A TB Action Plan For Scotland: ANNUAL REPORT / 2013

5a.

The IGRA test is currently under review by NICE and is due to be published in March 2011. This work should be considered by the Scottish Health Protection Network when available to inform guidelines on use of IGRA in Scotland.

The working group also notes that while IGRA may in time be shown to be more sensitive and specific than skin tests (which generally require more than one clinic visit by the patient) in the diagnosis of latent TB infection, the tests themselves are expensive and their introduction should be managed in the most cost effective way.

A HPN group established under the chair of Dr Alisdair MacConnachie reviewed the existing HPN guidance 'Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control in Scotland.'

The review considered the 2011 NICE TB guidance, ECDC guidance and peer reviewed literature to address the seven key areas identified by the HPN group for the use of IGRA:

1) New arrivals in the UK
2) Close contacts of confirmed cases
3) Immunocompromised individuals - including individuals starting TNF α therapy, HIV positive individuals
4) Healthcare workers
5) Children
6) Role of IGRA in the diagnosis of active disease
7) Prisons and prison population

The group also reviewed all other aspects of the guidance and have added additional sections including:

• Advantages /disadvantages of IGRA
• Samples required for IGRA
• Methadone & anti-tuberculosis treatment containing rifamycins
• Template letters - advise & inform letter for NHS staff

The final draft of the guidance is currently being prepared and will be circulated for stakeholder consultation prior to finalisation and publication.

One of the recommendations of the HPN guidance group was work to establish the current situation across the NHS Boards with respect to the use of IGRA. A piece of collaborative work between HPS and a summer internship student based in NHS Fife is currently investigating the relative use of IGRA and mantoux testing, respective positivity and local advantages and disadvantages of IGRA.

5c.

The Working Group recommends that Health Protection Scotland and SMRL should establish a group to develop a clear strategy for the systematic use of molecular typing of M. tuberculosis complex in Scotland.

HPS established a group to develop a clear strategy for the systematic use of the MIRU typing data.

The group:

• Reviewed the background literature and methodologies for application of MIRU and cluster detection
• Considered the epidemiology of strain type clusters in Scotland
• Reviewed the current practice in NHS Boards in relation to TB clusters
• Developed proposals for the practical application of MIRU, including combining the microbiological and epidemiological information
• Developed proposals for cluster investigation.

The final report from this group and HPS proposals for the implementation of the recommendations from the group were presented at the CPHM meeting (March 2013).

HPS is working to develop an algorithm and protocol based on the recommendations of the group for the timely detection of potential clusters and in particular those which involve two or more NHS Boards, which will then be piloted and implemented.

10c.

Health Protection Scotland will initiate a population based study (an anonymised data linkage exercise) to improve our evidence base around dual TB/HIV infection and associated risk factors in Scotland.

With approval from the Privacy Advisory Committee (PAC) data linkage has been completed for the TB dataset and the anonymous HIV dataset. The initial analysis has explored the proportion of co-infection among TB cases, time between the two diagnosis and the characteristics of those with co-infection including, sex, age, ethnicity, UK or non-UK born, country of birth.

11.

National guidelines should be reviewed for Scotland at a minimum of every 3 years. The Health Protection Network should lead the reviews.

See Action 5a, the current HPN guidance is currently being reviewed.

12.

An updated and dynamic surveillance system that provides real time functionality and that is efficient and easy to use, would significantly improve TB services across Scotland, and should be introduced as soon as possible. As a first step Scottish Government and HPS should establish a group involving NHS Board representatives as soon as possible to actively consider adopting a compatible version of ETS.

A group was established to consider a replacement for the current paper based surveillance of TB (ESMI). The group considered ETS (Enhanced Tuberculosis Surveillance - the system used in England and Wales, which has been successfully piloted in NHS Lothian in 2012/13) TrakCare, ICNet, SPHIMS and a bespoke web-based version of ESMI.

An initial agreement paper was presented to the Public Health Portfolio management group. The group felt that the clinical and quality outcomes for TB surveillance needed to be articulated more strongly. It was also noted by the group there was no allocated funding for any proposals, and this would need to be addressed before any tangible progress could be made. In light of the views of the Portfolio management group, developments with SPHIMS and plans by PHE for a replacement system for ETS, the group will meet again during the autumn 2013 to consider these points and scope the way forward.

14a.

HPS should continue to report annually to the Scottish Government (copied to NHS Boards) on TB. This report should include a section describing Scotland's performance on the specific ECDC indicators.

HPS produces an annual report on TB which is published in HPS weekly report. http://www.documents.hps.scot.nhs.uk/ewr/pdf2012/1244.pdf

HPS produces an annual Board level report for those Boards with 10 or more cases in the year, providing an epidemiological breakdown of Board level data to assist in local monitoring or development of local initiatives.

The paper detailing Scotland's performance on specific ECDC indicators is included in the papers for the TB Action Plan Monitoring group. A copy will be also be circulated to the NHS Boards.

17a.

Scottish Health Protection Network should review the output of the NICE initiative to develop guidance aimed at reducing the transmission of TB among hard-to-reach groups when it is published and to consider its applicability in Scotland.

The NICE guidance on Tuberculosis - hard to reach groups was published in March 2012. This was considered by the HPN group reviewing the guidance and referenced in the revised HPN guidance when appropriate.

18b.

The Scottish Government and HPS should explore the additional work required to develop the SIRS childhood vaccination call/recall system to enable Boards to record data in an effective manner. Scottish Government and HPS should also explore the required developments to link the Scottish Birth Record with SIRS.

A short life working group was established chaired by Dr David Cromie which considered selective neonatal immunisation - Hepatitis B and BCG.

A business case was developed for a change to SIRS to enable SIRS to record infants who are identified as at risk for BCG and generate lists that NHS Boards can use to schedule these infants for immunisation, the changes will also enable SIRS to generate lists to flag those infants for whom their 'at risk' status is unknown. 'At risk' and vaccination status will be recorded enabling ISD to generate uptake reports.

The business case was presented to eHealth PMG. PMG decision that due to other higher priority work this work will not be scheduled to 1st Quarter of 2014 at the earliest.

18c.

HPS should examine whether the existing CHSP school system BCG screening questionnaire for children at risk is still appropriate.

HPS developed a questionnaire regarding if and when the current CHSP school BCG screening questionnaire is used, which was completed by TB leads/immunisation coordinators. Paper summarising the findings of this work is included in papers for the TB Action Plan monitoring group.

18d.

In future, HPS should undertake a more detailed review of Board BCG audit activities so that best practice is shared across Scotland

No action taken yet.

13.

Multidisciplinary teams locally should routinely feedback local ESMI surveillance to local clinicians and audit the completeness and timeliness of surveillance data using the current paper based ESMI system.

This is an action for NHS Boards. HPS produces annual Board level TB surveillance reports based on the ESMI data submitted for those Boards with 10 or more cases a year and provides Boards with ad hoc data extracts in response to specific requests.

14b.

Each NHS Board TB service/MDT should report annually on TB prevention and control activities. These reports should be sent to their local clinical governance committee and copies to HPS. Local clinicians should be made aware of this report.

At present HPS has not received any reports on TB prevention and control activities for NHS Boards.