Diagnosis and management of tuberculosis, and measures for its

prevention and control

Implementing NICE guidance

2nd edition May 2012

NICE clinical guideline 117

Updated guidance

This guideline updates and replaces ‘Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control’ NICE clinical guideline (2006).

New recommendations, 1.1.1.1 to 1.1.1.18, on using interferon gamma tests (IGTs) for the diagnosis of latent tuberculosis (TB), have been added.

11 other recommendations have been amended.

What this presentation covers

Scope

Background and definitions

Epidemiology

Key priorities for implementation

New 2011 recommendations

Costs and savings

Discussion

NICE PH37: TB among hard-to-reach groups

NICE Pathway, NHS Evidence and Find out more

Scope

The update covered:

• the diagnosis of latent TB using interferon-gamma tests (IGT’s) alone or in combination with a tuberculin skin test, compared with tuberculin skin test alone in

 – adults and children at increased risk of infection

– adults and children who are immunocompromised.

•Other aspects of diagnosis and treatment of TB were not covered.

Background: TB

• Mycobacterium tuberculosis causes TB.

• The body’s immune system is stimulated once the bacteria have been inhaled.

• Latent TB –the bacteria lie dormant in the body.

• Active TB – symptoms, signs or abnormal chestX-ray.

Background: TB testing

• Until recently only Mantoux tests could indicate exposure. They can be inaccurate in certain groups.

• IGTs were developed to be more specificby removing false-positive results.

Definitions

• Close contacts

• Green Book

• Hard to reach groups

• High-incidence country

• High-incidence primary care organisation

• Household contacts

•‘Inform and advise’ information

• New entrants

• Respiratory TB

• Standard recommended regimen

• Dual strategy

Epidemiology

• There are marked differences in the incidence of TB in different parts of England and Wales, with most new cases occurring in cities.

• In 2009 in the UK, 9040 cases of TB were reported. This is an increase of 4.2% compared with 2008.

• Majority of cases in people who were not born in the UK (73%) and those aged 15–44 years (60%).

Overview of the recommendations

• 151 recommendations

• 7 key priorities for implementation – identified in 2006

• 18 recommendations were added to the 2006 recommendations – identified by the label ‘[new 2011]’

• 11 recommendations were amended since 2006 – identified by the label ‘[2006, amended 2011]’

• Of the 11 amended recommendations there are ten recommendations where it is believed the amendment may influence clinical practice

Key priorities for implementation

There are seven key priority recommendations. Two have been amended and five remain unchanged. The key priorities cover the following areas:

•Management of active TB (two recommendations).

•Improving adherence (two recommendations).

•New entrants screening (one recommendation).

•BCG vaccination ( two recommendations).

Diagnosing latent TB:general principles

• Offer Mantoux testing to diagnose latent TB in people who are household and non-household contacts.

• If Mantoux testing is positive or may be less reliable for example in BCG-vaccinated people, consider IGT.

• If Mantoux testing is inconclusive, refer the person to a TB specialist.

Diagnosing latent TB: high-risk countries

• Offer a Mantoux test to children aged 5–15 years. If positive, follow with an IGT.

• Offer either an IGT alone or a dual strategy in people aged 16–34 years.

• For people aged 35 or older, consider risks and benefits of likely subsequent treatment before offering testing.

• Offer Mantoux as the initial diagnostic test for latent TB infection in children under 5 years old who have recently arrived from a high-incidence country – if positive refer to TB specialist.

High incidence countries are those with more than 40 cases per 100,000 per year

Diagnosing latent TB: outbreaks and people who are

immunocompromised

Contacts – outbreak situation•When large numbers may need to be screened offer IGT to people aged 5 and older.

People who are immunocompromised•If latent TB is suspected in children who are immunocompromised, refer to a TB specialist.•For people who are immunocompromised, depending on the degree of immunosuppression, offer IGT alone or an IGT with a Mantoux test.

Diagnosing latent TB: healthcare workers and

hard to reach groupsHealthcare workers •Offer a Mantoux test to new NHS employees who are not from high-incidence countries and have not had BCG.•Offer IGT to new NHS employees who have recently arrived from high-incidence countries or have had contact with patients in settings where TB is highly prevalent.

Hard-to-reach populations•Offer a single IGT.

High incidence countries are those with more than 40 cases per 100,000 per year

Diagnosing latent TB: contacts under 5 years (1)

Household contacts aged 2–5 years•In children between 2 and 5 years offer Mantoux test as the initial diagnostic test for latent TB infection.•If initial Mantoux test is negative but the child is a contact of sputum-smear-positive disease offer IGT after 6 weeks and repeat Mantoux test.

Neonates who have been in close contact with sputum-smear-positive TB

•Who have not received at least 2 weeks anti-TB drug treatment should receive isoniazid, Mantoux test and IGT.

The guideline details the assessment and management of children older than 4 weeks but younger than 2 years who have:

•not had a BCG•had a BCG •been in close contact with a person with sputum-smear-positive TB.

Diagnosing latent TB:contacts under 5 years (2)

Costs and savings

Implementing this update is unlikely to result in a significant change in resource use in the NHS. However, recommendations in the following areas may result in additional costs or savings depending on local circumstances:

– Offer IGT or dual strategy to people aged 16–35 who are recent arrivals from highly prevalent countries (may have local cost implications if dual strategy employed).

– Consider single IGT for people aged 5 years and older in an outbreak situation (potential saving if both TST and IGT are currently being used).

2012: Costs and savings assumptions were not reviewed for the second edition of this slide set

Relevant NICE guidancePH37: Identifying and managing tuberculosis amonghard-to-reach groups was issued in March 2012.

The guidance aims to improve the way tuberculosis among hard-to-reach groups is identified and managed and sets out how commissioners and services can achieve this. Areas covered include:

- Commissioning multidisciplinary TB support for hard-to-reach groups

- Identifying and managing active TB in prisons or immigration removal centres

- Provision of rapid-access TB services

Discussion

• How can we ensure our organisation has access to IGTs?

• Are our policies for new entrants from high incidence countries concordant with the recommendations in this guideline? If not, how can we update them?

• How can we ensure that our staff understand which diagnostic tests should be used for which groups?

• Who do we need to update regarding the new advice for neonates children and young people?

NICE PathwayThis NICE Pathway covers: • Commissioning • Preventing the spread of TB• Diagnosing and managing active TB• Identifying and managing TB among hard to reach groups

NICE Tuberculosis

Pathway

NHS Evidence

NHS Evidence Tuberculosis

topic page

Visit NHS Evidence for the best available

evidence on tuberculosis

diagnosis, treatment and management

Find out more

Visit www.nice.org.uk/guidance/CG117 for:

•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing statement•audit support•baseline assessment tool.

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