Title: Improving the management and control of tuberculosis among hard to reach groups
Funder: Department of Health (England)

Abstract: AIMS AND OBJECTIVES: We aim to improve the management and control of tuberculosis among homeless people, prisoners and problem drug users (hard to reach groups) by evaluating novel approaches to case finding and management tailored to the needs of these groups. BACKGROUND: London is the only capital city in Western Europe with increasing rates of tuberculosis and has the largest outbreak of drug resistant tuberculosis in Western Europe (figure 1). Prisoners, homeless people and problem drug users in London have rates of tuberculosis exceeding rates seen in many developing countries (figure 2). They are “hard to reach” because they do not engage well with traditional hospital based services and have chaotic lifestyle factors that complicate management through insecure housing tenure, addiction issues and frequent contact with the criminal justice system. We have shown that they have a disproportionate impact on tuberculosis transmission and control and that without specific interventions tailored to the needs of these groups tuberculosis cannot be controlled. Such interventions are needed along the whole patient pathway (figure 3). Our research has led to important service developments including: The London Mobile X-Ray unit targeted at hard to reach groups; a national project to screen all new prisoners in selected prisons using digital chest X-rays; and the “Find and Treat” project which aims to improve case management of hard to reach patients across London. RESEARCH PLANS: We propose a series of interconnected projects to evaluate novel interventions for hard to reach tuberculosis patients. Study 1. Cross sectional survey on the prevalence of latent tuberculosis infection, HIV and hepatitis B and C in prisoners, drug users and homeless people to inform a mathematical model (study 7) of impact and cost effectiveness of screening hard to reach groups. Study 2. Observational study of the effectiveness of a new prison X-ray screening service with long term follow up through data linkage with national surveillance. Study 3. Cluster randomised controlled trial evaluating interventions to increase uptake of mobile x-ray screening in homeless populations. Study 4. Establishment and evaluation of a rapid diagnostic pathway to reduce loss to follow up prior to diagnosis. Study 5. Individually randomised controlled trial of clinic based directly observed treatment (DOT) vs. community based DOT to inform optimal treatment delivery for hard to reach groups. Study 6. Evaluation of a specialist clinical service to in-reach high quality tuberculosis care into prison. Study 7. Qualitative research to ensure that proposed interventions are acceptable and accessible to the target population and to inform understanding of barriers to services. Study 8. Development of a dynamic transmission model to predict public health impact of the interventions and inform economic analysis comparing costs to the savings made through averting future cases. RESEARCH TEAM: We are an established multidisciplinary team who have led major collaborative research and health service developments. Our work has improved patient care by changing practice, informing NICE guideline development and prompting significant investments in tuberculosis control. RESEARCH ENVIRONMENT: The Royal Free NHS Trust manages community tuberculosis services across the North Central Sector providing care to a high proportion of hard to reach tuberculosis patients in London. The “Find and Treat Service” is based in Soho but works specifically with hard to reach patients and case managers across London. The Health Protection Agency has national responsibility for tuberculosis surveillance and outbreak management and a key role in informing Department of Health policy decisions. The academic departments at University College London, Imperial College and University of York are international centres of excellence for infectious disease epidemiology, modelling and health economics. ANTICIPATED OUTPUTS: Our work will develop and evaluate the effectiveness of new service models and technologies to improve access to care and treatment outcomes for hard to reach patients. This will inform service commissioning and augment tuberculosis control in London throughout the programme and beyond. The findings will be generalisable to cities in low prevalence countries. PUBLIC INVOLVEMENT: Qualitative research is a cross cutting theme to ensure that the perspective of service users can inform our work and future service developments. ETHICAL IMPLICATIONS: This programme is largely health services research and involves vulnerable and marginalised populations. Studies will be submitted for MREC approval. JUSTIFICATION FOR RESOURCES: Resources primarily relate to NHS staff costs including staff with dual research and service roles.


Research activity codes: 4.3 INFLUENCES AND IMPACT;4.4 POPULATION SCREENING
Health categories: INFECTION