A TB Action Plan for Scotland

Scottish Government's policy on tuberculosis (TB)

4. Surveillance


4.1 Accurate, timely and efficient surveillance of TB cases is a vital foundation for good quality disease prevention and control. Without up-to-date and accurate information on the burden of disease and the epidemiology of TB cases it would become increasingly difficult to target services and provision to those most in need and thus prevent further cases of the infection. The Surveillance Subgroup reviewed the current surveillance of TB in Scotland and provided advice to the TB Action Plan Working Group on areas for action.

Key Issues

TB Surveillance

4.2 Tuberculosis surveillance was introduced in Scotland in 2000 through the Enhanced Surveillance of Mycobacterial Infections ( ESMI) scheme. This scheme is still in existence and has operated largely unchanged since its introduction. The scheme is paper based and slow, data only becomes available retrospectively and its completeness is likely to be affected by the extent to which clinicians locally are aware of and comply with the scheme

4.3 The TB Action Plan Working Group considers that ESMI is now out of date - and any replacement system should provide real time information for the clinical management of cases and for contact tracing. The Working Group believe that an updated and dynamic surveillance system that provides real time functionality and that is efficient and easy to use, would significantly improve TB services across Scotland, and should be introduced as soon as possible.

4.4 There are several potential solutions, including considering existing off-the-shelf solutions or designing a new TB surveillance system for Scotland. However in the course of preparing the TB Action Plan for Scotland it became clear that a web-based Enhanced Tuberculosis Surveillance system ( ETS), which was designed by the Health Protection Agency in England for their own surveillance purposes has already been implemented in England. Given the potential value of adopting an existing and proven surveillance system that would allow data be collected in a format consistent with other parts of the UK and link with TB reference laboratory results, the Working Group felt that the Scottish Government and Health Protection Scotland should establish a group involving NHS Board representatives as soon as possible to actively consider adopting a compatible version of ETS.

4.5 In the meantime, the Working Group felt that there is scope to improve the timeliness and completeness of the existing ESMI scheme. Multidisciplinary teams locally should routinely feedback local ESMI surveillance to local clinicians and audit the completeness and timeliness of the return of surveillance data using the current paper-based ESMI system.

Evaluation of TB control across Scotland

4.6 The surveillance of drug resistance and treatment outcome monitoring are essential tools for the evaluation of TB control. Surveillance data from ESMI and its eventual replacement should be used for TB service evaluation both nationally and locally.

4.7 At the National LevelHPS should continue to report annually to the Scottish Government (copied to NHS Boards) on TB. This report should include a section describing Scotland's performance on the specific ECDC indicators (See the ECDC Progressing towards TB Elimination document:

  • Information on local epidemiology of TB, trends, vulnerable populations
  • Treatment success rates nationally and by health boards
  • Drug resistance rates
  • Mortality data
  • Percentage of cases lost to follow up and reasons why

4.8 At the Local Level, each NHS Board TB service/multidisciplinary team should report annually on TB prevention and control activities. These reports should be sent to their local Clinical Governance Committee and copied to Health Protection Scotland. Local clinicians should be made aware of this report. The report should include:

  • Information on local epidemiology of TB, trends, vulnerable populations
  • Treatment success rates locally
  • Mortality data
  • Percentage of cases lost to follow up and reasons why
  • Contact tracing uptake and outcomes
  • Timeliness of service delivery
  • HIV testing uptake
  • Drug resistance rates
  • Summary data on Incidents and outbreaks data
  • Audit of compliance with recommendations in this document and those from the Health Protection Network 2009 guidance.

4.9 The WHO has set targets of a 90% cure rate for sensitive TB and >75% cure rate for drug resistant TB by 2015. These targets reflect the aspirations of the Scottish Government to deliver world class TB control and local services should be planned, delivered and monitored in a such a way as to support achievement of these targets.

Examples of objectives for a local TB service adapted from Global Plan to Stop TB 2011-2015, WHO 2010 (

  • Objective 1: Ensure early diagnosis of all TB cases (increase percentage of cases seen within two weeks of first presentation to NHS, decrease percentage of cases with delayed diagnosis over 12 weeks from symptom onset)
  • Objective 2: Ensure high quality treatment of all diagnosed cases of TB (increase percentage of cases on four drug regime, increase percentage of cases completing treatment within 12 months, maintain /increase percentage of cases with laboratory culture confirmation, drug resistance monitoring)
  • Objective 3: Strengthen monitoring and evaluation including measurement of the impact of the service on the burden of disease (numbers of cases, trends in TB rate in UK born & non UK born, deaths from TB, number of cases in children aged under 5 years, trends in cases amongst vulnerable groups, percentage uptake of HIV testing amongst cases, incident and outbreaks, MIRU data on clusters, drug resistance monitoring data)
  • Objective 4: Strengthen human resources for TB control (availability of TB specialist nurses, resources for directly observed therapy, training for TB specialist nurses, clinicians microbiologists, multidisciplinary meetings per annum, local professional awareness events held)
  • Objective 5: Ensure appropriate TB control through contact tracing and management of incidents and outbreaks (contact tracing timeliness, contact screening uptake and outcomes, review of incidents & outbreaks)
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