Notifications Of Tuberculosis In England Research Articles

Incidence and risk factors for drug intolerance and association with incomplete treatment for tuberculosis: analysis of national case registers for England, Wales and Northern Ireland, 2001–2010

Anti-tuberculosis drug regimens are efficacious, but drug intolerance can be severe and may impact on treatment completion rates. The Enhanced Tuberculosis Surveillance (ETS) system is a case register of all...

Recent increases in tuberculosis notifications in England and Wales--real or artefact?

In light of recent increases in tuberculosis notifications in England and Wales, this study examines data on the occurrence of tuberculosis from other sources to see if the increase seen in notifications is corroborated. Tuberculosis notifications for 1988-2000 were compared with laboratory reports of Mycobacterium tuberculosis complex isolates (1994-2000), national survey data for 1988, 1993 and 1998, and enhanced tuberculosis surveillance data for 1999 and 2000. Data from all three sources reveal a similar overall trend, with the increase most marked in 1999 and 2000 and a steady increase in the number of cases reported from London. The largest increase is seen in the 15-34 year age group. National survey and enhanced surveillance data show a continuing increase in the proportion of tuberculosis patients born abroad, and in number of patients from most non-White ethnic groups. All sources show an increased number of patients with extra-pulmonary disease. A similar level in the overall increase in cases, and their distribution by geographic region, age, sex and site of disease, observed using data from all three sources, suggests that much of the increase is likely to be real. Data from additional continuous years of enhanced surveillance will permit more accurate assessment of trends in population subgroups.

Tuberculosis: the silent epidemic.

Tuberculosis (TB) used to be a common cause of death in the UK, accounting for a quarter of all annual deaths in the 19th century. While the poor were most vulnerable to the disease, every stratum of society was affected, as witnessed by the suffering of the Brontë sisters and Keats among others. Improved social conditions and better nutrition helped to reduce the prevalence of TB, and the introduction of the BCG vaccine and successful antibiotic therapy reduced the incidence further. Indeed, in the 1970s some thought that there would be no TB at the millennium. However, following a steady decline in recent decades, there are now an increasing number of TB notifications in England and Wales. While most of the rise is accounted for by notifications in the London area, there has also been a significant rise in notifications in the South East and Trent. Three quarters of notifications relate to males, of whom the vast majority are aged 25–64 years. It is perhaps not surprising, therefore, that TB is ranked the fifth most important communicable disease by professionals and the fifth most important disease requiring further work (Horby et al, 2001).

Clusters of new tuberculosis cases in North-west London: a survey from three hospitals based on IS6110 RFLP typing

Objectives: The relative contributions of reactivation of latent infection and clusters of new infections to the overall incidence of tuberculosis in the U.K. is unknown. A study was carried out in North-West London to determine the feasibility of ISP6110 RFLP strain typing as a tool to investigate the relative contributions of these two sources.Methods: All available isolates of M. tuberculosis from specimens collected over a calendar year at three participating hospitals were typed by RFLP using an IS6110 probe. Isolates exhibiting a single band pattern were subject to further typing using an oligonucleotide direct repeat probe. Demographic and clinical information on cases was obtained from the National Survey of Tuberculosis Notifications in England and Wales and further information sought on clustered cases as identified by RFLP typing.Results: Twenty-seven (23%) of the 118 cases had shared IS6110 RFLP patterns. Strains from nine cases had single band patterns, but these were all distinguishable from each other when subjected to further typing by direct repeat probe. The remaining 18 cases belonged to eight clusters. Epidemiological links were established between all the patients in each cluster. The likelihood of being in a cluster was increased in cases with pulmonary smear-positive disease. It was lower in cases of Indian Sub-continent ethnic origin. For 10 of the 18 clustered cases epidemiological links had not been established by conventional contact tracing.Conclusions: Investigation of the relative contributions of reactivation of latent infection and new infection is feasible in a UK population, using IS6110 RFLP typing of M. tuberculosis isolates and epidemiological enquiries. This study in London identified clustered, presumably new cases, the majority of whom had not been linked epidemiologically. Comprehensive IS6110 RFLP typing of UK isolates would probably identify many clusters of incident tubercular infection.

Does vitamin d deficiency account for ethnic differences in tuberculosis seasonality in the UK?

Objectives. Notifications of tuberculosis in England and Wales are reported to peak in the summer season. The purpose of this study was to confirm that finding and to determine to what extent patients of Indian Subcontinent (ISC) ethnic origin contributed to the seasonality. The clinical presentation of the disease is presumed to occur some months following reactivation of the endogenous latent focus of tuberculosis infection. There arises the possibility of vitamin D deficiency producing immunological inadequacy at the end of winter and beginning of spring. Patients and methods. Monthly (or 4‐weekly) aggregated data over 7 years were collected from the three countries of mainland Britain, England, Wales, Scotland and from the city of Birmingham in England. The notifications from Birmingham were divided into those of ISC ethnic origin and ‘whites’. The presence or absence of seasonality was determined by fitting a sinusoidal curve by the technique called ‘cosinor analysis’. In this method amplitude gives a measure of the extent of the seasonal variation. Results. The summer peak of clinical diagnosis was confirmed in the UK series from England, Wales and Scotland. In England and Wales without Scotland a larger seasonal variation was present. Scotland, with a lower proportion of population of ISC ethnic origin, was examined separately and the results in Scotland alone failed to confirm seasonality. In the data from Birmingham, seasonality was confirmed with a greater amplitude, particularly in those over 60 years of age. The finding was influenced by those of ISC ethnic origin, seasonality not being present in the ‘white’ population. Conclusion. The results from Birmingham are very striking, but there were almost three times as many patients in the ISC ethnic group as in indigenous ‘white’ patients. A series with larger numbers of ‘white’ patients would be necessary to confirm the absence of seasonality in the ‘white’ population. The discussion reviews the evidence that vitamin D may have an important hormonal role in immunological defence in the prevention of tuberculosis.

Tuberculosis in England and Wales in 1993: results of a national survey. Public Health Laboratory Service/British Thoracic Society/Department of Health Collaborative Group.

BACKGROUND: A national survey of tuberculosis notifications in England and Wales was carried out in 1993 to determine the notification rate of tuberculosis and the trends in the occurrence of...

299-PA12 Tuberculosis notifications in England and Wales: potential effects of immigrant cases on mean age of presentation

299-PA12 Tuberculosis notifications in England and Wales: potential effects of immigrant cases on mean age of presentation

The increase in tuberculosis notifications in England and Wales since 1987

A retrospective study of tuberculosis notifications in England and Wales published by the Office of Population Censuses and Surveys. To analyse the rise in tuberculosis notifications in England and Wales by different sub groups over the time period 1982-91. The average annual percentage change in tuberculosis notification rates (per 100,000) for the groups were analysed by age, sex, standard region and disease site. The average annual increase in tuberculosis notifications from 1987-91 in females was +2.55 (95% confidence interval [CI] 0.5-4.7); males showed no significant change (-0.6%, 95% CI: -2.9 to +2.7). The increase was greater in younger subjects: 3.2% in females aged 25-44 (95% CI 0.9-5.5) and 4.3% in males aged 15-24 (95% CI 1.7-6.9). Only three standard regions showed an increase: the South East, the West Midlands, Yorkshire and Humberside. This increase was significant only in females from the South East, and was predominantly in non-respiratory tuberculosis. The rise in tuberculosis notification rates from 1987-91 has been predominantly in females, in those under 65, has occurred in 3 regions, and predominantly in non-respiratory tuberculosis. The analysis highlights some of the inadequacies of the present notification system for tuberculosis.

Laboratory reports of opportunistic and other mycobacterial infections and their relationship to notifications of tuberculosis in England and Wales

England and Wales, UK. To investigate: (1) whether misclassification of opportunistic mycobacterial disease had contributed to the failure of tuberculosis notifications to continue declining; (2) whether laboratory reports of Mycobacterium tuberculosis complex infections could be used to validate trends in the tuberculosis notification system. Descriptive epidemiological study using laboratory reports of infections to the Public Health Laboratory Service Communicable Disease Surveillance Centre, Medical Research Council National Surveys of Tuberculosis and tuberculosis notifications to the Office of Population Censuses and Surveys. Compared to 1983, an extra 1% of tuberculosis notifications in 1988 were opportunistic mycobacterial disease inappropriately notified as tuberculosis. On the basis of the expected proportion of microbiologically confirmed tuberculosis infections, laboratory reporting was incomplete: for one laboratory report there were four notifications. Misclassification of opportunistic mycobacterial infection was estimated to account for only a small proportion of the excess tuberculosis notifications since 1988. This excess of tuberculosis notifications could be due to artefact, for instance because a greater proportion of cases are being notified. Laboratory reports of tuberculosis infections are of limited use in validating the recent trends in tuberculosis notification rate. At present changes in the level of reporting of laboratory isolates are likely to obscure genuine trends.

BCG—mass or selective vaccination?

After years of decline, notifications of tuberculosis in England and Wales have recently increased. BCG immunization forms part of the programme of measures to control tuberculosis in this country. All tuberculin negative 10–13-year-old schoolchildren are offered vaccination. In addition BCG is offered selectively at any age to those considered to belong to groups at increased risk of tuberculosis. While the protective effect of BCG immunization in the population of this country is well established, the cost-effectiveness of the Schools' BCG programme has been the subject of considerable debate. If the rate of tuberculosis notifications in the 15–29-year-old age group within the white majority population, the major group to whom any potential benefit of the Schools' programme applies, continues to decline, serious consideration should be given to discontinuing this programme while strengthening the programme of selective immunization.

Drug-resistant tuberculosis

Notifications of tuberculosis in England and Wales declined steadily until 1987, when about 5100 cases were reported.1 Since then numbers have begun to rise, reaching a provisional figure of about 5700 in 1994.2 The proportion of isolates of Mycobacterium tuberculosis resistant to one or more conventional first-line antituberculosis drugs has remained steady at about 10%.3 The incidence of tuberculosis is also rising in other countries, but the speed of increase and the proportion of infections that are drug resistant vary. In this article we discuss drug-resistant tuberculosis in the UK and consider its prevention, treatment and control.

National survey of notifications of tuberculosis in England and Wales in 1993: Premiliminary results

National survey of notifications of tuberculosis in England and Wales in 1993: Premiliminary results

National survey of notifications of tuberculosis in England and Wales in 1988.

National survey of notifications of tuberculosis in England and Wales in 1988.

Tuberculosis and HIV: estimates of the overlap in England and Wales.

A study was designed to determine the extent of the interaction between tuberculosis and human immunodeficiency virus infection in England and Wales. Data were obtained from the United Kingdom national AIDS surveillance and the Medical Research Council tuberculosis notification surveys in England and Wales (1983 and 1988). The proportion of patients reported with AIDS known to have had tuberculosis and the proportion of patients notified with tuberculosis known to have HIV infection were estimated. Of the 4360 patients with AIDS reported by 30 June 1991, 200 (4.6%) were in patients reported to have had tuberculosis. Only one of the 3002 patients (0.03%) reported in the 1983 survey of tuberculosis notifications in England and Wales was known to be infected with HIV compared with nine of 2163 patients (0.42%) in the 1988 survey. Although the reported number of cases of HIV infection with tuberculosis in this country is increasing it remains small. Complete reporting of cases of AIDS and notification of cases of tuberculosis are essential to enable the two infections to be monitored as the HIV epidemic develops. Special studies, such as those reported here, will need to be undertaken regularly to assess the future extent of the interaction.

National survey of notifications of tuberculosis in England and Wales in 1988. Medical Research Council Cardiothoracic Epidemiology Group.

A survey was undertaken to determine the distribution of tuberculosis in England and Wales and, by comparison with the findings of similar surveys in 1978-9 and 1983, to study trends in the incidence of the disease by ethnic group over the decade. The survey included all cases of tuberculosis in England and Wales newly notified to the medical officers for environmental health during the six months from 2 January to 1 July 1988. Notification rates were calculated from population estimates from the 1988 Labour Force Survey. Clinical details were obtained from the clinician for 2149 (99.4%) of the 2163 newly notified and previously untreated patients. Over 90% were either white (53%) or of Indian, Pakistani, or Bangladeshi ethnic origin (39%). The notification rate in the white population was 4.7/100,000/year, a decline of 7.2% per year since 1978. The rate was 134.6/100,000/year in the population of Indian ethnic origin, and 100.5/100,000/year in that of Pakistani or Bangladeshi ethnic origin, a decline of 6% a year since 1978 for the two groups combined (standardised for age, country of birth, and length of time in the UK). In all ethnic groups rates of disease were much higher in the elderly than in the young. Bacteriological results were available in 1161 (80%) of the 1443 pulmonary cases. In 939 (81%) Mycobacterium tuberculosis was cultured; 614 cases (53%) also had positive smears, of which 424 (69%) were from white patients. Notification rates for tuberculosis in England and Wales declined over the decade, but major differences remained between ethnic groups.

HIV-related tuberculosis in England and Wales

Numbers of tuberculosis notifications in England and Wales increased by 8% from 1987 to 1989. An analysis of notifications by age and sex has been undertaken to determine whether this increase has been due to an increase in young male adults, as has occurred in the USA, implying that HIV is largely responsible for the increase in notifications. Though notifications increased by 9.5% in younger males between 1987 and 1989 they also increased by over 10% amongst most age groups of females, and elderly males. These findings would suggest that there are a number of factors causing a rise in tuberculosis notifications, and that HIV is not yet directly implicated in England and Wales.

The management of extra-pulmonary tuberculosis

Most cases of extra-pulmonary tuberculosis respond well to chemotherapy. The standard regimen is isoniazid + rifampicin daily for 6 months, with the addition of pyrazinamide for the first 2 months. Chemotherapy is given for 9 or 12 months in meningitis, and in some cases of lymphadenitis and bone and joint disease. If initial drug resistance is suspected, either streptomycin or ethambutol should be added to the first phase of treatment. Only a minority of cases need surgical treatment but surgical diagnostic procedures are often useful. Corticosteroids are not recommended for routine use but can be valuable in lymphadenitis, meningitis, pericarditis and genito-urinary disease.

National survey of tuberculosis notifications in England and Wales in 1983: Characteristics of disease

The number of newly notified, previously untreated patients in a survey of notifications of tuberculosis in England and Wales conducted by the MRC in 1983 was 26 % lower than in the previous MRC survey in 1978/79. In both surveys the great majority of patients were of White (about half) or Indian subcontinent (Indian, Pakistani or Bangladeshi) ethnic origin (just over a third). The notification rates in the Indian subcontinent (ISC) ethnic groups were much higher than for the White group and were highest in those most recently arrived in the UK. There were a number of differences in the findings for the White and the ISC ethnic groups.Nearly two-thirds of the White patients but less than half of the ISC patients were male and the White patients were, on average, older, about half aged 55 years or more compared with 14 % of the ISC patients.Respiratory disease occurred in 82 % of the White patients compared with 66 % of the ISC patients. Radiographically, at independent assessment, more of the White patients had pulmonary lesions, 88 % compared with 63 % and these were, on average, more extensive and cavitated than in the ISC patients. Isolated mediastinal lymphadenopathy, however, was more common in the ISC patients. The diagnosis was confirmed bacteriologically on culture of a respiratory specimen in a higher proportion of the White than the ISC patients (65 % and 41 % respectively) and more were positive on smear as well (45 % and 25 % respectively). The level of initial drug resistance was lower in the White patients: only 10 (1.6 %) of the 623 strains tested were resistant compared to 23 (12.8 %) of the 179 from ISC patients.In both White and ISC ethnic groups the commonest non-respiratory lesion was peripheral lymph node involvement, namely 37 % of the 369 White and 53 % of the 503 ISC patients with non-respiratory disease. The diagnosis was confirmed by bacteriological examination of the lymph node in 47 % of the ISC patients compared with 29 % of the White patients with a lesion. Bone or joint disease occurred in 11 % of the White and 20 % of the ISC patients; the commonest site in both groups was the spine. Genitourinary disease was present in 98 (27 %) of White and 24 (5 %) of ISC patients with a non-respiratory lesion. There were 61 patients with tuberculosis involving the central nervous system, including 55 with meningitis, the proportions being similar for the White and the ISC ethnic groups, 7 % and 5 % respectively.

Changes in annual tuberculosis notification rates between 1978/79 and 1983 for the population of Indian subcontinent ethnic origin resident in England.

In two national surveys of tuberculosis notifications in England conducted in 1978/79 and 1983 the estimated annual notification rates for the Indian subcontinent (Indian, Pakistani, and Bangladeshi) ethnic groups were considerably higher than the rate for the white ethnic group. The mean annual decline in rates between the surveys appeared to be greater for the Indian and the Pakistani and Bangladeshi ethnic groups, 15% and 16% respectively, than for the white ethnic group (7%). Data from two small sample population surveys, the National Dwelling and Housing Survey in 1978 and the Labour Force Survey in 1983, were used to calculate the rates. However, comparison of the estimates for the population of Indian subcontinent ethnic origin in England from these surveys revealed discrepancies between them. Additional information from the Labour Force Survey on the year of first entry to the United Kingdom (UK) permitted the calculation of new estimates for the 1978 population, and based on these estimates the annual notification rates for 1978/79 were 287 per 100,000 for the Indian and 286 per 100,000 for the Pakistani and Bangladeshi ethnic groups. The rates for 1983 were 178 and 169 respectively, and the mean annual decline between the surveys was 11% for the Indian and 12% for the Pakistani and Bangladeshi ethnic groups. There were important changes in the characteristics of the population of Indian subcontinent ethnic origin in England between 1978 and 1983, and therefore the rates for both surveys have been standardised by the method of direct standardisation to a common reference population. Standardizing for year of entry to the UK, place of birth (UK or abroad), age, and sex reduced the mean annual decline in the notification rate to 4% for the Indian and 9% for the Pakistani and Bangladeshi ethnic groups. The much greater reduction in the rate of decline in the Indian ethnic group is due to the substantial decline between the surveys in the proportion of recent immigrants, the group with the highest annual notification rate, in that population. Future trends will continue to be influenced by immigration patterns, but it will also be important to monitor the rates among the increasing proportion of the population born in the UK or resident in England for more than five years.

The geographical distribution of tuberculosis notifications in a national survey of England and Wales in 1983

A survey of all tuberculosis notifications in England and Wales for the first 6 months of 1983 has made it possible to estimate the annual notification rates for that year for the White and the Indian subcontinent (Indian, Pakistani and Bangladeshi) ethnic groups for the nine regions of England and Wales and for the 33 boroughs of Greater London. The rates have been compared with those estimated from an earlier 6-month survey in 1978/79. However, for the 53 counties and the 370 local authority areas outside Greater London only the overall rates could be calculated because population data by ethnic group were not available. There was considerable variation between the 9 regions in the notification rates for all ethnic groups combined (range 28.1 per 100,000 in Greater London to 4.5 per 100,000 in Anglia) and for the White ethnic group (range 13.1 per 100,000 in Greater London to 3.1 per 100,000 in Anglia). The rates for the Indian subcontinent (ISC) ethnic group were high in all the regions and were 15-60 times higher than the corresponding rates for the White ethnic group. Between 1978/79 and 1983 there was a decline in all of the regions in the notification rates for all ethnic groups combined and the White group. For the ISC ethnic group there was a decline in all regions apart from Anglia (where the number of cases was small). The difference in rates for the London boroughs, from 92.3 per 100,000 for Brent to 5.7 per 100,000 for Havering, were associated not only with the proportion of the population who were of ISC ethnic origin but also with indices of socio-economic class for the borough. There was, however, no evidence to suggest that high rates in the White population were a consequence of the presence of a large number of infectious patients of ISC ethnic origin. Notification rates for the 53 counties apart from Greater London ranged from 23.7 per 100,000 for the West Midlands to 3.1 per 100,000 for Surrey and with few exceptions there was a decline in rates between the surveys. Considering the 370 local authorities outside Greater London, the number with a notification rate of less than 5 per 100,000 increased from 73 in 1978/79 to 105 in the 1983 survey and the number of local authorities in which no cases were notified in the 6-month survey period increased from 32 to 41.