1. Tuberculosis (TB): clinical diagnosis and management of tuberculosis and measures for its prevention and control March 2006

2. What this presentation covers Background to NICE clinical guidelines Rationale for the TB guideline Key messages and priorities in the guideline Case studies Key implementation issues Where to go for more information

3. Changing clinical practice NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations to work towards implementing guidelines Compliance will be monitored by the Healthcare Commission

4. TB is a growing problem TB in England and Wales is on the increase TB is treatable, but it is important to detect it as early as possible

5. Anyone can catch TB Particular risks are: close contact weakened immune systems poor health and nutrition poor or crowded housing conditions living in a high incidence area

6. Tackle priorities – get results Treatment Observation Staying in contact Screening Vaccination

7. Use four drugs for 6 months For active respiratory TB use the standard recommended regimen 6 months2 months isoniazid and rifampicin pyrazinamide and ethambutol

8. Treat meningeal TB longer * or another fourth drug Plus glucocorticoid (dose = prednisolone equivalent) adults on rifampicin 20–40 mg adults not on rifampicin 10–20 mg children1–2 mg/kg, maximum 40 mg consider gradual withdrawal of the glucocorticoid starting within 2–3 weeks 12 months2 months isoniazid and rifampicin pyrazinamide and ethambutol*

9. Consider observation Consider risk factors for adherence to treatment. Directly observed therapy may be needed for: street- or shelter-dwelling homeless people with active TB patients with likely poor adherence, in particular those who have a history of non-adherence

10. Stay in contact Each person with TB needs a key worker Incomplete treatment increases the risk of relapse and drug resistance Key workers can keep treatment on course

11. Screen new entrants Identify new entrants for TB screening. Use: Port of Arrival reports new registrations with primary care records of entry to education (including university) links with statutory and voluntary groups working with new entrants

12. Case study – port of arrival Alexi arrives at Heathrow on a six month visa: he is asked for his chest X-ray and/or health report chest X-ray taken and examined details are entered in a database If this shows signs of TB: admitted to hospital or given referral letter Informing others: letter is copied to consultant in communicable disease control in area Alex is going to live What next?

13. Vaccinate at-risk neonates Vaccinate neonates at increased risk of TB, after discussion with parents or legal guardian Consider: place of birth family members places of birth family history

14. Key implementation issues Address communication/language barriers Monitor impact on laboratory services because of an increased need for liquid cultures and diagnostic tests Make sure that patients are referred to appropriately trained workers

15. Case study – practice nurse Bob is a practice nurse in a primary care trust that has a TB prevalence rate of 40 per 100,000 population. In the past 8 years he has come across only one TB patient. His primary care trust has sent him on a training session for the Mantoux test. Bob is nervous about carrying out the test and about reading the results correctly.

16. Work with partners Who are the key agencies outside the NHS? Local authorities Social services Housing services Prison services Voluntary sector services

17. Work with prisons Raise awareness of TB symptoms among staff and prisoners Screen prisoners for TB Carry out directly observed therapy within prisons Prison medical services should draw up a contingency plan for those leaving prison with TB to ensure continuity of care

18. Make best use of resources Diagnose in specialist TB clinics Free up resources by continuing care in general practice

19. Implement in stages STEP 1: Identify potential partner agencies STEP 2: Carry out baseline assessment of impact on: patient numbers staffing equipment and training budgets service provision STEP 3: Assess resource requirement STEP 4: Develop an action plan STEP 5: Develop, review and monitor progress against audit criteria

20. Access tools online Costing tools costing report costing template Audit criteria Implementation advice Available from: www.nice.org.uk/CG033

21. Access the guideline online Quick reference guide – a summary www.nice.org.uk/CG033quickrefguide NICE guideline – all of the recommendations www.nice.org.uk/CG033NICEguideline Full guideline – all of the evidence and rationale www.nice.org.uk/CG033fullguideline Information for the public – a plain English version www.nice.org.uk/CG033publicinfo

22. Everyone has a part to play This guideline should help healthcare professionals to: diagnose primary cases identify secondary cases treat active disease control latent infection prevent transmission