Tuberculosis cannot be controlled unless the disease is tackled effectively among socially excluded groups, warn experts in this week's BMJ.
Tuberculosis can infect anyone, but predominantly affects the poor, write Alistair Story and colleagues. In London, where over 40% of all cases in the UK in 2004 were reported, rates of tuberculosis have more than doubled since 1987 and are now the highest among homeless people, problem drug users, people living with HIV, prisoners and new entrants, particularly those from countries experiencing chronic civil conflict.
Recently published guidance from the National Institute of Health and Clinical Excellence (NICE) recommends chest x-ray screening for homeless people and entry screening for prisoners. Mobile x-ray units targeted at high risk groups are also being evaluated in London.
The guidance also suggests hospital admission for homeless people and those with clear socioeconomic need, allocation of a named key worker for all patients, and risk assessment to identify those patients unlikely to adhere to treatment. Directly Observed Therapy (DOT where a health worker or other responsible adult observes the patients taking their medication) is also recommended to improve adherence to treatment.
Most tuberculosis patients are not infectious, readily access health services, and complete treatment successfully without DOT, say the authors. As a result, they make only limited demands on services and pose little public health risk.
By contrast, many socially excluded patients are at risk of delayed presentation, poor adherence and loss to follow-up. A major and persistent outbreak including over 200 linked drug resistant cases disproportionately affecting homeless people, prisoners and problem drug users in London clearly illustrates the urgent need to strengthen tuberculosis control among socially excluded groups.