Tuberculosis
Tuberculosis - Summary
Tuberculosis (TB) is an infection caused by bacteria of the Mycobacterium tuberculosis complex. People are infected by inhaling the bacterium in sputum droplets released when a person with active TB of the lungs (pulmonary TB) coughs.
Pulmonary TB is the most common presentation. Extrapulmonary TB presents with symptoms specific to the site involved, and is a more common presentation in children, people born in countries with a high prevalence of TB, and immunosuppressed people.
Pulmonary involvement should be considered if the person has a cough that persists for more than 3 weeks, and which may be associated with sputum, breathlessness, or haemoptysis.
Extrapulmonary involvement should be considered if the person has symptoms such as swollen neck glands, bone or joint pain, abdominal pain, confusion, visual problems, or persistent headache, skin lesions, or chest pain.
Active TB should be suspected in anyone who has symptoms of weight loss, fever, night sweats, anorexia, or malaise, and is at high risk for TB. A person is considered to be at high risk for active TB if they:
Are born in high prevalence areas (e.g. sub-Saharan Africa, South East Asia, Eastern Europe).
Are close contacts of a person with active pulmonary TB.
Have had previous (especially incomplete) treatment for TB.
Have HIV, diabetes, chronic renal failure, previous gastrectomy, occupational lung disease, malignancy, non-resolving pneumonia, or solid organ transplants.
Are taking prolonged courses of corticosteroids, chemotherapy, or anti-tumour necrosis factors.
Are homeless, institutionalized, or living in prison or overcrowded conditions.
Have alcohol problems or are intravenous drug users.
If TB is suspected, management includes:
Excluding other conditions that present in a similar way e.g. chest infection, chronic obstructive pulmonary disease, and lung cancer.
Performing a chest examination and measuring respiratory rate, pulse rate, blood pressure, and oxygen saturation level to help decide whether admission to hospital is needed.
Examining other systems (e.g. spine, skin, gastrointestinal) depending on the person's symptoms, to identify extrapulmonary TB.
Arranging hospital admission if the person is unwell, otherwise, referring to a TB specialist for diagnosis and management (ideally within 2 weeks).
Arranging a chest X-ray and, if possible, sending three sputum samples (ideally, one taken in the early morning) for microscopy to look for acid-fast bacilli and for mycobacterial culture. If symptoms are highly suggestive of active TB, referral to a specialist should not be delayed whilst awaiting test results.
If TB is diagnosed, care will be co-ordinated through a specialist team and treatment will usually involve 6 months of isoniazid and rifampicin antibiotics, supplemented in the first 2 months with pyrazinamide and ethambutol antibiotics.
Primary care management of a person with confirmed TB involves:
Giving verbal and written information on TB.
Encouraging compliance with the treatment. Treatment is curative and the chance of relapse is small (1–3%) if treatment is completed as instructed.
Advising that pulmonary TB can be transmitted to others, and that screening will be arranged in secondary care for contacts considered to be at risk.
Advising on smoking cessation and avoidance of excess alcohol consumption.
Have I got the right topic?
This CKS topic is based on the National Institute for Health and Clinical Excellence (NICE) guideline Clinical diagnosis and management of tuberculosis, and measures for its prevention and control [NICE, 2006].
This CKS topic covers the assessment, referral, and management of active tuberculosis in primary care. This CKS topic also covers information about latent tuberculosis.
This CKS topic does not cover in detail the diagnosis or treatment regimens for active tuberculosis, nor does it cover in detail the screening or management of latent tuberculosis.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
April 2011 — new NICE guidance issued and old NICE references replaced with the new NICE reference. There was no change in text required.
October 2008 to January 2009 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 September 2008.
HTAs (Health Technology Assessments)
No new HTAs since 1 September 2008.
Economic appraisals
No new economic appraisals relevant to England since 1 September 2008.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Arshad, S., Bavan, L., Gajari, K., et al. (2009) Active screening at entry for tuberculosis among new immigrants: a systematic review and meta-analysis. European Respiratory Journal 35(6), 1336-1345. [Abstract] [Free Full-text]
Critchley, J.A., Young, F., Orton, L., and Garner, P. (2013) Corticosteroids for prevention of mortality in people with tuberculosis: a systematic review and meta-analysis. Lancet Infectious Diseases epub ahead of print. [Abstract]
Fox, G.J., Dobler, C.C., and Marks, G.B. (2011) Active case finding in contacts of people with tuberculosis (Cochrane Review). The Cochrane Library. Issue 9. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Horne, D.J., Royce, S.E., Gooze, L., et al. (2010) Sputum monitoring during tuberculosis treatment for predicting outcome: systematic review and meta-analysis. Lancet Infectious Diseases 10(6), 387-394. [Abstract] [Free Full-text]
Orenstein, E.W., Basu, S., Shah, N.S., et al. (2009) Treatment outcomes among patients with multidrug-resistant tuberculosis: systematic review and meta-analysis. Lancet Infectious Diseases 9(3), 153-161. [Abstract]
Primary evidence
Randomized controlled trials published since the last revision of this topic:
Conde, M.B., Efron, A., Loredo, C., et al. (2009) Moxifloxacin versus ethambutol in the initial treatment of tuberculosis: a double-blind, randomised, controlled phase II trial. Lancet 373(9670), 1183-1189. [Abstract] [Free Full-text]
An epidemiological study has been published since the last revision of this topic:
Wright, A., Zignol, M., Van Deun, A. et al. (2009) Epidemiology of antituberculosis drug resistance 2002-07: an updated analysis of the Global Project on Anti-Tuberculosis Drug Resistance Surveillance. Lancet 373(9678), 1861-1873. [Abstract]
Observational studies published since the last revision of this topic:
Becerra, M.C., Appleton, S.C., Franke, M.F., et al. (2011) Tuberculosis burden in households of patients with multidrug-resistant and extensively drug-resistant tuberculosis: a retrospective cohort study. Lancet 377(9760) 147-152. [Abstract]
Caley, M., Fowler, T., Welch, S., and Wood, A. (2010) Risk of developing tuberculosis from a school contact: retrospective cohort study, United Kingdom, 2009. Eurosurveillance 15(11), 1-4. [Abstract] [Free Full-text]
Kliiman, K., and Altraja, A. (2009) Predictors of extensively drug-resistant pulmonary tuberculosis. Annals of Internal Medicine 150 (11), 766-775. [Abstract]
New policies
No new national policies or guidelines since 1 September 2008.
The 2009 annual report on tuberculosis surveillance in the UK has been published by the Health Protection Agency
HPA (2009) Tuberculosis in the UK. Annual report on tuberculosis surveillance in the UK 2009. Health Protection Agency. www.hpa.org.uk [Free Full-text]
New safety alerts
No new safety alerts since 1 September 2008.
Changes in product availability
No changes in product availability since 1 September 2008.
Goals and outcome measures
Goals
To understand which people are at risk of tuberculosis (TB) and when to suspect TB
To make an accurate assessment of someone with suspected TB
To refer all people with suspected TB to a specialist for diagnosis, treatment, and follow up
To provide appropriate advice to people with TB in primary care
Background information
Definition
What is it?
Tuberculosis (TB) is an infection caused by bacteria of the Mycobacterium tuberculosis complex, predominantly Mycobacterium tuberculosis and more rarely Mycobacterium bovis. People are infected by inhaling the bacterium in sputum droplets that are released when a person with active TB of the lungs (pulmonary TB) coughs [MeReC, 2003].
Of immunocompetent adults infected with TB, approximately 10% have a lifetime risk of developing active (symptomatic) TB. In some people the bacteria lie dormant, causing no symptoms; this is known as latent TB. However, latent TB can be reactivated (for example, during illness or when taking certain drugs) [MeReC, 2003].
Pulmonary TB is the most common presentation. Extrapulmonary TB presents with symptoms specific to the site involved, and is a more common presentation in children, people born in countries with a high prevalence of TB, and in people who are immunosuppressed [DH, 2007].
Prevalence
How common is it?
In 1993 the World Health Organization (WHO) declared tuberculosis to be a global emergency. WHO estimates that about a third of the world's population is infected with Mycobacterium tuberculosis, that about nine million people are diagnosed with tuberculosis each year, and that tuberculosis causes nearly two million deaths each year [WHO, 2007].
In 2006, 8497 people were reported to have active (pulmonary and extrapulmonary) TB in the UK, a rate of 14 per 100,000 population, and 41% of these reports were in London [HPA, 2007]. In 2007, 8417 people were reported to have TB in the UK. In 2000, 6726 people were reported to have TB in the UK [HPA, 2008].
Risk factors
What are the risk factors?
Diagnosis
Diagnosis of tuberculosis
When to suspect active tuberculosis
When should I suspect active tuberculosis?
Suspect active tuberculosis (TB) in anyone who is at high risk for TB and has symptoms of weight loss, fever, night sweats, anorexia, or malaise.
Consider pulmonary involvement if the person has a cough that persists for more than 3 weeks, and which may be associated with sputum, breathlessness, or haemoptysis.
Consider extrapulmonary involvement if the person has symptoms such as:
Swollen neck glands (cervical lymphadenitis).
Bone pain, joint pain and swelling, or back pain (especially the spine).
Abdominal pain.
Confusion, visual problems, or persistent headache (cerebral TB).
Skin lesions (e.g. erythema nodosum, lupus vulgaris affecting the face).
Breathlessness, chest pain, or ankle swelling (TB pericarditis).
People from ethnic minority groups or with HIV are more likely to present with extrapulmonary TB.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion from review articles [MeReC, 2003; Campbell and Bah-Sow, 2006; Griffiths and Martineau, 2007].
No symptom is diagnostic for TB, and symptoms may be very variable. Expert opinion from review articles state that weight loss, fever, and night sweats are common in active TB but are not definitive indicators. A UK cohort study (n = 175) investigating symptoms for diagnosing TB found that in 25% of people these symptoms were absent [Breen et al, 2008].
Delays in the diagnosis of TB are common in primary care. Most of the transmission of TB occurs between the onset of cough and the start of treatment [MeReC, 2003], so an increased awareness of TB will promote early diagnosis, and limit the spread of infection [Storla et al, 2008].
People at high risk of active TB
Which people are considered at high risk of active TB?
The following are considered to be at high risk for active tuberculosis (TB):
People born in high prevalence areas (e.g. sub-Saharan Africa, South East Asia, Eastern Europe). See the Health Protection Agency website.
Close contacts (e.g. people living in the same house, or colleagues working in close proximity) of a person with active pulmonary TB.
People who have had previous (especially incomplete) treatment for TB.
People with HIV, diabetes, chronic renal failure, previous gastrectomy, occupational lung disease (e.g. silicosis), malignancy, non-resolving pneumonia, or solid organ transplants.
People who are taking prolonged courses of corticosteroids, or cancer chemotherapy, or anti-tumour necrosis factors (anti-TNF).
People who are homeless, institutionalized, or living in prison or overcrowded conditions.
People with alcohol problems, or who are intravenous drug users.
Basis for recommendation
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control [NICE, 2011], and expert opinion from review articles.
In the UK, cough is more likely to be due to lung cancer or pneumonia rather than active TB [Campbell and Bah-Sow, 2006]. However, if a person has been exposed to TB and has risk factors making them vulnerable to reactivation, the likelihood of a diagnosis increases.
In the UK, most people diagnosed with TB are from ethnic minority groups (e.g. Indian, Pakistani, Bangladeshi, or black African people) [HPA, 2007].
Over 70% of people diagnosed with TB were not born in the UK, and 80% of these were diagnosed more than 2 years after their arrival in the UK, suggesting migrational factors (such as poor housing and vitamin D deficiency) may have a role in reactivation. The risk of TB remains high among immigrants for the rest of their lifetime [HPA, 2007].
Prolonged contact with someone who is smear-positive for TB poses a significant risk of infection [Reichler et al, 2002; MeReC, 2003].
HIV was reported in 5.7% of people with TB in England and Wales between 1999 and 2003 [Ahmed et al, 2007]. TB was the most common AIDS-defining illness in 2002 [Delpech et al, 2004].
Anti-tumour necrosis factor drugs significantly increase the risk of reactivation [Gomez-Reino et al, 2003; Keane, 2005], and should only be started following a risk assessment for latent TB [British Thoracic Society, 2005].
Screening for latent TB
Do I need to screen for latent TB in primary care?
There is no national screening programme for latent tuberculosis (TB) in the UK. Latent TB is screened for as a function of contact tracing. Some new entrants arriving into the UK from areas of high TB prevalence are screened by radiography at Port Health.
At first registration in primary care, if a new entrant from a high TB prevalence country has not been screened for TB, then a referral should be made to the local TB services for screening and management.
Additional information
Additional information
Countries with a high prevalence of TB are those where more than 40 people per 100,000 population are affected (see the Health Protection Agency website).
The diagnosis of latent TB requires a tuberculin (for example, Mantoux) test. An interferon-gamma test will be used if the tuberculin test is positive or equivocal, especially in people who have previously been vaccinated against TB, or in people where a tuberculin test may be falsely negative (such as those who are immunosuppressed). See the Green Book (pdf) section on TB for information on vaccination and Mantoux testing.
People with latent TB have no symptoms, do not feel sick, and do not spread infection to others. The following will be considered for treatment of latent TB, to prevent reactivation [NICE, 2006]:
People less than 36 years of age, or who are HIV-positive, or who are healthcare workers, and who also have either:
A positive Mantoux test (6 mm or greater) without a prior Bacillus Calmette–Guerin (BCG) vaccination, or
A positive Mantoux test (15 mm or greater) and a positive gamma-interferon blood test with a prior BCG vaccination.
Children (1–15 years of age) with either:
A positive Mantoux test (6 mm or greater) without a prior BCG vaccination, or
A positive Mantoux test (15 mm or greater) and a positive interferon-gamma test (if performed) with a prior BCG vaccination.
People with evidence of TB scarring on chest radiography and without a history of adequate treatment.
Basis for recommendation
Basis for recommendation
This advice is based on the National Institute for Health and Clinical Excellence (NICE) guideline Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control [NICE, 2011], and expert opinion from review articles [Griffiths and Martineau, 2007].
DNA typing of TB strains in London suggests that reactivation of latent TB accounts for more people with active TB than person-to-person transmission. Therefore, identification and treatment of latent TB is of importance, and primary care may have a role in targeted screening of high risk people through routine health checks and new registrations, especially in areas with a high prevalence of TB [Griffiths and Martineau, 2007].
A survey given to Primary Care Trusts in England stated that Port Health notification of TB was the most common source of information to identify new entrants for latent TB screening. However this was 'erratic or infrequent'. The next most common source was GP registration [All-Party Parliamentary Group on Global Tuberculosis and British Thoracic Society, 2008].
Management
Management
Scenario: Management: covers the management in primary care of people with suspected active or confirmed TB.
Scenario: Management
Scenario: Management of tuberculosis (including people with HIV)
Management of suspected TB
How should I manage suspected active tuberculosis?
Exclude conditions that have symptoms similar to tuberculosis (TB). See the CKS topics on Asthma, Chest infections - adult, Chronic obstructive pulmonary disease, Cough - acute with chest signs in children, and Lung cancer - suspected.
Examine the person's chest and measure their respiratory rate, pulse rate, blood pressure, and oxygen saturation level, to help decide whether admission to hospital is needed. Examine other systems (for example, spine, skin, gastrointestinal) depending on the person's symptoms, to identify extrapulmonary TB.
Admit people who are unwell.
Refer all other people to a TB specialist for diagnosis and management (ideally within 2 weeks).
Admission is not required for most people; diagnosis and treatment can be carried out in the community under the care of a TB specialist.
Arrange chest X-ray and, if possible, send three sputum samples (ideally, one sample taken in the early morning) for microscopy to look for acid-fast bacilli and for mycobacterial culture.
Do not delay referral to a specialist by waiting for investigation results if symptoms are highly suggestive of active TB.
Additional information
Additional information
Diagnosis: chest X-ray and sputum samples for microscopy and culture can be organized in primary care. Other investigations such as molecular tests, tuberculin tests (for example, Mantoux), bronchoscopy, or computed tomography may be necessary, especially in people with extrapulmonary tuberculosis (TB), and should be carried out under the care of a specialist.
Sputum samples should be labelled for 'TB microscopy and culture'. Microscopy will detect acid-fast bacilli (smear-positive) within 24–48 hours. However a culture result, which is considered to be the 'gold standard' test for active TB, may take up to 6 weeks. Microscopy will not distinguish between different mycobacteria and whether the bacteria are living or dead, unlike culture tests.
Chest X-ray may show signs of a cavity, pleural effusion, lymphadenopathy, or parenchymal infiltrates (mainly in upper lobes).
Tuberculin skin tests (for example, Mantoux test) may be used in people with negative smears, cultures, and chest radiography, to help support a diagnosis of active TB. A positive test in people without a previous Bacillus Calmette–Guerin (BCG) vaccination is highly suggestive of TB. In people with a previous BCG vaccination, a tuberculin skin test can be misleading.
Management will usually involve 6 months of isoniazid and rifampicin antibiotics, supplemented in the first 2 months with pyrazinamide and ethambutol antibiotics. All people diagnosed with TB should have a risk assessment for drug-resistant TB, and a risk assessment and test for HIV.
Care is co-ordinated through a specialist team, and the individual will be allocated a key worker, who will monitor treatment adherence (through urine testing for drugs), response, and adverse effects. People considered at high risk of poor adherence (for example, homeless people) will have directly observed therapy (DOT), where antibiotics are given under the observation of the key worker.
Basis for recommendation
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control [NICE, 2011], and expert opinion from review articles [Geng et al, 2005; Campbell and Bah-Sow, 2006].
Examine for extrapulmonary TB, as 50% of people from ethnic minority groups or with HIV present with extrapulmonary disease [Davies, 2006].
National guidelines state that people with suspected active tuberculosis should be seen by a TB specialist for diagnosis, treatment, and follow up [Joint Tuberculosis Committee of the British Thoracic Society, 1998]. The Chief Medical Officer's action plan, published in 2004, recommended that people with suspected TB should be seen within 2 weeks [DH, 2004].
Treating people at home is no more likely to lead to cross infection than treating them in hospital [Campbell and Bah-Sow, 2006]. Hospital admission is unnecessary, unless there are clear clinical or socioeconomic reasons [NICE, 2011].
The diagnosis of active TB can be difficult, especially in primary care and in people with HIV [Getahun et al, 2007]. Sputum samples may not be possible, and people with extrapulmonary TB will require investigations not available in primary care. Even if sputum samples and chest X-ray are obtained, the results can be misleading.
In 2006 in the UK, only 62% of people with active TB had the diagnosis confirmed by a positive culture (e.g. there was difficulty in obtaining samples for culture) [HPA, 2007].
A normal chest X-ray in active pulmonary TB is uncommon, but the incidence appears to be rising. For example, a retrospective review of people (n = 518) with culture-positive TB showed that approximately 5% had a normal chest X-ray [Marciniuk et al, 1999].
Advice
What advice should I give someone with confirmed TB?
Encourage compliance with tuberculosis (TB) treatment. Explain that treatment is curative, and the chance of relapse is small (1–3%) if treatment is completed as instructed.
Provide support with accommodation and transport to hospital by liaising with social and housing services.
Reinforce TB education with written information.
Advise the person not to smoke, and not to drink excess alcohol.
If appropriate, advise that pulmonary TB can be transmitted to others, and tell the person that screening will be arranged in secondary care for contacts considered to be at risk.
Additional information
Additional information
Tuberculosis (TB) is a notifiable disease. The person who makes the diagnosis of TB (usually in secondary care) is legally responsible to notify a consultant in communicable disease control (CCDC).
The risk of a contact acquiring the infection depends on the nature and duration of their exposure. The CCDC (and TB nursing team) will initiate contact tracing in the following people exposed to active TB:
All household members.
Close contacts (such as partner, visitors to the house, close workplace associates) if the person with TB has a positive sputum smear result.
Casual contacts (such as work colleagues) if the person with TB is particularly infectious (for example, if 10% or more of close contacts develop TB), or casual contacts who have features which put them at risk of infection (such as healthcare workers, people known to be HIV-positive).
Basis for recommendation
Basis for recommendation
These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control [NICE, 2011], and expert opinion from review articles [MeReC, 2003; Campbell and Bah-Sow, 2006; Griffiths and Martineau, 2007].
Completing treatment will reduce the complications of TB for the individual and the community.
Only 79% of people completed TB treatment in 2005 in the UK [HPA, 2007]; 6% below the target set by the Chief Medical Officer [DH, 2004].
In 2006, 7% of people in the UK with active TB were resistant to isoniazid, and 1.1% had multidrug resistance [HPA, 2007].
If left untreated, a person with active pulmonary TB infects, on average, 10–15 people every year, and 10% of these people (for example, 2–3 people) will develop active TB over 2 years [DH, 2004].
Active TB can spread. Mortality from TB in the UK is around 8% [MeReC, 2003] and remains stable [HPA, 2007]. In England, 350 people die of TB every year [DH, 2004].
A systematic review of 42 observational studies suggests a strong link between smoking and TB [Slama et al, 2007].
Evidence
Evidence
Search strategy
Scope of search
A literature search was conducted for UK guidelines and systematic reviews on primary care management of tuberculosis, with particular focus on the following areas:
diagnosis and assessment
statistics on prevalence, incidence, populations, risk factors
referral criteria
The search included patients with HIV.
Search dates
January 2004 – September 2008
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Tuberculosis, Pulmonary/; exp Mycobacterium tuberculosis/; exp Tuberculosis/; tuberculosis.tw
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Topic specific literature search sources
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
References
Ahmed, A.B., Abubakar, I., Delpech, V. et al. (2007) The growing impact of HIV infection on the epidemiology of tuberculosis in England and Wales: 1999-2003. Thorax 62(8), 672-676. [Abstract] [Free Full-text]
All-Party Parliamentary Group on Global Tuberculosis and British Thoracic Society (2008) Putting tuberculosis on the local agenda. ..All-Party Parliamentary Group on Global Tuberculosis.www.appg-tb.org.uk [Free Full-text]
Breen, R.A., Leonard, O., Perrin, F.M. et al. (2008) How good are systemic symptoms and blood inflammatory markers at detecting individuals with tuberculosis? International Journal of Tuberculosis and Lung Disease 12(1), 44-49. [Abstract]
British Thoracic Society (2005) BTS recommendations for assessing risk and for managing Mycobacterium tuberculosis infection and disease in patients due to start anti-TNF-alpha treatment. Thorax 60(10), 800-805. [Free Full-text]
Campbell, I.A. and Bah-Sow, O. (2006) Pulmonary tuberculosis: diagnosis and treatment. British Medical Journal 332(7551), 1194-1197. [Free Full-text]
Davies, P. (2006) Extra-pulmonary tuberculosis. ..Priory Medical Journals.www.priory.com [Free Full-text]
Delpech, V., Antoine, D., Forde, J. et al. (2004) HIV and tuberculosis (TB) co-infections in the United Kingdom (UK): quantifying the problem [Abstract no: ThPeA6954]. International Conference on AIDS, Bangkok, Thailand..International Aids Society.www.iasociety.org
DH (2004) Stopping tuberculosis in England: an action plan from the Chief Medical Officer. ..Department of Health.www.dh.gov.uk [Free Full-text]
DH (2007) Immunisation against infectious disease - "The Green Book". Chapter 32 - Tuberculosis. ..Department of Health.www.dh.gov.uk [Free Full-text]
Geng, E., Kreiswirth, B., Burzynski, J. and Schluger, N.W. (2005) Clinical and radiographic correlates of primary and reactivation tuberculosis: a molecular epidemiology study. Journal of the American Medical Association 293(22), 2740-2745. [Abstract] [Free Full-text]
Getahun, H., Harrington, M., O'Brien, R. and Nunn, P. (2007) Diagnosis of smear-negative pulmonary tuberculosis in people with HIV infection or AIDS in resource-constrained settings: informing urgent policy changes. Lancet 369(9578), 2042-2049. [Abstract]
Gomez-Reino, J.J., Carmona, L., Valverde, V.R. et al. (2003) Treatment of rheumatoid arthritis with tumor necrosis factor inhibitors may predispose to significant increase in tuberculosis risk: a multicenter active-surveillance report. Arthritis and Rheumatism 48(8), 2122-2127. [Abstract] [Free Full-text]
Griffiths, C. and Martineau, A. (2007) The new tuberculosis. British Journal of General Practice 57(535), 94-95. [Free Full-text]
HPA (2007) Tuberculosis in the UK: annual report on tuberculosis surveillance and control in the UK 2007. ..London: Health Protection Agency Centre for Infections.www.hpa.org.uk [Free Full-text]
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Joint Tuberculosis Committee of the British Thoracic Society (1998) Chemotherapy and management of tuberculosis in the United Kingdom: recommendations 1998. Thorax 53(7), 536-548. [Abstract] [Free Full-text]
Keane, J. (2005) TNF-blocking agents and tuberculosis: new drugs illuminate an old topic. Rheumatology 44(6), 714-720. [Abstract] [Free Full-text]
Marciniuk, D.D., McNab, B.D., Martin, W.T. and Hoeppner, V.H. (1999) Detection of pulmonary tuberculosis in patients with a normal chest radiograph. Chest 115(2), 445-452. [Abstract] [Free Full-text]
MeReC (2003) Primary care aspects of tuberculosis. MeReC Bulletin 14(3), 9-12. [Free Full-text]
NICE (2006) Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control [Superseded]. .Clinical guideline 33.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NICE (2011) Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control (full NICE guideline). .Clinical guideline 117.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
Reichler, M.R., Reves, R., Bur, S. et al. (2002) Evaluation of investigations conducted to detect and prevent transmission of tuberculosis. Journal of the American Medical Association 287(8), 991-995. [Abstract] [Free Full-text]
Slama, K., Chiang, C.Y., Enarson, D.A. et al. (2007) Tobacco and tuberculosis: a qualitative systematic review and meta-analysis. International Journal of Tuberculosis and Lung Disease 11(10), 1049-1061. [Abstract]
Storla, D.G., Yimer, S. and Bjune, G.A. (2008) A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health 8(Jan), 15. [Abstract] [Free Full-text]
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