Tuberculosis

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 HPA 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.

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 TB screening algorithm (PDF, 24 KB) for new entrants published in the NICE guidelines 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 Unit.

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, Portugese,  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

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]

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. Health Protection Agency. Tuberculosis: Frequently asked questions 

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