Appendix 6: Ambitious goals
Updated 9 October 2025
Applies to England
© Crown copyright 2025
This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gov.uk.
Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.
This publication is available at https://www.gov.uk/government/publications/managing-tuberculosis-tb-in-prisons/appendix-6-ambitious-goals
To improve TB management in English prisons, several evidence-based and aspirational measures can be implemented, depending on the availability of resources and operational feasibility.
6.1 People arriving in immigration removal centres: active TB screening using chest X-rays
In addition to verbal screen on arrival, there is a strong rationale to support establishing active TB screening using chest X-rays (CXRs) (with or without computer-aided diagnostics (CAD)) for detained individuals arriving in immigration removal centres (IRCs). This is due to:
- an overall higher incidence of active TB in the IRC population (compared to prison and the general population)
- those being detained from the community (unlike Foreign National Offenders transferred from prison) are less likely to have had recent or any contact with the healthcare system
- despite using interpreters, language barriers may limit the effectiveness of verbal screening
- potential for a high degree of suspicion and fear in individuals entering detention resulting in lower likelihood to declare symptoms
- a high proportion of asymptomatic TB disease
- the open regime within IRCs result in more mixing between people, and shorter average length of stay, resulting in significant challenges in effective contact tracing after a TB case or outbreak is identified
At the time of writing this guidance, CXRs in IRCs are currently unavailable. Feasibility of the introduction of CXRs may be considered in the future and learning can be taken from the evaluation of this Welsh pilot study [1].
6.2 Progression of LTBI
LTBI may progress to TB disease at any point, particularly if the person’s immune system is weakened by drug treatments or another disease such as HIV [2]. However, progression most commonly occurs within the first 2 years after acquiring infection [3], which is why prompt screening for LTBI and treating of contacts of an infectious TB case is one of the most effective tools in preventing further cases of TB disease.
There is increasing recognition that TB does not exist within a binary paradigm of latent infection and active disease, but instead occurs on a spectrum [4]. This new framework includes a subclinical infectious state, in which a patient does not experience symptoms but may have radiological and/or microbiological abnormalities. Prevalence data suggests that subclinical TB may contribute substantially to transmission, thereby increasing the rationale for early diagnosis and treatment to make effective progress towards TB elimination [5]. Studies have reported that 79% of detained individuals in USA and 57% of prisoners in Tanzania with confirmed pulmonary TB were asymptomatic [6],[7] A new classification system of TB beyond latent-active has not yet been adopted by the World Health Organization (WHO) and so this guidance refers only to LTBI and active TB disease.
In IRCs the population is more transient than in the main prison estate, with 63% (2,907 out of 4,611) of detained individuals in 2024 having a length of stay equal to or less than 28 days [1]. This means that it is unlikely that testing, initiation and completion of LTBI treatment could be carried out without disruption during detention in an IRC and therefore is not currently recommended.
In 2024, economic modelling carried out by the University of Sheffield suggested that screening for TB disease and LTBI in prisoners born in high or medium TB incidence countries (at least 40 cases per 100,000 population) would be cost saving, averting one TB death per year and 6 TB cases per year (3 of these in the community) [8]. This strategy would save around £35,000 per year relative to the current standard of care. However, there is currently no national commissioning or finance for routine diagnostic testing for TB infection in secure settings and systematic screening is yet to be implemented.
6.3 Expansion of telemedicine facilities
Pathways to establish telemedicine have been hindered by multiple operational challenges from both hospitals (clinician reluctance, staff training, accessibility of systems) and the secure setting (availability of space in healthcare, Wi-Fi connectivity issues) as well as wider system-level issues preventing adoption [9]. However, where implementation has been successful, they have been very satisfactory and every effort should be made to set up pathways to enable this which will have long-lasting and significant benefits for residents, the secure setting and the NHS.
Where possible the initial assessment by the local NHS TB service is likely to be in-person at the hospital but follow-up by telemedicine may be preferable, if available, at the clinician’s discretion.
6.4 Use of point-of-care testing
In future, if point-of-care testing using PCR machines is available within the secure setting then healthcare teams may be more likely to test for TB as they can provide a rapid result within 90 minutes. Sputum sample processing within the healthcare department in the secure setting is safe if following the necessary protocols [10].
6.5 Role of occupational health
In 2025, a new HMPPS occupational health taskforce was established to address exposure of staff in the workplace. This group will develop appropriate pathways to access TB control and prevention facilities. This may be a service commissioned through the Occupational Health provider or an NHS approved TB screening service provider. The type of commissioned service will depend on the number of staff contacts exposed. For example, if only a few staff require screening, referrals may be arranged and commissioned through the local NHS TB service so that they attend their local hospital for an appointment. If several staff are exposed, it may be preferable to commission a bespoke in-reach mobile service to do larger scale contact tracing, CXR and LTBI screening. This latter option is likely to improve the uptake of screening.
References
-
Using chest X-ray to screen for Tuberculosis on arrival to prison: A service evaluation medRxiv
-
Tuberculosis PubMed
-
Quantifying the rates of late reactivation tuberculosis: a systematic review PubMed
-
New admissions and asymptomatic TB cases seem to fuel TB epidemic in prisons, a cross sectional survey in Tanzania PLOS Global Public Health
-
Integration, population commissioning and prison health and well-being – an exploration of benefits and challenges through the study of telemedicine Journal of Integrated Care, Emerald Publishing