IOSH Presentation 2012

Kim Cartlich 2012Tuberculosis

Aims • Basic awareness of Tuberculosis (TB)

• Gain knowledge of the disease process

• Be aware of local epidemiology / prevalence

• Recognise why TB is making a come back

• To understand the role of BCG vaccination and who requires it

• Know the role of the TB nurse

• Where to seek advice

What is TB?

• TB is an airborne communicable disease

• TB is caused by a bacteria called mycobacterium tuberculosis

• It is spread by tiny airborne particles expelled by individuals with infectious TB by cough, sneeze or spit

• If another person inhales air containing these bacteria transmission can occur

• TB bacteria prefer the lungs but can infect any organ in the body

• Consumption • Galloping consumption• Scrofula• Kings Evil • White plague• Phthisis

Famous people who had TB• Bronte sisters• Robert Burns• George Formby• Desmond Tutu• Eleanor Roosevelt• Vivian Leigh• Tom Jones • Nick Knowles

TB History

“It was the fashion to suffer from the lungs; poets especially; it was good form to spit blood after any emotion that was at all sensational, and to die before reaching the age of thirty.”Alexandre

Dumas

Past treatment for TB

2010/2011 TB Global facts

• 1.7 million people died from TB in 2009• This is equal to 4700 deaths per day• There were 9.4 million new TB cases in 2009• In 2010 the WHO reported the highest ever rates of MDR TB,

with peaks of 28% in some settings of the former soviet Union• XDR TB cases have been confirmed in 58 countriesHowever !• 2008 saw the highest level ever of people successfully treated

at 86%World Health Organisation 2012

Why the resurgence?

• Migration

• Poverty / war / civil unrest

• HIV

• Longevity

• Poor treatment and control in third world countries

Figure 1.4. Three-year average tuberculosis case rates by local areas*, UK,

2008-2010

Sources: Tuberculosis in the UK: Annual report on tuberculosis surveillance in the UK, 2011. London: Health Protection Agency. December 2011.

*England – Local Authorities,Scotland – NHS Boards, Wales – Local Health Boards, NI – data not available.

Figure 1.3. Tuberculosis case reports and rates by region, England, 2010

Sources: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS) mid-year population estimates. Data shown in Appendix B; ii, iii. Prepared by: TB Section - Health Protection Services, Colindale.

Lond

on

Wes

t Midl

ands

North

Wes

t

South

Eas

t

Yorks

hire

& the

Humbe

r

East M

idlan

ds

East o

f Eng

land

South

Wes

t

North

Eas

t0

500

1,000

1,500

2,000

2,500

3,000

3,500

0

5

10

15

20

25

30

35

40

45

50Number of cases

Region

Nu

mb

er

of

ca

se

s

Ra

te (

pe

r 1

00

, 00

0)

CI – Confidence interval

Figure 1.1. Tuberculosis case reports and rates, UK, 2000-2010

CI - Confidence interval

Sources: Enhanced Tuberculosis Surveillance (ETS). Enhanced Surveillance of Mycobacterial Infections (ESMI). Office for National Statistics (ONS) mid-year population estimates.

Prepared by: TB Section - Health Protection Services, Colindale.

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

0123456789101112131415

Number of cases

Year

Nu

mb

er

of

ca

se

s

Ra

te (

pe

r 1

00

, 00

0)

Figure 1.6. Tuberculosis case reports by place of birth and region/country, UK, 2010

*Numbers of cases stated in bars

Sources: Enhanced Tuberculosis Surveillance (ETS). Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS) mid-year population estimates. Prepared by: TB Section - Health Protection Services, Colindale.

England (95%)

Northern Ire

land (94%)

Scotla

nd (79%)

Wales (93%)

London (9

8%)

South East

(90%)

East Midlands (9

6%)

East of E

ngland (94%)

West Midlands (9

5%)

Yorkshire

& th

e Humber (87%)

North W

est (93%)

North East

(83%)

South W

est (86%)

0%10%20%30%40%50%60%70%80%90%

100%55

04

35 208

69

2713

519

353

322

553

361

488

71

124

1837

27 194

73

511

157

121

125

281

194

286

47

115

Non-UK-Born UK-born

Country/Region (% where place of birth known)

Perc

enta

ge o

f cas

es*

How is TB caught

• TB bacteria inhaled• Most lodged in the upper

respiratory tract (70-90%)• Some may reach the lungs

and multiply (10-30 %)• 2-10 weeks after infection

immune system usually intervenes and prevents spread of infection (latent)

• Only 10 % will go on to develop TB at some time in their life time

Signs & Symptoms of TB

• Cough

• Weight loss

• Night sweats

• Chest pain

• Extreme tiredness and lethargy

• Coughing up blood

TB Treatment • TB treatment in the UK is

free to the patient

• Medication is taken for minimum of 6 months

• Key to cure is concordance

• Occasional side effects

• Closely monitored

• Poor concordance can result in drug resistance

• Drug resistant TB is much more difficult to treat and much more expensive

Who is at risk of catching TB?• Elderly

• The very young (under 2yrs)

• Those with weakened immune systems e.g. HIV

• Pre existing lung conditions

• Homeless / alcoholics / Drug addicts

• Travel to a high risk area i.e.. more than 3 months

• New entrants to the country from high risk areas are most at risk in the first 3-5 years of settling in their chosen country of reactivating any latent TB

MDR TB and XDR TB

Multi drug resistant TB

Extensively drug resistant TB

• Poor treatment compliance

• Single drug therapy

• Poor calculation or regimes

• Malabsorption of drugs

• Prescribing / dispensing errors

Map showing MDR TB 2010

Why the problem

• Gaps in TB control• Extremely weak services

M/XDR-TB • management and care• Health workforce crisis• Inadequate laboratories• Quality of anti-TB drugs not

assured• No restriction or regulation of

anti-TB drug use• Absent infection control• Insufficient research• Major financial gaps

How to protect against TB

There is no 100% protection against TB

• BCG vaccination affords some protection ,for high risk groups• Knowledge about the disease is the best defence• Knowing who to contact for advice• Seeking professional advice if you know you have come in contact with a

case of TB• Promote general good cough hygiene

Remember ! TB is not as infectious as you think

The TB team

TB Clinicians

HPATB

Nursing Team

TB Incident , What to expect

Incident involving large numbers i.e. educational, establishment, nursing residential home ,prison , factory

• Health protection agency lead • Incident meeting is held , all relevant parties invited all

information is assessed. • Plan of action –timetable, screening , communication ,

press statements, • TB nurses screen, collate results inform HPA • Further meeting to assess need for further screening • Final outcome meeting

The role of the TB nurses• To support and visit all newly notified TB patients

• To instigate TB contact tracing

• Hold TB screening clinics in the community and Hospital setting

• Provide nurse Led prophylaxis clinic

• To provide a BCG vaccination service

• To screen new entrants from high prevalence areas of TB

• To and act as a resource for information on TB

Useful contact numbers

North Yorkshire & Humber Health Protection unit 01904 468900

TB Nursing Team CHCP 01482 617994