GP Perspective on Tb

1. GP Perspective on Tb John Staniforth 2008

2. Rugby Surgery Practice Area 2004

3. Introduction – Rugby Surgery

4. NPHSW Prevention and Control of Tb in Wales Appendix 3 Responsibilities of GP 1 • Surveillance: Maintain a high index suspicion Tb in those with risk factor • Specimens: Arrange collection specimens for microbiological testing from patients with suspected Tb • Referral: Arrange prompt referral of patients with suspected Tb to Tb physician/paediatrician at local hospital . • Prescriptions: Ensure no unreasonable delay

5. NPHSWResponsibilities of GP 2 5. New Registrations : on registration document country of origin; ask about Tb related symptoms; history of TB (R109 NICE) 6. New Registrations: Identify infants and children in high-risk groups who should have BCG vaccine (Health visitors input valuable here) Flag case notes as reminder to consider Tb if compatible symptoms in future 7. Case Conference – GP or deputy who knows the patient to attend to discuss cases possible DOT .

6. NPHSW Prevention Tb 3 9. Best Practice : Implement guidance at all times 10. Awareness: Promote awareness new national BCG programme amongst relevant staff and patients 11. Support the patient: during therapy and report concerns about adherence or side-effects to Tb physician or nurse

7. NICE/RCP Recommendations 1 R43: Patients advised to report symptoms of relapse and how to contact Tb service rapidly through primary care or Tb clinic • Key worker to ensure patient at increased risk of relapse is well informed about symptoms

8. NICE/RCP Recommendations 2 • R74PCOs with a high incidence of Tb should consider BCG vaccine all neonates soon after birth • R78 In low incidence areas PCOs should offer BCG to selected neonates who: • Were born in a high incidence area • Have one or more parents or grandparents born in a high incidence country • Is born into a family where a member has had Tb within the last 5 years

9. NICE/RCP Recommendations 3 • R106: Healthcare professionals including Primary Care staff responsible for screening new entrants should maintain a coordinated programme to: • Detect active Tb and start treatment • Detect latent Tb and start treatment • Provide BCG vaccination to those in high risk groups and those previously unvaccinated • Provide relevant information to all new entrants

10. NICE/RCP Recommendations 4 • R109: New Entrants should be identified for Tb screening from: • New Registrations in Primary Care • PofA report • Educational entrants including university • Contacts with statutory and voluntary groups with new entrants

11. New Entrants into UK • Types of Migration • Legal migrants • Overseas students • Asylum Seekers and refugees • Tb Risk Assessment • Enquiry concerning current symptoms possible TB • Enquire about past history of TB • Check for BCG scar • Arrange CXR and sputum sampling if indicated • Refer Chest Clinic if suspicion possible TB

12. New Entrants into UK 1NICE guidance R108 • Predictors of Tb Diagnosis • A chest x-ray suggestive of Tb is the only significant predictor of a diagnosis of TB (95.8% of those diagnosed with TB have an abnormal CXR (12.8.5) • A symptom questionnaire is less accurate in predicting active TB than CXR (survey East Timor Refugees to Australia 2002 • Assessment of New Entrants should include • Chest x-ray if not performed recently • Unless age under 11 years or possibly pregnant • Clinical assessment if abnormal CXR • Risk assessment for HIV • Mantoux test if normal recent CXR and • Younger than 16 years old or • Aged 16-35 from sub-Saharan Africa or country with Tb incidence >500/100k • Mantoux test for children younger than 11 years and pregnant women

13. New Entrants into UK 2NICE Guidance R108 • Interferon Gamma Test if • Mantoux positive 6mm< if not had BCG • Mantoux strongly positive 15mm< if had BCG • IGT positive – assess for active TB. CXR if not contraindicated • Treat for latent TB if • Younger than 35 and positive Mantoux inconsistent with BCG history and positive IGT and who are • Younger than 16 or • Age 16 – 35 from sub-Saharan Africa or country with Tb incidence >500/100k • Consider BCG vaccination if Mantoux negative • Inform and Advise: people without active Tb and not being offered BCG or treatment for latent TB

14. Surveillance Recognising Risk Factors for Tb • Close contacts of infectious cases • High prevalence regions – residents of, visitors to or contacts with those from HPR • Ethnic minority originating from HPR • Impaired immunity – HIV, very young or very old • Chronic poor health – Alcoholism, drug abuse, homelessness • Poor or crowded housing – hostel residency

15. Surveillance for Symptoms of TB • Pulmonary Tb • Chronic cough • Weight loss • Intermittent fever • Night sweats • Haemoptysis • Non- Pulmonary Tb • Fever • Weight loss • Unexplained symptoms

16. Spectrum of Tuberculous Disease 1 • Adrenal – Addison’s disease • CNS – meningitis which may be chronic: tuberculoma • Eye – choroiditis iridocyclitis phlyctenular conjunctivitis • Gut – especially ileocaecal; peritoneal with ascites • Genitourinary – kidney epididimis salpingitis tubal abscess • Lymph node – especially hilar and paratracheal; scrofula • Pericardial – constrictive pericarditis • Skeletal – arthritis osteomyelitis cold abscess vertebral body may cause cord compression (Potts paresis) • Skin – lupus vulgaris

17. Spectrum of Tuberculous Disease 2 • Tb Meningitis chronic headache lassitude anorexia vomiting. Meningism may take several weeks to develop: drowsiness, focal signs or seizures • Gut anorexia , weight loss, diarrhoea, abdominal pain, possible palpable mass. 50% have evidence pulmonary TB • Genitourinary sterile pyuria send EMU for culture also craggy epididimal swelling, cold loin abscess, urethral obstruction and hydronephrosis • Skeletal Paraspinal pain, swelling and discharge with malaise fever night sweats. Arthritis usually one joint: spine 50% hip or knee 30%; sacroiliac/other joint 20%. Pain, swelling oedema, stiffness, caseating granuloma, malaise, anorexia, night sweats. Psoas abscess

18. Spectrum of Tuberculous Disease 3 • Miliary TB • May occur at any time within 3 years of onset TB infection • May occur even later after reactivation or re-infection • Symptoms non-specific: malaise weight loss fever • Occasionally presents as TB meningitis • Often no signs at first but hepato-splenomegaly develops later with choroidal retinal tubercles • CXR may appear clear as miliary shadows not visible until 1 -2 mm diameter • Mantoux may be negative in severe disease

19. Recognising TB Case History • Tb may have unusual presentations which can be difficult to recognise at first • Mrs C – 36 year old lady • H/O Recent pain and swelling Right posterior thoracic area • O/E smooth poorly defined swelling. No fever No LAN Not tender Not inflamed. Imp Lipoma / Intercostal strain– temporise Review 1wk if problem • Attended A&E – CXR NAD see GP for further review – lump more painful now so refer as diagnosis uncertain • June 2003 Urgent referral surgeons • July 2003 Surgery OPA for CT scan ref Chest Clinic • Aug 2003 Chest clinic for aspiration/biopsy • Sept 2003 MTb start quadruple therapy

20. Supporting the Patient During TreatmentPotential Side Effects of TB Drugs 1 • Isoniazid • peripheral neuropathy is most common • Hepatitis– especially if alcohol dependence or pre-existing liver disease • Optic neuritis • Blood dyscrasias • Convulsions • Psychosis • Ethambutol (suspect if any subjective visual change) • Visual loss – test by Snellen chart pre treatment • Colour blindness • Restricted visual fields

21. Supporting the Patient During TreatmentPotential Side Effects of Tb Drugs 2 • Rifampicin – six known syndromes • Abdominal syndrome – colitis – anorexia nausea vomiting diarrhoea; liver failure • Influenza like illness – chills dizziness fever bone pain • Acute Renal failure • Respiratory syndrome - breathlessness • Shock - collapse • Thrombocytopenic purpura- also toxic epidermal necrolysis, pemphigoid • Urine, saliva and other body secretions coloured orange-red • Pyrazinamide • Liver toxicity • Gout • Diabetes • Sideroblastic anaemia

22. Supporting the Patient During TreatmentPotential Side Effects TB Drugs 3 • Streptomycin (Rarely used UK unless resistant organism) • Ototoxiciy • Renal toxicity: Excretion mainly renal. • Monitoring plasma levels and renal function very important • Impaired neuromuscular function c • contraindicated in Myasthenia Gravis • Stomatitis • Colitis • Side Effects increase after a cumulative dose of 100G – exceed only in exceptional circumstances • Intramuscular injection: dose 15mg/kg (max 1G) once daily • Reduce dose if weight <50kg or age 40y< • Poorly soluble – takes at least 5 minutes of vigouous shaking to dissolve

23. Monitoring TB Drug Therapy • Liver function test • Isoniazid, rifampicin and pyrazinamide can cause liver toxicity • Rifampicin may cause mild abnormal LFTs during initial phase treatment • Pre-treatment baseline LFT • If baseline LFT normal repeat if symptoms of fever malaise vomiting jaundice or unexplained malaise • If baseline LFT abnormal or alcohol dependent regular LFT (2 weekly) especially in first two months • Renal function • Avoid streptomycin or ethambutol if impaired renal function or reduce dose and monitor plasma drug levels and U&E regularly • Vision • check acuity pre treatment Ethambutol and if any symptoms visual change

24. Case Study – Problems with Liver function while on Tb therapy • A 32 year old female patient • March 2007 diagnosed rifampicin resistant cervical lymph node TB • June 2007: Reviewed by TB nurse continue isoniazid and ethambutol. Reporting skin irritation • July 2007 Returned from 3 week trip to Pakistan – developed malaise, nausea, pyrexia, rigors, retching • Urgent Bloods: ALT 3,150 BR 83 • Admission RGH –CXR clear Malaria screen negative Hepatitis A positive • Discharged ethambutol only • August 2007 Follow up clinic – problem whether able to restart isoniazid. Referred to gastroenterology for advice

25. Where Does the GP Fit Into Tb Surveillance and Management? • 47% Cases of Tb are diagnosed in primary care • GP has the advantage of continuity of care – we have comprehensive patient records, often know the patient and their family personally • GP also has close working relationship with District Nurse, Practice Nurse, Health Visitor and Community Pharmacist • GP is an easily identifiable and recognisable point of contact in the primary care service

26. Where May Problems Arise in GP Surveillance of TB? • Continuity of care is not always ideal • Medical records of new patients take a month to reach us • Hospital letters take up to a month to reach us • Patients often attend emergency surgery when we are very busy and the doctor may not have time to review paper records • Patients often default on follow up appointments or see a different doctor who is not aware of the context of the problem • Communication problems arise if patient not fluent in English: we do not always have time to use Language-Line, which in practice is a minimum 20 minute consultation

27. Where May Problems Arise in GP Surveillance 2? • Every general practice is different and every GP has had different experience • Tb cases are still small in absolute terms – some GPs have never seen a case of Tb and may not therefore consider it in the differential diagnosis • Incidence of Tb can vary greatly over small geographical areas: there may be small clusters of TB in localised areas which impact significantly on one practice but not an adjacent practice • Non-pulmonary Tb may be harder to diagnose as symptoms can be non-specific or attributed to another more common cause

28. Tb Surveillance Case History • Case Mr B – Discontinuity of care • Apr 2006 – saw GP North Tees area – works as waiter 3wk h/o Right low back pain with sciatica – Diagnosis probably musculoskeletal • May 2006 – Seen by JS History of 6 week back pain referred to Right testis sweats weight loss no cough/sputum Examination mild lumbo-sacral stiffness chest clear – for CXR X-Ray L/S spine FBC TFT ESR bone profile LFT U&E FPG RF CTD • Plan review 2wk = DNA • June 2006 – North Tees Osteopath’s report tender and swelling RSIJ – probably musculoskeletal Refer back to GP • Aug 2006 admitted Addenbrookes hospital lumbar paraspinal fluctuant mass: CT – extensive abscess L5 to S1

29. Surveillance New Registrations to General Practice Identify the origin of patient • From within UK – HPR boroughs mainly London also Birmingham • From outside UK – many countries have HPR • Registration at Reception Desk: Maintain confidentiality – information could not be discussed in reception where 30 other people can hear what you are saying. Registration form completion to include country/region of origin and health questionnaire • New Patient Check: Practice nurse can ask about symptoms Tb and origin at New Patient Check but the patients do not always attend for their appointment • Practice Administration could check registration document for country of origin. But could we identify a HPR borough for UK origin patients? Do PCT boundaries follow postal areas? • Marking notes of patients from HPR area – would have to be done so as to avoid potential breach confidentiality

30. High Incidence Countries for TBHealth Protection Agency 2006 • Total of 192 countries cited • 123 (64%) countries with high prevalence Tb (40</100k/pa) • These are not always the countries you may suspect as having HPR • Inner city GPs are registering more patients from east Europe and former Soviet Union countries and we need to be aware of possible Tb in people originating from these areas

31. Incidence of Tb by CountryWHO 2006

32. Tuberculosis Incidence UK 1 • Tb notification system established 1913 (NOID) • 1999 Enhanced Tb surveillance system gives more detailed clinical and demographic information • Early C20 – peak incidence reached at 300/100k/pa • 1980 – lowest incidence 10/100k/pa • 2006 UK incidence 15/100k/pa • Wide variations within UK 2005 • London – 46.3/100k/pa • West Midlands 17.5/100k/pa • Wales – 6.1/100k/pa

33. Tuberculosis Incidence UK 2 • Within regions may be wide variations • London boroughs up to x30 variation in incidence TB • Place of Birth • Non-UK born 103/100k/pa • UK born 4/100k/pa • Ethnic Origin UK born • Black African 41/100k/pa • Indian/Pakistani/Bangladeshi 38.6/100k/pa • Ethnic Origin non UK born • Black African 399/100k/pa • Indian/Pakistani/Bangladeshi 234.9/100k/pa

34. Tuberculosis Incidence UK 3England, Wales and Northern Ireland • Gender • Males 1.6/100k/pa (55% of total cases) • Female 12.9/100k/pa • Age • <15 years = 6% cases • 15-44 = 61% cases (70% of all non-UK born patients) • 45-64 = 18% cases • 65+ = 15% cases

35. Recent Tb Incidence CasesEngland, Wales, Northern Ireland (HPA)

36. Recent Tb Incidence RateEngland, Wales and Northern Ireland (HPA)

37. Tb –Rate Bands by PCT England per 100,000 Population (Mean Rate 2003-2005)

38. Supporting the Patient and Monitoring TreatmentCase History • Case: Mr A Recurrent Pulmonary Tb May 2006 • Multi-drug resistance to rifampicin and isoniazid • Open pulmonary Tb 2002 - prior failure to complete therapy – medication found on local tip • DOT community based from July 2006 including IM streptomycin • Early appointment 7:45am to see patient before surgery started • If nurse away GP had to administer medication • Ongoing problems side effects nausea vomiting pain at injection site • Sept 2006 Failed to comply with treatment / Repeat DNA for DOT– Consultant informed • Absconded to Pakistan Oct 2006 without completing therapy

39. DOT Impact on Primary Care • Mr A – primary care management as decided by Case Conference July 2006 • Daily IM streptomycin Monday to Friday for next 4 months to be given by Practise Nurse or GP every morning then three times a week for a further six months • Afternoon tablets to be monitored by District Nurse • Every second Monday morning to attend Chest Clinic for U&E LFT streptomycin levels and streptomycin • An informal contract agreed – patient responsible for complying with treatment and made aware of public health risk to others. Information given in Urdu • Practice or District Nurse to inform Chest Clinic if defaults on treatment

40. Tb Incidence by Decade - RS

41. Tb Incidence Since 2000 – RS5 Year Average is 2001 -2005

42. T Audit Total Tb Cases RS by Ethnic Group

43. Audit – Tb cases post 2000by Ethnic Group

44. Audit Type of Tb -RS

45. 2008 Tb Audit Summary RS • Number of cases not large but there can be a big impact of an individual case of Tb upon the GP service • Total 46 cases identified by computer search • 23 Cases since 2000 • 23 cases pre 2000 • One patient 4 separate episodes Tb • 6 patients reactivation or recurrence pulmonary TB • Think of non-pulmonary TB – around 30% cases in this audit

46. Conclusions 1 • The total incidence of cases of TB in an individual practice are small • However the impact of a single case of Tb can be disproportionate and create large demands on the service • Statistics based on geographical area can miss localities where there are small pockets of high Tb incidence

47. Conclusions 2 • Clear lines of communication between primary care and secondary care needed to facilitate referral – use the telephone and fax! • An information sheet for GPs including telephone and fax numbers and identifying points of contact and referral procedure would help • Should we develop a referral template on the lines of the new Rapid Access TIA referral service?

48. Conclusions 4 • Raising the profile of the Tb service – this needs to be carried out at the local level – include Health Visitors, District Nurses and Practice Nurses • In Newport there is a GP Educational forum held every 3 months at which specialists could speak to GPs about the current organisation and plans for the service and raise awareness of Tb in primary care