Policy responses and statements

Name of organisation:

Health Protection Scotland

Name of policy document:

Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control in Scotland

Deadline for response:

22 August 2008

Background: Dr Jim McMenamin contacted the College as chair of the Scottish TB guideline development group, and on behalf of the Health Protection Network, to request comments on the consultation document 'Tuberculosis: clinical diagnosis and management of tuberculosis and measures for its prevention and control in Scotland'.

This guideline builds on the framework of the NICE TB guideline and addresses specific issues for Scotland. The guideline was now ready for external consultation and the College's comments were requested to assist the guideline development group.

COMMENTS ON
HEALTH PROTECTION SCOTLAND
TUBERCULOSIS: CLINICAL DIAGNOSIS AND MANAGEMENT OF TUBERCULOSIS, AND MEASURES FOR ITS PREVENTION AND CONTROL IN SCOTLAND

The Royal College of Physicians of Edinburgh is pleased to respond to the Health Protection Agency on its consultation on the Scottish guideline on Tuberculosis.  The College supports the production of this approachable and clinically useful document.  It has a substantial number of positive attributes.

Positive Points

1. The guideline is a modification of the NICE TB document and is adapted for ease of use to health care professionals caring for patients with TB in Scotland.

2. The changes made are clear with a Saltire flag highlighting the changes and the word changes in blue.

3. It is easy to read and follow and will be useful for all health care professionals.

4. It has highlighted Audit points.

5. It has highlighted areas that may have resource issues within Scotland.

6. There are no major deviations from the NICE TB guideline, although this Scottish version is set out more clearly for health care professionals.

Most of the following matters are points of detail. 

Suggested changes

1. P12: 2nd saltire flag: We suggest a change to "but where TB is clinically suspected", instead of "but where anti-TB therapy is still clinically indicated".

2. P13: There should be a saltire flag at the second bullet point.  Also, the sentence should read "microbiology staff should have a low threshold for performing TB culture on the following samples even when not specifically requested", rather than "microbiology staff should have a low threshold for performing culture on the following samples even when specifically requested".

3. P13:  Final bullet point- we suggest change to "clinically suspected" rather than "clinically indicated".

4. P18:  We suggest a clarification on paragraph 1.2.2 "; and "'NHS' Boards"; and on 1.2.2.1 line 2, “there should be adequate arrangements for provision ...”.

5. P19:  1.2.2.4.  We suggest removing all Scottish changes as successive statements seem contradictory and confused.

6. P21:  We suggest keeping first and last sentences only.  The others are not relevant here i.e. "For people who were sputum smear negative at admission: that is people with 3 negative sputum samples taken on 3 separate days.  The infection risk to others is very small and as a result these patients can be nursed on an open ward (if no side room is available)".

7. P26:  We suggest a text clarification 1.4.1.3 such as “with an annual review/assessment (rather than an 'appointment') for 5 years”.

8. P27:  We suggest adding a further bullet point at the close of 1.4.3.3 to reflect the likelihood that patients with TB often have other conditions – “combined care for other co-occurring conditions”.

9. P29:  Under Referral, it says that the care of patients with MDR TB should be undertaken by a specialist in MDR TB.  MDR TB is rare in Scotland and there are no Scottish physicians with sufficient expertise to be considered as specialists.  Therefore the guideline as it stands would require patients to be transferred to England.  We suggest that the guideline should be amended to say that patients with MDR TB should be referred to the nearest Scottish respiratory unit where one of the physicians has a special interest in TB.  The physician there will communicate as necessary with the Scottish Mycobacteria Reference Lab and with colleagues who have more experience of dealing with these cases. This policy would also apply to the even rarer cases of XDR TB.

10. P30:  Paragraph 1.5.3.1.  We suggest clarifying the final 'Saltire' bullet point to reflect at-risk groups and settings as well as countries - ''Travel or residence … in a country or setting with high incidence of MDR TB”.

11. P32:  1.6.1.1 for children and adults: should link the Mantoux result with the statement about BCG vaccination and then say "interferon gamma positive (if available)".

12. P41:  Paragraph 1.8.1.1 about written notification - the new Public Health Act will allow for non-written or, probably, e-notification.  It would be worth checking the intention of the Act before assigning a method to the notification process.

13. P48:  1st bullet point should change to "500 or more per 100,000".

14. P53:  Paragraph 1.9.3.1.  We suggest strengthening the “awareness” to “alertness”, such as “Healthcare workers … should be alert to the signs and symptoms of …”. 

15. P54: 1.9.3.6.  Scotland does not have probation officers, so they should be deleted.

16. P60:  Insert the number of years - 4 - to replace 'xx'.

Overall, we find the document a high quality resource and user friendly guideline.  We hope you find these comments helpful.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[25 August 2008]