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Tuberculosis overview

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Tuberculosis

About

What is covered

This pathway makes recommendations on the prevention, diagnosis and management of latent and active TB, including both drug-susceptible and drug-resistant forms of the disease. It covers the organisation of relevant TB services. It relates to activities in any setting in which NHS or public health services for TB are received, provided or commissioned in the public, private and voluntary sectors.
It updates and replaces NICE's guidelines on 'Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control' and 'Identifying and managing tuberculosis among hard-to-reach groups'.

Updates

Updates to this pathway

10 February 2016 A recommendation has been amended to clarify that it is about assessing risk for and vaccinating the baby in vaccination for neonates.
12 January 2016 Major update on publication of the tuberculosis NICE guideline NG33.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control (update)

What is covered

This pathway makes recommendations on the prevention, diagnosis and management of latent and active TB, including both drug-susceptible and drug-resistant forms of the disease. It covers the organisation of relevant TB services. It relates to activities in any setting in which NHS or public health services for TB are received, provided or commissioned in the public, private and voluntary sectors.
It updates and replaces NICE's guidelines on 'Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control' and 'Identifying and managing tuberculosis among hard-to-reach groups'.

Updates

Updates to this pathway

10 February 2016 A recommendation has been amended to clarify that it is about assessing risk for and vaccinating the baby in vaccination for neonates.
12 January 2016 Major update on publication of the tuberculosis NICE guideline NG33.

Sources

The NICE guidance that was used to create the pathway.
Tuberculosis (2016) NICE guideline NG33

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Infection with mycobacteria of the M. tuberculosis complex, in which mycobacteria are growing and causing symptoms and signs of disease. This is distinct from latent TB, in which mycobacteria are present (possibly dormant), but are not causing disease. Symptoms include weakness, weight loss, fever, loss of appetite, chills and sweating at night. Other symptoms of TB disease depend on where in the body the bacteria are growing. If TB is in the lungs (pulmonary TB), the symptoms may include a cough, pain in the chest, and coughing up blood.
The TB case manager should work with the person diagnosed with TB to develop a health and social care plan, and support them to complete therapy successfully. The TB case manager should:
  • offer a risk assessment to every person with TB, to identify their needs and whether they should have enhanced case management including directly observed therapy
  • educate the person about TB and the treatment
  • develop an individual care plan after discussion with the person
  • gain the person's consent to the plan and agree a review date (for example, when moving from initiation to maintenance, or at each contact to ensure the person's needs are being met)
  • involve representatives from other allied professions and key workers from all organisations who work with the person, if appropriate
  • explore appropriate ways that peers and voluntary organisations can provide support.
TB case managers should ensure the health and social care plan (particularly if directly observed therapy is needed) identifies why a person may not attend for diagnostic testing or follow a treatment plan, and how they can be encouraged to do so. It should also include ways to address issues such as fear of stigmatisation, support needs or cultural beliefs, and may include information on:
  • demographics (for example, age, nationality, place of birth, length of time in UK)
  • all current prescribing regimens
  • housing needs and living situation, including looked-after children
  • substance misuse (drugs or alcohol)
  • any contact with the criminal justice system
  • HIV status
  • other health conditions (physical or mental)
  • communication factors (for example, language and literacy levels)
  • ability to access treatment (mobility and transport needs)
  • employment or entitlement to benefits
  • legal or immigration status (including risk of removal or relocation within the UK)
  • any enablers or incentives to overcome anything that is stopping diagnosis or treatment.
The health and social care plan should:
  • state who will be observing treatment and where (if the person is having directly observed therapy this should be provided at a location that is convenient and accessible to them, for example, at a methadone clinic)
  • include actions to take if contact with the person is lost (for example, keeping details of people who might be able to help re-establish contact)
  • refer to, and be coordinated with, any other care plan already established for the person
  • define the support needed to address any unmet health and social care needs (for example, support to gain housing or other benefits, or to help them access other health or social care services)
  • include a commitment from the person to complete their TB treatment
  • be supported by frequent contact with any key workers who work with the person.
NICE has produced pathways on alcohol-use disorders and drug misuse.
Involves follow up of a person suspected or confirmed to have TB. It needs a collaborative, multidisciplinary approach and should start as soon as possible after a suspected case is discovered.
Standard and enhanced case management is overseen by a case manager who will usually be a specialist TB nurse or (in low-incidence areas) a nurse with responsibilities that include TB. Depending on the person's circumstances and needs, case management can also be provided by appropriately trained and supported non-clinical members of the TB multidisciplinary team.
Close contacts are people who have had prolonged, frequent or intense contact with a person with infectious TB. For example, these could include household contacts – those who share a bedroom, kitchen, bathroom or sitting room with the index case. Close contacts may also include boyfriends or girlfriends and frequent visitors to the home of the index case. Depending in the circumstances, occasionally co-workers are classed as close contacts although they are more usually classed as social contacts.
Cohort review is a systematic quarterly audit of the management and treatment of all TB patients and their contacts. The 'cohort' is a group of cases counted over a specific time, usually 3 months. Brief details of the management and outcomes of each case are reviewed in a group setting. The case manager presents the cases they are responsible for, giving the opportunity to discuss problems and difficulties in case management, service strengths and weaknesses, and staff training needs.
Clinical investigations (diagnostic testing) of people identified as having had significant exposure to a case of TB, including tests to diagnose latent or active TB. The aims of contact investigations are to:
  • detect active TB earlier to offer treatment and prevent further transmission
  • detect latent TB that may benefit from drug treatment
  • detect people not infected but for whom BCG vaccination might be appropriate.
Identifying people who may have come into contact with a person with infectious TB and assessing them for risk of significant exposure to TB. The aim is to find associated cases, to detect people with latent TB and to identify those not infected but for whom BCG vaccination might be appropriate.

Diagnostic investigations for pulmonary TB

Suspected site of disease
Imaging techniques to be consideredTaking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
Specimen
Routine test
Additional test (if it would alter management
Pulmonary (adult)
X-ray
CT thorax
3 respiratory samples:
  • preferably spontaneously-produced, deep cough sputum samples, otherwise induced sputum or bronchoscopy and lavage
  • preferably 1 early morning sample
Microscopy
Culture
Histology
Pulmonary (young people aged 16 to 17 years)
X-ray
CT thorax
3 respiratory samples:
  • preferably spontaneously-produced, deep cough sputum samples, otherwise induced sputum or gastric lavage
  • preferably 1 early morning sample
Microscopy
Culture
Histology
Nucleic acid amplification test
Pulmonary (children aged 15 years or younger)
X-ray
3 respiratory samples:
  • preferably spontaneously-produced, deep cough sputum samples, otherwise induced sputum or gastric lavage
  • preferably 1 early morning sample
Microscopy
Culture
Histology
Nucleic acid amplification tests (1 per specimen)
Interferon-gamma release assay and/or tuberculin skin test (with expert input)
Methods of helping someone to overcome barriers to completing diagnostic investigations and TB treatment. Examples of barriers include
  • transport
  • housing
  • nutrition
  • immigration status.
The pathway from awareness raising and primary prevention, through diagnosis to treatment completion incorporating all aspects such as contact tracing and other infection control mechanisms, for example, access to isolation facilities. This includes governance and commissioning considerations so that a comprehensive clinical and public health service is developed and delivered across any agreed geographical footprint.
Management of TB for someone with clinically or socially complex needs. It starts as soon as TB is suspected. As part of enhanced case management, the need for directly observed treatment is considered, along with a package of supportive care tailored to the person's needs.
Tools such as health equity audit and health impact assessment have been used systematically to assess the potential effect of all policies, programmes and activities (including those without an explicit health focus) on health inequalities. Equity proofing helps ensure all policies and programmes address the social determinants of health and health inequalities. Including a health equity audit as part of the joint strategic needs assessment can help local authorities and their partners to:
  • develop strategy and plans according to need
  • identify and work with community and health partners
  • commission activities based on the best available evidence
  • implement interventions to tackle inequity.

Example of suitable corticosteroid regimen for adults

StageAccording to the modified BMRC criteria for disease severity:
Dose of dexamethasone by week
1
2 or 3
1
0.3 mg/kg/day (IV)
0.4 mg/kg/day (IV)
2
0.2 mg/kg/day (IV)
0.3 mg/kg/day (IV)
3
0.1 mg/kg/day (oral)
0.2 mg/kg/day (IV)
4
3 mg/day (oral)
0.1 mg/kg/day (IV)
5
2 mg/day (oral)
4 mg/day (oral)
6
1 mg/day (oral)
3 mg/day (oral)
7
2 mg/day (oral)
8
1 mg/day (oral)
Stage 1: GCS of 15 without focal neurological deficits; alert and oriented
Stage 2: GCS of 11-14 or 15 with focal neurological deficits
Stage 3: GCS of 10 or less, with or without focal neurological deficits
Follow-up clinic visits should not be conducted routinely after treatment completion.
A high-incidence country or area has more than 40 cases of TB per 100,000 people per year. Public Health England lists high incidence countries and areas of the UK on its website.
A high-incidence country or area has more than 40 cases of TB per 100,000 people per year. Public Health England lists high incidence countries and areas of the UK on its website.
A high-incidence country or area has more than 40 cases of TB per 100,000 people per year. Public Health England lists high incidence countries and areas of the UK on its website.
A high-incidence country or area has more than 40 cases of TB per 100,000 people per year. Public Health England lists high incidence countries and areas of the UK on its website.
Used in this pathway to mean adults, young people and children from any ethnic background, regardless of migration status who are at increased risk of having or contracting TB. This includes:
  • people classified as under-served
  • people identified as contacts according to the case finding recommendations
  • new entrants from high-incidence countries
  • people who are immunocompromised.
Close contacts are people who have had prolonged, frequent or intense contact with a person with infectious TB. For example, these could include household contacts – those who share a bedroom, kitchen, bathroom or sitting room with the index case. Close contacts may also include boyfriends or girlfriends and frequent visitors to the home of the index case. Depending in the circumstances, occasionally co-workers are classed as close contacts although they are more usually classed as social contacts.
A new entrant is anyone coming to work or settle in the UK. This includes immigrants, refugees, asylum seekers, students and people on work permits. It also includes UK-born people, or UK citizens, re-entering the country after a prolonged stay in a high-incidence country. A high-incidence country or area has more than 40 cases of TB per 100,000 people per year. Public Health England lists high incidence countries and areas of the UK on its website.
In this pathway, immunocompromised refers to a person who has a significantly impaired immune system. For instance, this may be because of prolonged corticosteroid use, tumour necrosis factor-alpha antagonists, antirejection therapy, immunosuppression-causing medication or comorbid states that affect the immune system, for example, HIV, chronic renal disease, many haematological and solid cancers, and diabetes.
For the purposes of TB control, a broad and inclusive definition of homelessness has been adopted that incorporates overcrowded and substandard accommodation. It includes people:
  • who share an enclosed air space with people at high risk of undetected active pulmonary tuberculosis (that is, those with a history of rough sleeping, hostel residence or substance misuse)
  • without the means to securely store prescribed medication
  • without private space in which to self-administer TB treatment
  • without secure accommodation in which to rest and recuperate in safety and dignity for the full duration of planned treatment.
In this pathway, immunocompromised refers to a person who has a significantly impaired immune system. For instance, this may be because of prolonged corticosteroid use, tumour necrosis factor-alpha antagonists, antirejection therapy, immunosuppression-causing medication or comorbid states that affect the immune system, for example, HIV, chronic renal disease, many haematological and solid cancers, and diabetes.
Private or prison-run holding centre for migrants waiting to be accepted by, or deported from, the UK. Also known as immigration detention centre and pre-departure accommodation.
Private or prison-run holding centres for migrants waiting to be accepted by, or deported from, the UK. Also known as immigration detention centres and pre-departure accommodation.
Assessment of risk of exposure to TB in a congregate setting to decide on the need for and extent of contact investigation. The risk assessment would take into consideration factors such as:
  • infectiousness of the index case
  • vulnerability of contacts to TB infection
  • length of contact with or exposure to an infectious case
  • the built environment (for example, size of the rooms, ventilation and overcrowding).
The initial person found to have TB, whose contacts are screened. The source of their infection may be found to be 1 of the contacts, but the person who presents first is regarded as the index case.
The firm skin reaction occurring after a tuberculin skin test to diagnose latent TB infection. It is measured, and the result used to determine whether the test result is classified as positive or negative. This pathway recommends a threshold of 5 mm for tuberculin skin test positivity.
Active smear-positive pulmonary TB, that is with acid fast bacilli visible on microscopy. Active TB affecting other parts of the respiratory tract or oral cavity, though rare, is also considered infectious.
An infection control measure in which people with infectious TB are kept away from others who may be at risk of infection. This pathway deals with 3 levels of isolation for infection control in hospital settings:
  • negative pressure rooms, which have air pressure continuously or automatically measured, as defined by NHS Property Services
  • single rooms that are not negative pressure but are vented to the outside of the building
  • beds on a ward, for which no particular engineering standards are needed.
People are defined as 'lost to follow up' if they cannot be contacted within 10 working days of:
  • their first missed outpatient appointment (if they are on self administered treatment)
  • their first missed directly observed therapy appointment (if they are on directly observed therapy).
A team of professionals with a mix of skills to meet the needs of someone with TB who also has complex physical and psychosocial issues (that is, someone who is under-served). Team members will include:
  • a social worker
  • voluntary sector and local housing representatives
  • TB lead physician and nurse
  • a case manager
  • a pharmacist
  • an infectious disease doctor/consultant in communicable disease control or health protection
  • a peer supporter or advocate
  • a psychiatrist.
Used to isolate some patients known or suspected to have infectious TB. A negative pressure room is one where the air from the room is sucked out into dedicated ducting through a filter and into the outside air, at a distance from all other air intakes. The pressure should be 10 pascals below the ambient air pressure.
Anyone coming to work or settle in the UK. This includes immigrants, refugees, asylum seekers, students and people on work permits. It also includes UK-born people, or UK citizens, re-entering the country after a prolonged stay in a high-incidence country.
People who may have experienced TB. They are often in a good position to help convey, with empathy, the need for testing or treatment. They may be recruited from specific populations. With support they can communicate health messages, assist with contact investigations or screening and offer people help while they are being tested or treated.

Site-specific investigations for bone and joint TB

Suspected site of disease
Imaging techniques to be consideredTaking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
Specimen
Routine test
Additional tests on primary specimen (if it would alter management)
Bone or joint TB
X-ray
CT
MRI
Biopsy or aspirate of paraspinal abscess
Biopsy of joint
Aspiration of joint fluid
Culture

Site-specific investigations for central nervous system TB

Suspected site of disease
Imaging techniques to be consideredTaking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
Specimen
Routine test
Additional tests on primary specimen (if it would alter management)
CT
MRI
Biopsy of suspected tuberculoma
Microscopy
Culture
Histology
Cerebrospinal fluid
Microscopy
Culture
Cytology
Meningeal
CT
MRI
Cerebrospinal fluid
Microscopy
Culture
Cytology
Adenosine deaminase assay

Site-specific investigations for disseminated TB

Suspected site of disease
Imaging techniques to be consideredTaking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
Specimen
Routine test
Additional tests on primary specimen (if it would alter management)
Disseminated
CT of the thorax and head
MRI
Ultrasound of the abdomen
Biopsy of site of disease, including lung, liver and bone marrow
Microscopy
Culture
Histology
Additional tests appropriate to site
Aspirate bone marrow
Bronchial wash
Cerebrospinal fluid
Microscopy (if sample available)
Culture
Cytology
Blood
Culture

Site-specific investigations for gastrointestinal TB

Suspected site of disease
Imaging techniques to be consideredTaking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
Specimen
Routine test
Additional tests on primary specimen (if it would alter management)
Gastrointestinal
Ultrasound
CT
Laparoscopy
Biopsy of omentum
Biopsy of bowel
Biopsy of liver
Microscopy
Culture
Histology
Ascitic fluid
Microscopy
Culture
Cytology

Site-specific investigations for genitourinary TB

Suspected site of disease
Imaging techniques to be considered
Specimen
Routine test
Additional tests on primary specimen (if it would alter management)
Genitourinary
Ultrasound
Intravenous urography
Laparoscopy
Early morning urine
Culture
Biopsy from site of disease, such as endometrial curettings or renal biopsy
Microscopy
Culture
Histology
Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

Site-specific investigations for localised tuberculous abscess

Suspected site of disease
Imaging techniques to be consideredTaking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
Specimen
Routine test
Additional tests on primary specimen (if it would alter management)
Abscess outside of the lymph nodes
Ultrasound or other appropriate imaging
Aspirate
Microscopy
Culture
Cytology
Biopsy
Microscopy
Culture
Histology

Site-specific investigations for lymph node TB

Suspected site of disease
Imaging techniques to be considered
Specimen
Routine test
Additional tests on primary specimen (if it would alter management)
Lymph node (including intrathoracic mediastinal adenopathy
Ultrasound
CT
MRI
Biopsy
Microscopy
Culture
Histology
Aspirate
Microscopy
Culture
Cytology
Nucleic acid amplification test
Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

Site-specific investigations for pericardial TB

Suspected site of disease
Imaging techniques to be consideredTaking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
Specimen
Routine test
Additional tests on primary specimen (if it would alter management)
Pericardial
Echocardiogram
Biopsy of pericardium
Microscopy
Culture
Histology
Pericardial fluid
Microscopy
Culture
Histology
Cytology

Site-specific investigations for pleural TB

Suspected site of disease
Imaging techniques to be consideredTaking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
Specimen
Routine test
Additional tests on primary specimen (if it would alter management)
Pleural
X-ray
Bronchoscopy
3 respiratory samples:
  • preferably spontaneously-produced, deep cough sputum samples, otherwise induced sputum or gastric lavage
  • preferably 1 early morning sample
Pleural biopsy
Microscopy
Culture
Histology
Pleural fluid
Microscopy
Culture
Histology

Site-specific investigations for skin TB

Suspected site of disease
Imaging techniques to be consideredTaking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
Specimen
Routine test
Additional tests on primary specimens (if it would alter management)
Skin
Biopsy
Microsopy
Culture
Microscopy
The number of bacilli found in a sputum sample, believed to relate to the degree of infectivity of the person. There are several systems but in general recording goes from no mycobacteria in 100 fields (0 or negative) to more than 10 acid-fast bacilli per field in at least 20 fields (grade 3).

Treatment regimen for people with TB that is resistant to 1 drug

Drug resistance
First 2 months (initial phase)
Continue with (continuation phase)
Isoniazid
Rifampicin, pyrazinamide and ethambutol
Rifampicin and ethambutol for 7 months (up to 10 months for extensive disease)
Pyrazinamide
Rifampicin, isoniazid (with pyridoxine) and ethambutol
Rifampicin and isoniazid (with pyridoxine) for 7 months
Ethambutol
Rifampicin, isoniazid (with pyridoxine) and pyrazinamide
Rifampicin and isoniazid (with pyridoxine) for 4 months
Rifampicin
A partnership of mixed professionals and lay people who have experience of leading, commissioning, managing or supporting people with TB. Board members are likely to include:
  • the voluntary sector
  • housing representatives
  • TB specialists and other clinicians
  • consultants in communicable disease control or health protection
  • peer supporter and advocate groups
  • clinical commissioning groups
  • executive officers
  • local government commissioners
  • an independent chair.
This list is not intended to be exhaustive; membership should be determined based on an area's needs, agreements and commissioning arrangements.
To encourage people to follow their treatment plan, involve people in treatment decisions from the start. Emphasise the importance of following the treatment plan when agreeing the regimen.
Multidisciplinary TB teams should implement strategies to encourage people to follow the treatment plan and prevent people stopping treatment early. These could include:
  • reminder letters, printed information, telephone calls, texts and apps using an appropriate language
  • health education counselling and patient-centred interviews
  • tailored health education booklets from quality sources (see providing information in this pathway)
  • home visits
  • random urine tests and other monitoring (for example, pill counts)
  • access to free TB treatment for everyone (irrespective of eligibility for other NHS care) and information about help with paying for prescriptions
  • social and psychological support (including cultural case management and broader social support)
  • advice and support for parents and carers
  • incentives and enablers to help people follow their treatment regimen.
For guidance on treatment adherence in prisons or immigration removal centres, see procedures for treating TB in prisons or immigration removal centres and arrangements for treating prisoners and detainees after their release in this pathway.
Used in this pathway to mean groups of adults, young people and children from any ethnic background, regardless of migration status. They are under-served if their social circumstances, language, culture or lifestyle (or those of their parents or carers) make it difficult to:
  • recognise the clinical onset of TB
  • access diagnostic and treatment services
  • self-administer treatment (or, in the case of children and young people, have treatment administered by a parent or carer)
  • attend regular appointments for clinical follow-up.
The groups classified as under-served in this pathway are:
  • people who are homeless
  • people who misuse substances
  • prisoners
  • vulnerable migrants.
Groups of children identified as potentially under-served include:
  • unaccompanied minors
  • children whose parents are under-served, including vulnerable migrants
  • children whose parents are in prison or who abuse substances
  • children from gypsy and traveller communities
  • looked-after children.
For the purposes of TB control, a broad and inclusive definition of homelessness has been adopted that incorporates overcrowded and substandard accommodation. It includes people:
  • who share an enclosed air space with those at high risk of undetected active pulmonary tuberculosis (that is, those with a history of rough sleeping, hostel residence or substance misuse)
  • without the means to securely store prescribed medication; without private space in which to self-administer TB treatment
  • without secure accommodation in which to rest and recuperate in safety and dignity for the full duration of planned treatment.
Substance misuse is defined as intoxication by – or regular excessive consumption of and/or dependence on – psychoactive substances, leading to social, psychological, physical or legal problems. It includes problematic use of both legal and illegal drugs.
Prisons include any state prison establishments, including young offender institutions.
Vulnerable migrants may include undocumented migrants and those with no recourse to public funds. Some refugees, asylum seekers and new entrants to the country may also fall into this category.
Substance misuse is defined as intoxication by – or regular excessive consumption of and/or dependence on – psychoactive substances, leading to social, psychological, physical or legal problems. It includes problematic use of both legal and illegal drugs.
May include undocumented migrants and those with no recourse to public funds. Some refugees, asylum seekers and new entrants to the country may also fall into this category.
In children whose parents are members of any of the above groups, offer directly observed therapy as part of enhanced case management and include advice and support for parents to assist with treatment completion.
Re-evaluate the need for directly observed therapy throughout the course of TB treatment whenever the person's (or in the case of children, parents') circumstances change.
NICE has produced pathways on alcohol-use disorders and drug misuse.

Glossary

systematically identifying people with active or latent TB using tests, examinations or other procedures
the person's ability or willingness to keep to a treatment regimen as directed
British Medical Research Council
British National Formulary
central nervous system
places where people congregate or an institutional setting such as a workplace, prison, hostel, or childcare or educational setting, where social contacts might have had significant exposure to TB
a person who has spent time with someone with infectious TB
blood-borne spread of TB that may or may not be accompanied by chest X-ray or high resolution CT changes
resistance to at least isoniazid and rifampicin, 1 injectable agent (capreomycin, kanamycin or amikacin) and 1 fluoroquinolone
active TB disease in any site other than the lungs or tracheobronchial tree
filtering face piece
Glasgow coma score
intravenous
infection with mycobacteria of the M. tuberculosis complex in which the bacteria are alive but not currently causing active disease (also known as latent TB infection)
TB resistant to isoniazid and rifampicin, with or without any other resistance
child aged 4 weeks or under
there is no robust, widely accepted threshold for an outbreak of a disease, but in practical terms an outbreak is the occurrence of an unusually high number of cases in associated people, in a small geographical area, or in a relatively short period of time
any state prison establishments, including young offender institutions
any state prison establishment, including a young offender institution
in the context of TB services, timely support from a specialist team
someone who has had contact with a person with infectious TB but has not been in prolonged, frequent or intense contact
a break in the prescribed anti-TB regimen for 2 weeks or more in the initial phase, or more than 20% of prescribed doses missed intermittently

Paths in this pathway

Pathway created: January 2012 Last updated: February 2016

© NICE 2016

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