Public Health England in their “Collaborative Tuberculosis Strategy for England” document states:
“Tuberculosis incidence in England is at its highest since the 1980s, higher than most other Western European countries, and nearly five times as high as in the US. Trends in England are in marked contrast to some comparable countries that have achieved consistent reductions by concerted approaches to TB treatment and control”
In England there were just over 8000 cases in 2012, this was only about 2000 lower than the whole of the USA.
The incidence of TB is heavily concentrated in certain urban and metropolitan areas, and to specific populations within them. The high risk groups are typically settled migrants who have been exposed to TB but whose immune system has kept it suppressed due to good health – known as latent TB, new migrants who have been infected in, or who have close links with, high incidence countries, or people with social risk factors like homelessness, drug or alcohol abuse where their immune system may be compromised.
Due to the demographics of Derby there is a relatively high incidence of TB each year ( approx. 60-80 cases) and in order to manage this level, the Derby Hospitals have a TB Unit covering the City and South Derbyshire.
I met with Deborah Harrison and Julie Gratton, at the Royal Derby Hospital, who have been responsible for the treatment and control of TB in Derby for many years. The fact that the incidence level has been relatively static for a decade has been down to their commitment , rigour and vigilance. Their role is as much about awareness, prevention, and containment, as it is about treatment of symptoms in a patient.
TB is a complex condition but my meeting with Deborah and Julie left me with a number of key messages:
• TB is a bacterial infection and is typically caught through sustained close contact with a carrier. Usually, this will be from a partner, or other people in the same household. It is possible, but rare, that it will be contracted in the work place, and most unlikely through casual contact in the street. In certain communities within Derby, there can be 10-20 people living in the same house; this represents a particular risk for the spread of the infection.
• It is fully treatable through medication and improved diet ( weight loss is a symptom of TB).
• In order to ensure speedy recovery for the individual (index case) and maximizing the containment of the spread of the infection to others, it is critical that the index case visits their GP at the earliest sign of the symptoms. This is where the on-going awareness work is so critical.
• After an infection is identified, the TB Unit team will also screen the people who have had contact with the index case. They will do this, first, with people who live close to the person infected, and then widen the screening to include people who have had lesser contact with the index case. They will continue to do this until they have sufficient negative readings to assure themselves that they have captured everyone. This is one of the key procedures for managing containment. It is important that all people required for screening come forwards and comply with this process.
Without this testing, the infection could multiply rapidly, as a result of one outbreak.
• Testing does not confirm that the individual is free of TB, it just means that they do not have the active symptoms. It may be “latent” which means that when their immune system is compromised, or when they get older, the TB may surface in an active form. So, people who have been “in contact” always have to remain vigilant.
• The extent of latent TB in Derby is unknown. A very expensive, and time-consuming treatment programme would be required to deal with all latent TB. This would be a never ending task.
• There is supposed to be New Entrant TB screening at the UK border but the belief is that that is ineffective.
Whilst the heart of the task of the TB team is clinical, they are presented with a wide variety of other social, cultural and healthcare issues in their work. A good proportion of the people that they deal with have little, or no knowledge of the English language. Many will have a lack of experience of a competent healthcare system in their home country and so they are unsure about how to engage with nursing professionals. The team will also be witness to other health issues e.g. poor diet, dental hygiene, under-age drinking and smoking, as well as sub-standard housing conditions, and financial difficulties. All of which can impact on the speed and nature of recovery. The TB team cannot ignore these issues and so feel conscientiously obliged to help wherever they can. Most of these issues are outside their field of experience or control.
One of the symptoms of TB is a loss of weight. A substantial healthy diet is an important part of the recovery process. Unfortunately there are cases where, due to their personal financial circumstances, it is very difficult for the individual to get the right food. Although the TB team have tried to arrange contributions from a food bank this has been unsuccessful in the past. As a result of my previous contacts with Derby City Mission (DCM) I made contact with them to see if they would be prepared to support the TB unit should they need emergency supplies. DCM agreed to do this and have already started supplying food parcels. There is scope for developing this relationship further between DCM and Derby Hospitals.
It became clear to me that the TB unit are a “victim of their own success” . They have managed to contain the TB problem to an extent that it is not high profile. This is a real testament to the competence of the TB Unit’s work. It feels that the biggest risk, now, is complacency. The spectre of a TB outbreak always represents a menacing presence ready to pounce at the moment that the attention is diverted onto other priorities. In the current climate of public finances, this is always a worrying possibility!