Tuberculosis overview

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Tuberculosis

Short Text

Commissioning, diagnosis and management of tuberculosis, and measures for its prevention and control including among hard-to-reach groups

Introduction

This pathway covers the commissioning, diagnosis and management of tuberculosis (TB), and measures for its prevention and control among the whole population. It also aims to improve the way TB is identified and managed among hard-to-reach groups, specifically among people who are homeless, substance misusers, prisoners and vulnerable migrants.
The incidence of TB is influenced by risk factors such as exposure to, and susceptibility to, TB and levels of deprivation (poverty, housing, nutrition and access to healthcare), and differs in different parts of England and Wales.
Where scientific evidence supports it, this pathway makes recommendations on service organisation, as well as for individual teams of healthcare professionals. The pathway aims to focus NHS resources where they will combat the spread of TB, and some sections deal with high- and low-incidence areas separately.
The pathway is designed for use by the National Health Service and other organisations in the public, voluntary and community sectors in England and Wales. Readers in other countries, particularly where the incidence of TB is higher, should exercise caution before applying the recommendations.
Unless otherwise specified, the recommendations for hard-to-reach groups focus on active, rather than latent TB.

Source guidance

The NICE guidance that was used to create the pathway.
Tuberculosis. NICE clinical guideline 117 (2011)
Tuberculosis - hard-to-reach groups. NICE public health guidance 37 (2012)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

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.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

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 the following topic.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

20 December 2013 Minor maintenance updates.
8 February 2013 Minor maintenance updates.

Supporting information

High-incidence country

In this pathway, a high-incidence country is defined as a country with more than 40 cases per 100,000 per year; these are listed by the Health Protection Agency – go to www.hpa.org.uk and search for 'WHO country data TB'.

Hard-to-reach groups

In this pathway, hard-to-reach groups include children, young people and adults whose social circumstances 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, have treatment administered by a parent or carer)
  • attend regular appointments for clinical follow-up.

Identifying active pulmonary TB among those using substance misuse services

  • In line with NICE's recommendations for people in hard-to-reach groups in this pathway, consider using simple incentives, such as providing hot drinks and snacks, to encourage people to attend for mobile X-ray screening.
  • Work closely with mobile X-ray teams and frontline staff in hostels and day centres to promote TB screening and to ensure appropriate onward referrals and follow-up.
  • Consider using peer educators to promote the uptake of TB screening in hostels and day centres.
  • Provide routine data to TB prevention and control programmes on: screening uptake, referrals and the number of active TB cases identified.
For commissioning information, see 'Identifying active pulmonary TB among those using homeless or substance misuse services' in active case-finding in this pathway.

Glossary

Bacille Calmette-Guèrin
Case management involves follow-up of a suspected or confirmed TB case. It requires 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 which include TB. Dependent upon the person's particular circumstances and needs, case management can also be provided by appropriately trained and supported non-clinical members of the TB multi-disciplinary team.
Can include a boyfriend or girlfriend and frequent visitors to the home of the index case, in addition to household contacts
A systematic appraisal of the way every case of TB has been managed in a given locality in terms of treatment completion rates and contact investigations over a specified time period.
Directly observed therapy.
Directly observed therapy (DOT) is when a trained health professional, or responsible lay person supported by a trained health professional, provides the prescribed medication and observes the person swallowing every dose.
A Mantoux test followed by an interferon-gamma test if the Mantoux is positive.
'Enablers' are methods of helping someone to overcome barriers to completing diagnostic investigations and TB treatment. Examples of barriers that may need to be overcome include: transport, housing, nutrition and immigration status.
Enhanced case management (ECM) is provided when someone has clinically or socially complex needs. It commences as soon as TB is suspected. As part of ECM, the need for directly observed treatment (DOT) is considered, in conjunction with a package of supportive care tailored to the person's needs.
Groups of children identified as potentially hard-to-reach or treat include:
  • unaccompanied minors
  • those whose parents are hard-to-reach, including vulnerable migrants
  • those whose parents are in prison or who abuse substances
  • those from traveller communities
  • looked-after children.
In this pathway, the term hard-to-reach groups is used to mean groups of adults, young people and children from any ethnic background, regardless of migration status. They are 'hard to reach' 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, have treatment administered by a parent or carer)
  • attend regular appointments for clinical follow-up.
A high-incidence country or area has more than 40 cases of TB per 100,000 people per year. The Health Protection Agency lists high incidence countries and areas of the UK at its website.
A high-incidence country or area has more than 40 cases of TB per 100,000 people per year. The Health Protection Agency lists high incidence countries and areas of the UK at its website.
Human immunodeficiency virus
For the purposes of TB control, a broad and inclusive definition of homelessness has been adopted which incorporates overcrowded and substandard accommodation. It includes people:
  • who share an enclosed air space with individuals 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.
A person sharing a bedroom, kitchen, bathroom or sitting room with the index case.
Immigration removal centres are private or prison-run holding centres for migrants waiting to be accepted by, or deported from, the UK. Immigration removal centres are also known as immigration detention centres and pre-departure accommodation.
The number of new cases of TB treated per year.
Advice on the risks and symptoms of TB, usually given in a standard letter.
A blood test carried out after, at the same time as, or instead of the Mantoux test. If the result is positive, more tests are undertaken to see if the person has TB.
Latent TB infection means someone is infected with mycobacteria of the M. tuberculosis complex, where the bacteria are alive but not currently causing active TB.
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)
  • cannot be contacted within 10 working days of their first missed DOT appointment (if they are on daily or three times per week DOT).
Multidrug-resistant
A process to ensure prisoners are not transferred until they are medically fit enough.
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 hard-to-reach). The team will meet regularly to plan, implement and evaluate a care pathway. Specific members should be able to meet to deal with urgent issues. Team members will include a social worker, voluntary sector and local housing representatives, TB lead physician and nurse, a case manager, a peer supporter/advocate and a psychiatrist.
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 hard-to-reach). The team will meet regularly to plan, implement and evaluate a care pathway. Specific members should be able to meet to deal with urgent issues. Team members will include a social worker, voluntary sector and local housing representatives, TB lead physician and nurse, a case manager, a peer supporter/advocate and a psychiatrist.
A person who has recently arrived in or returned to the UK from a high-incidence country.
Peers are members of the target population who may have experienced TB. They are often in a good position to help convey, with empathy, the need for screening or treatment. They may be recruited and supported to communicate health messages, assist with contact investigations or screening and to offer people support while they are being tested or treated.
Where the term 'prison' is used it applies to any of Her Majesty's prison establishments, including young offender institutions.
In the context of TB services, rapid access refers to timely support from a specialist team.
Tuberculosis affecting the lungs, pleural cavity, mediastinal lymph nodes or larynx
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.
Tuberculosis
TB prevention and control comprises:
  • active case-finding (contact investigations and screening of high-risk groups)
  • awareness-raising activities
  • diagnostic and treatment services
  • standard and enhanced case management (including the provision of directly observed therapy)
  • finding those lost to follow-up and encouraging them back into treatment
  • identification and management of latent infection
  • immunisation
  • incident and outbreak control
  • cohort review
  • monitoring and evaluation
  • the gathering of surveillance and outcome data.
Triage is the process by which people are classified according to the type and urgency of their symptoms/condition/situation. The aim is to get someone in need to the right place at the right time to see an appropriately skilled person/team.
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.

Commissioning tuberculosis services

View the 'Commissioning tuberculosis services' path

Preventing the spread of tuberculosis

View the 'Preventing the spread of tuberculosis' path

Diagnosing and managing active tuberculosis

View the 'Diagnosing and managing active tuberculosis' path

Identifying and managing tuberculosis among hard-to-reach groups

View the 'Identifying and managing tuberculosis among hard-to-reach groups' path

Patient experience in adult NHS services pathway

View the 'Patient experience in adult NHS services overview' path

Paths in this pathway

Pathway created: January 2012 Last updated: December 2013

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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