A TB Action Plan For Scotland: ANNUAL REPORT / 2013

4. Discussion and Next Steps

4.1 There are encouraging signs that the number of cases of tuberculosis in Scotland may be levelling off although it is too early to say that there is a downward trend. Since 2011, overall progress with the Action Plan has been very good. Patients have access to appropriate diagnostic services and clinical care provided by expert and multidisciplinary teams; there are low levels of drug resistance and public health services contribute to the prevention of ongoing transmission. However, there are challenging areas where programmes need to improve.

Targets and Monitoring Framework

4.2 To stay in line with ECDC targets, as set out in Progressing Towards TB Elimination: A Follow Up To The Framework Action Plan To Fight Tuberculosis In The European Union (2010), the goal of A TB Action Plan for Scotland should be 'To eliminate, by 2050, TB as a public health problem (incidence <1 per million population)'.

4.3 In Scotland, a monitoring framework is required to manage implementation and measure progress towards achievement of this goal. A peer review approach is to be encouraged with Boards, and the framework will be in three tiers: Tier one - strategic level outcomes and epidemiology, based on the ECDC indicators; Tier two - tactical level outputs, based on the Action Plan recommendations; Tier three - audit of clinical and public health activities, such as contact tracing, new entrant screening and neonatal BCG vaccination. A national group will develop this framework and progress will be monitored by the TB Action Plan Monitoring Group (APMG). To ensure the most up-to-date data, the Scottish Government and HPS will publish a joint annual report from 2014.

Strengthened Links to other Policy Areas Relevant to TB Prevention and Control

4.4 In Scotland, the main risk factors for TB infection are being non-UK born, and problem alcohol use. However, cases are becoming increasingly complex as individuals may have dual infection with TB and blood borne viruses (e.g. Hepatitis B, HIV, Hepatitis C); they may have underlying chronic conditions such as diabetes or coronary heart disease; they may be employed as care workers; they may share multiple occupancy accommodation, such as halls of residence or rural workers accommodation; and they may be mobile both internationally and internally, which can make identification and management of clusters of cases more difficult. Clearly, in order to tackle TB, it is necessary to develop links to many other policy areas.

4.5 Innovative approaches are required. One example is collaboration between the Royal College of General Practitioners (RCGP) and the Scottish Government to develop and pilot consulting room software that will prompt GPs to check for country specific health risks during new patient registrations. This electronic toolkit would also facilitate identification of a range of issues such as vaccination status, risk of diabetes or blood borne viruses, lifestyle risks such as smoking and excess alcohol use, and social risks such as vulnerability to domestic violence and poor housing. This would promote a joined up approach to caring for patients whether migrants, the elderly, Gypsy Travellers or young families.

4.6 Another approach is the development of a multidisciplinary TB network which will coordinate quarterly meetings to provide updates, share experiences and facilitate implementation of the Action Plan. It is expected that this will strengthen links between TB services and other services such as occupational health, drug and alcohol, infection control, pharmacy and primary care.

TB Case Finding for Migrants and New Entrants

4.7 New entrant case finding is a priority in A TB Action Plan for Scotland. The UK programme to screen migrants for active TB at the port of entry is being replaced by quality assured pre-entry screening. However, this will not identify latent TB infection (LTBI) which studies indicate could account for up to three out of four new cases in the UK.

4.8 The HPN guidelines state that 'new entrant screening should be incorporated within larger health screening programmes for new entrants and linked to local services in particular primary care'. Primary care is key to identification of new entrants, and screening of individuals from high risk (incidence >40/100,000) and very high risk countries (incidence >150/100,000) has been shown to be cost effective through primary care in England (£20,819 per case of active TB prevented for individuals from countries with an incidence >150/100,000). However, not all migrants register with primary care. For example, a study among migrants in Glasgow from the 8 countries which joined the EU in 2004 showed 58% of respondents had registered with a GP and 32% had used health services in the city. Furthermore, not all providers are aware of services to which new entrants are entitled nor the health risk factors associated with certain countries of origin. Nevertheless, latent TB case finding through universities and general practice has been found to be feasible and effective in Scotland. For example, in Grampian, of approximately 1,000 individuals tested in 2010-2011, approximately 20% were positive and followed up for LTBI.

4.9 A sub group of the TB Action Plan Monitoring Group has been established to develop a national approach to case finding/screening for new entrants and migrants from high incidence countries. The group is collaborating with Public Health England to develop pilots which will provide data on the costs and effectiveness of different methodologies. Once evidence based recommendations are available, funds will be sought for national implementation.

TB Case Finding among Individuals who Consume Excess Alcohol

4.10 Alcohol misuse is a recognised risk factor for TB and previous work has sought to investigate this association in Scotland. HPS will hold a one-day seminar in January 2014 to bring together experts in the field from both TB and alcohol misuse perspectives to explore this topic in more detail. The day will help inform future work which may be undertaken to further quantify the issue, identify potential areas for intervention/support, and support the sharing of good practice and initiatives across Boards.

Surveillance

4.11 The current paper-based enhanced surveillance system for TB provides detailed retrospective information on cases. This system is no longer fit for purpose and not in line with international best practice. Scotland requires a surveillance system that provides real time functionality and that can link to case and, liaise with other relevant networks, cluster management - including the use of MIRU data. The national TB surveillance and SHPIMS groups will explore the options to include a TB functionality in the SHPIMS system which is expected to be introduced in 2014. A pilot of the current PHE surveillance system has been carried out in NHS Lothian but PHE is developing an updated system expected to be ready in 2015. The TB surveillance group has already submitted a paper to the Scottish Government Public Health Portfolio Management Group in January 2013. This submission will be updated in light of the development of SHPIMS and the PHE system, and funds will be sought to ensure that progress is made.

TB Network

4.12 A survey of Boards indicated a general willingness to participate in a national TB network of multidisciplinary team staff/leads. The network will report to the Action Plan Monitoring Group and the key function will be to support implementation of the Action Plan, maintain quality and reduce variation in TB services across Boards. This will be achieved through the sharing of good practice and collaboration with existing networks such as the TB Nurses and Pharmacists Networks. In addition, the network will contribute to the development of national standards and audit tools, and lead the national TB study and workshop days. Methods of communication will include an email group and secure website. The network will take into account the different TB rates and circumstances across Boards, including time constraints, and the need for Boards to include time allocated for network tasks, such as development of audit tools and attendance at meetings, into individual work plans. The network will liaise with and learn from existing networks that have been shown to be effective e.g. the National Immunisation Coordinators Network, the Scottish Microbiology and Virology Network, the Pharmacy Network and the Sexual Health and Blood Borne Virus network. The first network meeting will take place in early 2014.