Tuberculosis (TB): clinical diagnosis and management of tuberculosis and measures for its prevention and control

1. Tuberculosis (TB): clinical diagnosis and management of tuberculosis and measures for its prevention and control March 2006

2. What this presentation covers • Background to NICE clinical guidelines • Rationale for the TB guideline • Key messages and priorities in the guideline • Case studies • Key implementation issues • Where to go for more information

3. Changing clinical practice • NICE guidelines are based on the best available evidence • The Department of Health asks NHS organisations to work towards implementing guidelines • Compliance will be monitored by the Healthcare Commission

4. TB is a growing problem • TB in England and Wales is on the increase • TB is treatable, but it is important to detect it as early as possible

5. Anyone can catch TB • Particular risks are: • close contact • weakened immune systems • poor health and nutrition • poor or crowded housing conditions • living in a high incidence area

6. Tackle priorities – get results • Treatment • Observation • Staying in contact • Screening • Vaccination

7. Use four drugs for 6 months • For active respiratory TB use the standard recommended regimen isoniazid and rifampicin pyrazinamide and ethambutol 2 months 6 months

8. Treat meningeal TB longer • * or another fourth drug • Plus glucocorticoid (dose = prednisolone equivalent) • adults on rifampicin 20–40 mg • adults not on rifampicin 10–20 mg • children1–2 mg/kg, maximum 40 mg • consider gradual withdrawal of the glucocorticoid starting within 2–3 weeks isoniazid and rifampicin pyrazinamide and ethambutol* 2 months 12 months

9. Consider observation • Consider risk factors for adherence to treatment. • Directly observed therapy may be needed for: • street- or shelter-dwelling homeless people with active TB • patients with likely poor adherence, in particular those who have a history of non-adherence

10. Stay in contact • Each person with TB needs a key worker • Incomplete treatment increases the risk of relapse and drug resistance • Key workers can keep treatment on course

11. Screen new entrants • Identify new entrants for TB screening. Use: • Port of Arrival reports • new registrations with primary care • records of entry to education (including university) • links with statutory and voluntary groups working with new entrants

12. Case study – port of arrival • Alexi arrives at Heathrow on a six month visa: • he is asked for his chest X-ray and/or health report • chest X-ray taken and examined • details are entered in a database • If this shows signs of TB: • admitted to hospital or given referral letter • Informing others: • letter is copied to consultant in communicable disease control in area Alex is going to live • What next?

13. Vaccinate at-risk neonates • Vaccinate neonates at increased risk of TB, after discussion with parents or legal guardian • Consider: • place of birth • family members’ places of birth • family history

14. Key implementation issues • Address communication/language barriers • Monitor impact on laboratory services because of an increased need for liquid cultures and diagnostic tests • Make sure that patients are referred to appropriately trained workers

15. Bob is a practice nurse in a primary care trust that has a TB prevalence rate of 40 per 100,000 population. In the past 8 years he has come across only one TB patient. His primary care trust has sent him on a training session for the Mantoux test. Bob is nervous about carrying out the test and about reading the results correctly. Case study – practice nurse

16. Work with partners • Who are the key agencies outside the NHS? • Local authorities • Social services • Housing services • Prison services • Voluntary sector services

17. Work with prisons • Raise awareness of TB symptoms among staff and prisoners • Screen prisoners for TB • Carry out directly observed therapy within prisons • Prison medical services should draw up a contingency plan for those leaving prison with TB to ensure continuity of care

18. Make best use of resources • Diagnose in specialist TB clinics • Free up resources by continuing care in general practice

19. Implement in stages • STEP 1: Identify potential partner agencies • STEP 2: Carry out baseline assessment of impact on: • patient numbers • staffing • equipment and training • budgets • service provision • STEP 3: Assess resource requirement • STEP 4: Develop an action plan • STEP 5: Develop, review and monitor progress against audit criteria

20. Access tools online • Costing tools • costing report • costing template • Audit criteria • Implementation advice • Available from: www.nice.org.uk/CG033

21. Access the guideline online • Quick reference guide – a summary www.nice.org.uk/CG033quickrefguide • NICE guideline – all of the recommendations www.nice.org.uk/CG033NICEguideline • Full guideline – all of the evidence and rationale www.nice.org.uk/CG033fullguideline • Information for the public – a plain English version www.nice.org.uk/CG033publicinfo

22. Everyone has a part to play • This guideline should help healthcare professionals to: • diagnose primary cases • identify secondary cases • treat active disease • control latent infection • prevent transmission