TB threat grows in Britain

Medical experts are warning about the developing threat of tuberculosis (TB) in Britain, and especially in London.

The Annual Public Health Report 2000/2001 produced by the East London & The City Health Authority highlights some of the conditions that have enabled TB to take a hold. Entitled “Health in the East End,” the report points out that under a third of the cases were among people who had lived in the area for less than five years. It showed that boroughs with high numbers of notified TB cases, such as Newham, Tower Hamlets and Hackney, were also those with higher than average levels of deprivation.

Homelessness is another factor. The report states that 25 percent of homeless people in London are infected with TB, however only around 2.5 percent show symptoms of the disease. The three boroughs mentioned above also include high numbers of homeless people. The incidence of HIV associated with TB is estimated at 7-8 percent in London, but the report points out this is probably an underestimate. From blood tests on pregnant women, Newham and Hackney have a higher HIV incidence than the London average.

A detailed analysis of TB cases in London has shown that 50 percent of sufferers were unemployed, five percent had experienced homelessness, over seven percent abused alcohol and seven percent were infected with HIV.

The nature of the tuberculosis bacterium, with its waxy coating of fatty acids and lipids (fats), means it needs persistent and consistent antibiotic treatment. The drugs need to be taken for a period of six to nine months. The report states, “Sticking to and completing a course of TB treatment is challenging in East London”. High population mobility, poverty, alcoholism, substance abuse and cultural barriers make completion of a drug regimen difficult.

Amongst the measures the report calls for are:

* An adequately resourced TB service and infrastructure, including appropriate ratios of TB specialist nurses and support staff to notifications.

* Specially constructed “negative-pressure” wards with an artificially maintained air pressure lower than that outside to contain the TB bacteria, which can be spread through the air.

* Effective infection control arrangements to ensure infectious and drug-resistant cases of TB are managed appropriately.

* A research programme on the specific barriers to compliance that affect TB patients in East London.

In July this year, London family doctors (GPs) have warned of the dangers of a developing TB epidemic in the capital. “This is a disaster waiting to happen. It is only a matter of time until London sees a serious out-break such as that in Leicester earlier this year”, said Dr Stewart Drage, secretary to several London GP committees. Dr Michael Soljak, Director of Public Health for Ealing, Hammersmith and Hounslow said that although three extra nurses had been recruited to work with the TB cases this was not enough to keep up with the rising levels of the disease. He said the increased number of nurses “would have been enough if we hadn’t seen the increase in cases. What we have found is that we are barely keeping up with the disease.”

In July 2000, Professor John Grange of the Centre for Infectious Disease at University College London said London had become a hotspot for the disease, and called for the number of specialist TB nurses to be increased to a level of one nurse to every 50 notified cases of the disease. The Department of Health dismissed his claim that the situation in Britain “was waiting for human disaster”.

Improvements in health care and the widespread use of antibiotics meant that TB was all but eradicated in the UK by the 1960s. In 1999, the Labour government abandoned the routine vaccination programme for school children with the long established BCG vaccine, but this has now been resumed in London with plans to restore it nationwide.

Since 1987 there has been a resurgence of the disease. In 1990, there were 1,600 cases in England and Wales. By 1999 there were 7,000 cases, with the biggest rise being amongst the 25-64 age group. In 2000, nearly 400 people died of the disease nation-wide. By 2001, the number of cases in Britain has risen to nearly 7,500, of which 3,000 were in London. In London 50 new cases are currently diagnosed each week. Commenting on the increase in TB cases in London, Dr Heather Milburn, a chest physician at Guy’s and St Thomas’ Hospital, said, “Those of us who look after TB patients may find we’re not able to cope.”

Districts in East London have been particularly affected: Newham with 108 cases per 100,000 of its population has made London “tuberculosis capital of the affluent Western world”. The figures even put it ahead of Russia, where the collapse of the public health system has led to 91 cases per 100,000, whereas in India the figure is 41 per 100,000.

The London Times of February 6 this year reports the concerns of Professor Grange, who said, “If you look at a graph of what happened in New York ten years ago, and what is happening now in London, the lines are very similar. TB is like a forest fire-it may start small, but you never know when the wind is going to get up and blow through the whole forest.”

“We have lobbied ministers, and the feedback has been ‘Problem what problem?’” adding, “The upsurge may go down. But if London goes the way of New York, some people will be sorry that they did not nip it at birth.”

An article in the January-February 2000 bulletin of the American Centres for Disease Control posed the question, “Could a Tuberculosis Epidemic Occur in London as it did in New York?” The paper, by Andrew C Hayward of Nottingham University and Richard J Coker of St Mary’s Hospital London, explained the similarities between London and New York.

In both cities the rates of TB infection are greatest in areas with low socio-economic conditions associated with large immigrant populations. In New York’s central Harlem the incidence of the disease rose from 79 per 100,000 in 1980 to 170 per 100,00 in 1989. In London, the boroughs of Newham, Tower Hamlets and Brent contained 77-79 cases per 100,000 at the time the paper was published. The article added that in some parts of London the rate had increased two to three-fold in the last 10 years. In both cities, the increased incidence was found mainly among young adults between 15-24 years of age. In both cities increasing rates amongst homeless people were noted. The association with HIV in both cities adds to the virulence of the disease.

In New York, by 1997, some 400 negative-pressure isolation facilities had been put in place. In 1995 in London there were only 103 such facilities.

The paper calls for London to learn the lessons of the epidemic in New York. “Urgent action is needed to strengthen TB control in London if an epidemic like that in New York City is to be avoided.”