Advice and guidance on the health needs of migrant patients for healthcare practitioners.
The primary care practitioner has very important roles to play in both the prevention and control of tuberculosis (TB); primarily through prompt recognition and referral of suspect cases to secondary care, and also in the support of patients through prolonged treatment.
Maintain long term vigilance for signs and symptoms of TB in at-risk groups, which include the non-UK born (even many years after arrival) and their families, or others who have links to endemic countries.
Consider the risk of TB in people who have recently arrived in the UK from countries of high incidence and arrange for TB screening to be offered as appropriate.
Non-UK born people are more likely than UK born people to get extra-pulmonary forms of TB. It is important to be vigilant for signs and symptoms consistent with extra-pulmonary TB.
Certain conditions such as diabetes are more common in certain ethnic groups, and can increase the risk of TB.
Inform at-risk patients about the symptoms of TB, and encourage them to seek prompt medical advice should they develop them.
Offer HIV testing to anyone diagnosed with TB.
The World Health Organization (WHO) reported that in 2014, approximately 9.6 million people fell ill with TB worldwide and there were 1.5 million deaths. WHO estimates that one-third of the world’s population is currently infected with latent TB infection (LTBI), where individuals have been infected with the bacteria but do not have symptoms and cannot transmit the disease.
Approximately 5 to 10% of people with LTBI become sick at some time during their life. People with both HIV and LTBI are much more likely to develop TB.
The highest rates of infection occur in Southeast Asia and sub-Saharan Africa according to the Global tuberculosis report 2015.
People who were born in a country with a high incidence of TB represent one of the groups at highest risk of TB in the UK. In 2013, the majority of non-UK born cases in the UK were from the Indian subcontinent and Africa.
UK-born people with links to endemic countries through social networks or travel are also at increased risk.
TB develops slowly. The highest risk period for the development of disease is soon after infection but it usually takes several months for symptoms to appear. It can, however, remain latent for many years before developing into active disease. This means that non-UK born people may continue to be at risk of developing disease for many years after initial arrival in the UK.
Diabetes increases the likelihood of reactivation of TB and is also more common in certain ethnic groups, such as in people from the Indian sub-continent.
Other conditions that suppress immunity such as renal failure, chemotherapy, or HIV can also lead to reactivation of TB disease.
In 2011, around 4% of people diagnosed with TB in England, Wales and Northern Ireland aged 14 and over were co-infected with HIV.
Although TB often affects the lungs (pulmonary TB), it can also affect other parts of the body (extra-pulmonary TB), such as lymph nodes, bones and spine and (rarely) the brain and central nervous system. Extra-pulmonary forms of disease are more common in the non UK-born population than in people who are UK-born.
Typical symptoms of pulmonary TB include:
- coughing for more than 3 weeks: coughing up blood in phlegm or mucus
- weight loss: slow at first, getting quicker as TB develops
- loss of appetite
- high temperature or fever
- night sweats
- extreme tiredness or lack of energy
Extra-pulmonary TB may present in a multitude of different ways, including localised pain, and it is important to be vigilant to this possible diagnosis in anyone who might be at risk.
Only pulmonary TB is generally infectious and the infection is usually spread through coughing. People with sputum smear positive (‘open’) pulmonary TB are much more infectious than those with sputum smear negative pulmonary disease. Close and prolonged contact, such as where people live in the same household, is usually required for transmission of TB to occur. Fully drug sensitive infectious cases often cease to be infectious after 2 weeks of effective treatment.
Pre-entry TB screening
In 2012, the UK government announced a new pre-entry screening programme for TB. Pre-entry screening is required for migrants applying for a UK visa for over 6 months, from countries with a TB incidence of over 40 per 100,000 population.
The screening includes a chest x-ray and symptom assessment and can include a sputum examination. Individuals who are found to have active TB of the lungs must complete treatment before their visa is granted. Children under 11 years old do not undergo chest X-ray screening unless a clinician deems it necessary, but a history of recent contact with a case of pulmonary TB will be taken alongside a symptom screen and a physical examination if considered necessary by the physician.
A TB screening for the UK: leaflet for patients is also available.
Pre-entry screening does not test for latent tuberculosis infection (LTBI) or for extra-pulmonary disease. Migrants from high incidence countries remain at a higher risk for TB many years after arrival in the UK. Primary care practitioners must remain alert to the signs and symptoms of TB among migrants.
See PHE tuberculosis screening guidance.
Latent TB infection (LTBI) screening
NICE guidance and the PHE and NHS England Collaborative TB strategy for England: 2015 to 2020 recommend LTBI screening for new entrants from high incidence areas for TB.
See guidance on screening latent TB infection.
Systematic LTBI testing and treatment programme for high-risk new entrants aged 16 to 35 years of age
In addition to LTBI screening offered to individuals in primary care, a national programme to systematically offer LTBI testing and treatment in England to new entrants has been funded by the NHS and is currently being implemented. Under the programme, LTBI testing should be offered to 16 to 35 year olds who have arrived in England in the last 5 years and who were born or lived for more than 6 months in sub Saharan Africa or countries where the TB incidence is more than 150 per 100,000 population. There is evidence that LTBI screening for those arriving from areas with a TB incidence or more than 150 per 100,000 is cost effective.
See PHE guidance on Latent TB Testing and Treatment for Migrants
An LTBI testing and treatment implementation algorithm and short introduction to LTBI testing and treatment are also available.
HIV and TB testing
NICE recommend that new entrant screening for TB should be included within larger new entrant screening programmes, linked to local services. GPs can use the opportunity to offer HIV testing alongside LTBI screening if appropriate, particularly to those from countries where dual infection with HIV and TB is common. LTBI testing may also be combined with other health checks, for example, hepatitis B and C as appropriate.
HIV testing should be offered to anyone who has been diagnosed with TB. Any person known to be living with HIV should be referred to HIV services for further risk assessment.
In the UK, secondary care specialist teams typically manage TB cases, including treatment of active disease, following NICE guidelines. These teams consist of physicians, nurses and social or outreach workers with expertise in the treatment of TB.
Treatment involves a combination of antibiotics for a minimum of 6 months with monitoring of treatment by the specialist team. Completion of treatment is vitally important to ensure that the patient is cured and to prevent the development of antibiotic resistance. Treatment of latent disease may be for 3 to 6 months depending on the antibiotic regimen used.
Advice for secondary care specialist teams about treatment of Multi Drug Resistant TB (MDR-TB) is available from the MDR-TB Clinical Advice Service. The forum provides an opportunity for online dialogue between experts and specialist teams on all aspects of the management of patients with MDR-TB (login required).
Prevention and control
The most important aspects of preventing and controlling TB in the population are:
- screening of at risk groups such as new entrants
- active case finding (and LTBI screening as appropriate) in under-served groups
- prompt recognition of cases and investigation of the contacts of cases
- adequate and complete treatment of known cases
- BCG vaccination
The NICE TB guidelines provide advice on preventing TB, case finding and adherence, treatment completion and follow-up in under-served groups, including vulnerable migrants.
Royal College of Nursing Tuberculosis case management and cohort review: guidance for health professionals complements existing guidance from NICE, with a clear and concise reference manual for frontline workers engaged in TB control.
TB is a notifiable disease in the UK. If a case is diagnosed, contact your local Health Protection Team.
When cases are identified contacts will be traced, screened and treated as appropriate. Contact tracing is usually carried out by local TB services. Where clusters or outbreaks are identified the local health protection team will become involved in investigation and control.
The role of the primary care practitioner in the prevention and control of TB is to:
- maintain vigilance for possible cases of active disease
- educate at-risk patients about the symptoms of TB and what to do if they develop them
- arrange screening for at-risk groups including new entrants from high incidence countries
- refer suspected cases on to specialist services promptly for assessment and treatment
- support patients through their treatment in conjunction with the specialist centres
- identify and refer patients who are eligible for BCG vaccination
For further information on BCG vaccination, see Tuberculosis: the green book, chapter 32.
The BCG World Atlas provides detailed information on current and past BCG policies and practices for over 180 countries.
Resources to share with patients
TB Alert’s Truth about TB website covers all aspects of TB for patients.
TB Alert’s patient information leaflets are available to order in English, Albanian, Bengali, Chinese, Farsi, French, Greek, Gujarati, Italian, Pashto, Polish, Portuguese, Punjabi, Romanian, Somali, Sorani, Spanish, Tamil, Turkish, Urdu and Vietnamese.
The Department of Health’s leaflet Tuberculosis: the disease, its treatment and prevention is free to download in English, Albanian, Bengali, Chinese, Farsi, French, Greek, Gujarati, Italian, Kurdish, Pashtu, Polish, Portuguese, Punjabi, Romanian, Somali, Spanish, Tamil, Turkish, Urdu and Vietnamese.
Patient.info’s tuberculosis leaflet was developed by TB Alert in partnership with north west London TB network.