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