Tuberculosis: management, control and prevention - PowerPoint Presentation

Tuberculosis: management, control and prevention Developed by: In partnership with:

The Truth About TB is a national programme that raises public and professional awareness of tuberculosis. This training resource has been developed by TB Alert, the national tuberculosis charity, in partnership with NHS England and Public Health England.

Aims and objectives Aim: to recognise how TB presents and to enhance early diagnosis and treatment through prompt referral to TB Specialist Services. Objectives: To provide an overview of the identification, prevention and treatment of Tuberculosis (TB) in your area of clinical practice. We will cover: e pidemiology a etiology and pathogenesis r isk factors early diagnosis t he impact of delay in diagnosis treatment of TB LTBI testing and treatment r ole of TB Specialist Services.

What is tuberculosis? TB is a bacillus, meaning rod shaped bacteria; it is from the genus mycobacteria .TB most usually affects the lungs but it can affect other parts of the body. Only TB of the lungs or throat is infectious. TB is an airborne disease which can be cured. TB is transmitted to others when a person with infectious TB coughs, talks, sings, laughs or sneezes. TB is a notifiable disease under Public Health (Control of Disease) Act 1984. TB incidence is decreasing globally, and has decreased in the UK since 2011.

Epidemiology of TB

TB notifications and rate, England, 2000-2014 Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS). Data as at: March 2015. Prepared by: TB Section, National Infection Service, PHE

TB notifications and rate by PHE Centre, England, 2000-2014 Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS). Data as at: March 2015. Prepared by: TB Section, National Infection Service, PHE

Three-year average tuberculosis case rates by local authority, England, 2012-2014 Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS). Data as at: March 2015. Prepared by: TB Section, National Infection Service, PHE

TB notifications and rates by place of birth, England, 2000-2014 Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS). Data as at: March 2015. Prepared by: TB Section, National Infection Service, PHE

Most frequent countries of birth for TB notifications and time, in years, between UK entry and notification (for non-UK born cases), England, 2014Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS). Data as at: March 2015. Prepared by: TB Section, National Infection Service, PHE Country of birth Cases no. Cases % Median time since entry United Kingdom 1,774 28.2 - India 1,288 20.5 7 (3 -14) Pakistan 791 12.6 10 (3 -25) Somalia 230 3.7 10 (3.5 -14.5) Bangladesh 207 3.3 8 (4 -19) Nepal 168 2.7 4 (3 -9) Nigeria 118 1.9 7 (2 -17) Philippines 111 1.8 9 (4 -13) Zimbabwe 107 1.7 11 (9 -12) Afghanistan 96 1.5 8 (4.5 -13) Romania 88 1.4 1 (0 -6) Eritrea 83 1.3 3 (0 -8) Kenya 81 1.3 19 (8 -41) Sri lanka 78 1.2 11 (4 -15) Poland 70 1.1 6 (2 -8) Others (each <1%) 1,007 15.8 8 (3 -16) Total 6,297 100.0 9 (3 -20)

Local epidemiology 2013 2014 Total notifications Incidence (n/100,000) UK born (%) Non-UK born (%) Pulmonary disease Extra-pulmonary disease

Local epidemiologyADD a local map showing the local burden of TB – possibly by LSOA (available from PHE’s Field Epidemiology Service)

Aetiology, pathogenesis and transmission of TB

Droplet nuclei containing TB bacilli are inhaled, enter the lungs, and travel to the alveoli. TB bacilli multiply in the alveoli.

A small number of TB bacilli enter the bloodstream and spread throughout the body. The bacilli may reach any part of the body. Within 2-10 weeks, the immune system produces immune cells called macrophages that surround the TB bacilli. The cells form a hard shell called a granuloma that keeps the bacilli contained and under control ( latent TB infection ).

If the immune system cannot keep the bacilli under control, the bacilli begin to multiply rapidly ( TB disease). This process can occur in different places in the body, such as the lungs, kidneys, brain, or bone. Of those infected: 5 % will progress to disease usually in the first two years 5 % will progress to disease some time in their lifetime

Risk factors for TB

Vulnerable groups Risk factors Overcrowding Homelessness Poor housing Older people Low income Poor nutrition Lack of resources and information Cultural / language barriers New immigrants, refugees Asian / African groups Children People with co-infection: HIV , Hep B, Hep C Substance misusers Homeless Prisoners Mental health patients People with co-morbidities: diabetes , immunosuppressive disorders Known TB contacts Immunosuppression, secondary to disease or medications Smoking Vitamin D deficiency

Stigma and TBThe risk factors associated with TB are factors that can themselves create stigma. Stigma can:prevent people seeking helplead to denial once diagnosed deter people from attending appointments or taking treatmentmake contact tracing difficult. A caring, respectful attitude is essential

Diagnosis and treatment of active TB

Typical presentation of TBGeneral symptoms: fever, night sweats, fatigue, anorexia, weight lossPulmonary symptoms: cough, haemoptysisExtra pulmonary symptoms:localised pain and/or swelling, lymphadenopathy, wounds that won’t heal N.B. extra pulmonary TB can mimic other diseases/conditions Have a high level of suspicion

Think TB!If you see a patient who is unwell, tired, maybe losing weight, maybe feverish, perhaps with swollen lymph glands or a cough for three weeks or longer….. ….. if they come from a high risk group …. could it be TB?

Diagnosis of TB in Primary CarePulmonary TB:refer for CXR andsputum x 3 (microscopy for Acid Fast Bacilli & culture) andblood for FBC, ESR and CRP Extra-pulmonary TB (depends on the site and most likely conducted in secondary care) fine needle aspirate (lymph node), pleural tap (pleural) lumbar puncture (meningitis) MRI scan (bone/joint) Refer EARLY to TB services

Standard treatment for TB is a minimum of 6 months: 2 months (initial phase) of Isoniazid, Rifampicin , Pyrazinamide and Ethambutol. Known as standard quadruple therapy. Followed by:4 months (continuation phase) of Isoniazid and Rifampicin . Known as standard dual therapy N.B. If there is central nervous system involvement the continuation phase of treatment is extended to 10 months making a 12 month full treatment plan. TB treatment is taken all together on an empty stomach 1 hour before breakfast; compliance is essential for cure. Treatment of active TB

Main treatment side effectsIsoniazid: fever, peripheral neuropathy and optic neuritis Pyrazinamide: use with caution in patients with gout Rifampicin: reddish colour to the urine Ethambutol: peripheral neuropathy, optic neuropathy and gout Generally – hepatotoxcity, nausea and skin rashes

Directly observed treatment Directly observed treatment is known as DOT.Each DOT case is assessed by the TB specialist team regarding the patient’s ability to adhere to the six-month treatment regimen.DOT is initiated for those at risk of being unable to adhere to treatment. A professional case worker, person trained to be a DOT observer, or a trusted family member or friend will watch the patient take their TB treatment. Primary care providers, such as GP practices or pharmacists, may be asked to provide DOT. `

Diagnosis and treatment oflatent TB infection (LTBI)

Active TB Latent TB cough, fever, night sweats, fatigue, anorexia, weight loss, haemoptysis asymptomatic requires urgent treatment with at least 6 months of anti-tuberculous treatment can be treated with 3 to 6 months of anti-tuberculous treatment to reduce 5-10% lifetime risk of reactivation may be an infection risk dependent on site and progression of disease never infectious close contacts are screened contacts d o not require screening notifiable disease not notifiable Active or latent TB?

Diagnosis and treatment of latent TB infection (LTBI) Latent TB is diagnosed when a patient has a positive Interferon Gamma Release Assay (IGRA) or a strongly positive tuberculin skin test in the absence of illness. C linical assessment and CXR (+/- CT Scan) are used to rule out active TB. Latent TB is treated with a 3 month course of two antibiotics, Isoniazid and Rifampicin, or a 6 month course of Isoniazid . People with latent TB have a 10–15% lifetime risk of going onto develop active TB disease. Diagnosis and treatment of latent TB infection is recommended for certain populations (see NICE) so that the burden of TB disease is reduced.

National LTBI testing and treatment programme fully-fundedprimary care based LTBI testing secondary care based treatment n ational protocols and pathways national indicators, monitoring and evaluation eligibility criteria for LTBI testing: b orn or spent >6 m in high TB incidence country (≥150/100,000 or SSA) e ntered the UK within the last 5 years (including entry via other countries) a ged between 16-35 years. no history of TB or LTBI, not previously screened for LTBI in UK C heck website: https ://www.gov.uk/guidance/tuberculosis- screening 30

LTBI testing and treatment algorithm 31

Control and prevention of TB

The TB Strategy for EnglandStrategy lists 10 key ‘areas for action’: improving access and early diagnosis high quality diagnostics h igh quality treatment and care services c ontact tracing v accination t ackling drug resistance  t ackling TB in under-served populations n ew entrant screening for LTBI e ffective surveillance and monitoring w orkforce strategy. www.gov.uk/government/publications/collaborative-tuberculosis-strategy-for-england 33 Launched in 2015 Aims to achieve a year-on-year decrease in TB incidence , a reduction in health inequalities and, ultimately, the elimination of TB as a public health problem

Contact tracingContact tracing is usually carried out by TB nurses. Results aid understanding of how infectious the TB index case is – this can inform further public health actions. TB transmission most often occurs among household contacts. Contact tracing is important because: 1% of contacts screened have active TB 10% of contacts screened have latent TB infection 60% of child contacts under 2 years will go onto develop active TB.

Vaccination with BCG The aim of the UK BCG immunisation programme is to immunise those at increased risk of developing severe disease and/or those at increased risk of exposure to TB infection.

Vaccination with BCGBCG immunisation should be offered to: all infants (aged 0–12 months) living in areas of the UK where annual incidence of TB is 40/100,000 or greater all infants (aged 0–12 months) with one or more parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greaterBCG is also offered to previously unvaccinated tuberculin-negative individuals under 16 years of age who are contacts of cases of respiratory TB, and individuals at occupational risk. In some areas, universal vaccination is offered .

Challenges in TB Mono drug resistance Multi drugresistance Duration of treatment Under resourced service Under-served groups Patients with complex needs Stigma Delayed presentation Delayed diagnosis

TB Specialist Services and their role in TB control

TB Specialist ServicesThe TB S pecialist Team includes specialist TB physicians, microbiologists, TB specialist nurses, TB case workers, public health teams and, in London, the Find & Treat Team. The role of the team:i nvestigation, diagnosis and treatment of suspected TB, active and latent co-ordination of care and support for patients on treatment for TB p rovision of support and advice to other services and the public n otification and public health responsibilities c ontact tracing and screening for TB e ducation and training. REFER EARLY

Local TB ServicesADD details of local TB Services HERE

Case study 146 year old male, ethnicity white UK born history of homelessness in the last 5 yearse xtensive drug and alcohol misuse most recent use 1 year agoa prisoner in the Philippines for 2 years, 1 year before presentation; shared a large cell with approx 70 other men, some unwell p resented at A&E after leaving a London prison that day with a mild cough, fevers, night sweats and weight loss h ad been investigated whilst in prison for TB CXR: Left upper lobe consolidation and left hilar lymphadenopathy i nitial microbiology: all 3 sputum specimens smear negative, culture pending bloods: U and Es mildly deranged, raised CRP, low Hb, HIV, Hep B and C negative d iagnosed and given thrice weekly DOT. Sputum cultured MTB some weeks later, housed whilst on TB treatment, fully recovered. Adhered to TB treatment with weekly support and incentives (cash and housing) to remain engaged.

Case study 232 year old male, Indian, born in Delhi, came to the UK 3 years ago presented to GP who referred to ENT, with enlarged and painful clavicular lymph node and 3 kg unexplained weight loss, well otherwiseCXR: normal bloods: raised CRP, mildly low HB, HIV negativemicrobiology: lymph node aspirate smear negative, culture negative h istology: granulomatous inflammation d iagnosed with Lymph Node TB on the basis of histological evidence l ymph nodes initially increased in size and required drainage to prevent bursting, then settled p atient treated with 6 months of standard TB treatment and fully recovered.

Case study 342 year old woman, Black African, born in Zimbabwe, arrived in UK 5 years ago identified through contact tracing of her brother who had sputum smear + pulmonary TB, fully sensitive organismh owever did not attend when invited for screening on 3 separate occasionspresented 3 months later with symptoms: mild dry cough, fevers, night sweats, headaches CXR: bi-lateral apical cavities, CT scan showed intra and extra thoracic lymphadenopathy b ronchoscopy : smear +, culture +, speciation MTB HIV +, newly diagnosed during TB investigations d iagnosed with TB and HIV co-infection t reated with standard TB treatment for 1 year with steroid treatment to reduce the risk of TB IRIS (a paradoxical immune response to TB treatment in at risk groups) commenced treatment for HIV once her TB treatment was well established recovered , however, required neurological rehabilitation and support.

Blank: for your case study (1)

Blank: for your case study (2)

Further information and resourcesTB Alert is the UK's national tuberculosis charity – the only charity working solely on fighting TB in the UK and overseas. The Truth About TB is TB Alert’s awareness programme. For information leaflets or awareness materials to display in your area of work : www.thetruthabout tb .org/resources/awareness-raising-resources For information about TB and patient stories: www.thetruthabout tb .org

References and further readingCollaborative TB Strategy for England 2015-2020: www.gov.uk/government/uploads/system/uploads/attachment_data/file/403231/Collaborative_TB_Strategy_for_England_2015_2020_.pdfTuberculosis: NICE, January 2016: www.nice.org.uk/guidance/ng33 Tuberculosis case management and cohort review, guidance for health professionals, RCN, 2012 (with BTS, PHE, National Treatment Agency for Substance Misuse): www2.rcn.org.uk/__data/assets/pdf_file/0010/439129/004204.pdf National Knowledge Service: www.gov.uk/government/collections/tuberculosis-and-other-mycobacterial-diseases-diagnosis-screening-management-and-data#nks-tb-treatment-and-management-advice

References and further reading (cont’d)PHE website (Tuberculosis) – for TB annual report: www.gov.uk/government/collections/tuberculosis-and-other-mycobacterial-diseases-diagnosis-screening-management-and-data PHE screening webpages: www.gov.uk/guidance/tuberculosis-screening PHE migrant health web pages: www.gov.uk/topic/health-protection/migrant-health-guide TB Alert’s national awareness programme The Truth About TB: www.thetruthabout tb .org Immunisation against infectious disease, DH, 2006: www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

Thanks and creditsTB Alert and Public Health England would like to thank Professor Chris Griffiths, Professor of Primary Care at Barts and The London, for chairing its primary care expert advisory group. We are also grateful to our advisers Steve Bradley, Dr Gill Craig, Katie Dee, Ann Dennis, Anna Hinton, Dr Mike Lane, Dr Jane Leese , Dr Justin Sacks, Dr Noel Snell, Natalie Winter and Heggy Wyatt. This resource was written by Cheryl Giles, TB specialist nurse at Brighton and Sussex University Hospitals. Dr Anjana Roy of Public Health England coordinated the surveys that informed this work, project management was by Dr Thoreya Swage, and project coordination by Mike Mandelbaum for TB Alert and Surinder Tamne for Public Health England. This teaching resource was developed alongside an e-learning course for primary care clinicians, available on the Royal College of GPs website at www.elearning.rcgp.org.uk/tb . 2016 update by Sarah Anderson, Jennifer Davidson, Gini Williams and Dominik Zenner,

Developed by TB Alert under The Truth About TB programme. In partnership with NHS England and Public Health England.