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Tuberculosis services: staff vaccination and screening

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Tuberculosis

About

What is covered

This interactive flowchart 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 interactive flowchart

9 January 2017 Tuberculosis (NICE quality standard 141) added.
27 May 2016
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.

Your responsibility

Guidelines

The recommendations in this interactive flowchart 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. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. 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 interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-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

Everything NICE has said on preventing, diagnosing and managing latent and active tuberculosis in an interactive flowchart

What is covered

This interactive flowchart 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 interactive flowchart

9 January 2017 Tuberculosis (NICE quality standard 141) added.
27 May 2016
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

NICE guidance and other sources used to create this interactive flowchart.
Tuberculosis (2016) NICE guideline NG33
Tuberculosis (2017) NICE quality standard 141

Quality standards

Quality statements

Latent tuberculosis testing for people from high-incidence countries

This quality statement is taken from the tuberculosis quality standard. The quality standard defines clinical best practice for tuberculosis and should be read in full.

Quality statement

People aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of tuberculosis (TB), are tested for latent TB infection when they register with a GP.

Rationale

Detecting latent TB infection in recent arrivals to the country is beneficial because they have a higher relative risk of progression to active, potentially infectious TB than the general population. The highest burden of TB disease and the largest proportion of new entrants from high incidence countries are aged 16 to 35 years. Early detection can lead to treatment of latent infection before it progresses to active disease. This can prevent onward transmission and the associated harms and costs of active TB.

Quality measures

Structure
a) Evidence of local arrangements to identify people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, when they register with a GP.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, are tested or referred for testing for latent TB infection when they register with a GP.
Data source: Local data collection.
Process
Proportion of people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, who are tested for latent TB infection when they register with a GP.
Numerator – the number in the denominator who are tested for latent TB infection.
Denominator – the number of people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, registering with a GP.
Data source: National data is collected in the Public Health England’s Database for the national latent tuberculosis screening programme in new migrants from high-incidence countries. The data collection includes patient-level data about those people who have been offered screening and those who have taken up the screening.
Outcome
TB incidence.
Data source: National and regional data on TB incidence in England are collected in Public Health England’s TB Strategy monitoring indicators.

What the quality statement means for different audiences

Service providers (general practices) have systems in place to identify people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, when they register with the practice. They should ensure that the people identified have latent TB infection testing.
Healthcare professionals (such as GPs and nurses) test for latent TB infection in people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, when they register with a GP. If the practice cannot perform the test, they should refer to the person to a service where it can be done.
Commissioners (NHS England and clinical commissioning groups) ensure that they commission primary care services that identify people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB. They should ensure that these primary care services provide or facilitate testing for latent TB infection for the people identified.
People aged 16 to 35 years who have come to England within the past 5 years from a country where there are a high number of TB cases have a test to find out if they have TB.

Source guidance

Tuberculosis (2016) NICE guideline NG33, recommendation 1.2.3.1

Definitions of terms used in this quality statement

Five years
The time period of 5 years is based on Public Health England’s Collaborative tuberculosis strategy for England: 2015 to 2020 and consensus of expert opinion.
High incidence of TB
The Collaborative tuberculosis strategy for England: 2015 to 2020 defines this as countries with an estimated TB incidence rate of more than 150 cases of TB per 100,000 people per year.
Public Health England lists countries and their estimated TB incidence in Tuberculosis (TB) by country: rates per 100,000 people. People who were born in, or have spent more than 6 months in a high-incidence country, should be tested.
Testing for latent TB infection
There are 2 types of test that can be used to diagnose latent TB infection. The Mantoux test should be used as the initial diagnostic test. It is a type of tuberculin skin test in which tuberculin is injected into the skin. The injection site is examined for signs of an immune response after 2 to 3 days.
If Mantoux testing is unavailable the interferon-gamma release assay (IGRA) test should be used. This is a blood test used to diagnose latent TB based on the response of white blood cells to TB antigens.
[Adapted from NICE’s full guideline on tuberculosis (glossary) and recommendation 1.2.3.1]

Equality and diversity considerations

When offering testing to people who have arrived in the country within the past 5 years, healthcare professionals should be aware that people in this group may not speak or read English or have English as their first language. They should have access to an interpreter or advocate if needed. 

Latent tuberculosis testing for adults with HIV

This quality statement is taken from the tuberculosis quality standard. The quality standard defines clinical best practice for tuberculosis and should be read in full.

Quality statement

Adults aged under 65 years who are diagnosed with HIV, are tested for latent tuberculosis (TB) infection.

Rationale

People with HIV are considered to have a high risk of progression to active TB because they are severely immunocompromised. Testing people when they are diagnosed with HIV can lead to early detection and treatment of latent infection before it progresses to active disease. This can prevent onward transmission and the associated harms and costs of active TB.

Quality measures

Structure
Evidence of local arrangements to ensure that adults aged under 65 years who are diagnosed with HIV, are referred for testing for latent TB infection.
Data source: Local data collection.
Process
Proportion of adults aged under 65 years diagnosed with HIV, who are tested for latent TB infection.
Numerator – the number in the denominator who are tested for latent TB infection.
Denominator – the number of adults aged under 65 years diagnosed with HIV.
Data source: Local data collection.
Outcome
TB incidence.
Data source: Local data collection. National and regional data on TB incidence in England are collected in Public Health England’s TB Strategy monitoring indicators.

What the quality statement means for different audiences

Service providers (primary, secondary and specialist care services) have systems in place for adults who have been diagnosed with HIV, aged under 65 years, to be referred for testing for latent TB infection.
Healthcare professionals (such as specialists, GPs and nurses) refer adults who have been diagnosed with HIV, aged under 65 years, for latent TB infection testing.
Commissioners (NHS England and clinical commissioning groups) ensure that they commission services that refer adults who are diagnosed with HIV, aged under 65 years, to a service that undertakes testing for latent TB infection.
Adults with HIV, who are aged under 65 years, have a test to find out if they have TB.

Source guidance

Tuberculosis (2016) NICE guideline NG33, recommendation 1.2.1.3

Definitions of terms used in this quality statement

Testing for latent TB infection in adults with HIV
For adults with HIV, an interferon-gamma release assay (IGRA) and a concurrent Mantoux test should be used.
The Mantoux test is a type of tuberculin skin test in which tuberculin is injected into the skin. The injection site is examined for signs of an immune response after 2 to 3 days. The IGRA test is a blood test used to diagnose latent TB based on the response of white blood cells to TB antigens.
[Adapted from NICE’s guideline on tuberculosis, recommendation 1.2.1.3, and the glossary from the full guideline on tuberculosis]

Equality and diversity considerations

Healthcare professionals referring adults with HIV for latent TB testing infection should be aware of and be sensitive to the fact that they may feel stigmatised because of their diagnosis of HIV.

Rapid diagnosis of pulmonary tuberculosis

This quality statement is taken from the tuberculosis quality standard. The quality standard defines clinical best practice for tuberculosis and should be read in full.

Quality statement

People who are referred to a tuberculosis (TB) service, who meet specific criteria, have rapid diagnostic nucleic acid amplification tests (NAATs).

Rationale

Diagnostic test accuracy and time to diagnosis or treatment initiation are critical for decision-making. Using NAATs significantly reduces the time to identify pulmonary M. tuberculosis and rifampicin resistance. Delayed diagnosis can delay the start of treatment, which may in turn lead to greater risks of morbidity (both long and short term) and mortality.

Quality measures

Structure
Evidence of local arrangements to ensure that people who are referred to a TB service, who meet specific criteria, have rapid diagnostic NAATs.
Data source: Local data collection.
Process
a) Proportion of people referred to TB services, who are aged 15 years or younger, who have rapid diagnostic NAATs to detect M. tuberculosis complex in primary respiratory specimens.
Numerator – the number in the denominator who have rapid diagnostic NAATs to detect M. tuberculosis complex in primary respiratory specimens.
Denominator – the number of people who are referred to TB services who are aged 15 years or younger.
Data source: Local data collection.
b) Proportion of people with HIV referred to TB services, who have rapid diagnostic NAATs to detect M. tuberculosis complex in primary respiratory specimens.
Numerator – the number in the denominator who have rapid diagnostic NAATs to detect M. tuberculosis complex in primary respiratory specimens.
Denominator – the number of people with HIV who are referred to TB services.
Data source: Local data collection.
c) Proportion of people referred to TB services, who are identified as having risk factors for multidrug resistance, who have rapid diagnostic NAATs to detect rifampicin drug resistance in primary respiratory specimens.
Numerator – the number in the denominator who have rapid diagnostic NAATs to detect rifampicin drug resistance on primary respiratory specimens.
Denominator – the number of people who are referred to TB services who are identified as having risk factors for multidrug resistance.
Data source: Local data collection.
Outcome
Proportion of people with pulmonary TB starting treatment within 2 months of symptom onset.
Data source: National and regional data on the proportion of pulmonary TB cases starting treatment within 2 months of symptom onset is collected in Public Health England’s TB Strategy monitoring indicators.

What the quality statement means for different audiences

Service providers (laboratory services) perform rapid diagnostic NAATs on primary respiratory specimens for people who are referred to TB services, who meet specific criteria.
Healthcare professionals (such as nurses, secondary care doctors, specialists and paediatricians) request rapid diagnostic NAATs on primary respiratory specimens for people who are referred to TB services, who meet specific criteria.
Commissioners (clinical commissioning groups) ensure that they commission services that can do rapid diagnostic NAATs on primary respiratory specimens for people who are referred to TB services, who meet specific criteria.
People who are suspected as having pulmonary TB and meet specific criteria, have a sample of sputum that they have coughed up from the lungs, which is tested using a type of test that can quickly confirm if they have TB.

Source guidance

Tuberculosis (2016) NICE guideline NG33, recommendations 1.3.3.1, 1.3.4.1, 1.3.4.2 and 1.4.1.1

Definitions of terms used in this quality statement

Specific criteria
The specific criteria are that there is clinical suspicion of pulmonary TB and:
  • the person is aged 15 years or younger or
  • the person has HIV or
  • the person has had a risk assessment that identifies risk factors for multidrug resistance or
  • rapid information about mycobacterial species would alter the person's care.
[NICE’s guideline on tuberculosis, recommendations 1.3.3.1, 1.3.4.1, 1.3.4.2 and 1.4.1.1]
NAAT
A test to detect fragments of bacterial nucleic acid, allowing rapid and specific diagnosis of M. tuberculosis directly from a range of clinical samples.
[Adapted from NICE’s full guideline on tuberculosis (glossary)]

Assessment

This quality statement is taken from the tuberculosis quality standard. The quality standard defines clinical best practice for tuberculosis and should be read in full.

Quality statement

People who have imaging features suggestive of active pulmonary tuberculosis (TB) are assessed by the next working day.

Rationale

Assessing people by the next working day helps to ensure that case management and infection control procedures start promptly. Delayed diagnosis can delay the start of treatment, which may in turn lead to greater risks of morbidity (both long and short term) and mortality.

Quality measures

Structure
Evidence of TB services having local arrangements in place to ensure that people who have imaging features suggestive of active pulmonary TB are assessed by the next working day.
Data source: Local data collection.
Process
Proportion of people with imaging features suggestive of active pulmonary TB who are assessed by the next working day after their results are received.
Numerator – the number in the denominator who are assessed by the next working day after their results are received.
Denominator – the number of people with imaging features suggestive of active pulmonary TB.
Data source: Local data collection.
Outcome
a) Proportion of people with active pulmonary TB starting treatment within 2 months of symptom onset.
Data source: National and regional data on the proportion of pulmonary TB cases starting treatment within 2 months of symptom onset is collected in Public Health England’s TB Strategy monitoring indicators.
b) Active pulmonary TB incidence.
Data source: Local data collection. National and regional data on TB incidence in England is collected in Public Health England’s TB Strategy monitoring indicators.

What the quality statement means for different audiences

Service providers (secondary care services) have systems in place to ensure that people who have imaging features suggestive of active TB are assessed no later than the next working day after their results are received.
Health and social care practitioners (such as a respiratory physician or nurse) assess people who have imaging features suggestive of active TB no later than the next working day after they receive the results.
Commissioners (clinical commissioning groups) ensure that they commission services that have the capacity to assess people who have imaging features suggestive of active TB no later than the next working day after their results are received.
People who have a chest X-ray that suggests they have active TB have an assessment no later than the first working day after their results are received by a health or social care practitioner such as a respiratory doctor or a nurse.

Source guidance

Tuberculosis (2016) NICE guideline NG33, recommendation 1.8.9.8

Definitions of terms used in this quality statement

Imaging features suggestive of active TB
These include but are not limited to:
  • evidence of extensive consolidation or cavities
  • predominantly upper lobe involvement.
[NICE’s guideline on tuberculosis, adapted from recommendation 1.8.9.8 and expert consensus]
Assessment
This type of assessment is done by a member of the TB service or the multidisciplinary team, or a person with expertise in respiratory medicine.
The assessment is to gather information about symptoms and general clinical information. Assessments are an ongoing process and should be reviewed and amended during the treatment period.
[Expert consensus]

Equality and diversity considerations

Healthcare professionals who are doing assessments on people who have imaging features suggestive of active TB should be aware that many of these people come from under-served groups. These groups may find it difficult to access TB services because of a lack of awareness of TB and its treatment and because of the stigma associated with a diagnosis of TB. 

Directly observed therapy

This quality statement is taken from the tuberculosis quality standard. The quality standard defines clinical best practice for tuberculosis and should be read in full.

Quality statement

People with active tuberculosis (TB) from under-served groups are offered directly observed therapy.

Rationale

The complex social and clinical interactions surrounding a person with TB can be a challenge to treatment participation and adherence. Suboptimal uptake of, and adherence to, TB treatment for people with active TB can lead to increased morbidity and mortality, increased infectiousness, and the emergence of drug resistance. Enhanced case management including directly observed therapy is key to improving treatment adherence and completion, in particular in relation to vulnerable groups or those at risk of non-adherence.

Quality measures

Structure
Evidence of local arrangements to ensure that people with active TB from under-served groups are offered directly observed therapy.
Data source: Local data collection.
Process
a) Proportion of people with active TB who are homeless who have directly observed therapy.
Numerator – the number in the denominator who have directly observed therapy.
Denominator – the number of people with active TB who are homeless.
Data source: Local data collection.
b) Proportion of people with active TB who misuse substances who have directly observed therapy.
Numerator – the number in the denominator who have directly observed therapy.
Denominator – the number of people with active TB who misuse substances.
Data source: Local data collection.
c) Proportion of people with active TB who have been in prison who have directly observed therapy.
Numerator – the number in the denominator who have directly observed therapy.
Denominator – the number of people with active TB who have been in prison.
Data source: Local data collection.
d) Proportion of people with active TB who are vulnerable migrants who have directly observed therapy.
Numerator – the number in the denominator who have directly observed therapy.
Denominator – the number of people with active TB who are vulnerable migrants.
Data source: Local data collection.
Outcome
a) Proportion of people from under-served groups with active TB lost to follow-up.
Data source: Local data collection. National and regional data on the proportion of people with drug-sensitive TB who were lost to follow-up at last reported outcome are collected in Public Health England’s TB Strategy monitoring indicators.
b) TB treatment completion rates for people from under-served groups.
Data source: Local data collection. National and regional data on the proportion of people with drug-sensitive TB with at least 1 social risk factor who completed treatment within 12 months are collected in Public Health England’s TB Strategy monitoring indicators.
c) TB treatment completion rates for people from under-served groups with multidrug-resistant TB.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that people with active TB from under-served groups are offered directly observed therapy as part of enhanced case management.
Health and social care practitioners (such as a nurse or lay person supported by a healthcare professional) offer directly observed therapy as part of enhanced case management to people with active TB from under-served groups.
Commissioners (clinical commissioning groups) ensure that they commission services that have the capacity to provide directly observed therapy as part of enhanced case management for people with active TB from under-served groups.
People with active TB who are likely to find it difficult to take their medicine regularly are offered the choice of meeting a specific healthcare worker each time they take a dose of anti-TB medicine.

Source guidance

Tuberculosis (2016) NICE guideline NG33, recommendation 1.7.1.3

Definitions of terms used in this quality statement

Under-served groups
This term includes people of any age, and from any ethnic background regardless of migration status. Groups classified as under-served include:
  • people who are homeless
  • people who misuse substances
  • people who have been in prison
  • vulnerable migrants.
[Adapted from NICE’s guideline on tuberculosis, ‘Terms used in this guideline’ section]
Directly observed therapy
This involves a trained health professional, or responsible lay person supported by a trained health professional, providing the prescribed TB medicine and watching the person swallow each dose. Directly observed therapy should be considered as an integral part of enhanced case management in complex cases such as those from under-served groups.
[Adapted from NICE’s full guideline on tuberculosis, section 9.2.6 and glossary]

Equality and diversity considerations

Healthcare professionals, and lay people supported by healthcare professionals, who are involved in providing directly observed therapy for people with TB from under-served groups should be aware that people from these groups face barriers to treatment completion. They may find it difficult to express what these barriers are and may feel stigmatised because of their diagnosis of TB. All communication with people with TB from under-served groups should be sensitive to their needs.

Accommodation

This quality statement is taken from the tuberculosis quality standard. The quality standard defines clinical best practice for tuberculosis and should be read in full.

Quality statement

People with active pulmonary tuberculosis (TB) who are homeless are offered accommodation for the duration of their treatment.

Rationale

Rates of active TB are high in people who are homeless. They also have a higher risk of delayed diagnosis, drug resistance, onward transmission and poor treatment outcomes. Providing accommodation for people who are homeless who have active TB helps to ensure they are not lost to follow-up for their TB care, promotes treatment adherence and completion of therapy, and reduces the probability that antimicrobial drug resistance will occur in the TB bacteria. It also helps them to have social stability and space to recover from their disease and to care for themselves.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people diagnosed with active pulmonary TB who are homeless are identified.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people diagnosed with active pulmonary TB who are homeless are offered accommodation for the duration of their treatment.
Data source: Local data collection.
Process
Proportion of people with active pulmonary TB who are homeless who are provided with accommodation for the duration of their treatment.
Numerator – the number in the denominator who are provided with accommodation for the duration of their treatment.
Denominator – the number of people with active pulmonary TB who are homeless.
Data source: Local data collection.
Outcome
a) TB treatment completion rates for people with active pulmonary TB who are homeless at the time of diagnosis.
Data source: Local data collection. National and regional data on the proportion of people with drug-sensitive TB and at least 1 social risk factor who completed treatment within 12 months are collected in Public Health England’s TB Strategy monitoring indicators.
b) TB prevalence rates.
Data source: Local data collection.
c) TB incidence in homeless people.
Data source: Local data collection. National and regional data on TB incidence in England is collected in Public Health England’s TB Strategy monitoring indicators.

What the quality statement means for different audiences

Service providers (secondary care services) have systems in place to identify people with active pulmonary TB who are homeless and ensure that they are provided with accommodation for the duration of their treatment.
Health and social care practitioners (TB multidisciplinary teams) assess the living circumstances of people with active pulmonary TB. If there is a housing need, they work with allied agencies to ensure that the person who is homeless has accommodation for the duration of their treatment.
Commissioners (local government and clinical commissioning groups) fund accommodation for people who are homeless and diagnosed with active pulmonary TB using health and public health resources, in line with the Care Act 2014.
People with active pulmonary TB who are homeless, or living in overcrowded accommodation with people at high risk of undetected TB, are given somewhere to live while they are receiving treatment for TB.

Source guidance

Tuberculosis (2016) NICE guideline NG33, recommendations 1.8.11.1, 1.8.11.2 and 1.8.11.3

Definitions of terms used in this quality statement

Homeless
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 TB (that is, people with a history of rough sleeping, hostel residence or substance misuse)
  • who are ineligible for state-funded accommodation
  • without the means to securely store prescribed medication
  • without secure accommodation for the full duration of planned treatment.
[Adapted from NICE’s guideline on tuberculosis, ‘Terms used in this guideline’ section and recommendation 1.8.11.3]
Accommodation
A secure, self-contained single room environment that is adequately heated and has facilities for bathing and for preparing food.
[Expert opinion]

Equality and diversity considerations

It is important to provide people who are homeless with accommodation for the duration of their treatment in order to prevent their homelessness from being a barrier to accessing services and completing treatment. Providing accommodation helps to remove the inequality between people who are homeless and people with secure accommodation.

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Implementation

NICE has produced resources to help implement its guidance on:

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

Your responsibility

Guidelines

The recommendations in this interactive flowchart 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. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. 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 interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-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.
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
Nucleic acid amplification test
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 interactive flowchart 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 interactive flowchart, 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 interactive flowchart, 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 interactive flowchart 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 interactive flowchart 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
Adenosine deaminase assay
Meningeal
CT
MRI
Cerebrospinal fluid
Microscopy
Culture
Cytology
Nucleic acid amplification test
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
Adenosine deaminase assay

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
Nucleic acid amplification test
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
Nucleic acid amplification test
Adenosine deaminase assay

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
Adenosine deaminase assay

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)
  • 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.
Used in this interactive flowchart 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 interactive flowchart 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.

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: June 2017

© NICE 2017

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