Tuberculosis

Key messages for primary care practitioners

  • The primary care practitioner has very important roles to play in both the prevention and control of TB (primarily through prompt recognition and referral of suspect cases to secondary care), and also in the support of patients through prolonged treatment.
  • It is important to maintain long term vigilance for signs and symptoms of TB in at risk groups, which include the non-UK born (even many years after arrival) and their families, or others who have links to endemic countries. 
  • The risk of TB should be considered in people who have recently arrived in the UK from countries of high incidence, with screening arranged as appropriate.
  • Non-UK born people are more likely than UK born people to get extra-pulmonary forms of TB and so it is important to be vigilant for signs and symptoms consistent with extra-pulmonary TB.
  • Certain conditions such as diabetes are more common in certain ethnic groups and can increase the risk of reactivation of latent TB. 
  • At risk patients should be educated about the symptoms of TB and encouraged to seek prompt medical advice should they develop them. 
  • Anyone diagnosed with TB should also be offered HIV testing.

Background information

Testing

Treatment

Prevention and control

Patient information (English only)

Patient information (English and other languages)

Other useful resources

References

Background information

  • The World Health Organization estimates that one-third of the world's population is currently infected with the TB bacillus [1].
  • Approximately 5-10% of people who are infected with TB bacilli (but who are not infected with HIV) become sick at some time during their life. People with HIV and TB infection are much more likely to develop TB [1].
  • The highest rates of infection occur in South-East Asia and sub-Saharan Africa [1].
  • People who were born in a country with a high incidence of TB represent one of the groups at highest risk of TB in the UK [2]. 
  • UK-born people with links to endemic countries through social networks or travel are also at increased risk [2,3].
  • TB develops slowly.  The highest risk period for development of disease is soon after infection but it usually takes several months for symptoms to appear. It can however remain latent for many years before developing into active disease. This means that non-UK born people may continue to be at risk of developing disease for many years after initial arrival in the UK [2].
  • Diabetes increases the likelihood of reactivation of TB [4] and is also more common in certain ethnic groups e.g. in people from the Indian sub-continent.
  • Other conditions that suppress immunity such as renal failure, chemotherapy, or HIV [1,2] can also lead to reactivation of TB disease.
  • Around 8% of people diagnosed with TB in the UK are co-infected with HIV.
  • Although TB often affects the lungs (pulmonary TB), it can also affect other parts of the body (extra-pulmonary TB), such as lymph nodes, bones and spine and (rarely) the brain and central nervous system. Extra-pulmonary forms of disease are more common in the non UK-born population than in people who are UK-born.
  • Typical symptoms of pulmonary TB include:
    • Coughing for more than three weeks: Coughing up blood in phlegm/mucus
    • Weight loss: Slow at first, getting quicker as TB develops
    • Loss of appetite
    • High temperature or fever
    • Night sweats
    • Extreme tiredness or lack of energy
  • Extra-pulmonary TB may present in a multitude of different ways, including localised pain, and it is important to be vigilant to this possible diagnosis in anyone who might be at risk.
  • Only pulmonary TB is generally infectious and the infection is usually spread through coughing.  People with sputum smear positive ("open") pulmonary TB are much more infectious than those with sputum smear negative pulmonary disease. Close and prolonged contact, such as where people live in the same household, is usually required for transmission of TB to occur.  Sputum smear positive cases usually cease to be infectious after a couple of weeks of effective treatment [2,5].
  • For further background information please see the PHE TB web pages.

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Testing

In the UK, clinical management of TB is generally conducted according to NICE guidelines [external link] by secondary care specialist teams, which may be based in dedicated TB services or in general respiratory disease services depending on local arrangements. These teams consist of physicians, nurses and social outreach workers with expertise in the treatment of TB. Any patients with suspected TB should be referred to your local team for diagnosis.

Pre-entry TB screening

In 2012 the UK Government announced a new pre-entry screening programme for TB. Following a pilot scheme, pre-entry screening is currently being introduced in countries with a high incidence of TB for migrants applying for a UK visa for over 6 months. The screening includes a chest x-ray and symptom assessment and can include a sputum examination. Individuals who are found to have active TB of the lungs must complete treatment before their visa is granted. Children under 11 years old do not undergo chest x-ray screening unless a clinician deems it necessary, but a medical questionnaire must be completed by their parent(s)/guardian(s). Further details on exemptions are available from the gov.uk website. This programme will replace the chest x-ray TB screening programme at Heathrow and Gatwick airports.

Pre-entry screening does not test for latent tuberculosis infection (LTBI) or for extra-pulmonary disease. Migrants from high incidence countries remain at a higher risk for TB many years after arrival in the UK and extra-pulmonary TB is more common in non-UK born, than UK-born, individuals [6]. It is therefore vital that primary care practitioners remain alert to the signs and symptoms of TB among migrants and offer LTBI screening in accordance with the NICE TB guidelines.

Further information, including a full list of the countries where pre-entry screening is in place, is available on the Home Office website and the gov.uk website.

Screening guidelines for new entrants

Any person known to be HIV positive should be referred to HIV services for further risk assessment. If not known to be HIV positive, screening for TB should be arranged according to the NICE guidelines screening for latent tuberculosis in new entrants from a high-incidence country [external link] and in accordance with local service arrangements.

Anyone who has TB diagnosed should also be offered HIV testing [external link].

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Treatment

Treatment of active disease in the UK is done according to NICE guidelines [external link] by secondary care specialist teams. It involves a combination of antibiotics for a minimum of six months with monitoring of treatment by the specialist team. Completion of treatment is vitally important to ensure that the patient is cured and to prevent the development of antibiotic resistance. Treatment of latent disease may be for three to six months depending on the antibiotic regimen used.

Advice for secondary care specialist teams about treatment of Multi Drug Resistant TB (MDR-TB) is available from the MDR-TB Clinical Advice Service [external link].

The role of the primary care practitioner in the treatment of TB is to:

  • maintain vigilance for possible cases of active disease
  • refer suspected cases on to specialist services promptly for assessment and treatment 
  • support patients through their treatment in conjunction with the specialist centres

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Prevention and control

The most important aspects of preventing and controlling TB in the population are prompt recognition of cases and adequate treatment, followed by investigation of the contacts of cases. TB is a notifiable disease and when cases are identified contacts will be traced, screened and treated as appropriate. Who does this will vary depending on local circumstances but contact tracing is usually carried out by local TB services. Where clusters or outbreaks are identified the local health protection team will become involved in investigation and control. Screening of at risk groups such as new entrants is the third element of prevention and control of TB, and BCG vaccination is the fourth.

The role of the primary care practitioner in the prevention and control of TB is to:

  • maintain vigilance for possible cases of active disease
  • educate at risk patients about the symptoms of TB and what to do if they develop them
  • arrange screening for at risk groups including new entrants and the non-UK born
  • refer suspected cases on to specialist services promptly for assessment and treatment 
  • support patients through their treatment in conjunction with the specialist centres
  • identify and refer patients who are eligible for BCG vaccination [external link]. For further information see Chapter 32 of Immunisation against Infectious Disease (more commonly referred to as the "The Green Book" [external link]).

Tuberculosis is a notifiable disease in the UK. If a case is diagnosed it should be notified to your local Health Protection Team.

For further information on treatment and prevention please see the NICE guidelines [external link].

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Patient information (English only)

Patient UK tuberculosis clinical information leaflets [external link] developed by TB Alert in partnership with the North West London TB Network to provide a useful overview of key issues in tuberculosis. They support the advice given to TB patients by TB nurses and other health care specialists.

The Truth About TB website from TB Alert [external link]

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Patient information (English and other languages)

TB, BCG vaccine and your baby [external link] (Department of Health information leaflet). Available in English, Arabic, Polish, Latvian, Punjabi, Bengali, Estonian, Lithuanian, Turkish, Chinese, Gujarati, Urdu and Portuguese.

TB information cards for patients [external link] to provide information on the tests that will be conducted in TB clinics. Available in English, Bengali, Farsi, French, Gujarati, Hindi, Polish, Punjabi, Somali, Tamil, Turkish, Urdu.

Tuberculosis - the disease, its treatment and prevention [external link] (Department of Health information leaflet). Available in English, Albanian, Bengali, Chinese, Farsi, French, Greek, Gujarati, Italian, Kurdish, Pashto, Polish, Portuguese,  Punjabi, Romanian, Somali, Spanish, Tamil, Turkish, Urdu, and Vietnamese.

TB Alert clinical information leaflets [external link] available in English, Albanian, Bengali, Chinese, Farsi, French, Greek, Gujarati, Italian, Pashto, Polish, Portuguese, Punjabi, Romanian, Somali, Sorani, Spanish, Tamil, Turkish, Urdu, Vietnamese

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Other useful resources

TB in primary care [external link] training video from HPA migrant health event 12 November 2012

BCG Atlas [external link] a database of global BCG Policies and Practices produced by McGill University and the Public Health Agency of Canada.

National Knowledge Service - TB [external link] a collaborative project, co-ordinated by the HPA working with the NHS and various voluntary organisations which brings together sources of information and knowledge on tuberculosis for healthcare professionals and patients.

TB Alert [external link] TB Alert is the UK's national tuberculosis charity, working to address tuberculosis both in the UK and overseas.

NaTHNaC TB factsheet for health professionals [external link]

Resources for health professionals involved in the management of TB [external link]

HPA position statement on the use of Interferon Gamma Release Assay (IGRA) tests for TB

Tuberculosis case management and cohort review [external link] - guidance for health professionals published by the Royal College of Nursing

Identifying and managing tuberculosis among hard-to-reach groups [external link] - NICE guidance issued March 2012

MDR-TB Clinical Advice Service [external link]

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References

  1. World Health Organization. Tuberculosis fact sheet [external link]  
  2. Health Protection Agency. Tuberculosis in the UK: Annual report on tuberculosis surveillance in the UK 2010 
  3. Health Protection Agency. Migrant Health: Infectious diseases in non-UK born populations in the UK. An update to the baseline report - 2011 
  4. John Moore-Gillon. Diabetes and tuberculosis: a gathering storm? Thorax 2010;65:571-572.
  5. Public Health England. Tuberculosis: Frequently asked questions 
  6. Kruijshaar ME, Abubakar I. Increase in extrapulmonary tuberculosis in England and Wales 1999-2006. Thorax 2009; 64:1090-1095.

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