Tuberculosis

Baroness Masham of Ilton Excerpts

Thursday 11th December 2014 Grand Committee

[Baroness Masham of Ilton (CB)]

My Lords, I thank the noble Baroness, Lady Suttie, for this important debate.

Many people think TB is a thing of the past. However, here in London, Newham has been named the capital of tuberculosis in Europe. With modern travel, the world is very small. I will mention a few points on the international scene before concentrating on the UK.

I was very impressed and moved recently by a film on drug-resistant TB, shot in Africa. The 2014 WHO report also states that the problem of drug-resistant TB is worsening, with an estimated 480,000 new cases of MDR-TB in 2013. This, too, may be an underestimate, since estimates of the true burden of drug-resistant TB across sub-Saharan Africa, Asia and eastern Europe are impaired by the fact that drug-resistant testing and treatment services are broadly unavailable at the majority of healthcare facilities.

Of greater concern was that of the estimated half a million cases of multi-drug-resistant TB around the world only 136,000 were officially diagnosed. It is perhaps more dire to note that 9% of those with MDR are estimated to have extensively drug-resistant TB or, in other words, that close to 50,000 people worldwide have a form of the disease that we do not currently have the necessary tools to treat.

TB is caused by bacteria. It is airborne and infectious, transmitted when a sick patient coughs or sneezes. TB has been estimated by the Lancet to be the deadliest disease in the world. The World Health Organization estimates that TB kills 1.5 million people every year. Like many other bacteria, TB is increasingly resistant to our best drugs.

We must not be complacent here in the UK. We have many demands on our NHS, but infections need controlling and preventing whenever possible. It is much easier to treat an infection in the early stages. Here in the UK, there were 7,982 cases of TB in 2013. This is a reduction of 10.6% over the previous two years. London, however, has the highest rate of any capital city in western Europe. Birmingham’s rate is even higher. Both are near the World Health Organization’s definition of a high-risk area. Before 2012, rates of TB in the UK rose steadily from the year 2000. Only 15% of TB cases in the UK occurred in people who had entered the UK in the previous two years. TB remains concentrated among the most deprived populations. In 2013, 70% of cases were resistant in the 40% most deprived areas. Nearly half of cases were among the unemployed, while 10% had social risk factors, including a history of alcohol and drug misuse, homelessness and imprisonment. More than a quarter of patients with TB in their lungs started treatment more than four months after the onset of symptoms. On average, patients in the UK wait 72 days between the onset of symptoms and diagnosis with TB. This increases the severity of symptoms and increases the likelihood that patients will transmit the disease.

There are two main reasons for this problem. Healthcare professionals in the UK often do not consider TB in the first instance. Thus, patients can be misdiagnosed. Patients can be reluctant to come forward due to stigma, lack of awareness of the disease and reluctance to access healthcare. In London, the Find and Treat service has overcome some of the challenges on the patient side. Find and Treat is a service based around a mobile X-ray unit in the back of a van which travels to hostels and other homeless places across the capital to screen marginalised and high-risk groups. I have visited this unit at work and I can tell your Lordships that it is run by enthusiastic, dedicated people. I assure your Lordships that if you had time you would find a visit most interesting. The unit even has access for a wheelchair, which is unusual. Most units for screening breast cancer do not have this facility.

The service frequently employs previous service users to offer mentoring to current patients, offering all-important social care and helping previous service users develop employable skill and experience. Find and Treat accordingly has a higher treatment completion rate than the UK national average, despite working with hard-to-reach, marginalised populations. The draft collaborative TB strategy for England recommended the scale-up of Find and Treat to become a national outreach service. This is welcome, but it must be done correctly.

TB is just one of several interlinked conditions across the UK that suffer from delayed and incomplete diagnosis. Some 30,000 people in the UK with HIV do not know their status. Half of all those with hepatitis C do not know their status. Some 630,000 people with type 2 diabetes do not know their condition and 11.5 million people are considered to be at high risk of developing type 2 diabetes. These conditions are linked. People with HIV are 20 to 30 times more likely to develop TB. People with diabetes are three times more likely to develop TB. Hepatitis C and HIV infection are connected by similar methods of transmission. All these conditions are found predominately in areas of high health inequalities. Many of these people are unaware of their status and are not accessing healthcare. HIV, hepatitis C, diabetes and TB can all be screened for in less than 15 minutes.

I must declare an interest, as among the all-party health groups I serve on, I am a member of the All-Party Parliamentary Group on HIV and AIDS, the All-Party Parliamentary Group on Global Tuberculosis, the All-Party Parliamentary Hepatology Group and the All-Party Parliamentary Group for Diabetes. Therefore, I agree with scaling-up Find and Treat to include these conditions. This would maximise the efficiency of the outreach service, making the most of a single contact with an individual to screen for multiple conditions. It would reduce stigma related to any single disease by making such tests part of routine health screening. It would target areas of high health inequalities, adapt a preventative approach to health and, most importantly, save money. The Find and Treat budget is under £1 million a year. The lifetime cost of HIV treatment in the UK has been estimated at over £300,000 per person, so an outreach service would need to help prevent only three cases of HIV to break even. Most importantly, an outreach programme such as this would save life.

We must do more to prevent these infections. I hope that in the next 10 years there will be a vaccine and more new drugs for TB, but I also hope that the Minister will commission her department to explore the possibilities of an integrated national outreach service for HIV, hepatitis C, diabetes and TB across the country. I look forward to the Minister’s reply.