The Newham latent tuberculosis infection screening and treatment project Dr. Heinke Kunst Consultant in Respiratory Medicine

The new national TB strategy 19. January 2015 Press release PHE and NHS England launch joint £11.5m strategy to wipe out TB

Professor Sir Bruce Keogh, NHS England’s Medical Director said: This is an important strategy which is why NHS England is committing £10 million towards tackling the high rates of TB incidence in England. This money will focus on TB screening and any subsequent treatment. Our goal is to eliminate TB as a public health problem

Epidemiology Newham

Treatment of LTBI in migrants Reduction of active TB cases, since 5- 10% of identified LTBI cases will progress to active TB if untreated Reduction of TB rates in East London will result in savings to secondary and primary care as TB rates and numbers decline Reduction in health related consequences (significant morbidity and mortality) Reduction of non-health related consequences of active TB disease – time off work – Loss of earnings – time out of education

LTBI treatment in primary care Newham is the only CCG in the UK currently treating LTBI in migrants in primary care If we can show that LTBI can be cost- effectively treated in primary care, this will lead to LTBI treatment in primary care nationwide

Primary care treatment Patients’ acceptability of treatment is likely to be higher in primary since care can be provided closer to home Avoidance of difficult pathway in secondary care with long waiting times in outpatient clinics Multiple encounters with healthcare professionals can be avoided because patients can be monitored in primary care by their GP Patients’ satisfaction is likely to be higher in primary care compared to secondary care.

Primary care treatment Treatment in primary care is likely to be more cost- effective than referral to secondary care treatment. Increase of knowledge and awareness of signs and symptoms of TB amongst GPs, practice nurses, pharmacists will enable earlier diagnosis of TB Increase of speed with which those with LTBI are referred though the patient care pathway leading to better patient experience and outcome

IGRA Screening All new patients at health check Left High Risk Country in last 10yrs* HIV/hepatitis screening “Look Back” for existing patients Results of IGRA tests by Patient invited to GP appt.

Exclusion of active TB by GP Previous TB/ treatment for TB or LTBI treatment do not screen, IGRA remains positive Cough Fever Night sweats Weight loss Chest signs Supraclavicular or cervical lymphadenopathy

Exclusion of active TB… CRP FBC ALT Bilirubin ESR HIV Hepatitis B/C CXR

Referral to Secondary Care Adverse reaction to Rifinah Hepatitis B/C Other liver disease Malnutrition Immunosuppression Pregnancy – defer Rx

Initiation of treatment in primary care GP sends 3 month batch prescription via EPS Dispense medication and provide liver function tests (LFTs) form for tests to be done at weeks 2 Importance of treatment adherence and completion Advice and information on managing side effects, adherence issues and interactions Provision of patient information leaflet At week two of the treatment, patients are reminded via phone/text that their LFTs are due Pharmacists should contact GP 5-7days after LFT have been done for results and recommendations to dispense month 2 medication

Treatment in primary care The pharmacist counsels the patient, promoting adherence, advising on adverse effects on their first visit, and arranging liver function tests after 2 weeks In case of adverse events and drug induced liver injury (DILI), GPs and community pharmacists will follow the existing Newham treatment manual and standardised referral pathway to secondary care.

Role of secondary care Referrals and s to secondary care before treatment Abnormal LFTs Hepatitis B, C Symptoms suggestive of pulmonary TB ( dry cough) Referrals and s to secondary care after treatment initiation Abnormal LFT’s Adverse effects eg vomiting

Potential problems with current LTBI screening and treatment protocol in primary care Exclusion of active TB in primary care ( CXR, bloods, symptoms and signs) Adherence (how can we ensure that patients are adhering to treatment?) Safety (adverse effects) Patient satisfaction

Implementing new entrant latent TB screening 1/3 of patients identified with latent TB identified do not attend TB clinics How do we monitor adherence to treatment High non- completion of LTBI treatment in secondary care (70%) Jimenez-Fuentes MA, de Souza-Galvao ML, Mila Auge C, et al. Rifampicin plus isoniazid for the prevention of tuberculosis in an immigrant population. Int J Tuberc Lung Dis 2013;17(3):326-32

Adherence protocol Start of treatment 30 days 60 days 90 days Counselling about adverse effects X Counselling about adherence X X X Pill count X X X Mars- 5 tool questionnaire X X X Urine test (Colour and INH metabolites) X X X Questionnaire about adherence/ adverse effects X Patient satisfaction questionnaire X

Large scale LTBI treatment project What is the risk for resistant tuberculosis if Rifinah is given as preventive therapy and poor adherence? Will there be an increase in multi- drug TB? Isoniazid preventive therapy and risk for resistant tuberculosis. Balcells ME, Thomas SL, Godfrey-Faussett P, Grant AD. Emerg Infect Dis May;12(5):744-51

Patient satisfaction questionnaire Patients’ rating of the healthcare professionals on a scale of 0-10 with “0” being the worst possible care and “10” being the best possible care Relational Empathy 1.The healthcare professionals treated me in a very friendly and courteous manner Perceived technical competency and professional care 1.The healthcare professionals were good in explaining my condition 1.The healthcare professionals were good in explaining my medication and side-effects 1.I had some doubts about the competency of the health care professionals dealing with me Accessibility and convenience 1.I found it hard to come to see the healthcare professionals since the location was inconvenient 1.I always had to wait long to see the healthcare professionals Time spent with healthcare professional 1.The time when I was seen by the healthcare professionals was convenient for me 1.The healthcare professionals spent plenty of time with me Patient general satisfaction 1.The medical care that I have been receiving was just about perfect 1.All my expectations have been met Please use the space below to provide additional feedback on your experience of care you received.

Risk factors and barriers for LTBI treatment To identify factors associated with non- acceptance, non-adherence or poor completion of treatment. Patient questionnaire to identify barriers

Smear positive TB diagnosed by Newham project First patient diagnosed with active smear positive TB on BAL 28year old gentleman Unwell for one month Night sweats for 2 weeks, dry cough In UK last 5 years CXR highly abnormal with LUL changes

CXR and blood tests 9.January Bronchoscopy 12. january Start of ATT 12. january

Patient with Erythema nodosum Screened for LTBI in august 2014 Refused treatment since wanted to get pregnant Clinic review 3.december 2014 Skin lesions consistent with EN

Patient refusing investigations and treatment

33 year old lady asymptomatic Screened as part of Newham project CRP 71.5, ESR 78 EBUS Histology granulomatous changes

Thank you