Newham Scrutiny Commission on Tuberculosis

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Newham Scrutiny Commission on Tuberculosis

• Graham Bothamley
• Sector TB Network

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Outline

• Dispel myths about TB
• Role of the TB Network
• Using epidemiological data
• Future targets and recommendations

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Myths about TB

• TB only affects immigrants
• TB is caused by poverty
• HIV is entirely responsible for the increase in
  TB
• TB is a dirty disease, spread by spitting
• It is easy to catch TB
• TB cant be cured
• TB is just another disease

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TB only affects immigrants

• 38 TB in White UK (1998 survey)
• 31 white TB infectious compared to 14 in
  other ethnic groups
• Rose et al. Thorax 2001 56 173-9
• PHLS data. www.phls.co.uk/facts/TB

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TB is caused by poverty

• TB occurs when Mycobacterium tuberculosis meets a
  susceptible host
• vitamin D deficiency
• genetics e.g. HLA-DR15
• Transmitted by coughing
• Close proximity overcrowding more important and
  more easily tackled
• Wilkinson et al. Lancet 2000 355 618-21
• Bothamley et al. J Infect Dis 1989
• Mangtani et al. BMJ 1995 310963-6

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HIV is responsible for all the increase in TB

• Only 11 of TB increase in London from 1993 to
  1998 due to HIV
• HIV patients are less infectious
• More extra-pulmonary TB if HIV
• Rose et al. Thorax 2002 57 442-5
• Jones et al. Am Rev Respir Dis 1993 148 1292-7
• Espinal et al. Lancet 2000 355 275-80
• Bonora et al. Lancet 2000 355 2077

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TB is a dirty disease, spread by spitting

• Airborne infection
• Coughing behaviour
• Not transferred by cutlery, cups etc.
• Anyone can get TB!
• Riley et al. Am J Hygiene 1959 70 185-96

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It is easy to catch TB

• Destroyed by u.v. light, drying 30 min
• Has to be airborne
• Plane - 0/146 or 3/277 PPD converters submarine
  - 2 cases
• 2 months of close contact
• Riley et al. Am J Hygiene 1959 70 185-96
• McFarland et al. Lancet 1993 112-3
• Wang. Am J Infect Control 2000 28 233-8
• Houk et al. Arch Environ Health 1968 16 4-6

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TB cant be cured

• 6-month course 98.7 cure rate for all TB
• Even 65 (87/134) MDRTB cured
• BTS. Br J Dis Chest 1984 78 330-6
• Goble et al. N Engl J Med 1993 328 527-32

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TB is just another disease

• Infectious
• 3 cases per index in first two years
• 4.5 cases per index overall
• Long incubation
• One-third of world infected
• Blower et al. Nature Medicine 1995 1 815-21
• Dye et al. JAMA 1999 282 677-86

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The TB Network

• Co-operation between different TB Units
• Sector based
• Aims
• Equity of access to healthcare across Sector
• Set standards based on national, DoH, LRO
• Monitor implementation of standards
• Share good practice

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Progress in TB to date

• Outcome gt90 cured
• Nursenotification ratio lt150
• HIV testing
• all offered
• TB nurses all trained
• Policies and structure

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Treatment completion
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Lost to follow-up/defaulted
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TB nurse provision (borough)
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Audits

• Clinical Management
• management against BTS guidelines 1999
• outcome and HIV testing 2000
• inpatient stay requirements (White et al. J Publ
  Health Med 2002 24 49-52)
• contact tracing against BTS guidelines
• Access to healthcare
• DOT according to local guidelines (local ?
  Sector)
• GP registration (from 1 April 2002)
• Indices of quality
• patient satisfaction and process
• child TB known index vs. de novo
• proportion of smear-negative lung TB

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DOT and adherence
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London Service Framework for TB

• Collation of national guidelines
• BTS guidelines for management 1998/2000
• Department of Health
• Prevention and Control 1996
• Homeless 1996
• HIV related and MDRTB 1998
• Structure for assessment
• Identified gaps in service
• Costing and commissioning

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LSF - report

• Lack of isolation rooms with negative pressure
• Bacteriology
• delay in culture results
• delay in antibiotic sensitivities

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MDR TB in London
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Estimated costs to NHS (Newham)
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Predictions from trend data

• TB in new entrants
• Infectious TB
• Indices of improvement
• proportion of smear-negative to total PTB
• child TB rates
• primary TB (recent infection)
• deaths from TB

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TB - Newham
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New entrant PTB
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Pulmonary vs all TB by ethnic group
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Quality indices or predictors
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Future targets

• Early diagnosis
• Treatment
• Prevention

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Future targets early diagnosis

• Sputum smear result within 24 h
• Rifampicin PCR for smear-positives
• Health promotion of symptoms of TB
• Greater GP awareness
• risk groups
• value of sputum smear
• registration of new arrivals

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Future targets - treatment

• DOT (current audit)
• Support for alcoholics
• Joint management for HIV and paediatrics
• Improved patient satisfaction
• New combined drugs

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Future targets - prevention

• Housing policy
• Education
• Planning permission

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Housing policy - recommendations

• Sve index sharing bedroom with child ?immediate
  rehousing (15-20 p.a.)
• Parents should not have to share bedroom with
  child
• Minimum standards of room occupancy and
  ventilation

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Education - recommendations

• School programmes re health risk behaviour (e.g.
  coughing openly)
• Knowledge of symptoms of TB
• Reduce stigma culturally sensitive
• Access to NHS services

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Planning permission

• Minimum standards for hospitals
• Negative pressure facilities
• Minimum standards for renovations re ventilation
  and estimated occupancy

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Government Action

• Resources
• Ensure essential supplies
• PHLS and return of information
• Reform Public Health Act 1984

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TB costs
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Essential supplies

• Monopoly supplier for tuberculin and BCG
• No isoniazid 300mg tablets recognised
• No safeguards against loss of supply
• European supplies not accepted

Unavailable
Unavailable
2002
1998
2000
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Isoniazid outbreak North London

• 4 in 2000 now gt100 cases
• Transmission outside household contacts
• Poor adherence
• Maintaining treatment in prisons
• Supported by a single nurse
• Delayed action

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Public Health (Control of Diseases) Act 1984

• Section 37
• notifiable disease, serious risk of infection
• local authority officer e.g. social worker in
  London
• do all acts necessary to admit to hospital
• Section 38
• detain in a hospital
• if leaves, subject to a level 1 fine
• Police under no obligation to assist
• Costs 5k

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New York

• More flexible legal framework
• Positive incentives
• Housing
• 5-25 food coupons per week
• Support in dealing with substance abuse
• Use least restrictive measure possible
• Infectious patients in isolation rooms
• Non-infectious patients in hospital with
  excellent facilities

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New York outcome of legal action 1993-1995
excluding deaths or still treated
Gasner et al. NEJM 1999 340 359-66
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Priorities for 2003

• Prevent MDRTB
• Reduce impact of isoniazid outbreak
• Reduce transmission of TB
• screening of new entrants
• contact tracing
• Raise government awareness

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Targets 2003-2008

• Housing policy across Sector standard
• Universal registration with a GP
• Improve adherence
• Incentives
• Community DOT (hostels for alcoholics)
• Legal reform
• Advocacy
• New screening facilities