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Public Health England plans national primary care TB screening programme

Public health officials are planning a nationally co-ordinated programme of targeted TB screening in primary care, to combat rising infection rates in some urban areas of England.

Experts at Public Health England (PHE) claim the best way to ‘reverse the tide’ is for GP practices to start screening for latent TB in at-risk groups, particularly immigrants from areas with a high incidence of the disease.

PHE hopes to submit the plans to the National Screening Committee ‘very soon’ for evaluation and a decision on whether to adopt the programme. The GPC welcomed the move, but warned ministers’ plans to limit migrants’ access to the NHS could exacerbate problems detecting the disease.

There were 8,571 cases of TB in the UK in 2012, down slightly from 8,963 in 2011. But the number is likely to climb again – and surpass the rate in the United States by 2014 – if overall trends continue, PHE says.

Three-quarters of cases are among immigrants but the incidence is also high among disadvantaged and vulnerable communities in inner cities; some London boroughs have rates higher than parts of sub-Saharan Africa.

Although immigrants undergo screening for active TB infection before entering the UK, PHE says nearly half of cases among immigrants occur within five years of arrival, suggesting they have latent TB infection contracted overseas.

Current proactive TB screening programmes commmissioned by local authorities, such as ‘Find and Treat’, must be better co-ordinated, according to the PHE researchers, who say services are highly variable and not always following the needs of local populations.

They argue a ‘pragmatic solution’ is to have ‘a quality-assured primary-care based screening programme’. A previous pilot study showed targeted screening and treatment for latent TB among immigrants from regions with a high TB incidence of more than 150 cases per 100,000 would be cost-effective in primary care, at £20,818 for each case prevented.

The proposals are laid out in a comment article in The Lancet, co-authored by Dr Dominik Zenner from University College London.

Dr Zenner, who heads up PHE’s TB screening unit, told Pulse a national programme would ensure areas with the highest incidences of TB could prioritise the screening strategy.

‘Areas such as London boroughs with a very high incidence of TB have many competing commissioning priorities – ironically meaning you’re less likely to have a programme for TB screening in a high-incidence borough because there are so many competing priorities compared with a nice, leafy area,’ he said.

‘Having a national programme would lead to a co-ordinated approach with an agreed algorithm and a central pot [of money] ensuring the areas with the greatest need can also prioritise the screening.’

Dr Zenner said PHE would be submitting the proposal ‘very soon’ to the National Screening Committee, as part of a national TB strategy being developed with the NHS, the British Thoracic Society and charities such as TB Alert.

He said once the NSC made a decision the timing of a new programme would also depend partly on when the national strategy is launched.

Dr Zenner said there were ‘a number of approaches’ to screening on the table, but these would likely include testing new registrants and using primary care data to flag up at risk groups for calling in.

Dr Richard Vautrey, GPC deputy chair and a GP in Leeds, said: ‘This is clearly an important issue in many parts of the country and we would agree that there needs to be more investment in to this area of work.’

But he added: ‘We would be particularly concerned that the Government’s proposals to limit the access of migrants to NHS care may make the problem of detecting and treating TB worse.’

Dr Michelle Drage, chief executive of Londonwide LMCs, said: ‘TB is a disease which should not exist in the world’s greatest city. Its exponential rise over the last decade is a direct result of the dramatic increase in social deprivation London’s GPs are seeing on a day to day basis.’

‘It shouldn’t be so, and there is an urgent public health imperative to prevent as well as treat.  We are supportive of a properly resourced TB screening programme in London and would welcome discussions on how this can be best delivered.’

Lancet 2013; available online 18 October

This article was updated on 18 October to clarify that Public Health England hopes to submit its plans to the National Screening Committee ‘very soon’.