Tuberculosis (TB) is an infectious airborne disease. It can affect any organ in the body but those who have TB in the lungs can pass this infection to others easily. People can be exposed to TB bacteria and some may not develop the active disease. It can remain sleeping / latent with one having no symptoms but for some it can become active affecting the lungs or any other organ. If the lungs are affected especially in adults by coughing, sneezing it can be transferred by the droplets in the air, with regular contact with the index case/ person with active TB. The importance of knowing the symptoms of TB which are a productive coughing over 3 weeks with blood, weight loss, night sweats, fever, chest pain and tiredness can assist with early detection and diagnosis.
Tuberculosis is a notifiable disease and in the UK this is statutorily. Surveillance by Communicable Disease Centre and Public Health England (PHE) provides us with data for TB rates for migrants in the UK. We can then use this data to assist in proactive planning of services of greater need.
Migration in Europe has increased over the last 10 years and London has been one of the highest affected cities with the region of Newham seeing an increase of TB as a result. (PHE 2014).
In their report, “Public Health England (PHE) reported 2,985 TB cases among London residents, a rate of 36 per 100,000 population. London had 38% of the 7,892 TB diagnosed in the UK in 2013, and had the highest rate of disease.” (PHE 2014).
TB remains a priority for PHE with the “launch of a national collaborative TB strategy which focuses on prevention as one of the key elements as a driver to reduce the spread of the disease.” PHE (2014).
According to (PHE 2014) “ London compared to other Western Europe cities has the highest number of TB cases and Newham region is mostly affected, the highest numbers and rates in Newham were (335 cases, 107 per 100,000)”.
FIG 1.
(Source PHE 2013)
Figure 1, shows that TB amongst those from Pakistan, India and Black African are higher than other ethnic groups listed with figure 2, below showing the rates of TB in these three groups dominating that of the others.
FIG 2.
The highest TB rates amongst migrants are from those who come from a country with a high risk of TB and according to (PHE 2013) many are diagnosed 2-3 years after settling in the UK. Therefore we are seeing people having been exposed to TB in their home country and this lies dormant and can become active due to many contributory factors. Late diagnosis of TB for migrants remain an issue as if the bacteria is identified early, active TB can be reduced.
In Newham TB not only affects the migrant population but disadvantaged hard to reach groups such as the homeless, intravenous drug users, those with alcoholic abuse and those who have left prison. Screening for TB in migrants from the Port of Health has now ceased and screening hard to reach groups have not been effective or consistent in different areas in London. Migrants also include asylum seekers, refugees, unaccompanied children 0-16 age group who fall into the looked after children care in the UK. Figure 3 below shows countries with the non UK born cases of TB in 2013.
“Most frequent countries of birth for non-UK born tuberculosis cases and time since entry to the UK to tuberculosis diagnosis, UK, 2013”
Country of birth Number of cases Percentage of cases* Median time since entry to UK (IQR)**
India
Pakistan
Somalia
Bangladesh
Nepal
Nigeria
Philippines
Zimbabwe
Sri Lanka
Kenya
Romania
Afghanistan 1,615 29.8
20.4
5.4 4.6 3.1 3.0 2.5 1.9 1.8 1.6 1.3 1.2 1.2 1.1
1.0 5 (2 -13)
7 (2 -22)
9 (4 -13)
7 (3 -18) 3 (2 -6)
7 (3 -11)
8 (5 -12)
11 (7 -12) 7 (3 -13)
22 (8 -37)
2 (0 -4)
6 (2 -11)
5 (2 -7.5)
4 (2 -7)
7 (4 -11)
1,103
292
248
170
164
136
105
95
84
70
67
Poland 66
Eritrea 62
China 56
Others (each <1%) 1,082 20.0 5 (1 -13)
Total* 5,415 100 7 (3 -14)
Source PHE 2014
Fig 4 TB case rate by local authority of residence, London, 2013
“Newham (335 cases, 107 per 100,000) and Brent (279, 89 per 100,000) local authorities, followed by Ealing (213 cases, 63 per 100,000), Hounslow (163, 63 per 100,000) and Harrow (147 cases, 61 per 100,000. “
(Source TB London Project 2013)
The impact of TB:
TB has an impact on the wider determinants of health and the social impact for migrants and hard to reach groups has been a key factor in the rise of inequalities in Newham.
Using Dahlgren and Whitehead (1993) Social Model of Health in Fig 5: we will explore the different factors that influence health for those with TB. In Newham people with TB, are surrounded with influences that affect their health and some can be modified. This is linked to behaviour, culture, education, stigma and lifestyle and good examples of health promotion could assist them to make better choices, reviewing cultural norms and peer pressures. This also involves capital distribution to provide effective health care for those with TB.
The structural factors play an important role for those with TB from access and affordability to health care, provision of services, housing and working conditions. Not all migrants are entitled to free health care for example student dependants have to pay to see a General Practitioner in the UK.
Figure 5.
Risk, protective and contributory factors:
Anyone can be affected by TB but those most at risk in London Newham are vulnerable hard to reach groups, migrants and those with a weakened immune system. People who have HIV, diabetes, chronic kidney disease, on steroid treatment, smokers, unvaccinated from the BCG and those who had a previous history of TB and did not complete treatment remain at risk. This is supported by Doherty et al 1995.
In London Newham there is evidence that those diagnosed with active TB have been in contact with people with TB, live in overcrowded conditions, have poor nutrition, homeless, have alcohol abuse or unemployed. Therefore we can see that high levels of deprivation contribute to the growth of TB for these vulnerable groups with these social determinants a key to be addressed. (Beijer et al 2012).
Behavioural factors by migrants and hard to reach groups play an important role in addressing the rise of TB in Newham. Non -attendance to clinics for new migrant health checks remain an issue due to the possible lack of understanding the importance of attending, stigma attached to TB and even unable to read the clinic letter with English not being a first language. Some migrants may not be able to read in their own language and do not have any social support.
Contributing factors:
According to (Rechel et al.2013) many migrants come to the UK healthy but this can deteriorate due to many factors and these can vary from their entry status. Asylum seekers and refugees may have health related issues associated from war, conflict, trauma, emotional loss and even loss of their social and economic identity especially those who are educated and had wealth or had their own home.
Poor housing, being homeless or unemployed and low income have an impact on anyone’s health but for these vulnerable groups the impact is harsh. According to (Jayaweera 2014),”when people are homeless and have TB this affects the opportunity to treat the disease as this group do not have access to health services and many do not know that their symptoms are TB related”. This has been seen in a voluntary run clinics in London who supports hard to reach groups unable to access health care. (Doctors of the World 2010).
Life style factors such as smoking, according to Yu G-P, Hsieh C-C, Peng J (1988) is strongly linked to TB and this is seen in the rates of TB in both the Somali and Nepalese population.
Barriers continue to exist for hard to reach groups and migrants unable to access health care. Some of these barriers include, language difficulty, lack of knowledge on how the National Health Service (NHS) works, entitlement to care, cultural sigma associated with TB. (Philmore et al 2010; Johnson 2006).
Protective factors: Anyone who has had the BCG vaccination has an 80% protection from getting TB. (DOH 2006). Those who have not received the vaccine are at risk especially if their immune system is suppressed or have contact with someone with active TB disease.
Research has shown that vitamin D poses a protective factor against TB and diabetes. For migrants coming to the UK from a warm country the lack of sunshine can have an effect with the levels of vitamin D dropping. (Selvaraj P et al 2000). Screening migrants and hard to reach groups in London Newham for TB provides a protective factor to detect latent TB with the objective of reducing active TB disease.
TB awareness forms a protector factor for all residents in the UK. However in London Newham, the signs and symptoms of TB for migrants and hard to reach groups is necessary.
Social support provides a protective factor especially in migrant ethnic groups where TB has a stigma as seen in the Somali population. Having social support according to (Prevalin and Rose 2003) “improves recovery and can limit people making negative health changes as smoking a contributory factor to TB, compliance with taking medication and attending clinic appointments”. When there is limited social networks and support according to (Cacioppo and Patrick 2009) there is a decrease in the immunity and even unhealthy behaviours are increased.
Public Health Interventions: A social determinants of health approach
It is imperative that we look at the social determinants of health which affect migrants, and hard to reach groups and by doing so we can review how screening is delivered and how TB is managed also looking at the various ethnic groups who may hold different views, stigma and understanding of TB. There is a continued need to address poverty and deprivation amongst migrants and hard to reach groups according to (Abubakar et al 2012)”. When we focus on addressing this we can reduce not only the incidence of TB but reduce inequalities in this group.
In a review by Marmott “health inequalities in England post-2010 there was criticism for neglecting to examine and make recommendations using health policy to enable better practice for ethnic minority groups”. (Salway et al 2010 ), found the report by Marmott “did not examine the impact of migration factors and the relationship with ethnicity and socio demographic needs and barriers for migrants” If we encompass all these factors and work collaboratively this can have a robust effect on how we work with policy makers to have drivers for this group.
At a community level we need to include holistic assessments for health and social care, long term conditions, substance use, sexual health, mental and housing, communicable disease. This is supported by the published guidance (NHS England et al 2015)” with primary care and other organisations working collaboratively providing access and care for people with no fixed abode”.
How we screen and manage TB amongst migrants from different ethnic groups need to be addressed. There is also a need to revise how screening is delivered to the homeless, IDU and incentives to attract this group which can be supported by primary care, outreach workers, and local housing support workers. Engaging at grass roots or on ground level and not nurse, doctor led clinic level is needed. The problem of TB amongst migrants and hard to reach groups in Newham needs to have partnership working with Local Authority including interpreters, employment support and education.
Engaging with local community groups, the media, faith groups, crèche facilities and employers in addressing TB can assist in disparities.
.
This collaborative working between Primary Care, Social and Housing can strengthen and improve existing TB services but can also look at redesign of current models used. Outreach services can improve by enhanced accessibility of services with working late nights in the community with provision of screening, housing, employment advice for hard to reach groups and migrants who work shifts. Working and engaging with employers on ensuring that migrants are screened for TB and using the local media, radio and newspaper are tools that can be effective at community level.
At a national level “The Collaborative Tuberculosis strategy for England 2015 -2020 sets out to resource services to tackle TB by supporting and empowering local services with a solid framework and pathway”. This will include the provision of more nurses specialised in TB, additional clinics and interpreters.
London Newham can take examples from Cuba as reported in Health Check BBC World Service 2015: “The Prevention Better than Cure Health System” in Cuba works. “The Cuban health service surpasses other low and medium income countries and in some cases, outperforms much richer ones too. Cuba has a lower infant mortality rate than the US and a similar life expectancy.”
Cuba uses a preventative model to care at primary care level. Death rate in Cuba from infectious diseases are rare due to of a hugely successful vaccination and late nights outreach programme.
The UK can take models of good practice with positive examples from Peru. According to the Pan- American Health Organisation (PAHO 2012) “Peru had a heavy burden of TB world- wide and reached the WHO target in achieving 85% treatment for TB patients”. This was achieved by investing in primary and prevention, health education, social support, transport, access, addressing social deprivation and engaging in local community. (Talbot et al 2011).
In Peru to assist with stigma of TB they removed “the element of blame and position TB as a disease easily spread in highly populated areas with wider socio economic problems”. (Talbot et al 2011). This action used in Peru can work well with the Somali and Nepalese groups in London where stigma and social isolation exist. (Barel et al 2007).
In conclusion: Partnership working can reduce the wider socio-economic issues, reduce financial costs providing a preventative measure in reducing TB in migrant and hard to reach groups. The investment in primary care will also build a stronger community as it offers support with proactive, diverse community groups.
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