A TB Action Plan For Scotland: ANNUAL REPORT / 2013

EXECUTIVE SUMMARY

Tuberculosis is a major global health problem. Although global TB mortality has decreased by 41% since 1990, there is still a lot of work to be done: there were 8.7 million new infections globally in 2011, with 1.4 million preventable deaths. Scotland is committed to the 2008 European Centre for Disease Prevention and Control (ECDC) Framework Action Plan to Fight TB in the European Union, the aim of which is 'To eliminate, by 2050, TB as a public health problem (incidence <1 per million population)'. This 2013 Annual Report provides an update on progress since the Scottish Government published A TB Action Plan for Scotland in 2011, and gives recommendations for continued action to ensure early case and cluster detection, effective clinical care, and the prevention of onward transmission.

In Scotland, TB rates have been increasing since 2005 and there is a mean increasing five year trend from 7.8 per 100,000 in 2008, to 8.8 per 100,000 in 2012. Rates have begun to level off and in 2012 incidence decreased by 9.4% compared to 2011; but it is too early to say that this is the beginning of a downward trend. Of 408 cases reported in 2012, the majority were from Greater Glasgow and Clyde (48.5%), Lothian (20.1%) and Grampian (8.8%) NHS Boards. The main risk factors for infection are being non-UK born and problem alcohol use. However, cases are becoming increasingly complex as individuals may have dual infection with TB and blood borne viruses; they may have underlying chronic conditions such as diabetes or coronary heart disease; they may be employed as care workers; they may share multiple occupancy accommodation; and they may be both internationally and internally mobile.

Progress with the Action Plan recommendations and the ECDC indicators is generally good. National strategies, guidance, quality control and reporting systems are available; patients have access to appropriate diagnostic services, and clinical care, provided by expert and multidisciplinary teams; there are low levels of drug resistance; and public health services contribute to the prevention of transmission. However, there are challenging areas where programmes need to improve. For example, only four of 14 NHS boards implement active case finding for latent TB in new entrants and nine of 14 report engagement with primary care to support services with the problem drinker at-risk group; treatment success rates for pulmonary smear positive cases in 2011 were 75.6% against an 85% target (10% below target); and the current paper-based surveillance system is not fit for purpose. Key recommendations to address these challenges are:

1. Explicit adoption of the ECDC target 'To eliminate, by 2050, TB as a public health problem (incidence <1 per million population)'.

2. Clear articulation of a strategic and monitoring framework to manage implementation and measure progress towards achievement of this goal.

3. Strengthened linkages to other policy areas such as long term conditions, primary care, health improvement (smoking, alcohol, diet), blood borne viruses, mental health, occupational health, migrant health and the third sector.

4. Systematic and standardised approaches to case finding and follow up of TB among migrants migrants/new entrants and those at risk due to excess alcohol intake.

5. Clear guidance on, and support for the use of, new technologies to identify and follow up cases and clusters of illness, such as IGRA testing, MIRU cluster analysis and electronic surveillance systems.

6. Supportive networking to share good practice, reduce variation and maintain quality in TB services.

Tuberculosis still poses a considerable threat to the population of Scotland. To build on the excellent work so far, the Action Plan requires a clear strategic direction, plus, rigorous implementation and monitoring across Scotland.