System to detect tuberculosis in new arrivals to UK must be improved
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7238.870 (Published 25 March 2000) Cite this as: BMJ 2000;320:870
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
EDITOR- Hargreaves suggests that screening for tuberculosis among
refugees and asylum seekers must be improved. However the yield of cases
of tuberculosis detected by new arrival screening in the UK is low2,
although it does provide an opportunity for the use of chemoprophylaxis,
and BCG as appropriate3. In my own health district, which screens on
average 40% of 110 new arrivals per year, no cases of tuberculosis have
been detected in 5 years. Screening new arrivals for tuberculosis is not
easy, given the lack of resources identified by Hargreaves. In addition,
refugees and asylum seekers (and their GPs) are unlikely to consider
screening for tuberculosis to be either their most important, or their
most immediate health need.
Another group of people for whom tuberculosis screening is important,
and which should be easier to implement, are doctors. All doctors require
pre-employment screening for tuberculosis3. This also provides a back up
system for doctors recently arrived in the UK, who may not have been
screened through the imperfect Port Health system.
There have recently been three cases of smear negative pulmonary
tuberculosis within a six-month period, among doctors living in the
doctors’ residence of one of our local hospitals. All three doctors had
all arrived in the UK within the preceding 3 years. With the benefit of
DNA typing of isolates from the three cases, the incident team was able to
establish that they were unrelated sporadic cases. A risk assessment
concluded that screening should initially be restricted to close contacts
of the three sporadic cases. No secondary cases have been detected among
the contacts.
During the incident, the occupational health screening details of the
three doctors were not easy to obtain, and were incomplete. Two of the
cases had previous BCG, and the BCG status of the third case (a locum) was
unknown. Current guidelines recommend Heaf testing for health care
workers without prior BCG, and chest x-ray only for those with suspicious
symptoms3.
Doctors from the Indian subcontinent working in the UK have a high
incidence of tuberculosis (17.0 per 10,000/year), which is thought to
represent a high ethnic, rather than an occupational risk4. In view of
the risk to patients from doctors with tuberculosis, we need to be
confident that occupational health departments are screening doctors
effectively for tuberculosis, and that systems are in place to readily
identify the screening status of any doctor working in the NHS.
Yours sincerely,
Dr.Kenneth .Lamden FRCS MHPHM
Consultant in communicable disease control
South Lancashire Health Authority, Grove House, Langton Brow, The Green, Eccleston, Lancashire PR7 5PD
email: ken.lamden@slancs-ha.nwest.nhs.uk
1. Hargreaves S. System to detect tuberculosis in new arrivals to UK
must be improved. BMJ 2000;320:870 (25 March).
2. Lavender M. Screening immigrants for tuberculosis in Newcastle upon
Tyne. J Publ Hlth Med 1997;19:320-323.
3. Joint Tuberculosis Committee of the British Thoracic Society. Control
and prevention of tuberculosis in the United Kingdom: Code of Practice
1994. Thorax 1994;49:1193-1200.
4. Hill A, Burge A, Skinner C. Tuberculosis in National Health Service
hospital staff in the West Midlands region of England, 1992-5. Thorax
1997;52:994-997.
Competing interests: No competing interests
Sally Hargreaves1 expresses concern over the lack of screening of
refugees and asylums seekers for tuberculosis in the United Kingdom..
There is little evidence that port of arrival screening has
discovered significant tuberculosis pathology 2,3. The ideal place for
screening could be the GP’s surgery but as Hargreaves points out general
practitioners have shown little enthusiasm for it.
Before, we embark on an expensive and complex scheme of screening
for tuberculosis, evidence for its benefits must be shown. Equating
tuberculosis with asylum seekers and refugees and subjecting them to
unnecessary radiological examinations may well raise issues of human
rights.
Tuberculosis epidemiology in Birmingham shows an assured declining
rates from year to year. New transmission of tuberculosis infection in
white children has come to a halt and is declining rapidly in children of
Asian origin. The increase in total number of cases reflects increase in
the number, not the rate, of Asians in the past three decades. Added to
this is the ageing4 of the Asian population and incidence of age onset
diabetes5. In the elderly, Tuberculosis in this age group is not new
infection but arises most commonly as a consequence of endogenous
reactivation of previously dormant pulmonary foci that occurred much
earlier in life. Screening will not reveal these dormant foci.
Early diagnosis, vigorous treatment and follow up has long been the
lynchpin of WHO strategy for controlling the spread of tuberculosis.
Population screening is not recommended by WHO 6.
I am confident the tuberculosis programme in Birmingham is robust
enough to deal promptly with evidence of tuberculosis in new arrivals
without influencing the transmission of the infection in the metropolis.
We have no programme for screening of new arrivals and do not intend to
introduce one for the refugees and new arrivals..
Dr S.S.Bakhshi
References
1.Hargreaves S. System to detect tuberculosis in new arrivals to UK
must be improved. BMJ 2000;320:870
2. Bakhshi S. Screening immigrants at risk of tuberculosis. Br Med J
1994;308:416
3. Lavender M. Screening immigrants for tuberculosis in Newcastle
upon Tyne. JPHM 1997;19: 320-323
4. Stead WW, Dutt AK. Tuberculosis in the elderly. Semin. Respir.
Infect. 4: 189-197
5. Rieder HL, Cauthen GM, Comstock GW, Snider DE. Epidemiology of
tuberculosis in the United states. Epidemiol. Rev. 11: 89-95
6. WHO Report on the Global Tuberculosis Epidemic 1998. TB- A Cross
Road . WHO 1998
Competing interests: No competing interests
In 1991 when I was a Franklin Adams Scholar at the University of
Bristol, I did a study with the co-operation of Bristol and Weston Health
Authority. We (My Supervisor was Dr A.W. Macara, Department of
Epidemiology at the University of Bristol) tried to find the level of TB
screening among overseas students at the University of Bristol. The University
of Bristol decided to mail our questionnaires to all overseas students
the0mselves because of privacy issues. The University computer system messed up
and many of these were sent to wrong addresses. We never found out
how many actually received our questionnaires. We received nearly 150
replies out of approximate 600 overseas students. As there was no way to
find that how many actually received our questionnaires the response rate
was difficult to estimate. But we had some interesting results. All these
percentages are of the respondents.
Port of Entry
Gatwick=40%
Heathrow=46%
Examination at port of entry=7%
Gatwick examined =17.8%
Heathrow examined= 1.5%
Students who were examined came from the following countries:
1. Sri Lanka
2. Pakistan
3. Hong Kong
4. Nigeria
5. Germany
6. Norway
Only 27 % students got an invitation to attend the chest clinic.
But the interesting point was that 73% of students who were invited
attended the clinic.
The reference to Chest clinic by respected GPs was to nationals of
20 different countries mostly from developing countries of Africa and Asia
but included a few countries of then Western Europe.
Our findings were that a student could miss TB screening if he or she
1. Came through any other port of entry except Gatwick or Heathrow
2. Did not register with GP/SHS
3. Did not attend a chest clinic
Our recommendations were as follows:
1. Educational institution should refer overseas students to
Chest Clinics.
2. Health Visitors should pursue non-Attendants.
3. Registration staff at GP/SHS should be educated High Risk regions.
Due to the reasons described in the first paragraph this study was
not submitted for publication to any journal. I presented some of the
findings in a conference of GPs in Pakistan in 1995. I have used those
slides to prepare this response.
Rana Jawad Asghar, MD MPH
Research Associate
Division of Infectious Diseases,
Stanford University, USA
Email: jawad@alumni.washington.edu
Competing interests: No competing interests
General practitioners are screening for tuberculosis in new arrivals to the UK in Hackney
EDITOR-Tuberculosis is increasing in London. Almost a quarter of those with tuberculosis in East London have arrived in the United Kingdom in the previous year (East London Tuberculosis Service database). The availability of cheap housing has made Hackney a common first destination for new entrants, refugees and asylum seekers. Sally Hargreaves notes that the Port of Arrival scheme has a poor yield and recommends screening of new arrivals by general practitioners1.
The Lower Clapton Health Centre has been screening for tuberculosis in all those registering at the practice since April 19972. Verbal screening identifies new arrivals and those with a high risk of tuberculosis and is then followed by tuberculin skin testing in those under 35 years if required. During this period there have been 12 cases of tuberculosis from this practice of 10,500. Four were identified through the screening process (approximately 1,000 new registrations each year), of whom two were sputum smear-positive and therefore potentially infectious. The other two had smear-negative pulmonary tuberculosis, suggesting that screening had fulfilled a significant function in the early diagnosis of tuberculosis, before the infectious state had arisen. One patient developed lymph node tuberculosis 6 weeks after the initial screening, at which the patient had no symptoms and a grade 2 Heaf test. A further three were refugees in the country for 2, 4 and 5 years respectively. Thus, screening for tuberculosis in new arrivals taking place in general practice and is effective in detecting cases early.
However, 29 out of 348 patients treated for tuberculosis at the Homerton Hospital in Hackney since 1997 have not registered with a general practitioner. This number includes all four cases of multi-drug resistant tuberculosis, three of whom were new arrivals and one a refugee since 1993. Sixteen who had arrived in the UK during the previous year and two longstanding refugees were identified as having tuberculosis through the Port of Arrival scheme and have still been unable to register with a general practice. Three of the 29 without a family doctor have since died. This group of 29 included 5 children and one man of 91 years. These facts illustrate the "inverse care law", whereby those in greatest need of health care find access most difficult or fail to attend for health screening3.
Screening of new arrivals for tuberculosis remains valuable and should take place in both primary care and hospital-based schemes in order to ensure the maximum benefit in terms of preventing the spread of tuberculosis and especially of drug-resistant disease.
Graham H. Bothamley, consultant physician
East London Tuberculosis Service,
Homerton Hospital, London E9 6SR
Chris Griffiths, senior lecturer in general practice
Mirima Beeks, general practitioner
Meg MacDonald, practice nurse
Esther Beasley, nurse practitioner
Lower Clapton Health Centre, London E5 0PD
1. Hargreaves S. System to detect tuberculosis in new arrivals to UK must be improved. BMJ 2000; 320: 870.
2. Bothamley G, Rowan J, Griffiths C, Beeks M, MacDonald M, Beasley E, Feder G, van den Bosch C. Screening for tuberculosis: where should it take place? Eur Respir J 1999; 14: 454s.
3. Griffiths C, Cooke S, Toon P. Registration health checks: inverse care in the inner city? Br J Gen Pract 1994; 44: 201-4.
Competing interests: No competing interests