1. Tuberculosis in Ealing 1. Overview Appendix 2

2. What is TB Tuberculosis, or TB, is a disease caused by a germ (Mycobacterium tuberculosis). TB usually affects the lungs, but can affect other parts of the body, such as the lymph nodes (glands), the bones and (rarely) the brain. Infection with the TB germ may not develop into TB disease.

3. Symptoms Fever Night sweats Persistent cough Losing weight Losing appetite Blood in your sputum (phlegm or spit) at any time

4. Treatment Standard treatment for TB: –4 drugs for 2 months –2 drugs for 4 months Non standard treatment normally represents –either resistance to the bacteria or –reaction to the medication

5. Prevention and control of TB 1.Treatment of TB patients 2.Contact tracing (screening people who have been in contact with a known TB patient) 3.Providing treatment for people with TB infection but not disease 4.Education and Health Promotion 5.BCG vaccination

6. Epidemiology

7. Number of people notified with TB in Ealing Local Authority Notifications 2005 (rate/100,000) Notifications 2006 (rate/100,000) Notifications 2007 (rate/100,000) Percentage change betw. 2006-2007 Brent 287 (107.18)238 (88.88)274 (102.33)+15.13 Ealing242 (79.34)237 (77.70)246 (80.65)+3.80 Hammersmith & Fulham 90 (51.66)81 (46.50)69 (39.61)-14.81 Harrow 133 (63.11)124 (58.84)121 (57.42)-2.42 Hillingdon 143 (57.74)126 (50.88)127 (51.28)+0.79 Hounslow 169 (79.38)140 (65.76)139 (65.29)-0.71 Kensington & Chelsea 48 (27.53)53 (30.40)32 (18.35)-39.62 Westminster 98 (44.14)85 (38.29)88 (39.64)+3.53 Sector Total 1210 (66.68)1084 (59.74)1096 (60.40)+1.11

8. Ethnicity NW London (=Ealing)

9. Age and Gender

10. Year of Entry

13. Drug resistance in Ealing Year Isoniazid resistance (UK rate) Rifampicin Resistance (UK rate) MDR TB (UK rate) 20021.3% (6.9%)0.0% (1.2%)0.0% (1.0%) 20031.4% (6.9%)1.4% (1.8%)2.1% (1.3%) 20042.6% (6.8%)0.0% (1.5%)1.5% (1.1%) 20054.0% (7.0%)0.0% (1.4%)1.1% (1.0%) 20064.4% (7.0%)0.0% (??%)1.6% (1.1%)

14. Barriers to seeking treatment Culture Fear / Shame Stigma Knowledge Service (GP, EHT)

15. Chest Clinic no. referred less than 2 weeks (%) no. referred between 2 - 4 weeks (%) no. referred over 4 weeks (%) Chelsea & West.12(75)3(19)1(6) Charing Cross13(45)3(10)13(45) Ealing8(21)6(16)24(63) Hammersmith4(80)1(20)0(0) Hillingdon 0(0)2(50)2 Northwick Park64(80)3(4)13(16) St. Mary’s27(66)4(10)10(24) West Middlesex18(56)4(13)10(31) Willesden18(75)2(8)4(17) Total164(61)28(10)77(29) Delay between first contact with a health professional and referral to a TB clinic* * NWL HPU (2007) Patient delay audit report

16. Reasons Waiting for results from their investigations. (What the investigations were was not specified) TB not being suspected or being misdiagnosed by the GP.

17. Delay between referral to TB clinic and first appointment at the TB clinic Chest Clinicno. seen less than 2 weeks (%) no. seen between 2 - 4 weeks (%) no. seen over 4 weeks (%) Chelsea & West.12(71)2(12)3(18) Charing Cross24(73)4(12)5(15) Ealing33(70)6(13)8(17) Hammersmith3(60)1(20)1 Hillingdon20(91)2(9)0(0) Northwick Park92(97)1(1)2(2) St. Mary’s33(85)2(5)4(10) West Middlesex17(53)5(16)10(31) Willesden21(60)11(31)3(9) Total255(78)34(11)36(11) * NWL HPU (2007) Patient delay audit report

18. Reasons Waiting for investigation results Patient not being able to attend an earlier appointment

19. Other work Close working relationship with NW London Sector Performance management from SHA London Good communication with other TB clinics across London Find and Treat team Working with Crisis and other homeless / drug and alcohol agencies

20. Action taken Health promotion activities in the Somalian community (Community advocate worker) School assemblies Mobile X-ray Unit screening in Ealing (SHA London) Annual activities on World TB day (23 March yearly) – (TB team) ‘Advertising’ – TB alert (PCT) Streamlining the TB Service (TB Service, PCT) Increase of staff in 2008 (PCT) LAA targets (PCT)

21. Staffing 1 TB Associate Specialist – doctor (three sessions per week) 5 WTE TB Specialist Nurses 1 Administrator support worker (full time) 1 Somalian Outreach Worker

22. Tuberculosis in Ealing - 2. Housing

23. What is TB Tuberculosis, or TB, is a disease caused by a germ (Mycobacterium tuberculosis). TB usually affects the lungs, but can affect other parts of the body, such as the lymph nodes (glands), the bones and (rarely) the brain. Infection with the TB germ may not develop into TB disease.

24. Symptoms Fever Night sweats Persistent cough Losing weight Losing appetite Blood in your sputum (phlegm or spit) at any time

25. Infection risk Infectiousness of person with TB Environment in which exposure occurred Duration of exposure Virulence of the organism

26. NICE Close contacts of infectious cases Those who have lived in, travel to or receive visitors from places where TB is still very common Those who live in ethnic minority communities originating from places where TB is very common Those with immune systems weakened by HIV infection or other medical problems The very young and the elderly, as their immune systems are less robust Those with chronic poor health and nutrition because of lifestyle problems such as homelessness, drug abuse or alcoholism Those living in poor or crowded housing conditions, including those living in hostels.

28. Impact of housing Completion of TB treatment and stable accommodation Improved completion when stable accommodation Improved completion = less risk of TB resistant strain Recommendation from NICE Useful adherence strategies include: assisting or advising patients regarding links to social security benefits and housing/social services.

29. Conclusion Housing and TB are linked –Overcrowding increases the risk of acquiring TB disease and TB infection –Stable housing improved adherence to TB treatment –Improved adherence = less risk of resistant strain of TB

30. Experiences from Ealing TB Service People had their tenancy agreement terminated after the landlord found out the patient had TB (rare instance) Mainly single men with TB living in hostel accommodation and being moved at very short notice (also they do not appear to qualify for housing) Mother and x amount of children living in one room (=overcrowding)

31. Housing department at Ealing does not give priority or support to patients affected by TB (service issue) Where patients were referred, they were ‘forced’ to relocate to somewhere else, but not in Ealing (??) No communication from Housing department to TB Service (service issue) Experiences from Ealing TB Service

32. Tuberculosis in Ealing 3. Stigma and Interagency working

33. Marriage breakup Not being able to marry Risk of dying because of TB treatment TB treatment changes your appearance/looks Refuse to sharing food/utensils Not realising TB is curable Stigma – result

34. Avoid seeking health care Deny the illness Isolation Poverty Family network disappearing Difficulty in contact tracing Stigma – result

35. TB sufferer says: “When you have TB, people will laugh at you and say you have HIV. That is why we wouldn’t want people to know. But the best thing is to let people know so that people can help you and you avoid transmitting it to many people.” Link with HIV: TB-HIV stigma leads to TB patients being socially shunned, physically isolated and considered sexually ‘immoral’

36. the body of a woman who died from TB in India was kept in a car for five days by her employer Conclusion TB can make a person socially isolated (or the feeling of being socially isolated) PSExamples are from international literature. Not all may apply in Ealing. PPSMost of the stigma issues apply to South-East Asian communities (Indian, Bangladeshi etc.) and African communities (Somalian)

37. TB Alert (UK’s national TB charity) North West London HPU (network and TB outbreak management) Schools (assemblies, health promotion) Voluntary sector (health promotion, raising awareness) Interagency working

38. Local businesses (Money exchange) Café (Khat chewing) Mosque (after prayers on Friday) Gantaar (Assistance / Support agency) RAAD (Refugee support) Somalian Children Support Group (after school kids club) Interagency working

39. Our staff (advocacy workers) Ahmed Yassin Mohammed Ahmed