Guidance

Management of tuberculosis in secure settings in England

Updated 9 October 2025

Applies to England

1. Outline and purpose of guidance

This guidance is intended to support the collaborative approach to prevention, diagnosis and management of tuberculosis (TB) in secure settings.

This guidance is evidence based and developed through expert opinion agreed by a multiagency group established within the Health and Justice Transform NHS England (NHSE) Clinical Reference Group, chaired by the UK Health Security Agency (UKHSA), and including partners from His Majesty’s Prison and Probation Service (HMPPS), NHSE, Home Office, NHS TB services, NHS-commissioned providers of secure setting healthcare services, and people with lived experience of imprisonment. See full list of contributors in Appendix 1.

This guidance covers multiple settings which are listed in the section Who this guidance is for, below. These settings will collectively be referred to as ‘secure settings’. Those who are resident in these settings, including prisoners in prisons and detained individuals in immigration removal centres (IRCs), will be collectively known as ‘residents’. Those who are responsible for non-healthcare actions within these secure settings are referred to as ‘governor’ in prisons, ‘centre managers’ or ‘director’ in IRCs, and ‘manager’ in Approved Premises; these terms may be used interchangeably.

2. What has changed

The previous version of this guidance was in 2 parts:

a) Management of TB in prisons for prison healthcare teams (published in 2013)

b) Guidance for health protection teams (HPTs) on responding to TB incidents and outbreaks in prisons and other places of detention (published in 2014).

The following changes have been made to this guidance:

• single combined guidance for all audiences in secure settings
• updated evidence included
• updated links throughout document
• updated names of organisations where changes to governance structures have occurred

3. Who this guidance is for

This guidance is targeted at:

• healthcare and non-healthcare teams in secure settings
• local TB services
• NHS commissioners
• HPTs
• TB Control Boards

The guidance outlines how to detect and manage cases, notify necessary stakeholders of TB cases and manage outbreaks including preventing new cases in residents and staff.

The settings in England covered by this guidance are:

• prisons and young offender institutions (YOIs) with residents aged 18 and above
• approved premises (APs)
• IRCs and residential short-term holding facilities (maximum stay for 7 days) and residential holding rooms (maximum stay for 96 hours)

Primary healthcare and preventative services in prisons, YOIs and IRCs are predominantly commissioned through regional Health and Justice NHSE with oversight from National Health and Justice NHSE.

Secondary healthcare, for example TB specialist care, is provided by NHS services in the local area. In several areas of England there is no dedicated TB service and the broader respiratory service at the local NHS hospital has the equivalent responsibilities for TB management in their local area. These services are commissioned through the local Integrated Care Board (ICB). Throughout this guidance, when we refer to the local NHS TB service this is interchangeable with the broader respiratory service depending on what is locally available.

APs are governed by HMPPS. However, access to healthcare is provided differently to other secure settings, and in the same way as to anyone else in the community. Any person in an AP who has confirmed or presumed TB should be notified in the same way as set out below.

This guidance does not cover the following settings.

• the children and young people secure estate (CYPSE)
• forensic NHS hospitals
• policy custody and courts
• non-residential holding rooms (maximum stay of 24 hours), for example in airports or ports
• mass accommodation sites for people seeking asylum

4. What this guidance covers

This guidance covers: 

• roles and responsibilities
• verbal TB screening for residents arriving in secure settings
• identification of cases or outbreaks of TB within secure settings
• management of residents in secure settings with active TB
• management of incidents or outbreaks of TB within secure settings, including contact tracing
• continuity of care following transfer or release of residents in secure settings
• infection prevention and control (IPC) measures
• occupational health for staff
• improving the awareness and knowledge of TB in secure settings

This guidance aligns and builds on other relevant publications on Management of incidents and outbreaks of communicable disease in secure settings in England and Infection control in prisons and places of detention

5. Background

5.1 Overview of TB

TB is a bacterial infection which can spread to other people through the air by inhaling small droplets which may have come from the airways of an infected person. In some people, infection may progress to disease. In approximately half of all adults diagnosed with TB, the infection is limited to the lungs, but can affect any part of the body, including lymph nodes (glands), bones, and the central nervous system, where it may cause meningitis [1]. A list of TB symptoms can be found in Section 8.

TB is a serious condition, but it can usually be completely cured if diagnosed early and treated promptly with the right combination of specific antibiotics. The length of treatment for drug-sensitive TB disease is a minimum of 6 months, but may be longer, for example, for TB in the brain or in some cases of drug-resistant TB.

Latent TB infection (LTBI) is where an individual has been infected with the bacteria which cause TB, which has not yet progressed to cause disease, but may go on to do so. People with LTBI do not have symptoms of disease and they are not infectious. In LTBI, TB bacteria cannot be detected, so diagnosis is assisted by assessing the person’s immune response to the bacteria, for example with an interferon gamma release assay (IGRA) blood test or tuberculin skin test (TST), also known as Mantoux test [2]. LTBI can be treated with antibiotics, which can reduce the risk of future active TB disease.

5.2 TB in England

Numbers and rates of TB notifications in England are rising. In 2024, a total of 5,480 people were notified with TB in England, an increase of 13% compared with 2023 and an annual TB notification rate of 9.5 per 100,000 (provisional data) [3].

TB rates in England are highest in urban areas and remain associated with social risk factors (alcohol misuse, drug misuse, homelessness, imprisonment, mental health needs and asylum seeker status) and indices of deprivation. Individuals born outside of the UK account for most TB notifications in England (81.5%, 46.2 per 100,000).

5.3 TB in secure settings

In 2023, 111 people notified with TB in England and Wales (2.2% of all TB notifications) reported current or recent imprisonment. People with a history of imprisonment within the previous 5 years have a TB notification rate in England and Wales 4 times that of the general population (rate of 32.6 per 100,000) [4], [5]. People notified with active TB who have history of imprisonment are more likely to be male (risk ratio 11.4), UK-born (risk ratio 3.9) and of white ethnicity (risk ratio 10.5) than those without a prison history.

People with a history of imprisonment are more likely to have a strain of TB that closely relates to a strain detected in another person in England (their strains exhibit ‘genomic clustering) than if they had not been in prison (risk ratio 4.5). Genomic and epidemiological data supports that direct transmission of TB is occurring in prison populations in England.

Factors contributing to the risk of TB transmission in secure settings include:

• people with risk factors for TB moving through the criminal justice system and to and from the community
• insensitive verbal questionnaires being used as the mainstay of screening at reception, so active TB disease can be brought into prisons
• large populations being held in confined spaces and, often, in over-crowded conditions, which can enable transmission
• delays to TB diagnosis and treatment which lead to long periods of TB transmission prior to its detection
• movement of residents with TB and their contacts within the prison estate, which can disseminate the infection to additional sites.

The above factors can lead to TB outbreaks, large numbers of potential contacts and complex contact tracing exercises.

Transmission of TB to staff is not uncommon in secure settings. Staff may have prolonged close contact with residents, for example, during hospital bed watch with variable use of personal protective equipment (PPE). Further evidence is available in Appendix 2.1. Information on transmission in other settings is provided in Appendix 2.2.

6. Roles and responsibilities

The management of TB incidents and outbreaks in secure settings requires close collaboration between all system partners, who are each responsible for different aspects of management within a secure setting. An overview of the roles and responsibilities of system partners and in the context of TB in secure settings are set out below, with more detailed information provided in the Management of incidents and outbreaks of communicable disease in secure settings and Appendix 3.

During a TB incident or outbreak, where an incident management team (IMT) has been established, the IMT (with all relevant stakeholders present) are responsible for agreeing the public health actions that are required. In the absence of an IMT, the HPT will lead on decisions regarding required public health actions (see Section 10.2). Decisions concerning implementation of any actions are co-ordinated by the chair of the IMT. Agreement is required between commissioners, healthcare providers and the HMPPS/Home Office as to whether actions can be accommodated within NHS business-as-usual (BAU) provision or bespoke commissioning arrangements are required. The general principle is that services for residents in secure settings are the responsibility of the regional health and justice (H&J) commissioner, whereas services for staff exposed at work are the responsibility of their employer.

Although signing the TB outbreak/incident management plan agreement is not mandatory, it is strongly encouraged as a best practice for all partner agencies involved in the management of TB outbreaks and incidents in secure settings.

The roles and responsibilities of the various local, regional and national stakeholders are available in Appendix 3.

7. Testing or screening of people arriving in secure settings for TB disease

Chest X-rays (CXRs) are highly sensitive (87% to 98%) for pulmonary TB disease, meaning they would correctly identify a positive case 87 to 98% of the time. NICE guidance recommends that, if the facilities are available in the secure setting, digital CXR should be undertaken for all new arrivals within 48 hours, if they have not had a CXR in the past 6 months [6]. Most secure settings do not currently have these facilities available. In the absence of radiography, reception verbal screening for TB symptoms currently remains the mainstay of TB screening in secure sites. This is an insensitive tool to identify TB disease but may help identify some individuals with symptoms compatible with active disease who may require further testing.

In this guidance, a new, 2-stage TB verbal screening questionnaire (with recall, if required) is introduced. This approach supersedes the previous single initial screening at reception on the day of arrival, in an effort to enhance detection. (For this section, ‘secure settings’ excludes APs which are considered separately in Section 7.3.

Table 1. TB verbal screening on arrival – summary

	Reception screening	Secondary screen	Recall appointment (if required)
When	Day 0 (within 24 hours)	Day 2 to 7 (within a week of arrival)	3 weeks after reception or secondary screen
Questions asked	Symptom screen for TB. History of current or previous TB treatment	Repeat symptom screen for TB. Full history of previous TB diagnosis and treatment	Repeat symptom screen for TB

Appendix 5 presents TB verbal screening outcome pathways. Screening for active TB using CXRs as an option in IRCs is detailed in Appendix 6.1.

7.1 People arriving in the secure setting already on TB treatment

Residents who arrive in the secure setting with a history of previous incomplete treatment should usually be admitted to a single cell and then urgently discussed with the local NHS TB service as to whether isolation precautions need to be maintained.

The local NHS TB service should be informed by the secure setting healthcare team within one working day of any person with TB being transferred into the secure setting while on treatment.

To enable appropriate management, as a minimum, the following information should be gathered by the secure setting healthcare team in liaison with the TB service involved in their TB care:

• name, date of birth, NHS number
• prison or identification number
• site of TB disease
• culture and antibiotic sensitivity results
• when and where TB treatment was started
• which treatment they are taking (drug, dose) and whether an urgent prescription is needed – the local NHS TB service can arrange for urgent supply of medications not brought in with the resident, or plan to supply the next prescription
• whether they have been adherent with directly or video observed therapy (DOT/VOT) as reported verbally by patient – for example, whether a TB nurse visits them regularly
• whether there is suspicion of multidrug-resistant TB (MDR-TB) if full sensitivities are not available

7.2 Screening people being transferred from other secure settings

The records of residents arriving in secure settings following direct transfer from another prison or IRC should be reviewed on the clinical management system (example SystmOne) for any relevant TB history (previously reported symptoms, TB treatment, or TB contact). Such a review of electronic health records may:

• identify symptoms, which may have been previously overlooked, such as a persistent cough previously treated as a simple chest infection which warrants a referral and further investigation
• support continuity of treatment for residents already in receipt of TB treatment who are transferred – for planned transfers within the estate, the healthcare service in the sending establishment should liaise with the healthcare service in the receiving establishment to ensure swift transfer of clinical information to ensure continuity of care

If a resident identified as a close contact of a case with active TB has been moved before they have been tested for TB, the receiving healthcare team should ensure they are tested. If a resident has been tested for TB but is moved before their results are actioned, they must be followed up and managed appropriately by the receiving healthcare team. If a resident is moved whilst receiving treatment for LTBI the receiving healthcare team must inform their local TB service and follow up appropriately in accordance with local pathways. 

7.3 People arriving in approved premises

There is no opportunity for verbal symptom screens on arrival in APs since there is no in-house healthcare provision. Residents in APs are supported by AP staff to register with their local GP practice as part of their induction. See Section 13 for further information about continuity of care on release.

7.4 Routine testing for LTBI in secure settings

While identification of active TB should be prioritised in secure settings, measures to routinely identify and manage individuals with LTBI is an important component in reducing the current high incidence of TB disease and transmission in these settings. There is currently no national commissioning or finance for routine diagnostic testing for TB infection in secure settings and systematic testing and treatment is yet to be implemented. Section 15.1 of this guidance gives recommendations for how to implement routine LTBI testing if a local decision is made to commission this within a region. This may be of greater importance in areas of high incidence, or secure settings with a high proportion of foreign national residents.

8. Residents with symptoms compatible with TB disease on arrival at a secure site or develop during their stay

The secure setting healthcare doctor or nurse should assess any resident in a secure setting with any of the following symptoms:

• history of a cough
• coughing up blood
• unexplained weight loss
• high temperature
• drenching night sweats
• swollen lymph nodes
• loss of appetite
• tiredness
• backpain

If an individual is identified as having any of the above the symptoms, they should be promptly referred to the local NHS TB service. If the individual is coughing up fresh blood or is clinically unstable, urgent transfer to a local emergency department should be considered, with staff taking appropriate transmission-based precautions.

If a resident has symptoms compatible with pulmonary or laryngeal TB, they should be placed in respiratory isolation as soon as possible Section 11.1.1. Residents who are isolating away from others should have regular opportunities to discuss their wellbeing and any anxieties with a member of staff. A review of infectiousness should be considered and discussed at 2 weeks of treatment with the clinical team responsible for care.

8.1 Investigating people with symptoms of TB

Hospital admission should be based on clinical need. If the individual is well enough, it may be possible to achieve a TB diagnosis in a secure setting. This may reduce diagnostic delay, avoid hospital transfers, reduce the stigma of attending hospital while handcuffed to officers and limit staff exposure (during transfers and bed-watch).

8.2 Telemedicine

Where appropriate facilities are available, telemedicine may be a preferred option for some virtual hospital appointments via video-link from the secure setting to the NHS TB team. Telemedicine can facilitate in-reach services into the secure settings to deliver prompt, cost- and time-saving clinical review [7],[8], while reducing reliance on escort staff availability for hospital transfers (the cost of which is remunerated by NHSE commissioners). Telemedicine appointments should be offered at the discretion of the TB clinician Appendix 6.3.

8.3 Sputum samples for TB diagnosis

In residents in whom pulmonary TB is suspected, collect 3 sputum specimens under supervision, ideally on consecutive days and into transparent, screw-capped, leak-proof containers. High quality sputum samples are thick and with sticky material on visual inspection. At least one of the specimens should be collected early in the morning, as soon as the person wakes up and pre-breakfast to represent the pulmonary secretions collected overnight. Label the specimens with the date of collection and adequate patient identifiers, and send to the local microbiology laboratory as soon as possible after collection for acid fast bacilli smear and culture. If available locally, request TB polymerase chain reaction (PCR) testing for one of the sputum samples. Specimens can be kept in the specimen fridge if they are being collected over the weekend. Possible use of point of care testing machines is discussed in Appendix 6.4.

8.4 TB microscopy and PCR

Smear microscopy and TB PCR are rapid and highly sensitive tests, with a good positive predictive value for infectious pulmonary disease. They can also be organised immediately from the secure setting. Poor quality specimens, for example saliva rather than sputum, may give false negative results, although may still yield a positive TB PCR.

TB PCR testing may also give early indication if the person may have multi-drug-resistant TB (MDR-TB) [9].

The secure setting healthcare team should flag samples as important with the local microbiology laboratory so that results can be communicated by phone and/or email, as well as electronic transfer, to enable prompt public health action. If possible, a second member of the healthcare team should also be allocated to follow up results. Culture must also always be requested from an appropriate laboratory, even if point-of-care (POC) PCR testing is done.

If the smear, TB PCR and/or CXR are consistent with TB, the person should remain in respiratory isolation and a prompt referral be made to local NHS TB services [10]. IGRA tests are designed to detect TB infection; they are not recommended as a diagnostic test for active TB disease [11].

8.5 Chest X-ray

Where a resident has symptoms compatible with active TB disease, a CXR should be performed as soon as possible and, where available, within the secure setting for example via mobile or ultra-mobile radiology. Where these are not available, refer the patient to the local radiology department, or CXR can be done as part of a local NHS TB service assessment. Where organised by the secure setting healthcare team, results of the CXR should be followed up urgently.

Any resident with an abnormal CXR suggestive of TB, regardless of symptoms and/or sputum sample results, should be referred urgently to the local NHS TB service and a copy of the CXR electronically transferred to the relevant TB service’s radiology platform.

8.6 Management of a resident with potentially infectious TB

A person is defined as having potentially infectious TB if they are a person:

• in whom there is a clinical suspicion of pulmonary or laryngeal TB, pending the outcome of diagnostic tests
• with a CXR compatible with active TB disease, pending the outcome of diagnostic tests and specialist review
• with confirmed pulmonary or laryngeal drug-sensitive TB until at least 2 weeks of treatment have been taken with good adherence and absorption and the local NHS TB service have deemed them safe to de-isolate
• with confirmed pulmonary or laryngeal TB and non-adherent with treatment or previous history of incomplete treatment, for as long as deemed necessary by the local NHS TB service and HPT

A person with active TB disease with no lung or laryngeal involvement (extra-pulmonary TB) is not normally infectious and does not require isolation.

A person diagnosed with LTBI is not infectious and does not require isolation, regardless of treatment status. However, residents and staff diagnosed with LTBI who have not been treated should remain vigilant for symptoms of TB disease developing, as they may require prompt respiratory isolation and investigation.

See Section 10.3.1 for the definition of the infectious period for contact tracing purposes.  

8.7 Medical hold

The HMPPS Policy PSO 3050 Continuity of Healthcare for residents is currently under review and due to be published in 2025 to 2026. HMPPS operational guidance (January 2024) supports the effective use and management of medical holds.

This guidance clarified that a medical hold is used to indicate a requirement for additional care and planning when considering whether a prisoner is suitable for transfer. It includes those:

• who must not be transferred

• who require significant planning to facilitate a safe move or

• who have upcoming appointments that are urgent

In the case of a resident with TB, HMPPS would not expect them to be transferred if they were being isolated as a communicable disease control measure or if they were receiving treatment that could not be continued in another prison. A medical hold in these circumstances would be appropriate and regularly reviewed between prison and healthcare to ensure that the hold is lifted as soon as the prisoner was available for safe transfer. There is a similar policy in place by the Home Office for detained individuals in IRCs Section 13.4.

8.8 Reporting cases of TB

All residents with presumed or confirmed active TB must be reported, as soon as possible (usually within 24 hours), to the local HPT and to the local NHS TB service in line with the guidance on notifying suspected or confirmed cases of active TB [12].

The following information should be provided on reporting:

• name
• date of birth
• date of onset of symptoms
• description of symptoms
• date of arrival in the secure setting
• whether they arrived on transfer from another secure setting or from the community

The local NHS TB Service is responsible for formally notifying the individual onto the National TB Surveillance System (NTBS) within 3 working days of presuming or confirming TB in accordance with the Health Protection (Notification) Regulations (2010). The notification to NTBS should not be delayed if the full details of the patient are not available, as the notification can support the public health response and mitigate against further transmission.

Latent TB and extrapulmonary TB may also require notification to the HPT (check local protocols) but this is less urgent as it is not infectious to others.

See Appendix 7 for a diagram outlining notification and referral routes.

8.9 Management of people with confirmed pulmonary or laryngeal TB

The initial assessment by the local NHS TB service will likely take place in person at the hospital. Any future consultations will be arranged collaboratively between the clinician and the prison healthcare team, in coordination with the prison, to ensure that staff are available to provide escort as needed.

Prison healthcare should give the resident written and verbal information (including easy read format, if appropriate) about their diagnosis and treatment, and update their medical records on the clinical information system as necessary. Interpreters should be used where appropriate.

Only those who need to be aware of the resident’s diagnosis of TB should be informed. Take care to avoid stigmatisation of people who have TB. A useful checklist to support local practice and management is available in Appendix 8.

9. Directly observed treatment (DOT)

DOT is a tool which can be utilised as part of a patient-centred, enhanced management approach. It aims to improve treatment adherence by assigning a designated individual who administers, supervises, witnesses and records the swallowing of every dose of TB medication by a patient. Ensuring adherence to treatment is important to reduce infectiousness, prevent disease progression and to reduce the risk of developing drug resistance. DOT is particularly used in the treatment of active disease. It is also used in individuals who have been identified as having risk factors for non-adherence as listed in the Royal College of Nursing (RCN) Case Management Tool [13] (this includes current imprisonment).

By default, DOT is recommended in all secure settings and most residents in secure sites will receive their treatment this way. However, there are instances where DOT could reduce TB treatment adherence in some individuals in secure sites if it is prohibitively prescriptive about when the resident needs to present themselves to healthcare. In these cases, individualised patient risk assessments and tailored plans made with the patient about how they will receive their medication can be used to optimise treatment completion.

Clinical records for all TB patients should be regularly audited by the secure setting healthcare provider to ensure treatment is being prescribed and supplied, and to evidence adherence in line with professional standards [14]. Where doses have been missed a reason for this should be stated.

9.1 Treatment monitoring by the local NHS TB service

The local NHS TB service (TB nurse) should visit the patient where possible within 5 days of them commencing TB treatment to assess side effects and clinical issues, and advise on adherence. The secure setting healthcare team and the TB nurse should then agree upon a schedule for the TB nurse to follow-up.

TB treatments may cause drug-induced liver toxicity and other toxicities detectable by blood tests. Local NHS TB services will make recommendations on which blood tests should be performed and when for individual patients determined by their treatment regimen and personal medical history.

TB treatments can be associated with other side-effects such as nausea and vomiting, rashes, changes in nerve sensation and visual disturbances. Healthcare staff should encourage residents to report any side effects they are experiencing. Healthcare staff should then communicate these as soon as possible (same working day) to the NHS TB services, who will advise on further clinical management.

Concerns regarding treatment adherence and missed doses (including if doses were missed due to factors beyond the control of the resident) should be reported by the secure setting healthcare team to the NHS TB service as soon as possible (same working day), who will advise.

9.2 Person with presumed or confirmed active TB disease who declines to engage with care

If a resident in a secure setting with presumed or confirmed active TB disease declines investigations or does not adhere with their treatment, an IMT should be promptly convened to review next steps. Continuous engagement, mental capacity assessment (if indicated) and support should be provided to the resident by the healthcare staff and the local NHS TB team.

The HPT and IMT need to consider the infectious risk posed and the best place to manage the resident to mitigate the risk to others. The HPT may also seek advice from the National UKHSA Health & Justice Team if required.

If a resident with presumed or confirmed active TB disease is not engaging with healthcare in community settings, for example if they are on release from prison or IRC Section 13.2 or in an AP, as a last resort, the local authority may apply to a magistrate for a Part 2A order under the Public Health (Control of Disease) Act 1984.

10. Incident or outbreak management

The UKHSA Management of incidents and outbreaks of communicable disease in secure settings guidance is important preliminary reading relevant to this section.

10.1 Definitions

TB incident

A TB incident is where any person (staff or resident) with pulmonary or laryngeal TB has been in a secure setting during their infectious period.

TB outbreak

A TB outbreak is an incident in which 2 or more cases of TB are linked by time, place, common exposure or TB strain. These are suggestive of recent transmission and may include cases diagnosed in the community with epidemiological links to the same secure setting.

10.2 Establishing an incident management team (IMT)

Following notification of a TB incident or outbreak in a secure setting, the HPT will conduct an initial risk assessment with the secure setting. The HPT will decide on a course of action which may include providing public health advice or convening an IMT to support with coordinating the incident response. The HPT or IMT will determine the extent of contact tracing, TB screening and other actions as necessary.

Where no IMT is established, the HPT will be responsible for offering advice and guidance to the secure setting. This should be shared with relevant stakeholders as required such as those listed in the IMT membership below.

A suggested IMT membership is provided in Appendix 9 and their roles and responsibilities are outlined in Appendix 3. The chair of the IMT should remain the same throughout the incident response where possible to improve continuity and avoid loss of operational information.

The IMT Membership is also provided in the outbreak management guidance. 

10.3 Contact tracing

Contact tracing in secure settings is often difficult and requires careful planning and implementation. Responsibilities for contact tracing are set out in Appendix 3.

Once it is published, the following section of this guidance should be read in conjunction with the UKHSA TB Contact Tracing – Operational Guidance for UKHSA Health Protection Teams, which is currently being developed.

10.3.1 Definition of infectious period following identification of an index case in a secure setting

Where there is a reliable history of onset of a cough or hoarseness of voice, contact investigation should extend back to the date of symptom onset. If the date of onset of cough is unknown or unreliable, then the inclusion period for contact investigations is defined as beginning 3 months before the first finding consistent with TB disease. This period can be readjusted on a case-by-case basis according to epidemiological findings and clinical considerations.

In IRCs the infectious period of detained individuals is likely to be similar to other secure site residents. However, due to the shorter average length of stay (only 10% of detained individuals stay longer than 3 months) [15] a more reasonable target to set for an infectious period for contact tracing where symptom onset is unknown is 28  days prior to the individual ‘s first finding consistent with TB disease. It is acknowledged that the open regime and freedom of movement within an IRC limits the feasibility of full contract tracing in these settings, as set out in this guidance. The extent of the feasible contract tracing would be decided on a case-by-case basis as agreed in the IMT. It is likely to include those with whom the detained individual has shared a room, any known friends with whom they have had prolonged or cumulative contact, and staff known to have direct contact.

In APs the average length of stay is similarly approximately 28 days, which may also be a more reasonable period to use for contact tracing in this setting. For staff working in IRC’s and AP’s see Section 10.3.5.

It is current ‘custom and practice’ to prioritise contacts who have had 8 hours cumulative contact with the index case for initial screening exercises. Contacts who are immunocompromised should be prioritised when they have had 4 hours of cumulative contact. Different risk profiles exist, and will be further informed by the local dynamic risk assessment; the IMT may choose to reduce these thresholds for screening following local risk assessment [16] (this includes current imprisonment).

10.3.2 Definition of a ‘close contact’

‘Close contacts’ in a secure setting will be agreed by the IMT, but will usually include the following types of contact during the case’s infectious period:

• residents who have shared a cell with the case
• immunocompromised individuals who may have had contact with the case
• individuals who spent time with the case during activities, for example education or gym sessions
• staff members who have spent time with the person with active TB disease in the secure setting, where no appropriate PPE was worn Section 11.1.3
• staff members who have spent time with case on bed watch duties or during transfer in enclosed vehicles where no appropriate PPE was worn
• any similar categories of staff or residents if the case has recently transferred from another secure setting or have been through the courts
• visitors to the secure setting who spent time with the case
• close contacts within household and/or work settings if the case is a recent entrant to the secure setting from community or participates in temporary release for work or family contact outside the secure setting.

As requested by the HPT incident lead, the following information about close contacts should be provided as soon as possible (usually within 72 hours):

• names, resident or ID numbers, dates of birth, and the current location of residents who are identified as close contacts
• names, addresses and dates of birth of all staff (prison officers, education or healthcare staff) who are identified as close contacts
• names, addresses and dates of birth of any other individuals (for example visitors, family or work colleagues) who are identified as close contacts

Support from the governor or manager and/or national HMPPS or Home Office may need to be sought via the IMT in relation to finding information about residents who have already transferred to other establishments, or where the index case has been in more than one establishment during their infectious period. The probation case management system (for example nDelius), accessed by the Head of Offender Management Delivery, can identify released residents still known to probation or the licensing system. Any community contacts should be followed up by the local NHS TB service.

The local HPT should refer close contacts who are out of the area to the relevant regional HPT for follow-up.

10.3.3 Investigations of close contacts of person with active TB disease

Following the identification of an individual with active TB disease in secure settings, close contacts should be assessed to identify any additional people with active TB disease (including those who may have been the source of transmission to the index case) and those with LTBI at risk of progressing to active TB disease (the risk of progressing to active disease is greatest in the first 2 years following infection).

TB screening during contact tracing exercises usually follows a ‘stone in the pond’ approach. If after an initial round of screening there is evidence of possible onward transmission, a second risk assessment may be carried out to extend screening to more contacts.

Evidence supportive of transmission from a person diagnosed with active TB may include:

• finding of a person or people with active TB disease
• identification of clustering (similarity) between TB strains on whole genomic sequencing in culture-confirmed cases
• a higher-than-expected rate of LTBI in those screened
• LTBI conversion in contacts (from IGRA negative prior to or immediately after contact with the infectious case to positive approximately 8 weeks after contact)

Timelines and the mode of testing close contacts will be agreed at the IMT. There may be situations in secure settings in which identifying close contacts, especially estimating duration of contact, is not possible. This may be on account of limited understanding of the mixing patterns of residents or inaccurate declaration of contacts, for example because there has been illicit activity. There may also be occasions where transmission has been presumed or confirmed beyond close contacts. In these situations, rather than adopting a ‘stone in a pond’ approach, it may be more appropriate to consider whole-wing or whole-prison testing. This is an approach that requires agreement by the IMT and will depend on multiple factors including the infectiousness of the index case, the time from onset to diagnosis and the environment which individuals have been sharing as well as resource implications.

Transfer of residents between secure estate sites should ideally be minimised during an incident or outbreak, until contact tracing is complete and results have been appropriately actioned. This will minimise loss-to-follow-up and reduce potential seeding of TB to new sites.

Maintaining confidentiality of all individuals is very important throughout all contact tracing processes. 

The responsibility for commissioning TB testing in different types of close contacts (for example residents, secure staff, healthcare staff, visitors and contacts now based in the community) is set out in the roles and responsibilities section of this guidance Section 6.

10.3.4 Contact tracing in residents  

The following actions representing enhanced active case finding among resident close contacts should be conducted, ideally in order:

1. Systematically identify all close contacts of the index case who are resident in secure settings and add a flag to their Content Management System (example SystmOne).
2. Provide written and verbal information about signs and symptoms of TB to all close contacts, using language line and providing written information in other languages, where necessary.
3. Arrange clinical assessments of all close contacts to check for TB symptoms Section 8. This should happen 8 weeks post exposure to the index case. Ideally this would be conducted by a healthcare professional experienced in TB. Consider risk factors such as immunocompromise and signs and symptoms of extrapulmonary TB.
4. For close contacts who have respiratory symptoms compatible with pulmonary TB, request medical hold Section 13.4 and place in respiratory isolation Section 11.1. Arrange sputum testing (AFB smear microscopy and culture and TB PCR) as a priority. Prompt CXR and an appropriate clinical review should also be arranged for any individual found to have symptoms compatible with pulmonary TB.
5. Ideally, arrange CXR for all close contacts, as this is a sensitive diagnostic tool to screen for active, pulmonary TB disease. Radiology may be commissioned as an in-reach mobile service to avoid hospital transfers and enable efficient timely screening of multiple close contacts.
6. Once active TB is excluded (or concurrently, close contacts should be tested for LTBI using an IGRA blood test (unless there is a previous history of TB treatment, as the IGRA test may remain positive after successful treatment). This testing may be done by prison healthcare staff (if agreed with NHS TB service locally), through a provider laboratory or through an in-reach mobile service (which may be able to conduct radiology concurrently). Healthcare staff require appropriate training, and results must be shared with a named clinician who can interpret IGRA results and who will take responsibility for actioning results appropriately.
7. Update clinical management system (example SystmOne) with screening outcomes.
8. Urgently refer all residents identified with symptoms compatible with active TB disease, positive microbiology and/or radiology indicative of pulmonary TB to local NHS TB services. Those with LTBI should be routinely referred to the local NHS TB service for discussion of treatment and next steps.
9. Any close contacts who have been transferred or released prior to completing TB testing must be notified to the relevant local HPT (or via International Health Regulations (IHR) National Focal Point (NFP) if they have been transferred overseas) to facilitate the required follow-up.
10. While IGRA tests are commonly used for TB testing, they are primarily tests for LTBI and can miss up to 1 in 5 active TB cases among close contacts. Relying on IGRA alone may lead to undetected cases and ongoing transmission. Methods of testing for TB should be agreed by the IMT in consultation with relevant stakeholders.

In secure settings, contacts may have other risk factors for TB disease or LTBI (such as risk of exposure in their country of birth or social risk factors). Results from screening may reflect the background rate of LTBI in that population and not recent transmission within the prison.

10.3.5 Contact tracing in staff

The following actions should be conducted for staff close contacts:

1. Systematically identify all staff close contacts of the index case.
2. Provide written and verbal information about signs and symptoms of TB to all staff close contacts.
3. Consider whether wider communication about risk of TB transmission in the setting to all staff is required.
4. Arrange clinical assessments and TB screening for all staff close contacts as per locally agreed pathways Section 12.1.
5. Staff should be encouraged and provided with support to attend assessments, including allocated time in work hours.
6. Arrange referrals of symptomatic staff to occupational health who will require a risk assessment prior to returning to work. Asymptomatic staff can continue to work during screening process Section 12.1.

10.3.6 Contact tracing in others, including visitors

The following actions should be taken for visitor close contacts:

1. Systematically identify all other close contacts of the index case.
2. Provide contacts with written and verbal information about signs and symptoms of TB.
3. Arrange referrals to local NHS TB service for clinical assessments and investigation of all other close contacts according to local arrangements.

10.3.7 Declaring a TB incident or outbreak over

If an IMT has been established, this will collectively agree when an TB incident or outbreak is considered over. This is usually when all reasonable effort has been made to follow-up close contacts and there has been no further evidence of transmission within the setting.

11. Infection prevention and control

Transmission-based precautions are put in place to stop a pathogen, in this case TB, being transmitted from one person to another. This might be resident to staff or resident to resident. Transmission based precautions for a resident with TB are to be put in place only while the person is considered infectious Section 8.6.

Step down of transmission-based precautions should be approved by the local NHS TB service in liaison with secure setting healthcare services and the HPT.

The secure setting health and safety team and the healthcare provider are responsible for providing the necessary IPC resources and training to prevent occupational health exposure for their staff respectively.

11.1 Transmission-based precautions for TB 

During the infectious period of TB (Section 8.6) the following precautions apply.

11.1.1 Isolation

Isolate any resident with suspected or confirmed infectious TB in a single room/cell with the door kept shut. Only essential staff or visitors should enter, wearing appropriate PPE (following infection control guidelines). The resident should avoid all non-essential contact with other residents and staff. Prison staff should ensure that all urgent and routine healthcare needs of the resident continue to be met. If MDR-TB is confirmed, the resident must   be transferred to a hospital with negative pressure facilities and remain there until de-isolation criteria are met. Residents leaving the room while infectious must wear a fluid-resistant surgical mask (FRSM) if tolerated. This must not compromise care or cause distress. Access to fresh air and exercise should be supported safely, preferably outdoors, without risking exposure to others. Use non-stigmatising signage (for example colour-coded indicators or staff room boards) to discreetly signal infection risk to avoid revealing the diagnosis. Ventilation systems must be assessed to ensure air from the isolation room is not extracted into other areas. Seek advice from the HPT or UKHSA IPC team as needed.

The room that the resident is isolated in must have hygiene and toileting facilities. If external showers are used:

• the resident must wear an FRSM to and from the shower
• the resident should shower alone, ideally when other residents are locked down
• staff should clean the shower area afterwards
• the resident should wear a clean FRSM after showering – staff accompanying the resident should wear full PPE

11.1.2 Safe management of the environment and equipment

The cell or room that the resident is isolating in, and any showering facilities that they use, should be kept visibly clean, in a good state of repair and be free of non-essential items, particularly those that are difficult to clean.

Only essential items should be kept in the room, noting that after the infectious period these items may require decontaminating [17]. Shared items or equipment that enter the room of resident with TB that are to be used by or on another resident will require thorough decontamination prior to reuse. No special precautions are required regarding crockery or eating utensils that have been used by a resident with TB. Standard washing procedures used by the local kitchen services apply.  

The resident should be provided with materials to clean their single isolation cell using either:

• general purpose detergent in warm water followed by a solution of 1,000 parts per million (ppm) available chlorine
• a combined detergent or disinfectant solution at a dilution of 1,000 ppm available chlorine

The secure setting is responsible for providing cleaning chemicals and materials as well as ensuring cleaning staff or residents are appropriately trained to undertake isolation cell cleaning using the appropriate PPE (for example, trained biohazard cleaners). Items contaminated with sputum should be managed as infectious clinical waste.  

11.1.3 Personal protective equipment (PPE) for staff and visitors

To protect staff or visitors from exposure to TB, they should wear respiratory protective equipment (RPE) when in direct contact with the infectious resident. This can be either a filtering face piece (FFP3) mask or a powered respirator hood. FFP3 respirators can be either valved or non-valved and should be:

• single use (disposable) and fluid resistant (EN149)
• fit tested on all staff or visitors to ensure an adequate fit following manufacturer’s guidelines
• fit checked as per manufacturer’s guidelines every time it is put on to ensure a good seal or fit (HSE guidelines for putting on respirators and preforming a fit check)
• compatible with other facial protection used either for infection or security purposes
• facial hair may impede the seal of the mask and must not interfere with the seal surface

Further information regarding fitting and fit checking of respirators can be found on the Health and Safety Executive website.

Powered hoods or respirator hoods have the advantage of being compatible with facial hair and do not require fit testing. Any powered hoods that are used must comply with HSE guidance [18] and have a decontamination schedule in place. They should be stored and maintained as per manufacturer’s instructions.

Putting on and removing RPE should be undertaken when outside the isolation cell or room, after the door is closed and any security chain to the patient has been removed. Hand hygiene should always be undertaken before putting on and removing RPE. 

All other PPE should be used as per standard and transmission-based IPC precautions. Secure setting staff should work with healthcare staff and the local NHS TB service to risk assess what other items of PPE are required, including aprons or gloves. For example, gloves may be recommended if the staff member is going to handle used tissues, equipment or furniture. PPE other than the RPE outlined above should be put on and removed in the resident’s cell or room. Hand hygiene with water and soap or hand sanitiser should always be carried out on removal of gloves as well as after leaving the resident’s cell or room. 

Advice for how to put on and take off all PPE, including videos, can be found at COVID-19: personal protective equipment use for aerosol generating procedures (the same donning-doffing advice for other respiratory infections apply). Please note that this guidance is of a general nature and that an employer should consider specific conditions of work and applicable legislation including the Health and Safety at Work Act 1974. 

The risk of measures such as bed watching in hospital rooms during the infectious period should be discussed with NHS hospital healthcare staff. Without appropriate enhanced respiratory protection, this exposure is equal to or greater than household contacts of TB patients. Officers should only conduct bed watches in an infectious patient’s room if a security risk assessment determines it is appropriate, and they are wearing suitable PPE. This assessment is the responsibility of the governor or manager of the secure setting, in consultation with Health and Safety and Occupational Health as needed. It should consider any vulnerabilities the officer may have, such as immunocompromising conditions, including diabetes. The outcome must be clearly communicated during handover to those assigning staff to bed watches while maintaining confidentiality.

12. Occupational health provision for staff

All staff in secure settings should be provided with information about the signs and symptoms of TB and how it is spread during their induction. This should be revisited with repeated training as required Section 14.

12.1 Staff exposures during TB incident or outbreaks

During a TB incident or outbreak, it is the responsibility of the secure setting to commission TB screening for secure staff close contacts identified as part of contact tracing by following the steps set out in Section 10.3.5. Likewise, it is the responsibility of the secure setting healthcare provider to commission TB screening for healthcare staff. Secure setting occupational health, in liaison with the local NHS TB service, are responsible for reviewing staff who are showing signs of TB who may require a risk assessment prior to returning to work. More information available in Appendix 6.5.

12.2 BCG vaccination

BCG vaccination is of limited efficacy in the protection against TB. Previous BCG vaccination does not alter the management of close contacts following exposure, who still require screening, and BCG scar checks offer no value. IGRA positivity (unlike the interpretation of Mantoux testing) is unaffected by previous BCG vaccination. Follow the green book advice on BCG vaccination.

Secure settings should prioritise effective testing and management of staff identified as close contacts of a person with infectious TB and raising general awareness of the risk of TB transmission in the setting Section 10 over BCG vaccination or scar checks, the former being more helpful in reducing the risk of secondary cases and onward transmission than the latter.

13. Continuity of care following release, transfer, removal or deportation

Careful planning and risk assessment around release into the community and/or transfer between secure settings is critical to ensure continuity of care and avoid loss to follow-up for people with active TB or LTBI, and people identified at risk of TB infection who have not yet been assessed. Communication between teams involved in care is vital; multi-disciplinary meetings can be useful in this regard. Community release may occur at very short notice from all secure settings, as can transfers between settings despite the recommendation that the resident is put on ‘medical hold’ Section 8.7. The clinical management system (example SystmOne) should therefore be kept up to date at the time of TB diagnosis, or identification of close contacts, to avoid dependency on healthcare staff to write discharge letters at short notice.

The secure setting healthcare services should draw up a plan for transfer or release (including directly from a court appearance) for any resident with active or latent TB, which includes firm arrangements for clinical follow-up, medicines supply and treatment monitoring. This will then require close liaison with the receiving setting and local NHS TB service, including transfer on National Tuberculosis Surveillance (NTBS). Ideally a meeting between prison healthcare staff and the clinical team responsible for ongoing care of the person should be arranged prior to release or transfer, so that ongoing care arrangements can be agreed.

IRCs are considered separately in this section Section 13.4.

13.1 Court attendance

Residents with infectious TB should not attend court in person while they are infectious to others but could attend via a virtual video link if available. If attendance is compulsory during the resident’s infectious period, then appropriate PPE should be worn by the resident and officers on escort duty (Section 11.1.3). The court and transport facilities should be informed in advance.

The prison healthcare team should liaise with the prison or offender management department regarding court attendances once the resident is no longer infectious. The decision to attend court should be informed by the local NHS TB service’s risk assessment of the resident. If a resident from a prison with TB is required to attend court they should be returned to the same prison after the court hearing on medical grounds.

All relevant health and community agencies, particularly the local NHS TB service, should be informed to prepare for the transfer of care to the community if there is any possibility of the resident being released from court.

13.2 Release and community follow-up

If a secure setting needs to release someone with active TB or LTBI, or someone identified at risk of TB infection who have not yet been assessed, into the community, they should:

• identify release or transfer dates early and notify the local NHS TB service
• ensure a care plan is in place for transfer to community TB services
• involve all relevant community support agencies (for example drug services, APs) at the point of diagnosis
• hold a multidisciplinary team (MDT) meeting to coordinate care and discuss DOT if needed
• notify the local HPT in advance of any release or transfer
• ensure TB medication accompanies the resident during transfer, court appearance, or release
• keep a 7-day supply of TB medication on hand for unexpected release/transfer (unless nearing end of treatment)
• maintain accurate, up-to-date electronic medical records, including current TB treatment
• ensure summary letter from NHS TB team (with diagnosis, treatment, investigations) is uploaded to health records and provided at release or transfer
• update the NTBS with the resident’s current location
• collect release address or contact details where possible to support follow-up in the community

13.3 Accommodation for those at risk of homelessness after release

Residents with TB who are at risk of homelessness after release should have accommodation identified for them in advance of release. This may require close liaison with other agencies including local authorities, probation services and homelessness prevention teams. DOT or Video Observed Treatment (VOT) should be arranged in the community in conjunction with the relevant NHS TB clinic prior to release.

The patient themselves may not know where they are going on release in advance, but agencies should mitigate any discontinuity in care on their behalf, using MDT meetings if required.

The patient should be made aware of their treatment plan at the point of release and where to access a supply of their medicines post-release. The use of a language line may be required for residents who do not speak English and are at risk of becoming lost to follow up on release.

13.4 Release or transfer of detained individuals at immigration removal centres

Detained individuals in IRCs with infectious TB should be on ‘medical hold’ and not transferred to other secure settings to reduce the risk of transmission and improve continuity of care. Detained individuals in IRCs with infectious TB should not be scheduled for travel overseas during their infectious period Section 8.6.

The decision to detain an individual under immigration powers must take into account whether there is a realistic prospect of their removal from the UK within a reasonable timeframe. If it becomes clear that removal is no longer a realistic prospect within a reasonable timeframe due to the individual’s circumstances, a decision must be made  whether to release them from immigration detention.

For detained individuals with infectious TB, if release is decided, the responsible authority and the IMT should work together to ensure appropriate and safe release arrangements. This typically includes securing suitable accommodation through the local authority and notifying the NHS TB team to reduce transmission risk and maintain continuity of care.

In such cases, an urgent case conference involving the Home Office, HPT, NHS TB team and local authority may be beneficial to manage and mitigate risks effectively.

The Home Office cannot lawfully detain an individual indefinitely while release arrangements are made. If necessary, the local authority may apply to a magistrate for a Part 2A order, imposing restrictions or requirements on the individual upon release to help prevent disease transmission. Further guidance is available in the Health Protection Regulations Toolkit 2010.

The local NHS TB service should provide the IRC healthcare team with a letter for the detained individual outlining their investigations, diagnosis, and treatment plan. The individual should receive a paper copy of this letter, and an electronic copy should be uploaded to their medical records. This documentation should be presented to their receiving clinic or doctor to ensure continuity of care. Where language barriers exist, written information should be provided in the individual’s preferred language.

13.5 Removal or deportation of detained individuals with infectious TB

Detained individuals in IRCs with infectious TB should not be removed or deported during their infectious period. UKHSA operational guidance for HPTs on the management of TB and air travel offers further advice [19]. If removal or deportation does occur against public health advice, the secure setting must urgently contact the local  HPT. The HPT would then conduct a risk assessment and consider actions to mitigate risk, including informing the UK IHR NFP. The UK IHR NFP would be expected to share any information relevant to transferring the individual’s clinical care to the receiving country as soon as possible and ideally in advance of travel.

This information would include:

• name
• date of birth
• details of travel to receiving country (for example flights, dates)
• any contact details or location details in receiving country to allow the individual to be followed up
• clinical details (diagnosis, treatment, resistance, current medications and how much has been supplied)

Any detained individual who is being removed or deported from the UK is permitted to be given a supply of up to 3 months of any medicines. If being released into the community on TB medicines, they should be supplied with at least 2 weeks’ worth of medications. There should always be one month’s supply ‘in hand’ for each patient at the IRC to accommodate short-notice transfer or releases unless the patient has less than one month of treatment remaining. This minimises the risk of omitted doses. Any issues with a medication supply at the time of release may require an urgent arrangement with the local NHS TB team for support.

14. Improving the awareness and knowledge of TB in secure settings

Secure staff in a setting are often the first to notice if a resident is unwell, and their ability and confidence to signpost them to healthcare results in a quicker diagnosis. This is more likely if they are empowered with knowledge and understanding about the risks of TB in secure settings. Addressing stigma and misinformation concerning TB in secure settings is also very necessary as this is a common barrier for seeking healthcare [20].

The local healthcare team should raise awareness about TB in the setting through regular local training days for healthcare staff, where possible with peer led awareness around TB. HMPPS should also ensure secure setting staff are appropriately informed through induction and regular training. The HPT and H&J NHSE regional leads may be able to support with this.

Resources about TB in secure settings, such as leaflets and posters, have been co-produced by UKHSA and people with lived experience. There is also likely to be better engagement with incident or outbreak response if there is a good baseline understanding of what TB is and how it spreads. Engagement work during guidance development has highlighted the need to strengthen awareness and knowledge of TB. For further information see Appendix 2.3. This is therefore an important time to revisit resident and staff training.

15. Latent TB testing

15.1 Latent TB infection testing (outside of outbreak response)

In secure settings, robust contact tracing and subsequent testing of close contacts to identify cases of active TB, should be prioritised over routine LTBI screening. This is because the prompt identification and management of cases of active TB and people most likely to progress to active TB is of the greatest overall benefit to both the individuals affected and the populations living in close proximity. LTBI testing of close contacts in the context of incident or outbreak response is discussed in Section 10.3  and should only be completed following or concurrent with a symptom screen and CXR to rule out active disease.

However, as discussed in Section 7.4, measures to routinely identify and manage LTBI cases are also required to reduce the current high incidence of TB disease and transmission in these settings. LTBI testing should only be conducted when clear pathways are established to treat residents and staff who test positive. Routine LTBI testing should not be conducted until such pathways are in place.

15.2 Routine and enhanced targeted testing for LTBI

Secure settings may opt to routinely test residents and staff for LTBI. The first step is to always conduct a symptom screen; if positive, the person requires investigations for active TB disease. If the symptom screen is negative, then IGRA is the preferred test to identify people with LTBI as it is unaffected by prior BCG vaccination [21].

LTBI testing could be performed for:

• all or selected residents at reception
• all or selected staff at an initial occupational health check or through mass screening days, the frequency of which should be determined by local incidence, turnover of residents and staff, and resource

Outside of an outbreak, it is not practical to provide routine LTBI testing for residents or staff in secure settings off-site via NHS TB outpatient services. Therefore, if routine LTBI testing is offered, this should only be conducted via in-reach into the prison estate.

Cost-effectiveness of routine LTBI testing may be improved by being preferentially offered to those in highest risk groups, specifically those born in middle- and high-burden countries[22] rather than all residents or staff [23]. Such ‘enhanced targeted testing’ may also be extended to those with other social risk factors for TB (history of rough sleeping, substance abuse and/or seeking asylum). 

15.3 Routine LTBI testing in foreign national prisons

The evidence of cost savings to support bespoke commissioning of a routine LTBI testing programme in foreign national prisons is stronger than for other prisons due to a higher incidence of TB in these prisons [24]. This would require a local commissioning decision in agreement with HMPPS and regional H&J NHSE commissioners.

15.4 Routine LTBI testing in immigration removal centres

While there is a higher background incidence of LTBI in the IRC population than in non-foreign national prisons, the shorter average length of stay for people detained in IRCs and the challenges of undertaking testing without significant loss-to-follow-up in these settings is challenging and therefore cannot be routinely recommended.

Priority should be instead given to raising awareness and understanding of the signs and symptoms of TB and accurately and promptly detecting active cases of TB in these settings. To this end, if radiology facilities were made available for active TB screening on arrival of all detained individuals in IRCs this would be considerably more effective than routine LTBI testing.

16. References

1. What is TB and what are we doing to combat it? UK Health Security Agency

2. Management of latent Mycobacterium tuberculosis infection: WHO guidelines for low tuberculosis burden countries, European Respiratory Society

3. National quarterly report of tuberculosis in England: quarter 4, 2024, provisional data, GOV.UK

4. 2025 CMO Report. Health protection chapter for prisons and probation (due for publication in summer 2025)

5. TB in prisons

6. Table 3, Diagnostic accuracy of symptoms, chest radiography, and molecular WHO-recommended rapid diagnostic tests for screening for TB disease – WHO consolidated guidelines on tuberculosis – NCBI Bookshelf

7. Improving care quality with prison telemedicine: The effects of context and multiplicity on successful implementation and use – PubMed

8. Telemedicine Can Reduce Correctional Health Care Costs: An Evaluation of a Prison Telemedicine Network (research report)

9. Xpert® MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults – PMC

10. Xpert® MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults – PMC

11. Use of interferon-gamma release assays in support of TB diagnosis

12. Notifying suspected or confirmed active tuberculosis (TB)

13. (RCN) RCoN. A case management tool for TB prevention, care and control in the UK Case Management TB Publications Royal College of Nursing 2023

14. Royal Pharmaceutical Society. Optimising Medicines in Secure Environments

15. Home Office. Summary of latest statistics

16. (RCN) RCoN. A case management tool for TB prevention, care and control in the UK Case Management TB, Publications, Royal College of Nursing 2023

17. Detection of M. tuberculosis in the environment as a tool for identifying high-risk locations for tuberculosis transmission – ScienceDirect

18. Respiratory protective equipment at work: A practical guide HSG53

19. Toolkit 2: summary of health protection legislation

20. Tackling TB in inclusion health groups: a toolkit for a multi-agency approach

21. Pai M, Zwerling A, Menzies D. Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update Annals of Internal Medicine 2008: volume 149, issue 3, pages 177-84

22. Global Programme on Tuberculosis and Lung Health

23. Cost-effectiveness of tuberculosis infection screening at first reception into English prisons: a model-based analysis – PubMed

24. UKHSA Biobehavioural surveys conducted between 2022 and 2024 (currently unpublished but data included in CMO report which will be published in the summer 2025)