A TB Action Plan for Scotland

5. Public Health Services

Introduction

5.1 TB is a disease of significant public health importance. It is a communicable disease that if undiagnosed and unchecked can spread amongst populations and, particularly, amongst those whose are vulnerable or have other serious conditions such as HIV. While TB is not necessarily a disease that will spread very easily from person to person, the potential for transmission remains and there is a sufficient cultural memory of TB that the risk of transmission can in itself cause fear and alarm. Concerns around drug-resistant strains of the disease also support the need to limit the spread of disease wherever possible. The role of public health services in reducing TB transmission at a population level and in responding to TB incidents is therefore crucial. These issues were considered by the Public Health Services Subgroup.

Key issues

Contact Tracing

5.2 Contact tracing is a key public health approach to minimising the spread of TB in the population. When a patient with TB is identified, public health teams undertake work to trace all close contacts of that case and to assess and if necessary test them for infection. Although only a low proportion of these contacts of TB patients go on to develop active TB disease, this work can reduce the potential for further community spread of the infection. Contact tracing can be a laborious and resource intensive exercise, particularly in the case of individuals with many social contacts or whose contact history is not clearly understood.

5.3 The 2009 Scottish Health Protection Network guidance document provides detailed guidance on approaches to contact tracing in a range of settings, including at schools, and in community care, as well as amongst travellers on aircraft. In order to ensure contact tracing approaches across the country are as effective as possible and consistent with guidance 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). New Entrant Screening

5.4 Current national policy on port health states that Immigration Control staff risk-assess new entrants to the United Kingdom who arrive through ports. Those coming from high-risk countries and intending to stay in the United Kingdom for more than 6 months, and all refugees and asylum seekers, should be referred to Port Health Control Units ( PHCU).

5.5 NHS Board Consultants in Public Health Medicine are notified of medical examinations by port health units (including chest X-ray status) via standard procedures. Consultants in Public Health Medicine are expected to arrange appropriate follow-up, usually by passing the information on to local NHS tuberculosis services.

5.6 In the past few years there has been a rapid increase in the number of referrals from Immigration Control. The Health Protection Agency's Tuberculosis in the UK 2010 annual report, published in October 2010 (available in electronic format on the Health Protection Agency website at: http://www.hpa.org.uk/Publications/InfectiousDiseases/Tuberculosis/1011TuberculosisintheUK/), found the majority (79%) of non- UK born patients were diagnosed with active TB two or more years after arrival in the UK. There is currently substantial debate about the value of port entry screening for TB.

5.7 It is not fully understood why individuals develop TB more than two years following entry to the UK but this could also be related to either latent infection on entry to the UK, infection once within the UK or perhaps frequent travel abroad. However surveillance information in Scotland clearly indicates the value in ensuring such individuals are appropriately screened for TB infection. One of the key recommendations in the Health Protection Agency report on screening is that identification and treatment of latent tuberculosis infection should be strengthened amongst groups at high risk of TB.

5.8 The Working Group recommends that 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. The Working Group in particularly highlights the potential benefit of TB multidisciplinary teams linking with local inequalities groups and teams. All NHS Boards will have well established groups, and in some cases, dedicated teams that promote equality and diversity. This work is set in the context of the Scottish Government policy of "Fair for All". These groups may be able help to raise awareness of TB in ethnic groups and provide advice to multidisciplinary teams on how to better engage with those in varied ethnic populations.

5.9 In Scotland the 2009 Scottish Health Protection Network guidance (see paragraph 3.3) advised that new entrants should be identified for screening from, for example, new registrations with primary care. To ensure screening/case finding can be as effective as possible, it is important that migrants (including temporary workers) are positively supported to register with local GPs . This work should recognise that new entrants to countries can present particular challenges for health services, not least difficulties in respect of language/cultural barriers. Therefore multidisciplinary teams should work with statutory and voluntary groups that have regular contact with new entrants to support them registering with GPs.

5.10 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.

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

5.12 It should be recognised that these actions will increase demand on public health and clinical services.

Detecting TB in high risk groups

5.13 It is a recognised fact that certain population sub-groups are at higher risk of TB than others. Individuals from other parts of the world, including the Indian sub-continent, sub-Saharan Africa and China, and some parts of Eastern Europe, are more likely to be at risk of being infected. Likewise those from deprived areas, with serious alcohol or drug related problems, or with certain other co-morbidities are equally likely to be at greater risk. 5.14 This is an important area and the TB Action Plan Working Group recognises the importance of ensuring equitable treatment to all members of society in line with the Quality Strategy.

5.15 The main risk factor for TB infection in Scotland, excluding place of birth, is problem alcohol use. However incidence of TB is influenced by - and associated with - other social risk factors as well. These include poor nutrition, poor access to healthcare, homelessness, problem drug use and imprisonment. It is of note that some of these groups are almost hidden within the community and unlikely to register with GPs to access primary care. They may present late and adhere poorly to treatment, increasing the risk of spread of TB and emerging drug resistance. TB is one of a number of disease that contributes to the continuing inequality in health experienced by those living in deprived communities relative to those in affluent communities.

5.16 A stocktake of TB services within Scotland carried out by Health Protection Scotland for the TB Action Plan highlighted that of those Boards that responded to the stocktake, five do not undertake work to detect TB in populations that are at higher risk of being infected.

5.17 The Working Group is aware of the NICE initiative to develop guidance on the public health programme aimed at reducing the transmission of TB among hard-to-reach groups. NICE defines hard to reach groups as:

Children, young people and adults whose social circumstances or lifestyle, or those of their parents or carers, make it difficult to:

• o recognise the clinical onset of tuberculosis
• o access diagnostic and treatment services
• o self-administer treatment (or, in the case of children and young people, have treatment administered by a parent or carer)
• o attend regular appointments for clinical follow-up.

5.18 Scotland has contributed to the development of this guidance. The Working Group recommends that the Scottish Health Protection Network review the output of this work when it is published (expected March 2011) to consider its applicability in Scotland.

5.19 In the meantime, and while this work is progressing, 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. This work should include discussions with local partners such as addiction services about approaches to raise awareness of TB amongst hard-to-reach groups in their area.

5.20 Because of importance of problem alcohol use as a risk factor, 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.

Vaccination

5.21 Scottish BCG policy follows national guidelines of the Joint Committee on Vaccination and Immunisation ( JCVI). Current policy is as set out in the Department of Health's Immunisation against infectious disease (the 'Green Book', which is available in electronic format at: ( http://www.dh.gov.uk/en/Publichealth/Immunisation/Greenbook/index.htm). These recommendations are set out in the box on page 25.

The JCVI recommends immunisation for the groups listed below (unless BCG immunisation has been previously carried out or the tuberculin skin test is positive or there are contra-indications): all infants (aged 0 to 12 months) living in areas of the UK where the annual incidence of TB is 40/100,000 or greater* all infants (aged 0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater previously unvaccinated children aged one to five years with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. These children should be identified at suitable opportunities, and can normally be vaccinated without tuberculin testing previously unvaccinated, tuberculin-negative children aged from six to under 16 years of age with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. previously unvaccinated tuberculin-negative individuals under 16 years of age who are contacts of cases of TB previously unvaccinated, tuberculin-negative individuals under 16 years of age who were born in or who have lived for a prolonged period (at least three months) in a country with an annual TB incidence of 40/100,000 or greater. In addition, unvaccinated, tuberculin-negative individuals aged under 35 years in the following occupations are recommended to receive BCG: healthcare workers who will have contact with patients or clinical materials (both NHS and non- NHS facilities) laboratory staff who will have contact with patients, clinical materials or derived isolates veterinary and staff such as abattoir workers who handle animal species known to be susceptible to TB, e.g. simians prison staff working directly with prisoners staff of care homes for the elderly staff of hostels for homeless people and facilities accommodating refugees and asylum seekers.

Newborn BCG Services in Scotland

5.22 The Information Services Division ( ISD) Child Health Information Team recently reviewed BCG immunisation data recording on the Scottish Immunisation and Recall System ( SIRS). SIRS facilitates the automated identification of babies requiring BCG immunisation through the recording of details about the country of birth of baby's parents and grandparents. Ideally these details would be recorded on the "Pregnancy Record" part of the Scottish Woman Held Maternity Record ( SWHMR) and an alert indicated on the relevant field of the Neonatal section of the SWHMR. There would, however, need to be some modification to SWHMR to allow the country of birth of parents and grandparents to be adequately recorded. Details of vaccination should also be entered into this part of the SWHMR. Unfortunately, the SWHMR is paper-based in most parts of Scotland, so the information cannot be forwarded electronically to SIRS. Information could also be entered into the clinical section of the Scottish Birth Record ( SBR), for those NHS Boards which use this facility. The SBR would need to be modified to allow recording of country of birth of parents and grandparents, and it does not yet have an electronic link to SIRS so data has to be printed off and re-entered. If the details are not recorded at birth they should be recorded at the 10 day visit by the health visitor and passed on to SIRS. It is thought that currently these details are being recorded at the 10 day visit rather than during pregnancy or at birth. Where the new born baby has been immunised details should also be entered onto SIRS. The system identifies from the entered fields the child's TB risk status based on TB incidence of reference data. NHS Boards have local arrangements for calling children requiring BCG immunisation to clinics. The results from a recent ISD study showed that there was considerable variation amongst Boards for TB risk status not recorded on SIRS (a range 3-15%). The recording of parents/grandparents country of birth not recorded by NHS Board is also variable (range 3-40%).

BCG Services for Older Children

5.23 According to current JCVI advice, previously unvaccinated older children with specific risk factors for TB who would formerly have been offered BCG through the schools' programme should be identified at suitable opportunities, and tested and vaccinated if appropriate. The school catch up campaign across Scotland was completed in 2007. It is unclear how many Boards still continue to use the Child Health Systems Programme ( CHSP) BCG screening questionnaire to systematically identify schoolchildren who may be at risk. Some Boards have developed their own questionnaires while other Boards identify children at birth.

Improving BCG Services

5.24 The Working Group believes that the national focus for improvement in BCG services should be on newborns where BCG immunisation is most effective. The Public Health Services Subgroup provided a number of key points for Boards to consider to promote improvements in new born BCG vaccination, specifically:

• A new born baby within identified risk groups should have the same chance of BCG immunisation wherever that baby is born/lives within Scotland.

• A robust audit system is key to successful implementation of neonate vaccination and Boards/multidisciplinary teams should ensure that they audit neonatal BCG immunisation on a regular basis.
• Boards should ensure that BCG services are co-ordinated and monitored. One option for doing this would be to nominate a lead within Board Health Protection Teams to undertake his role

5.25 The Action Plan Working Group therefore recommends that NHS Boards should review roles and responsibilities for neonatal BCG immunisation in their locality to re-examine current operational plans, in light of the above.

5.26 At the national level, it is recognised that development of existing IT systems can support and promote BCG vaccination. 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. Work should also be done to explore the required developments to link the Scottish Birth Record with SIRS.

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

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

Occupational Health: Clearance and Vaccination

5.29 Healthcare professionals can be at increased risk of exposure to TB and are currently recommended for BCG vaccination under national vaccination policy. The Scottish Government published guidance on health clearance of healthcare workers for TB and blood borne viruses in May 2008 (see: http://www.scotland.gov.uk3947d348-f7e2-4787-9e94-2ff287db28a0). This guidance sets out the requirements for screening of new healthcare workers (which can include existing healthcare workers moving to new posts or carrying out certain types of procedure for the first time) for TB. This guidance includes the requirement that:

• Employees new to the NHS who will be working with patients or clinical specimens should not start work until they have completed a TB screen or health check, or documentary evidence is provided of such screening having taken place within the preceding 12 months.

5.30 This guidance was based on existing guidance from NICE and JCVI and reflects a UK expert opinion. It may not fully reflect the different epidemiological picture in Scotland compared with some parts of England. The document does acknowledge that not all healthcare workers are at an equal risk of TB. There are likely to be categories of healthcare workers who are at particular risk of TB, and this should be part of the clinical risk assessment when the use of BCG is being considered for a healthcare worker over 35 years of age (given that there is no data on the protection afforded by BCG vaccine when it is given to adults aged 35 years or over).

5.31 Anecdotal reporting is that occupational health professionals do not necessarily agree that this universal approach is proportionate in Scotland, particularly in cases where it is clear there is a low risk of TB. Work is currently underway by the Senior Occupational Physicians Group in conjunction with NHSQIS to examine performance across Scotland in occupational health departments against the health clearance guidance. The value of this work is supported by the Action Plan Working Group who agreed that any recommendations to change current guidance should await the outcome of the survey.

5.32 The Action Plan Working Group therefore recommends that, in light of the above considerations the Scottish Government should establish a process to review the TB elements of the 2008 health clearance guidance documenthttp://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.