In London, tuberculosis prevalence rates were found to be higher among the
homeless population, drug abusers, HIV patients and prisoners, which in turn
reflects on the social and economic situation in England.
Unless tackled in socially affected groups it may 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.
The occurrence of tuberculosis in England closely reflects indices of
poverty and overcrowding, they add. If the major determinants of a disease
are social, so must be the remedies.
Tuberculosis cannot be controlled unless the disease is tackled effectively
among socially excluded groups. This demands co-ordinated action beyond
established control strategies that will require significant and sustained
investment, they conclude.