The London Chest TB Team 3 TB nurse specialists, 3 TB nurses Outreach worker Admin support Advocates Bengali & Somali TB consultant Specialist Paediactric team at RLH
Case finding DIRECT REFERRALS TO SERVICE Following ref (A&E, GP, in-patients) Result of contact tracing Mobile X-Ray Unit (MXU) London Pathway Drug treatment agencies Homeless hostels PULM Nurse triage CXR, bloods, sputum, booked medical Sometimes same day Non-pulm Booked into next most appropriate slot.
Case management Risk assessment drugs/alcohol work/benefits, immigration status homeless/tenancy stability mental health Should only see Dr x3 times in 6 months Nurse case manages Resupplies medication 2/52 LFT side effect monitoring and management monthly clinic appointments DOT data collection
Contact tracing Stone in pond principle Min 5, aim for 10 for PULM CONTACTS Household, place of work, worship, social Mantoux for <16 yrs old Subjective, non-specific but quick Prev BCG > 15 mm - No BCG >6mm Positive > referred paeds with IGRA IGRA > 16 35 If positive > offered chemoprophlaxis >35 CXR x2
Paediatric Specialist service with joint clinic every other Weds at Royal London 15 active cases per year 25% pulmonary Contacts of index Aiming for family clinic Lead - Anna Riddel Refer via TB office
Referrals Pulmonary refer straight away Nurse triage sometimes same day If possible CXR, sputum for AFB s, bloods Lymph node referral TB service & ENT One Stop Shop ENT referral
What we can t do Mantoux testing Only done in context of contact tracing Not to be used diagnostically if you think they have TB, refer as such BCG vaccination Only done for contacts (unvaccinated, Mantoux negative, <35yrs)
Referral pathway Refer directly (not Choose and Book) 0208 983 2441 0208 983 2292 (fax) TBTeamenquires@bartshealth.nhs.uk Website being updated Mon-Fri, (9-1700)
The 10 % Enhanced case finding and case management in hard to each groups
Hard to reach groups Difficulty in recognize the clinical onset of TB access diagnostic and treatment services self-administer treatment attend regular appointments for clinical follow-up Substance misuse, homelessness, prison, subgroups of migrants The numbers Roughly 10-15% of our cases
Our strategy Multi disciplinary Social care team component Outreach into community Awareness raising Active case finding Identify high risk patients and actively find and engage with patients Enhanced case management DOT Use of other agencies
DOT Directly Observed Therapy x3 per week for fully sensitive cases daily for drug resistance Home/community/pharmacy/clinic based Improves adherence Pharmacy DOT 8 patients used service All completed treatment High levels of patient/pharmacist/nursing satisfaction Cost effective 5 per pharm visit v s 1-2hrs nurses time 6 months Rx = 78 DOT visits
Drug resistance Fully sensitive TB 200-300 Multi drug resistant MDR TB 6,500-40,000 Mean 17,000 Extensively drug resistant - XDR TB 35-68% cure rate (+/- surgery) Isoniazid resistant outbreak White/Black, male, UK born, Prison, hard drug use TH demographic IVDU ageing cohort Dock st/homeless hostels/prison
Case study 33 yr old, 19 weeks pregnant admitted to Royal London LRTI Hard drug use, alcohol, CSW Pulmonary Isoniazid resistant TB 58 year old History hard drug use Methadone, alcohol Depression AF, HF, DM Culture pos TB - Multi-Agency working - TH Floating Support, TV Edwards Solic, HPA/PH/PCT/HE1/TH Housing/Soc Services - One death, one completed 9 months Rx
Changing trends? Number of new cases per clinic
Changing trends? 30% % of patients with one or more risk factor for poor adherence 25% 20% 15% 10% Tower Hamlets Waltham Forest Newham Hackney 5% 0% 2009 2010 2011 2012
Challenges Convincing CCG s that there is a problem getting funding and maintaining it Latent TB Neglected assumption that will fail Rx drug resistance, adherence Better use of piggy back with methadone Rx HCV/HBV ^ screening & Rx, better collaboration between providers Money service reviews
Tower Hamlets TB Team Refer directly (not Choose and Book) 0208 983 2441 0208 983 2292 (fax) Tbteamenquires@bartshealth.nhs.uk Website being updated Mon-Fri, (9-1700)