The UK is the only country in Western Europe with rising rates of tuberculosis (TB), and cases in London have increased more than 50% since 1999. Nationwide, there are now more than 9,000 cases of TB diagnosed per year (9,040 in 2009). The problem is becoming particularly acute in London, where 40% of all UK TB cases are diagnosed. In a Comment published Online First in The Lancet, Global TB expert Professor Alimuddin Zumla, University College London, UK, calls for recommendations from a recent UK TB review to be implemented urgently to keep this re-emerging problem under control. A World Report in this week's Lancet also discusses TB in homeless people in London.
The death toll from TB (often called the 'white plague' in Victorian times) in the UK began to fall in London at the start of the 20th century as living standards (better housing, nutrition and economic status) improved and subsequent TB control was achieved by the introduction in the early 1960s of anti-TB drugs, improved health services and BCG vaccination. By the early 1980s TB was considered to be conquered in the UK and National Health Service (NHS) TB services were scaled down considerably.
Alarmingly, TB has returned to London with a vengeance with an increase in the number of TB cases by nearly 50% since 1999, from 2,309 cases in 1999 to 3,450 cases in 2009 accounting for nearly 40% of all TB cases in the UK. Since current detection methods (sputum microscopy and culture) only detect up to 70% of active cases, and UK doctors generally need to strongly suspect TB as a possibility before diagnosing it, it is likely the number of cases reported is underestimated.
The increase in the number of TB cases seen in the UK has largely been in non-UK born groups; in 2009 these were black African (28%), Indian (27%) and White (10%)3. Interestingly most of these were not in new migrants; 85% of cases born overseas had lived in the UK for two or more years and about half had lived here for five or more years (indicating that the TB was not imported into the UK) and TB was shown to be common in London boroughs experiencing relative deprivation. Cases of drug resistant TB are also increasing in London.
Professor Zumla says: "Poor housing, inadequate ventilation, and overcrowding—conditions prevalent in Victorian Britain—are causes of the higher TB incidence rates in certain London boroughs. In all European countries, the disease is mainly concentrated in high-risk groups, such as migrants, refugees, homeless people, drug users, prisoners, and HIV-infected groups."
He highlights the issue of spread within prisons, and from prisoners and prison staff to the community. A retrospective 4 year (2004-2007) study of 205 prisoners with newly diagnosed TB showed that prisoners were more likely to be UK born (47% versus 25%), to be white (33% versus 22%) and to have pulmonary TB (75% versus 56%) compared to all other TB patients seen in the UK during that period (29,340 cases in those aged 16 years or older).
The situation in London is, says Professor Zumla, reminiscent of the multi-drug resistant TB outbreaks in prisons in the USA in the 1990s, that required a large financial investment to be brought under control. Professor Zumla refers to the recent London TB Service Review Assessment, written by the Public Health Assessment Support Team (a social enterprise organisation in London) that recommends:
- An urgent and radical re-think on delivery of NHS TB Services
- The urgent need to establish a multi-agency Board including service users for TB Control for London which will closely monitor the performance these services and achieve a year on year reduction in the incidence of TB.
- Greater integration across the full range of bodies involved in TB control, including NHS services, port health, health protection units, Directors of Public Health, local authorities, the third sector, and the office of the London Mayor
- Standardised pathways of care for TB in London, through the use of a Manual of Clinical Policies and Protocols, to be based on the New York model. ie, a community based model of care, moving away from the more traditional clinic model found in the UK.
- Improvements to the accessibility and responsiveness of TB NHS services in line with the needs of local people.
Professor Zumla concludes: "This review, if implemented by the UK NHS, would allow standardisation of TB clinical policy and practice and improve responsiveness of London's TB services needs. An immediate and serious long-term political and financial commitment is needed from the UK Government through the NHS if the tide is to be turned against the return of the white plague in London, and if tuberculosis is to be controlled. Such measures will erase London's reputation as the tuberculosis capital of Europe."
Professor Alimuddin Zumla, University College London, UK. T) +44 (0) 207-679 9311 E) a.zumla@ucl.ac.uk
For full Comment, see: http://press.thelancet.com/tblondon.pdf
For full World Report, see: http://press.thelancet.com/wr1812.pdf
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The Lancet