A TB Action Plan for Scotland

Laboratory Services and Diagnostic Tools

Culturing TB bacteria (bacteriological diagnosis)

1

At a minimum all specimens should now be cultured in liquid media as this reduces by more than half the time to result from 27 to 13 days as compared with solid culture

Precious samples (e.g. CSF, biopsies, lymph nodes) and those requiring incubation at other than 36 ⁰C such as skin biopsies and abscesses should receive solid culture in addition to liquid culture.

Specimens should not be cultured on solid media alone.

NHS Laboratories

Immediately

Laboratory quality assurance

2

All laboratories carrying out mycobacterial microscopy and culture should be Clinical Pathology Accreditation ( CPA) accredited, have specific quality systems and undertake appropriate External and Internal Quality Assurance.

NHS Laboratories

Immediately

Laboratory service availability

3

The Scottish Government will support a 5 day minimum service, pending more evidence becoming available about potential implications of service increase to six days in terms of cost and quality. This will be reviewed in time.

Scottish Government

Immediately

Optimisation of laboratory services

4

In line with the Quality Strategy and the commitment to reducing unnecessary duplication, the Scottish Government will support work through the Scottish Microbiology Forum to consider the centralisation of Scottish mycobacterial diagnostic services into a smaller number of laboratories with higher throughput and defined quality standards in laboratories in Scotland

Scottish Microbiology Forum (with Scottish Government Support)

By end 2011.

Future Developments

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 IGRAs may in time to 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.

Scottish Health Protection Network

Work to commence once NICE publishes (due March).

5b

Scottish Government should ensure a mechanism exists for the appropriate Scottish body to assess these developments on an ongoing basis to ensure the best quality and most efficient diagnostic tools are available in Scotland.

Scottish Government

Mechanism discussed and agreed by end 2011.

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 and SMRL

Group to be established by end 2011

Clinical Services

Strategic Planning

6

TB should be a Board priority for those areas in Scotland with the highest incidence of cases.

Other Boards with lower incidence of TB should however also review their response to TB in line with recommendations in this report.

NHS Boards

Immediately

Improving clinical management

7a

No TB patient should be treated by a single consultant without the involvement or oversight of a multidisciplinary team. Evidence shows that treatment of TB should be initiated by a specialist and supervision of management should be as part of an multidisciplinary team, including primary care.

GPs and primary care teams (including pharmacists) have a crucial role in the early detection of TB and, in collaboration with others, the overall care and treatment of their patients.

NHS Boards

Multidisciplinary teams and associated protocols should be in place by end 2011.

7b

All TB patients in Scotland should have their care plans reviewed by a TB multidisciplinary team. In patients with suspected TB, initiation of anti- TB therapy should be discussed with a TB specialist to ensure optimal investigation and management.

Sharing best practice

8a

The Scottish Government should ensure that a national network of multidisciplinary team staff/leads is supported and facilitated.

Scottish Government

Network established in 2011

8b

Recognising the key role of TB Nurses, the Scottish Government should ensure that the national TB Nurses Network is supported and facilitated.

Arrangements for supporting the Network should be put in place immediately.

8c

To ensure that clinicians from across Scotland working in the field of TB have the opportunity to meet and discuss issues, the Scottish Government should ensure an annual national meeting of all health professionals involved in treatment and management of the disease is funded and facilitated

First meeting to take place in 2011 and annually thereafter

Access to negative pressure facilities

9a

NHS Board should have documented arrangements in place to ensure access to negative pressure facilities where these are required. Individual circumstances may make this challenging but at a minimum single rooms should be used where required for the period that any patient would be considered to be infectious.

NHS Boards/

multidisciplinary teams

Documented arrangement in place by end 2011

9b

Patients with MDR/ XDRTB should be managed in negative pressure facilities with en-suite facilities without exception. All patients with suspected MDR/ XDRTB, pending microbiological results should be managed in a negative pressure room with en-suite facilities.

9c

These arrangements should be understood by all relevant staff involved in patient management and should, for example, form a core part of multidisciplinary team operational documentation.

Tuberculosis and HIV/ AIDS

10a

Existing guidance on HIV screening of TB patients should be implemented routinely across Scotland, and health professionals should be reminded of this guidance. Moreover multidisciplinary teams should ensure that HIV screening has been carried out during patient reviews.

NHS Boards/

Multidisciplinary teams

Immediately

10b

Patients co-infected with HIV and TB should be directly managed by a physician with expertise in the management of both conditions. Ideally this should be an adult or paediatric trained infectious diseases physician.

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. This work will commence in 2011

Health Protection Scotland

Commence in 2011

National guidelines for TB control

11

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

Scottish Health Protection Network

Ongoing

Surveillance

Good quality, efficient and effective surveillance of TB

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 Health Protection Scotland should establish a group involving NHS Board representatives as soon as possible to actively consider adopting a compatible version of ETS

Scottish Government, Health Protection Scotland and NHS Boards

Group should be established immediately and timescales for work agreed before the end of 2011.

Improving ESMI as an interim measure

13

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

Multidisciplinary teams.

Annually

Improving TB service evaluation at national and local level

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

Health Protection Scotland

Annually

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 copied to Health Protection Scotland. Local clinicians should be made aware of this report

NHS Boards/

Multidisciplinary teams

Public Health Services

Contact Tracing

15

Multidisciplinary teams locally should be responsible for auditing contact tracing actions to ensure that they follow national guidance. ( http://www.documents.hps.scot.nhs.uk/about-hps/hpn/tuberculosis-guidelines.pdf)

Multidisciplinary teams

Ongoing

New Entrant Screening

16a

Multidisciplinary teams should explore locally how best to identify new entrants within their own areas and to implement local systems of case-finding for latent TB infection in these entrants. NHS Boards should be encouraged to emphasize the importance of case-finding TB in new and recent entrants.

Multidisciplinary teams

By March 2012

16b

Multidisciplinary teams should work with statutory and voluntary groups that have regular contact with new entrants to support them registering with GPs.

NHS Board/

Multidisciplinary teams

Ongoing

16c

Primary care staff should identify and refer those individuals known to be at risk of TB and NHS Boards should ensure that primary care staff are able to assess new entrants and refer as appropriate (for chest x-ray, to a local skin test/interferon gamma clinic, or a TB clinic) in line with National Guidance.

Primary Care staff

By March 2012

16d

Multidisciplinary teams locally should ensure the provision of adequate language translation facilities to support case-finding by staff

NHS Boards/ Multidisciplinary teams

By March 2012

Detecting TB in high risk groups

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.

Scottish Health Protection Network

When NICE report is available (expected March 2011)

17b

In the meantime, multidisciplinary teams/local services should be aware of those groups in their area which are most difficult to reach and should design approaches to better reach them

Multidisciplinary teams

By March 2012

17c

Multidisciplinary teams/local services should engage with primary care teams to highlight the increased risk of TB amongst problem alcohol users. Multidisciplinary teams should also link with the local Alcohol and Drug Partnerships to raise awareness of the increased risk of TB in those with problem alcohol and drug use.

Multidisciplinary teams

By March 2012

Vaccination

18a

NHS Boards should review roles and responsibilities for neonatal BCG immunisation in their locality to re-examine current operational plans

NHS Boards

By end 2011

18b

The Scottish Government and Health Protection Scotland 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 Health Protection Scotland should also explore the required developments to link the Scottish Birth Record with SIRS.

Scottish Government/Health Protection Scotland

By end 2011

18c

Health Protection Scotland should examine whether the existing CHSP school system BCG screening questionnaire for identifying children at risk is still appropriate.

Health Protection Scotland

By end 2011

18d

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

Health Protection Scotland

Ongoing

Health clearance and vaccination of those at occupational risk

19

The Scottish Government should establish a process to review the TB elements of the 2008 health clearance guidance document http://www.scotland.gov.uk3947d348-f7e2-4787-9e94-2ff287db28a0).

This review should take account of the audit of performance against the existing guidance that is already under way by the Senior Occupational Physicians Group. Any review should seek to ensure that subsequent guidance takes a risk-based approach

Scottish Government

Process established by end 2011

Monitoring and Ensuring Progress

Monitoring Progress

20a

An Action Plan Monitoring Group should be established by the Scottish Government, to monitor progress against recommendations and to provide advice to Ministers, NHS Boards or other delivery partners to ensure the ambition of this Action Plan is achieved.

Scottish Government

20b

This group should meet at least annually and should have a small membership so as to be as effective as possible

Action Plan Monitoring Group

20c

The group should establish key performance indicators ( KPIs) for the recommendations within the Action Plan where appropriate, to enable measurement of progress.

Action Plan Monitoring Group

20d

The group should report annually to Ministers on overall progress in delivery of the Action Plan, or by exception in the case of particular problems.

Action Plan Monitoring Group

20e

The group should provide a report on progress to the national annual meeting of TB clinicians/nurses.

Action Plan Monitoring Group