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Health protection: Tuberculosis (TB) - blog by Dr Paul Cosford

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P Cosford 2013To commence our themed day on tuberculosis as part of ‘Protecting Health: Nursing and Midwifery Successes and Challenges,’ I am delighted to introduce a blog by Dr Paul Cosford, Director for Health Protection and Medical Director at Public Health England:

It’s a really exciting time of year for PHE and TB with our collaborative strategy for consultation in its final stages of development, and World TB Day on March 24th.  Since PHE’s establishment last year, we’ve made TB one of our main priorities.  We’re leading a coalition of key stakeholders that make up a National TB Oversight Group to develop this stronger national approach, and local TB Boards have been established in London and are being set up in other areas with a high TB burden.

TB rates in the UK have increased over the last two decades, and the UK now has one of the highest incidence rates of any Western European country. Within the UK, TB is very unequally distributed, with certain sub-groups, such as migrants, ethnic minority groups, and those with social risk factors such as homelessness and history of imprisonment disproportionately affected. Action is required to ensure that best practice in prevention, control and treatment is delivered to all communities across the country.

Although recently improved NHS TB services aimed at early diagnosis and initiatives to prevent transmission in hard-to-reach groups are in place, these measures are unlikely to reverse the problem. Present trends of TB in the UK suggest that within the next 2 years, the UK will have more new TB cases than the whole of the USA (Figure 1 Trends in TB USA/UK comparison )!

At its heart, the strategy will provide support to local clinical, preventive and social care services in the NHS, local government and wider health and social care system. Many of the actions needed to eliminate the burden of TB require strengthened and more integrated local services which ensure consistent, evidence based prevention, treatment and support to patients, their families and other contacts, especially so because  TB does not exist in isolation from other health and social concerns. We are determined to see a sustained reduction in TB, and will work tirelessly to support local partners in those areas where the burden is greatest to achieve a year-on-year reduction of new cases.

The local control programme, through the establishment of TB Control Boards, would ensure accountability and coordination of activities between public health, local government and the NHS. Measures to be implemented would include those aimed at identifying and treating latent infection before it becomes disease, preventing transmission within the UK, preventing development of drug resistance and diagnosing active TB earlier.

The anti-microbial resistance (AMR) picture painted by Professor Watson and Carole Fry’s blog on Tuesday rings very true with the TB treatment, and we frequently detect multi-drug resistant (MDR) TB, and even extensively drug resistant strains (XDR). 

But is this a significant problem for us? Absolutely!  Resistance to at least one antibiotic of first choice in the treatment of TB is just over seven per cent. This means that of the four choices of antibiotic typically used, one does not work to treat the condition in over 7 in 100 cases. In a further 1-2 in 100 cases, the two best drugs out of a possible four choices may not work. History tells us that if we do not act now, the problem is likely to get worse with time.

All of our nurses in hospitals, general practices, the community and schools, as well as health visitors and midwives (not just our excellent specialist TB nurses!) have essential frontline roles to play in  TB control – whether this is identifying symptoms, advising other healthcare professionals, appropriate infection helping to prevent the emergence of antibiotic resistance, responding to TB incidents and outbreaks in settings such as schools, and ensuring that they themselves are also protected and screened if needed. 

Community-based nurses have an important role to play in providing BCG vaccine, in particular in identifying children who have arrived from high prevalence countries abroad, or who live in areas with high TB case rates.  We also wouldn’t be able to produce such a comprehensive TB Annual Report without the data provided by our nurses – as well as physicians, microbiologists and surveillance officers from across the UK - and TB nurses are integral members of multi-disciplinary teams across the country.

We all need to work together not only to create the vision and ambition to eliminate TB, but to deliver the leadership, coordination and effective services required to make a real difference to this significant public health challenge. 

Why not make a commitment to making a difference in this area by making a pledge as part of NHS Change Day. Go to Protecting Health Campaign Pledge to sign up to our pledge or make your own by visiting NHS Change Day

References and further reading

D Zenner, A Zumla, P Gill, P Cosford, I Abubakar (2013) Reversing the tide of the UK tuberculosis epidemic. The Lancet, Volume 382, Issue 9901, Pages 1311 - 1312, 19 October 2013

TB NICE Guidelines

NHS Conditions Information,

Tuberculosis in the UK: Annual report on tuberculosis surveillance in the UK, 2013. London: Public Health England, August 2013

 The Truth About TB, TB Alert

Figure 1: Trends in the annual number of cases of tuberculosis in the UK compared with the USA. Dotted lines show projected numbers, assuming present annual percentage change continues for 2 more years. (Based on data from Public Health England (UK) and the Centers for Disease Control and Prevention (USA).)

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