TB in Migrant populations: UK. Graham Bothamley British Thoracic Society, TBSAG

Transcription

1 TB in Migrant populations: UK Graham Bothamley British Thoracic Society, TBSAG 1

2 London and migration 1975: 86% white UK 2015: 45% white UK Estimated 600,000 undocumented Number of Africans equivalent to Sheffield 57% births to non-uk born mothers Judah B. This is London; Life and Death in the World City Picador,

3 TB prevalence in London High risk group No. Denominator Prevalence (per 100,000) Asylum seeker , Recent migrant , HIV , Alcoholism , Problem drug user , Homeless 29 10, Prison 29 5, Story et al. Thorax 2007; 62: 667

4 TB prevalence in London High risk group No. Denominator Prevalence (per 100,000) HIV , Homeless 29 10, Prison 29 5, Alcoholism , Problem drug user , Recent migrant , Asylum seeker , Story et al. Thorax 2007; 67: 667

5 Points of testing 1. Pre-entry screening with visa 2. At point of entry (UK Border Agency) 3. Referred to local TB service (from PHE) 4. At GP registration 5. Ad hoc, on basis of no prior testing (NHS) 5

6 Public Health England 2015 PRE-ENTRY SCREENING 6

7 UK pre-entry screening report PHE,

8 UK pre-entry screening report PHE,

9 New entrant pre-visa screening Oct 2005 to Dec

10 TB cases and rates in pre-entry screen UK pre-entry screening report PHE,

11 10 countries with highest UK visas UK pre-entry screening report PHE,

12 MDR as percentage of all TB

13 Proportion of MDR cases from Eastern Europe, Asia ad Sub- Saharan Africa with additional resistance, UK 2011 (HPA) 13

14 UK Border Agency and Public Health England referrals POINT OF ENTRY SCREENING 14

15 UK immigration 15

16 New entrant TB Number yrs 6-10 yrs >10 yrs Data from Homerton University Hospital 16

17 Screening for LTBI Percent preventive treatment Port of Entry GP registration 0 Data from Homerton University Hospital 17

18 RCT: Griffiths et al. Lancet 2007; 369: GP REGISTRATION 18

19 19

20 Effectiveness of TB screening: cluster randomisation of practices 53 Hackney practices 1 pilot 2 refused randomised 25 control Practices 25 intervention practices 20

21 Randomisation Factors 1. Partnership size 2. Training practice status 3. List size 4. Practice nurse employed 5. Health check rate for new patients 6. Use of EMIS computer system

22 Study Intervention 1. Educational visits to practices to promote TB screening and awareness 2. TB specialist nurse support 3. Incentives 4. Audit Target population: new and existing patients in general practice 22

23 25 control practices 121,291 existing patients 25 intervention practices 116,780 existing patients 48,984 new pts 44,986 new pts 23,051 (47%) checks 23,573 (52%) checks 84 (0.4%) screened 13,478(57%) screened 84 Heafs 1,996 (17%) Heafs 23

24 Outcome: active TB Control Intervention Primary Care Total Percentage Odds ratio = 1.68 (95% CI: ) 1.61 (95% CI: ) adjusted for clustering 24

25 Outcome: latent TB Control Intervention Primary Care 5 11 Total Percentage 9 19 Odds ratio = 3.00 (95% CI: ) 1.61 (95% CI: ) adjusted for clustering 25

26 Local enhanced service for TB Started Apr 2004 Educational session Fixed payment per practice Claim for Number of tuberculin skin tests Number of patients starting preventive treatment Number of patients diagnosed with TB 26

27 TB patients without a GP Number Data from Homerton University Hospital 27

28 National screening guide, PHE 2015 Local incidence > 20 per 100,000 Aged years (65 years, NICE 2016) From high incidence area (> 150 per 100,000) Immigrated in last 5 years Resident > 6 months in high incidence area Ensure no active TB before LTBI treatment same population (WHO >100 per 100,000) Latent TB Testing and Treatment for Migrants: A practical guide for commissioners and practitioners. PHE,

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30 Algorithm 30

31 General migrant health Vaccination status (rubella etc.) Screen for HIV and hepatitis Acute mental illness, e.g. PTSD Nutrition and EtOH Diabetes, renal impairment 31

32 Monitoring and evaluation National template to record data EMIS Web, SystemOne and Vision Systematic program Proportion of eligible new entrants tested % IGRA+ offered preventive therapy Proportion of IGRA+ given preventive therapy Proportion completed preventive therapy Latent TB Testing and Treatment for Migrants: A practical guide for commissioners and practitioners. PHE,

33 Other contacts with NHS LOCAL PLAN 33

34 Hackney populations (2011 census) Hackney White UK African Afro-Caribbean White Other EU Indian sub-continent Other TK Mixed White non-eu White Irish Chinese Middle East Vietnamese Somali SE Asia TB 34

35 Hackney populations (2011 census) Hackney White UK African Afro-Caribbean White Other EU Indian sub-continent Other TK Mixed White non-eu White Irish Chinese Middle East Vietnamese Somali SE Asia 17% TB 35

36 Screening for active TB (WHO 2015) Ethnicity Local incidence (per 100,000) Somali 17,000 Turkish/Kurdish 331 SE Asia 302 Vietnamese 215 Sub-Saharan Africa (non-somali) 112 Indian subcontinent

37 Early diagnosis Likely TB patients Send sputum early (1997) New entrant screening (1998) preventive treatment for 35 yr and under GP screening (2003) Direct radiology referrals (2004) Culture for TB routine (e.g. LN, 2006) Direct histology referrals (2008) 37

38 Trends in number and rates of tuberculosis in London, Newham and City and Hackney Numbers of TB cases Rates of tuberculosis per 100,000 Year Year 38

39 Sources of TB cases 100% 80% 60% 40% 20% Other Screening A&E Cancer referrals GP 0% Data from Homerton University Hospital 39

40 Interval between migration and TB Percent of all TB notifications st year 2nd year 3rd year 4th year Total Cumulative data for (627 notifications) 40

41 Late TB after migration Proportion of TB for < Data for (627 notifications) Data from Homerton University Hospital 41

42 Points of testing current UK 1. Pre-entry screening with visa 2. At point of entry (UK Border Agency) 3. Referred to local TB service (from PHE) 2. At GP registration screening 3. Ad hoc, on basis of no prior testing (NHS) 42