Title page
Contents
About Public Health England 2
Acknowledgements 3
Glossary of acronyms 5
Foreword 6
Executive summary 8
Chapter 1: Burden of TB in USPs 11
1.1. Defining Under-Served Populations (USPs) 11
1.2. Routinely collected data for USPs 13
1.3. Social risk factors in notified TB cases 13
1.4. Demographic characteristics of USPs with TB and SRFs 15
1.5. Geographical distribution of USPs with TB and SRFs 16
1.6. Clinical characteristics of USPs with TB and SRFs 19
1.7. Drug resistance among USPs with TB and SRFs 19
1.8. TB outcomes among the USPs with TB and SRFs 20
1.9. TB cases that were unemployed, asylum seekers or resident in an immigration removal centre 21
1.10. Deprivation 21
1.11. Data challenges for USP, TBCBs and TB stakeholders 22
1.12. Measuring success for TB control among USPs 23
Chapter 2: Under-served migrants in the UK 24
2.1. Defining under-served migrants in the UK 24
2.2. The burden of TB among migrants in England: active TB disease 25
2.3. New entrant latent TB infection testing 27
2.4. Challenges for TBCBs working with migrant populations 28
2.5. Recommendations and resources for TBCBs and their partners working with under-served migrants 29
2.6. Exemplars of good practice on working with vulnerable migrant populations 32
Chapter 3: People in contact with the criminal justice system 37
3.1. Defining people in contact with the criminal justice system 37
3.2. The burden of TB among people in contact with the CJS 38
3.3. Overlapping risk factors among people in contact with CJS 42
3.4. Diagnosis and management of TB in prisons and other PPDs 42
3.5. Challenges for TBCBs and their partners in working with people in CJS 44
3.6. Recommendations and resources for TBCBs and their partners on working with people in the CJS 47
3.7. Exemplars of good practice on working with people in CJS 50
Chapter 4: People who misuse drugs or alcohol 53
4.1. Defining people who misuse drugs or alcohol 53
4.2. The burden of TB among people who misuse drugs or alcohol 53
4.3. Geographic distribution of people with TB who misuse drugs or alcohol 54
4.4. The challenges for TBCBs and other stakeholders working with TB patients who misuse drugs or alcohol 57
4.5. Recommendations and resources for TBCBs and their partners working with people who misuse drugs or alcohol 58
4.6. Exemplars of good practice on working with people who misuse drugs or alcohol 61
Chapter 5: People living with a mental health problem 62
5.1. Defining people living with or recovering from a mental health problem 62
5.2. The burden of TB among people living with or recovering from mental health problems 63
5.3. Challenges for TBCBs and others working with people with mental illness 64
5.4. Recommendations and resources for TBCB and their partners working with people with mental illness 65
Chapter 6: Homelessness and TB 67
6.1. Defining homelessness 67
6.2. The burden of TB among homeless people 68
6.3. Challenges for TBCBs and their partners working with homeless people 71
6.4. Recommendations and resources for TBCBs and other stakeholders working with the homeless 73
6.5. The TB patient's pathway to accommodation 75
Chapter 7: Local government and its role in tackling TB in USPs 85
7.1. The generic role of local authorities in supporting USPs with TB 86
7.2. The role of the local authority Director of Public Health in supporting USPs with TB 87
7.3. What can local authorities do for USPs with TB? 87
7.4. Is there a role for Council Scrutiny of TB? 88
7.5. Recommendations for TB Control Boards 88
Chapter 8: TB Control Boards, Clinical Commissioning Groups and USPs-roles and responsibilities 90
8.1. TB Control Boards 90
8.2. Responsibilities of TB Control Boards 91
8.3. Responsibilities of Clinical Commissioning Groups (CCGs) 92
Chapter 9: Community, Voluntary Sector and Programmes of Work 94
9.1. The Voluntary, Community and Social Enterprise Sector and TB Control Boards 94
9.2/9.3. Exemplars of good practice of working with the Voluntary, Community and Social Enterprise Sector 96
Chapter 10: Models of Care for USPs 99
10.1. Diagnosis, treatment and social care integration: Find and Treat Service 99
10.2. A 'One Stop' service-Olallo House offering accommodation and social support to improve TB treatment completion 102
10.3. The Housing First Model 102
10.4. Integrated care plans for TB services and substance misuse services 103
10.5/10.4. Pharmacies providing DOT 105
10.6/10.5. Video (or virtually) Observed Therapy 107
10.7/10.6. London TB Extended contact tracing (LTBEx) model 108
10.8/10.7. Low cost solutions to support treatment adherence 109
References 110
Appendix 1: Additional Data Resources on TB in USPs 117
Appendix 2: Findings from a survey of TBCBs to assess the needs of USPs 130
Appendix 3: Checklist to help accommodate TB patients with no recourse to public funds 134
Appendix 4: Members of the Task and Finish Group in the USPs (USPs) 136
Table 1.1. Number and proportion of TB cases with social risk factors by PHE Centre, England, 2010-2015 18
Table 2.1. Terminology relation of migrants living in the UK and estimated numbers 24
Table 2.2. Most frequent countries of birth for TB cases and time between entry to the UK and TB notification, England, 2015 27
Table 3.1/Table 3.2. DXR machines currently available in prisons across England 43
Table 5.1. Reported mental health problems among patients with TB by place of birth, LTBR, 2009-2015 64
Figure 1.1. Overlapping groups of USPs with multiple complex needs 12
Figure 1.2. Proportion of TB cases with at least one social risk factor, England, 2010-2015 14
Figure 1.3. Venn diagram showing the number of TB cases with overlapping social risk factors, England, 2010-2015 15
Figure 1.4. Number and proportion of TB cases with social risk factors by place of birth 2010-2015 16
Figure 1.5. Number of TB cases with at least one social risk factor by local authority, England, 2010-2015 (box shows enlarged map of London area) 17
Figure 1.6. Proportion TB cases with at least one social risk factor (SRF) by clinical characteristics, England, 2010-2015 19
Figure 1.7. Last recorded TB outcome for drug sensitive cohort by SRF, 2010-2014 (includes those aged 15 years and older) 20
Figure 1.8. Last recorded TB outcome for drug resistant cohort by two SRF, 2010-2013, England (includes those aged 15years and older) 20
Figure 1.9/Figure 1.10. Rate of TB by deprivation decile, England, 2015 21
Figure 2.1. TB case notifications and rates by country of birth 2000-2015 26
Figure 2.2. Trend in TB case notifications for the top five countries of birth of non-UK born cases, England, 2006-2015 (Five most frequent countries of birth in 2015) 26
Figure 3.1. Segmentation of population defined as 'people in contact with the criminal justice system' in both community and custodial settings 37
Figure 3.2. Multiple complex needs among people in contact with the CJS 38
Figure 3.3/Figure 3.1. Reports of notified TB cases (single incidents and those linked to outbreaks) among people in PPDs notified to PHE (2015) 39
Figure 3.4/Figure 3.2. TB cases in PPDs reported to PHE by calendar year (2010-2015) 40
Figure 3.5. Number of TB cases with current or history of imprisonment by local authority, England, 2010-2015 41
Figure 3.6. Overlap between prisoners, problem drug users and homelessness among people diagnosed with TB in London 2003 42
Figure 4.1a. Number of TB cases with drug misuse by local authority, England, 2010-2015 55
Figure 4.1b. Number of TB cases with alcohol misuse by local authority, England, 2010-2015 56
Figure 4.2. Referral pathway for suspected TB in a client of the drugs and alcohol services 59
Figure 5.1. Number of TB patients treated in London with reported mental health problems, LTBR, 2009-2015 63
Figure 6.1. Number of TB cases with current or history of homelessness by local authority, England, 2010-2015 70
Figure 6.2. The TB patient's journey to accommodation 76
Figure 8.1. TB case notification numbers by TB Control Board, England, 2015 90
Boxes
Box E10.1. Ad-hoc screening of USPs in Birmingham, Sandwell and Dudley using the mobile x-ray unit and Find and Treat 101
Table A1.1. Number and proportion of TB case notifications with social risk factors by local authority, England, 2010-2015 118
Table A1.2. Number and proportion of TB cases with social risk factors by place of birth, England, 2010-2015 126
Table A1.3. Characteristics of TB cases with social risk factors, England, 2010-2015 127
Table A1.4. Clinical characteristics of TB cases with at least one social risk factor, England, 2010-2015 128
Table A1.5. Last recorded TB outcome for the entire drug sensitive cohort by social risk factor, England, 2010-2014 129
Table A1.6. Last recorded TB outcome for the drug resistant cohort by social risk factor, England, 2010-2013 129