Introduction & summary section

Internal Clinical Guidelines Team (UK)

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Internal Clinical Guidelines Team (UK). Tuberculosis: Prevention, Diagnosis, Management and Service Organisation. London: National Institute for Health and Care Excellence (UK); 2016 Jan. (NICE Guideline, No. 33.)

See 2019 Partial Update

September 2019: Minor wording changes have been made by NICE to recommendation 1.7.4.2 and footnotes added to reflect new restrictions and precautions for the use of fluoroquinolone antibiotics. May 2019: Recommendation 1.6.1.8 has been amended to add in more detail about the meaning of contacts. November 2018: Recommendation 1.1.3.16 on BCG vaccinations for healthcare workers and other NHS employees was updated after a surveillance review.

September 2019: Minor wording changes have been made by NICE to recommendation 1.7.4.2 and footnotes added to reflect new restrictions and precautions for the use of fluoroquinolone antibiotics. May 2019: Recommendation 1.6.1.8 has been amended to add in more detail about the meaning of contacts. November 2018: Recommendation 1.1.3.16 on BCG vaccinations for healthcare workers and other NHS employees was updated after a surveillance review.

Tuberculosis: Prevention, Diagnosis, Management and Service Organisation.

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1Introduction & summary section

1.1. Background information [2011, updated 2016]

This guideline makes recommendations on the prevention, diagnosis and management of latent and active tuberculosis (TB), including both drug susceptible and drug resistant forms of the disease. It covers the organisation of relevant TB services. It relates to activities undertaken in any setting in which NHS or public health services for TB are received, provided or commissioned in the public, private and voluntary sectors.

The NHS and Public Health England have already begun work to reduce the harm caused by TB to many individuals and communities. TB is a notifiable disease, meaning that clinicians have a statutory duty to notify Local Authorities or a local Public Health England Centre of suspected cases, and efforts have been made to strengthen services and ensure clear lines of accountability and responsibility. However, a stronger approach to TB control is now needed in order to build on this work. Indicators of TB incidence and TB treatment outcomes have been included in the Public Health Outcomes Framework^a, and a collaborative TB control strategy has been designed that brings together best practice in clinical care, social support and public health. Agencies at all levels – including national and local government, clinical commissioning groups and third sector partners – are committed to working in partnership to decrease the incidence of TB, fight the spread of drug resistant forms of the disease, reduce current health inequality and, ultimately, eliminate TB as a public health problem.

What causes TB?

TB is a curable disease caused by a bacterium called Mycobacterium tuberculosis (‘M. tuberculosis’ or ‘M.Tb’), or other bacterium in the M. tuberculosis complex (that is, M. bovis or M. africanum). It is spread by one person inhaling the bacterium in droplets coughed out by someone with infectious tuberculosis. Not all forms of tuberculosis are infectious. Those with TB in organs other than the lungs are not infectious to others, nor are people with just latent tuberculosis (see below). Some people with pulmonary tuberculosis are infectious, particularly those with bacteria which can be seen on simple microscope examination of the sputum, who are termed ‘smear positive’. The risk is greatest in those with prolonged, close household exposure to a person with infectious TB.

What happens after infection?

Once inhaled the bacteria reach the lung and grow slowly over several weeks. The body’s immune system is stimulated, which can be shown by a Mantoux test or an interferon gamma-release assay (IGRA). In most people the immune system either kills the bacteria or builds a defensive barrier around the infection but the TB bacteria are not killed and lie dormant. This is called latent tuberculosis; the person is not ill and is not infectious. Sometimes at the time of the initial infection, bacteria get into the blood stream and can be carried to other parts of the body, such as bones, lymph glands or the brain, before the defensive barrier is built. It is estimated that one third of the world’s population, two billion people, have latent tuberculosis.

If the immune system fails to build the defensive barrier, or the barrier fails later, latent tuberculosis can spread within the lung (pulmonary tuberculosis) or develop in the other part(s) of the body it has spread to (extrapulmonary tuberculosis). Only some of those with latent tuberculosis will develop symptoms (‘active tuberculosis’). About half the cases of active tuberculosis develop within a few years of the original infection, particularly in children and young adults. The other half of active TB cases arise from reactivation of the latent infection many years later.

Who catches TB?

Anyone can catch TB but those at particular risk are those who have been exposed to TB bacteria, and those who are less able to fight latent infection. They include:

close contacts of infectious cases;
those who have lived in, travel to or receive visitors from places where TB is still very common;
those who live in ethnic minority communities originating from places where TB is very common;
those with immune systems weakened by HIV infection or other medical problems;
infants, young children and the elderly, as their immune systems are less robust;
those with chronic poor health and nutrition because of lifestyle problems such as homelessness or problem drug or alcohol use;
those living in poor or crowded housing conditions, including those living in hostels;
those who have spent time in prison.

What are the symptoms of TB?

Because TB can affect many sites in the body, there can be a wide range of symptoms, some of which are not specific and may delay diagnosis.

Typical symptoms of pulmonary TB include chronic cough, weight loss, intermittent fever, night sweats and coughing blood. TB in parts other than the lungs has symptoms which depend on the site, and may be accompanied by intermittent fever or weight loss. In young children, particularly those aged younger than 12 months, a failure to gain weight or grow at a ‘normal’ rate are more common than weight loss. TB is a possible diagnosis to be considered in anyone with intermittent fever, weight loss and other unexplained symptoms. Latent tuberculosis without disease, however, has no symptoms.

How is TB diagnosed?

TB is diagnosed in a number of ways. Definite diagnosis is achieved by culturing the TB bacterium from sputum or other samples. This not only confirms the diagnosis, but also shows which of the TB drugs the bacterium is sensitive to. Tissue samples from biopsies may show changes that suggest TB, as do certain X-ray changes, particularly on chest X-rays. Newer rapid molecular diagnostics – nucleic acid amplification tests (NAATs) – that are able to detect small amounts of genetic material from the mycobacterium by repeatedly amplifying target sequences are also available.

Mantoux tests and IGRAs can show if someone has been exposed to TB and may have latent infection. Skin tests use a tiny dose of TB protein injected under the skin. In people who have been exposed to TB this gives a positive reaction, which is seen as a raised, red area. IGRAs involve taking a blood sample, which is processed at a laboratory to identify interferon gamma released from T cells in response to specific TB antigens.

How is TB treated?

TB is completely curable if the correct drugs are taken for the correct length of time. Before drug treatment for TB nearly half of all persons with active tuberculosis died from it. Several antibiotics need to be taken over a number of months to prevent resistance developing to the TB drugs. The great majority of TB bacteria are sensitive to the antibiotics used (rifampicin, isoniazid, pyrazinamide and ethambutol). A minority of cases, 7.8% in the UK in 2013, are resistant to one of the first line antibiotics^b. Isoniazid and rifampicin are ineffective in 1% of cases. These cases are said to be of multi-drug resistant TB (MDR TB), which is harder to treat (see Appendix K for details of TB epidemiology).

TB bacteria grow very slowly and divide only occasionally when the antibiotics start to kill them, so treatment usually has to be continued for six months to ensure all active and dormant bacteria are killed and the person with TB is cured. People with pulmonary TB are usually not infectious after two weeks of treatment. Drug-resistant forms of the bacteria require treatment for longer than six months. MDR TB is particularly serious, requiring significantly prolonged (up to 24 months) treatment, with the infectious period lasting much longer.

In latent tuberculosis there are many thousand times fewer TB bacteria than in active tuberculosis. Treatment with a single drug (isoniazid) for six months, or two drugs (isoniazid and rifampicin) for a shorter time, is sufficient to kill most or all of the dormant bacteria, reducing the risk that the person will develop active tuberculosis later in their life.

Following TB treatment, the disease can return (relapse) in a small number of people, because not all bacteria have been killed. This is obviously much more likely if the course of treatment has been interrupted, not completed or otherwise not followed. However, it is also possible to catch TB a second time, unlike some other infectious diseases.

1.2. Epidemiology of TB in England and Wales [2011, updated 2016]

Up-to-date epidemiological information, including reports of notifications and enhanced surveillance, is available from Public Health England (https://www.gov.uk/government/organisations/public-health-england).

Historical trends

The TB notification system, implemented in 1913, showed that recorded TB rates peaked in England and Wales in the early part of the twentieth century, when 300 new cases per 100,000 people were reported every year. Since then, until the mid 1980s at least, the incidence of tuberculosis has been falling: in 1987 there were only 10 new cases per 100,000 people.

Geographical variations in incidence

There are marked differences in the incidence of tuberculosis in different parts of the UK, with most new cases occurring in cities. For example, there were less than 4 new cases per year per 100,000 population in the south west of England in 2013, as compared to 35.5 in London – a figure that did not include the incidence of tuberculosis among people who are homeless (a key high-risk population)^c. There are also substantial variations in incidence of TB within cities, with as much as a thirtyfold difference between different London boroughs.

Variations in incidence by ethnicity and place of birth

Risk of TB is significantly higher in people from minority ethnic groups and in people born outside of the UK, as is evident in Table 1. The majority of cases in people born abroad occur after they have lived in the UK for several years.

Table 1

Tuberculosis rates in the UK by ethnicity and place of birth, 2013.

1.3. GDG and SDG membership ICG technical team and peer review

1.3.1. Guideline Development Group 2016

Ibrahim Abubakar (Guideline Co-Chair)^**
Professor in Infectious Disease Epidemiology, University College London
Andrew Hayward (Guideline Co-Chair)^**
Professor of Infectious Disease Epidemiology and Inclusion Health Research, University College London
Faizan Ahmed
GP, Manchester
Sudy Anaraki^**
Consultant in Communicable Disease Control, North East and North Central London Health Protection Team
Christine Bell^**
TB/Respiratory Nurse, Manchester Royal Infirmary
Toby Capstick (co-opted expert member)
Lead Respiratory Pharmacist, Leeds Teaching Hospitals NHS Trust
Ann Chapman
Consultant in Infectious Diseases and General Medicine, Monklands Hospital NHS Lanarkshire
Timothy Collyns
Consultant Medical Microbiologist, Leeds Teaching Hospitals NHS Trust
Francis Drobniewski
Professor of Global Health and Tuberculosis, Imperial College, London
Michael Eisenhut
Consultant Paediatrician, Luton & Dunstable Hospital NHS Foundation Trust
Mango Hoto^**
Patient and carer member
Uday Katkar^**
GP Locum, Stoke-on-Trent
Marc Lipman^**
Consultant Respiratory Physician, Royal Free London NHS Foundation Trust
Amy McConville^**
Patient and carer member
Tessa Marshall (until October 2013)
Patient and carer member, TB Alert
Philip Monk (until July 2013)
Consultant in Communicable Disease Control
Horace Reid^**
Patient and carer member
Bertie Squire
Consultant Physician in Infectious Diseases, Liverpool School of Tropical Medicine
Alistair Story^**
Consultant TB Nurse, London
John Watson – (co-opted expert member)
Consultant in Respiratory Medicine, The Leeds Teaching Hospital NHS Trust

1.3.2. Service Delivery Group co-optees 2016

Vanya Grant
Divisional Clinical Director for Infection, UCLH
John Hayward
Independent Consultant in Public Health, London
Alan Higgins
Director of Public Health, Oldham
Onn Min Kon
Consultant Respiratory Physician, London
Philip Monk
Consultant in Health Protection, Leicester
Ikenna Obianwa
Community Development Officer, London

For a full list of guideline development group and service delivery group declarations of interest, see Appendix A.

1.3.3. Internal Clinical Guidelines team

Emma Banks (until June 2014)
Project Manager
Julia Bidonde (from September 2014)
Technical Analyst
Margaret Derry (from September 2014)
Project Manager
Stephen Duffield (January to April 2014)
Technical Analyst
Susan Ellerby
Clinical Adviser
Nicole Elliott (until June 2014)
Associate Director
Chris Gibbons
Health Economist
Michael Heath (until October 2014)
Programme Manager
Ruaraidh Hill (from September 2013 to May 2014)
Analyst, Centre for Public Health
Lucy Hoppe
Lead Technical Analyst
Andrew Hoy (from September 2013 to August 2014)
Analyst, Centre for Public Health
Rachel Kettle (from August 2013)
Lead Technical Analyst, Centre for Public Health
Hugh McGuire (from March 2014)
Technical Adviser
Claire McLeod (from September 2013)
Analyst, Centre for Public Health
Stephanie Mills (until April 2013)
Project Manager
Lakshmi Murthy (from January to October 2014)
Analyst, Centre for Public Health
Kay Nolan
Associate Director, Centre for Public Health
Suzi Peden (until August 2013)
Technical Analyst, Centre for Public Health
Robby Richey (June 2013 to June 2014)
Technical Analyst
Gabriel Rogers
Technical Adviser, Health Economics
Susan Spiers (from June 2014)
Associate Director
Catherine Swann
Associate Director, Centre for Public Health
Toni Tan (until March 2014)
Technical Adviser

1.3.4. Peer review

Professor Peter Ormerod

1.4. Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Committee makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Committee is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also ‘Patient-centred care’).

Interventions that must (or must not) be used

We usually use ‘must’ or ‘must not’ only if there is a legal duty to apply the recommendation. Occasionally we use ‘must’ (or ‘must not’) if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a ‘strong’ recommendation

We use ‘offer’ (and similar words such as ‘refer’ or ‘advise’) when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, ‘Do not offer…’) when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use ‘consider’ when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient’s values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of ‘The guidelines manual’ (January 2009). This does not apply to any recommendations ending [2006], [2011] and [2012] (see ‘Update information’ box below for details about how recommendations are labelled). In particular, for recommendations labelled [2006] and [2012], the word ‘consider’ may not necessarily be used to denote the strength of the recommendation.

Update information

Our first guideline on TB was published in 2006. This was updated in 2011. This guideline is an update of tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control (published March 2011) and will replace it. It also incorporates and adapts the guideline on identifying and managing TB in hard-to-reach groups published in March 2012.

It has not been possible to update all sections and recommendations in this update of the guideline. This means some of the recommendations that have not been reviewed may not reflect current practice. Areas for review and update were identified, prioritised and agreed through the scoping process.

Areas that have not been reviewed in this update may be addressed 2 years after publication, when NICE next considers updating this guideline. NICE may undertake a more rapid update of discrete areas of the guideline if new and relevant evidence is published.

Recommendations in the guideline update have been labelled to show:

the year each recommendation was written and the year(s) of any updates
which parts of the guideline are open for stakeholder comment at consultation.

1.5. Recommendations

1.

Offer Mantoux^e testing to diagnose latent TB in adults aged 18 to 65 who are close contacts of a person with pulmonary or laryngeal TB.

If the Mantoux test is inconclusive, refer the person to a TB specialist.
If the Mantoux test is positive (an induration of 5 mm or larger, regardless of BCG history), consider an interferon-gamma release assay.
If either is positive, assess for active TB (see sections 3.2 to 3.7); if this assessment is negative, offer them treatment for latent TB infection (see section 7). [2011, amended 2016]

2.

Only consider using interferon-gamma release assays alone in children and young people if Mantoux testing is not available or is impractical. This includes, for example, situations in which large numbers need to be tested (see section 10.2.20 and recommendation 15). [new 2016]

3.

Refer children younger than 2 years and in close contact with people with smear-negative pulmonary or laryngeal TB to a specialist to determine what testing strategy for latent TB should be done. This should be a paediatrician with experience and training in TB, or a general paediatrician with advice from a specialised clinician. [new 2016]

4.

If a neonate has been in close contact with people with smear-positive pulmonary or laryngeal TB who have not had at least 2 weeks of anti-TB treatment:

Assess for active TB (see sections 3.2 to 3.7).
Start isoniazid (with pyridoxine).
Carry out a Mantoux test after 6 weeks of treatment.
If the Mantoux test is inconclusive, refer the child to a TB specialist.
If the Mantoux test is positive (5 mm or larger, regardless of BCG history), reassess for active TB; if this assessment is negative, continue isoniazid (with pyridoxine) for a total of 6 months.
If the Mantoux test is negative, reassess for active TB and consider an interferon-gamma release assay:
- if the interferon-gamma release assay is negative then stop isoniazid (and pyridoxine) and give a BCG vaccination (see section 8)
- if the interferon-gamma release assay is positive, reassess for active TB; if this assessment for active TB is negative, continue isoniazid (with pyridoxine) for a total of 6 months. [new 2016]

5.

If a child aged between 4 weeks and 2 years has been in close contact with people with smear-positive pulmonary or laryngeal TB who have not had at least 2 weeks of anti-TB treatment:

Assess for active TB.
Start treatment for latent TB (see section 7) and carry out a Mantoux test.
If the Mantoux test is inconclusive, refer the child to a TB specialist.
If the Mantoux test is positive (5 mm or larger, regardless of BCG history), reassess for active TB; if this assessment is negative, complete treatment for latent TB.
If the Mantoux test is negative, continue treatment for latent TB, reassess for active TB after 6 weeks and repeat the Mantoux test:
- if the Mantoux test is negative, consider an interferon-gamma release assay
- if the interferon-gamma release assay is negative, treatment for latent TB may be stopped; give a BCG vaccination if the child has not already had one
- if either test is positive, reassess for active TB; if this assessment is negative, complete treatment for latent TB. [new 2016]

6.

If a child or young person aged between 2 and 17 years has been in close contact with people with pulmonary or laryngeal TB:

Offer Mantoux testing.
If the Mantoux test is inconclusive, refer the child or young person to a TB specialist.
If the Mantoux test is positive (5 mm or larger, regardless of BCG history), assess for active TB; if this assessment is negative, offer them treatment for latent TB infection.
If the initial Mantoux test is negative, offer an interferon-gamma release assay after 6 weeks and repeat the Mantoux test. [new 2016]

7.

Assess and manage TB in new entrants from high incidence countries who present to healthcare services as follows:

assess risk of HIV, including HIV prevalence rates in the country of origin, and take this into account when deciding whether to give a BCG vaccination
offer testing for latent TB (see section 3.1)
assess for active TB if the test for latent TB is positive (see sections 3.3 to 3.7)
offer treatment to people aged 65 years or younger in whom active TB has been excluded but who have a positive Mantoux test or a positive interferon-gamma release assay for latent TB infection (see section 7)
consider offering BCG for unvaccinated people who are Mantoux- or interferon-gamma release assay-negative (see section 8)
give ‘inform and advise’ information to people who do not have active TB and are not being offered BCG or treatment for latent TB infection. (see section 9.2) [2006, amended 2011 and 2016]

8.

Offer Mantoux testing as the initial diagnostic test for latent TB infection in people who have recently arrived from a high-incidence country who present to healthcare services. If the Mantoux test is positive (5 mm or larger, regardless of BCG history):

assess for active TB (see section 3.2 to 3.7), and
if this assessment is negative, offer them treatment for latent TB infection (see section 7).

If Mantoux testing is unavailable, offer an interferon-gamma release assay. [2006, amended 2011 and 2016]

9.

Primary care services should support local, community-based and voluntary organisations that work with vulnerable migrants to ensure they:

register with a primary care provider
know how to use NHS services (emergency or primary care). [2012]

10.

Healthcare professionals, including primary care staff, responsible for testing new entrants should test all vulnerable migrants who have not previously been checked. This is regardless of when they arrived in England. People born in countries with an incidence of more than 150 per 100,000 per year should be made a priority for latent TB testing when they arrive here. [2012, amended 2016]

11.

If latent TB is suspected in children and young people who are anticipated to be or are currently immunocompromised (for example, if they are from a high incidence country or have been in close contact with people with suspected infectious or confirmed pulmonary or laryngeal TB), refer to a TB specialist. [2016]

12.

In adults who are anticipated to be or are currently immunocompromised, do a risk assessment to establish whether testing should be offered, taking into account their:

risk of progression to active TB based on how severely they are immunocompromised and for how long they have been immunocompromised
risk factors for TB infection, such as country of birth or recent contact with an index case with suspected infectious or confirmed pulmonary or laryngeal TB. [new 2016]

13.

For adults who are severely immunocompromised, such as those with HIV and CD4 counts of fewer than 200 cells/mm³, or after solid organ or allogeneic stem cell transplant, offer an interferon-gamma release assay and a concurrent Mantoux test.

If either test is positive (for Mantoux, this is an induration of 5 mm or larger, regardless of BCG history), assess for active TB.
If this assessment is negative, offer them treatment for latent TB infection. [new 2016]

14.

For other adults who are immunocompromised, consider an interferon-gamma release assay alone or an interferon-gamma release assay with a concurrent Mantoux test.

If either test is positive (for Mantoux, this is an induration of 5 mm or larger, regardless of BCG history), assess for active TB
If this assessment is negative, offer them treatment for latent TB infection. [new 2016]

15.

In an incident situation when large numbers of people may need to be screened, consider a single interferon-gamma release assay for people aged 18–65 years. For children and young people, follow recommendations 2 to 6. [2011, amended 2016]

16.

Offer a Mantoux test to new NHS employees who will be in contact with patients or clinical materials, if the employees:

are not new entrants from high-incidence countries and
have not had BCG vaccination (for example, they are without a BCG scar, other documentation or a reliable history).

If the Mantoux test is positive, offer an interferon-gamma release assay. If this is positive, assess for active TB; if this assessment is negative, offer them treatment for latent TB infection. [2011, amended 2016]

17.

Offer a Mantoux test to new NHS employees who are from a high-incidence country.

If the Mantoux test is positive (5 mm or larger, regardless of BCG history), assess for active TB; if this assessment is negative, offer them treatment for latent TB infection.
If Mantoux testing is unavailable, offer an interferon-gamma release assay. [new 2016]

18.

Offer an interferon-gamma release assay to new NHS employees who have had contact with patients in settings where TB is highly prevalent:

If the interferon-gamma release assay is positive, assess for active TB and
if this assessment is negative, offer them treatment for latent TB infection. [2011, amended 2016]

19.

Healthcare workers who are immunocompromised should be screened in the same way as other people who are immunocompromised (see recommendations 11 to 14). [2011]

20.

Offer people younger than 65 years from under-served groups a single interferon-gamma release assay. [2011, amended 2016]

21.

Substance misuse services with access to an interferon-gamma release assay should provide testing for people younger than 65 years who misuse substances if they:

live in a high incidence area
are likely to be involved with substance misuse services or other support services on a regular basis (for example, for opioid substitution therapy), when support should be available for directly observed preventive therapy. [2012, amended 2016]

22.

In high incidence areas (and at prisons that receive prisoners from high incidence areas), prison health services should offer an interferon-gamma release assay for TB to inmates younger than 65 years who are in regular contact with substance misuse services or other support services. This is provided arrangements have been made for this support to continue after release. [2012, amended 2016]

23.

Substance misuse services and prison health services should incorporate interferon-gamma release assay testing with screening for hepatitis B and C, and HIV testing. They should refer prisoners and people who misuse substances with positive interferon-gamma release assays to local multidisciplinary TB teams for further clinical investigations. For prisoners, these investigations should be done in the prison if practically possible. [2012, amended 2016]

24.

If the interferon-gamma release assay is positive, assess for active TB (see sections 3.2 to 3.7); if this assessment is negative, offer them treatment for latent TB infection (see section 7). [new 2016]

25.

If TB is a possibility, microbiology staff should consider carrying out TB culture on samples (see recommendations 29 and 30), even if it is not requested. [2006, amended 2016]

26.

If there are clinical signs and symptoms consistent with a diagnosis of TB, start treatment without waiting for culture results. [2006]

27.

Consider completing the standard recommended regimen (see recommendations 59 and 60), even if subsequent culture results are negative. [2006, amended 2016]

28.

Take a chest X-ray; do further diagnostic investigations (as detailed below and summarised in ‘Diagnostic investigations for pulmonary TB’ table) if chest X-ray appearances suggest TB. [2016]

29.

Send multiple respiratory samples (3 deep cough sputum samples, preferably including 1 early morning sample) for TB microscopy and culture. [2016]

This should be before starting treatment if possible, or, failing that, within 7 days of starting treatment in people with life-threatening disease. [2006, amended 2016]
Obtain spontaneously-produced, deep cough sputum samples if possible, otherwise use:
- 3 gastric lavages or 3 inductions of sputum in children and young people (see recommendation 102) [new 2016] or
- induction of sputum or bronchoscopy and lavage in adults. [2006, amended 2016]
Laboratory practices should be in accordance with the UK’s Standards for Microbiology Investigations. [new 2016]

30.

Send samples for TB culture from autopsy samples if pulmonary or laryngeal TB is a possibility. [2006]

31.

Request rapid diagnostic nucleic acid amplification tests for the M. tuberculosis complex (M. tuberculosis, M. bovis, M. africanum) on primary specimens (listed in ‘Diagnostic investigations for pulmonary TB’ table) if there is clinical suspicion of TB disease, and:

the person has HIV or
rapid information about mycobacterial species would alter the person’s care or
the need for a large contact-tracing initiative is being explored. [new 2016]

32.

In children aged 15 years or younger with suspected pulmonary TB, offer rapid diagnostic nucleic acid amplification tests for the M. tuberculosis complex (M. tuberculosis, M. bovis, M. africanum). Usually only 1 nucleic acid amplification test is needed per specimen type (for example, spontaneous sputum, induced sputum or gastric lavage). (Listed in ‘Diagnostic investigations for pulmonary TB’ table). [new 2016]

33.

In young people aged 16–18 years use the same criteria as in adults to decide whether to request rapid diagnostic nucleic acid amplification tests (see ‘Diagnostic investigations for pulmonary TB’ table).

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional tests (if it would alter management)
Pulmonary (adult)	X-ray^b CT thorax	3 respiratory samples: preferably spontaneously-produced, deep cough sputum samples, otherwise induced sputum or bronchoscopy and lavage preferably 1 early morning sample	Microscopy Culture Histology	Nucleic acid amplification test
Pulmonary (young people aged 16–17 years)	X-ray^b CT thorax	3 respiratory samples: preferably spontaneously-produced, deep cough sputum samples, otherwise induced sputum or gastric lavage preferably 1 early morning sample	Microscopy Culture Histology	Nucleic acid amplification test
Pulmonary (children aged 15 years or younger)	X-ray^b CT thorax	3 respiratory samples: preferably spontaneously-produced, deep cough sputum samples, otherwise induced sputum or gastric lavage preferably 1 early morning sample	Microscopy Culture Histology Nucleic acid amplification tests (1 per specimen type)	Interferon-gamma release assay and/or tuberculin skin test (with expert input)

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
b: Routine test (see recommendation 28)

[new 2016]

34.

Either a paediatrician with experience and training in TB or a general paediatrician with advice from a specialised clinician should investigate and manage TB in children and young people. [new 2016]

35.

An expert in paediatric TB may request interferon-gamma release assays and tuberculin skin tests. Interpret these together with other diagnostic tools (such as history taking, clinical examination and imaging). [new 2016]

36.

Discuss the advantages and disadvantages of both biopsy and needle aspiration with the patient, with the aim of obtaining adequate material for diagnosis. [2006]

37.

Do not place part or all of any of the samples in formalin (or other fixative agent) when sending for TB culture. [2006, amended 2016]

38.

Think about a diagnosis of extrapulmonary TB even if rapid diagnostic tests in, for example, cerebrospinal fluid, pleural fluid or ascitic fluid are negative. [new 2016]

39.

Offer all patients presenting with extrapulmonary TB a chest X-ray and, if possible, culture of a spontaneously-produced respiratory sample to exclude or confirm coexisting pulmonary TB (see sections 3.2 to 3.5). Also, consider site-specific tests as described below to exclude or confirm additional sites of TB. [new 2016]

40.

Refer to an expert for sites not listed here, including TB of the eye and other rare sites of disease. [new 2016]

Pleural TB

41.

Use the site-specific investigations listed in the ‘Site-specific investigations for pleural TB’ table to diagnose and assess pleural TB.

Site-specific investigations for pleural TB

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional tests on primary specimen (if it would alter management)
Pleural	X-ray Bronchoscopy	3 respiratory samples: preferably spontaneously-produced, deep cough sputum samples, otherwise induced sputum or gastric lavage preferably 1 early morning sample Pleural biopsy	Microscopy Culture Histology	–
Pleural	X-ray Bronchoscopy	Pleural fluid	Microscopy Culture Cytology	Adenosine deaminase assay

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

[new 2016]

Central nervous system TB

42.

Use the site-specific investigations listed in the ‘Site-specific investigations for central nervous system TB’ table to diagnose and assess central nervous system TB.

Site-specific investigations for central nervous system TB

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional tests on primary specimen (if it would alter management)
Central nervous system	CT^b MRI^b	Biopsy of suspected tuberculoma	Microscopy Culture Histology	–
Central nervous system	CT^b MRI^b	Cerebrospinal fluid	Microscopy Culture Cytology	Adenosine deaminase assay
Meningeal	CT^b MRI^b	Cerebrospinal fluid	Microscopy Culture Cytology	Nucleic acid amplification test Adenosine deaminase assay

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment
b: Routine test (see recommendation 43)

[new 2016]

43.

Offer a CT or MRI scan to people in whom central nervous system involvement is suspected. [2016]

44.

Offer treatment for TB meningitis if clinical signs and other laboratory findings are consistent with the diagnosis, even if a rapid diagnostic test is negative. [new 2016]

Lymph node TB (including intrathoracic mediastinal adenopathy)

45.

Use the site-specific investigations listed in the ‘Site-specific investigations for lymph node TB’ table to diagnose and assess lymph node TB (including intrathoracic mediastinal adenopathy).

Site-specific investigations for lymph node TB

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional tests on primary specimen (if it would alter management)
Lymph node (including intrathoracic mediastinal adenopathy)	Ultrasound CT MRI	Biopsy	Microscopy Culture Histology	Nucleic acid amplification test
Lymph node (including intrathoracic mediastinal adenopathy)	Ultrasound CT MRI	Aspirate	Microscopy Culture Cytology	Nucleic acid amplification test

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

[new 2016]

Pericardial TB

46.

Use the site-specific investigations listed in the ‘Site-specific investigations for pericardial TB’ table to diagnose and assess pericardial TB.

Site-specific investigations for pericardial TB

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional tests on primary specimen (if it would alter management)
Pericardial	Echocardiogram	Biopsy of pericardium	Microscopy Culture Histology	–
Pericardial	Echocardiogram	Pericardial fluid	Microscopy Culture Cytology	Nucleic acid amplification test Adenosine deaminase assay

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

[new 2016]

Gastrointestinal TB

47.

Use the site-specific investigations listed in the ‘Site-specific investigations for gastrointestinal TB’ table to diagnose and assess gastrointestinal TB.

Site-specific investigations for gastrointestinal TB

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional tests on primary specimen (if it would alter management)
Gastrointestinal	Ultrasound CT Laparoscopy	Biopsy of omentum Biopsy of bowel Biopsy of liver	Microscopy Culture Histology	–
Gastrointestinal	Ultrasound CT Laparoscopy	Ascitic fluid	Microscopy Culture Cytology	Adenosine deaminase assay

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

[new 2016]

Genitourinary TB

48.

Use the site-specific investigations listed in the ‘Site-specific investigations for genitourinary TB’ table to diagnose and assess genitourinary TB.

Site-specific investigations for genitourinary TB

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional tests on primary specimen (if it would alter management)
Genitourinary	Ultrasound Intravenous urography Laparoscopy	Early morning urine	Culture	–
Genitourinary	Ultrasound Intravenous urography Laparoscopy	Biopsy from site of disease, such as endometrial curettings or renal biopsy	Microscopy Culture Histology	–

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

[new 2016]

Bone and joint TB

49.

Use the site-specific investigations listed in the ‘Site-specific investigations for bone and joint TB’ table to diagnose and assess bone and joint TB.

Site-specific investigations for bone and joint TB

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional test on primary specimen (if it would alter management)
Bone or joint TB	X-ray CT MRI	Biopsy or aspirate of paraspinal abscess Biopsy of joint Aspiration of joint fluid	Culture	–

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

[new 2016]

Disseminated TB

50.

Use the site-specific investigations listed in the ‘Site-specific investigations for disseminated TB’ table to diagnose and assess disseminated TB.

Site-specific investigations for disseminated TB

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional tests on primary specimen (if it would alter management)
Disseminated	CT of the thorax and head MRI Ultrasound of the abdomen	Biopsy of site of disease, including lung, liver and bone marrow	Microscopy Culture Histology	Additional tests appropriate to site
		Aspirate bone marrow Bronchial wash Cerebrospinal fluid	Microscopy (if sample available) Culture Cytology
		Blood	Culture

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

[new 2016]

Skin TB

51.

Use the site-specific investigations listed in the ‘Site-specific investigations for skin TB’ table to diagnose and assess skin TB.

Site-specific investigations for skin TB

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional tests on primary specimen (if it would alter management)
Skin	-	Biopsy	Microscopy Culture Histology	-

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

[2016]

Localised tuberculous abscess

52.

Use the site-specific investigations listed in the ‘Site-specific investigations for localised tuberculous abscess’ table to diagnose and assess TB in a localised, tuberculous abscess at a site other than a lymph node.

Site-specific investigations for localised tuberculous abscess

Suspected site of disease	Possible imaging techniques^a	Specimen	Routine test	Additional tests on primary specimen (if it would alter management)
Abscess outside of the lymph nodes	Ultrasound or other appropriate imaging	Aspirate	Microscopy Culture Cytology	–
Abscess outside of the lymph nodes	Ultrasound or other appropriate imaging	Biopsy	Microscopy Culture Histology	–

a: Taking into account, for example, the exact site of suspected disease and the availability of the test at the time of assessment

[2016]

53.

Use fixed-dose combination tablets as part of any TB treatment regimen. [2006]

54.

Do not offer anti-TB treatment dosing regimens of fewer than 3 times per week. [2006, amended 2016]

55.

Offer a daily dosing schedule to people with active pulmonary TB. [2006, amended 2016]

56.

Consider a daily dosing schedule as first choice in people with active extrapulmonary TB. [2006, amended 2016]

57.

Consider 3 times weekly dosing for people with active TB only if:

risk assessment identifies a need for directly observed therapy and enhanced case management (see section 9.2) and
daily directly observed therapy is not possible. [2006, amended 2016]

58.

Once a diagnosis of active TB is made:

the clinician responsible for care should refer the person with TB to a clinician with training in, and experience of, the specialised care of people with TB
the TB service should include specialised nurses and health visitors
TB in children should be managed by a TB specialist (see recommendation 34), and by paediatric trained nursing staff, where possible.

If these arrangements are not possible, seek advice from more specialised colleagues throughout the treatment period. [2016]

59.

For people with active TB without central nervous system involvement, offer:

isoniazid (with pyridoxine), rifampicin, pyrazinamide and ethambutol for 2 months then
isoniazid (with pyridoxine) and rifampicin for a further 4 months.

Modify the treatment regimen according to drug susceptibility testing. [2016]

60.

For people with active TB of the central nervous system, offer:

isoniazid (with pyridoxine), rifampicin, pyrazinamide and ethambutol for 2 months then
isoniazid (with pyridoxine) and rifampicin for a further 10 months.

Modify the treatment regimen according to drug susceptibility testing. [2016]

61.

Test people with active spinal TB who have neurological signs or symptoms for central nervous system involvement (see recommendation 43). Manage direct spinal cord involvement (for example, a spinal cord tuberculoma) as TB of the central nervous system. [2016]

62.

For people with active spinal TB without central nervous system involvement, do not extend treatment beyond 6 months for residual effects (for example, persistent bending of the spine or vertebral loss). [2016]

63.

Test people with disseminated (including miliary) TB who have neurological signs or symptoms for central nervous system involvement. If there is evidence of central nervous system involvement, treat as for TB of the central nervous system. [2016]

64.

Treat active peripheral lymph node TB in people who have had an affected gland surgically removed with the standard recommended regimen. [new 2016]

65.

For people with active TB of the lymph nodes, do not routinely extend treatment beyond 6 months for newly enlarged lymph nodes or sinus formation, or for residual enlargement of the lymph nodes or sinuses. [new 2016]

Central nervous system TB

66.

At the start of an anti-TB treatment regimen, offer people with active TB of the central nervous system dexamethasone or prednisolone, initially at a high dose with gradual withdrawal over 4–8 weeks. An example of a suitable regimen is listed in the table below.

Example of suitable corticosteroid regimen for adults

	Stage^a
Dose of dexamethasone by week	1	2 or 3
1	0.3 mg/kg/day (IV)	0.4 mg/kg/day (IV)
2	0.2 mg/kg/day (IV)	0.3 mg/kg/day (IV)
3	0.1 mg/kg/day (oral)	0.2 mg/kg/day (IV)
4	3 mg/day (oral)	0.1 mg/kg/day (IV)
5	2 mg/day (oral)	4 mg/day (oral)
6	1 mg/day (oral)	3 mg/day (oral)
7	–	2 mg/day (oral)
8	–	1 mg/day (oral)

a: According to the modified British Medical Research Council criteria for disease severity:
Stage 1: Glasgow coma score of 15 without focal neurological deficits; alert and oriented
Stage 2: Glasgow coma score of 14–11 or 15 with focal neurological deficits
Stage 3: Glasgow coma score of 10 or less, with or without focal neurological deficits
: Abbreviation: IV, intravenous

67.

At the start of an anti-TB treatment regimen, offer children and young people with active TB of the central nervous system dexamethasone or prednisolone. This should initially be at a high dose with gradual withdrawal over 4–8 weeks in line with the British National Formulary for Children. [new 2016]

Pericardial TB

68.: At the start of an anti-TB treatment regimen, offer adults with active pericardial TB oral prednisolone at a starting dose of 60 mg/day, gradually withdrawing it 2–3 weeks after starting treatment. [2016]
69.: At the start of an anti-TB treatment regimen, offer children and young people with active pericardial TB oral prednisolone in line with the British National Formulary for Children. Gradually withdraw prednisolone 2–3 weeks after starting treatment. [2016]
70.: If surgery is indicated, the surgeon should fully explain what is involved to the person, either with or after consulting a TB specialist. Discuss the possible benefits and risks with the person and their family members or carers, as appropriate, so that they can make an informed decision. [new 2016]

Central nervous system TB

71.: Consider referring people with TB of the central nervous system for surgery as a therapeutic intervention only if there is evidence of raised intracranial pressure. [new 2016]

Spinal TB

72.: Do not routinely refer people with spinal TB for surgery to eradicate the disease. [new 2016]
73.: Consider referring people with spinal TB for surgery if there is spinal instability or evidence of spinal cord compression. [new 2016]

Drug resistant TB

74.

Consider surgery as a therapeutic intervention in people with potentially resectable multidrug-resistant disease if:

optimal medical therapy under direct observation has not worked or
medical therapy is likely to fail because of extensively drug-resistant TB. [new 2016]

75.

If the person has a comorbidity or coexisting condition such as:

HIV or
severe liver disease, for example, Child-Pugh level B or C or
stage 4 or 5 chronic kidney disease (a glomerular filtration rate of <30 ml/minute/1.73m2) or
diabetes or
eye disease or impaired vision or
pregnancy or breastfeeding or
a history of alcohol or substance misuse

work with a specialist multidisciplinary team with experience of managing TB and the comorbidity or coexisting condition. [new 2016]

76.

For people with HIV and active TB without central nervous system involvement, do not routinely extend treatment beyond 6 months. [new 2016]

77.

For people with HIV and active TB with central nervous system involvement, do not routinely extend treatment beyond 12 months. [new 2016]

78.

Take into account drug-to-drug interactions when co-prescribing antiretroviral and anti-TB drugs. [new 2016]

79.

In people who have experienced a treatment interruption because of drug-induced hepatotoxicity:

investigate other causes of acute liver reactions and
wait until aspartate or alanine transaminase levels fall below twice the upper limit of normal, bilirubin levels return to the normal range and hepatotoxic symptoms have resolved then
sequentially reintroduce each of the anti-TB drugs at full dose over a period of no more than 10 days, starting with ethambutol and either isoniazid (with pyridoxine) or rifampicin. [new 2016]

80.

In people with severe or highly infectious TB who need to interrupt standard therapy because of a reaction, consider continuing treatment with:

for hepatotoxicity, a combination of at least 2 anti-TB drugs of low hepatotoxicity (such as ethambutol and streptomycin, with or without a quinolone, such as levofloxacin or moxifloxacin) and monitor with a liver specialist for further reactions
for a cutaneous reaction, a combination of at least 2 anti-TB drugs with a low risk of cutaneous reactions (such as ethambutol and streptomycin) and monitor with a dermatologist for further reactions. [new 2016]

81.

If another reaction of a similar or greater severity occurs because of reintroducing a particular drug, do not give that drug in future regimens and consider extending the total regimen accordingly. [new 2016]

82.

Follow-up clinic visits should not be conducted routinely after treatment completion. [2006]

83.

Tell patients to watch for symptoms of relapse and how to contact the TB service rapidly through primary care or a TB clinic. Key workers should ensure that patients at increased risk of relapse are particularly well informed about symptoms. [2006]

84.

Patients who have had drug-resistant TB should be considered for follow-up for 12 months after completing treatment. Patients who have had multidrug-resistant TB should be considered for prolonged follow-up. [2006]

85.

As soon as possible, explore options to reduce the psychosocial impact of prolonged isolation. For example, through providing free access to internet, telephone and television, and accompanied walks in the open air. [new 2016]

86.

For people with clinically suspected TB, a TB specialist should request rapid diagnostic nucleic acid amplification tests for rifampicin resistance on primary specimens if a risk assessment for multidrug resistance identifies any of the following risk factors:

history of previous TB drug treatment, particularly if there was known to be poor adherence to that treatment
contact with a known case of multidrug-resistant TB
birth or residence in a country in which the World Health Organization reports that a high proportion (5% or more) of new TB cases are multidrug-resistant.

Start infection control measures. [new 2016]

87.

If the rapid diagnostic nucleic acid amplification test for rifampicin resistance is positive:

continue infection control measures until pulmonary or laryngeal disease has been excluded
manage treatment along with a multidisciplinary team with experience of managing multidrug-resistant TB (see section 10)
offer a treatment regimen involving at least 6 drugs to which the mycobacterium is likely to be sensitive
test for resistance to second-line drugs. [new 2016]

88.

If the rapid diagnostic nucleic acid amplification test for the M. tuberculosis complex is positive but rifampicin resistance is not detected, treat as drug-susceptible TB with the standard regimen. (see section 4) [new 2016]

89.

If the rapid diagnostic nucleic acid amplification test for the M. tuberculosis complex is negative in a person at high risk of multidrug-resistant TB:

obtain further specimens for nucleic acid amplification testing and culture, if possible
use rapid rifampicin resistance detection on cultures that become positive for the M. tuberculosis complex
consider waiting for the results of further tests before starting treatment if the person is well
if urgent treatment is needed, consider managing as multidrug-resistant TB until sensitivity results are available. [new 2016]

90.

When definitive phenotypic susceptibility results are available, modify treatment as needed. (see sections 4 and 5) [new 2016]

91.

Consider more intensive clinical follow-up for people with multidrug-resistant TB. This includes people having directly observed therapy(see sections 4.11 and 9.2) throughout treatment because of the complexity of treatment and risk of adverse events. [new 2016]

92.

Discuss the options for organising care for people with multidrug-resistant TB with clinicians who specialise in this. Seek the person’s views and take them into account, and consider shared care (see section 10.2). [2006]

93.

For people with TB, without central nervous system involvement, that is resistant to just 1 drug consider the treatments in the ‘Recommended drug regimens for non-MDR drug-resistant TB’ table.

Drug resistance	First 2 months (initial phase)	Continue with (continuation phase)
Isoniazid	Rifampicin, pyrazinamide and ethambutol	Rifampicin and ethambutol for 7 months (up to 10 months for extensive disease)
Pyrazinamide	Rifampicin, isoniazid (with pyridoxine) and ethambutol	Rifampicin and isoniazid (with pyridoxine) for 7 months
Ethambutol	Rifampicin, isoniazid (with pyridoxine) and pyrazinamide	Rifampicin and isoniazid (with pyridoxine) for 4 months
Rifampicin	As for multidrug-resistant TB

[new 2016]

94.

For people with drug-resistant TB and central nervous system involvement, involve a TB specialist with experience in managing drug-resistant TB in decisions about the most appropriate regimen and the duration of treatment. [new 2016]

95.

Ensure healthcare settings can promptly identify people with suspected infectious or confirmed pulmonary or laryngeal TB before or at presentation. Ensure people working in the settings follow the recommendations about testing and treatments.(see sections 3.2 to 3.5 and section 5) [new 2016]

96.

Put people with suspected infectious or confirmed pulmonary or laryngeal TB who will remain in a hospital setting (including emergency, outpatients or inpatient care) in a single room. If this is not possible, keep the person’s waiting times to a minimum. This may involve prioritising their care above that of other patients. [new 2016]

97.

Minimise the number and duration of visits a person with TB makes to an outpatient department while they are still infectious. To minimise the risk of infection, people with infectious TB should be seen at times or in places away from other people. [new 2016]

98.

In hospital settings, risk assess people with suspected infectious or confirmed pulmonary TB for multidrug-resistant TB (see section 5). Care for people deemed to be at low risk in a single room, as a minimum. For people deemed to be at high risk:

provide care in a negative pressure room and
have specimens sent for rapid diagnostic tests, such as nucleic acid amplification tests. [new 2016]

99.

Unless there is a clear clinical or public health need, such as homelessness, people with suspected infectious or confirmed pulmonary TB should not be admitted to hospital for diagnostic tests or for care. [2006, amended 2016]

100.

Do not admit people with suspected infectious or confirmed pulmonary TB to a ward containing people who are immunocompromised, such as transplant recipients, people with HIV and those on anti-tumour necrosis factor alpha or other biologics, unless they can be cared for in a negative pressure room on the same ward. [new 2016]

101.

Assess any visitors to a child with suspected active TB in hospital for symptoms of infectious TB, and keep them separate from other people until they have been excluded as a source of infection (see sections 3.1 and 11). [new 2016]

102.

In people who may have TB, only carry out aerosol-generating procedures such as bronchoscopy, sputum induction or nebuliser treatment in an appropriately engineered and ventilated area (ideally a negative pressure room). [new 2016]

103.

Explain to inpatients with suspected infectious or confirmed pulmonary or laryngeal TB that they will need to wear a surgical mask in the hospital whenever they leave their room. Ask them to continue wearing it until they have had at least 2 weeks of treatment. [2016]

104.

Offer people advice on simple respiratory hygiene measures. [new 2016]

105.

In non-healthcare settings catering for large numbers of people and populations at high risk of TB (such as detention settings, residential hostels and day centres):

promote simple respiratory hygiene
ensure awareness of symptoms of potentially infectious TB to enable prompt healthcare referral
work with the local public health team and the local authority to ensure accommodation for people with TB
ensure adequate ventilation. [new 2016]

106.

If people with suspected or known infectious multidrug-resistant TB are admitted to hospital, admit them to a negative pressure room. If none is available locally, transfer them to a hospital that has these facilities and a clinician experienced in managing complex drug-resistant cases. Carry out care in a negative pressure room for people with:

suspected multidrug-resistant TB, until non-resistance is confirmed
confirmed multidrug-resistant TB, until they have 3 negative smears at weekly intervals and ideally have a negative culture. [new 2016]

107.

Staff and visitors should wear filtering face piece (FFP3) masks during contact with a person with suspected or known multidrug-resistant TB while the person is thought to be infectious. [2016]

108.

Before deciding to discharge a person with suspected or known multidrug-resistant TB from hospital, agree with the person and their carers secure arrangements for supervising and administering all anti-TB therapy. [2016]

109.

Ensure negative pressure rooms used for infection control in multidrug-resistant TB meet the standards of the Interdepartmental Working Group on Tuberculosis, and are clearly identified for staff, for example by a standard sign. Keep such signs up to date. [2016]

Healthcare settings

110.

Care for people with a continuing clinical or public health need for admission with pulmonary TB in a single room (as a minimum) until they have completed 2 weeks of the standard treatment regimen (see section 4) if they:

are unlikely to be rifampicin resistant (that is, do not have risk factors for multidrug-resistant TB) or
have negative rifampicin resistance on nucleic acid amplification test or culture. [new 2016]

111.

Consider de-escalating isolation after 2 weeks of treatment, taking into account the risks and benefits, if:

the person is showing tolerance to the prescribed treatment
there is agreement to adhere to treatment
there is resolution of cough
there is definite clinical improvement on treatment; for example, remaining afebrile for a week
there are not immunocompromised people, such as transplant recipients, people with HIV and those on anti-tumour necrosis factor alpha or other biologics, in the same accommodation
the person’s initial smear grade was not high; for example, 2 or less
there is not extensive pulmonary involvement, including cavitation
there is no laryngeal TB. [new 2016]

112.

Consider discharging from hospital people:

who do not have a continuing clinical or public health need for admission with pulmonary TB and
who are unlikely to be rifampicin resistant (that is, do not have risk factors for multidrug-resistant TB or
who have negative rifampicin resistance on nucleic acid amplification test or culture.

If discharged, the person should avoid congregate settings for the first 2 weeks of their treatment. [new 2016]

Non-healthcare settings

113.

In prisons or immigration removal centres, everyone with X-ray changes indicative of active TB, as well as those with symptoms who are awaiting X-ray, should be isolated in an adequately ventilated individual room or cell. Prisoners and detainees should be retained on medical hold until they have:

proven smear-negative and had an X-ray that does not suggest active TB or
had a negative risk assessment for multidrug-resistant TB and completed 2 weeks of the standard treatment regimen. [2012, amended 2016]

Multidrug-resistant TB

114.

Consider earlier discharge for people with confirmed multidrug-resistant TB, if there are suitable facilities for home isolation and the person will adhere to the care plan. [new 2016]

115.

For people with confirmed multidrug-resistant TB whose symptoms have improved and who are unable to produce sputum, discharge decisions should be taken by the multidisciplinary team and the health protection team. [new 2016]

116.

Discuss the decision to discharge a person with suspected or known multidrug-resistant TB with:

the infection control team and
the local microbiologist and
the local TB service and
the health protection team. [2016]

117.

Be aware that certain groups of people with latent TB are at increased risk of going on to develop active TB, including people who:

are HIV-positive
are younger than 5 years
have excessive alcohol intake
are injecting drug users
have had solid organ transplantation
have a haematological malignancy
are having chemotherapy
have had a jejunoileal bypass
have diabetes
have chronic kidney disease or receive haemodialysis
have had a gastrectomy
are having treatment with anti-tumour necrosis factor-alpha or other biologic agents
have silicosis. [new 2016]

118.

For people, including those with HIV, aged younger than 65 years with evidence of latent TB who have been in close contact with people who have suspected infectious or confirmed active pulmonary or laryngeal drug-sensitive TB, offer either of the following drug treatments:

3 months of isoniazid (with pyridoxine) and rifampicin or
6 months of isoniazid (with pyridoxine). [new 2016]

119.

For adults between the ages of 35 and 65 years, offer drug treatments only if hepatotoxicity is not a concern. [new 2016]

120.

Base the choice of regimen on the person’s clinical circumstances. Offer:

3 months of isoniazid (with pyridoxine) and rifampicin to people younger than 35 years if hepatotoxicity is a concern after an assessment of both liver function (including transaminase levels) and risk factors
6 months of isoniazid (with pyridoxine) if interactions with rifamycins are a concern, for example, in people with HIV or who have had a transplant. [new 2016]

121.

Clearly explain the risks and potential benefits of each treatment regimen. In discussion with the person, select a suitable regimen if they wish to proceed with preventive treatment. [new 2016]

122.

Offer testing for HIV before starting treatment for latent TB. See NICE guidelines on increasing the uptake of HIV testing among black Africans in England and increasing the uptake of HIV testing among men who have sex with men. [new 2016]

123.

Offer adults testing for hepatitis B and C before starting treatment for latent TB. See NICE guidelines on hepatitis B and C: ways to promote and offer testing to people at increased risk of infection and hepatitis B (chronic): diagnosis and management of chronic hepatitis B in children, young people and adults. [new 2016]

124.

Consider testing children and young people for hepatitis B and C before starting treatment for latent TB. See NICE guidelines on hepatitis B and C: ways to promote and offer testing to people at increased risk of infection and hepatitis B (chronic): diagnosis and management of chronic hepatitis B in children, young people and adults. [new 2016]

125.

If a person also has severe liver disease, for example, Child-Pugh level B or C, work with a specialist multidisciplinary team with experience of managing TB and liver disease. [new 2016]

126.

Manage treatment with caution, ensuring careful monitoring of liver function, in:

people with non-severe liver disease
people with abnormal liver function (including abnormal transaminase levels) before starting treatment for latent TB infection
people who misuse alcohol or drugs. [new 2016]

127.

Ensure people having treatment for latent TB who also have social risk factors, such as misusing alcohol or drugs or being homeless, are linked to support services. They should also have an assessment of social needs and stability, including potential barriers to adherence or treatment completion (see section 9). [new 2016]

128.

People in the groups listed in recommendation 118 who do not have treatment for latent TB, as specified in recommendations 118, 120-1, 125-7, for any reason should be advised of the risks and symptoms of TB (on the basis of an individual risk assessment), usually in a standard letter of the type referred to as ‘Inform and advise’ information (see section 9.2). [new 2016]

129.

When BCG is being recommended, discuss the benefits and risks of vaccination or remaining unvaccinated with the person (or, if a child, with the parents), so that they can make an informed decision. Tailor this discussion to the person, use appropriate language, and take into account cultural sensitivities and stigma. [2006]

130.

If people identified for BCG vaccination through occupational health, contact tracing or new entrant screening are also considered to be at increased risk of being HIV positive, offer them HIV testing before BCG vaccination. [2006]

131.

Discuss neonatal BCG vaccination for any baby at increased risk of TB with the parents or legal guardian. [2006]

132.

Primary care organisations with a high incidence of TB should consider vaccinating all neonates soon after birth. [2006]

133.

In areas with a low incidence of TB (see Public Health England’s TB rate bands, published in their Annual Report), primary care organisations should offer BCG vaccination to selected neonates who:

were born in an area with a high incidence of TB or
have 1 or more parents or grandparents who were born in a high-incidence country or
have a family history of TB in the past 5 years. [2006]

134.

Routine BCG vaccination is not recommended for children aged 10–14 years.

Healthcare professionals should opportunistically identify unvaccinated children older than 4 weeks and younger than 16 years at increased risk of TB who would have qualified for neonatal BCG (see section 8.2) and provide Mantoux testing (see section 3.1) and BCG vaccination (if Mantoux-negative).
This opportunistic vaccination should be in line with the Green Book. [2006, amended 2016]

135.

Mantoux testing should not be done routinely before BCG vaccination in children younger than 6 years unless they have a history of residence or prolonged stay (more than 1 month) in a country with a high incidence of TB. [2006]

136.

Offer BCG vaccination to new entrants who are Mantoux- or interferon-gamma release assay-negative who:

are from high-incidence countries and
are previously unvaccinated (that is, without adequate documentation or a BCG scar) and
are aged:
- younger than 16 years or
- 16–35 years from sub-Saharan Africa or a country with a TB incidence of 500 per 100,000 or more. [2006, amended 2016]

137.

Offer BCG vaccination to healthcare workers and other NHS employees who have contact with patients or clinical specimens, irrespective of age, who:

are previously unvaccinated (that is, without adequate documentation or a BCG scar), and
are Mantoux (or interferon-gamma release assay) negative. [2006, amended 2016]

138.

Offer BCG vaccination to Mantoux- (or interferon-gamma release assay-) negative contacts of people with pulmonary and laryngeal TB (see section 3.1) if they:

have not been vaccinated previously (that is, there is no adequate documentation or a BCG scar) and
aged 35 years or younger or
aged 36 years and older and a healthcare or laboratory worker who has contact with patients or clinical materials. [2006, amended 2016]

139.

Offer BCG vaccination to previously unvaccinated, Mantoux- or interferon-gamma release assay-negative people aged 35 years or younger in the following groups at increased risk of exposure to TB, in accordance with the Green Book:

veterinary and other staff such as abattoir workers who handle animal species known to be susceptible to TB, such as simians
prison staff working directly with prisoners
staff of care homes for older people
staff of hostels for people who are homeless and facilities accommodating refugees and asylum seekers
people going to live or work with local people for more than 3 months in a high-incidence country. [2006, amended 2016]

140.

To improve the uptake of BCG vaccination, identify eligible groups (in line with the Department of Health’s Green Book) opportunistically through several routes, for example:

new registrations in primary care and with antenatal services, or other points of contact with secondary or tertiary care
people entering education, including university
links with statutory and voluntary groups working with new entrants and looked-after children and young people
during contact investigations. [new 2016]

141.

When BCG vaccination is being recommended, discuss the benefits and risks of vaccination or remaining unvaccinated with the person (or, if a child, with the parents), so that they can make an informed decision. Tailor this discussion to the person, use appropriate language, and take into account cultural sensitivities and stigma. [2006]

142.

If people identified for BCG vaccination through occupational health, contact tracing or new entrant screening are also considered to be at increased risk of being HIV-positive, offer them HIV testing before BCG vaccination. [2006]

BCG vaccination in neonates (0–4 weeks)

143.

Identify babies eligible for vaccination (in line with the Green Book) before birth, ideally through antenatal services. [new 2016]

144.

Preferably vaccinate babies at increased risk of TB before discharge from hospital or before handover from midwifery to primary care. Otherwise, vaccinate as soon as possible afterwards, for example, at the 6 week postnatal check. [new 2016]

145.

Incorporate computer reminders into maternity service (obstetrics) IT systems for staff, to identify and offer BCG vaccination to babies eligible for vaccination. [new 2016]

146.

Provide education and training for postnatal ward staff, midwives, health visitors and other clinicians on identifying babies eligible for vaccination, local service information and providing BCG vaccination, including:

case definition for at-risk groups to be offered vaccination
information about the local BCG vaccination policy that can be given verbally, in writing or in any other appropriate format (see section 8) to parents and carers at the routine examination of the baby before discharge
local service information about BCG vaccination, such as pre-discharge availability of neonatal vaccination, local BCG clinics and referral for BCG vaccination if this is not available in maternity services
administration of BCG vaccination and contraindications. [new 2016]

Encouraging uptake among infants, older children and new entrants

147.

Deliver the following interventions in primary care settings to improve uptake of BCG vaccination in people from eligible groups (as outlined in the Green Book):

education and support for practice staff, including:
- raising awareness of relevant guidelines and case definition for at-risk groups
- promoting BCG and TB testing in eligible groups
incorporating reminders for staff (prompts about eligibility for BCG) on practice computers (for example, embedded in medical records)
consider financial incentives for practices for identifying eligible groups for BCG and TB testing
reminders (‘immunisations due’) and recall (‘immunisations overdue’) for people who are eligible for vaccination or for parents of infants and children who are eligible, as outlined in the Green Book. (This could include written reminders, telephone calls from a member of staff or a computerised auto dialler, text messages or a combination of these approaches.) [new 2016]

148.

Use home visits to give information and advice to people who are disadvantaged on the importance of immunisation. This should be delivered by trained lay health workers, community-based healthcare staff or nurses. [new 2016]

Improving adherence: case management including directly observed therapy

149.

Allocate a named TB case manager to everyone with active TB as soon as possible after diagnosis (and within 5 days). The clinical team should tell each person who their named TB case manager is and provide contact details. [2006, 2012 amended 2016]

150.

The TB case managers should work with the person diagnosed with TB to develop a health and social care plan, and support them to complete therapy successfully. The TB case manager should:

offer an incident risk assessment to every person with TB, to identify their needs and whether they should have enhanced case management including directly observed therapy
educate the person about TB and the treatment
develop an individual care plan after discussion with the person
gain the person’s consent to the plan and agree a review date (for example, when moving from initiation to maintenance, or at each contact to ensure the person’s needs are being met)
coordinate discharge planning, especially for people on directly observed therapy
involve representatives from other allied professions and key workers from all organisations who work with the person if appropriate
explore appropriate ways that peers and voluntary organisations can provide support. [2006, 2012, amended 2016]

151.

Offer directly observed therapy as part of enhanced case management in people who:

do not adhere to treatment (or have not in the past)
have been treated previously for TB
have a history of homelessness, drug or alcohol misuse
are currently in prison, or have been in the past 5 years
have a major psychiatric, memory or cognitive disorder
are in denial of the TB diagnosis
have multidrug-resistant TB
request directly observed therapy after discussion with the clinical team
are too ill to administer the treatment themselves. [2012, amended 2016]

152.

In children whose parents are members of any of the above groups, offer directly observed therapy as part of enhanced case management and include advice and support for parents to assist with treatment completion. [2016]

153.

Re-evaluate the need for directly observed therapy throughout the course of TB treatment whenever the person’s (or in the case of children, parents’) circumstances change. [new 2016]

154.

TB case managers should ensure the health and social care plan (particularly if directly observed therapy is needed) identifies why a person may not attend for diagnostic testing or follow a treatment plan, and how they can be encouraged to do so. It should also include ways to address issues such as fear of stigmatisation, support needs and/or cultural beliefs, and may include information on:

demographics (for example, age, nationality, place of birth, length of time in UK)
all current prescribing regimens
housing needs and living situation, including looked-after children
substance misuse (drugs or alcohol)
any contact with the criminal justice system
the need for hepatitis B and C or HIV testing (see recommendations 123, 124 and 125)
HIV status
other health conditions (physical or mental)
communication factors (for example, language and literacy levels)
ability to access treatment (mobility and transport needs)
employment or entitlement to benefits
legal or immigration status (including risk of removal or relocation within the UK)
any enablers or incentives to overcome anything that is stopping diagnosis or treatment. [2012, amended 2016]

155.

The health and social care plan should:

state who will be observing treatment and where (if the person is having directly observed therapy this should be provided at a location that is convenient and accessible to them, for example, at a methadone clinic) [2012, amended 2016]
include actions to take if contact with the person is lost (for example, keeping details of people who might be able to help re-establish contact) [2012]
refer to, and be coordinated with, any other care plan already established for the person [2012]
define the support needed to address any unmet health and social care needs (for example, support to gain housing or other benefits, or to help them access other health or social care services) [2012, amended 2016]
include a commitment from the person to complete their TB treatment [2012, amended 2016]
be supported by frequent contact with any key workers who work with the person. [2006 amended 2011, amended 2016]

156.

Multidisciplinary TB teams should aim to find people with active TB who are lost to follow-up, or who stop using services before completing diagnostic investigations. They should report all those lost to follow-up to local Public Health England teams, GPs, the referring organisation and specialist outreach teams. [2012]

Other strategies to encourage people to follow their treatment plan

157.

To encourage people to follow their treatment plan, involve people in treatment decisions for active or latent TB from the start. Emphasise the importance of following the treatment plan when agreeing the regimen. [2016]

158.

Multidisciplinary TB teams should implement strategies for active and latent TB to encourage people to follow the treatment plan and prevent people stopping treatment early. These could include:

reminder letters, printed information, telephone calls, texts and apps using an appropriate language [2006, amended 2016]
health education counselling and patient-centred interviews [2006, amended 2016]
tailored health education booklets from quality sources [2006, amended 2016]
home visits [2006]
random urine tests and other monitoring (for example, pill counts) [2006]
access to free TB treatment for everyone (irrespective of eligibility for other NHS care) and information about help with paying for prescriptions [2006, 2012, amended 2016]
social and psychological support (including cultural case management and broader social support) [new 2016]
advice and support for parents and carers [new 2016]
incentives and enablers to help people follow their treatment regimen. [new 2016]

159.

TB control boards should ensure services take into account the barriers facing vulnerable migrants who may need treatment, and in particular the stigma they may face. Other issues include the location of services (both geographically and in terms of opening times) and people’s language and cultural needs, in terms of the format of advice and the type of information given. [2012, amended 2016]

Strategies in prisons or immigration removal centres

160.

On arrival at a prison or immigration removal centre, healthcare professionals should ask all prisoners and detainees (including those being transferred from other establishments) if they are taking TB medication, to ensure continuity of treatment. [2012]

161.

All prisoners and immigration removal centre detainees having treatment for active TB should have a named TB case manager. The case manager should be responsible for contingency planning for discharge from prison or detention. [2012]

162.

Prisons and immigration removal centres should ensure multidisciplinary TB staff have access to prisoners and detainees who need treatment (for example, by being given security clearance). [2012]

163.

All prisoners having treatment for active TB should have directly observed therapy. [2012]

164.

Prison health services should have contingency, liaison and handover arrangements to ensure continuity of care before any prisoner on TB treatment is transferred between prisons or released. In addition, other agencies working with prisoners or detainees should also be involved in this planning. [2012]

165.

Prison and immigration removal centre healthcare services should liaise with the named TB case manager (from the multidisciplinary TB team) to ensure contingency plans for continuation of treatment are drawn up for prisoners and immigration removal centre detainees with TB. [2012]

166.

Multidisciplinary TB teams should ensure accommodation is available for the duration of TB treatment after the prisoner or detainee’s release. [2012]

167.

Multidisciplinary TB teams should ensure directly observed therapy is arranged for prisoners or detainees being treated for TB after their release. This should be available close to where they will live in the community. [2012]

168.

Multidisciplinary TB teams (in collaboration with Public Health England, primary care, the voluntary sector and Health Education England) should identify and support an ongoing TB education programme for local professionals in contact with the general public, and at-risk groups in particular. This includes, for example, staff in emergency departments, GPs and wider primary care staff, people who work in housing support services, staff who support migrants and those working in walk-in centres, hostels, substance misuse projects and prisons. [2012, amended 2016]

169.

Multidisciplinary TB teams should ensure the education programme increases other professionals’ awareness of the possibility of TB and reduces the stigma associated with it. The programme should include detail on:

causes of TB, how it is transmitted, and the signs and symptoms
lifestyle factors that may mask symptoms
local epidemiology, highlighting under-served groups, other high-risk groups and the fact that TB also occurs in people without risk factors
principles of TB control:
- early diagnosis and active case-finding
- how to support treatment (including directly observed therapy)
- drug resistance
- awareness of drug interactions (including factors such as effect on contraception efficacy)
- contact investigation after diagnosing an active case
- the importance of adhering to treatment
- treatment for TB is free for everyone (irrespective of eligibility for other NHS care)
- social and cultural barriers to accessing health services (for example, fear of stigma and staff attitudes)
- local referral pathways, including details of who to refer and how
- the role of allied professionals in awareness-raising, identifying cases and helping people complete treatment
- misinformation that causes fear about TB, including concerns about housing people with the condition
- the best ways to effectively communicate all the above topics with different groups. [2012, amended 2016]

170.

Statutory, community and voluntary organisations and advocates working with the general public, and under-served and high-risk groups in particular, should share information on TB education and awareness training with all frontline staff. (They should get information on this from the local multidisciplinary TB team.) [2012, amended 2016]

171.

If possible, statutory, community and voluntary organisations should ensure peers from under-served groups and anyone else with experience of TB contribute to, or lead, awareness-raising activities. (Peers who lead such activities will need training and support.) [2012, amended 2016]

172.

Multidisciplinary TB teams should help professionals working in relevant statutory, community and voluntary organisations to raise awareness of TB among under-served and other high-risk groups. These professionals should be able to explain that treatment for TB is free and confidential for everyone (irrespective of eligibility for other NHS care). They should also be able to provide people with details of:

how to recognise symptoms in adults and children
how people get TB
the benefits of diagnosis and treatment (including the fact that TB is treatable and curable)
location and opening hours of testing services
referral pathways, including self-referral
the potential interaction of TB medication with other drugs, for example, oral contraceptives and opioids (especially methadone) and HIV treatment
TB/HIV co-infection
how to address the myths about TB infection and treatment (for example, to counter the belief that TB is hereditary)
how to address the stigma associated with TB
the risk of migrants from high-incidence countries developing active TB – even if they have already screened negative for it
contact tracing. [2012, amended 2016]

173.

Multidisciplinary TB teams and others working with at-risk groups should use high quality material to raise awareness of TB (see recommendations 177 to 181). [2012, amended 2016]

174.

Multidisciplinary TB teams and others working with the general public, and with under-served and other high-risk groups in particular, should include information on TB with other health-related messages and existing health promotion programmes tailored to the target group. [2012, amended 2016]

175.

Multidisciplinary TB teams should work in partnership with voluntary organisations and ‘community champions’ to increase awareness of TB, in particular among under-served groups at risk of infection but also in the general population. If possible, peers who have experience of TB should contribute to awareness-raising activities and support people in treatment. [2012, amended 2016]

176.

National organisations (for example, National Knowledge Service – Tuberculosis, TB Alert, Public Health England, Department of Health and NHS Choices) should work together to develop generic, quality-assured template materials with consistent up-to-date messages. These materials should be made freely available and designed so that they can be adapted to local needs. [new 2016]

177.

Multidisciplinary TB teams should use these templates for general awareness raising and targeted activities in under-served and other high-risk groups. Involve the target group in developing and piloting the materials. [new 2016]

178.

The content of any materials should:

be up-to-date and attractively designed, including pictures and colour if possible
be culturally appropriate, taking into account the language, actions, customs, beliefs and values of the group they are aimed at
be tailored to the target population’s needs
include risks and benefits of treatment, and how to access services, advice and support
dispel myths
show that, by deciding to be tested and treated for TB, a person can be empowered to take responsibility for their own health
use language that encourages the person to believe that they can change their behaviour
be simple and succinct. [new 2016]

179.

Make the material available in a range of formats such as written, braille, text messages, electronic, audio (including podcasts), pictorial and video. Make them freely available in a variety of ways, for example, online, as print materials or on memory sticks. [new 2016]

180.

Disseminate materials in ways likely to reach target groups, for example, via culturally specific radio or TV stations, at shelters, and at community, commercial or religious venues that target groups attend regularly. [new 2016]

181.

Public Health England, in partnership with NHS England, should take responsibility for national oversight of TB prevention and control activities. This includes setting up TB control boards (see Developing the TB prevention and control programme). [2012, amended 2016]

182.

Public Health England and NHS England should consider working together to establish control boards in agreed geographical areas and employ appropriate staff (see recommendation on TB control board staff). [new 2016]

183.

Clinical commissioning groups and local authority public health teams working in partnership with Public Health England and NHS England should consider collaborative commissioning arrangements through TB control boards. This could, for example, include working with 1 or more clinical commissioning groups to cover a major metropolitan district, region or TB control board area taking into account:

local TB incidence
local at-risk populations and their movements across different geographical areas
existing service configurations for organisations involved in TB prevention and control
the need to share services, such as mobile X-ray facilities, across different geographical areas. [2012, amended 2016]

184.

TB control boards should develop TB prevention and control programmes working with commissioners, Public Health England and NHS England. The board could include clinical, commissioning (from clinical commissioning groups, local government and the voluntary sector) and public health leaders and people with TB or groups who advocate on their behalf from across the control board area. This may include identifying a lead clinical commissioning group, which could be led by an executive director of that commissioning group working with the board. Feedback mechanisms between local commissioning groups and the TB control board should be developed. [new 2016]

185.

An executive director of local commissioning groups, working with the local director of public health or another nominated public health consultant, should lead implementation of the programme in their locality. The lead should ensure a comprehensive prevention and control programme is commissioned to support the level of need (see needs assessment recommendations) and that they work with the control board regularly. [2012, amended 2016]

186.

Working together through TB control boards and local networks, commissioners, local government and Public Health England should ensure TB prevention and control programmes set up multidisciplinary TB teams to provide all TB services (see recommendations on commissioning multi-disciplinary TB teams). They should ensure that local strategy and service commissioning focuses on an end-to-end pathway. [2012, amended 2016]

187.

Working together through TB control boards, commissioners and Public Health England should ensure the TB prevention and control programme is informed by relevant NICE guidance and developed in collaboration with clinical services. It should also be informed by the standard minimum data set collected through local needs assessment and service audit. [2012, amended 2016]

188.

Working together through TB control boards, commissioners and Public Health England should ensure the TB prevention and control programme targets all ages, including children, and covers all aspects of TB prevention and control (see Developing the TB prevention and control programme), including but not limited to:

active case finding (contact investigations and identifying latent TB in high-risk groups)
awareness-raising activities
standard and enhanced case management (including providing directly observed therapy and free treatment)
finding those lost to follow-up and encouraging them back into treatment
incident and outbreak control
monitoring, evaluating and gathering surveillance and outcome data. [2012, amended 2016]

189.

Working together through TB control boards, commissioners, Public Health England and the voluntary sector should ensure TB prevention and control programmes take account of the need to work with other programmes targeting specific high-risk groups, such as those who are under-served. Examples include programmes focused on the health of asylum seekers and refugees, under-served children, homelessness and housing, offenders and substance misusers. [2012, amended 2016]

190.

TB control boards should consider integrating TB and HIV services, joint clinics and training opportunities. [new 2016]

191.

Commissioners should consider commissioning support and advice to all groups diagnosed with TB irrespective of whether they are under served (see Raising and sustaining awareness of TB). [new 2016]

192.

TB control boards should be responsible for developing a TB prevention and control programme based on the national strategy and evidence-based models. [new 2016]

193.

TB control boards should plan, oversee, support and monitor local TB control, including clinical and public health services and workforce planning. [new 2016]

196.

TB control boards should assess services in their area, identify gaps in provision and develop plans to meet these, including:

undertaking a workforce review to support local or regional commissioning of TB services to meet the needs of their population (see sections 10.2.12 and 10.2.14)
supporting development of appropriate services and pathways to improve access and early diagnosis (see sections 10.2.18, 10.2.22, and 10.2.24)
negotiating arrangements to cover the cost of additional services to address specific gaps in current TB control arrangements. [new 2016]

195.

TB control boards should ensure cohort review is undertaken at least quarterly, and the results are fed back to local clinical and TB networks. These should be agreed by accountable bodies such as clinical commissioning groups, trust management, regional Public Health England and centre directors and local authority directors of public health as agreed, all of whom should make sure appropriate action is taken. [new 2016]

196.

TB control boards should enable full and consistent use of national guidelines including:

ensuring the needs of all people with TB, particularly under-served populations, are addressed
ensuring contact tracing arrangements are appropriate to the needs of the population (see section 11)
assuring themselves that TB control in low-incidence areas is established and delivered appropriately (see section 10.2.10)
assuring themselves that multidrug-resistant TB is managed appropriately (see section 6) and mechanisms are in place to ensure:
- there is sufficient clinical expertise available to manage cases
- regional multidrug-resistant TB networks take account of expert advice. [new 2016]

197.

TB control boards should develop links and partnerships and establish agreed relationships and lines of accountability between TB control boards and local clinical and TB networks. This includes engaging with other key stakeholders to ensure universal coverage of TB control efforts. [new 2016]

198.

TB control boards should collaborate with their local and regional partners. They should agree and establish regular monitoring, surveillance and reporting arrangements with all partners to support needs assessment (see section 10.2.12) and regular audit and evaluation. [new 2016]

199.

TB control board staff should have clearly defined roles and responsibilities. Their roles and responsibilities should include:

Establishing the links, partnerships and relationships between all aspects of the control board area within their remit (if necessary across usual geographical commissioning boundaries).
Developing and supporting adoption and implementation of evidence-based model service specifications for the clinical and public health actions needed to control TB including:
- improving access and early diagnosis (see sections 9.2, 10.2.18, 10.2.22 and 10.2.24)
- diagnostics, treatment and care services (see sections 3, 4, 5, 7 and 9)
- contact investigations and tracing (see sections 3.1 and 6)
- cohort review (see section 10.2.14)
- vaccination (see section 8)
- drug resistance (see section 5)
- tackling TB in under-served populations
- surveillance, monitoring and quality assurance
- workforce development and commissioning (see section 10.2.16 and 10.2.18). [new 2016]

200.

TB control boards should ensure there is enough capacity available to them to manage a sudden increase in demand such as:

TB contact investigations, (such as incidents in congregate settings)
large scale active case-finding initiatives in under-served groups in the community
outbreaks in a variety of settings or sites where transmission risk may be high, including but not limited to schools, workplaces, hostels and prisons. [new 2016]

201.

To set up, monitor and evaluate a TB control programme, TB control boards should:

agree plans within their partnerships to assess local services against the service specifications
develop plans and quality standards to secure improvements
establish quality assurance mechanisms and regular audits including, but not limited to, cohort review for all aspects of the TB control board partnership plans. [new 2016]

Coordination of the TB networks

202.

TB control boards should (in collaboration with commissioners) consider the need for a TB network local coordinator, particularly if working across multiple clinical commissioning group areas (see Strategic Oversight recommendation). [new 2016]

203.

The coordinator should work in close collaboration with clinicians and all relevant multidisciplinary TB teams to develop the network and be responsible for:

setting up the network and developing it based on needs, reporting back to the TB control board regularly
establishing the links, partnerships and relationships across their local network (if necessary across usual geographical commissioning boundaries). [new 2016]

204.

TB control boards should consider setting up a regional multidisciplinary TB network to oversee management of multidrug-resistant TB. This could:

Identify designated regional expert centres.
Ensure all healthcare professionals who suspect or treat a case of multidrug-resistant TB are informed about and have access to specialist advisory services for multidrug-resistant TB. This includes the designated expert centre in their regional network and may also include the national advisory service for multidrug-resistant TB (currently provided by the British Thoracic Society).
Ensure all cases of multidrug-resistant TB are discussed at the regional multidisciplinary TB team meeting in the local clinical network.
Formally consider and record the advice from the specialist advisory services for multidrug-resistant TB provided by the designated regional expert centre or the national advisory service for multidrug-resistant TB. [new 2016]

205.

Commissioners in rural areas (working with the TB control board) should consider collaborative approaches to deliver and manage TB services. They could, for example, set up a network including areas with high and low incidence of TB. [new 2016]

206.

Directors of public health, in discussion with local health protection teams, should ensure that TB is part of the joint strategic needs assessment. [2012, amended 2016]

207.

Directors of public health should provide commissioners of TB prevention and control programmes and TB control boards with local needs assessment information annually using data provided by Public Health England. [2012, amended 2016]

208.

Commissioners of TB prevention and control programmes should ensure services reflect the needs of their area, identified by needs assessment. Health and wellbeing boards should ensure that local TB services have been commissioned based on local needs identified through needs assessment. [2012, amended 2016]

209.

Directors of public health and TB control boards should use cohort review (see cohort review) and other methods to collect data on the following, to inform local needs assessment:

Number of annual notified TB cases (see Public Health England’s enhanced TB surveillance data and annual ‘suite of indicators’).
Size, composition (for example, age and ethnicity) and distribution of local at-risk groups.
Indices of social deprivation.
Local statutory and non-statutory services working with these groups.
Organisation of local TB services, including the composition and capacity of the local multidisciplinary TB team (see the results of local audit) and location of services. This may also include data to support evaluating the need for integrated TB/HIV services including joint clinics.
Numbers needing enhanced case management (see Adherence recommendations and local cohort review reports).
Numbers receiving directly observed therapy from the start of, or at any point during, treatment (see Public Health England’s enhanced TB surveillance data).
Evidence of recent transmission (for example, using DNA fingerprinting or surrogate markers such as number of cases in children under 5 years (see UK TB strain-typing database and local incident and outbreak reports).
Completeness and yield of contact investigations. This includes: proportion of smear-positive cases with 0, 5 or more contacts identified; proportion of identified contacts clinically assessed; and proportion of contacts with latent TB infection who successfully complete treatment.
Active case-finding initiatives, incident contact investigations and identification of latent TB infection in high risk groups.
Treatment outcomes for everyone grouped according to social risk factors and by the use of directly observed therapy (including rates of loss to follow-up and treatment interruptions – see Public Health England’s enhanced TB surveillance data).
Local education and awareness-raising programmes for under-served groups, professionals and practitioners working with them.
Views and experiences of people with TB, carers and the services working with them. [2012, amended 2016]

210.

Local needs assessments should also be equity proofed to assess the potential effect of planning, commissioning and policy decisions on health inequalities (see planning and commissioning services in NICE’s local government briefing on health inequalities and population health). [new 2016]

211.

TB control boards and prevention and control programme leads should initiate, audit and evaluate cohort reviews in their commissioning area. Quarterly cohort review meetings should take place in the area covered by the programme. Combine these meetings with others if possible, or use technology to make it easier for clinicians and case managers to attend. [2012, amended 2016]

212.

TB case managers should present standardised information on each case, including: demographic information, HIV test results, pre-treatment and ongoing status (clinical, laboratory, radiology), adherence to treatment and the results of contact investigations. [2012, amended 2016]

213.

TB case managers and key allied professionals from the TB prevention and control programme should attend cohort review meetings. This could include the lead clinician (who may or may not be the case manager). Either a paediatrician with experience and training in the treatment of TB or a general paediatrician with advice from a specialised clinician should be present when cases of children with TB are presented. [2012, amended 2016]

214.

The chair of the cohort review should not work for any of the TB services included in the review. Examples of possible chairs include a public health consultant, a specialist physician or a senior TB nurse, preferably from a different geographical area. Alternatively the chair could be a representative from the local Public Health England health protection team or the TB control board. [2012, amended 2016]

215.

Multidisciplinary TB teams, in conjunction with Public Health England units, should collate and present cohort review data on TB treatment and the outcome of contact investigations at the review meetings. In addition, progress towards national, regional and local service targets should be presented. [2012, amended 2016]

216.

TB control boards, directors of public health and local public health consultants should ensure outputs from the cohort review feed into the needs assessment for TB services. TB control board directors should attend the cohort review at least once a year. [2012, amended 2016]

217.

TB case managers should feed back promptly to multidisciplinary TB teams on issues identified as a result of cohort review. The results of the cohort review should be collated locally and agreed by the chair before being fed back to TB control boards, commissioners and health and wellbeing boards regularly and via needs assessment. [2012, amended 2016]

218.

People participating in a cohort review should review the results and evaluate local services (for example, auditing adverse outcomes, rates of culture confirmation, treatment completion rates or time to diagnosis). [2012, amended 2016]

219.

Commissioners should ensure multidisciplinary TB teams:

Have the skills and resources to manage the care of people with active TB who are not from under-served groups. [2012, amended 2016]
Include at least 1 TB case manager with responsibility for planning and coordinating the care of under-served people and those with active TB who receive enhanced case management. [2012, amended 2016]
Have the resources to manage latent TB care in under-served groups and the wider population. [new 2016]
Include a range of clinical specialties in the multidisciplinary TB team, including paediatrics, infection control and respiratory medicine. [2012]
Have regular attendance at these multidisciplinary team and cohort review meetings for all team members included as a programmed activity as part of their work planning. [new 2016]
Have the skills and resources necessary to manage the care of people with complex social and clinical needs (either directly or via an established route). This includes the ability to provide prompt access (or if necessary, referral) to skilled outreach and advocacy workers who can draw on the services of allied practitioners. The aim is to address people’s housing, asylum, immigration, welfare, substance dependency and other health and social care needs. (The allied practitioner support should include both a specified housing officer and a social worker.) [2012]
Can provide rapid access TB clinics for all cases, including under-served groups. [2012]
Consider providing administration support for TB nurses and case managers so they have capacity for clinical and case management work. This could include giving TB nurses access to computer hardware and software. [new 2016]
Have the resources to provide a continuous service throughout the year, ensuring the TB service accounts for the following to manage continuity of care:
planned absence (for example, professional development, mandatory training, annual, maternity or paternity leave)
unplanned absence (such as sickness absence). [2012, amended 2016]
Can provide prompt access to a professional who has training and experience in assessing and protecting children and vulnerable adults at risk of abuse or neglect. [2012]
Have access to funds through local government and clinical commissioning groups that can be used flexibly to improve adherence to treatment among under-served groups. For example, funds could be used to provide transport to clinics, to provide support or enablers for treatment, or for paying outreach workers or community services to support directly observed therapy. Funds may also be used to provide accommodation during treatment (see section 10.2.22 and 10.2.31). [2012, amended 2016]
Have the resources to provide ongoing TB awareness-raising activities for professional, community and voluntary (including advocacy) groups that work with populations at high risk of TB (see section 9.2). These resources could be financed by local government or clinical commissioning groups. [2012, amended 2016]

220.

Commissioners should ensure NHS Improvement’s safe staffing principles are applied when commissioning TB services.^f^,^g [new 2016]

221.

TB control boards and local TB services should consider employing trained, non-clinically qualified professionals to work alongside clinical teams to agreed protocols, and to contribute to a variety of activities. Examples of this may include awareness raising and supporting people to attend appointments (including other health and social care appointments). They could also help with collecting samples, contact tracing, case management including directly observed therapy and cohort review, or any other aspect of the service if:

they are trained to deliver the intervention or processes effectively
they are supported, mentored and supervised by a named case manager such as a TB nurse
they have the skills to monitor, evaluate and report on their work practices and outcomes to maintain a process of ongoing evaluation and service improvement in relation to cohort review (see cohort review recommendations). [new 2016]

222.

TB control boards should ensure that people working in the TB service have the right knowledge, engagement, advocacy and communication skills to meet the needs (for example, language, cultural or other requirements) of all the groups they may work with. [new 2016]

223.

Commissioners should consider different needs across traditional geographical and organisational boundaries are taken into account. Put agreements in place so that staff can work across these boundaries, covering the whole service or TB control board area if appropriate. [new 2016]

224.

Commissioners and TB control boards should ensure they put in place appropriate governance (including clear lines of accountability and extension of scope of practice) and data sharing practices and agreements. This includes ensuring they are part of service level agreements between NHS and non-NHS services, for example, the third sector or local government, and appropriate training has been completed. [new 2016]

225.

TB control boards should ensure there is sufficient capacity available to them to manage a sudden increase in demand such as:

TB contact investigations (for example incidents in congregate settings)
large scale active case-finding initiatives in under-served groups in the community
outbreaks in a variety of settings or sites where transmission risk may be high, including but not limited to schools, workplaces, hostels and prisons. [new 2016]

Active case finding in underserved groups

226.: Multidisciplinary TB teams should follow NICE recommendations on contact tracing (see Case finding section). They should coordinate contact investigations at places where the person with TB spends significant amounts of time. Examples could include pubs, crack houses, parks and community centres. The aim is to help identify people who have been living with them and people they frequently socialise with. [2012]
227.: Multidisciplinary TB teams dealing with someone from an under-served group should work alongside health and social care professionals known to them to help trace relevant contacts. They should also work in partnership with voluntary, community and statutory organisations to conduct outreach contact investigations. [2012]
228.: Multidisciplinary TB teams should, if available and appropriate, encourage peer educators or TB programme support workers to help with contact investigations involving under-served people who have complex social networks. [2012]
229.: Multidisciplinary TB teams in discussion with local Public Health England health protection teams should consider using digital mobile X-ray for active case-finding in settings identified by looking at social networks as places where under-served people at risk congregate. They should also provide the necessary support so that multidisciplinary TB teams can use strain-typing and social network analysis to ascertain where transmission is occurring in the community. (Examples of transmission sites may include pubs, crack houses, hostels and day centres.) They should focus on active case-finding in the settings identified. [2012, amended 2016]

Incident and outbreak response

230.

Multidisciplinary TB teams should coordinate incident or outbreak contact investigations at places where the person with active TB spends significant amounts of time. Examples include workplaces, schools, colleges, universities, childcare settings. Identify people that the person with TB frequently spends substantial time with as outlined in the Active case finding section. [new 2016]

231.

Multidisciplinary TB teams should refer any incident in a congregate setting to the Public Health England health protection team for risk assessment within 5 working days of suspicion of a potential incident. [new 2016]

232.

TB control boards working with local health protection teams should, through local arrangements, mobilise existing staff or have access to an incident team that will:

undertake an incident risk assessment and provide advice
support or undertake contact investigations
provide information and communication support to the multidisciplinary TB team, the local director of public health, the setting where the incident has occurred and the people affected including:
- written advice, printed or by email
- question and answer sessions
- telephone advice
- media engagement
gather and collate data, and report on outcomes to measure the effectiveness of the investigation (for example, offering testing to all people identified at risk and monitoring uptake).
report back to TB control boards at appropriate times. This includes when outcomes of initial investigation of people classified as close contacts are available. It also includes when a decision is made to broaden the investigation to the next stage using the concentric circle method for risk assessment. [new 2016]

233.

When incidents have been identified, multidisciplinary TB teams in discussion with local Public Health England health protection teams should consider providing support for strain-typing and other analysis to ascertain where transmission is occurring. (Examples of transmission sites may include workplaces, schools, colleges, universities, childcare settings). [new 2016]

234.

In all types of contact investigation scenarios (active case finding, incident or outbreak investigations) multidisciplinary TB teams should investigate all people who have been in contact with children who have pulmonary or extrapulmonary TB to identify the primary source of infection. If necessary, they should look beyond immediate close contacts to find the source. [2012, amended 2016]

235.

Multidisciplinary TB teams should establish relationships with statutory, community and voluntary organisations that work with people at risk of TB to develop appropriate TB referral pathways. They should ensure these organisations know how to refer people to local TB services. [2012]

236.

Multidisciplinary TB teams should accept referrals from healthcare providers and allied organisations working in the community with under-served groups. This includes voluntary and statutory organisations (for example, mobile X-ray teams or community organisations or outreach workers working with vulnerable migrants). [2012]

237.

Multidisciplinary TB teams should accept self-referrals to TB clinics by people who suspect they have TB or have recently been in contact with someone with TB. [2012, amended 2016]

238.

Multidisciplinary TB teams should consider accepting direct referrals from emergency departments (see recommendations on Direct referral from emergency departments to multidisciplinary TB teams). [new 2016]

239.

Healthcare professionals should consider urgent referral to TB clinics for people with suspected active TB. They should also ensure the results from first-line diagnostic tests (including a sputum smear and chest X-ray) are available before the person sees a specialist. (Note: this should not delay the referral.) [2012, amended 2016]

240.

Multidisciplinary TB teams should have pathways to triage referrals, start investigations and collect clinical information before the person is seen by a physician.

241.

While triaging, multidisciplinary TB teams should ensure everyone is given information about TB as part of the process (see section 9.2). This should include who the person should contact if they have any questions and how to access advice or information from support groups, national charities such as TB Alert and other sources such as local government (for example, public health or social care teams). [new 2016]

242.

Multidisciplinary TB teams should ensure people who have a smear-positive result or imaging features highly suggestive of smear-positive TB (for example, evidence of cavitation on chest X-ray) are assessed the next working day. This is so that case management and infection control procedures start promptly. [2012, amended 2016]

243.

The multidisciplinary TB team should assess people who are not smear-positive but have imaging that suggests pulmonary or laryngeal TB as soon as possible. This should be no later than 5 working days after a referral. [2012, amended 2016]

244.

Multidisciplinary TB teams should, where necessary, be able to provide or arrange outreach services to ensure sputum samples or other assessments such as contact investigations can be arranged in the community. [2016]

245.

Local hospitals, clinical commissioning groups and the local multidisciplinary team should consider developing a local pathway for people with imaging highly suggestive of active TB. The pathway should enable them to be referred by the radiology department by the next working day to multidisciplinary TB teams. Consider including the following in the pathway:

Agreed standardised radiology codes to identify imaging investigations highly suggestive of active TB.
Regular liaison between multidisciplinary TB teams and the radiology department (for example, weekly) to ensure all patients have been referred to the multidisciplinary team for triage using the agreed local mechanism or pathway. [new 2016]

246.

Report results of all pathology or other diagnostic results suggesting TB to the multidisciplinary TB team and clinician who ask for them. [new 2016]

247.

Commissioners and multidisciplinary teams should consider working with emergency departments to develop direct referral pathways for people with suspected active TB so that:

the local multidisciplinary team is informed of all suspected cases of TB using the appropriate process
referral is accepted from any appropriate healthcare professional, for example an on-call radiologist. [new 2016]

248.

Emergency department clinicians should ensure first-line diagnostic tests for TB (see recommendation 33) are performed on anyone presenting with suspected TB. [new 2016]

249.

Emergency departments should consider carrying out audits of their direct referrals because of suspected active TB and the outcomes of diagnosis. [new 2016]

250.

Multidisciplinary TB teams should consider training emergency department staff in:

using approaches that do not stigmatise people with TB
giving people with TB appropriate advice (see sections 6 and 9). [new 2016]

251.

Multidisciplinary TB teams, prisons, custody suites and immigration removal centre healthcare services should have named TB liaison leads to ensure they can communicate effectively with each other. [2012, amended 2016]

252.

Prison, custody suites and immigration removal centre healthcare services should develop a TB policy by working with the TB control board and multidisciplinary TB team and the local Public Health England health protection team. [2012, amended 2016]

253.

Multidisciplinary TB teams, in conjunction with prisons, custody suites and immigration removal centre healthcare services, should agree a care pathway for TB. This is to ensure that any suspected or confirmed cases are reported to, and managed by, the multidisciplinary TB team. [2012, amended 2016]

254.

Multidisciplinary TB teams, in liaison with prisons, custody suites or immigration removal centre healthcare providers, should manage all cases of active TB. Investigations and follow-up should be undertaken within the prison or immigration removal centre if possible. [2012, amended 2016]

255.

Multidisciplinary TB teams should assess the living circumstances of people with TB. Where there is a housing need they should work with allied agencies to ensure that all those who are entitled to state-funded accommodation receive it as early as possible during their treatment, for example, as a result of a statutory homelessness review and identified need. [2012, amended 2016]

256.

Multidisciplinary TB teams, commissioners, local authority housing lead officers and other social landlords, providers of hostel accommodation, hospital discharge teams, Public Health England and the Local Government Association should work together to agree a process for identifying and providing accommodation for homeless people diagnosed with active pulmonary TB who are otherwise ineligible for state-funded accommodation. This includes people who are not sleeping rough but do not have access to housing or recourse to public funds. The process should detail the person’s eligibility and ensure they are given accommodation for the duration of their TB treatment. [2012, amended 2016]

257.

Local government and clinical commissioning groups should fund accommodation for homeless people diagnosed with active TB who are otherwise ineligible for state-funded accommodation. Use health and public health resources, in line with the Care Act 2014. [2012, amended 2016]

258.

Multidisciplinary TB teams should make people who would not otherwise be entitled to state-funded accommodation aware that they may lose this accommodation if they do not comply with treatment. They should ensure plans are made to continue housing people once their TB treatment is completed. [2012]

259.

Public Health England, working with the Local Government Association and their special interest groups, should consider working with national housing organisations such as the Chartered Institute of Housing, Homeless Link, Sitra and the National Housing Federation to raise the profile of TB. This is to ensure people with TB are considered a priority for housing.

260.

Consider training housing commissioners and frontline staff on TB and the need for housing support, so that they understand that a stable home life is a prerequisite to successful TB treatment. [new 2016]

261.

Once a person has been diagnosed with active TB, the diagnosing physician should inform relevant colleagues so that the need for contact tracing can be assessed without delay. Contact tracing should not be delayed until notification. [2006]

262.

Offer screening to the close contacts of any person with pulmonary or laryngeal TB. [2006, amended 2016]

263.

Assess symptomatic close contacts for active TB (see section 3.2 to 3.5). [new 2016]

264.

In asymptomatic close contacts younger than 65 years, consider standard testing for latent TB (see section 3.1), followed by consideration of BCG vaccination (see section 8) or treatment for latent TB infection (see section 7) once active TB has been ruled out for people who:

are previously unvaccinated and
are contacts of a person with smear-positive pulmonary or laryngeal TB and
are Mantoux- or interferon-gamma release assay-negative. [2006, amended 2016]

265.

In asymptomatic close contacts older than 65 years, consider a chest X-ray (if there are no contraindications), possibly leading to further investigation for active TB. [2006, amended 2016]

266.

Do not routinely assess social contacts of people with TB, who will include most workplace contacts. [2006, amended 2016]

267.

Assess the need for tracing social contacts of people with pulmonary or laryngeal TB if:

the index case is judged to be particularly infectious (for example, evidenced by transmission to close contacts) or
any social contacts are known to possess features that put them at high risk of going on to develop active TB. [2006, amended 2016]

268.

Offer ‘inform and advise’ information to all contacts of people with smear-positive TB (see section 9.2). [2006]

269.

After diagnosis of TB in an aircraft traveller, do not routinely carry out contact tracing of fellow passengers. [2006, amended 2016]

270.

The notifying clinician should inform the relevant consultant in communicable disease control or health protection if:

less than 3 months has elapsed since the flight and the flight was longer than 8 hours and
the index case is sputum-smear-positive and either
the index case has multidrug-resistant TB or
the index case coughed frequently during the flight. [2006]

271.

The consultant in communicable disease control or health protection should provide the airline with ‘inform and advise’ information to send to passengers seated in the same part of the aircraft as the index case. [2006]

272.

If the TB index case is an aircraft crew member, contact tracing of passengers should not routinely take place. [2006]

273.

If the TB index case is an aircraft crew member, contact tracing of other members of staff is appropriate, in accordance with the usual principles for screening workplace colleagues. [2006]

274.

After diagnosis of TB in a school pupil or member of staff, the consultant in communicable disease control or health protection should be prepared to explain the prevention and control procedures to staff, parents and the press. Advice on managing these incidents and their public relations is available from the Public Health England health protection team and the local authority. [2006, amended 2016]

275.

If a school pupil is diagnosed with smear-positive TB, carry out a risk assessment of the need to test the rest of his or her class (if there is a single class group), or the rest of the year group who share classes, as part of contact tracing. [2006]

276.

If a teacher has smear-positive TB, assess the pupils in his or her classes during the preceding 3 months as part of contact tracing. [2006]

277.

Consider extending contact tracing in schools to include children and teachers involved in extracurricular activities, and non-teaching staff, on the basis of:

the degree of infectivity of the index case
the length of time the index case was in contact with others
whether contacts are unusually susceptible to infection
the proximity of contact. [2006, amended 2016]

278.

Treat secondary cases of smear-positive TB as index cases for contact tracing. [2006]

279.

If the index case of a school pupil’s TB infection is not found, and the child is not in a high-risk group for TB, contact tracing and screening (by either symptom enquiry or chest X-ray) should be considered for all relevant members of staff at the school. [2006]

280.

When an adult who works in childcare (including people who provide childcare informally) is diagnosed with smear-positive TB, follow recommendations 259 to 266. [2006]

281.

If TB is diagnosed in a hospital inpatient, do a risk assessment. This should take into account:

the degree of infectivity of the index case
the length of time before the infectious patient was isolated
whether other patients are unusually susceptible to infection
the proximity of contact. [2006, amended 2016]

282.

Carry out contact tracing and testing only for patients for whom the risk is regarded as significant. [2006]

283.

Regard patients as at risk of infection if they spent more than 8 hours in the same bay as an inpatient with smear-positive TB who had a cough. Document the risk in the contact’s clinical notes, for the attention of the contact’s consultant. Give the contact ‘inform and advise’ information, and inform their GP. [2006]

284.

If patients were exposed to a patient with smear-positive TB for long enough to be equivalent to close contacts (as determined by the risk assessment), or an exposed patient is known to be particularly susceptible to infection, manage their TB risk in the same way as close contacts. [2006, amended 2016]

285.

If an inpatient with smear-positive TB is found to have multidrug-resistant TB, or if exposed patients are HIV positive, trace contacts following the Interdepartmental Working Group on Tuberculosis guidelines. [2006]

286.

In cases of doubt when planning contact tracing after diagnosing smear-positive TB in an inpatient, seek further advice from the local or national Public Health England or Wales unit or people experienced in the field. [2006, amended 2016]

287.

In areas of identified need (see section 10.2), including major urban centres with a high incidence of TB, commissioners should:

ensure there is a programme of active case-finding using mobile X-ray in places where homeless people and people who misuse substances congregate (this includes: homeless day centres, rolling shelters, hostels and temporary shelters established as part of cold weather initiatives and venues housing needle and syringe programmes)
base the frequency of screening at any 1 location on population turnover
where local demand does not warrant a mobile X-ray team, consider commissioning mobile X-ray capacity from another area. [2006, amended 2012]

288.

Multidisciplinary TB teams should consider using simple incentives, such as providing hot drinks and snacks, to encourage people to attend for screening. [2006, amended 2012, amended 2016]

289.

Commissioners of TB prevention and control programmes should consider offering people who are homeless and people who misuse substances other health interventions when they are screened for TB at a mobile X-ray unit. (Examples may include blood-borne virus screening, dentistry and podiatry services.) [2012]

290.

Multidisciplinary TB teams should work closely with mobile X-ray teams and frontline staff in hostels and day centres to promote TB screening and to ensure appropriate onward referrals and follow-up. [2012]

291.

Multidisciplinary TB teams should consider using peer educators to promote the uptake of TB screening in hostels and day centres. [2012]

292.

Multidisciplinary TB teams should provide routine data to TB control boards on: screening uptake, referrals and the number of active TB cases identified. [2012]

293.

Employees new to the NHS who will be working with patients or clinical specimens should not start work until they have completed a TB screen or health check, or documentary evidence is provided of such screening having taken place within the preceding 12 months. [2006]

294.

Employees new to the NHS who will not have contact with patients or clinical specimens should not start work if they have signs or symptoms of TB. [2006]

295.

Health checks for employees new to the NHS who will have contact with patients or clinical materials should include:

assessment of personal or family history of TB
asking about symptoms and signs, possibly by questionnaire
documentary evidence of TB skin (or interferon-gamma release assay) testing within the past 5 years and/or BCG scar check by an occupational health professional, not relying on the applicant’s personal assessment. [2006]

296.

See recommendations 16 to 19 for screening new NHS employees for latent TB. [2006, amended 2011]

297.

Employees who will be working with patients or clinical specimens and who are Mantoux- or interferon-gamma release assay-negative should have an individual risk assessment for HIV infection before BCG vaccination is given. [2006, amended 2016]

298.

Offer BCG vaccination to employees of any age who are new to the NHS and are from countries of high TB incidence, or who have had contact with patients in settings with a high TB prevalence, and who are Mantoux- or interferon-gamma release assay-negative. [2006, amended 2011]

299.

If a new employee from the UK or other low-incidence setting, who has not had a BCG vaccination, has a positive Mantoux test and a positive interferon-gamma release assay, they should have a medical assessment and a chest X ray. They should be referred to a TB clinic to determine whether they need TB treatment if the chest X-ray is abnormal, or to determine whether they need treatment of latent TB infection if the chest X-ray is normal. [2006, amended 2011, amended 2016]

300.

If a prospective or current healthcare worker who is Mantoux- (or interferon-gamma release assay-) negative declines BCG vaccination, explain the risks and supplement the oral explanation with written advice. If the person still declines BCG vaccination, he or she should not work where there is a risk of exposure to TB. The employer will need to consider each case individually, taking account of employment and health and safety obligations. [2006]

301.

Screen clinical students, agency and locum staff and contract ancillary workers who have contact with patients or clinical materials for TB to the same standard as new employees in healthcare environments, according to the recommendations set out above. Seek documentary evidence of screening to this standard from locum agencies and contractors who carry out their own screening. [2006]

302.

NHS trusts arranging care for NHS patients in non-NHS settings should ensure that healthcare workers who have contact with patients or clinical materials in these settings have been screened for TB to the same standard as new employees in NHS settings. [2006]

303.

Include reminders of the symptoms of TB, and the need for prompt reporting of such symptoms, with annual reminders about occupational health for staff who:

are in regular contact with TB patients or clinical materials or
have worked in a high-risk clinical setting for 4 weeks or longer.

Give one-off reminders after a TB incident on a ward. [2006]

304.

If no documentary evidence of previous screening is available, screen staff in contact with patients or clinical material who are transferring jobs within the NHS as for new employees (see recommendations 16, 17 and 18). [2006]

305.

Assess the risk of TB for a new healthcare worker who knows he or she is HIV-positive at the time of recruitment as part of the occupational health checks. [2006]

306.

The employer, through the occupational health department, should be aware of the settings with increased risk of exposure to TB, and that these pose increased risks to HIV-positive healthcare workers. [2006]

307.

Healthcare workers who are found to be HIV-positive during employment should have medical and occupational assessments of TB risk, and may need to modify their work to reduce exposure. [2006]

308.

Healthcare professionals in prisons and immigration removal centres should ensure prisoners and detainees are screened for TB within 48 hours of arrival. [2012]

309.

Prisons with Department of Health-funded static digital X-ray facilities for TB screening should X-ray all new prisoners and detainees (including those being transferred from other establishments) if they have not had a chest X-ray in the past 6 months. This should take place within 48 hours of arrival. [2012]

310.

Prison and immigration removal centre health staff should report all suspected and confirmed TB cases to the local multidisciplinary TB team within 1 working day. [2012]

311.

Multidisciplinary TB staff should visit every confirmed TB case in a prison or immigration removal centre in their locality within 5 working days. [2012]

312.

If a case of active TB is identified, the local Public Health England unit, in conjunction with the multidisciplinary TB team, should plan a contact investigations exercise. They should also consider using mobile X-ray to check for further cases. [2012]

1.6. Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

Which strategies and interventions are effective and cost effective in promoting the uptake of diagnostic efforts for people with suspected latent TB, and in promoting the uptake of and adherence to treatment in those with a positive diagnosis?
Why this is important
Identifying and effectively treating people with latent TB is a cornerstone of TB control. Encouraging people at risk of infection to be tested and have treatment is therefore vital. Despite this, the Committee found little evidence on strategies to promote these. Randomised controlled trials in at-risk populations are needed.
In people with suspected TB, what is the relative clinical and cost effectiveness of universal and risk-based use of rapid nucleic acid amplification tests?
Why this is important
The Guideline Committee noted that there were 2 possible approaches to using rapid nucleic acid amplification tests for suspected TB. The current approach is to use them only if TB is strongly suspected and rapid information about mycobacterial species would alter the person’s care. Another approach is to use them in anyone with a possible diagnosis of TB. There is a tradeoff between ensuring that all people with active TB are diagnosed and avoiding a large number of false positives, which lead to unnecessary treatment. This trade-off may lead to differences in the cost effectiveness of each approach. NICE’s systematic review of the diagnosis of active TB did not identify any robust evidence on this, nor did the health technology assessment on using nucleic acid amplification tests to detect drug resistance. Cost-effectiveness studies are needed to improve understanding in this area.
Is it more cost effective to organise rapid diagnostic services in local or centralised laboratories?
Why this is important
The relative clinical and cost effectiveness of rapid diagnostic tests may be heavily influenced by whether the services delivering them are arranged locally or in centralised laboratories. The organisation of laboratory services may affect the time taken to start appropriate treatment, with subsequent effects on morbidity and mortality rates. In terms of cost effectiveness, there is a balance between these factors and the relative costs of providing localised and centralised services. UK-based cost-effectiveness studies are needed to improve service organisation.
How accurate, effective and cost effective are point-of-care diagnostics?
Why this is important
Point-of-care diagnostics may shorten the time between suspicion of disease or drug resistance and starting appropriate treatment. However, NICE identified no evidence in this area. The diagnostic accuracy of these tests should be compared with those currently used, in cross-sectional and cost-effectiveness studies, to determine whether they have a place in UK practice. Outcomes should also include time waiting for results and the cost effectiveness of the tests.
Apart from culture, what other diagnostic tests or combinations of tests are effective in establishing an accurate diagnosis of active respiratory TB in children and young people with suspected active TB?
Why this is important
The Guideline Committee noted the lack of evidence on the diagnosis of active TB in children. The disease manifests differently in children than in adults, and more evidence would have been useful to the Committee. Cross-sectional studies are needed to examine the relative accuracy of different tests, and the most appropriate specimen type for these tests, compared with tests currently in use. In particular, the poor accuracy of many tests in children means that diagnostic strategies – that is, combinations of tests – should be investigated, including both tests with high sensitivity and tests based on host response.
In people with suspected TB disease, which fluid or tissue samples provide the highest accuracy in nucleic acid amplification tests?
Why this is important
In order to maximise the accuracy of nucleic acid amplification tests in the diagnosis of active TB disease, the GDG felt that additional information regarding the type of optimal specimen – tissue compared to fluid – would have been useful to their decision-making. The reviews conducted found only limited evidence for this. Cross-sectional studies of nucleic acid amplification tests using linked specimens – that is, tissue and fluid specimens taken from and compared in the same person – should be conducted.
How should the standard recommended regimen for active TB be adapted to accommodate comorbidities or coexisting conditions?
Why this is important
NICE conducted an evidence review into the most effective regimens for active TB in people with comorbidities or coexisting conditions (including HIV, liver disease, renal disease, diabetes, substance use, including methadone use, pregnancy and breastfeeding and impaired vision or eye disease), but did not identify any evidence. People in these groups are at increased risk of drug–drug, and do not respond to anti-TB therapy in the same was as those without a comorbidity or coexisting condition. They may therefore need an adapted regimen to improve the likelihood of treatment success and reduce the risk of adverse events. Randomised controlled trials are needed to compare the standard recommended regimen with alternatives for active TB in these people. Alternatively, given the relatively small numbers of people in these groups, prospective observational cohort studies could be conducted to assess treatment success and adverse events for different regiments.
For people with active, drug susceptible TB who experience treatment interruptions because of adverse events, particularly hepatotoxicity, what approach to re-establishing treatment is most effective in reducing mortality and morbidity?
Why this is important
There is little evidence on re-establishing treatment after interruptions because of adverse events. This is key to ensuring treatment success without relapse or the emergence of drug resistance, but avoiding further adverse events is also important. Randomised controlled trials are needed to compare approaches to reestablishing treatment for active, drug susceptible TB after it is interrupted because of adverse events, particularly hepatotoxicity. These trials should assess mortality, treatment success or failure, rates of relapse, the recurrence of adverse events and the emergence of drug resistance. Approaches evaluated could compare, for example, restarting regimens with lengthening their duration, as well as sequential reintroduction. Approaches should vary depending on the proportion of doses missed and the stage of treatment (initial or continuation phase) in which the interruption occurred. Prospective observational cohort studies with multivariable analyses may also be useful.
What are the costs of adverse events, particularly hepatotoxicity, in people who are undergoing treatment for TB, including effects on quality of life?
Why this is important
The health economists for this guidance were unable to identify reliable data on how adverse events affected quality of life and costs in people being treated for TB. Such data are essential in producing economic models that reflect the real costs of treatment. Data need to be collected and reported on the quality of life and other costs of adverse events, particularly hepatotoxicity, experienced by people being treated for TB.
Combine data from different national and local registries to improve data use.
Why this is important
There are gaps in the evidence base for several areas of the guideline. These include the best approach to re-establishing treatment after an interruption and the optimal duration of isolation for infection control. The Committee acknowledged that there are excellent sources of information available - such as cohort review databases, the London TB database and the national Enhanced TB Surveillance System database - but these are not linked in any way. A study group with access to these registries and databases could focus on identifying people who have:
- experienced treatment interruptions, and link the management approach to outcomes such as mortality, treatment failure, relapse and drug resistance, as well as to costs; or
- undergone isolation, and link the duration of isolation to TB infection rates, treatment outcomes, measures of quality of life and costs.
For isoniazid-resistant TB, what is the most effective regimen for reducing mortality and morbidity?
Why this is important
There is little evidence for the treatment of isoniazid resistant TB. This is the most common form of drug resistance in the UK, occurring in 7.5% of TB cases. Currently, treatment is not always successful, even when the recommended drugs are given for the recommended time and there are no adherence issues. It is particularly difficult to treat if there are treatment interruptions or if the central nervous system is involved. Randomised controlled trials are needed to compare different anti-TB regimens for isoniazid-resistant TB, assessing mortality, treatment success or treatment failure, rates of relapse and adverse events.
What effects does isolation have on the quality of life of people being treated for TB?
Why this is important
Isolation is known to significantly affect a person’s quality of life. Despite this, the Guideline Committee identified no reliable data on the impact of isolation on quality of life. This information is essential in producing economic models that reflect the real costs of isolation. Data on the impact of isolation on quality of life need to be collected and reported.
For people with latent TB, are shorter regimens effective in preventing the development of active TB? If so, which regimen is the most effective?
Why this is important
Shorter regimens with minimal side-effect profiles would help encourage people with latent TB to have and adhere to treatment. Randomised controlled trials comparing the effectiveness of shorter regimens, such as those containing rifabutin or rifapentine, with the current standard regimen (6 month of isoniazid and 3 month of isoniazid and rifampicin) in preventing the development of active TB are needed. Measurements are also needed of the incidence of adverse events, particularly hepatotoxicity. The systematic reviews for this guideline noted the increased risk of hepatotoxicity associated with pyrazinamide-containing regimens. Given this, the Committee, did not feel that these regimens need be investigated further. Trials would need to be of sufficient size to take into account the low rate of progression from latent to active TB.
Strategies to improve treatment completion in those infected with latent TB infection and at risk of non-adherence
Is Directly Observed preventative Therapy (DOPT) and other support strategies effective and cost effective compared self-administered therapy in promoting the uptake of and adherence to treatment in those populations who should be offered DOT as part of enhanced case management for active TB?
Why this is important
Effectively treating people with latent TB is considered a cornerstone of TB control. Supporting people at risk of non-adherence to treatment is therefore vital to these efforts. Despite this, little evidence was identified on the effectiveness or cost effectiveness of DOPT in groups at high risk of non-adherence. Randomised controlled trials in these populations should be conducted.
Support strategies to improve treatment completion in those infected with active TB
Are peer support workers, non-clinical support workers effective and cost effective compared self-administered therapy and traditional clinical staff (i.e. TB nurses) in reducing time to diagnosis, promoting diagnostic testing uptake, adherence to treatment and improving contact tracing in under-served and high risk groups. What barriers and facilitators can impact on the effectiveness and cost effectiveness of these interventions?
Why this is important
The GDG noted that there was evidence that various support strategies using trained peers or non-clinical staff were effective in supporting TB control efforts although there was non-available from the UK. They also noted there was no consistent evidence comparing these outcomes to normal care (i.e. TB control nurses) or self-administered therapy, or in assessing the cost effectiveness of these interventions to normal care. Further, there was no systematic information on the barriers and facilitators that may affect these outcomes when comparing clinical and non-clinical staff in delivering the same interventions. The GDG considered these interventions to be of particular importance to under-served and high risk groups. Randomised controlled trials and qualitative assessment of the impact in these populations should be conducted.
Organisation of TB prevention and control services through TB control boards
Are TB control boards effective and cost effective?
Why this is important
Throughout their discussions, the GDG were aware of the new developments and funding for supporting TB prevention and control efforts in the UK namely the National Strategy and the ring fenced monies being made available to support the national strategy through development of TB Controls Boards across the UK. The organisation of TB prevention and control activities through more regionalised mechanisms such as TB control boards was considered to be a corner stone of improving TB service delivery and reducing variation, improving access to expertise with the potential to impact the time taken to diagnose TB and initiate appropriate treatment, support treatment completion and improve contact tracing all of which should have downstream impacts on overall morbidity and mortality rates. Quantitative, qualitative and process evaluations of TB control boards using a mixed methods approach to include benchmarking against relevant NICE guideline recommendations and on-going evaluation of surveillance data are recommended.
Referral mechanisms and their impact on reducing time to diagnosis
Are rapid radiological referral and direct referral from emergency departments effective and cost effective at reducing time to diagnosis and diagnostic uptake compared to current practice.
Why this is important
The GDG consider time to diagnosis a key outcome in managing TB prevention and control both in terms of outcomes for the person affected but also in reducing transmission risk to the general population. There was some strong evidence available on the effectiveness of a rapid referral process in one area of the UK but as the population served has a particular epidemiology this created some uncertainty when extrapolating this evidence to the population as a whole, other than audit data there there was no empirical evidence for emergency department referral but given the part of the health services contact with certain high risk groups who may not have a GP this mechanism needs further evaluation. Furthermore, neither process had cost-effectiveness evaluations available.

Footnotes

a: Public Health England. Public Health Outcomes Framework 2013 to 2016. Public Health England; London: 2014.
b: Public Health England. Tuberculosis in the UK 2014 report. Public Health England; London: 2014.
c: Public Health England. Tuberculosis in the UK 2014 report. Public Health England; London: 2014.
**: Guideline Development Group members who were core members of the Service delivery Group
e: At the time of publication (December 2016) the BNF states: ‘The Mantoux test is recommended for tuberculin skin testing, but no licensed preparation is currently available. Guidance for healthcare professionals is available at www.dh.gov.uk/immunisation.
f: The staffing ratios used in Public Health England and NHS England’s collaborative tuberculosis strategy for England (published in 2015) came from NICE’s guideline on tuberculosis: identification and management in under-served groups (published in 2012) which has been replaced by this guideline.
g: NICE’s 2012 guideline on tuberculosis: identification and management in under-served groups recommended 1 WTE case manager per 40 incident cases needing standard management and 1 WTE case manager per 20 incident cases needing enhanced case management.

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Internal Clinical Guidelines Team (UK). Tuberculosis: Prevention, Diagnosis, Management and Service Organisation. London: National Institute for Health and Care Excellence (UK); 2016 Jan. (NICE Guideline, No. 33.) 1, Introduction & summary section.
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Background information [2011, updated 2016]
Epidemiology of TB in England and Wales [2011, updated 2016]
GDG and SDG membership ICG technical team and peer review
Strength of recommendations
Recommendations
Research recommendations

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Tuberculosis: Prevention, Diagnosis, Management and Service Organisation.

1Introduction & summary section

1.1. Background information [2011, updated 2016]

What causes TB?

What happens after infection?

Who catches TB?

What are the symptoms of TB?

How is TB diagnosed?

How is TB treated?

1.2. Epidemiology of TB in England and Wales [2011, updated 2016]

Historical trends

Geographical variations in incidence

Variations in incidence by ethnicity and place of birth

Table 1

1.3. GDG and SDG membership ICG technical team and peer review

1.3.1. Guideline Development Group 2016

1.3.2. Service Delivery Group co-optees 2016

1.3.3. Internal Clinical Guidelines team

1.3.4. Peer review

1.4. Strength of recommendations

Interventions that must (or must not) be used

Interventions that should (or should not) be used – a ‘strong’ recommendation

Interventions that could be used

Recommendation wording in guideline updates

Update information

1.5. Recommendations

Pleural TB

Site-specific investigations for pleural TB

Central nervous system TB

Site-specific investigations for central nervous system TB

Lymph node TB (including intrathoracic mediastinal adenopathy)

Site-specific investigations for lymph node TB

Pericardial TB

Site-specific investigations for pericardial TB

Gastrointestinal TB

Site-specific investigations for gastrointestinal TB

Genitourinary TB

Site-specific investigations for genitourinary TB

Bone and joint TB

Site-specific investigations for bone and joint TB

Disseminated TB

Site-specific investigations for disseminated TB

Skin TB

Site-specific investigations for skin TB

Localised tuberculous abscess

Site-specific investigations for localised tuberculous abscess

Central nervous system TB

Example of suitable corticosteroid regimen for adults

Pericardial TB

Central nervous system TB

Spinal TB

Drug resistant TB

Healthcare settings

Non-healthcare settings

Multidrug-resistant TB

BCG vaccination in neonates (0–4 weeks)

Encouraging uptake among infants, older children and new entrants

Improving adherence: case management including directly observed therapy

Other strategies to encourage people to follow their treatment plan

Strategies in prisons or immigration removal centres

Coordination of the TB networks

Active case finding in underserved groups

Incident and outbreak response

1.6. Research recommendations

Footnotes

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