Managing Tuberculosis Today Hann Hanna a Kaur Kaur - TB L TB Lea ead d Nurse Sp Nurse Spec eciali ialist st BIR BIRMIN MINGH GHAM AM & S & SOLIH OLIHULL ULL TB SERVI TB SERVICE CE Te Tel: l: 012 0121 1 42 424 4 19 1935 35 E-ma mail il: : ha hann nna.k a.kau aur@nh r@nhs.ne s.net
OUT OUTLINE LINE: Epide Epidemiology miology – in in Br Brief ief (PHE (PHE Slides) Slides) TB TB an and d Diagn Diagnos osis is (Act (Active ive an and d La Late tent nt) TB TB Pat Pathwa hway y – Cas Case e Sce Scena narios rios Con Conta tact ct Tra Tracing cing – Scr Scree eening ning (NICE (NICE 20 2016 16) BCG BCG Pro Progr gramme amme Incide Incident nt Man Manag ageme ement nt TB TB Ser Service vice Upd Updat ate e on on The The Collabo Collabora rative tive TB TB Str Strat ateg egy: y: - Pub Publi lic c Hea Health lth En Engla gland nd an and d NHS NHS En Engla gland nd 20 2015 15
TB TB Case ase Notifications otifications and and Rates Rates, , England, England, 2000 2000-2015 2015 Tuberculosis in England: 2016 Report 10,000 16 15 9,000 14 Number of cases 13 8,000 Rate (per 100,000) 12 7,000 11 10 6,000 9 5,000 8 7 4,000 6 5 3,000 4 2,000 3 2 1,000 1 0 0 Year I 95% CI Number of cases Rate per 100,000
Three-year average TB rates by local authority district, England, 2013-2015 London Tuberculosis rate (per 100,000 ) 0.0-4.9 5.0-9.9 10.0-14.9 15.0-19.9 20.0-29.9 30.0-39.9 40.0-49.9 >50.0
Tuberculo Tuberculosis sis Cases ases and and Rates Rates in in the West the West Miidlan Miidlands ds Eng England land, , 20 2002 02 to to 20 2015 15 *Data for 2015 for England is not yet available and data for the West Midlands is provisional. Note: 2013 mid-year population estimates from the Office of National Statistics (ONS) were used to calculate rates. Data sources: Enhanced Tuberculosis Surveillance (ETS) downloaded on 12 March 2016. Prepared by: chanice.taylor@phe.gov.uk Field Epidemiology Service (Birmingham), Public Health England
Tuberculos Tuberculosis in is in Birmingham Birmingham Average Average 350 Notifications 350 Notifications Annually Annually Numbers and rates of TB in Birmingham, the West Midlands and England, 2010-2015 • In recent years, Birmingham has accounted for the majority of cases in the West Midlands; in 2015 35% of cases were Birmingham residents. • The rate in Birmingham has consistently been higher than both the West Midlands and England, however there has been a year on year decrease since 2012. The rate in 2015 was 22.8 per 100,000. • 68% of cases were born outside of the UK. • 13% of cases in Birmingham had at least one social risk factor (homelessness, imprisonment, drug use or alcohol abuse).
Tuberculosis in Birmingham: Average Contacts Screened Per Year: 2500 Rate of TB in Birmingham by Ward, 2015 • The rates in Birmingham varied by electoral ward, with areas showing some of the largest and smallest rates in England. • The highest rates were seen Lozells and East Handsworth, Soho and Aston (65.3, 59.7 and 54.3 per 100,000 respectively). • 76% of cases in these three high incidence areas were born outside of the UK. • The lowest rates were seen in Bartley Green, Sutton Four Oaks and Sheldon (3.9, 4.1 and 4.5 per 100,000 respectively).
Tuberculos Tuberculosis in is in Solihull Solihull Numbers and rates of TB in Solihull, West Midlands and England, 2010-2015 • In 2015, as in recent years, the incidence rate in Solihull has been lower than both the West Midlands and national average. • In the past three years the rate in Solihull has remained relatively stable (range: 6.7-7.2 per 100,000). • 62% of cases were born outside of the UK and there with no cases with social risk factors. • Six of the 14 wards in Solihull had no cases of TB. The highest rates were seen in Shirley West (25.0 per 100,000), Shirley South (16.0) and Knowle (9.2).
BIRMINGHAM & SOLIHULL TB SERVICE: LATENT CASES - 2010 - 2016 (to date) Data: Dendrite/Birmingham & Solihull 500 471 450 385 400 363 405 345 350 300 263 250 223 200 150 100 50 0 2010 2011 2012 2013 2014 2015 2016
Proportion of TB Cases with at least One Social Risk Factor*, England, 2010-2015 14 12 Proportion of cases (%) 10 8 6 4 2 0 Drug misuse Alcohol Prison At least one 2 or more risk misuse Homelessness risk factor factors Social risk factor 2010 2011 2012 2013 2014 2015
Tuberculosis (Active): Tuberculosis, or TB, is an Infectious Bacterial Disease caused by Mycobacterium Tuberculosis (MTB) , which most commonly affects the Lungs, but can affect Any Part of the Body. It is Transmitted from Person to Person via Droplets from the Throat and Lungs of People with the Active Pulmonary Disease. http://www.who.int/topics/tuberculosis/en/ /
Sites of Disease Sites of Disease: • Centr Central al Nervous Nervous System: System: usually usually occurs as Meningitis, occurs as Meningitis, but can occur but can occur in in Brain Brain or Spin or Spine • Miliar Miliary: : occurs when occurs when Bacill Bacilli i spread t spread to o all all parts o parts of f the bo the body; dy; rare, rare, but but fat fatal al if if untrea untreated ted • Lymph Lymph Nodes Nodes (Neck (Neck and Axi and Axilla) lla)
Pathogenesis A small number of tubercle bacilli enter the bloodstream and spread throughout the body. The tubercle bacilli may reach any part of the body, including areas where TB disease is more likely to develop (such as the brain, larynx, lymph node, lung, spine, bone, or kidney).
Probability TB Will Be Transmitted : Sus Susce cept ptibil ibility ity of the of the • exposed exposed person person Infect Infectious iousne ness ss of per of perso son n • with TB with TB (i (i.e., .e., numb number er of of ba bacill cilli i TB TB pa patien tient t ex expe pels ls into into th the air e air) Env Environ ironmen menta tal l fact factor ors s th that at • affect affect the the co conc ncen entr trat ation ion of of MTB MTB or orga ganisms nisms Proximity Pro ximity , , freq freque uenc ncy, y, an and d • du dura ration tion of exp of expos osur ure e (e.g., (e.g., close clos e co cont ntac acts ts) Can Can be be tra trans nsmitte mitted d from from • Childr Children en, , th thou ough gh less less li like kely ly
TB Signs TB S igns and S and Symptoms: ymptoms: Pulmonary: Coug Cough h – more more t tha han 3 week n 3 weeks • Loss of A Lo ss of App ppetite etite / We / Weight Lo ight Loss ss • Feve Fe ver r – more more t tha han 3 week n 3 weeks • Nigh Ni ght t swea sweats ts • Extra-Pulmonary: ?Site SiteLy Lymph mph Nod Nodes es: : Swelling Swelling Br Brain ain / CNS / CNS: : Hea Heada dach che e / Confus / Confusion ion Spine Spine: : Pain Pain / deformit / deformity y / d / disab isabil ility ity
Diagnosis of Tuberculosis: Active • Microbiology of pathological samples - discharged pus or biopsy material / FNA Sputum Culture • Histopathological pattern of Inflammation • Radiographic Image • Tuberculin Skin Testing (TST) / Interferon-gamma release assay (IGRA) • Clinical Diagnosis
Latent Latent TB TB: Latent Latent tuber tuberculos culosis infection infection (LTBI), (LTBI), define defined as as a state state of of persis persistent tent immune mmune resp response onse to to prior prior- acquired acquired Mycobacterium Mycobacterium tube tuberculosis rculosis antigens antige ns without without evidence evidence of of clinically clinically manifested manifested active active TB TB. It It affects affects ab about out one one-third third of of th the world’s po populatio pulation. Approximate Approximately ly 10 10% of of people people with with LT LTBI BI will will devel develop op active active TB TB disease disease in in their their lifetim lifetime. The The majority majority devel develop op the the disea disease se within within the the first first five five years years after after initial initial infection infection. Cur Currently rently available ailable tr treatments eatments have have an an efficacy efficacy ranging ranging from from 60 60% to to 90 90%. Guidelines Guidelines on on the the Management Management of of Latent Latent Tube Tuberculos rculosis is Inf Infection ection , World orld Health Health Or Organisat ganisatio ion, n, 2015 2015.
Why Scree Why Screen n for La for Latent TB? tent TB? Systematic testing and treatment of LTBI in at-risk populations is a critical component of WHO’s eight- point framework adapted from the End TB Strategy to target pre-elimination and, ultimately, elimination in low incidence countries. Guidelines on the Management of Latent Tuberculosis Infection , World Health Organisation, 2015
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