The Strategic Health Authority for London London and TB 4 October 2007 Lynn Altass NHSL Public Health – TB North Central London TB Network Manager

What do we look for with TB in London?  Signs and symptoms of TB  Global picture of TB  Local picture of TB  Relevance to national TB Action Plan  NICE TB Guidelines

Tuberculosis (TB)  TB is a notifiable, infectious disease  Serious but curable  Affects 9 million people world wide annually and 2 million people die from TB every year  8171 people in UK developed TB disease in 2006  Approximately 350 people in the UK die from TB annually  It is caused by a mycobacteria called Mycobacterium tuberculosis  Usually affects the lungs (50+%) but can affect other parts of the body

 Chronic cough for more than 3 weeks (sometimes with blood)  Fever and night sweats  Tiredness  Loss of weight and appetite Symptoms of TB

 Persistent cough78%  Weight loss/loss of appetite74%  Fatigue/tiredness68%  Fever/high temperature 60%  Night sweats55%  Blood in ‘phlegm’/sputum 37% Symptoms - TB (of the lung)

Confirming TB  Chest X-ray  Sputum test for mycobacteria  Testing for drug resistance by culture  Skin (tuberculin skin test/mantoux) test  Gamma Interferon testing for exposure / contact tracing

TB is spread from person to person through the air by:  Coughing  Sneezing  Singing  Shouting  Swearing! The above form fine airborne droplets containing TB which can be breathed in

TB rates across the World

New TB notifications in London residents by ethnic group reported to the London TB Register  Around a third of new TB notifications in London residents during each year 2002 to 2006 were Black-African.  The proportion of new TB notifications in London residents being classed as Indian increased each year from 2002 to 2006, from 19% in 2002 to 22.2% in 2006.

Proportion of new TB notifications in London residents by place of birth and year of notification - reported to the London TB Register

Proportion of new TB notifications that were UK born by Sector of residence and year of notification – reported to the London TB Register

Local/London picture - what do we look at?  Numbers of TB notifications;  TB rates;  Details such as age, ethnicity, sex;  Where TB patients live;  Patient flows in and out of local services and across London;  TB notifications trajectory for future service planning.

Number of TB notifications and rate by region, England, Wales and Northern Ireland, 2005 Sources: Enhanced TB Surveillance, ONS population estimates

TB cases, rate per 100,000 population 1982 – 2005 Source: J Watson, Centre for Infections, HPA

TB rate per 100,000 pop. Copyright HPA Centre for Infections “Hot Spot” analysis of TB notifications and service provision ETS

Density of new TB notifications in London residents, mapped by ONS Lower Layer Super Output Area – reported to the London TB Register, 2006

NCL PCTs TB notification rates per 100,000 population

Comparison of the 2 maps

TB rates by age group, England, Wales and Northern Ireland, 2001, 2003 and 2005 Sources: Enhanced Tuberculosis Surveillance, Office for National Statistics mid-year population estimates

Breakdown of NCL TB notifications  37.7% of the 2001 census population were aged 20 – 39 years  52% of the TB population were aged 20 – 39  47% of the 2001 census population were male  57.2% of the TB population were male

 Treatment completion is the most important aspect of control  Usually takes 6 months for drugs to kill the TB bugs – longer in some cases  DOT (directly observed therapy)  Patients require support during that time  Is free at the TB clinics TB treatment

TB is treated by taking a number of tablets for at least 6 months

If TB is not treated….  TB can come back  Risks to public  It may be harder to treat the second time  May need hospitalisation  Increased risk of drug resistance  Increased cost of treatment

Groups most at risk  Close contacts of infectious persons  Immigrants from high prevalence countries  Alcohol and substance misuse  Malnourished  Homeless  HIV  Health care workers

Tracking the North London Isoniazid resistant TB outbreak

Aims of TB services  Early diagnosis  Reduce transmission  Decrease TB  Provide effective TB treatment  Minimise spread of the disease  Reduce disability/death from TB  Prevent the emergence of drug resistant TB  Multi-disciplinary service

Headlines Increase in TB in the UK is the increase in London Much of the increase is in those born abroad Important increases in the marginalised and young adults Patient groups and patient needs have changed An effective TB service needs to prevent and control as well as treat