Tuberculosis (TB):

clinical diagnosis and management of tuberculosis and measures for its prevention and control

March 2006

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

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

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

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

Tackle priorities – get results

Treatment

Observation

Staying in contact

Screening

Vaccination

Use four drugs for 6 months

For active respiratory TB use the standard recommended regimen

6 months2 months

isoniazid and rifampicin

pyrazinamide and ethambutol

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*

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

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

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

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?

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

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

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.

Work with partners

Who are the key agencies outside the NHS?

•Local authorities •Social services•Housing services•Prison services •Voluntary sector services

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

Make best use of resources

Diagnose in specialist TB clinics

Free up resources by continuing care in general practice

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

Access tools online

Costing tools

•costing report

•costing template

Audit criteria

Implementation advice

Available from: www.nice.org.uk/CG033

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

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