Select Committee on Health Appendices to the Minutes of Evidence

Attachment 2



  Tuberculosis remains an important public health problem in England and Wales. The decline in case numbers which had been seen throughout most of the 20th century ceased in the late 1980s, and numbers have since increased from just over 5,000 cases in 1987 to over 6,000 in 1999. Almost all of this excess is accounted for by a rise in cases in London from around 1,500 in 1987 to just over 2,500 cases in 1999.

  There are substantial health inequalities. Most of the increase has occurred in young adults and most of these were either born abroad or belong to ethnic minority groups originating in parts of the world with a high incidence of tuberculosis. Rates of tuberculosis are particularly high among recently arrived immigrants. Other contributors to the recent increase in tuberculosis include extra cases occurring as a result of co-infection with HIV and a continuing small contribution from homeless people. The association between tuberculosis and poverty is well recognised, although the effects of this factor are overshadowed by the high risk of tuberculosis in other groups.

  More than any other areas London is home to the largest number of people belonging to groups at highest risk of tuberculosis and now accounts for 40 per cent of all tuberculosis cases compared to 16 per cent in 1987. Eight of the 13 district health authorities with more than 100 cases of tuberculosis reported in 1998 were in London and the overall rate in London in 1998 (32 per 100,000 population) was nearly three times greater than the rate for England and Wales as a whole (11 per 100,000 population).


  The response to tuberculosis in London requires co-ordination across a wide range of agencies. The Director of Public Health for the London region, supported by the Public Health Laboratory Service, is taking the lead in promoting development of tuberculosis services in London. Other agencies involved include: Department of Health, Home Office, District Health Authorities, NHS Hospital and Community Trusts and Primary Care Groups/Trusts. Other statutory agencies and voluntary bodies are also playing a part in the effort to enhance prevention and control. This is especially important among those at greater risk such as certain ethnic minority groups, the homeless and those with HIV infection.


  The substantial and increasing burden presented by tuberculosis in some London districts has meant that they have had to prioritise their tuberculosis control efforts and abandon other routine preventative measures such as screening of new immigrants for tuberculosis. Patient mobility, particularly in those recently arrived in London, lack of familiarity with the NHS, language difficulties and, in the case of the homeless, lack of a stable home environment, all contribute to problems in the management of cases. Successful completion of therapy involving three or more drugs over a minimum period of six months may be particularly difficult to ensure in all patients.


  The PHLS is supporting colleagues at a local and regional level to develop services for tuberculosis in London through a combination of enhanced surveillance to provide an accurate and timely picture of the occurrence of the disease (including drug resistant disease), and accurate and timely laboratory diagnosis to support clinical management as well as local Public Health action. The PHLS CDSC London regional unit on behalf of the London Regional Office is leading a sector wide approach and several special working groups (eg new entrants' screening, HIV (and tuberculosis)). In addition the PHLS is supporting the development of a London wide tuberculosis register and is supporting local investigations into clusters of cases of tuberculosis.


  Tuberculosis in London will only be controlled, and the recent increases reversed, by improvements in services to promptly diagnose and treat active disease, control the spread of infection and prevent future infections. A co-ordinated approach is essential for the success of these measures.


  Hayward A. Tuberculosis control in London—the need for change. NHE executive, London, 1998.

  Prepared by Dr John Watson, head of Epidemiology Division CDSC and Dr Helen Maguire, CDSC London.

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Prepared 28 March 2001