Substance misusers
Homeless
Prisoners
Mental health patients
Stigma and TB
• The risk factors associated with TB are factors that can
themselves create stigma.
A caring, respectful
attitude is essential
• Stigma can:
• prevent people seeking help
• lead to denial once diagnosed
• deter people from attending appointments or taking
treatment
• make contact tracing difficult.
www.thetruthabouttb.org
Diagnosis and treatment of
active TB
www.thetruthabouttb.org
Typical presentation of TB
• General symptoms:
• fever, night sweats, fatigue, anorexia,
weight loss
• Pulmonary symptoms:
• cough, haemoptysis
• Extra pulmonary symptoms:
• localised pain and/or swelling,
lymphadenopathy, wounds that won’t
heal
N.B. extra pulmonary TB can
mimic other diseases/conditions
www.thetruthabouttb.org
Have a high level
of suspicion
Think TB!
If you see a patient who is unwell, tired,
maybe losing weight, maybe feverish,
perhaps with swollen lymph glands or a
cough for three weeks or longer…..
….. if they come from a high risk group
…. could it be TB?
www.thetruthabouttb.org
Diagnosis of TB in Primary Care
Refer EARLY to TB services
Pulmonary TB:
• refer for CXR
and
• sputum x 3 (microscopy
for Acid Fast Bacilli &
culture)
and
• blood for FBC, ESR and
CRP
Extra-pulmonary TB
(depends on the site and
most likely conducted in
secondary care)
• fine needle aspirate
(lymph node),
• pleural tap (pleural)
• lumbar puncture
(meningitis)
• MRI scan (bone/joint)
www.thetruthabouttb.org
Treatment of active TB
Standard treatment for TB is a minimum of 6 months:
• 2 months (initial phase) of Isoniazid, Rifampicin, Pyrazinamide and
Ethambutol. Known as standard quadruple therapy.
Followed by:
• 4 months (continuation phase) of Isoniazid and Rifampicin. Known as
standard dual therapy
N.B. If there is central nervous system involvement the continuation phase
of treatment is extended to 10 months making a 12 month full treatment
plan.
• TB treatment is taken all together on an empty stomach 1 hour before
breakfast; compliance is essential for cure.
www.thetruthabouttb.org
Main treatment side effects
• Isoniazid: fever, peripheral neuropathy and optic neuritis
• Pyrazinamide: use with caution in patients with gout
• Rifampicin: reddish colour to the urine
• Ethambutol: peripheral neuropathy, optic neuropathy and
gout
Generally – hepatotoxcity, nausea and skin rashes
www.thetruthabouttb.org
Directly observed treatment
• Directly observed treatment is known as DOT.
• Each DOT case is assessed by the TB specialist team
regarding the patient’s ability to adhere to the six-month
treatment regimen.
• DOT is initiated for those at risk of being unable to adhere to
treatment.
• A professional case worker, person trained to be a DOT
observer, or a trusted family member or friend will watch the
patient take their TB treatment.
• Primary care providers, such as GP practices
or pharmacists, may be asked to provide DOT.
`
www.thetruthabouttb.org
Diagnosis and treatment of
latent TB infection (LTBI)
www.thetruthabouttb.org
Active or latent TB?
Active TB
Latent TB
cough, fever, night sweats, fatigue,
anorexia, weight loss, haemoptysis
asymptomatic
requires urgent treatment with at
least 6 months of anti-tuberculous
treatment
can be treated with 3 to 6 months of
anti-tuberculous treatment to
reduce 5-10% lifetime risk of
reactivation
may be an infection risk dependent
on site and progression of disease
never infectious
close contacts are screened
contacts do not require screening
notifiable disease
not notifiable
www.thetruthabouttb.org
Diagnosis and treatment of
latent TB infection (LTBI)
• Latent TB is diagnosed when a patient has a positive Interferon Gamma
Release Assay (IGRA) or a strongly positive tuberculin skin test in the
absence of illness. Clinical assessment and CXR (+/- CT Scan) are used
to rule out active TB.
• Latent TB is treated with a 3 month course of two antibiotics, Isoniazid
and Rifampicin, or a 6 month course of Isoniazid .
• People with latent TB have a 10–15% lifetime risk of
going onto develop active TB disease.
• Diagnosis and treatment of latent TB infection
is recommended for certain populations (see NICE)
so that the burden of TB disease is reduced.
www.thetruthabouttb.org
National LTBI testing and treatment programme
•
•
•
•
•
fully-funded
primary care based LTBI testing
secondary care based treatment
national protocols and pathways
national indicators, monitoring
and evaluation
• eligibility criteria for LTBI testing:
•
•
•
•
born or spent >6 m in high TB incidence country (≥150/100,000 or SSA)
entered the UK within the last 5 years (including entry via other countries)
aged between 16-35 years.
no history of TB or LTBI, not previously screened for LTBI in UK
Check website: https://www.gov.uk/guidance/tuberculosis-screening
30
www.thetruthabouttb.org
LTBI testing and treatment algorithm
Latent Tuberculosis Infection (LTBI) testing and treatment algorithm
1 Full eligibility criteria a) Born or spent >6 months in high TB incidence country (150 cases per 100,000 or more/Sub-Saharan Africa); b) Entered the UK within the last 5 years (including where entry was via
other countries (e.g. within EU/EEA); c) Aged 16-35 years; d) No history of TB either treated or untreated; e) Never screened for TB in UK. Also review indication for LTBI screening using NICE guidance
(e.g. if outside age group).
2 TB contacts should be referred to the local TB service. TB suggestive symptoms include a) Cough> 3 weeks; b) Haemoptysis (cough with blood); c) Night sweats; d) Unexplained weight loss; e)
Unexplained fever; f) Lymph node swelling (especially cervical).
3 The invitation letter advises patients to seek clinical care if they have symptoms of TB
4 The recommended investigations prior to referral will depend on local arrangements, but might include CXR and sputum collection as appropriate NB- colours of the boxes denote location and
responsibilities: blue- systematic identification mechanism; Green- Primary Care; Orange- Secondary Care
5 Also offer HIV test according to BHIVA/HPA recommendations and consider hepatitis B/C testing where appropriate.
31
www.thetruthabouttb.org
Control and prevention of TB
www.thetruthabouttb.org
The TB Strategy for England
Launched in 2015
Aims to achieve a year-on-year decrease in TB incidence, a reduction in health
inequalities and, ultimately, the elimination of TB as a public health problem
Strategy lists 10 key ‘areas for action’:
•
•
•
•
•
•
•
•
•
•
improving access and early diagnosis
high quality diagnostics
high quality treatment and care services
contact tracing
vaccination
tackling drug resistance
tackling TB in under-served populations
new entrant screening for LTBI
effective surveillance and monitoring
workforce strategy.
www.gov.uk/government/publications/collaborative-tuberculosis-strategy-for-england
33
www.thetruthabouttb.org
Contact tracing
• Contact tracing is usually carried
out by TB nurses. Results aid
understanding of how infectious
the TB index case is – this can
inform further public health
actions.
• TB transmission most often occurs
among household contacts.
Contact tracing is important
because:
• 1% of contacts screened have
active TB
• 10% of contacts screened have
latent TB infection
• 60% of child contacts under
2 years will go onto develop
active TB.
www.thetruthabouttb.org
Vaccination with BCG
The aim of the UK BCG immunisation programme is to
immunise those at increased risk of developing severe
disease and/or those at increased risk of exposure to TB
infection.
www.thetruthabouttb.org
Vaccination with BCG
BCG immunisation should be offered to:
• all infants (aged 0–12 months) living in areas of the UK where
annual incidence of TB is 40/100,000 or greater
• all infants (aged 0–12 months) with one or more parent or
grandparent who was born in a country where the annual incidence
of TB is 40/100,000 or greater
• BCG is also offered to previously unvaccinated tuberculin-negative
individuals under 16 years of age who are contacts of cases of
respiratory TB, and individuals at occupational risk.
In some areas, universal vaccination is offered.
www.thetruthabouttb.org
Delayed
presentation
Stigma
Under
resourced
service
Under-served
groups
Mono drug
resistance
Challenges in TB
Delayed
diagnosis
Multi drug
resistance
Duration of
treatment
Patients with
complex needs
www.thetruthabouttb.org
TB Specialist Services and their
role in TB control
www.thetruthabouttb.org
TB Specialist Services
• The TB Specialist Team includes specialist TB physicians,
microbiologists, TB specialist nurses, TB case workers, public health
teams and, in London, the Find & Treat Team.
• The role of the team:
• investigation, diagnosis and treatment of suspected TB, active
and latent
• co-ordination of care and support for patients on treatment for TB
• provision of support and advice to other services and the public
• notification and public health responsibilities
• contact tracing and screening for TB
• education and training.
REFER EARLY
www.thetruthabouttb.org
Local TB Services
ADD details of local TB Services HERE
www.thetruthabouttb.org
Case study 1
•
•
•
•
•
•
•
•
•
•
46 year old male, ethnicity white UK born
history of homelessness in the last 5 years
extensive drug and alcohol misuse most recent use 1 year ago
a prisoner in the Philippines for 2 years, 1 year before presentation; shared a
large cell with approx 70 other men, some unwell
presented at A&E after leaving a London prison that day with a mild cough,
fevers, night sweats and weight loss
had been investigated whilst in prison for TB
CXR: Left upper lobe consolidation and left hilar lymphadenopathy
initial microbiology: all 3 sputum specimens smear negative, culture pending
bloods: U and Es mildly deranged, raised CRP, low Hb, HIV, Hep B and C
negative
diagnosed and given thrice weekly DOT. Sputum cultured MTB some weeks
later, housed whilst on TB treatment, fully recovered. Adhered to TB treatment
with weekly support and incentives (cash and housing) to remain engaged.
www.thetruthabouttb.org
Case study 2
• 32 year old male, Indian, born in Delhi, came to the UK 3 years ago
• presented to GP who referred to ENT, with enlarged and painful
clavicular lymph node and 3 kg unexplained weight loss, well
otherwise
• CXR: normal
• bloods: raised CRP, mildly low HB, HIV negative
• microbiology: lymph node aspirate smear negative, culture negative
• histology: granulomatous inflammation
• diagnosed with Lymph Node TB on the basis of histological evidence
• lymph nodes initially increased in size and required drainage to
prevent bursting, then settled
• patient treated with 6 months of standard TB treatment and fully
recovered.
www.thetruthabouttb.org
Case study 3
• 42 year old woman, Black African, born in Zimbabwe, arrived in UK 5 years ago
• identified through contact tracing of her brother who had sputum smear +
pulmonary TB, fully sensitive organism
• however did not attend when invited for screening on 3 separate occasions
• presented 3 months later with symptoms: mild dry cough, fevers, night sweats,
headaches
• CXR: bi-lateral apical cavities, CT scan showed intra and extra thoracic
lymphadenopathy
• bronchoscopy: smear +, culture +, speciation MTB
• HIV +, newly diagnosed during TB investigations
• diagnosed with TB and HIV co-infection
• treated with standard TB treatment for 1 year with steroid treatment to reduce the
risk of TB IRIS (a paradoxical immune response to TB treatment in at risk groups)
• commenced treatment for HIV once her TB treatment was well established
• recovered, however, required neurological rehabilitation and support.
www.thetruthabouttb.org
Blank: for your case study (1)
www.thetruthabouttb.org
Blank: for your case study (2)
www.thetruthabouttb.org
Further information and resources
TB Alert is the UK's national tuberculosis charity – the only
charity working solely on fighting TB in the UK and
overseas. The Truth About TB is TB Alert’s awareness
programme.
For information leaflets or awareness materials to
display in your area of work:
www.thetruthabouttb.org/resources/awareness-raising-resources
For information about TB and patient stories:
www.thetruthabouttb.org
www.thetruthabouttb.org
References and further reading
•
Collaborative TB Strategy for England 2015-2020:
www.gov.uk/government/uploads/system/uploads/attachment_data/file/40
3231/Collaborative_TB_Strategy_for_England_2015_2020_.pdf
•
Tuberculosis: NICE, January 2016: www.nice.org.uk/guidance/ng33
•
Tuberculosis case management and cohort review, guidance for health
professionals, RCN, 2012 (with BTS, PHE, National Treatment Agency for
Substance Misuse):
www2.rcn.org.uk/__data/assets/pdf_file/0010/439129/004204.pdf
•
National Knowledge Service:
www.gov.uk/government/collections/tuberculosis-and-othermycobacterial-diseases-diagnosis-screening-management-and-data#nkstb-treatment-and-management-advice
www.thetruthabouttb.org
References and further reading (cont’d)
•
PHE website (Tuberculosis) – for TB annual report:
www.gov.uk/government/collections/tuberculosis-and-othermycobacterial-diseases-diagnosis-screening-management-and-data
•
PHE screening webpages:
www.gov.uk/guidance/tuberculosis-screening
•
PHE migrant health web pages:
www.gov.uk/topic/health-protection/migrant-health-guide
•
TB Alert’s national awareness programme The Truth About TB:
www.thetruthabouttb.org
•
Immunisation against infectious disease, DH, 2006:
www.gov.uk/government/collections/immunisation-against-infectiousdisease-the-green-book
www.thetruthabouttb.org
Thanks and credits
TB Alert and Public Health England would like to thank Professor Chris Griffiths,
Professor of Primary Care at Barts and The London, for chairing its primary care expert
advisory group. We are also grateful to our advisers Steve Bradley, Dr Gill Craig, Katie
Dee, Ann Dennis, Anna Hinton, Dr Mike Lane, Dr Jane Leese, Dr Justin Sacks, Dr Noel
Snell, Natalie Winter and Heggy Wyatt.
This resource was written by Cheryl Giles, TB specialist nurse at Brighton and Sussex
University Hospitals. Dr Anjana Roy of Public Health England coordinated the surveys
that informed this work, project management was by Dr Thoreya Swage, and project
coordination by Mike Mandelbaum for TB Alert and Surinder Tamne for Public Health
England.
This teaching resource was developed alongside an e-learning course for primary care
clinicians, available on the Royal College of GPs website at
www.elearning.rcgp.org.uk/tb.
2016 update by Sarah Anderson, Jennifer Davidson, Gini Williams and Dominik Zenner,
www.thetruthabouttb.org
Developed by TB Alert under The Truth
About TB programme.
In partnership with NHS England and
Public Health England.