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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

Year Lothian NHS Board
1997 48
1998 49
1999 70
2000 61
2001 55
2002 58
2003 56
2004 91
2005 75
2006 58

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 tuberculosis.

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

Area Average Annual Rate – 2004-2006
Edinburgh 10.9
 North East 16.1
 North West 9.1
 South Central 8.9
 South East 11.6
 South West 8.8
East Lothian 6.9
Midlothian 4.0
West Lothian 6.9

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 those populations.

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 homeless services.
  • 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.

Key point

TB is amenable to control, provided that a sustainable approach is put in place to address a projected rise in TB cases in Lothian.