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Tackling TB in the South East
1. Tackling TB in the South East
14 June 2016
Dr Bernadette Purcell
CCDC and TB lead
2. Key discussion points
Background: key drivers
Local TB Control Board (South England)
Proposed delivery plan for Collaborative TB strategy
TB networks and cohort review
PHE role – examples of local cases
2 TB Update: Tackling TB in the South East
3. Why TB and Why now?
1. TB incidence in England was rising…
3 TB Update: Tackling TB in the South East
4. 4 TB Update: Tackling TB in the South East
2. TB is unequally distributed
5. Rate of TB by deprivation , England 2014
5 TB Update: Tackling TB in the South East
6. TB case notifications and rates by place of birth, England 2000-2014
6 TB Update: Tackling TB in the South East
8. TACKLING DRUG-RESISTANT INFECTIONS GLOBALLY :FINAL REPORT AND
RECOMMENDATIONSTHE REVIEW ONANTIMICROBIAL RESISTANCE
JIM O’NEILL MAY 2016
8 TB Update: Tackling TB in the South East
10. TBCB - South
Chaired by Dr Jenny Harries OBE – RD South of England - PHE
Good representation from – DDs of PHE (South), DPHs (SE&SW), Lead
CCGs representatives, TB clinicians, lead nurses, paediatrician,
microbiologist, CCDCs, and national TB leads.
Agreed – ToRs and strategic plan
Meets quarterly and provides;
an over-arching support to six local TB networks in planning, overseeing,
supporting and monitoring all aspects of local TB control.
an accountability structure for TB control supported by the National TB
office.
10 TB Update: Tackling TB in the South East
11. SE network
Thames Valley
Wessex
Surrey & Sussex
Kent
11
SW networks
Devon, Cornwall &
Somerset
Bristol, North
Somerset, South Glos
Bath & North East
Somerset,
Gloucestershire,
Swindon and Wiltshire
PHE TB Co-ordination Board
TB Strategy time limited
working groups
TB Delivery Board
Chaired by Head of TB Strategy Implementation
PHE National Executive
National TB Programme Board
Co-chaired by PHE and NHS England director
NHS England National Executive
SE TB
consultant lead
SW TB
consultant lead
South of England TBCB
Chaired by Regional Director,
PHE South
Structure & Governance
of SoE TBCB
SW TB
networks
SE TB
networks
12. Special features of South TBCB
1- Large geographical patch – 49 CCGs and multiple LAs
• South has the highest number of TB cases of any region outside London
• Some key hotspots such as Slough, Reading, Oxfordshire and Bristol.
• Raising TB as a priority for low prevalence areas/CCGs and hospitals.
2- Unique epidemiology (2014)
• Over 50% of the cases were pulmonary
• 60% of SW and 55% of SE cases were among males.
• Majority of the cases were among young population 30-40 years (mobile).
• 47% of SW and 24% of SE cases were from white ethnic background.
•
12 TB Update: Tackling TB in the South East
2011-2013
13. Our Delivery Plan
SE
………………………………………………………………………….
SW
1. Surrey and Sussex
2. Kent
3. Thames Valley
4. Wessex
1. Devon, Cornwall &
Somerset
2. Bristol, North
Somerset, South
Glos
3. Bath & North East
Somerset,
Gloucestershire,
Swindon and
Wiltshire
HNA
HNA
HNA
HNA
HNA
HNA
HNA
Gaps,
needs,
strengths
identified
Collaborative
TB strategy
with 10
recommendat
ions
Collaborative
TB strategy
with 10
recommendat
ions
+
+
=
=
1. local Action
/Priority
2.local Action
/Priority
3. local Action
/Priority
1. local Action
/Priority
2.local Action
/Priority
3. local Action
/Priority
Quarterly progress
reports for the
board
Quarterly
progress reports
for the board
Formation of Task
and finish groups
for large action
requiring collective
work btw networks
+ Quarterly progress
reports for the
national teams as
per their matrixes
+
+
Quarterly
progress reports
for the national
teams as per
their matrixes
April/May 2016 May/June 2016
+
Formation of Task
and finish groups
for large action
requiring collective
work btw networks
June/July 2016
Ongoing activities - Cohort Review + Specific audits at regional or local level + Internal & External
communications
Gaps,
needs,
strengths
identified
Localriskregistertoidentifyanyrisksand
issues
TB Update: Tackling TB in the South East13
14. Progress of the board so far;
TB Update: Tackling TB in the South East
Bristol CCG
7 CCGs met eligibility for LTB
screening programme
Southampton -
CCG
West Sussex
CrawleyCCG
Combined Reading
and Slough CCGs
Oxfordshire
CCG
North East Hampshire
and Famham CCG
HNA – Good progress and
expected to complete with
recommendations in next 6-8
weeks
Collaboration with national
delivery team and participation
on national T&F Groups
Established Cohort Reviews
and network meetings
Bids approved, funds received
and screening started in three
areas already
Building strong relationships
with health and social care
partners (LA, CCG, 2ndary
care and 3rd sector
organisations)
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15. Plans for coming months
• Development of TB indicators for monitoring local progress
• Development of TB indicators for monitoring TBCB’s progress
• Quarterly monitoring/reporting of these indicators at both network/TBCB
• Complete Health Needs Assessments
• Development of T&FGs based on specific gaps/themes identified via HNA
• TBCB to support local networks with any issues reported by them
• Improve communication, co-ordination, management of information.s- C
• Cross- cutting areas: e.g. prisons and detention centres, homelessness,
asylum- seekers
• CCG, Primary care and patient engagement
• Ideas/ suggestions?
• ross- cutting areas: e.g. prisons and detention
centres, homelessness, asylum seekers15 TB Update: Tackling TB in the South East
16. TB networks and cohort reviews
• Four well established across the South East
• Cohort reviews running 3-6 monthly since 2012
• Guest chair, external speakers, CPD
• Improving measurable indicators (treatment
completion, losses to follow up, HIV testing,
contact screening)
• Peer support, mutual aid, morale and career
development for TB nurses
• Quarterly review of TB Clusters across South East
TB Update: Tackling TB in the South
East
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17. Managing TB situations: example TB screening among
homeless in Hastings after a TB related death, 2015
112 people were assessed and x-rayed
5 with abnormal CXRs
45 IGRA tested
3 positive t- spot
Keep under surveillance
TB cluster strain
Good feedback from those screened- raised
awareness
Neighbourhood police fully engaged.
TB Update: Tackling TB in the South
East
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18. Managing challenging cases…
• Non- compliant,
poor discharge,
intentionally
homeless,
behavioural
issues +++
• Multiple
agencies
involved over 15
months
• 10 Part 2A
Orders in total
(each order costs
£1k-£6k- LA
funded
TB Update: Tackling TB in the South
East
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19. It’s a team effort…
NHS TB nurses and clinicians, microbiologists, network members
PHE SE TB network leads (Muhammad Abid, Clare Humphreys,
Anand Fernandes, Karthik Paranthaman, Angeline Walker) HP
nurses (Sara Blake, Jen Duffy, Ann Black, Alexis Stevens) surveillance
and information officers (Nigel Bainton, Nigel Freeman, Sue White,
David van Santen,) Kevin Carroll, Trish Mannes
TBCB members, inc CCG leads, primary care, 3rd sector
TB Update: Tackling TB in the South
East
19
Since the 1980s -steady rise in cases of active TB –
Now familiar graph- England came to have one of the highest TB rates in Western Europe. The incidence of TB in England - four times higher than that of the US –) predicted if current trends continue, England would have more TB cases than in the whole of the US put together. London–accounting for almost 40% of all cases.
TB unequally distributed- certain groups disproportionally affected-
- new migrants,
-those with social risk factors
Therefore if we want to tackle inequalities in health- TB is a good place to start..
nearly one in ten TB cases in 2014 had at least one social risk factor, and there has been no reduction in the number of cases with social risk factors over the past five years
o a higher proportion of those with social risk factors have drug resistant TB and worse TB outcomes, which highlights the added importance of tackling TB in this group, including through targeted outreach services
the past three years there has been a year on year decline in the number of TB cases in England, down to 6,520 in 2014, a rate of 12.0 per 100,000
mainly due to a reduction in cases in the non-UK born population, which make up nearly three-quarters of all TB cases in England
o reflect recent declines in the number of migrants from high TB burden countries and the impact of pre-entry TB screening
o the majority of non-UK born cases (86%) are now notified more than two years after entering the UK, and are likely to be due to reactivation of latent TB infection
o there has been no downward trend in the incidence of TB in the UK born population in the past decade,
o 15% of cases in the UK born population had at least one social risk factor,
The most vulnerable- rates are not decreasing over last decade- e/g/ insecure or overcrowding- substance misuse/ alcohol issues- more likely to become infected- more likely to develop disease and complications- less easy to complete treatment- therefore more likely to have complications – be infectious for longer- also transmit the infection
We are concerned to reduce the possibility of multi-drug resistant TB from taking hold- much harder to treat- and worse outcomes for patients and communities.
Estimated 3 billion of the worlds population exposed to TB- so large pool of latent infection exists..
The final recommendations of the Review on Antimicrobial Resistance (AMR) led by Lord Jim O’Neill and commissioned by David Cameron were released last week, warning that AMR infections such as drug-resistant tuberculosis will kill 10 million people annually without an urgent expansion of new resources and funds.
The report highlights drug resistant tuberculosis as a 'cornerstone of the global AMR challenge', highlighting that one-quarter of the potential ten million annual AMR deaths by 2050 outlined in the report could be caused by drug-resistant tuberculosis without urgent action, which equates to one MDR-TB death every 12 seconds.
PHE’s Collaborative TB Strategy with NHS .
Context- WHO stop TB targets (WHO launched the “Global Plan to End TB 2016-2020: The Paradigm Shift” please find it at: http://www.stoptb.org/global/plan/)
Exciting , new, first time for England- launched in parliament last year with full support of NHSE
Ambitious: Aims to Bring down the incidence year on year, tackle inequalities in health and (eventually eliminate TB as public health problem)
10 point action plan- from new diagnostics- to better access to services
Key focus on vulnerable- underserved-those who need enhanced management to get through and complete their treatment.
7 boards for TB control- monitor progress across every area of the country.
It was evident that the people being assessed were co-operative and appreciative. This was also a very good opportunity to further raise awareness and give information about TB, and in this both the TB nurse and the ‘peer educators’ from Find and Treat were invaluable.