• TB only affects immigrants/new entrants
• HIV is entirely responsible for the increase in TB
• TB is a dirty disease, spread by spitting
• It is easy to catch TB
• TB can’t be cured
• TB is just another disease

• In the UK and other industrialised countries, TB declined rapidly over the twentieth century, but was never eradicated.  In the 1940s, 50,000 cases were notified each year.   The current figure for England and Wales varies between 5,000 and 8,000.  In 1913, it was more than 113,000).
• Today, an estimated one third of the world’s population – nearly two billion people – are infected.  Eight million people a year develop the active disease and three million will die – one TB death every ten seconds.
• TB was declared a global health emergency by the World Health Organisation in 1993.
• Nearly all countries in the world are now affected by the resurgence of TB, caused primarily by increasing poverty, poor access to health services, migration and HIV co-infection.

• Anyone can catch TB
• TB is increasing in the UK, but it remains quite rare.  It is mostly confined to major cities – about 40% of all cases are in London.
• In the UK, people who are most at risk of developing TB are:
• Close contacts of an infectious case (someone in the household, or close family)
• Those who have lived in places where TB is still common;
• Those whose immune system is weakened by HIV or other medical conditions;
• Young children and very elderly people;
• Those who experience chronic poor health as a result of – for example – homelessness, alcoholism and drug abuse.

• People with active TB affecting the lungs and respiratory tract can infect others but are not always infectious.  Other forms of TB, for example of the lymph glands or bone, are not infectious.  The great majority of people do not develop TB after they have been infected.
• The TB germ is carried in the air on tiny droplets of mucus and saliva produced when an infectious person talks, coughs or sneezes.  Others then inhale the droplets.
• In poorly ventilated areas, the bacillus can remain suspended in the air for several hours.
• Most people who get TB have had prolonged exposure to an infected person, usually someone in the same household.
• It is extremely rare for children with TB to be infectious; children usually get TB from adults with respiratory TB.

• The majority of TB contacts experience nothing.  Studies show that only about 30% of healthy people closely exposed to TB will become infected; of these, only 5-10% will go on to develop the disease.  Young children exposed to TB are more likely to develop the disease than healthy adults.
• What happens to the TB bacilli once in the lung is largely determined by a person’s individual immune response.  70% of healthy TB contacts will stop the bacillus spreading. The remainder will show evidence of infection. 
• For the 5-10% who go on to develop the disease, the risk is greatest within the first five years after infection;
• A small number of people who become infected develop what is called primary disease, usually within eight weeks of exposure.  This can go unnoticed and can resolve without treatment, leaving a small scar on the lung and surrounding lymph nodes which can be seen by chest X-ray.
• Children are more likely to develop primary disease than adults.
• If the immune system can’t kill or contain the bacilli, they multiply, resulting in damage to the surrounding tissues.  TB bacilli can live in almost any part of the body, so the effects are extremely varied depending on the site of the disease.

• When someone is diagnosed with TB, a team of specialist health professionals will assess the infection risk posed to others.  If TB bacilli are found in the sputum of the TB sufferer, their close contacts (household and close family and friends) will be assessed to see if they have been infected.
• Other contacts, such as work colleagues, school mates, etc, will only be assessed if the TB sufferer is deemed to be a serious infection risk.
• If a person is identified as a contact at risk from TB, he/she will be routinely invited for screening. Screening consists of a skin test to determine if the immune system recognises TB. The tuberculin skin test (Mantoux) involves a small and virtually painless injection into the skin of the forearm, which is read as the size of the bump after 48-72 h;(hyperlink to picture)
• In the UK, the majority of people have had the BCG vaccine, so their skin will often be mildly positive.  This does not mean that they have TB, just that their immune systems recognise TB.
• It may also be necessary to have a chest x-ray when the skin test is done or if the skin test is strongly positive;
• TB can develop some time after exposure, so contacts may be followed up for one year, with further appointments for screening.  They are advised to look out for the symptoms of TB.
• People who have a strongly positive skin test and/or evidence of TB infection on a chest X-ray, or who are unwell, will be assessed further by a specialist.  They may be treated with a course of anti-TB drugs.

• Understanding how TB is spread
• The discovery of the BCG vaccine (1923)
• The introduction of an effective range of antibiotics (1950s);
• Drug trials by the UK MRC which shortened treatment to 6 months (1960s to 1970s)
• The gene sequence of TB (1998)

These treatments, combined with better housing and diet (among other factors), have helped reduce TB rates.

• It is very safe.  The risk of serious side-effects with hepatitis (inflammation of the liver and jaundice) or eye damage (possible with ethambutol only) is very low;
• If there is a problem with the treatment, the TB team will usually be able to find it early, to prevent any significant damage
• Not taking the treatment, however, carries a risk of permanent disability or even death, in addition to the risk of giving TB to other people.

   

• There is a vaccine against TB called the BCG, but it does not prevent TB in all cases.
• BCG immunisation can increase a person’s immunity to TB and protect against the dangerous forms of the disease, such as TB meningitis.
• BCG immunisation programmes vary across the UK, according to the local risk of TB infection.
• Please contact your local Primary Care Trust (PCT) for local information on BCG vaccination.

• Multi-Drug Resistant (MDR) TB occurs when TB germs become resistant to the two most powerful antibiotics normally used to treat TB (Isoniazid and Rifampicin).
• This means these medicines will not work effectively as they can no longer kill the TB bacteria.
• It can be caused by inconsistent or incorrect treatment of TB.
• Samples which contain TB germs can be tested in the laboratory to see if they will be killed by different antibiotics.  If they are not, it is likely that the patient will not get better on the usual TB medicines and this may suggest MDR TB.
• MDR TB treatment may last for eighteen months or longer.
• Isoniazid-resistant TB is increasingly prevalent in North and East London.

• HIV infection is the single most powerful influence on the chance of TB infection becoming the active TB disease.
• The weakened immune system of HIV positive individuals makes it easier for TB bacilli to grow, leading to an increased risk of developing disease.
• The higher the HIV prevalence in a population, the greater the impact of TB on HIV-positive individuals.
• 95% of HIV-infected people live in developing countries (WHO).
• TB disease probably occurs in 50% of people co-infected with TB and HIV on a global basis (WHO).
• 5% of TB cases in London are in HIV positive patients.

• If caught early and treated completely and effectively, TB is NOT fatal;
• Less than 1.2% of patients in NE London died as a direct result of tuberculosis in 2001.

• Figures for England and Wales are quite stable, but levels of TB in London have doubled since their low point of 1445 cases in 1987. (hyperlink to refernce in Thorax)
• 33% of TB in the UK and 54% of potentially infectious TB is found in the ethnic white population in the U.K.   It is misleading and simplistic to argue that TB is a problem caused by immigrants.
• Stigma surrounding the disease often prevents those with symptoms coming forward for treatment.
• High TB-risk groups can have problems accessing primary care.
• TB can affect both healthy people and those whose immune system is weak. Elderly people, diabetics, alcoholics, people on immune suppressing drugs like steroids or with kidney failure, and people with AIDS are especially affected.
• Globalisation has led to increased population movement through economic migration, travel, escape from conflict/persecution etc.  Global movement of tuberculosis is an inevitable consequence.
• TB can be associated with a variety of social-medical risk factors to which the new entrant community can be susceptible:
• poor housing (especially in terms of ventilation) and overcrowding
• poor diet
• limited access to education and healthcare
• language barriers.

• TB depends on whether you or your community might have been exposed to the germ. 
• Overcrowding makes the spread of TB more likely.
• Low Vitamin D levels - these are more common in winter and those with darker skin. 

• Trained personnel - approximately one specialist TB nurse is in place per forty notifications in NE London, in line with London standards and based on 2002 levels.  This is the minimum and some services are better resourced than others.  Adequate numbers of consultants, microbiologists and administrative staff are also important.
• Collaborative working between different TB services throughout NE London, as supported by the NE London TB Network.
• Development of local partnerships between TB services, Primary Care Trusts. local authorities and the Health Protection Agency.
• Patient-centred TB services.  Services are more accessible and flexible; patients have a named nurse and consultant throughout their course of treatment; and the whole treatment process is more responsive to their own needs.
• Improved diagnostic services and isolation facilities.  The TB Network works with microbiology services and infection control teams to raise standards.
• Improved monitoring of TB – effective control is dependent on being able to access reliable, up-to-date information.  The Health Protection Agency and the TB Network work closely with TB services to strengthen monitoring through the use of the TB Register computer system.
• Health Promotion activities.
• Innovative practice/research.

• Incidence levels are still comparatively low, but the steady increases recorded in London over the last 15 years are a cause for concern.
• Effective planning and management of TB now should prevent it running out of control in the future.
• There’s no room for complacency and long-term commitment to TB control is required from health services and the Government.

• TB services only isolate patients when absolutely necessary.
• There is a need for more innovative approaches to treating patients with drug resistant forms of tuberculosis, particularly when isolation in a hospital is likely to be counter-productive.
• Sanatoriums are unlikely to be re-introduced in the UK, but intermediate care facilities, where a range of socio-medical support services could be provided to the patient, may be an option.

• Staff potentially at risk of suffering from TB are
• Staff recruited from localities with rates greater than 40 cases per100,000 people;
• Staff who have lived for more than 3 months in the last five years in a ‘high risk’ area;
• Staff showing symptoms associated with TB;
• Staff unable to demonstrate adequate immunity to TB;
• Staff declaring themselves to be suffering from immunosuppression/ deficiency.