Tuberculosis
Introduction
Tuberculosis (TB) is an infection caused by the bacteria Mycobacterium tuberculosis. TB most commonly affects the respiratory system with 55% of cases classed as Pulmonary TB, but it can affect any body system including lymph nodes, kidneys, brain and bone1. TB is spread by infected droplets from the upper airways, which are released on coughing and sneezing, however, it takes close and prolonged exposure for the infection to be transmitted. Only around 5-10% of people who are infected with Mycobacterium tuberculosis go on to develop active disease2.
TB infection can be either active or latent. The most common symptoms a person with active TB may experience are:
- Persistent cough lasting over 3 weeks
- Weight loss
- Fever and night sweats
- Increased fatigue
Latent TB is when a person is infected with TB bacteria but does not have active disease or symptoms, and people with latent TB cannot spread the infection. However, latent TB can develop into active disease and in England the majority of newly diagnosed active TB cases (75%) are due to reactivation of latent TB, resulting from infection acquired outside the UK3. There is a greater risk of reactivation from latent to active TB in individuals who also have immune compromise such as HIV-positive individuals, patients on chemotherapy or in old age4.
Early diagnosis of TB is crucial to reduce the rates of TB within the UK. As the majority of active TB cases in the UK are due to reactivation of latent TB, diagnosis has focused on screening high-risk groups for latent TB and contact tracing. All confirmed TB cases in England, Wales and Northern Ireland must be notified through the National TB Surveillance System. Most TB cases are very treatable using a combination of anti-TB medications for a minimum 6-month period5. However, multi-drug resistant TB is a growing concern, with around 1 in 10 culture-confirmed cases of TB displaying resistance to one of the first line drug options6. If left untreated, TB can have devastating consequences for the infected individual, leading to deteriorating health and eventually death.
Why is it important to Population Health?
TB is important to population health for many reasons:
Disease Burden: TB rates in England peaked in 2011 at 15.6 per 100 000 and have subsequently declined to below 10 per 100 000, which is the WHO’s definition for a low incidence country. However, since 2019 the rate in decline of TB incidence has slowed and the most recent data shows that TB rates increased by 10% from 2022 to 2023. As TB services recover from the Covid-19 pandemic we may see a further growth in TB cases7. This reversal in decline of TB cases is a worrying trend and highlights the importance of a population health approach to tackling TB, with a clear focus on system-wide approaches to address health inequalities.
TB rates in Derbyshire are lower than the national average, at 2 per 100 000. However, managing TB in a low-incidence setting presents a range of challenges for public health interventions. Derbyshire covers a large geographical area and ensuring equitable access to services across this area can be challenging. Within low incidence areas, securing funding and commissioning services can be challenging, meaning staff who work in TB services can be over-burdened with their workload and services are less resilient when faced with new challenges.
Inequalities and Social Risk Factors (SRF): TB cases are very unequally distributed in the UK, with specific groups of the population at much higher risk of being diagnosed with TB.
- Ethnicity: Three out of four new TB cases are from people born outside of the UK, with the highest notification rates in those from Indian ethnic groups8.
- Socioeconomic status: TB continues to disproportionately affect the most deprived populations both globally and within the UK, exacerbating existing inequalities in our society. The rates of TB are seven times higher in the most deprived areas of the UK compared to the least9.
- Social Risk Factors (SRF): In the UK certain social characteristics are associated with an increased risk of TB, 15-20% of new TB notifications in the UK are associated with one of the following social risk factors; drug and alcohol misuse, homelessness, imprisonment, mental health needs and asylum seeker status10. Although people with these SRF represent a diverse group, they often share experience of social exclusion and typically experience multiple overlapping risk factors for poor health.
- Access to healthcare and treatment: People from key ethnic groups, more deprived socioeconomic status and those with SRF all face additional barriers to accessing healthcare services and completing treatment regimes. In addition to this, a lack of knowledge about TB and the associated symptoms among the public can lead to delays in diagnosis and treatment initiation. Within some communities, the perceived stigma of a TB diagnosis can again delay diagnosis and access to treatment, further exacerbating health inequalities.
- No recourse to public funds: Despite the low incidence of TB in Derbyshire, identified cases are often very complex with additional challenges of no recourse to public funds and nowhere to live. With these cases there is an increased risk of non-adherence to treatment and significantly increased financial and time cost on the regional workforce. There is no nationally agreed pathway on how best to support these patients.
Multi-Drug Resistant (MDR) TB: Globally the rising rates of MDR-TB are of real concern, around half a million people are diagnosed with MDR-TB every year and worryingly just over half of these are successfully treated. Drug-resistant TB is a major contributor to anti-microbial resistance11.
In the UK around 1 in 10 of people with culture confirmed TB are identified as having bacteria resistant to at least one of the four first-line antibiotics12,13. Patients usually acquire drug-resistant TB either as a result of spread of a drug-resistant strain from another person or due to ineffective or incomplete treatment. Certain population groups are at higher risk of MDR-TB, including non-UK born individuals who are from areas with high MDR-TB rates and those who have an associated SRF. Homelessness is a particularly important SRF, accommodation is a crucial part of TB management. Without somewhere stable to live, people with TB are less able to take their treatment, attend healthcare appointments and recover from illness.
MDR-TB threatens to worsen the inequalities in outcomes among those with TB infection. Furthermore, drug-resistant TB requires prolonged and complex treatment regimens which have significant implications for both patient physical and mental wellbeing. In addition to the economic cost of managing TB, the financial cost of treating MDR-TB is twenty times the cost of standard treatment for drug-sensitive TB. Treatment for MDR-TB is estimated at £50 000 - £70 000 per person, compared to £5000 in drug-sensitive TB14.
Prevention and Promotion: In their ‘End TB Strategy’ the WHO has set out targets to reduce TB incidence rates by 80% by 2030 and 90% by 2035 (as compared to 2015 incidence)15. In line with this strategy, the UKHSA and NHS England have set out a 5-year action plan to support a year-on-year reduction in TB incidence in the UK16. The policy has 5 key priorities:
- Recovery from COVID-19
- Prevent TB
- Detect TB
- Control TB
- Workforce
The action plan emphasises the need to focus on specific population groups, including those with SRF, new entrants to the UK, people with drug-resistant TB and children with TB, and underlines the importance of system-wide approaches to address health inequalities.
Population health action to address the priorities from the TB action plan is essential. Ensuring effective education on the risk factors and symptoms of TB, supporting early diagnosis and providing services that are integrated and accessible for high-risk groups, to ensure treatment completion and reduce transmission.
The Derbyshire Population Health Approach
The Derbyshire Population Health Approach focuses on prevention, population health, evidence-informed practices, causes, and collaboration. It emphasises proactive measures to prevent health issues, tailors interventions to specific populations, incorporates evidence-informed practices, addresses underlying causes, and promotes collaboration for effective action.
When considering the topic of TB within The Derbyshire Population Health Approach:
• Prevention
TB prevention encompasses two fundamental approaches:
- Preventing transmission from infected patients with active symptoms
- Preventing reactivation of latent TB in infected individuals
Both approaches require early diagnosis and prompt initiation of treatment. Education is crucial to ensure both healthcare professionals and the Derbyshire community understand the risk factors and symptoms associated with TB. The Southern Derbyshire and Chesterfield Hospital TB services provide teaching and training with key healthcare professionals who work with high-risk patient groups and support health promotional activities within the Derbyshire community. TB services in Derbyshire face a number of challenges trying to control TB in a low incidence area. Due to low patient numbers, there can be a lack of organisational focus and funding for TB services, the services that do exist lack resilience to cope with an increased workload or changes to staffing levels. Furthermore, in areas where TB is rare, there is often lower awareness of TB among both healthcare professionals and other key sectors. This can lead to diagnostic delay of TB cases.
Screening of high-risk groups for latent TB is a key priority and should be offered to all 16-35 year olds who have arrived in the last 5-years and from a country where TB incidence is more than 150 per 100 000 population17. Pre-entry screening for active pulmonary TB is a requirement for migrants who apply for a UK visa who reside in a high TB incidence country18. Screening is also offered to people in contact with substance misuse services and prison health services19.
The BCG vaccine is also used to prevent TB infection, it is recommended for use in key high-risk groups: household contacts or equivalent exposure contacts of cases with smear-positive pulmonary TB, children under 2-years of age in contact with smear-positive pulmonary TB and all newborn babies who are contacts of TB cases. The BCG immunisation program is targeted at infants and children who are most at risk of developing severe disease and/or exposure to TB infection, including all infants/children with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100 000 or greater and all infants living in areas of the UK where annual incidence of TB is 40/100 000 or greater.
• Population
The burden of TB falls disproportionately on more socioeconomically challenged groups, with rates of new TB infection 7 times higher in the most deprived areas of the UK compared to the least deprived.
The East Midlands reflects the wider trends seen in the UK, the highest rates of TB are concentrated in urban areas and 4 times the number of new TB cases were identified in the most deprived areas compared to the least deprived. In the East Midlands, SRF are associated with 15-20% of TB cases, with homelessness being the most common risk factor20. Those with SRF are more likely to be male, UK born, white, have infectious pulmonary TB with higher rates of transmission and higher risk of not completing drug treatment, thus developing resistance. Although people with these SRF represent a diverse group, they often share experience of social exclusion and typically experience multiple overlapping risk factors for poor health.
There have been a number of cases in Derbyshire of people with TB with no recourse to public funds and nowhere to live. Stable accommodation is vital to ensure a person with TB is supported to complete their treatment. Treatment regimens are a minimum of 6-months with regular healthcare visits; without stable accommodation it is extremely difficult to adhere to this, this increases the risk of people becoming very unwell, spreading TB and developing MDR-TB.
In order to achieve the targets, set out in the ‘TB: action plan for England, 2021 to 2026’, TB services must be appropriate and accessible for high-risk groups, whilst being integrated in a system-wide approach with other key sectors such as housing, drug and alcohol teams and immigration.
• Evidence
The ’TB: action plan for England, 2021 to 2026’ sets out 5 priorities with relevant action points to improve the prevention, detection and control of TB in England. The plan outlines the core outcomes and indicators and who the key stakeholder and partners are in achieving these.
TB is closely linked to deprivation and SRF; it will not be possible to meet the targets set out in the ‘TB: action plan for England’ without improving TB control in these groups. The ‘Tackling TB in inclusion health groups: toolkit for multi-agency approach’ sets out recommendations to address barriers to delivering integrated and accessible care, provides examples of good practice and tools and resources for services to use locally.
As Derbyshire has a very low TB incidence, this can present a distinct set of challenges for TB services. The Public Health England resource on TB in low incidence areas provides evidence based solutions and examples of best clinical practice to support low incidence areas in managing TB. Chesterfield Hospital is used as an example of best clinical practice in the resource, the TB service was linked to the Infection and Prevention Control Team in the hospital. The redesign improved the resilience of the TB service and enabled a number of improvements, including provision of a 7-day service, education delivery to under-served population and wider healthcare professional and active management of patients in their home.
• Causes
The causes and risk factors associated with TB are well understood. A public health approach to tackling TB must take a system wide approach, promoting education for the general population and healthcare workers, providing integrated and accessible TB services and understanding the wider determinants that contribute to a person’s risk of developing TB such as socioeconomic deprivation, housing and migration status.
• Collaboration
Managing TB effectively requires collaboration across the NHS, Local Authority, community, voluntary and independent sectors. Engaging healthcare providers, policymakers, community groups and key sectors such as housing and immigration, ensures that strategies are comprehensive and align with both the needs of the local community and global efforts to tackle TB.
Latest Derbyshire Data
Trend Data
Prevalence Maps of Derbyshire
The maps below illustrate Lower Super Output Areas (LSOAs) and Middle Super Output Areas (MSOAs) for Derbyshire. LSOAs and MSOAs are geographical divisions used for statistical purposes, allowing for more detailed analysis of local data. In these maps, you can explore various health indicators and data for Derbyshire, providing valuable insights into the area’s health and wellbeing.