Tuberculosis among under served populations

LTP Priority: Tuberculosis among under served populations

Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service

Type of Interventions: Pharmacies providing supervised TB treatment DOT and opioid substitution treatment (OST)

Major driver of health inequalities in your area of work

TB in people with social risk factors can be seen as a barometer of health inequalities and tackling it will play a key role in enabling local authorities, the NHS and PHE to successfully reduce health inequalities. The under-served population is often defined as having multiple, complex needs so the wider determinants of health are important to consider as is the bringing together of many organisations, not only in the health sector but also local government, social care, housing, justice, NHS commissioners, the third sector and voluntary groups.

In 2017, 12.6% of all TB cases in England had at least one social risk factor; the highest proportion since data collection began in 2010. These cases were nearly twice as likely to have infectious TB and nearly twice as likely to die of TB; they had poorer treatment outcomes and were more likely to have drug resistant TB.

Between 2016 and 2017, the proportion of people with a current or a history of drug misuse increased to 5.0% (229/4,603) *.

Treatment completion (2016 – 2017) *

  • Among people with drug sensitive TB notified in 2016, treatment completion at last recorded outcome was lower for those with a Social Risk Factor (SRF) (80.0%, 420/525) compared to people without a SRF (87.7%, 3,762/4,292).
  • The proportion of people that had died at their last recorded outcome was 2.5 times higher in those with alcohol misuse (11.6%, 21/181) compared to those with no alcohol misuse (4.7%, 229/4,890).

Delay from symptom onset to treatment (2016 – 2017) *

  • The proportion of people with pulmonary TB and a SRF who experienced a delay from symptom onset to treatment start of more than four months was slightly higher than those without a SRF (33.9%, 130/383 versus 31.6%, 568/1,798).

Drug resistance TB (2016 – 2017) *

  • The proportion of people with a SRF that had initial MDR/RR-TB (2.7%, 11/404) was nearly double that of those without a SRF (1.5%, 35/2,295).  Smoking and TB (2016 – 2017) *
  • Where information was known, 18.1% (783/4,316) of people with TB were current smokers. Sixty-two percent (59.4%, 282/475) of people with a SRF were current smokers, compared with 12.2% (426/3,490) of people without a SRF.

Reference

*Tuberculosis in England:2018: Public Health England

Target groups

Deprivation and inclusion health groups. Incidence and mortality rates for those with respiratory disease are higher in disadvantaged groups and areas of social deprivation

Intervention

Pharmacies providing supervised TB treatment DOT and opioid substitution treatment (OST): Commission as appropriate TB clinical services and alcohol and drug treatment services to provide concomitant prescribing of opioid substitution treatment (OST) and TB medication.

What outcomes is it expected to lead to?

Consideration should be given to commissioning community pharmacies to provide directly observed therapy (DOT) especially for those attending services for opioid substitution treatment (OST) which would enhance adherence to TB treatment. Commission alcohol and drug treatment services to act as DOT providers or commission community pharmacists to supervise DOT alongside OST.

Evidence

Tackling TB among the under-served populations

Public Health England (PHE) in partnership with NHS England, local government and TB Alert (third sector partner) have developed a Resource to guide the actions of TB control boards (TBCBs) and their partners in the NHS, local authorities and third sector to identify and meet the health and social care needs of under-served populations (USPs) in relation to prevention, diagnosis and treatment of TB. This resource brings together, in one place, information related to USPs and TB and supports stakeholders build collaborative programmes of work to reduce the burden of TB among local vulnerable and marginalized people with multiple complex needs. The resource can be accessed by clicking here.

The resource ‘Tackling TB in under-served populations’ provides England’s seven TB Control Boards (TBCBs) and their partners with recommendations for action and exemplars of good practice around which to reduce the burden of TB among USPs. One of the chapters “Models of Care for USPs includes a model on the use of pharmacies to support DOT in the community to ensure treatment completion.

TB patients, especially those with complex issues such as those in USPs, do not always take their medicines as intended or complete the whole course, with the associated worse outcomes, potential to develop drug resistant TB and become infectious to other people. TB outcomes in people with at least one SRF are worse than for those without a SRF. Between 2012 and 2016, treatment completion was lower for people with drug sensitive TB who had a SRF (82.0%, 2,278/2,779) compared to those without a SRF (90.1%, 22,653/25,132) (figure 1.8, table A1.5) in resource Tackling TB in Under-Served Populations : A Resource for TB Control Boards and their partners (January 2019).

One way to improve the taking and completion of TB treatment would be for pharmacists to be commissioned to provide a supervised TB drug administration scheme or DOT. Many pharmacists and or pharmacy technicians across the country are commissioned to provide a supervised administration scheme for methadone and buprenorphine, and similar scheme for TB treatment could potentially be set up as demonstrated in Birmingham (E10.2 page 133). This service would have to be commissioned locally by CCGs, who would develop a service level agreement, which would set out the requirements of the service and the associated funding. Pharmacists are already familiar with providing such a service to people who are addicted to, e.g. diamorphine, little to no additional training would be required for the provision of the service for TB patients. In addition, pharmacy teams could provide advice on how to take TB medicines to improve adherence and monitor side effects referring as necessary back to the TB service team if concerned.

Evidence exists to show that people who access community pharmacies may not always access other conventional NHS services. Community pharmacies could be specifically targeted to reach out to USPs in the community including, for example, asylum seekers, people from ethnic backgrounds homeless, people who misuse drugs or alcohol and travellers. Trained pharmacy teams working alongside other primary or secondary care professionals could also help support TB patients to take their medicines as intended having been involved in the treatment decisions.