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TB: The Coventry perspective. Dr Thekli Gee University Hospitals Coventry & Warwickshire. Outline. TB in Coventry: Epidemiology Resources New diagnostic approaches. Epidemiology. Occurrence. Nearly a third of the world’s population is infected with TB

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Slide1 l.jpg

TB: The Coventry perspective

Dr Thekli Gee

University Hospitals Coventry & Warwickshire


Outline l.jpg
Outline

TB in Coventry:

  • Epidemiology

  • Resources

  • New diagnostic approaches



Occurrence l.jpg
Occurrence

  • Nearly a third of the world’s population is infected with TB

  • TB kills almost 3 million people per year.


Tuberculosis notifications england wales 1913 2006 l.jpg

chemotherapy

BCG vaccination

Tuberculosis notifications England & Wales 1913 - 2006

Source: Statutory Notifications of Infectious Diseases (NOIDs)


Coventry tb rate by year 1999 2006 l.jpg

Coventry

2007

Rate per 100,000 population

35

30

25

20

Coventry PCT

West Midlands

rate

England & Wales

Linear (Coventry PCT)

15

10

5

0

1999

2000

2001

2002

2003

2004

2005

2006

Coventry TB rate by year 1999-2006


Tuberculosis case reports and rates by region country england wales and northern ireland 2006 l.jpg

Coventry

2007

Tuberculosis case reports and rates by region/country, England, Wales and Northern Ireland, 2006




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Why Is TB Increasing?

Multiple contributing factors:

  • Homelessness

  • Intravenous drug use

  • HIV infection

  • Drug-resistant strains of TB

  • Reduced TB control and treatment resources

  • Immigration from high TB prevalence areas


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Tuberculosis case reports by place of birth and ethnic group, England, Wales and Northern Ireland, 2001 - 2006


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Changing populations group, England, Wales and Northern Ireland, 2001 - 2006

  • Coventry City council

    • 1215 asylum seekers on housing list

  • Coventry refugee centre

    • 8000 asylum seekers & refugees registered

    • 1571 registered at Meridian Health Centre


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Afghanistan group, England, Wales and Northern Ireland, 2001 - 2006

Iraq

Iran

Burundi

Democratic Republic of Congo

Ethiopia

Eritrea

Somalia

Sudan

Zimbabwe

Changing populations


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Resources group, England, Wales and Northern Ireland, 2001 - 2006

Increasing numbers of TB cases

Increased demand on TB services


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Impact on resources group, England, Wales and Northern Ireland, 2001 - 2006

  • Hospital & community TB services

    • TB clinic

    • TB nurse time

  • Infection control

    • Isolation facilities

    • TB incidents

  • Occupational health

    • Pre-employment screening

    • HCW contacts

  • Laboratory services


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Impact on resources group, England, Wales and Northern Ireland, 2001 - 2006

  • Hospital & community TB services

    • TB clinic

    • TB nurse time

  • Infection control

    • Isolation facilities

    • TB incidents

  • Occupational health

    • Pre-employment screening

    • HCW contacts

  • Laboratory services


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23 incidents in since January 2007 group, England, Wales and Northern Ireland, 2001 - 2006

18 Patients

Not isolated early enough / at all during admission

Mostly medical wards

2 Cardiothoracic ward

1 haematology day unit

5 Health care workers

3 qualified nurses

1 nursing student

Ward host

TB incidents at UHCW NHS Trust


Impact on resources18 l.jpg

2007 group, England, Wales and Northern Ireland, 2001 - 2006

Impact on resources

  • Hospital & community TB services

    • TB clinic

    • TB nurse time

  • Infection control

    • TB incidents

    • Isolation facilities

  • Occupational health

    • Pre-employment screening

    • Annual reminders

    • HCW contacts

  • Laboratory services


Impact on resources19 l.jpg

2006 group, England, Wales and Northern Ireland, 2001 - 2006

Impact on resources

  • Hospital & community TB services

    • TB clinic

    • TB nurse time

  • Infection control

    • TB incidents

    • Isolation facilities

  • Occupational health

    • Pre-employment screening

    • Annual reminders

    • HCW contacts

  • Laboratory services


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2004 group, England, Wales and Northern Ireland, 2001 - 2006

2007

2006

2007

TB national strategy


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Controlling TB: group, England, Wales and Northern Ireland, 2001 - 2006

  • Diagnosing primary cases

  • Treating active disease

  • Preventing transmission

  • Identifying secondary cases

  • Controlling latent infection


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Current diagnostic test for latent TB group, England, Wales and Northern Ireland, 2001 - 2006

  • Diagnosis of latent TB relies on the tuberculin skin test.

  • 101 years old

    • Developed 1907 by Charles Mantoux

  • The oldest diagnostic test still in use.

The skin test enters its 6th decade of use. (Canada 1957)


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48-72 hours later group, England, Wales and Northern Ireland, 2001 - 2006

  • No longer available

Tuberculin skin tests

  • Mantoux test

  • Heaf test


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Tuberculin skin tests group, England, Wales and Northern Ireland, 2001 - 2006

  • Poor specificity:

    • antigenic cross-reactivity

      • BCG

      • environmental mycobacteria

  • Poor sensitivity:

    • 75-90% in active disease

      • lower in disseminated TB and HIV infection

  • Need for return visit

    • 50% DNA rate

  • Operator variability

    • inoculation & reading

  • Painful inflammation & scarring

  • Boosting effect if used repeatedly


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New approaches group, England, Wales and Northern Ireland, 2001 - 2006


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TB Interferon- group, England, Wales and Northern Ireland, 2001 - 2006g release assays(TIGRA)

  • Principle of TIGRA

    • Detect IFN-g produced by effector T-cells that recognise M. tuberculosis proteins

      ESAT-6 & CFP-10

      • Absent in BCG

      • Absent in most non-tuberculous Mycobacteria

        • Exceptions: M. marinum, M. kansasii


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T-Spot.TB® group, England, Wales and Northern Ireland, 2001 - 2006

Detects individual effector T-cells that produce IFN-g in response to M.tuberculosis antigens

Enzyme linked immunospot technique (ELISPOT).

QuantiFERON Gold®

Measures IFN-g in the supernatant of the antigen stimulated cells

Enzyme linked immunosorbant assay technique (ELISA)

Two Tests available


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Method - group, England, Wales and Northern Ireland, 2001 - 2006T-Spot.TB®

  • Specimens must be processed within 8 hours of venepuncture


Elispot l.jpg
ELISPOT group, England, Wales and Northern Ireland, 2001 - 2006

-ve

+ve


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ELISPOT Reader group, England, Wales and Northern Ireland, 2001 - 2006


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Role of TIGRAs group, England, Wales and Northern Ireland, 2001 - 2006

  • Detection of latent TB:

    • TB contacts

    • Healthcare workers

      • New employment screens

      • Following TB exposure incidents

    • Before starting immunosuppression

      • anti-TNF-α drugs e.g infliximab

      • Pre-transplantation

  • Detection of active extra-pulmonary TB

    • If difficult to diagnose by conventional methods

    • Closely competing diagnoses e.g. Sarcoid vs TB


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Contact tracing: group, England, Wales and Northern Ireland, 2001 - 2006When to use a TIGRA

  • NICE:

    • Following positive Mantoux test

      • Most cost effective

      • May miss some cases

  • CDC

    • In place of Mantoux test

      • Shifts burden of work from TB nurses to lab


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Business case group, England, Wales and Northern Ireland, 2001 - 2006

  • Laboratory service

    • 5 day to 6 day service

    • Warwickshire wide (Network)

  • TIGRA

    • Tspot.TB

    • Microbiology / Immunology


Summary l.jpg
Summary group, England, Wales and Northern Ireland, 2001 - 2006

  • TB increasing in Coventry

  • Increased demand on resources

  • New approaches considered

    • e.g. TIGRAs


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