After a long period when
tuberculosis (TB) was considered
to be an ‘old’ disease, it has
started to re-emerge as a threat
to public health, reflecting
another facet of sustainability:
that creating a sustainable reduction in a
communicable disease has to be maintained.
The tuberculosis rate in Lothian is rising. From
2004-2006 there were 74 cases a year compared
with 57 between 2000-2003 (see Table 1 for
annual figures). The incidence rate between 2004
-2006 is 9.3 per 100,000 compared with 7.4 per
100,000 between 2000-2003.
Table 1: TB notifications for Scotland and
Lothian NHS Board, 1997-2006
||Lothian NHS Board
Source: Statutory Notification of Infectious Disease scheme, ISD
The tuberculosis rate in Scotland has been
static since 2000 at just under 8 per 100,000,
although other parts of the UK, notably London,
have seen dramatic increases in the incidence
of TB over the same period. The current rate in
London is 45 per 100,000 (2006) and the overall
UK rate is 14 per 100,000. To tackle this increase
an action plan from the Chief Medical Officer of
England was produced in 2004, although there is
not yet an equivalent in Scotland.
Between 1999 -2000 31% of TB cases in Lothian
were born outside the UK, by 2004 nearly 50%
of cases were in foreign born. Across the UK in
2006, 70% of cases were non UK born and 80%
of these had entered the UK two or more years
before their diagnosis with TB. Within Lothian, in
addition to being non UK born, alcohol misuse
and homelessness are important risk factors for
The TB incidence rates by local area in
Lothian are shown in Table 2. The incidence of
TB is highest in the north east area of Edinburgh.
However, the south west and south east areas of
the city also have higher than average rates. Mid,
East and West Lothian have lower incidence rates
than the Lothian average.
Table 2: Rate of TB Notifications per 100,000 of population in Lothian
||Average Annual Rate – 2004-2006
| North East
| North West
| South Central
| South East
| South West
Projected demand for TB public health services in Lothian
Over the next two decades it is predicted that there
will be a net rise in the size of the population in
Lothian to 875,000 in 2024 and a 50% rise in the
size of the population aged 65 years and over. This
change is also likely to increase the number of
cases of TB as it is known that older people who
grew up in an era when TB was more common,
were exposed to TB during their childhood or in
early adult life. They then go on to develop active
TB as they get older.
The number of people arriving from countries
with a high incidence of TB, for example, from
Eastern Europe (especially the former Soviet Union
countries) and sub-Saharan Africa is also predicted
to increase due to economic migration to the UK.
Sustained control of TB in Lothian
Creating a sustainable approach to the control of
TB in a population depends on:
- Early diagnosis – which requires both public
and professional awareness of TB;
- Effective treatment – standard treatment lasts
six months but some groups are more at risk
from not taking medicine as intended including
alcohol users, drug users and homeless people;
- Active case finding through effective contact
tracing by TB specialist nurses; and
- Good surveillance to allow identification of high
risk populations and targeted case finding in
TB specialist nurses are crucial to the provision
of an effective TB control service. They are
central to providing effective treatment,
organising contact tracing of pulmonary and
non-pulmonary cases, providing skin testing,
BCG clinics and incident management.
Currently in Lothian there are 1.5 TB nurses. In
comparison, Greater Glasgow and Clyde has five
TB specialist nurses in sectors across the area.
During 2008/09 national recommendations
from the Scottish version of the National Institute
for Clinical Excellence (NICE) guidelines will need
to be implemented across Lothian and a selective
neonatal BCG programme including locality clinics
will need to be developed in accordance with the
recent Chief Medical Officer letter.
Key actions for TB control in NHS Lothian
during 2008/09 include:
- Provision of more supervised treatment after risk
assessment of all patients to identify those at risk
of not completing treatment. Those particularly at
risk include alcohol users, drug users, and those
with mental illness. In Lothian, it is estimated that
25% of TB patients seen by the health service
fall into these categories. Currently, Lothian can
only offer supervised treatment to a small number
of extremely high risk individual cases because
of limitations in nursing capacity. A range of
alternative models for directly observed therapy
including working with pharmacy and community
will be developed with Community Health
Partnerships and primary care.
- Introducing interferon gamma testing to identify
latent TB infection in accordance with NICE.
- The TB service recognises the increasing
proportion of TB cases in new entrants to
Lothian and the rest of the UK and will continue
to work with primary care services to develop
opportunities for new entrants to be screened.
A local strategy for this process will need to be
developed with Community Health Partnerships
and primary care. Further work also needs
to be developed with local alcohol and
- The development of a selective neonatal BCG
service with locality clinics for babies, children
and young people. There will also be a one-off
school age BCG catch up.
- Raising awareness of TB amongst professionals
and the public.
- The development of improved local surveillance
methods and a patient management database.
TB is amenable to control, provided that a
sustainable approach is put in place to address
a projected rise in TB cases in Lothian.