Tuberculosis in Ealing 1. Overview Appendix 2. What is TB Tuberculosis, or TB, is a disease caused by a germ (Mycobacterium tuberculosis). TB usually.

Tuberculosis in Ealing1. Overview

•Appendix 2

What is TB• Tuberculosis, or TB, is a disease caused by a germ

(Mycobacterium tuberculosis).

• TB usually affects the lungs, but can affect other parts of the body, such as the lymph nodes (glands), the bones and (rarely) the brain.

• Infection with the TB germ may not develop into TB disease.

Symptoms• Fever• Night sweats • Persistent cough • Losing weight• Losing appetite • Blood in your sputum (phlegm or spit) at any time

Treatment• Standard treatment for TB:

– 4 drugs for 2 months– 2 drugs for 4 months

• Non standard treatment normally represents – either resistance to the bacteria or – reaction to the medication

Prevention and control of TB

1. Treatment of TB patients2. Contact tracing (screening people who have been in

contact with a known TB patient)3. Providing treatment for people with TB infection but not

disease4. Education and Health Promotion5. BCG vaccination

Epidemiology

Number of people notified with TB in Ealing

Local AuthorityNotifications 2005 (rate/100,000)

Notifications 2006 (rate/100,000)

Notifications2007(rate/100,000)

Percentage change betw. 2006-2007

Brent 287 (107.18) 238 (88.88) 274 (102.33) +15.13

Ealing 242 (79.34) 237 (77.70) 246 (80.65) +3.80

Hammersmith & Fulham

90 (51.66) 81 (46.50) 69 (39.61) -14.81

Harrow 133 (63.11) 124 (58.84) 121 (57.42) -2.42

Hillingdon 143 (57.74) 126 (50.88) 127 (51.28) +0.79

Hounslow 169 (79.38) 140 (65.76) 139 (65.29) -0.71

Kensington & Chelsea

48 (27.53) 53 (30.40) 32 (18.35) -39.62

Westminster 98 (44.14) 85 (38.29) 88 (39.64) +3.53

Sector Total 1210 (66.68) 1084 (59.74) 1096 (60.40) +1.11

Ethnicity NW London (=Ealing)

0

10

20

30

40

50

60

70

80

90

100

Ban

glad

eshi

Bla

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Bla

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Car

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Bla

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Chi

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Indi

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Oth

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Pak

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Unk

now

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Whi

te

2002

2003

2004

2005

2006

Age and GenderTB Notifications by Age and Sex (2007)

0

20

40

60

80

100

120

140

160

180

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

Age Group

No

. o

f n

oti

ficati

on

s

male

female

Year of EntryYear of Entry for Non UK-born TB cases by PCT (2007)

0

50

100

150

200

250

300

Brent Ealing Hammersmithand Fulham

Harrow Hillingdon Hounslow Kensingtonand Chelsea

Westminster

PCT

No

. o

f n

oti

fic

ati

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s

Not stated

Within 5 Years

6-10 Years

10+

Drug resistance in Ealing

YearIsoniazid resistance

(UK rate)Rifampicin Resistance

(UK rate)MDR TB

(UK rate)

2002 1.3% (6.9%) 0.0% (1.2%) 0.0% (1.0%)

2003 1.4% (6.9%) 1.4% (1.8%) 2.1% (1.3%)

2004 2.6% (6.8%) 0.0% (1.5%) 1.5% (1.1%)

2005 4.0% (7.0%) 0.0% (1.4%) 1.1% (1.0%)

2006 4.4% (7.0%) 0.0% (??%) 1.6% (1.1%)

Barriers to seeking treatment

• Culture• Fear / Shame• Stigma• Knowledge• Service (GP, EHT)

Chest Clinicno. referred less than 2 weeks (%)

no. referred between 2 - 4 weeks (%)

no. referred over 4 weeks (%)

Chelsea & West. 12 (75) 3 (19) 1 (6)

Charing Cross 13 (45) 3 (10) 13 (45)

Ealing 8 (21) 6 (16) 24 (63)

Hammersmith 4 (80) 1 (20) 0 (0)

Hillingdon  0 (0) 2 (50) 2 (50)

Northwick Park 64 (80) 3 (4) 13 (16)

St. Mary’s 27 (66) 4 (10) 10 (24)

West Middlesex 18 (56) 4 (13) 10 (31)

Willesden 18 (75) 2 (8) 4 (17)

Total 164 (61) 28 (10) 77 (29)

Delay between first contact with a health professional and referral to a TB clinic*

* NWL HPU (2007) Patient delay audit report

Reasons• Waiting for results from their investigations. (What the

investigations were was not specified)

• TB not being suspected or being misdiagnosed by the GP.

Delay between referral to TB clinic and first appointment at the TB clinic Chest Clinic no. seen less than 2 weeks (%)

no. seen between 2 - 4 weeks (%)

no. seen over 4 weeks (%)

Chelsea & West. 12 (71) 2 (12) 3 (18)

Charing Cross 24 (73) 4 (12) 5 (15)

Ealing 33 (70) 6 (13) 8 (17)

Hammersmith 3 (60) 1 (20) 1 (20)

Hillingdon 20 (91) 2 (9) 0 (0)

Northwick Park 92 (97) 1 (1) 2 (2)

St. Mary’s 33 (85) 2 (5) 4 (10)

West Middlesex 17 (53) 5 (16) 10 (31)

Willesden 21 (60) 11 (31) 3 (9)

Total 255 (78) 34 (11) 36 (11)

* NWL HPU (2007) Patient delay audit report

Reasons

• Waiting for investigation results

• Patient not being able to attend an earlier appointment

Other work

• Close working relationship with NW London Sector

• Performance management from SHA London

• Good communication with other TB clinics across London

• Find and Treat team

• Working with Crisis and other homeless / drug and alcohol agencies

Action taken• Health promotion activities in the Somalian community

(Community advocate worker)• School assemblies• Mobile X-ray Unit screening in Ealing (SHA London)• Annual activities on World TB day (23 March yearly) – (TB

team)• ‘Advertising’ – TB alert (PCT)• Streamlining the TB Service (TB Service, PCT)• Increase of staff in 2008 (PCT)• LAA targets (PCT)

Staffing

• 1 TB Associate Specialist – doctor (three sessions per week)• 5 WTE TB Specialist Nurses• 1 Administrator support worker (full time)• 1 Somalian Outreach Worker

Tuberculosis in Ealing-

2. Housing

What is TB• Tuberculosis, or TB, is a disease caused by a germ

(Mycobacterium tuberculosis).

• TB usually affects the lungs, but can affect other parts of the body, such as the lymph nodes (glands), the bones and (rarely) the brain.

• Infection with the TB germ may not develop into TB disease.

Symptoms• Fever• Night sweats • Persistent cough • Losing weight• Losing appetite • Blood in your sputum (phlegm or spit) at any time

Infection risk• Infectiousness of person with TB

• Environment in which exposure occurred

• Duration of exposure

• Virulence of the organism

NICE• Close contacts of infectious cases• Those who have lived in, travel to or receive visitors from places where

TB is still very common• Those who live in ethnic minority communities originating from places

where TB is very common• Those with immune systems weakened by HIV infection or other medical

problems• The very young and the elderly, as their immune systems are less

robust

• Those with chronic poor health and nutrition because of lifestyle problems such as homelessness, drug abuse or alcoholism

• Those living in poor or crowded housing conditions, including those living in hostels.

Impact of housingCompletion of TB treatment and stable accommodation

Improved completion when stable accommodation

Improved completion = less risk of TB resistant strain

Recommendation from NICEUseful adherence strategies include:• assisting or advising patients regarding links to

social security benefits and housing/social services.

Conclusion• Housing and TB are linked

– Overcrowding increases the risk of acquiring TB disease and TB infection

– Stable housing improved adherence to TB treatment

– Improved adherence = less risk of resistant strain of TB

Experiences from Ealing TB Service

• People had their tenancy agreement terminated after the landlord found out the patient had TB (rare instance)

• Mainly single men with TB living in hostel accommodation and being moved at very short notice (also they do not appear to qualify for housing)

• Mother and x amount of children living in one room (=overcrowding)

• Housing department at Ealing does not give priority or support to patients affected by TB (service issue)

• Where patients were referred, they were ‘forced’ to relocate to somewhere else, but not in Ealing (??)

• No communication from Housing department to TB Service (service issue)

Experiences from Ealing TB Service

Tuberculosis in Ealing

3. Stigma and Interagency working

• Marriage breakup

• Not being able to marry

• Risk of dying because of TB treatment

• TB treatment changes your appearance/looks

• Refuse to sharing food/utensils

• Not realising TB is curable

Stigma – result

• Avoid seeking health care

• Deny the illness

• Isolation

• Poverty

• Family network disappearing

• Difficulty in contact tracing

Stigma – result

TB sufferer says:“When you have TB, people will laugh at you and say you have HIV. That is why we wouldn’t want people to know. But the best thing is to let people know so that people can help you and you avoid transmitting it to many people.”

Link with HIV:TB-HIV stigma leads to TB patients being socially shunned, physically isolated and considered sexually ‘immoral’

• the body of a woman who died from TB in India was kept in a car for five days by her employer

ConclusionTB can make a person socially isolated (or the feeling of being

socially isolated)

PS Examples are from international literature. Not all may apply in Ealing.

PPS Most of the stigma issues apply to South-East Asiancommunities (Indian, Bangladeshi etc.) and African communities (Somalian)

• TB Alert (UK’s national TB charity)

• North West London HPU (network and TB outbreak management)

• Schools (assemblies, health promotion)

• Voluntary sector (health promotion, raising awareness)

Interagency working

• Local businesses (Money exchange)

• Café (Khat chewing)

• Mosque (after prayers on Friday)

• Gantaar (Assistance / Support agency)

• RAAD (Refugee support)

• Somalian Children Support Group (after school kids club)

Interagency working

Our staff (advocacy workers)

Ahmed YassinMohammed Ahmed