Main messages

Healthcare professionals, particularly primary care practitioners, have very important roles to play in both the prevention and control of tuberculosis (TB) – primarily through prompt recognition and referral of suspect cases to secondary care and in the support of patients through prolonged treatment.

Consider the risk of active TB in people who have recently arrived in the UK, especially those from countries of high incidence or who may have other risk factors associated with TB and arrange for TB screening to be offered as appropriate.

Latent TB testing should be offered to 16 to 35 year-olds who have arrived in England in the last 5 years and who were born or lived for more than 6 months in sub-Saharan Africa or countries where the TB incidence is more than 150 per 100,000 population.

Maintain long-term vigilance for signs and symptoms of TB in at-risk groups, which include the non-UK born (even many years after arrival) and their families, or others who have links to endemic countries.

Non-UK born people are more likely than UK born people to get extra-pulmonary forms of TB. It is important to be vigilant for signs and symptoms consistent with extra-pulmonary TB.

Inform at-risk patients about the symptoms of TB and encourage them to seek prompt medical advice should they develop them.

Offer HIV testing to anyone diagnosed with TB.

Background

The disease

Tuberculosis (TB) is an infectious disease, caused by bacteria of the Mycobacterium tuberculosis complex. It is predominantly spread by the respiratory route; people with active TB disease in their lungs breathe out infectious bacteria, which may then be inhaled by others.

TB develops slowly. The highest risk period for the development of disease is soon after infection but it usually takes several months for symptoms of active TB disease to appear.

TB infection can however remain latent for many years. Latent TB infection (LTBI) is an asymptomatic, non-infectious form of TB, that can develop into active TB disease, leading to symptoms and potential transmission. Approximately 5% to 10% of people with LTBI develop active disease at some point during their life, usually in the first few years after infection.

Diabetes increases the likelihood of reactivation of TB and, in the UK, is more common in people of Bangladeshi, Pakistani and Indian descent than in the general population. Other conditions or treatments that suppress immunity such as renal failure, chemotherapy, or HIV can also lead to reactivation of TB disease.

Although TB often affects the lungs (pulmonary TB), it can also affect other parts of the body (extra-pulmonary TB), such as lymph nodes, bones and spine and (rarely) the brain and central nervous system. Extra-pulmonary forms of disease are more common in the non UK-born population than in people who are UK-born.

Although TB often affects the lungs (pulmonary TB), it can also affect other parts of the body (extra-pulmonary TB), such as lymph nodes, bones and spine and (rarely) the brain and central nervous system. Extra-pulmonary forms of disease are more common in the non UK-born population than in people who are UK-born.

Typical symptoms of pulmonary TB include:

• coughing for more than 3 weeks – coughing up blood in phlegm or mucus
• weight loss – slow at first, getting quicker as TB develops
• loss of appetite
• high temperature or fever
• night sweats
• extreme tiredness or lack of energy

Extra-pulmonary TB may present in a multitude of different ways, including localised pain, and it is important to be vigilant to this possible diagnosis in anyone who might be at risk.

Only pulmonary and laryngeal TB are generally infectious. People with sputum smear positive (‘open’) pulmonary TB are much more infectious than those with sputum smear negative pulmonary disease (though people with sputum smear negative pulmonary disease can also contribute to transmission). Close and prolonged contact, such as between people living in the same household or in communal accommodation settings, is usually required for transmission of TB to occur. Fully drug sensitive infectious cases usually cease to be infectious after 2 weeks of effective treatment.

Identifying infectious individuals early is key to halting transmission and eradicating TB.

See Tuberculosis and other mycobacterial diseases: diagnosis, screening, management and data.

Epidemiology

The World Health Organisation (WHO) reported that in 2021, approximately 10.6 million people fell ill with TB worldwide and there were 1.6 million associated deaths. WHO estimates that one quarter of the world’s population may have latent TB infection (LTBI), creating a reservoir from which new cases can potentially arise.

According to the WHO Global Tuberculosis report 2022, most TB cases in 2021 were in the WHO regions of South-East Asia (45%), Africa (23%) and the Western Pacific (18%), with smaller shares in the Eastern Mediterranean (8.1%), the Americas (2.9%) and Europe (2.2%).

TB in migrant populations

People born in a country with a high incidence of TB represent one of the groups at highest risk of developing active TB in the UK. People born outside the UK accounted for most TB notifications in England (76.4%) in 2021. Most non-UK born cases were from the Indian subcontinent and Africa. India, Pakistan, Romania, Somalia and Eritrea were the top 5 countries of birth for people with TB in the non-UK born population.

The increased risk of TB observed among migrants is not determined solely by pre-migration exposure in a high incidence country. Multiple and complex risk factors related to country of origin, countries of transit, and living conditions on arrival in the UK can all contribute to the increased burden of TB. These factors can include exposure to TB, HIV, malnutrition, barriers in accessing and navigating healthcare, immunisation coverage, poor living conditions, stigma and marginalisation.

Non-UK born people may continue to be at risk of developing disease for many years after arrival in the UK. The vast majority (86%) of TB notifications in non-UK born individuals in 2021 occurred more than 2 years after UK entry, with 44% occurring in people 11 years or more after UK entry.

UK-born people who maintain links to high incidence countries through social networks or travel are also at increased risk.

TB screening in migrants

UK TB control and prevention strategies focus on early detection and treatment of groups who are at particular risk of TB, including migrants from high incidence countries. In line with international guidance, there are separate national screening programmes for the detection of active TB disease and latent TB in migrants in the UK. Migrants from high incidence countries may be screened for active TB disease before entry to the UK and for latent TB infection after entry to the UK. However, many migrant routes do not have pre-entry screening in place and, in these situations, screening for both active TB disease and latent infection needs to occur in the UK.

Wider provision of TB screening services is determined locally and is subject to local resource prioritisation. There is variation in service provision and practitioners should check locally available services, which may include mobile outreach services, with their local commissioners.

There have also been specific official routes to the UK opened for eligible migrants (for example from Afghanistan or Ukraine). As these populations and routes have specific features there are tailored TB screening recommendations for these groups. The links to these are in the Resources section below.

Screening for active TB in UK migrants

Pre-entry TB screening – migrants arriving in the UK via formal visa routes

Pre-entry screening for active pulmonary TB is a requirement for migrants who apply for a visa to the UK, intend to stay for longer than 6 months and who reside in a high TB incidence country (more than 40 cases per 100,000 population). The screening includes a chest x-ray and symptom assessment and can include a sputum examination. Individuals identified with active TB of the lungs must complete treatment before their visa is granted. Children under 11 years old do not undergo chest X-ray screening unless a clinician deems it necessary, but a history of recent contact with a case of pulmonary TB will be taken alongside a symptom screen and a physical examination if considered necessary by the physician.

See the UK tuberculosis technical instructions.

Visa applicant information on TB screening is available.

Pre-entry screening does not test for latent tuberculosis infection (LTBI) or for extra-pulmonary disease. Migrants from high-incidence countries remain at a higher risk for TB many years after arrival in the UK. Primary care practitioners must therefore remain alert to the signs and symptoms of TB among migrants.

Active TB disease screening – migrants arriving by unofficial routes

The pre-entry screening programme only covers a subset of migrants who arrive via a formal visa route and stay in the country for more than 6 months.

Migrants who arrive by unofficial routes are not covered by the pre-entry screening programme. Such people may be from high incidence countries and/or experience complex risk factors relating to their trajectory of migration, further increasing their risk of TB. Migration data indicate this group is increasing in number, are experiencing longer stays in the UK and often have shared living arrangements.

The UK Health Security Agency (UKHSA) therefore recommends, in line with international guidance (from the European Centre for Disease Control (ECDC) and guidance from (WHO), migrants who arrive from high TB incidence countries (more than 40 cases per 100,000 population), who are not covered by the pre-entry screening programme, should be offered screening for active TB disease as soon as possible after arrival. This should be initiated at the first point of contact with healthcare services or upon registration with primary care services.

Screening allows early identification of those with active TB, including those with drug resistant TB, and start of early treatment, preventing onward transmission and averting new cases. This aligns with the pre-entry screening programme and enables parity across migrant groups.

Screening for active disease should include:

• children over 11 and (non-pregnant) adults: a symptom check, chest X-ray and where appropriate (person is coughing and able to produce sputum) a sputum assessment
• children aged 11 and under: a symptom check at the first point on contact with health care
• pregnant women: a symptom check and a sputum examination where appropriate

If the person has symptoms or an abnormal X-ray they should be referred for appropriate specialist assessment and investigation within one working day in line with National Institute for Health and Care Excellence (NICE) guidelines on TB.

Neither TST (Mantoux test) nor Interferon Gamma Release Assay (IGRA) tests should be used to exclude active TB in adults or children.

See UKHSA tuberculosis screening guidance.

Rates of TB by country are available.

Active TB disease screening – migrants arriving by specific resettlement, relocation and humanitarian assistance migration pathways

Migrants from high incidence countries, who experience forced migration, may arrive by a government supported humanitarian assistance pathway or resettlement scheme, (for example, Afghan Resettlement and Relocation Scheme 2021, Ukrainian Family Scheme 2022), or by mass evacuation (UK evacuation of Sudan 2023). Given the rapid timeframe associated with the movement of these individuals to the UK, the normal requirement for pre-entry screening is usually not feasible. Under these circumstances, UKHSA recommend screening for active TB disease is undertaken as soon as possible in the local area where migrants settle. These population groups may have specific features that increase TB risk and this may result in additional mitigation recommendations Resources section.

Latent TB infection (LTBI) screening

Guidance from NICE and the UKHSA and NHS England (NHSE) action plan for 2021 to 2026 recommend LTBI screening for new entrants from high incidence areas for TB.

See guidance on screening latent TB infection.

LTBI testing and treatment

Evidence suggests that in low-incidence countries such as England, most cases of active TB in migrants result from reactivation of LTBI. There is evidence that LTBI screening for those arriving from areas with a TB incidence or more than 150 per 100,000 is cost effective.

LTBI testing via a single IGRA test should therefore be offered to all migrants meeting the following criteria:

• 16 to 35 years old
• arrived in England in the last 5 years (including entry via other countries)
• born or lived for more than 6 months in sub-Saharan Africa or countries where the TB incidence is more than 150 per 100,000 population.
• no previous history of TB or LTBI (clinically assess for new exposure)
• not previously screened for LTBI in the UK

A programmatic LTBI testing and treatment programme for migrants from high-incidence countries has been established to facilitate this in England (commissioned by NHSE). However, programmatic NHSE LTBI screening is currently only available in the highest TB incidence areas of the England, though some areas have local arrangements for LTBI screening services for migrants in line with NICE guidance.

In areas where programmatic LTBI testing and treatment is not established, screening for LTBI is still recommended. Practitioners can check locally available pathways with their local commissioners. IGRA tests can be requested directly in primary care where pathways exist, or via referral to the local TB service if required.

Patients with positive LTBI screening should be referred to the local specialist TB service for treatment.

Educating patients about symptoms of reactivation and the need for prompt medical assessment are also important to reduce the spread of active TB.

See guidance on latent TB testing and treatment for migrants.

An LTBI testing and treatment implementation algorithm and short introduction to LTBI testing and treatment are also available.

See rates of TB by country.

HIV and TB testing

NICE recommend that new entrant screening for TB should be included within larger new entrant screening programmes, linked to local services. GPs can use the opportunity to offer HIV testing alongside LTBI screening, if appropriate, particularly to those from countries where dual infection with HIV and TB is common. LTBI testing may also be combined with other health checks, for example, hepatitis B and C, as appropriate.

HIV testing should be offered to anyone who has been diagnosed with TB. Any person known to be living with HIV should be referred to HIV services for further risk assessment.

Treatment

In the UK, secondary care specialist teams manage TB cases, including treatment of active disease, following NICE guidelines. These teams consist of physicians, nurses, pharmacists and social or outreach workers with expertise in the treatment of TB.

Treatment involves a combination of antibiotics for a minimum of 6 months with monitoring of treatment by the specialist team. Completion of treatment is vitally important to ensure that the patient is cured and to prevent the development of antibiotic resistance.

Directly observed therapy (DOT) has traditionally been recommended to support those with complex social needs to complete treatment. New evidence indicates that video observed therapy (VOT), where treatment observation is conducted remotely by patients submitting videos of themselves taking their treatment via smartphones, is a more acceptable, effective and cost-effective approach and could therefore help reduce treatment and outcome inequalities in vulnerable groups.

Treatment of latent disease may be for 3 to 6 months depending on the antibiotic regimen used.

As some migrant groups may experience short-notice and/or multiple changes to their place of residence depending on availability of accommodation, TB services should seek to ensure appropriate hand over to services local to where patients move to. It is also important for TB services to identify people who are lost to follow up and, together with primary care professionals if appropriate, support them to re-engage in treatment.
Advice for all secondary care specialist teams about treatment of multidrug-resistant TB (MDR-TB) is freely available from the MDR-TB Clinical Advice Service. The forum provides an opportunity for online dialogue between experts and specialist teams on all aspects of the management of patients with MDR-TB (login required).

Prevention and control

The most important aspects of preventing and controlling TB in the population are:

• screening of at-risk groups such as new entrants
• active case finding (and LTBI screening as appropriate) in under-served groups
• prompt recognition of cases and investigation of the contacts of cases
• adequate and complete treatment of known cases
• BCG vaccination

The NICE TB guidelines provide advice on preventing TB, case finding and adherence, treatment completion and follow-up in under-served groups, including vulnerable migrants.

The Royal College of Nursing A Case Management Tool for TB Prevention, Care and Control in the UK complements existing guidance from NICE, with a concise reference manual for frontline workers engaged in TB control.

TB is a notifiable disease in the UK. If a case is diagnosed, contact your local UKHSA Health Protection Team.

When cases are identified contacts will be traced, screened and treated as appropriate. Initial contact tracing is usually carried out by local TB services. Where congregate settings, clusters or outbreaks are identified the local health protection team will become involved in investigation and control.

The role of the primary care practitioner in the prevention and control of TB is to:

• maintain vigilance for possible cases of active disease
• educate at-risk patients about the symptoms of TB and what to do if they develop them
• arrange screening for at-risk individuals including new entrants from high-incidence countries
• refer suspected cases on to specialist services promptly for assessment and treatment
• work with secondary care teams to develop rapid access TB pathways
• work with secondary care TB services to support patients who have been lost to the care pathway to reengage and to ensure effective handover of care if the patient relocates
• identify and refer patients who are eligible for BCG vaccination

For further information on BCG vaccination, see Tuberculosis: the green book, chapter 32.

The BCG World Atlas provides detailed information on current and past BCG policies and practices for over 180 countries.

Resources

Resources to share with patients

General information on access to health services

TB Alert’s Truth about TB website covers all aspects of TB for patients.

TB Alert’s patient information guidance is available to order in English, Albanian, Bengali, Chinese, Farsi, French, Greek, Gujarati, Italian, Pashto, Polish, Portuguese, Punjabi, Romanian, Somali, Sorani, Spanish, Tamil, Turkish, Urdu and Vietnamese.

The Department of Health’s guidance Tuberculosis: the disease, its treatment and prevention is free to download in English, Albanian, Bengali, Chinese, Farsi, French, Greek, Gujarati, Italian, Kurdish, Pashtu, Polish, Portuguese, Punjabi, Romanian, Somali, Spanish, Tamil, Turkish, Urdu and Vietnamese.

Patient.info’s tuberculosis guidance developed by TB Alert although at present those claiming asylum when they arrive in the UK are unlikely to have been screened before entry.

Resources for local authorities and clinical commissioning groups

Public Health England’s regional team in Yorkshire and The Humber has developed a directory of information for local authorities and clinical commissioning groups (PDF, 1.58MB) to support people with tuberculosis who have no money, no recourse to public funds and no accommodation.

For recommendations for active and latent TB screening for migrants who have travelled to the UK via the Afghanistan Relocations and Assistance Policy (ARAP) programme see Afghan relocation and resettlement schemes: advice for primary care

For recommendations for active TB screening for migrants arriving in the UK via the Ukraine resettlement programme see Arrivals from Ukraine: advice for primary care.