TB remains one of the most deadly infectious diseases worldwide, killing 1.4m people, with nearly another 9m having the disease, mainly in developing countries, and an increasing prevalence year on year.1
There were 6,523 TB cases reported in England in 2014.
NICE published its latest recommendations on TB, which is a notifiable disease, in January.2
Mycobacterium tuberculosis causes TB. An anaerobic bacterium, M tuberculosis needs oxygen to survive and spreads from person to person via airborne droplets, released when an infected person coughs or sneezes.
TB is common in the lungs, but is also found in the bones, skin and nervous system.
In healthy people, the immune system can kill TB bacteria. If the immune system cannot kill the bacteria, it can stop them spreading and prevent symptoms from developing, known as latent TB.
Latent TB is when a person has TB bacteria in their body, but there are no symptoms, so they do not feel unwell.
If the immune system cannot destroy or minimise the bacteria, active TB can develop later on. Latent TB can become active many years after the initial colonisation, if the person’s immune system is weakened by another illness.
The new NICE guideline covers preventing, identifying and managing latent and active TB in children, young people and adults.
It makes recommendations for improving ways of finding people with TB in the community, with a new recommendation that everybody aged under 65 years with latent TB should be treated (the previous age limit was 35 years).2
The guideline reinforces the view that the effective management of TB requires close working between hospitals, the community and the voluntary sector.
It also combines clinical advice with public health guidance.2
The key messages on TB prevention centre on raising and sustaining awareness of the disease, including public and healthcare professionals’ awareness that TB can be a possibility as a differential diagnosis, and clear messages that it is treatable.2
Prevention and identification are especially important in high-risk populations, such as the immunosuppressed, the homeless, those with alcohol and drug dependency, prisoners and residents of hostels and long-stay institutions.
Specific risk factors for TB include having lived in Asia, Latin America, eastern Europe or Africa for years, and exposure to an infectious TB case.
With this in mind, we should be cognisant of symptoms that might indicate TB (box 1), so that early detection and treatment can be implemented.
The guidance recommends that healthcare professionals should actively think of and search out potential TB cases in our at-risk populations.2
One aspect of prevention is the management and treatment of latent TB. NICE has now recommended extending the age range for its treatment, raising the upper age limit from 35 to 65 years.
The length of time on medication for latent TB, depending on the patient group, is either three or six months, which could improve adherence and reduce costs.
BCG vaccination is recommended for people between the ages of 16 and 35 years who are at occupational risk of exposure to TB.3
The NICE guidance recommends that the clinician responsible for care should refer the patient with TB to a clinician with training in, and experience of, the specialised care of people with TB.2
The TB service should include specialised nurses and health visitors, and all active TB in children should be managed by a TB specialist, and paediatric trained nursing staff, where possible.
This reflects the recommendation for multidisciplinary teams and the new guidance renames TB services as the multidisciplinary TB team to reflect the specific groups that have responsibility for the services provided. New to the recommendations is that anybody can refer a suspected case of TB.2
Drug-resistant TB, which can occur because of the prolonged nature of the treatment, remains problematic. Patients forget or stop their medication for a variety of reasons, so drug resistance increases.
Directly observed therapy (DOT) is highly recommended and is particularly indicated in groups where adherence cannot be assumed, although it is labour-intensive.
NICE recommends daily dosing of medications unless the patient is under a DOT regimen and being case managed, when recommended dosing is three times weekly.2
The key recommendations concern awareness and thinking of the disease in our populations. TB is still a problem, it should never be far from our minds and we need to be aware of it and of what to do if we suspect or find it.
- Jane Scullion is a respiratory nurse consultation in Leicestershire and Dr Steve Holmes is GP with an interest in respiratory care in Somerset
- Médecins Sans Frontières. Tuberculosis
- NICE. Tuberculosis. NG33. London, NICE, January 2016
- NHS Choices. Who should have the BCG (TB) vaccine?
Photo: Scott Camazine/SCIENCE PHOTO LIBRARY