1. Topical news – point of care testing for sore throats
Confidence in RTIs
Talking with patients and parents
An audit of real work
Bronchiolitis TB
Malaria

2. “Sore throat – test and treat” 35 Boots
Under the scheme, those suffering from sore throats will be able to visit their local pharmacy, to undergo tests to see if antibiotics would help them.
Every year, around 1.2 million people visit their GP with such complaints.
More than six in ten walk away with antibiotics – even though just one in ten is suffering from a bacterial infection which will respond to the drugs, research shows.
Only 44% (of those who answered) would have gone to GP

3. Any good? - J Antimicrob Chemother 2016; 71: 3293–3299
Pilot study – data collected and analysed by Boots
£7.50 for the test (and then £10 if they “needed a/b) – RADT (a POCT!!) - 96% sensitivity 98% specificity
In a background of –
Research by the Wellcome Trust showed that patients associate antibiotics with having ‘a real illness’ and ‘proof that they are ill’.
They also found evidence that patients look up symptoms beforehand so that they know what to say to their GP to obtain antibiotics

5. Age No
12- 4
16- 74
26- 99
35- 66
45- 47
55- 32
65+ 16

6. Centor? 1) Absence cough 2) Fever 3) Exudates 4) Anterior cervical lymphadenothy
Supported by studies
/ BMC Medicine2011
Over 14 year olds
Even with 3 or 4 post Centor probability is 15% or 32%
Penicillin 500mg 10 days (Erythro) NOT amoxi
Don’t give benzydamine?

7. Sub group analysis? – of the Boots study
Timing counts
For those with Centor score 3 or 4,
and had a story of 72 h or more - 87/112 tested negative.
and had a story of 48 h or less - 21/36 tested positive
So if less than 48 hours 60% test positive
Or if more than 72 hours 20% test positive

8. A different scoring system (feverPAIN) for sore throat has been assessed and been shown to be as effective as group A streptococcal antigen testing
Little P, Hobbs FD, Moore M et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM BMJ 2013; 347: f5806.

9. How many days do they last?
50% %
days to clear
3 7
1 2
Cough?
Earache?
Coryza?
Croup?
Bronchitis
Patient,co.uk says “most ear aches will clear up in 3 days.....!”
How do we say to parents – or people – 50% clear in 10 days one out of ten will still be coughing at three weeks, and be safe for those who do get a pneumonia
* Is it the cough or the child

11. Paediatric fever observations
Dr Laird
By Soha Amar, Alex Greenhalgh, Cleone Pardoe, Eleanor Wells

12. NICE Guidelines
“Infants and children under 5 years who are seen in person by a healthcare professional should have their temperature, heart rate, respiratory rate and capillary refill time measured and recorded if fever is suspected.”
Fever in Under 5’s, QS64, updated July URL:
NICE guideance Feverish child. URL:

13. Importance
Fever is one of the most common reasons for children to present to primary care
If a serious underlying disease is not diagnosed and treated early, morbidity and risk of mortality is increased.
Children < 5 years old may have few clinical signs
GPs are faced with the challenge of being able to accurately triage children who present with febrile illnesses; without unnecessary investigations and treatment.

14. Importance
NICE traffic light system is a simple clinical tool to assist clinicians in making an initial assessment of children who present with fever.
Designed for children up to 5 years old

16. Method Search: All patients at Karis Medical Centre
Under 5 years old on 29/03/16
Presented with coded ‘fever symptoms’, ‘URTI’, ‘gastroenteritis’ or ‘UTI’ in last 6 months
Used the consultation suggested by EMIS for each patient that met the search terms
Excluded: telephone consultations, no history documented, presented to A&E or asymptomatic on presentation

17. Results Total no. of patients = 167 Graphs
Proportion of children who had each of the values measured (HR, CRT, RR, temperature)
Proportion of children with fever who had the other 3 parameters measured
Proportion of children who had 0, 1, 2, 3 or 4 parameters measured in total

18. Proportion of children who had temp, HR, RR, CRT measured

19. Number of parameters measured in a suspected fever case

20. Children who had a fever

21. Results summary Not good at measuring all 4 parameters
12% had all 4 measured
70% had temperature measured
In children with a fever <25% had all 4 parameters measured
16% of all patients had no vital signs recorded

22. Discussion Use of paracetamol/ ibuprofen Difficult examination
Not recording when value is normal
Medico-legal transparency
Thorough assessment
Effect of clinical judgement
Effect of clinical judgement
- Important not to underestimate the clinical experience of GPs and being able to assess a patient as a whole (inc. history/PMH) not just based as a whole.
The guidance recommends the traffic light system is used alongside clinical judgement
Use of paracetamol/ibuprofen
As they act as apyrexial agents, it is not enough to rely on ‘no fever’ as a reason to not measure the other parameters. The other paramaters can back up your clinical suspicions.
Difficult examination
We understand it may not be possible to do respiratory rate if crying/moving around a lot. But temperature should be possible in most children
Not recording when value is normal
In terms of what we found, it may have been the case that if the value was normal it was not recorded. In some cases no value was recorded but ‘normal’ was – we took this to have been taken.
Medico-legal transparency
- Good practice that in a child with a fever/suspected fever that these are done – especially as NICE recommends
Would be better to record specific numbers
Thorough assessment

23. Research
3 studies considered the use of the NICE traffic light system in recognising serious infection.
Sukanya De et al (2013) Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study, BMJ 2013
Verbakel et al (2014) Sepsis and meningitis in hospitalised children: performance of clinical signs and their prediction. Pediatric Emergency Care
Thompson M et al (2009). How well do vital signs identify children with serious infections in paediatric emergency care? Arch Dis Chil 2009

24. Sukanya De et al, BMJ 2013 Red features Red + amber
2 year retrospective analysis of prospective study - n= 15,781 children, < 5 years old presented with fever
Results:
1,140 children had a serious bacterial infection
157 (13.8%) of these were missed as they fell in the ‘Green Zone’ % were UTIs.
Conclusion:
Traffic light system failed to pick up a significant number of bacterial infections (esp. UTIs).
RCTs
Limitations: Only looked at bacterial infections
Low specificity indicates that clinical judgement should be used alongside the traffic light system.
But traffic light + urianlysis had false positive of 78% and false negative of 8.1%. But validity of result questionable – reference standard for illness severity was the unverified diagnosis of clinican
Red features
Red + amber
Traffic light + urine analysis
Sensitivity
47.9%
85.8%
(95% CI %)
92.1%
Specificity
75.9%
28.5%
(95% CI %)
22.3%
Sukanya De, Williams GJ, Hayden A et al. Accuracy of the “traffic light” clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study, BMJ 2013

25. Verbakel et al (2014) Red features Red + amber Sensitivity 62% 100%
Retrospective study – assessed diagnostic value of clinical prediction rules for identifying sepsis and meningitis
N = 9678, children aged up to 16 years, presenting to UK ED.
Case group: Retrospective diagnosis of meningitis, bacteraemia or sepsis (n=50).
Control group: Diagnosis of self-limiting/mild infection. (culture or CSF negative)
NICE Traffic Light Results:
Limitations:
Only assessed 9 of the 17 ‘amber’ features and 11 of the 18 ‘red’ features
No info about ‘green’ features
The sample included children up to age 16 years
Red features
Red + amber
Sensitivity
62%
100%
Specificity
74.5%
0.12%
Verbakel JY, MacFaul R, Aertgeerts B et al. (2014) Sepsis and meningitis in hospitalised children: performance of clinicl signs and their prediction rules in a case-control study. Pediatric Emergency Care 30: 373–80

26. Thompson M et al, 2009 Sensitivity Specificity 1 or more of: 80% 39%
DESIGN:
Prospective cohort of children presenting with suspected acute infection
Recorded vital signs, level of consciousness, activity level, respiratory distress, hydration
Paediatric assessment unit at a teaching hospital in England.
50% referred from GP
RESULTS:
CONCLUSIONS:
The diagnostic value of combined vital signs and the NICE traffic light system remains to be determined in populations where the prevalence of severe illness is much lower.
Sensitivity
Specificity
1 or more of:
Temp >39
Tachycardia
Tachypnoea
Sats <94%
80%
39%
NICE traffic light
85%
29%
Thompson M, Coad N, Harnden A et al. How well do vital signs identify children with serious infections in paediatric emergency care? Arch Dis Chil 2009

27. Limitations Did not include non-coded consultations
Only included common causes of fever in search terms
Only looked at infective causes of fever
Only 1 consultation analysed per patient
We didn’t search for free text, so may not have picked up some patients from the sample
Included temperature symptoms, gastroenteritis, UTI, viral URTI and URTI – not totally inclusive of all causes of a fever but did give us a sample of common conditions.

28. Recommendations
All 4 parameters should be performed and documented in all children with measured pyrexia
And when you are suspecting a fever
Feverish child template on EMIS
Laminated print out of normal/abnormal vital sign reference ranges and traffic light system
Reaudit
If we were to re audit, we would ideally use search terms which are in the NICE traffic light system – and include more serious conditions such as meningitis.

29. Implementation - template
Template created

30. Implementation - trigger
Protocol to launch template, triggered by entering temperature code

31. Respiratory Syncytial Virus RSV The sleeping giant
RSV is the commonest cause of severe respiratory illness such as bronchiolitis (inflammation of the bronchioles) in young children aged under 2 years. It is also the commonest cause of hospital admissions due to acute respiratory illness in young children.
RSV infections may be overlooked in older children and adults. Several studies have shown that RSV causes severe respiratory illness in elderly people and that outbreaks are associated with higher death rates. Peak numbers of RSV infections are reported in December and January every winter (in older people), although the size of the peak varies from winter to winter.

32. Fig 1 Epidemiology of respiratory syncytial virus infection
Fig 1 Epidemiology of respiratory syncytial virus infection. Note the close correlation between peaks of bronchiolitis (upper panel) and laboratory reports of RSV infection (lower panel). Adapted from information published by the Public Health Laboratory Service based on data from the Office of Population Censuses and Surveys and the Communicable Disease Surveillance Centre
Bush, A. et al. BMJ 2007;335:
Copyright ©2007 BMJ Publishing Group Ltd.

34. Assessment and diagnosis (CKS)
Children under 2 years of age and most commonly in the first year of life, peaking between 3 and 6 months.
symptoms usually peak between 3 and 5 days, and that cough resolves in 90% of infants within 3 weeks.
coryzal prodrome lasting 1 to 3 days, followed by persistent cough and either tachypnoea or chest recession (or both) and either wheeze or crackles on chest auscultation (or both).
fever (in around 30% of cases, usually of less than 39°C)
poor feeding (typically after 3 to 5 days of illness).
young infants with this disease (in particular those under 6 weeks of age) may present with apnoea without other clinical signs.
Consider a diagnosis of pneumonia if the child has high fever (over 39°C) and/or persistently focal crackles.
(In older infants and young children : Think about a diagnosis of viral‑induced wheeze or early‑onset asthma)
Take into account that these conditions are unusual in children under 1 year of age.
Measure oxygen saturation in every child presenting with suspected bronchiolitis, including those presenting to primary care if pulse oximetry is available.
Suspect impending respiratory failure, and take appropriate action as these children may need intensive care if any of the following are present:
signs of exhaustion, for example listlessness or decreased respiratory effort
recurrent apnoea
failure to maintain adequate oxygen saturation despite oxygen supplementation.

35. Assessment / Referral (CKS)
Immediately refer (999 ambulance):
apnoea (observed or reported)
child looks seriously unwell to a healthcare professional
severe respiratory distress (grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute)
central cyanosis
persistent oxygen saturation of less than 92% when breathing air.
Consider referring:
Respiratory rate of over 60 breaths/minute
difficulty with breastfeeding or inadequate oral fluid intake (50–75% of usual volume, taking account of risk factors
clinical dehydration.
Sats <94%
Risk factors for more severe bronchiolitis:
chronic lung disease (including bronchopulmonary dysplasia)
haemodynamically significant congenital heart disease
age in young infants (under 3 months)
premature birth, particularly under 32 weeks
neuromuscular disorders
immunodeficiency.
Factors that might affect a carer's ability:
social circumstances
the skill and confidence of the carer in looking after a child with bronchiolitis at home
confidence in being able to spot red flag symptoms
distance to healthcare in case of deterioration.
Assessment / Referral (CKS)

36. Bronchiolitis Excellent article:
Clinical Review: Acute bronchiolitis Andrew Bush, Anne H Thomson BMJ  2007;335: , doi: /bmj AD
Or -
Or – different angle - Green Book ata/file/148494/Green-Book-Chapter-27a-dh_ pdf
1 Introduction -
1.1 b ackground
Bronchiolitis of infancy is a clinically diagnosed respiratory condition presenting with breathing difficulties, cough, poor feeding, irritability and, in the very young, apnoea. These clinical features, together with wheeze and/or crepitations on auscultation combine to make the diagnosis. Bronchiolitis most commonly presents in infants aged three to six months.1
Bronchiolitis occurs in association with viral infections (respiratory syncytial virus; RSV, in around 75% of cases)2 and is seasonal, with peak prevalence in the winter months (November to March) when such viruses are widespread in the community. Re-infection during a single season is possible.
The burden of disease is significant. Around 70% of all infants will be infected with RSV in their first year of life and 22% develop symptomatic disease. Since RSV is associated with only 75% of bronchiolitis cases, it may be estimated that around a third of all infants will develop bronchiolitis (from all viruses) in their first year of life.3 For Scotland this translates to approximately 15,000 infants. Around 3% of all infants younger than one year are admitted to hospital with bronchiolitis.4
Based on Scottish morbidity recording for the years 2001 to 2003 a mean of 1,976 children per year (aged up to 12 months) were admitted to hospital with bronchiolitis as the principal diagnosis.5
The rate of admissions to hospital with bronchiolitis has increased over the past 10 years. The reasons for this are not fully understood and are likely to be multifactorial and include improved survival of preterm infants.4
In most infants the disease is self limiting, typically lasting between three and seven days.
Most infants are managed at home, often with primary care support. Admission to hospital is generally to receive supportive care such as nasal suction, supplemental oxygen or nasogastric tube feeding.
Children with underlying medical problems (prematurity, cardiac disease or underlying respiratory disease) are more susceptible to severe disease and so have higher rates of hospitalisation.4 In preterm infants less than six months of age, admission rate with acute bronchiolitis is 6.9% with admission to intensive care more frequent in such patients.4
In a UK study, the RSV-attributed death rate (measured in infants aged one to 12 months) was 8.4 per 100,000 population.6
Twenty percent of infants with bronchiolitis (40-50% of those hospitalised) proceed to a grumbling, sometimes protracted, respiratory syndrome of persistent cough and recurrent viral induced wheeze.7 Ongoing symptoms may relate to continuing inflammation and temporary cilial dysfunction.8 An association between acute bronchiolitis and later respiratory morbidity is recognised.9
2 D iagnosis
2.1 clinical definition
The diagnosis of bronchiolitis is a clinical one based on typical history and findings on physical examination.11 Clinicians in different countries use different criteria to diagnose acute bronchiolitis.12
A consensus guideline from the UK developed using a Delphi panel reported a 90% consensus on the definition of bronchiolitis as ‘a seasonal viral illness characterised by fever, nasal discharge and dry, wheezy cough. On examination there are fine inspiratory crackles and/or high pitched expiratory wheeze’.12
Bronchiolitis typically has a coryzal phase for two to three days which precedes the onset of other symptoms.1
In the first 72 hours of the illness, infants with bronchiolitis may deteriorate clinically before symptom improvement.1
A number of other conditions can mimic acute bronchiolitis. Pulmonary causes of bronchiolitis-like symptoms include asthma, pneumonia, congenital lung disease, cystic fibrosis or inhaled
foreign body. Non-pulmonary causes include CHD, sepsis or severe metabolic acidosis.13

37. BMJ Review
Very sensible advice about bronchiolitis, with clear guidelines
80% of cases caused by RSV (vaccination ineffective and can get re- infection); other causes are human metapneumovirus, rhinovirus, adenovirus, influenza/ parainfluenza and enteroviruses
Main thrust is that treatments are pretty ineffective and main focus is on identifying infants who are ill enough to need supportive treatment in hospital e.g. oxygen, supplementary feeding, ventilation
Reminds us not to reach for inhalers in all that wheezes
Mentions a good patient leaflet
Talks about smoking.
Breast feeding reduces the risk of RSV-related hospitalisation and should be encouraged
and supported. (SIGN)

38. Absolute indications for hospital referral for acute bronchiolitis
Cyanosis or really severe respiratory distress (respiratory rate >70 breaths/min, nasal flaring and/or grunting, severe chest wall recession)
O2 saturations < 94% (for hospitals admit <92%, can be discharged if >94%)
Marked lethargy leading to poor feeding
Respiratory distress preventing feeding (<50% of usual intake in past 24 hours)
Apnoeic episodes
Diagnostic uncertainty (toxic infant, temperature 40 degrees centigrade)
Pulse oximetry should be performed in every child who attends hospital with acute
bronchiolitis.
Infants with oxygen saturation ≤92% require inpatient care.
Decision making around hospitalisation of infants with oxygen saturations between
92% and 94% should be supported by detailed clinical assessment, consideration
of the phase of the illness and take into account social and geographical factors.
Infants with oxygen saturations >94% in room air may be considered for
discharge.
Diagnostic uncertainty (toxic infant, temperature 40 degrees centigrade) – those with these features may not have bronchiolitis, rare to have v high temp, nor to look mottled and toxic

39. Relative indications for hospital referral for acute bronchiolitis
Congenital heart disease
Any survivor of extreme prematurity
Any pre-existing lung disease or immunodeficiency
Down's syndrome: these babies have a degree of pulmonary hypoplasia and may also have potential or actual upper airway obstruction
Social factors: isolated family (concerns about the ability of the family to notice any deterioration)

40. Bronchioloitis Separate Topic Chronic symptoms?
Recurrent wheeze in 2/3rd those with compared with 1/5th those without
Got better over following 3 seasons
8.1 chronic symptoms
An association between acute bronchiolitis and later respiratory morbidity is recognised. The
mechanisms for this are poorly understood. There is debate as to whether the primary insult
to the lung is the acute bronchiolitic illness, or whether there is prior genetic/environmental
predisposition to respiratory morbidity. The severity of acute bronchiolitis may be the best
predictor of chronic respiratory symptoms.88
8.1.1 one year
Two small prospective cohort studies confirm high rates of recurrent wheeze episodes in the 12
months following hospitalisation for RSV bronchiolitis.89,90 A Dutch study (n=130) reported a
recurrent wheeze rate of 61% in those with, compared with 21% in those infants without, signs
of airflow limitation at presentation.89 A German study (n=126) reported recurrent wheeze in
31% of infants hospitalised with RSV bronchiolitis compared with 3.6% in controls.89 In extended
follow up the Dutch study measured an overall decline in the number of wheeze episodes over
three years but with seasonal increases in wheeze episodes in the winter months.91

41. Overview
Tuberculosis (TB) is an infectious disease that is spread by droplet transmission
Pathogen is Mycobacterium Tuberculosis
Primarily affects respiratory system (4/5)
GI/ GU/Skin/Skeletal (Pott’s)/CNS
Most do not die...
...but if concurrent HIV infection then poorer outcome more likely
Extrapulmonary involvement occurs in 1/5 of all TB cases e.g. Cutaneous, skeletal (of spine called Pott’s disease), genitourinary, GI, ocular
2/3 of have no evidence of pulmonary infection on CXR or sputum culture

42. Infectivity/ Susceptability
Close contact of TB patient:
Infectious pulmonary TB patient will infect a further people each year.
Household members - 1 in 3 chance of contracting the infection.
Risk also extends to healthcare workers and close contacts at school or work.
Ethnic minority groups: 72% of TB patients are from ethnic minority backgrounds (predominantly from South Asia and sub-Saharan Africa).
Born in/ arrived / returned from high-prevalence areas within the last five years
Most diagnosed within five years of entering the UK but their lifetime risk of developing TB remains higher than average (their children and close contacts born in the UK too).
High in people from the Indian subcontinent and sub-Saharan Africa.
Homeless patients, alcoholics and other drug abusers:. Accurate estimates of the rates of TB in homeless people are unknown but thought to be more than 150 times the UK average. Persons who have recently been in prison may also be at increased risk.
HIV-positive and other immunocompromised patients:
worldwide, up to 60% of AIDS patients develop TB: causes 1/3 of all AIDS-related deaths.
Rates of such concurrent infections in the UK are proportionally low but at least 3% of people with TB are HIV-positive. 
Immunosuppressant drugs (eg, infliximab and etanercept, azathioprine, ciclosporin, etc).
Elderly patients: LTBI may reactivate in elderly patients.
Other conditions: Haematological and some solid cancers/ long-term steroids/ diabetes/ end-stage renal disease, silicosis and gastrectomy/jejuno-ileal bypass all confer an increased risk.
Children:
young children are particularly susceptible to mycobacterial infection, due to their immature immune systems.
Children themselves are rarely infectious -cavitating disease is uncommon

43. Overview from 2015 (WHO and PHE)
10.4 million new (incident) TB cases worldwide
5.9 million (56%) men,
3.5 million (34%) women
1.0 million (10%) children.
People living with HIV accounted for 1.2 million (11%) of all new TB cases
60% of the new cases: India, Indonesia, China, Nigeria, Pakistan and S A.
1.4 million TB deaths in 2015, and an additional 0.4 million deaths resulting from TB disease among HIV-positive people.
Global Incidence 2015 = 142/100,000(1)
Europe Incidence 2015 = 36/100,000(2)
UK: 5,758 TB cases were notified in England in 2015
10.5 /100,000 population (reduction since the peak of 8,280 cases in =15.6/100,000)
W Midlands 12/ , London 26/100,000
84.5% completed treatment in 12/12 from 2014
Deaths in drug sensitive cases who had died 5.5% (351) of those notified in 2014
London massively No1 (incidence 40), Wmids No2

44. Birmingham
Birmingham has one of the highest rates of TB in the West Midlands.
Cases per 100,000 population
35 (below the 40/100,000 rate often quoted as the threshold for declaring a “high rate area”). This rate is mainly due to very high rates in Heart of Birmingham teaching Primary Care Trust (HOBtPCT) area. The incidence of TB cases per 100,000 population varies from
27 in South Birmingham, to
43 in Birmingham East & North and
99.3 in the Heart of Birmingham, (nearly 2.5 times the DH threshold)

45. Not everyone who is infected will develop serious symptoms.
Around 90% of otherwise healthy people who have come into contact with and been infected with the TB bacteria will not develop the disease.
Of the 10% who develop infectious disease,
up to half will do so within the first two years while
the remainder develop the disease later on. It may take many years before someone infected with TB develops the disease.
For the majority of people who become infected it is latent TB infection.
Latent TB can become reactivated and cause TB later in life especially if a person’s immune system becomes weakened through, for example, old age, some medical treatments, serious illness, poor diet, or through generally poor living conditions.

47. TB case notifications and rates, England, 2000-2015
I 95% CI
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS), Office for National Statistics (ONS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

48. TB case notifications and rates by TB control board, England, 2015
North West (n=570, rate=7.9*)
North East, Yorkshire & the Humber (n=569, rate=7.1*)
East Midlands (n=354, rate=7.6*)
West Midlands (n=708, rate=12.3*)
East of England (n=393, rate=6.2*)
South of England (n=893, rate=6.3*)
London (n=2,269, rate=26.2*)
TB case notifications and rates by TB control board, England, 2015
Number of TB cases
Highest number of TB cases
Lowest number of TB cases
* per 100,000
Contains Ordnance Survey data © Crown copyright and database right 2015
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

49. TB case notifications and rates by age group and place of birth, England, 2015
I 95% CI (too narrow to be visible)
I 95% CI
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS), Labour Force Survey (LFS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

50. TB case notifications and rates by PHE Centre, England, 2015
I 95% CI
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS), Office for National Statistics (ONS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

51. TB case notifications and rates by place of birth, England, 2000-2015
I 95% CI (too narrow to be visible)
I 95% CI
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS), Labour Force Survey (LFS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

52. Tuberculosis in England: 2016 report
Trend in TB case notifications for the top five countries of birth* of non-UK born cases, England,
* Five most frequent countries of birth in 2015
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

53. Tuberculosis in England: 2016 report
TB case notifications and rates by place of birth and ethnic group, England, 2015
I 95% CI
Please note: rates by ethnic group are displayed as labels.
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS), Labour Force Survey (LFS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

54. Tuberculosis in England: 2016 report
Number and proportion of TB cases with HIV co-infection, England,
* Only available from 2003 onwards
** Proportion is calculated using the number of notified TB cases with HIV co-infection plus the number of un-notified MTBC isolates which matched to an HIV case as the numerator, and the number of all notified TB cases (with or without HIV co-infection) plus the number of un-notified TB isolates which matched to an HIV case as the denominator
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS), Survey of prevalent HIV infections diagnosed (SOPHID), HIV & AIDS new diagnoses database (HANDD)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

55. Tuberculosis in England: 2016 report
TB outcome at 12 months for drug sensitive cases with expected treatment duration <12 months*, England, 2014
* Excludes cases in the drug resistant cohort and those with CNS, spinal, miliary or cryptic disseminated TB
** Not evaluated includes missing, unknown and transferred out
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

56. Tuberculosis in England: 2016 report
Last recorded TB outcome for drug sensitive cohort with CNS, spinal, miliary or cryptic disseminated* TB, England, 2014
n = 689
* Excludes cases in the drug resistant cohort and only includes drug sensitive TB cases with CNS, spinal, miliary or cryptic disseminated TB
** Not evaluated includes missing, unknown and transferred out
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

57. Tuberculosis in England: 2016 report
Number and proportion of TB cases with initial drug resistance, England,
I 95% CI
 * Culture confirmed cases with DST results for at least isoniazid and rifampicin resistant to isoniazid without MDR-TB
** Culture confirmed cases with DST results for at least isoniazid and rifampicin resistant to rifampicin, including those with MDR-TB
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

58. Rate of TB by deprivation decile, England, 2015
I 95% CI
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS), Index of Multiple Deprivation (IMD 2010)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

59. Clinical Presentation
Classic features associated with active TB are as follows:
Cough
Weight loss/anorexia
Fever
Night sweats
Haemoptysis
Chest pain

60. NICE recommendations
Has recommended screening for high-risk groups when they register to a general practice
Clinical assessment
CXR
Mantoux test
consideration of BCG for unvaccinated people who are Mantoux negative
In the event of a diagnosis of tuberculosis the trace contacts (generally > 1 month) of the patient should undergo a Mantoux test and chest radiography
High-risk defined as defined as people who have recently arrived in or returned to the UK from high-incidence countries, with an incidence of more than 40 per 100,000 per year, as listed by the Health Protection Agency; at risk because of their occupation e.g. Healthcare workers, vetinary staff, prison staff
Mantoux test: to interpret with caution as false positive results can occur with BCG vaccination, and opportunisitic mycobacterium infections; false negative can occur with immunosuppression e.g. HIV, chemotherapy; or with extensive TB infection
Mantoux test: negative if 0-4mm induration
Interferon-gamma test (if available) if Mantoux test is positive (6 mm or greater) in someone who has not had BCG vaccination, or strongly positive (15 mm or greater) in someone who has been vaccinated
Consult local guidelines for detailed advice.

61. Treatment and Management
Management of tuberculosis (TB) should be supervised by specialists
Primary care health professionals should be familiar with treatment regimens and the associated adverse effects and interactions
In West Midlands managed by HEFT
All prescribing, F/U and contact tracing
Asymptomatic patients:
Mantoux > 10mm but normal CXR: Isoniazid for 6/12, or Isoniazid and Rifampicin for 3/12
Symptomatic patients:
The standard treatment for active TB (e.g. pulmonary TB) involves a six-month drug regimen consisting of (1):
a 6-month, four-drug initial regimen (6 months of isoniazid and rifampicin supplemented in the first 2 months with pyrazinamide and ethambutol) should be used to treat active RESPIRATORY TB
If a patient has fully drug-sensitive pulmonary TB the s/he becomes non-infectious within two weeks of commencing treatment

62. Prevention is better than cure
Progress made last century through improved living and sanitary conditions
Vaccination using BCG was for all children
Now only targeted, high risk groups
As per WHO guidance 2004(5)
Treating low-risk not cost-effective as most unlikely to acquire TB
BCG: intradermal injection; provides immunity lasting >15 years to 70-80% recipients

63. Prevention Strategies
Key to reducing TB incidence:
Vaccination of all high risk infants
Vaccination of all migrants from high risk countries without previous vaccination
Education of families via primary care, schools, health visitors of signs/symptoms of TB, especially in higher risk areas
Ensuring that access – and possibly outreach? – to homeless and drug/alcohol misusers is available
ALSO LTB-LIS

64. LIS - Latent Tuberculosis Infection Screening Programme (4/16 – 3/17)
Patients who were born in or have spent more than 6 months in a country with high incidence of TB (> or =150/100,000TB incidence rates
Patients who entered the UK within the last 5 years (including where entry was via other countries within the EU/EEA).
The practice will send the LTBI clinical search results as above for verification to be sent to the CCG by 30th April 2016
1st April 2016 all new year old registrants to complete the LTBI Questionnaire to determine if they meet the LTBI screening programme criteria. These patients will be added to the LTBI register
All positive (above) invited for interferon gamma release assay (IGRA) test
If positive referred to HEFT for treatment

65. LTB-LIS progress so Far

66. Tests
Skin tests:
PPD tuberculin injection – read at hours (induration) (Previous BCG mild reaction only)
Mantoux TB, Heaf, Tine all variants of the above
IGRA (Interferon Gamma Release Assay) osition_Statement_November_f_2012.pdf
T spot (UK) or QuantiFERON-Gold (Australia)
Blood is stimulated with synthetic antigens (strains of M.tuberculosis, absent from the BCG vaccine-strain Mycobacterium bovis) and
the amount of, interferon gamma cytokine produced by the T cells, or number of activated T cells is measured.
Therefore these tests are less influenced by prior BCG vaccination.
Sensitivity at least – STS, specificity much better
But also less reliable when T cell responsiveness or populations reduced (HIV)
CXR/ Sputum/ESR...
Anti-TB antibodies – poor sens and specificty

67. Treatment Drug treatment A six-month, four-drug initial regimen
Respiratory TB:
6/12 of isoniazid and rifampicin (supplemented in first 2/12 with pyrazinamide and ethambutol) should be used to treat active.
Meningeal TB:
12/12 Isoniazid, Pyrazinamide, Rifampicin and a fourth drug (eg, ethambutol) for first 2/12), followed by Isoniazid and Rifampicin for the rest of the treatment period; and
prednisolone mg (adults) or equivalent if on rifampicin, otherwise mg; children: equivalent to prednisolone 1-2 mg/kg, maximum 40 mg): gradual withdrawal of the glucocorticoid considered, starting within 2-3 weeks of initiation.
Patients with HIV co-infection should be treated in line with the British HIV Association guideline.[12]

68. Malaria – prophylaxis BNF Yellow Book
- these are current guidelines – search from
BNF
Yellow Book

69. No single action is 100% - so it is the combination
Awareness of risk - country, exposure, time of day SPLEEN PREGNANCY other conditions, warfarin
Bite prevention – DEET (sunscreen), nets, clothing, knock
Chemoprophylaxis - Use the BNF? And ask if in doubt
Diagnose promptly and treat without delay
Do we? Not in “normal” surgery!
Stand-by treatment

70. What are we thinking about?
Fewer than one in five British travellers to malarial regions takes prophylactic drugs a London symposium heard last week
Senior specialists in tropical diseases outlined the main conditions a UK based doctor was likely to encounter, including malaria, parasites, skin complaints, and diarrhoeal diseases, but also said that travellers were more likely to be affected by a road traffic crash than contract a tropical disease.
2013 BMJ “news” article

71. We appear not to ask the right questions?
132 prospective patients presenting with fever, GIT, rash had notes assessed for travel history
A travel history was only documented 26/132 - (19.7%)
Of those who travelled no pre travel or return sexual history taken
Price, V. A., Smith, R. A.S., Douthwaite, S., Thomas, S., Almond, D. S., Miller, A. R.O., Beeching, N. J., Thompson, G., Ustianowski, A. and Beadsworth, M. B.J. (2011), General Physicians Do Not Take Adequate Travel Histories. Journal of Travel Medicine 2011, 18: 271–274. doi: /j x

72. With tragic results
A 19 year old student phoned an official health service telephone helpline with a 10 day history of aching legs, vomiting, diarrhoea, and abdominal pain. She mentioned a recent trip to Uganda but was reassured and told she had “flu.” The next day her boyfriend took her to see her doctor, where she mentioned general malaise, tiredness, and occasional nausea; the doctor diagnosed a viral illness and advised her to keep taking paracetamol. Three days later a friend found her dead in bed in her university halls of residence. The coroner recorded death due to cerebral malaria.
"When she arrived back on January 12, 2006, there developed a clinical picture typical of malaria including non-specific flu-like symptoms, vomiting, diarrhoea and abdominal pain.
"On January 22, 2006 she was told during a telephone consultation with NHS Direct and an out-of-hours GP service that she had flu. That was not the case.
"While she may have developed some degree of immunity from the disease, by the time of her visit she had lost the benefit of this Read more: Follow on Twitter | DailyMail on Facebook

73. Who and when. – falciparum BMJ 2012; 344 doi: http://dx. doi. org/10
184 deaths in twenty years - Highest death rate in the elderly
Case fatality rate in tourists = 3% (81/2746)
In those born in Africa, visiting 0.4% (36/8937)
Inverse relation between mortality in a region visited and the number of cases seen
Gambia is talked about (“winter sun, December is a bad month, old people, no prophylaxis, delay in diagnosis – ‘flu season)

74. Who and when. – Vivax BMJ 2015; 350 doi: http://dx. doi. org/10
25% of imported malaria
Getting less common (notifications down, travel up)
78% India and Pakistan – mostly from visiting relatives
October to March travellers – latency median 143 days (April to September 37 days)

75. Malaria - diagnosis
Getting the history is crucial “Any travel in the last year to an area which may be malarial?”
Symptoms typically are
Cough
Fatigue
Malaise
Shaking chills
Arthralgia
Myalgia
Less commonly - Anorexia and lethargy, Nausea and vomiting, Diarrhea, Jaundice

76. What worries parents when their preschool children are acutely ill, and why: a qualitative study BMJ, Oct 1996; 313: Joe Kai
Parents' difficulties and information needs in coping with acute illness in preschool children: a qualitative study BMJ, Oct 1996; 313: Joe Kai

77. What worries parents when their preschool children are acutely ill, and why:
Results: Fever, cough, and the possibility of meningitis were parents' primary concerns when their children became acutely ill. Parents' concerns reflected lay beliefs, their interpretation of medical knowledge, and their fears that their child might die or be permanently harmed. Parents worried about failing to recognise a serious problem. Concerns were expressed within the context of keenly felt pressure, emphasising parents' responsibility to protect their child from harm. They were grounded in two linked factors: parents' sense of personal control when faced with illness in their child and the perceived threat posed by an illness.
Conclusions: Better understanding of parents' concerns may promote effective communication between health professionals and parents. Modification of parents' personal control and perceived threat using appropriate information and education that acknowledge and address their concerns may be a means of empowering parents.

78. Parents' difficulties and information needs in coping with acute illness in preschool children: a qualitative study
Results: Parents felt disempowered when dealing with acute illness in their children because of difficulties making sense of the illness. Central to parents' difficulties were their experiences of inadequate information sharing by their general practitioners and variations in their doctors' decisions and behaviour. Disparity between parents' beliefs and expectations about illness and treatment and professionals' behaviour further frustrated parents' attempts to understand illness. Parents expressed a need for a range of accessible and specific information to support them through their negotiation of children's illness.
Conclusions: Communication with parents requires greater recognition of parents' difficulties. Professionals have considerable potential to empower parents by sharing more information and skills. Such information should be consistent and address parents' concerns, beliefs, and expressed needs if this potential is to be realised.

79. tachment_data/file/567255/GPinHoursEngBulletin2016Wk4 4.pdf

80. A good website resource
Antibiotic Research UK