BMJ  2006;333:200 (22 July), doi:10.1136/bmj.333.7560.200-a

Letter

Tuberculosis and social exclusion

New approach is needed

EDITOR—The editorial by Story et al is a timely reminder of the growing problem of tuberculosis in London.¹ As tuberculosis control improves, social exclusion will characterise an increasing proportion of cases, as shown by the current outbreak of isoniazid resistant tuberculosis (> 260 with the same strain).^{2 3} The number of patients lost to follow-up with complex medical and social problems requires a new approach.

At London's Homerton University Hospital, an initial risk assessment for adherence identifies patients with tuberculosis who would also be classified in the editorial as socially excluded: homeless people, problem drug users, prisoners, people with an alcohol problem and concurrent HIV infection. The assessment includes psychiatric illness. Enhanced surveillance identifies people who have recently come from countries experiencing chronic civil strife. The table indicates the increasing percentage of tuberculosis patients with one or more of these factors. The proportion of those receiving directly observed therapy (DOT) has increased in line with the greater risk of non-adherence, and yet a high number of patients are still lost to follow-up.

View this table: [in this window] [in a new window]   Categories of social exclusion and outcome in treatment of tuberculosis (TB)

 

A case worker coordinates the different services required. However, there is no statutory obligation to house "intentionally" homeless people or those who cannot prove right of residence. Drug rehabilitation services can provide methadone replacement for opiates but cannot deal with cocaine addiction. Alcohol addiction is tackled entirely by voluntary organisations, and the psychiatric services can deal with acute psychotic episodes, but struggle with personality disorders and social pathology. An acute ward is expensive and a poor environment in which to tackle these problems. A unit that has rooms with ensuite facilities, access to rehabilitation, and areas for exercise has been successful in Boston.⁴ A similar unit in London would likely be cost effective (estimated cost of the current outbreak of isoniazid resistant tuberculosis is > £2m (3m; $3.8m)⁵).

NE London TB Network, Homerton University Hospital, London E9 6SR graham.bothamley{at}homerton.nhs.uk

---

Competing interests: None declared.

References

1. Story A, van Hest R, Hayward A. Tuberculosis and social exclusion. BMJ 2006;333: 57-8. (8 July.)[Free Full Text]
2. Nolan CM, Valdiserri RO, Cohn DL, et al. Tuberculosis elimination revisited: obstacles, opportunities and a renewed commitment—Advisory Council for the Elimination of Tuberculosis (ACET). Morb Mortal Wkly Rep MMWR 1999;48: 1-13.[Medline]
3. Maguire H, Ruddy M, Bothamley G, Patel B, Lipman M, Drobniewski F, et al. Multidrug resistance emerging in North London outbreak. Thorax 2006;61: 547-8.[Free Full Text]
4. Singleton L, Turner M, Haskal R, Etkind S, Tricario M, Nardell E. Long-term hospitalization for tuberculosis control; experience with a medical-psychosocial inpatient unit. JAMA 1997;278: 838-42.[Abstract]
5. White VL, Moore-Gillon J. Resource implications of those with multidrug resistant tuberculosis. Thorax 2000;55: 962-3.[Abstract/Free Full Text]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Related Article

Tuberculosis and social exclusion

Alistair Story, Rob van Hest, and Andrew Hayward
BMJ 2006 333: 57-58. [Extract] [Full Text] [PDF]