Dr Lika Nehaul NPHS TB Lead / CCDC An Overview of the Epidemiology and Management of Tuberculosis in Wales Dr Lika Nehaul NPHS TB Lead / CCDC

Presentation outline Epidemiology of tuberculosis Sources of clinical guidance What makes for effective TB services in Wales What the NPHS TB Programme Group is doing to promote best practice in the management of TB

Estimated numbers of new cases, 2006 AFR 28% WPR 22% SEAR 34% EUR 5% EMR 7% AMR 4% Estimated number of new TB cases (all forms) No estimate 0–999 1000–9999 10 000–99 999 100 000–999 999 1 000 000 or more The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2006. All rights reserved

New TB cases per 100,000 population in 2006 9.2 million new TB cases and 1.7 million deaths in 2006 World: case rates rising during 1990s, now stable or falling slowly Europe: case rates up by 40% during 1990s, now falling slowly Estimated new TB cases (all forms) per 100 000 population No estimate 0-24 25-49 50-99 100-299 300 or more Africa: case rates up by 200+% during 1990s, now falling slowly

TB notification rates, European Union By country group, 1996-2006 20 40 60 80 100 120 140 160 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 TB cases / 100 000 (age-standardised)* Romania (EU accession 2007) Baltic States EU accession 2004 EU pre-2004 Including countries with data by age-group: EU pre-2004: Austria, Belgium, Denmark, Finland, France, Germany, Italy, Luxembourg, The Netherlands, Portugal, Sweden, United Kingdom EU accession 2004: Czech Republic, Hungary, Malta, Poland, Slovakia, Slovenia (excluding Baltic States) Baltic States: Estonia, Latvia, Lithuania (EU Member States since 2004) * based on WHO World Population Standard, 2000-2025 average (Ahmad OA, Boschi-Pinto C, Lopez AD et al.) Source: Euro TB

Countries with XDR-TB confirmed Cases as of 1 December 2007 Argentina Japan Armenia Latvia Azerbaijan Lithuania Australia Mexico Bangladesh Mozambique Brazil Netherlands The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2005. All rights reserved Canada Norway Chile Peru China, Hong Kong SAR Czech Republic Poland Ecuador Portugal Estonia Republic of Korea France Romania Georgia Russian Federation Germany Slovenia Ireland South Africa India Spain Islamic Republic of Iran Spain UK Israel Sweden USA Italy Thailand Vietnam Based on information provided to WHO Stop TB Department - 1 December 2007

Figure 1.1.1. Tuberculosis case reports and rates by region/country, England, Wales and Northern Ireland, 2006 44.8 17.5 13.7 8.5 10.2 13.3 8.0 5.6 6.4 3.6 500 1000 1500 2000 2500 3000 3500 4000 London West Midlands Yorkshire and the Humber South East North West East Midlands East of England South West Wales North East Northern Ireland Region/country Number of cases 5 10 15 20 25 30 35 40 45 50 Rate (per 100,000) Sources: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS), Northern Ireland Statistics and Research Agency (NISRA)

Tuberculosis cases and rates in Wales reported by Enhanced TB Surveillance 1999-2006 Source: NPHS CDSC

TB Programme Aims To reduce avoidable morbidity and mortality associated with tuberculosis To minimise the transmission of infection by early diagnosis and effective treatment To prevent the emergence and spread of drug resistant TB To ensure standardisation of TB management across Wales To facilitate the continuous monitoring of local and regional trends in TB, in order that any identified change in incidence can be identified and addressed as necessary

Programme aims to be achieved by: Promoting and facilitating best practice in the prevention and control of TB Promoting a culture of collaborative working amongst health care professionals involved in the management of TB Strengthening the provision of specialist microbiological TB diagnostic tests available in Wales Further improving enhanced TB surveillance

Clinical Guidance JCVI guidance on BCG vaccination in Green Book TB Chapter (updated on-line November 2007) – follow JCVI guidance for BCG vaccination NICE TB Guideline, published March 2006 Interdepartmental Working Group on Tuberculosis Guidance on the Prevention and Control of Transmission of HIV-related TB and drug-resistant TB (1998)

TB Services: Clinical Radiology (Specialist) Microbiology Pathology Infection Prevention & Control Public Health – includes co-ordination of surveillance

Services need to be patient-focused Treatment for a minimum of 6 months Still a stigma in many communities Co-morbidity and social problems For inpatients in isolation with MDR-TB, maintain balance between need to protect others and the mental wellbeing of the patient, based on RA Need to ensure that the patient and everyone involved in their care understands and is ‘signed-up’ to the care plan

TB control Early diagnosis especially of pulmonary disease important, so that treatment may be started promptly Notify cases of TB disease on clinical suspicion by telephone, included those diagnosed PM (follow-up with formal notification on ETS form) Be vigilant for TB especially in high-risk groups but remember anyone can get TB TB can be a travel-related disease in people spending long periods of time in high-incidence countries

Effective management of TB requires: An understanding of own roles and responsibilities, those of team members and other departments / sectors providing TB services That TB nurse is informed of patients with TB Knowing who has lead responsibility (cf incidents and clusters in community vs NHS Trust premises) An appreciation of the risks of transmission in health-care settings especially IP wards and OP settings Knowledge & understanding of infection prevention and control measures, infection control policies, and their rationale Collaborative working by everyone involved in TB control

Management of TB – special arrangements Access to TB specialist for advice Children People with HIV co-infection Patients with MDR pulmonary TB to be managed by TB specialists in centres with negative-pressure facilities – transfer arrangements to involve Infection Prevention & Control Team at referring and receiving hospitals Commissioning services for Welsh residents receiving specialist TB services in England and clinical support for contact tracing in Wales

Other issues Management of human contacts of bovine tuberculosis

How will the NPHS TB Programme Group help? Facilitate the provision of special TB microbiological services in Wales Publish guidance and links to national guidance on the NPHS Intranet site: Framework document for BCG vaccination of infants and children aged up to under 16 Disseminate and promote the Framework for the provision of TB services for people living in Wales in the coming months, in liaison with Welsh Assembly Government Undertake an audit of the implementation of the NICE TB Guideline in Wales in 2008-09

In summary Incidence of TB in Wales relatively stable year-on-year Diagnose TB early by maintaining vigilance and investigating appropriately Notify cases on clinical suspicion Effective clinical management, underpinned by collaborative working essential to keep TB under control and to further reduce incidence

Acknowledgements NPHS CDSC – Michael Perry, Dr Daniel Thomas, Rhian Hughes Health Protection Agency CfI – Dr Ibrahim Abubakar World Health Organisation – Dr Paul Nunn Euro TB

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