1. Dr Lika Nehaul NPHS TB Lead / CCDC
An Overview of the Epidemiology and Management of Tuberculosis in Wales
Dr Lika Nehaul
NPHS TB Lead / CCDC

2. Presentation outline Epidemiology of tuberculosis
Sources of clinical guidance
What makes for effective TB services in Wales
What the NPHS TB Programme Group is doing to promote best practice in the management of TB

3. Estimated numbers of new cases, 2006
AFR 28%
WPR 22%
SEAR 34%
EUR 5%
EMR 7%
AMR 4%
Estimated number of new TB cases (all forms)
No estimate
0–999
1000–9999
10 000–99 999 –
or more
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Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
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4. New TB cases per 100,000 population in 2006
9.2 million new TB cases and 1.7 million deaths in 2006
World: case rates rising during 1990s, now stable or falling slowly
Europe: case rates up by 40% during 1990s, now falling slowly
Estimated new TB cases (all forms) per population
No estimate
0-24
25-49
50-99
300 or more
Africa: case rates up by 200+% during 1990s, now falling slowly

5. TB notification rates, European Union By country group, 1996-200620 40 60 80
100
120
140
160
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
TB cases /
(age-standardised)*
Romania
(EU accession 2007)
Baltic States
EU accession 2004
EU pre-2004
Including countries with data by age-group:
EU pre-2004: Austria, Belgium, Denmark, Finland, France, Germany, Italy, Luxembourg, The Netherlands, Portugal, Sweden, United Kingdom
EU accession 2004: Czech Republic, Hungary, Malta, Poland, Slovakia, Slovenia (excluding Baltic States)
Baltic States: Estonia, Latvia, Lithuania (EU Member States since 2004)
* based on WHO World Population Standard, average (Ahmad OA, Boschi-Pinto C, Lopez AD et al.)
Source: Euro TB

6. Countries with XDR-TB confirmed Cases as of 1 December 2007
Argentina
Japan
Armenia
Latvia
Azerbaijan
Lithuania
Australia
Mexico
Bangladesh
Mozambique
Brazil
Netherlands
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO All rights reserved
Canada
Norway
Chile
Peru
China, Hong Kong SAR
Czech Republic
Poland
Ecuador
Portugal
Estonia
Republic of Korea
France
Romania
Georgia
Russian Federation
Germany
Slovenia
Ireland
South Africa
India
Spain
Islamic Republic of Iran
Spain UK
Israel
Sweden
USA
Italy
Thailand
Vietnam
Based on information provided to WHO Stop TB Department December 2007

7. Figure Tuberculosis case reports and rates by region/country, England, Wales and Northern Ireland, 2006
44.8
17.5
13.7
8.5
10.2
13.3
8.0
5.6
6.4
3.6
500
1000
1500
2000
2500
3000
3500
4000
London
West Midlands
Yorkshire and the Humber
South East
North West
East Midlands
East of England
South West
Wales
North East
Northern Ireland
Region/country
Number of cases 5 10 15 20 25 30 35 40 45 50
Rate (per 100,000)
Sources: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS), Northern Ireland Statistics and Research Agency (NISRA)

8. Tuberculosis cases and rates in Wales reported by Enhanced TB Surveillance 1999-2006
Source: NPHS CDSC

10. TB Programme Aims
To reduce avoidable morbidity and mortality associated with tuberculosis
To minimise the transmission of infection by early diagnosis and effective treatment
To prevent the emergence and spread of drug resistant TB
To ensure standardisation of TB management across Wales
To facilitate the continuous monitoring of local and regional trends in TB, in order that any identified change in incidence can be identified and addressed as necessary

11. Programme aims to be achieved by:
Promoting and facilitating best practice in the prevention and control of TB
Promoting a culture of collaborative working amongst health care professionals involved in the management of TB
Strengthening the provision of specialist microbiological TB diagnostic tests available in Wales
Further improving enhanced TB surveillance

12. Clinical Guidance
JCVI guidance on BCG vaccination in Green Book TB Chapter (updated on-line November 2007) – follow JCVI guidance for BCG vaccination
NICE TB Guideline, published March 2006
Interdepartmental Working Group on Tuberculosis Guidance on the Prevention and Control of Transmission of HIV-related TB and drug-resistant TB (1998)

13. TB Services: Clinical Radiology (Specialist) Microbiology Pathology
Infection Prevention & Control
Public Health – includes co-ordination of surveillance

14. Services need to be patient-focused
Treatment for a minimum of 6 months
Still a stigma in many communities
Co-morbidity and social problems
For inpatients in isolation with MDR-TB, maintain balance between need to protect others and the mental wellbeing of the patient, based on RA
Need to ensure that the patient and everyone involved in their care understands and is ‘signed-up’ to the care plan

15. TB control
Early diagnosis especially of pulmonary disease important, so that treatment may be started promptly
Notify cases of TB disease on clinical suspicion by telephone, included those diagnosed PM (follow-up with formal notification on ETS form)
Be vigilant for TB especially in high-risk groups but remember anyone can get TB
TB can be a travel-related disease in people spending long periods of time in high-incidence countries

16. Effective management of TB requires:
An understanding of own roles and responsibilities, those of team members and other departments / sectors providing TB services
That TB nurse is informed of patients with TB
Knowing who has lead responsibility (cf incidents and clusters in community vs NHS Trust premises)
An appreciation of the risks of transmission in health-care settings especially IP wards and OP settings
Knowledge & understanding of infection prevention and control measures, infection control policies, and their rationale
Collaborative working by everyone involved in TB control

17. Management of TB – special arrangements
Access to TB specialist for advice
Children
People with HIV co-infection
Patients with MDR pulmonary TB to be managed by TB specialists in centres with negative-pressure facilities – transfer arrangements to involve Infection Prevention & Control Team at referring and receiving hospitals
Commissioning services for Welsh residents receiving specialist TB services in England and clinical support for contact tracing in Wales

18. Other issues
Management of human contacts of bovine tuberculosis

19. How will the NPHS TB Programme Group help?
Facilitate the provision of special TB microbiological services in Wales
Publish guidance and links to national guidance on the NPHS Intranet site:
Framework document for BCG vaccination of infants and children aged up to under 16
Disseminate and promote the Framework for the provision of TB services for people living in Wales in the coming months, in liaison with Welsh Assembly Government
Undertake an audit of the implementation of the NICE TB Guideline in Wales in

20. In summary Incidence of TB in Wales relatively stable year-on-year
Diagnose TB early by maintaining vigilance and investigating appropriately
Notify cases on clinical suspicion
Effective clinical management, underpinned by collaborative working essential to keep TB under control and to further reduce incidence

21. Acknowledgements
NPHS CDSC – Michael Perry, Dr Daniel Thomas, Rhian Hughes
Health Protection Agency CfI – Dr Ibrahim Abubakar
World Health Organisation – Dr Paul Nunn
Euro TB

22. Questions
and Comments