Quality standard
Quality statement 1: Latent tuberculosis testing for people from high-incidence countries
Quality statement 1: Latent tuberculosis testing for people from high-incidence countries
Quality statement
People aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of tuberculosis (TB), are tested for latent TB infection when they register with a GP.
Rationale
Detecting latent TB infection in recent arrivals to the country is beneficial because they have a higher relative risk of progression to active, potentially infectious TB than the general population. The highest burden of TB disease and the largest proportion of new entrants from high-incidence countries are aged 16 to 35 years. Early detection can lead to treatment of latent infection before it progresses to active disease. This can prevent onward transmission and the associated harms and costs of active TB.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements to identify people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, when they register with a GP.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from service protocols.
b) Evidence of local arrangements to ensure that people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, are tested or referred for testing for latent TB infection when they register with a GP.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from service protocols.
Process
Proportion of people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, who are tested for latent TB infection when they register with a GP.
Numerator – the number in the denominator who are tested for latent TB infection.
Denominator – the number of people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, registering with a GP.
Data source: The Office for Health Improvement and Disparities' latent tuberculosis infection testing and treatment programme for migrants. The data collection includes the number of people tested for latent TB infection as a proportion of the total number of individuals offered a test.
Outcome
TB incidence.
Data source: National and regional data on TB incidence in England is collected in the Office for Health Improvement and Disparities' TB strategy monitoring indicators.
What the quality statement means for different audiences
Service providers (general practices) have systems in place to identify people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, when they register with the practice. They should ensure that the people identified have latent TB infection testing.
Healthcare professionals (such as GPs and nurses) test for latent TB infection in people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB, when they register with a GP. If the practice cannot perform the test, they should refer to the person to a service where it can be done.
Commissioners (NHS England, integrated care systems and clinical commissioning groups) ensure that they commission primary care services that identify people aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of TB. They should ensure that these primary care services provide or facilitate testing for latent TB infection for the people identified.
People aged 16 to 35 years who have come to England within the past 5 years from a country where there are a high number of TB cases have a test to find out if they have TB.
Source guidance
Tuberculosis. NICE guideline NG33 (2016), recommendation 1.2.3.1
Definitions of terms used in this quality statement
5 years
The time period of 5 years is based on Public Health England's Collaborative tuberculosis strategy for England: 2015 to 2020 and consensus of expert opinion.
High incidence of TB
The Public Health England's collaborative tuberculosis strategy for England: 2015 to 2020 defines this as countries with an estimated TB incidence rate of more than 150 cases of TB per 100,000 people per year.
Countries and their estimated TB incidence are listed in Public Health England's Tuberculosis by country: rates per 100,000 people. People who were born in, or have spent more than 6 months in a high-incidence country, should be tested.
[Adapted from Public Health England's Collaborative tuberculosis strategy for England: 2015 to 2020 and Public Health England's Latent TB infection testing and treatment for migrants: a practical guide for commissioners and practitioners]
Testing for latent TB infection
There are 2 types of test that can be used to diagnose latent TB infection. The Mantoux test should be used as the initial diagnostic test. It is a type of tuberculin skin test in which tuberculin is injected into the skin. The injection site is examined for signs of an immune response after 2 to 3 days.
If Mantoux testing is unavailable the interferon-gamma release assay (IGRA) test should be used. This is a blood test used to diagnose latent TB based on the response of white blood cells to TB antigens.
[Adapted from NICE's guideline on tuberculosis, full guideline glossary and recommendation 1.2.3.1]
Equality and diversity considerations
When offering testing to people who have arrived in the country within the past 5 years, healthcare professionals should be aware that people in this group may not speak or read English or have English as their first language. They should have access to an interpreter or advocate if needed.