north west tb control board stakeholder event · · 2015-07-16north west tb control board...
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Follow the discussion on Twitter @TBSummitNW #NWTBCB
North West TB Control Board
Stakeholder Event
TB is increasing. Lets make the North West TB free
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Graham Urwin Director of Commissioning and Operations, NHS England – Greater Manchester and Lancashire
Welcome
TB is increasing. Lets make the North West TB free
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Products
• Highlight the importance of the TB agenda and the need for a system wide approach
• Celebrate the work already underway
• Introduce the National TB strategy and the role of the North West TB Control Board
• Outline our priority work programmes
• Offer an opportunity to discuss and shape work going forward.
Purpose of the day
TB is increasing. Lets make the North West TB free
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Jane Rossini
Acting Deputy Centre Director
North West PHE Centre
TB in the North West – Why it matters?
TB is increasing. Lets make the North West TB free
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TB is increasing. Lets make the North West TB free
The Global Picture
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• The incidence of TB in England is higher than most other Western European countries and more than four times as high as in the US.
• In 2013 there were 7,290 TB cases reported, an incidence of 13.5 cases per 100,000
• Rates of the disease have not shown a sustained reduction in recent years
The burden of TB in England
TB is increasing. Lets make the North West TB free
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Products
• .
• .
Tuberculosis numbers and rates by region, England, 2013
TB is increasing. Lets make the North West TB free
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
0
500
1000
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2000
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3500
East Midlands East of England London North East North West South East South West West Midlands Yorkshire andthe Humber
Inci
de
nce
pe
r 1
00
,00
00
po
pu
lati
on
TB c
ase
re
po
rts
Region
TB case reports and incidence by region, 2013
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TB is increasing. Lets make the North West TB free
Incidence of TB in the North West
742 700 734 733 799 810 823 777 716 0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
620
640
660
680
700
720
740
760
780
800
820
840
2005 2006 2007 2008 2009 2010 2011 2012 2013
Inci
de
nce
pe
r 1
00
,00
0 p
op
ula
tio
n
TB c
ase
re
po
rts
Year
TB counts and incidence in the North West, 2013
North West Count North West Rate England Rate
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TB is increasing. Lets make the North West TB free
Incidence of TB in the North West
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TB is increasing. Lets make the North West TB free
TB mortality in the North West and England 1993-2010
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.901
99
3
199
4
199
5
199
6
199
7
199
8
199
9
200
0
200
1
200
2
200
3
200
4
200
5
200
6
200
7
200
8
200
9
201
0
North West England
Year
Dir
ec
tly
Sta
nd
ard
ise
d M
ort
ali
ty R
ate
per
10
0,0
00
Po
pu
lati
on
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TB is increasing. Lets make the North West TB free
Incidence of TB in the North West for those aged 0-4
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
2005-2007 2008-2010 2011-2013
Inci
de
nce
pe
r 1
00
,00
0 p
op
ula
tio
n
Three year average
TB incidence in the 0-4 years age group
Cheshire and Merseyside Cumbria and Lancashire Greater Manchester North West
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TB is increasing. Lets make the North West TB free
Ethnicity of cases
28 45 29 2 5
160 59
445
1709
148
1031
25 30 102
1039
320
1764
157
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Nu
mb
er
of
TB C
ase
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rts
Ethnic Group
Ethnic profile of North West TB cases by country of birth, 2005-2014
UK Born Non-UK Born
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TB is increasing. Lets make the North West TB free
TB rates and deprivation in the North West
0.0
5.0
10.0
15.0
20.0
25.0
30.0
0
50
100
150
200
250
300
350
400
Q1 - 0-20% most deprivedquintile
Q2 - 20-40% second mostdeprived quintile
Q3 - 40-60% mid deprivedquintile
Q4 - 60-80% second leastdeprived quintile
Q5 - 80-100% leastdeprived quintile
Incid
en
ce p
er
100,0
00 p
op
ula
tio
n
Nu
mb
er
of
case r
ep
ort
s
Deprivation profile of North West TB cases, 2013
TB case reports Incidence
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Products
• The epidemiology of TB in the North West shows a unique picture
• We have seen a drop in numbers over the last two years
• The work undertaken over recent years has given us an in-depth understanding of the disease
• We need to ensure that we continue to tailor our prevention and control strategies towards the most vulnerable groups
Summary
TB is increasing. Lets make the North West TB free
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Katie Dee Deputy Centre Director,
Cheshire and Merseyside Centre, Public Health England
The North West TB Summit
TB is increasing. Lets make the North West TB free
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The Challenge
o Rising numbers in adults and children
o Little awareness of the issue beyond TB experts
o PCT level planning too small for TB
o Lack of granular understanding of epidemiology and impact on communities
o No collective view on the best action
to take
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The Challenge
1907 1857 1785 1893 2021 2187 2177 2275 2352 2438 0
500
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0.0
2.0
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6.0
8.0
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12.0
14.0
16.0
18.0
2000-2002 2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008 2007-2009 2008-2010 2009-2011
Nu
mb
er o
f cases
Inci
de
nce
of
TB p
er
10
0.0
00
Year
Trend in incidence of TB - rolling three year average showing 95% confidence intervals
North West (number) North West (rate) England (rate)
Source: ETS, HPA
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Serious Concerns
0.0
1.0
2.0
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4.0
5.0
6.0
7.0
8.0
9.0
10.0
Three year average
TB incidence for those aged 0-4 years
Cheshire & Merseyside Cumbria & Lancashire
Greater Manchester North West
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The Solution
o The expertise is within the North West
o We have demonstrated success in other areas – and can apply these techniques to TB
o Create momentum
o Establish the TB Summit
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Our Initial priorities
o Get TB on peoples agendas
o Tell the story
o Develop a sense of urgency
o Mobilise action
o Scope key issues
o Dig further into the data
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Reducing the incidence of TB in the North West
Goal:
Primary Drivers: Secondary Drivers:
Social determinants
BCG Vaccination
Early Detection
Quality of Clinical care
Treatment Completion
Screening for Latent Disease
Factors that increase risk of disease progression
Poverty, migration, overcrowding
Identifying eligible babies Vaccinate all eligible babies
Audit, understand status quo
Get TB onto Local Authority agenda, into all policies
Implementing Cohort Review
Improving diagnostic services
Improving clinical recognition Reducing late presentation
Improving access to, and delivery of DOT
Addressing TB Nursing
Implementation of IGRA testing
HIV Co-infection
Smoking Alcohol, drug use
Nutrition, diabetes
Improved contact tracing
Up to date workforce database Sharing best practice
Paediatric TB Audit, understand status quo
Communicating the Summit
All children seen by specialist services
Creating a network
Collaborative design
Regular updates on early successes (bulletins)
Facilitating NW consultation on policy and papers
Scoping…
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TB SUMMIT
Implementing Cohort Review
Strengthening the TB Nursing
Workforce
Developing the role of Local Authority in TB Prevention
and Control Improving service delivery and coverage of
neonatal BCG Vaccination
Developing a model of care for children with TB
Communicating the work of the
TB Summit
Workstreams
TB is increasing. Lets make the North West TB free
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Successes
o Cohort Audit – only area in the UK delivering on this scale
o Children – reviewed care pathway and developed new hub and spoke model
o Workforce – annual survey for last three years
o Community engagement – detailed insight work in two communities
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Successes
o TB is on everyone's agenda
o Communicated the importance of TB through bulletins, website, Twitter, patient stories, annual conference, vision & brand etc.
o Reviewed the Neonatal BCG vaccination programme and published an assurance tool kit
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What will success look like?
Ultimate success = Reverse the trend
(numbers coming down)
Success in other ways:
Strategy tailored to local circumstances Improvements in how patients/contacts are managed All eligible children receiving BCG vaccination Robust workforce model for TB nursing TB as a core part of the inequalities agenda
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Graham Urwin Director of Commissioning and Operations, NHS England – Greater Manchester and Lancashire
Transitioning to a North West TB Control Board
TB is increasing. Lets make the North West TB free
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Products
‘To bring together best practice in
clinical care, social support and
public health to strengthen TB
control, with the aim of achieving
a year on year decrease in
incidence, a reduction in health
inequalities and, ultimately, the
elimination of TB as a public
health problem in England’
Our shared ambition
TB is increasing. Lets make the North West TB free
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Products
Nine TB Control Boards
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Products Why is it a priority?
• Thought of as a ‘disease of the past’, but has been steadily
increasing over the past 25 years
• The vast majority of cases are curable if detected early
• Not evenly spread across the population – higher rates in
more deprived communities
• The Chief Medical Officer has identified the inequalities
associated with TB, and rising levels of antimicrobial
resistance, as an important priority for England .
• Even in high incidence areas: TB is a rare disease.
Collective action at scale is needed to deliver a reduction in
cases.
TB is increasing. Lets make the North West TB free
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National TB Strategy 2015-20
1. Improve access to services and ensure early diagnosis 2. Provide universal access to high quality diagnostics 3. Improve treatment and care services 4. Ensure comprehensive contact tracing 5. Improve BCG vaccination uptake 6. Reduce drug-resistant TB 7. Tackle TB in under-served populations 8. Systematically implement new entrant latent TB screening 9. Strengthen surveillance and monitoring 10. Ensure an appropriate workforce to deliver TB control
TB is increasing. Lets make the North West TB free
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Products
.
Establishment of TB Control Board
In process of transition from NW TB Summit to NW TB
Control board:-
• Scope out the requirements of the Board and
identify appropriate membership
• Establish clear governance and reporting
arrangements between national and local groups
• Understand the funding flows to support
implementation of the national strategy
• Agree our action plan for the first year.
TB is increasing. Lets make the North West TB free
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Proposed future reporting and governance arrangements
North West TB Control Board
Cheshire & Merseyside TB Network
Cumbria & Lancashire TB Network
Greater Manchester TB Network
National TB Board
TB is increasing. Lets make the North West TB free
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Products What will success look like?
• TB control board established with clear
governance across the North West system
• Strong system leadership to join up health,
social care, voluntary and third sectors
• An annual work plan with measurable outcomes
• Ultimately - a year on year reduction in TB
incidence TB is increasing. Lets make the North West
TB free
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Grainne Nixon
Lancashire and Cumbria Health Protection Team
TB Strategy Structures for Cumbria and
Lancashire: 2015/16
TB is increasing. Lets make the North West TB free
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Products
• Arrangements for Lancashire and Cumbria…
• Cumbria and Lancashire TB Stakeholder Group (established clinical network)
• North West TB Cohort Review/Audit since 2012 (NWTB Summit)
• Lancashire TB Service Improvement Group convened 2013
Background
TB is increasing. Lets make the North West TB free
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Products
• The TB Stakeholder Group Cumbria and Lancashire TB Clinical Reference Group (CRG)
• TB Service Improvement Group Strategic TB Commissioning Board
• Obtain support from the Lancashire CCG Collaborative Commissioning Board
• Integration of Cumbria CCG into new structures
Build on existing structures
TB is increasing. Lets make the North West TB free
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Products
.
Governance and Interdependency
TB is increasing. Lets make the North West TB free
Figure 2: Lancashire Strategic TB Commissioning Board. Governance and Interdependency Organogram
National TB Programme Board
Lancashire Strategic TB
Commissioning Board
NW TB Control Board Health and Justice (PHE)
FES (PHE)
Lancashire and Cumbria TB
Clinical Reference Group
Cumbria and
Lancashire LA
Public Health
Leadership
Group Health and
wellbeing
boards
Lancashire Collaborative
Commissioning Board
NHSE area team
Immunisation leads
TB Cohort review/s TB Service providers
Cumbria
CCG (tbc)
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Products
• Expert understanding of clinical aspects of TB (reports, research, guidance and statutory responsibilities related to the delivery of TB services)
• Maintain strong communication links across all providers
• Horizon scanning, identifying and prioritising potential innovations
• Reviewing local intelligence against TBC Board Benchmarks
• Sense checking and fine-tuning new strategies and commissioning proposals
Functions of the TB clinical reference group
TB is increasing. Lets make the North West TB free
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Products
• To act on behalf of the Lancashire (CCG) Collaborative Commissioning Group (and Cumbria CCG)
• To identify local commissioning priorities for prevention, detection and treatment of TB infection for Cumbria and Lancashire.
• To work with Local Authority, NHSE and PHE partners around commissioning priorities outside CCG remit (e.g. prisons, substance misuse)
• To provide a co-ordinated structure for reporting to the NW TB Control Board
• To allow Health and Wellbeing Board oversight via the C&L Public Health Leadership Group
Lancashire and South Cumbria TB Strategic (Commissioning) Board. Objectives:
TB is increasing. Lets make the North West TB free
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Products
1. Convene and agree ToRs for CRG and C&L TB Commissioning Board
2. Review existing systems and identify priority areas for implementation of new LTBI screening systems.
3. Identify mechanisms and cost of bringing existing TB services in line with locally or nationally agreed service specifications
4. Review of existing diagnostic methods and services
Priorities for 2015/16
TB is increasing. Lets make the North West TB free
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Graham Urwin, Jane Rossini,
Katie Dee, Grainne Nixon
Panel Discussion
TB is increasing. Lets make the North West TB free
@TBSummitNW
#NWTBCB
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Please return to your seats for 11am
Thank you
Refreshment Break
TB is increasing. Lets make the North West TB free
@TBSummitNW
#NWTBCB
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Priority Workstreams
North West TB Control Board
TB is increasing. Lets make the North West TB free
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Professor Mark Woodhead Professor of Respiratory Medicine, Central Manchester
University Hospitals NHS Foundation Trust Chair, NW TB Cohort Audit Steering Group
North West TB Cohort Audit
TB is increasing. Lets make the North West TB free
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•Systematic review of every TB case reported in the NW
•16 face to face meetings per year
•Chaired by Senior Clinicians and TB Nurse Specialists
•Open, non-judgemental discussion
Process
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Process
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North West Totals Year 1 Year 2 Year 3
1 100% of patients will have a SRA carried out 93% 99% 99%
2 At least 5 contacts identified for smear +ive cases 57% 56% 56%
3 At least 90% of identified contacts of smear +ive are assessed 85% 86% 86%
4 100% of child contacts are assessed (any site of disease) 88% 90% 93%
5 100% of cases will be offered an HIV test 66% 80% 92%
6 At least 85% of non drug resistant cases will complete in 12 months 86% 87% 86%
7 Less than 2% of cases will be reported as lost to follow up 3% 3% 1.4%
8 100% of cases will be logged onto ETS within 5 working days 71% 88%
9 100% of cases will be categorised with an ECM level 0-3 100% 100%
ECM Levels – Breakdown across the Levels 0 - 3
ECM 0 39% 36%
ECM 1 27% 33%
ECM 2 20% 18%
ECM 3 14% 12%
Year 3 figures are provisional
Success of Cohort – NW Outcomes
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North West Totals Year 1 Year 2 Year 3
1 100% of patients will have a SRA carried out 93% 99% 99%
2 At least 5 contacts identified for smear +ive cases 57% 56% 56%
3 At least 90% of identified contacts of smear +ive are assessed 85% 86% 86%
4 100% of child contacts are assessed (any site of disease) 88% 90% 93%
5 100% of cases will be offered an HIV test 66% 80% 92%
6 At least 85% of non drug resistant cases will complete in 12 months 86% 87% 86%
7 Less than 2% of cases will be reported as lost to follow up 3% 3% 1.4%
8 100% of cases will be logged onto ETS within 5 working days 71% 88%
9 100% of cases will be categorised with an ECM level 0-3 100% 100%
ECM Levels – Breakdown across the Levels 0 - 3
ECM 0 39% 36%
ECM 1 27% 33%
ECM 2 20% 18%
ECM 3 14% 12%
Year 3 figures are provisional
Success of Cohort – NW Outcomes
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Changing Practice through TB Cohort Audit in the NW: Qualitative Evidence of Impact – presented to the BTS Winter Conference,
December 2014
– A vibrant, unique and valued Community of Practice has been developed
– Interchange of experience and ideas across a large number of teams and professionals leading to enhanced mutual respect between different roles and a shared sense of purpose
Success of Cohort – Qualitative Research
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Changing Practice through TB Cohort Audit in the NW: Qualitative Evidence of Impact – presented to the BTS Winter Conference,
December 2014
– A vibrant, unique and valued Community of Practice has been developed
– Interchange of experience and ideas across a large number of teams and professionals leading to enhanced mutual respect between different roles and a shared sense of purpose
– This multidisciplinary regional approach to TB cohort audit has promoted local and regional team working, exchange of good practices and local initiatives to improve care.
– There is a very strong ownership of the process from Public Health, Nurses and Clinicians and they want it to continue
– TB Cohort audit is seen as a tool for quality improvement that improves patient safety.
Success of Cohort – Qualitative Research
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• Equitable delivery and outcomes of tuberculosis treatment and care in the North West of England: analysis of North West TB Cohort Audit data – The Union World Conference on Lung Health 2015
– Despite high levels of socioeconomic deprivation, TB patients in the most deprived group had similar care to more affluent individuals, suggesting that access to, and delivery of TB care in the North West of England is equitable. The extent to which the cohort audit process contributes to, and sustains this standard of care deserves further study.
Success of Cohort – Additional Research
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• Equitable delivery and outcomes of tuberculosis treatment and care in the North West of England: analysis of North West TB Cohort Audit data – The Union World Conference on Lung Health 2015
– Despite high levels of socioeconomic deprivation, TB patients in the most deprived group had similar care to more affluent individuals, suggesting that access to, and delivery of TB care in the North West of England is equitable. The extent to which the cohort audit process contributes to, and sustains this standard of care deserves further study.
• Introduction of Cohort Audit in the North West of England – ARNS Conference 2014
– Success reflected in; maintenance of high compliance with contract tracing; significant improvement in HIV testing in areas where compliance previously low; timely recording of active TB onto ETS
– The introduction of ECM levels providing better understanding of impact on workforce of treating ECM cases.
• Defining “Enhanced Case Management” (ECM) in relation to cohort reviews of tuberculosis cases in North West England – FIS Conference 2013
– Unique development and introduction of ECM levels in the North West invaluable
Success of Cohort – Additional Research
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TB control boards will have
the following responsibilities:
• to ensure TB cohort review is undertaken
every 3–4 months and fed back to the TB
control board, commissioners, TB service
provider management and the local
directors of public health; and that
appropriate action is taken as a result of
cohort review
TB Strategy
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Dr Fran Child Consultant in Paediatric Respiratory Medicine
Royal Manchester Children’s Hospital Paediatric Representative NW TB Summit
TB in Children
North West Region
TB is increasing. Lets make the North West TB free
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>1500 children/year assessed or screened for latent or active TB
40-70 cases TB disease / year
6% NW TB cases are children
70% paediatric cases are in Greater Manchester
3 deaths and 8 cases TB meningitis in last 5 years
Scale of the problem
Children < 16 years NW Region
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Following TB infection, children progress to TB disease more quickly than adults
(typically within 12 months)
Measure of TB transmission in the community
Why is TB in Children Important?
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Age Disseminated
TB / TB
Meningitis
Pulmonary
TB
No Disease
< 1 yr 10-20% 30-40% 50%
1-2 yrs 2-5% 10-20% 75-80%
2-5 yrs 0.5% 5% 95%
5-10 yrs <0.5% 2% 98%
>10 yrs <0.5% 10-20% 80-90%
Marais et al Int J Tub Lung Dis 2004
Risk of disease following primary
infection
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Age Disseminated
TB / TB
Meningitis
Pulmonary
TB
No Disease
< 1 yr 10-20% 30-40% 50%
1-2 yrs 2-5% 10-20% 75-80%
2-5 yrs 0.5% 5% 95%
5-10 yrs <0.5% 2% 98%
>10 yrs <0.5% 10-20% 80-90%
Marais et al Int J Tub Lung Dis 2004
Risk of disease following primary
infection
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“ Either a paediatrician with experience and training in the treatment of TB or a general paediatrician with advice from a specialised clinician should investigate and manage TB in children and young people”
NICE TB guideline 2015 (consultation)
How should care for children with TB be
provided?
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Cumbria and Lancashire
Cheshire and Merseyside
Annual TB Notifications by CCG in Northwest 2009-14 Children aged < 16 years
Total cases = 40-70/yr
< 5 cases
6-15 cases
16-25 cases
26-35 cases
36-45 cases
46-55 cases
Cumbria and Lancashire
Greater Manchester
Cheshire and Merseyside
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Cumbria and Lancashire
Cheshire and Merseyside
Annual TB Notifications by CCG in Northwest 2009-14 Children aged < 16 years
Total cases = 40-70/yr 25 DGH
2 Tertiary Centres
< 5 cases
6-15 cases
16-25 cases
26-35 cases
36-45 cases
46-55 cases
Cumbria and Lancashire
Cheshire and Merseyside
Greater Manchester
Royal Manchester Children’s Hospital
AlderHey Children’s Hospital
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Shared Expertise
Better Outcome
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Contacts < 16yrs assessed (%)
0102030405060708090
100
Cases who had an HIV test (%)
0102030405060708090
100
NW Cohort Review Year 2 April 2014-April 2015
n=1434 n=87
NW Cohort Audit
Paediatric Outcomes
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Cumbria and Lancashire
Cheshire and Merseyside
Northwest Region 2012: Hospital care for children with TB disease
Outside North West Region
DGH +/- RMCH
RMCH
DGH – Blackburn
AlderHey
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TB notifications in children aged <16 yrs Northwest region 2001-15
0
10
20
30
40
50
60
70
Number of cases
RMCH
Rest of Greater Manchester
Rest of NW region
*2015 data estimated from actual number of cases to May 2015 at RMCH and RMCH seeing 52% cases in NW region
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• 209 cases of TB disease (205 children)
• 92 (44%) symptoms, 117 (56%) screening
• 23% culture positive, 0% HIV positive
• 192 (92%) completed treatment
• 14 (7%) transferred out
• 3 (1%) lost to follow-up
• Significant long term sequelae in 13/92 (14%) with symptoms but 0/117 (0%) screening
RMCH Children’s TB Service 2003-13
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1. Variable patterns and standards of care
2. 30% GM cases potentially preventable
3. Delays in diagnosis and treatment
4. Incomplete assessment and follow-up
5. Solo clinicians and TB nurses
6. Difficulties providing surge capacity
7. Long travelling distances for patients
8. Incomplete data capture
Key Messages
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Consistently high standards
Multidisciplinary expertise
Access to specialist investigations and support
Rapidly and readily accessible
Surge capacity
Regular review of performance and outcome
Best Model of Care
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North West TB Summit Stakeholders around NW
Hub and Spoke Model 4 levels of DGH +/- tertiary care determined by expertise / patient numbers
Agreed evidence based care pathway and assessment proforma Defined points of integration between secondary and tertiary care
Clear roles and responsibilities Quality measures
Pilot in 3 DGHs in Greater Manchester
Endorsed by Greater Manchester, Lancashire and Cumbria Strategic Clinical Network Group for Children
Networked care endorsed by NICE 2015 (consultation)
What have we done so far?
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Formal mandate for a paediatric TB network across the North West
Appropriate commissioning
Regular audit of clinically important paediatric outcomes across the NW
Next Steps
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Professor Bertie Squire Consultant Physician, Liverpool School of Tropical Medicine and Royal Liverpool & Broadgreen University Hospital Trust
TB Nursing Workforce
TB is increasing. Lets make the North West TB free
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Products
Royal College of Nursing:
• 1 Nurse: 40 standard patients
• 1 Nurse: 20 patients with enhanced case management (ECM)
• PLUS full clerical support
Workforce Guidelines
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Products
• Workforce data available for all NW TB Services
• Last survey carried out in November 2014
• Can compare against notification numbers
TB Nurse workforce annual survey
TB is increasing. Lets make the North West TB free
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Products Monitoring SCM/ECM
TB is increasing. Lets make the North West TB free
Year 2 Year 3
Standard Case Management
ECM 0 39% 36%
Enhanced Case Management
ECM 1 27% 33%
ECM 2 20% 18%
ECM 3 14% 12%
• North West figures.
• Variation across the footprints
• All record a percentage of cases requiring ECM greater than 50%
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Products
• 7/17 services below the recommended RCN levels
• Cover for leave and sickness often not available
• Clerical support absent or patchy in many TB Services
• Rapid increase is possible in EFFECTIVE TB nurse numbers at low cost by DEDICATED admin staff (? Band 3) to free up Band 6-7 Nurses
Survey Overview
TB is increasing. Lets make the North West TB free
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Products
• Qualitative data collection, 2014
• Purposive sampling
• Themes were triangulated with 8 key
informants from the TB Cohort Audit
Steering Group
Qualitative Review
TB is increasing. Lets make the North West TB free
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Products
• …..
Qualitative Review - Results
TB is increasing. Lets make the North West TB free
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Products
Community of Practice
Qualitative review - Conclusions
TB is increasing. Lets make the North West TB free
Interchange of experience and ideas
Shared sense of purpose
Multidisciplinary regional approach
Promoted local and regional team working, exchange of good practices and local initiatives to improve care.
Strong ownership of the process from Public Health, Nurses and Clinicians
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Products • Each TB control board to develop a workforce
strategy in line with the National Quality Board guide to staff capability and capacity
• Commissioners should specify in contracts the outcomes and quality standards required and actively seek assurance that there are sufficient numbers of nursing and support staff capable to meet these
• Provide the TB workforce with a career framework; continued professional development and opportunities to influence policy at a local and national level
National Strategy
TB is increasing. Lets make the North West TB free
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Products
TB Control Board to establish a workforce group to:
• Consider impact of LTBI Screening introduction on workforce
• Improve workforce planning
• Develop standardised job descriptions/skills passport etc.
• Link with national workstream
What Next?
TB is increasing. Lets make the North West TB free
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Dr Alison Giles
Chief Executive, Our Life
Engaging with Communities
TB is increasing. Lets make the North West TB free
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Products
• Engagement specialists
• A focus on wellbeing and health issues
• Supporting local authorities, housing, and NHS
Who we are
TB is increasing. Lets make the North West TB free
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Products Why are we involved in TB?
TB is increasing. Lets make the North West TB free
Engagement
Social housing TB
Public Health
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Products
• To include representation from PHE, NHS England, CCGs, DsPH, DASS, NHS, patient advocates, third sector
• To ensure an appropriate workforce strategy is developed and implemented
What about the housing sector?
TB Control Board responsibilities
TB is increasing. Lets make the North West TB free
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Products There is a need for training and practical resources to:
• Understand linkages between housing and TB
• Prevent TB spread through housing and homelessness statutory duties
• Build links between health and housing workforces through the Workforce Strategy
• Build housing-related outcomes into the TB Service Specification
• Ensure NICE Guidance PH37 is delivered including accommodation
From our work
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• To ensure the needs of under-served populations are addressed and health inequalities are reduced
• To ensure appropriate TB awareness-raising in collaboration with the third sector, local authorities and other organisations who provide this
TB Control Board responsibilities
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“How to ensure that TB does not become a lightning conductor for existing social
prejudices is a serious question”
To be ‘appropriate’, we need to make community engagement a priority and support communities to co-
design and co-produce the activities
Make community engagement a priority
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Products By training and supporting frontline workers and community members to lead peer-research, we have:
• Raised awareness of the facts about TB among the communities concerned e.g. White working class, South Asian Heritage
• Reduced stigma and discrimination
• Created community champions who can spread information, support case-finding, and support adherence to treatment
From our work
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0161 233 7500
www.ourlife.org.uk
@AlisonGiles2
Contact us
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Mike Mandelbaum
Chief Executive, TB Alert
Engaging with Communities:
Commissioning the Third Sector
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• Why has TB increased in the UK
– Migration patterns
– Overly focused on bio-clinical aspects
• The complexity of TB…
– Prevention – Access – Diagnosis – Treatment and Care – Control
The complexity of TB
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• TB Control Boards should work closely with the third sector and include representation from patient advocates and the third sector A1. Improve access and early diagnosis
• Raise awareness and tackle stigma
• Train voluntary agencies working with migrants / signposting
A3. Improve treatment and care services • Community-based DOT providers
• Fast track to social care
A4. Contract tracing • Community outreach workers
The third sector in the Strategy (1)
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Products A6. Drug-resistant TB
• Tackle social risk factors • Community-based DOT providers
A7. Tackle TB in under-served populations • Multi-disciplinary case management and support involving
third sector • Primary care registration among vulnerable migrants
A8. New entrant screening • Awareness and health education (non-primary care models)
A10. Workforce development • Multi-disciplinary teams involving third sector and
potentially trained lay workers
The third sector in the Strategy (2)
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• Should the third sector – Deliver occasional local projects on the fringes, or
– Fulfil its potential by mainstreaming and working to scale
• To impact to scale – It must be commissioned
– The evidence base needs continual strengthening
Fringe or mainstream?
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• To establish the role of the third sector as commissioned service providers – Guidance, evidence and good practice, monitoring
tools
– Advice, commissioning support and training • Work with TBCBs in four regions
• Local advice and commissioning support
• Range of training programmes for statutory and third sectors
– Network of organisations tackling the
socio-economic and cultural aspects of TB • Stop TB UK
TB Alert 2015 – 2018
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• Reflects WHO’s Engage-TB operational guidance on integrating community-based tuberculosis activities into the work of non-governmental and other civil society organisations
Engage-TB
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Peter Ormerod
Chair BTS Joint TB Committee
Latent TB Screening
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• 75% of TB cases in E&W are in the foreign-born
• Only 10% of cases occur within 2 years of first entry
• Therefore many cases potentially preventable by treating those with latent TB infection (+ve IGRA blood test)
• 15% of adults and >20% children with LTBI will develop active in their lifetime without treatment
• LTBI treatment reduces TB by 60-65% IN ADULTS and 80-90% IN CHILDREN
Why is New Entrant Screening Important?
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• R124 : New Entrant Screening should be incorporated within larger Health Screening programme for new immigrants, linked with local services
• R125 : Assessment for, and management of TB in New Immigrants should consist of the following:- Risk assessment for HIV (if appropriate)
If IGRA +ve assess for active TB
Treat latent TB (LTBI) if under 35
Consider BCG if Mantoux negative
Current NICE recommendations
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• R126 : New Entrants should be identified from:- Port of Arrival Reports
New registrations with primary care
Entry to Education, including University
Links with Statutory and Voluntary Groups working with New Entrants.
• These are the responsibility of the CCG (previously PCT), rather than the individual GP.
NICE Recommendations (2)
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• Draft guidance just issued
• 'Screening' New Entrants not covered as not in scope
• Opportunistic LTBI screening mentioned
• Up to age 65; LTBI treatment unless concerns re hepatotoxicity
• Also links to Hep B , C and HIV Testing (R119-124)
NICE 2015
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Products The effect of introducing systematic LTBI treatment in East Lancashire
What happens with systematic LTBI treatment?
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• One of the 10 aims within the PHE/NHSE national strategy is to:
“Systematically implement new entrant latent TB screening”
• LTBI screening for new entrants from TB high incidence areas is an effective and cost effective public health intervention and is recommended by NICE .
• While systematic LTBI screening requires an initial resource investment, it has been shown that the prevention of cases will yield budget savings after about four years
National Strategy
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• New entrants (16 – 35 years old) who were born or lived in Sub Saharan Africa, or countries with an estimated TB incidence of greater than 150 per 100,000 and who arrived in the England within the last five years.
• Ensure robust policies for LTBI screening for other high risk population groups where this is NICE recommended (such as in patients with immunosuppression)
Eligibility
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• LASCA producing data for Greater Manchester and Lancashire/South Cumbria
• Need to check who is doing what and how
• Secondary or primary care?
• Skin test (Mantoux) based?
• Blood test (IGRA) based?
• Latter could be moved to primary care
Key Analysis Needed
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• Superficially looks as if active case numbers down 50% therefore less workforce needed
• However TB nurses (covering BwD and East Lancs) now looking after approx 150 LTBI cases p.a. from contact tracing and NI screening
• These need support/monitoring
• ? 2 LTBI equivalent to 1 case without ECM
Impact on the workforce
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Sue Henry Facilitator
Round Table Discussions
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Jane Rossini Acting Deputy Centre Director
North West PHE Centre
Closing Remarks and Next Steps
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• Finalise roles and responsibilities for the Board
• Set out governance structure
• Refresh Terms of Reference and membership
• First meeting of the Board in September (interim governance in place until this point)
• Input from today to be written up and circulated to attendees
Next Steps
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