Tuberculosis in recent migrants to the UK: Examining new-entrant health screening and delays to diagnosis from the patient's perspective.

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BACKGROUNDTuberculosis (TB) is an infectious disease. In 2012 there were 9.3 million new cases of active TB worldwide and over 9,000 in the UK. TB is transmitted by coughing from a patient with disease affecting the lungs. For those in contact with them, who themselves breath in the TB bacteria, 3 things might happen: their immune system may clear the infection completely; they may become unwell with TB (active TB); or the bacteria may enter the body and remain there 'dormant' - latent TB infection. Approximately one third of the world's population is thought to be infected with TB. Of these, approximately 1 in 10 will go on to develop active TB at some point in their life. Diagnosis and prophylactic treatment of latent TB can reduce an individual's risk of developing active disease in the future and is an important tool in reducing rates of TB both in the UK and elsewhere.AIMThis project will examine two patient journeys: the first is their journey from migration to arrival in the UK and experience of TB screening; the second will explore illness pathways from initial symptoms of TB to health-seeking behaviours and healthcare encounters. The study will be set in east London, now the 'TB capital of Western Europe'. Barts Health NHS Trust is the largest TB service in the country and treats approximately 700 new cases of TB per annum.TB SCREENINGTo reduce the spread of infectious TB several strategies for TB screening exist in the UK. Some of these processes have recently changed. Screening when someone enters the country is being been phased out. A new system of pre-entry screening in a migrant's country of origin has been implemented. Some GPs screen patients when they register. However, most TB screening programmes target active TB which affects the lungs therefore missing the 50% of TB which affects other parts of the body and also missing latent TB infection. It is also unclear what proportion of patients who develop active TB in this country do not undergo screening because they fall outside these pathways. It is our impression that TB screening is not sufficiently well organised.ACCESS TO HEALTHCAREMany patients with undiagnosed active TB attend Emergency Departments rather than their GP. Some have been unwell for months. When people who have recently moved to this country do become unwell, they often struggle to access healthcare services. This can cause a delay in diagnosis, resulting in wider spread of disease, higher costs, greater illness and even death. METHODSParticipants for this study will be recruited from TB clinics. The research will be conducted by a doctor who has significant experience working within the local community and with TB patients. Patients will be asked for their written consent and information will be collected from a questionnaire and an interview. Patients will be asked to tell their stories from migration through to diagnosis without interruption. To ensure the specific issues surrounding TB screening and healthcare access are covered, a limited number of more direct semi-structured interview questions will be used to 'fill in the gaps' of the patient's narrative.OUTCOMESThis project will provide detailed insight into the limitations of the current systems for TB screening and healthcare provision for migrants. Outcomes will include specific and detailed policy recommendations about how the organisation of these services could be more effective and accessible. The results will highlight key strategic areas which should be targeted with a view to reducing the disease burden of TB in the UK. The findings will also be applicable to migrant groups within other settings (and with other infectious diseases) and to TB screening in major urban centres within countries of low TB prevalence.