NHS SHETLAND TUBERCULOSIS ANNUAL REPORT

Transcription

1 NHS SHETLAND TUBERCULOSIS ANNUAL REPORT Prepared by Wendy Hatrick October 2015

2 NHS Shetland Tuberculosis Annual Report Acronyms and Abbreviations AIDS Acquired Immuno-Deficiency Syndrome ARI BCG CGC CHCP CoIC DOT DOTS DPH ECDC ESMI HIV HPS IGRA ISD MDR-TB PHCU SIRS SMRL TB TST WHO XDR-TB Aberdeen Royal Infirmary Bacille-Calmette- Guérin skin test to diagnose TB Clinical Governance Committee Community Health & Care Partnership Control of Infection Committee Directly Observed Treatment Directly Observed Therapy Strategy The basis package that underpins the Stop TB Strategy (WHO) Director of Public Health European Centre for Disease Control Enhanced Surveillance of Mycobacterial Infections Human Immuno-deficiency Virus Health Protection Scotland Interferon-Gamma Release Assay a blood test used to diagnose TB Information Services Division Multi- Drug Resistant Tuberculosis (resistance to, at least, isoniazid and rifampicin) Public Health Control Units Scottish Information System Scottish Mycobacteria Resistance Laboratory Tuberculosis Tuberculosis Skin Test World Health Organisation Extensively Drug Resistant Tuberculosis

3 Contents Introduction 1. Tuberculosis 4 2. Tuberculosis Services in Shetland Vaccination NHS Shetland Tuberculosis Notifications References 15 Tables Table 1: Latent and Active TB 4 Table 2: Tuberculosis definitions 7 Table 3: Tuberculosis notifications in Shetland Table 4: Recommendations for BCG Vaccination 12 2

4 Introduction Tuberculosis (TB) remains a major global health problem. It causes ill-health among millions of people each year and ranks as the second leading cause of death from an infectious disease worldwide, after the human immune-deficiency virus (HIV). The latest estimates are that an estimated 9 million people developed TB and 1.5 million died from the disease, 360,000 of whom were HIV-positive. TB is slowly declining each year and it is estimated that 37 million lives were saved between 2000 and 2013 through effective diagnosis and treatment. However, given that most deaths from TB are preventable, the death toll from the disease is unacceptably high (WHO, 2014). Short-course regimens of first-line drugs that can cure around 90% of cases have been available since the 1980s (WHO, 2012). While TB is not necessarily a disease that will spread very easily from person to person, the potential for transmission remains and there is a sufficient cultural memory of TB that the risk of transmission can in itself cause fear and alarm. Concerns around drug-resistant strains of the disease also support the need to limit the spread of disease wherever possible. The role of public health services in reducing TB transmission at a population level and in responding to TB incidents is therefore crucial. The number of patients with tuberculosis (TB) increased steadily in Scotland between 2005 and Human immunodeficiency virus (HIV) infection has been a contributory factor to increases in TB in a number of comparable industrialised countries (HPS, 2014). In Scotland a total of 393 cases of TB were reported to the Enhanced Surveillance of Mycobacterial Infections (ESMI) scheme in 2013, this was a decrease of 3.2% in the number of cases and a decrease of 3.4% in the incidence, compared to 2012 (HPS, 2014). This represented a continued decrease in numbers of TB cases and while it is not possible to tell whether this is the start of a downward trend, it is an encouraging finding. In Shetland in 2014/2015, there was one new cases of pulmonary tuberculosis. Caution must be taken in drawing any conclusion of this small number in our relatively small population of 23,065 (NHS Shetland, 2015). Numbers may be small locally, but we need to ensure the Shetland population continues to have access to the best quality clinical, laboratory and public health services in relation to tuberculosis. The purpose of this Annual Report is to present local information relating to tuberculosis and its management for the period April 2014-March The Annual report will be presented to the Board via the Control of Infection Committee, and through risk management and clinical governance channels to the Clinical Governance Committee. 3

5 1. Tuberculosis 1.1 Tuberculosis (TB) is a disease caused by infection with a bacterium called Mycobacterium tuberculosis. The organism is related to a number of different bacteria which together are called the Mycobacterium tuberculosis complex. 1.2 TB commonly infects people's lungs and respiratory tracts and in these cases it is known as pulmonary or respiratory TB. However, TB can infect almost any part of the body as non-pulmonary or non-respiratory TB. Pulmonary (or respiratory) tuberculosis is a TB infection of the lungs themselves, or of the bronchi or trachea (the windpipes) or of the larynx (the voice box) Non-pulmonary (or non-respiratory) tuberculosis is a TB infection of any other part of the body, provided there is also no TB infection of the lungs as described above. 1.3 The symptoms of TB vary, depending on which part of the body is infected. General symptoms include fever, night sweats, weight loss, loss of appetite and lethargy. Pulmonary TB usually causes a persistent, severe cough with sputum which may have blood in it. Non-pulmonary TB causes symptoms which are related to the organ infected. For example TB of the glands may cause swelling in the neck and a discharge. 1.4 TB infection can be latent or active. The symptoms of latent and active TB are summarised in Table 1 below. A person with active TB may spread TB infection to others, usually has a positive tuberculin skin test (see 1.11 below) or positive TB blood test, and may have an abnormal chest x-ray or positive sputum smear or culture. Latent TB A person has: No symptoms of TB Does not feel unwell Cannot spread TB to others Usually has a positive skin test or TB blood test Has a normal chest x-ray and sputum test May convert to active TB later in life if individual's immune system declines TABLE 1: Latent and Active TB Active TB Symptoms may include: A bad cough that lasts 3 weeks or longer Pain in the chest Coughing up blood or sputum Weakness or fatigue Weight loss No appetite Chills Fever Sweating at night 4

6 1.5 When a person is infected with TB, their diagnosis will be one of active or latent TB. Latent TB means whilst a person is infected with Mycobacterium tuberculosis, they have no active disease: no symptoms, and are not infectious. The main risk here is that approximately 10% of people with latent TB will go on to develop active TB at some point in their lives. In other cases the initial infection is diagnosed as active TB disease and in these cases it usually becomes a slowly progressive disease which is likely to be fatal if left untreated. An initial TB infection may also become a latent TB infection, where the infected person feels completely well while the bacteria remain alive but dormant in their body. A latent TB infection may become active later in life if, for example, the person's immune system is weakened (by age, other diseases or medical treatments). In this case, it progresses to the active TB disease, already described. 1.6 Treatment for TB requires a course of a combination of usually four antibiotics, which a patient must take for at least six months. Because of the specialist nature of the disease, some doctors and nurses specialise in treating TB and work together as a team to look after TB patients. 1.7 The bacteria which cause TB can develop resistance to the drugs usually used to treat the condition. For this reason, it is very important that every patient completes their full course of TB treatment. If the bacteria develop resistance to the antibiotics the disease becomes much more difficult to treat. There has been an increasing risk of TB bacteria developing resistance to the main antibiotics used to treat the disease. This is known as multi-drug resistant TB (MDR- TB). More recently, some TB bacteria have developed many more antibiotic resistances; this is known as extensively drug resistant TB (XDR- TB) and is extremely difficult to treat. Treatment of drug-resistant TB also takes much longer than non-drug resistant TB and is also significantly more expensive. 1.8 When HIV and TB disease occur together they interact and treatment becomes very complicated, with several different drugs required. Those with such 'co-infection' may have a poorer outcome unless both conditions are identified early and treatment is very closely supervised. 1.9 Currently, the only available vaccine against TB is the Bacillus Calmette- Guerin (BCG) vaccine. The BCG vaccine contains live bacteria that have been modified to be safe. Studies of the effectiveness of the BCG vaccine have given widely varying results, but meta-analyses have shown the vaccine to be 70 to 80% effective against the most severe forms of TB, such as TB meningitis in children. The vaccine is less effective at preventing respiratory disease, which is the more common form in adults. Protection has been shown to last for 10 to 15 years. There are few data on the protection afforded by BCG vaccine when it is given to adults aged 16 and over and virtually no data for persons aged 35 years or over. For more information on the BCG vaccine, see the Department of Health publication Immunisation Against Infectious Disease (the 'Green Book') which is available in electronic format at the following link: 5

7 1.10 The tuberculin skin test is a diagnostic tool for TB. It helps to determine if someone has an immune response to the bacterium that causes TB. The skin test is administered and then read 2-3 days later. Administration involves injecting a small amount of tuberculin protein into the skin with a needle and syringe. A person who has been exposed to TB bacteria previously, who currently has TB, or who has had a BCG vaccination in the past, will normally mount an immune response in the skin containing the tuberculin bacterial proteins. If the test is positive, further investigation may be necessary New diagnostic tests for TB have recently been developed called Interferon Gamma Release Assays (IGRAs). Interferon Gamma Release Assays (IGRAs) are currently under review by NICE. IGRAs are whole-blood tests that can aid in the diagnosis of Mycobacterium tuberculosis infection, measuring a person s immune reactivity to the bacterium. The value of the IGRA tests are that they are not confounded (i.e. are more specific than skin testing) by previous BCG vaccination and have a role in diagnosis of latent TB infection. They can however be very misleading if used in the diagnosis of active TB infection and in their current format should not be used for this purpose. They may sometimes be more sensitive than skin testing, but longitudinal data is lacking at present. IGRAs may have significant benefits for the diagnosis of latent TB infection, improving clinical care and contact tracing. New IGRA guidance is being released by NICE and this work will inform guidelines on use of IGRA in Scotland. The Working Group also notes that while IGRAs may in time to be shown to be more sensitive and specific than skin tests (which generally require more than one clinic visit by the patient) in the diagnosis of latent TB infection, these tests are expensive and their introduction should be managed in the most cost effective way. More generally molecular and other diagnostic tools are evolving and there needs to be ongoing review of these new technologies. As with IGRA the Scottish Government should ensure a mechanism exists for the appropriate Scottish body to assess these developments on an ongoing basis to ensure the best quality and most efficient diagnostic tools are available in Scotland. This may be best achieved though a Scottish Health Technology assessment. 6

8 TABLE 2: Tuberculosis definitions Tuberculosis Definitions Case: A case of tuberculosis is defined by one of the following Confirmed: culture confirmed disease due to Mycobacterium tuberculosis, M. bovis or M. africanum. Probable: in the absence of culture confirmation, Signs and/or symptoms compatible with TB and Treatment with 2 or more anti-tuberculous drugs and Either microscopic or histological evidence of mycobacterial infection or a positive tuberculin test result. Possible: in the absence of culture confirmation Microscopic / histological evidence of mycobacterial infection or positive tuberculin test results, and / or sign and / or symptoms compatible with TB and Treatment with 2 or more tuberculous drugs Culture confirmed cases of active TB diagnosed at post mortem should be classified as confirmed. Active cases identified at post mortem on the basis of histopathological findings, in the absence of culture confirmation, should be classified as probable. Chemoprophylaxis: Administration of antituberculous drugs to prevent the development of infection or to prevent the progression of infection to manifest disease, usually on the basis of a positive tuberculin reaction without symptoms or radiological changes. Chemoprophylaxis patients should not be statutorily notified as cases of TB Contact: A person who has been in association with an infected person or animal or contaminated environment (eg laboratory) which might provide a significant opportunity to acquire infection with M. tuberculosis, M. bovis or M. africum. A Global Issue 1.12 Tuberculosis occurs across the world, although the World Health Organisation (WHO) estimates that 95% of TB cases now occur in developing countries. The effective treatments for TB described above have been available since the 1940s and many countries have made great progress in controlling the disease. However, despite the availability of effective drugs TB remains one of the leading causes of human illness and premature death in the world. The WHO Global Tuberculosis Control 2014 ( indicates that there were an estimated 14 million people living with TB in While TB has been declining globally in recent years, it is actually increasing in Europe. Accordingly the European Centre for Disease Control (ECDC) has a 7

9 programme of work to tackle TB under its Framework action Plan to fight TB in the EU. (Available in electronic format at the following link: The Scottish Government takes seriously the WHO resolution and the work of the ECDC to tackle TB and recognises the impact of the global TB burden on the Scottish population. The Scottish Government published TB Action Plan for Scotland in 2011 and the TB Action Plan for Scotland Annual Report 2013 was published in November The Annual Report includes a range of recommendations for NHS Territorial and Special Health Boards to take forward together with partners in Primary Care, Social Services and the community. Scotland is committed to global action on tuberculosis. The TB Annual report 2013 can be found at The Scottish Dimension 1.15 The impact of this global public health threat is very much felt in Scotland. The development of drug resistance due to inadequate treatment and higher prevalence of disease in certain countries (due to poor detection and high levels of HIV in the population) has a significant impact on the UK and Scotland. While in the recent past the number of TB cases in Scotland has been largely stable, epidemiological data from the last 4 years suggests that this picture is changing. Until the last year we have been seeing an increase in cases that mirrors the picture in some other parts of Europe (Sweden, Ireland). This has presented a number of challenges for the NHS in Scotland Cases of tuberculosis are currently recorded in Scotland using two different systems. The first is a system of notification of infectious diseases. This notification system has been in place since 1976 and simply records whether a patient with tuberculosis has pulmonary or non-pulmonary disease. The second system is the Enhanced Surveillance of Mycobacterial Infections (ESMI) system which has been operating since This system records much more information about tuberculosis cases, including details of their diagnosis, treatment and how well they have recovered. The detailed information on tuberculosis in Scotland is based on the ESMI data In 2013 the incidence of TB in Scotland was lower than that of the whole of the UK population: 7.4 per 100,000 population in Scotland. This was a decrease of 3.2% in the number of cases and a decrease of 3.4% in the incidence, compared with This represents the third consecutive decrease in annual numbers of tuberculosis cases and incidence since 2010, and is in contrast to a stabilising in numbers of cases reported in England and the whole of the UK (HPS, Historically, Scottish TB incidence has been higher in Greater Glasgow and Clyde and Lothian NHS Boards. In 2013, Greater Glasgow and Clyde notified the majority of cases (169 TB cases 43% of Scotland s total, an incidence of 14.9 per 100,000 of the population). Lothian had 78 cases and Grampian had 53 (incidence for both 9.2 per 100,000). 8

10 The Shetland picture 1.20 Although many Shetlanders will remember their parents and neighbours being affected by TB, it is now an infrequent infection. This reflects the situation in the rest of Scotland. In 1948 in Shetland there were 24 new cases of TB notified, 187 people were known to be suffering from TB, and there were 16 deaths due to TB. At that time TB patients were treated in the Zetland County Sanatorium. Over the last 20 years there have been only one or two cases of TB most years in Shetland, (except for 1994, when there was an outbreak on a ship). For almost half of this period there have been no cases recorded (see table 3 over) Shetland had one case of tuberculosis notified in Cases of tuberculosis locally may be small but the changing epidemiology globally and in Scotland means the need for vigilance of services in surveillance and awareness of symptoms is ever important. It is naive and simplistic to think that tuberculosis is a problem whose cause is immigration alone. Year Number of TB Number of TB Year Cases notified Cases notified TABLE 3: Tuberculosis notifications in Shetland

11 2. Tuberculosis Services in Shetland 2.1 Notification: Both respiratory and non-respiratory TB are statutorily notifiable. The doctor suspecting the diagnosis is responsible for notification. Information from the following sources should be directed, both informally and formally to the Director of Public Health (DPH) and the Department of Public Health without delay, so that appropriate action can be taken. Clinicians: where a hospital clinician or GP suspects TB, even if not confirmed bacteriologically, this information should be passed immediately to the Department of Public Health. The clinician is statutorily required to complete a notification form, but should also give as many other details as possible. Hospital Laboratory Staff: As soon as mycobacterial infection is suspected, sufficient information should be imparted immediately, by telephone to the referring clinician, and by the notification form, to the DPH, so that further details of the patient s condition and whereabouts can be obtained. This is particularly important when organisms are seen on direct staining of a sputum smear. Hospital Pathologists: The Shetland pathology service is in Aberdeen. If they suspect TB from a pathology specimen of a patient residing in Shetland, they should contact Shetland DPH by telephone, and via the notification form. 2.2 The Department of Public Health notifies all known and suspected cases of TB along with other notifiable diseases to Health Protection Scotland at the end of every week. Where further evidence (e.g. from bacteriology or post mortem specimens) suggests the diagnosis has been erroneous or that the infection has been caused by an atypical mycobacterium, then this information is passed on so that the records can be corrected centrally. It is much better to notify a case of TB and subsequently denotify it, than not to notify a case which is clinically likely to be TB. 2.3 Hospital admission is often not necessary but may be indicated for medical or social reasons. Local treatment will usually be undertaken in collaboration with consultants in Infectious Diseases or Chest Medicine in Aberdeen. GP involvement in follow up must only be as part of shared care with that Consultant. If smear positive patients are being managed in hospital, or other institutions, they should be in isolation for a minimum of 2 weeks with effective therapy. It is recommended that patients with infectious TB should not be in the same ward as immuno-compromised patients, therefore all infectious TB patients requiring hospital admission should be transferred to Aberdeen. After 2 weeks therapy patients can be deemed noninfectious, even if they remain smear positive, since the bacilli in the sputum are assumed to be dead. (The evidence for this is limited however). This does not apply to patients with HIV and multi drug resistant cases. Treatment of TB requires at least 6 months of combination chemotherapy, administered daily, or three times a week. Chemotherapy regimens are internationally agreed, and clinicians should refer to the latest BTS chemotherapy guidelines. The 6 months regime has been shown to be highly effective for pulmonary TB, and many extra-pulmonary forms of TB. TB meningitis should be treated for 12 months. These regimes are given by the oral route. 10

12 2.4 The term multi-drug resistant tuberculosis (MDRTB) is generally applied to strains which are resistant to both rifampicin and isoniazid, but many strains are also resistant to other anti-mycobacterial agents. Drug resistant TB strains usually arise from poor clinical management and/or poor compliance with standard treatment regimes. They can then be passed from person to person, so that subsequent infections simply reflect the mechanism of spread of TB. Guidance on the management of HIV associated and MDRTB suggests referral of Shetland patients to Edinburgh Western General Hospital which has appropriate negative pressure isolation facilities. 2.5 Treatment will be decided by the Thoracic Medicine Consultant, in liaison with SMRL. MDRTB Treatment will involve at least 3 drugs, to be taken for a minimum of 9 months after becoming culture negative. All treatment should be fully supervised, with Directly Observed Therapy (DOT), (unless there are exceptional circumstances). If admitted to hospital, the patient should not be discharged until secure arrangements have been made with the appropriate Primary Care Team for continuing treatment supervision. Public Health should also be aware of the discharge. 2.6 Follow up should include regular sputum examination and annual chest x-rays for up to 5 years. (Life-long for HIV-infected patients). Follow up should be done by the TB specialist, who will liaise with the GP. Chemoprophylaxis regimes should also be decided by the TB specialist. 2.7 Drug susceptibility can only be monitored if all isolates and specimens are processed by SMRL. ESMI also collects data on resistance. The laboratory should inform the DPH immediately by telephone on discovery of a case of MDRTB. The DPH should then inform the Scottish Department of Health and HPS. For patients first diagnosed outside Scotland, the person who establishes first medical contact with the patient should inform the other appropriate agencies, especially the SMRL. 2.8 Contact tracing includes registering the index case and details of the illness, particularly the duration and degree of infectivity. Those at risk must then be contacted, the need for attendance should be explained and possible fears and anxieties explored. Follow up must be made as easy as possible to ensure attendance. Contact tracing must include monitoring attendance so that appropriate action can be taken if a contact fails to attend. Accurate and up to date records should be kept of all cases and their contacts. Contact tracing is the responsibility of the Public Health Department. The tracer in Shetland will usually be the Public Health Nurse. The tracer will compile a list of contacts to be screened for each index case. These contacts will then be informed that they have been in contact with an infective case of TB and that screening and follow up may be necessary. It is important that GPs are aware of the contact tracing guidelines, so that they can give appropriate advice and reassurance to their patients. 2.9 New Entrant Screening: The incidence of TB in many immigrant groups in the UK is high, and the highest rates of disease occur within five years of first entry to the UK. The incidence of TB varies within countries, and some countries have a higher incidence of drug resistant strains, so monitoring and surveillance are 11

13 important. Although Shetland receives only small numbers of immigrants each year, it is nonetheless important to be aware of this important health risk in this population All immigrants (or other entrants, e.g. students, planning to stay in the country for 6 months or more) from countries with a high incidence of disease should be screened. In Shetland this includes au-pairs and teenagers coming on the Global Classroom Exchange Programme Current national policy on port health states that Immigration Control staff riskassess new entrants to the United Kingdom who arrive through ports. Those coming from high-risk countries and intending to stay in the United Kingdom for more than 6 months, and all refugees and asylum seekers, are referred to Port Health Control Units ( PHCU). Screening not only allows the identification of cases, but also allows chemoprophylaxis and BCGs to be given to those who may benefit from them. When potential cases have been identified at port of entry, forms are issued to Shetland Health Board by the Port Health Control Unit. It is the responsibility of Public Health to ensure any follow-up is done At present the arrangement for ports informing health boards of new arrivals cannot be relied upon, so additional methods for identifying those at risk are required. In Shetland this primarily involves GPs and schools being alert to new people registering on their lists. In addition new entrants such as au-pairs and students do not need Port Health Forms, so it is important GPs and schools are alert to their need for screening, and inform Public Health when such entrants register. The DPH should ensure that the full protocol has been applied if not carried out at port of entry. In practice this will be done by the Public Health Specialist, or Primary Care Staff. This should include a health status interview including current symptoms, previous TB and BCG. Mantoux testing should be limited to those without a BCG scar. Screening and Mantoux testing should be carried out in the home or at a health centre convenient to the immigrant. 12

14 3. Vaccination 3.1 Scottish BCG policy follows national guidelines of the Joint Committee on Vaccination and Immunisation (JCVI). Current policy is as set out in the Department of Health's Immunisation against infectious disease (the 'Green Book'). The JCVI recommends immunisation for the groups listed below (unless BCG immunisation has been previously carried out or the tuberculin skin test is positive or there are contra-indications): all infants (aged 0 to 12 months) living in areas of the UK where the annual incidence of TB is 40/100,000 or greater all infants (aged 0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater previously unvaccinated children aged one to five years with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. These children should be identified at suitable opportunities, and can normally be vaccinated without tuberculin testing previously unvaccinated, tuberculin-negative children aged from six to under 16 years of age with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. previously unvaccinated tuberculin-negative individuals under 16 years of age who are contacts of cases of TB previously unvaccinated, tuberculin-negative individuals under 16 years of age who were born in or who have lived for a prolonged period (at least three months) in a country with an annual TB incidence of 40/100,000 or greater. In addition, unvaccinated, tuberculin-negative individuals aged under 35 years in the following occupations are recommended to receive BCG: healthcare workers who will have contact with patients or clinical materials (both NHS and non- NHS facilities) laboratory staff who will have contact with patients, clinical materials or derived isolates veterinary and staff such as abattoir workers who handle animal species known to be susceptible to TB, e.g. simians prison staff working directly with prisoners staff of care homes for the elderly staff of hostels for homeless people and facilities accommodating refugees and asylum seekers. TABLE 4: Recommendations for BCG Vaccination 3.2 Newborn BCG Services: The Information Services Division (ISD) Child Health Information Team recently reviewed BCG immunisation data recording on the Scottish Immunisation and Recall System (SIRS). SIRS facilitates the automated identification of babies requiring BCG immunisation through the recording of details about the country of birth of baby's parents and grandparents. BCG services should 13

15 be focused on the identification and BCG immunisation of newborns at risk in order to be most effective. 3.3 BCG Services for Older Children: According to current JCVI advice, previously unvaccinated older children with specific risk factors for TB who would formerly have been offered BCG through the schools' programme should be identified at suitable opportunities, and tested and vaccinated if appropriate. The school catch up campaign across Scotland was completed in In Shetland BCG screening to identify schoolchildren who may be at risk, is part of the questionnaire completed by parents at their child s entrance to Primary 1 and secondary school. 3.4 In Shetland individuals who require BCG vaccination or mantoux testing is small. A co-ordinated, robust and monitored service is operated out of the Child Health Service. Identification of newborn babies who are recommended to have immunisation is made ante-natally by the midwife or health visitor, with further opportunity to identify newborns at risk in immediate post-natal period via the Maternity Unit, and on the 10 th day by the health visitor. BCG vaccination if appropriate is then offered at a date and time convenient for the patient, usually at the next local clinic. As numbers requiring vaccination locally is small, clinics may be arranged to suit the specific needs of patients, i.e. should a family be planning travel back home to a tuberculosis endemic country. This hopefully means high compliance of all individuals identified as requiring vaccination. 3.5 Local BCG Vaccination Clinics April 2014-March Mantoux and BCG Vaccination Clinics are usually held locally in the Child Health Department of the Gilbert Bain Hospital. During the period , 3 Mantoux tests were carried out, and 17 BCGs administered (NHS Grampian: 4; NHS Shetland: 13. These clinics are nurse-run. Numbers identified as at risk and requiring vaccination are low, so in order to maintain skills training is done with NHS Grampian colleagues, and updated annually. 14

16 4. NHS Shetland Tuberculosis Notifications Single case of TB (December 2014) There was one case of Tb in a patient who subsequently died. This was not an infectious TB and there was no specific Public Health action required. 5. References NHS Shetland Control of Infection Annual Report NHS Shetland 2015 GP local registration figures NHS Shetland Procedures for the Management of Tuberculosis (Chapter 11 of NHS Shetland Infection Control Manual) Last accessed 6 Oct 2015 Health Protection Scotland. Enhanced Surveillance of Mycobacterial Infections (ESMI) in Scotland: 2014 tuberculosis annual report for Scotland. last accessed 6 October 2015 Scottish Government (2011) A TB Action Plan for Scotland. Edinburgh WHO (2014) Global Tuberculosis Report 2014, Geneva last accessed 6 October