The aim of this paper is to examine Tuberculosis (TB) as a public health concern in England. Issues revolving around health promotion, for example the National Health Services’ TB screening and vaccination programmes and the epidemiology of TB in England, will be examined. That is not all; this paper will also seek to identify and address policies regarding TB, at the international, national as well as the local level, concluding notes made, and recommendations made according to the gaps that will be identified.
Health is a state in which a person is completely free of illness. The World Health Organisation (WHO) defines it more conclusively as “a state of complete physical, mental and social well-being and not merely the absence of disease” (WHO, 1946). Public health then can be described as the process whose aim is the prevention of diseases and illnesses, the protection of life and the promotion of health in a given population (Orme et al, 2003).
To be able to focus on and intervene in a particular area and employ preventive measures, public health also gauges and monitors the trends and prevalence levels of diseases (Naidoo & Wills, 2005). However, public health’s concern is not only to prevent health risks and promote health in a population, but also empowering persons in order to improve and positively steer their own health (Ottawa charter, 1986).
Tuberculosis is a kind of bacterial infection, spread through inhaling tiny saliva droplets from an infected persons sneezes or coughs. The bacteria that is responsible for tuberculosis is called Mycobacterium tuberculosis, very slow-moving bacteria, and it is therefore very difficult to detect any symptoms for months or years following infection. The effects of tuberculosis are mostly experienced in the lungs (in this case it is called pulmonary TB) although the infection could spread to other parts like the nervous system, bones, lymph glands, joints and kidneys and can also cause a severe type of meningitis. TB is usually accompanied by symptoms like persistent coughs which, in case they cause damage on blood vessels, may result to coughing up of blood; the infected person may also feel unusually tired, have fevers resulting in night sweats and loss of weight. Mycobacterium bovis, which is closely-related to Mycobacterium tuberculosis, causes TB in animals (called bovine TB), especially in cattle. This bacterium can also infect humans, which it used to before called started being tested for TB and milk started being pasteurised (NHS, 2005).
After being infected by TB, the infected persons’ immune systems, in about 9 out of 10 cases, are able to kill the bacteria. However, there is also the possibility of the immune systems failing to kill the bacteria. In this case, the immune systems may manage to surround the infection with a defensive barrier, meaning that no symptoms will be experienced, despite the fact that the TB will remain in the infected persons’ bodies. This is called latent TB. Still, the immune system may become incapable of either killing or containing the infection, allowing it to slowly spread to the lungs. This is known as active TB. A latent infection of TB can also develop into an active infection in case the infected person’s immune system is weakened later (NHS, 2005).
Tuberculosis is a disease of global importance, as declared by the World Health Organisation (WHO) in 1993 as a “global emergency”. Today, it is the second biggest death causing communicable disease (NATHNAC, 2007).
TB Incidence in England
In the 1960s and 1970s, England – through better housing and nutrition; milk pasteurisation; better drug treatments; x-ray programmes; public health early detection and treatment programmes; and immunisation. However, England lost this control level starting from the 19190s, when TB re-emerged as a public health concern. More cases were now being reported due to increase in migration, with most of the migrating people coming from countries with more TB prevalence than England. Also making small but significant contributions to the problem was ageing of the already established population and prevalence of TB in HIV-infected people (Department of Health, 2004).
Before the introduction of antibiotics, TB was a major health concern in England. However, after their introduction, the condition became less common, although the TB cases have been rising in recent years, especially among the communities of ethnic minorities, arising from places where it is widespread. TB is still a major health concern in the world, with over 9 million new infections and almost 2 million TB-related deaths having been recorded in 2007. In the same year, 7 752 new TB cases were recorded in England. A third of the world’s population is estimated to be infected with latent TB (NHS, 2005).
In 2007, Africa had a per capita incidence rate of 350 cases per 100 000, the highest in the world. South and Southeast Asia, had the most cases, where, annually, about 3 million new cases were reported, with 600 000 of them resulting in deaths, most of them in Bangladesh, Indonesia, India, Myanmar and Thailand. Global TB incidence rise has been attributed to the increase of the world population and the vulnerability of HIV-infected persons to TB infection, particularly in Africa. TB is known to enhance HIV progression and the opposite is also true. TB is the major cause of deaths among persons with HIV in low-income parts of the world (NATHNAC, 2007).
Epidemiology is the study of a health-related condition’s risk-factors, determinants as well as its distribution within a given population. The study involves investigating the relationships of a health condition to age-groups or specific people within given populations and using the results in the prevention and control of the health problems (Bonita et al, 2006).
Age and Sex Risk Factors
In 2006, 8497 TB cases were recorded in the United Kingdom (14 per 100 000 population). The largest number of cases (40 percent) and the highest incidence rate (44.8 per 100 000 population) were reported in the region of London. Most of the cases were reported in young adults between the 15 and 44 years of age, with 72 percent of them being non-UK born. A fifth of the cases involved non-UK born persons who had arrived in the UK two years before the diagnoses (Kruijshaar et al, 2007).
The table below shows the number of TB cases reported in England, N. Ireland and Wales and their rates, annual percentage changes, from 2000 to 2006.
Source: Tuberculosis in the UK: Annual report on tuberculosis surveillance and control in the UK, 2007.
Place of Birth and Ethnic Group as Risk Factors
Of the cases involving non-UK born persons those from South Asia accounted for 47 percent of the cases, with sub-Saharan Africa accounting for 37 percent of them. Among the UK-born cases, 67 percent of the cases were of white ethnicity. The rates of 36 per 100 000) and 32 per 100 000 (the highest rates) were recorded in the Bangladeshi/Indian/Pakistani and black African ethnic groups respectively, with the white ethnic group’s rate being 3 per 100 000 population (Kruijshaar et al, 2007).
45 percent of the cases (the majority) involving the non-UK born populations were from the Bangladeshi/Pakistani/Indian ethnic group, while a rate of 395 per 100 000 (the highest) belonged to the black African ethnic group. Of the 84 percent information available since entry time to diagnosis time, for non-UK born populations, 81 percent had arrived in the UK 2 or more years before TB diagnosis 30 percent had arrived in the UK 2 to 4 years before diagnosis; 21 percent 5 to 9 years before; 29 percent 10 or more years before diagnosis (Kruijshaar et al, 2007).
The chart below shows non-UK born TB cases in England, Wales and N. Ireland by birth-region, in 2006.
Source: Tuberculosis in the UK: Annual report on tuberculosis surveillance and control in the UK, 2007.
Of the tested cases whose results that showed drug susceptibility, 7.7 percent showed resistance to at least one first-line drug. Multi-drug resistance was still low, at about one percent, levels consistent with the Action Plan 1 of the Chief Medical Officer’s, although higher levels were recorded in some regions. The chart below shows the proportion of TB cases with first-line drug resistance by age-group and birth-place, England, Wales and Northern Ireland, in 2006 (Kruijshaar et al, 2007).
The graph below shows the proportion of TB cases with first-line drug-resistance in England, Wales and N. Ireland by age-group, birth-place, in 2006.
Source: Tuberculosis in the UK: Annual report on tuberculosis surveillance and control in the UK, 2007.
Another risk factor is HIV infection, as already mentioned earlier.
In 2009, the number of TB cases provisionally reported to improved national surveillance was 9 153. This is a 14.9 per 100 000 population rate and represents 5.5 percent rise compared 2008’s provisionally reported cases. England had the vast majority of reported case (92 percent). Provisional figures rose by 5.3 percent. Of the cases, 5 percent were from Scotland, 2.4 percent from Wales, 0.5 percent from N Ireland. Scotland had only a small increase in provisional cases, while N. Ireland and Wales had a bigger proportional change (a decrease and an increase, respectively). Recently, though, both countries have had wide provisional reports fluctuations (HPA, 2010).
In England, the largest proportion of cases was reported in London (41%), then West Midlands (12.3%). There was a rise in cases reported in 8 of 9 regions, the only decrease (-2%) being reported in the North East. Of the cases, 73% were found in non-UK born persons, with most of the being reported in persons from South Asia (55 percent) and sub-Saharan Africa (30 percent). Of these, only 21 percent were diagnosed within 2 years of arrival in the UK. Persons between 15 and 44 years of age accounted for 60 percent of the reported cases; those between 45 and 64 years of age accounted for 21 percent of the cases, while those with 65 years and above accounted for 15 percent; 5 percent of the cases were below 15 years (HPA, 2010).
The table below shows the provisional case reports of TB and the annual change in percentage by country, UK, 2005-2009.
Source: HPA: Tuberculosis Update, March 2010.
The observed rise in 2010 is the highest rise in the number of reported cases ever since 2005. Consistent enhanced national surveillance for the last 10 years implies a rise in TB nationally. Efforts aimed at stemming the rise, including the measures targeted at high-burden areas (as detailed in the CMO’s 2004 Action Plan) ought to be strengthened. The measures include high-class clinical services delivering prompt diagnosis of infectious cases and also ensuring treatment; identifying latent infections and applying preventive therapy; applying innovative methods like DNA finger-printing to help identify high-transmission areas; discovering the high-risk groups like immigrants, the homeless and prisoners, and targeting resources of public health to enhance diagnosis and TB treatment in such populations (HPA, 2010).
The figure below shows the provisional number of cases of TB by region, in England, between 2005 and 2009.
Source: HPA: Tuberculosis Update, March 2010.
TB mortality data is collected by monitoring treatment outcome. This data includes post-mortem-diagnosed cases and cases that result in death before completion of treatment, inside of twelve months from the beginning of treatment or date of notification. When deaths are recorded, the dates of death and TB’s contribution to those deaths often remain unknown. Also, post-treatment deaths are not recorded. This graph does not include deaths that occurred in 2008 but were un-registered until 2009. Also, only those deaths for which TB was the primary cause are included. This data does not include individuals whose cause of death was classified as ‘late effects of TB’ or ‘sequelae of TB’ (HPA Centre for Infections, 2010).
The graph below shows TB mortality in England and Wales, from 1913 to 2008
Source: Health Protection Agency Centre for Infections.
There are three categories of health promotion: prevention, public-health policy and health education. Prevention aspect can be put into 3 parts: primary prevention, secondary prevention and tertiary prevention. Primary prevention is greatly important as its aim is preventing the onset of diseases. An example of primary prevention method is vaccinations for TB, in order to prevent TB onset. TB screening is a secondary prevention method whose aim is early TB detection to prevent it from causing damage. Health promotion’s objective is encouraging and enabling individuals have more control over their lives and improving their health (Ottawa Charter, 1986).
The Department of Health and devolved administrations are responsible for the national policy on TB control and eradication, National policy on tuberculosis control and elimination in England. The most important steps towards TB control and eradication were clearly outlined in Action Plan by the Chief Medical Officer (CMO), which was published in 2004. A commissioning toolkit was published in order to help implement the policy outlined in the document. The work of this commissioning toolkit is to help high/low incidence areas plan and commission high quality TB services (Kruijshaar et al, 2007).
Specific advice regarding commissioning models or the responsibility for programmes of diagnosing, treating and controlling TB, are not included in the Action Plan. However, concerning the strategic health authorities’ (SHAs’) leadership role, the Action Plan has reference to consideration of the need for appropriate-level commissioning of dedicated services and facilities, for instance, for multi-drug resistant TB (CMO, 2007).
Also, the Action Plan requires primary care trusts (PCTs) to full-range TB services commissioning to the agreed criteria, with no explanation on whether the criteria are to be agreed on the local or international level, or whether all primary care trusts are required to do that, or it is only the PCTs with high-enough local TB rates to warrant full-range commissioning of services. Nevertheless, the Action Plan recommends that high-incidence areas PCTs develop specific TB service commissioning that is appropriate to the needs of their populations. All together, in order to be able to respond to TB outbreaks if need arises, the Action Plan also recommends that all primary care trusts plan for the need for TB services (CMO, 2007).
Effective TB management is clearly a public health obligation, without regard for the setting of occurrence. If there is failure in any management aspect, it can cause rapid escalation of problems, and serious results for the affected people, besides resulting in additional resources for organisations responsible for TB management. The financial implications of ineffective management of TB are very high. For instance, 7 years subsequent to identification, a London drug-resistant outbreak was still not under control, resulting in about 300 connected cases. Clinicians and public health stakeholders had, for long, been convinced that for NHS to effectively respond to the anticipated TB rise, it is essential to use specific tools in TB service commissioning. Effective commissioning calls for long-term plans and continuation in service development, as well as service re-configuration. PCT population enlargement will most probably make TB to be given a higher priority in high-rate TB areas, making the real cost of appropriate TB management or the cost of lack of TB management clearer (CMO, 2007).
According to ukvisas.org.uk those applying for UK visas of more than 6 months have to undergo screening and obtain certificates showing that they are free from infectious pulmonary TB. The initiative is part of the Five Year Strategy for Asylum and Immigration. For example testing is already in place in countries like Ghana, Bangladesh, Tanzania, Rwanda, Pakistan, Sudan, Thailand, etc. The website describes this programme as part of “our’ firm but fair’ policy on immigration”, for the benefit of the public health and as a form of support for the Action Plan set by the Department of Health. Applicants may also benefit by detecting TB early, while host countries may benefit from early detection of infected persons.
It will also support the Department of Health’s Tuberculosis Action Plan. The programme also has advantages for applicants who may benefit from and early diagnosis of TB. Host countries will also benefit from earlier detection of individuals with the disease.
Screening generates information about infectious tuberculosis among travellers to the UK and helps us to better understand the effect of migration on tuberculosis in the UK. We will also be looking at ways to share data about tuberculosis rates with host countries to inform their own public health programmes.
A further benefit of the programme is that successful applicants will no longer need to undergo medical inspection on arrival in the UK before being allowed to enter the country. This can be a time consuming process but can be avoided if those coming to the UK carry their screening certificate in their hand luggage to present to an immigration officer on arrival in the UK.
To help applicants, their sponsors and others with an interest in the UK’s entry clearance operations overseas, we have prepared two sets of questions and answers (Q&A) which we hope will provide answers to most of the questions that this scheme will raise:
The National Strain Typing Service, launched in May 2010 was developed because of the need for a full molecular TB strain typing programme, and is aimed at informing TB control as well as target resources better and more efficiently. The National Strain Typing Service’ aim is to ensure there is a standard typing system, put in place a central database with typing as well as epidemiological data, and also provide approved operational guidelines on the use of molecular typing data in public health. The service uses the Mycobacterium Interspersed Repetitive Unit-Variable Number Tandem method of typing to single out strains, with the cases with similar types of strains being highly likely connected to an outbreak (HPA, 2010).
The method can help identify case clusters derived from single index cases. Linking the Strain Typing Database to the Enhanced TB Surveillance System is a powerful tool for investigating growth and clusters’ characteristics. The linkage allows temporal and geographical strain types’ distribution and demographic and clinical features of cases as well as examination of their identified contacts. Collected information will be applied at local and national levels; to enable epidemiological cluster investigation and also raise awareness of out-breaks crossing regional boundaries (Kruijshaar et al, 2007).
Spreading the service throughout England will lead to better cluster control and support the basic defective which is necessary for finding case contacts and ensuring early treatment. The strain typing data is be accessible to front-line teams in real time to assist in controlling TB at the earliest chance possible. Eventually, the service will enhance understanding of TB transmission dynamics and help reinforce prevention of TB as well as its control. Data generated though this initiative can help progress of future research, help people understand the differing transmissibility, dangerously strong characteristics of the strains (HPA, 2010).
The TB group at the APA Centre for Emergency Preparedness and Response (CEPR) has a major research programme dedicated to supporting global goal of developing and evaluating a TB vaccine. The programme focus, in part, is to fully understand behaviours of pathogenic mycobacteria during the process of infection in order to identify new possibilities of a vaccine target. The studies also help identify important possible biochemical pathways and recognise expressible cell-surface molecules, by cells while growing in a host (Kruijshaar et al, 2007).
The pathways and molecules may be used new as new diagnostics or therapeutics molecules targets. The CMO’s 2004 Action Plan the key action in reining in TB as creating awareness. Awareness enables people to seek early treatment and reduce onward transmission, thus improving health, saving lives and saving money. This awareness is primarily targeted at highly affected communities like the black African and South Asian communities, the homeless people, substance-abusers, prisoners and ex-prisoners (Kruijshaar et al, 2007).
If a new, more effective vaccine is developed, it would greatly impact on reducing TB’s global incidence. This is one of the major research priorities for the UK Department of Health, the World Health Organisation, the European Union and other international health agencies. It is also in the United Nations Millennium Development Goal 6. Developing an improved TB vaccine is quite a lengthy process. However, the numerous international organisations – as well as the funding bodies – are strongly committed to evaluate new formulations as well as delivery systems in clinical trials for the next five to ten years. One of the Global Plans to Stop TB’S objectives is to have a safe, inexpensive, licensed new TB vaccine by 2010 and the National Health Agency is contributing to this important Plan (HPA, 2010).
There needs to be a well planned response to TB, even in low-incident areas, so that in case of incidents or outbreaks, or significant changes in the demography of populations, local providers of health services can be able to respond effectively. Properly planned services will be needed in order to effectively control the epidemic and reverse the trend of TB in England. Effectively controlling TB can bring about significant short-term and long-standing financial savings and SHAs/PCTs will have to deal with these challenges with no extra central funding, giving TB the priority it should be given and appreciating the cost-effectiveness of TB treatment and well-organised services.
These approaches will depend on the responsibility of public health, health protection and clinical services staff and their full commitment to the commissioning process. On the other hand, because TB calls for co-ordinated efforts between hospitals, labs, primary/other care services, commissioners should not just delegate all the responsibility to their local health protection unit colleagues. To ensure success, health-protection and local clinicians should cooperate fully; they must follow the recognised guidelines; ensure patients are comprehensively assessed, i.e. physically, psychosocially and financially.
It is crucial to have a patient-centred management method, especially considering the length the treatments take. However, there should be a patient-centred method and protection of other community members. The other thing is that commissioners should also consider developing refined working relationships with local authority, NGO sector and volunteering partners. Also, commissioners should know that, in general practice, TB diagnoses are often never confirmed and that TB diagnoses and treatments would best be offered by specialist services. For timely TB identification and quick exclusion of persons without TB, the commissioned services should never include managing suspected TB (CMO, 2007).
Although the TB incidence and mortality rates in England are decreasing, due to health promotion programmes, there still exist considerable disparities in terms of levels of deprivation and screening uptake. Intensifying public health campaigns can help decrease TB by focusing on known risk factors. However, due to the clustering together of risks, it might prove hard to determine each factor’s individual contribution at a population’s level.
However, because population risk factors for cervical cancer vary across England, it is difficult to identify the most at risk group. In the future, other data, such as that on sexually transmitted infections, needs to be reported at a level of detail so that screening programmes can be effectively targeted at population at an increased risk of cervical cancer.
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