TUBERCULOSIS IN LONDON
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 Londonthe
need for change. NHE executive, London, 1998.
Prepared by Dr John Watson, head of Epidemiology
Division CDSC and Dr Helen Maguire, CDSC London.