Tim Baker

Problems of TB management in London.

Effective TB management in London has been compromised by the failure to match increasing notifications with increases in nursing and medical resources.

The consequent need to prioritise activity has lead to compromises in services provision.  In one high prevalence borough nurses have had to abandon new entrant screening to focus on patient support and contact screening.  Consultant clinic appointments must also be  rationed in order to maintain a fast referral system for new patients.

Case management problems are further compounded by the socio-economic problems associated with patients living in inner city boroughs.


Robert N Davidson and Robert J Wilkinson

Vitamin D deficiency and Vitamin D receptor polymorphisms as risk factors
for TB among Gujarati Indians.

The notification rate of TB amongst Gujarati Asians in Harrowis as high as
809/100000 amongst those who arrived in the UK within the last 5 years;
this suggests that their is an acquired immunodeficiency associated with
immigration. In our study of 103 untreated Gujarati TB patients and 116
Gujarati household contacts, serum 25-hydroxycholecalciferol (25-OH Vit D)
was low in all subjects. Vit D deficiency was associated with active TB (OR
2.91, 95% CL 1.3-6.5, p= 0.008), and an undetectable 25-OH Vit D (< 7
nmol/l) level carried a higher risk (OR 9.88, 95% CL 1.3-76.2, p = 0.009).
Although there was no independent association between Vit D receptor
genotype and TB, the combination of genotype TT/Tt and 25-OH Vit D
deficiency was associated with disease (O.R 2.8, 95% C.L. 1.2-6.5) and the
presence of genotype ff or an undetectable 25-OH VitD level was strongly
associated with disease (O.R 5.1, 95% C.L. 1.4-18.4).
These findings indicate that Vitamin D deficiency may account for some of
the increased risk of TB in immigrants; if so, it would be easily



Dr. John Moore-Gillon

TB in London

There are more cases of TB in London than any other European city.  Cases of TB in London have risen by over 80% in the past 15 years.  They now make up 40% of all cases of TB in England and Wales and 50% of drug-resistant cases.

Management of TB in London is complicated by a number of factors:

Over 90 different countries of birth are reported by London TB cases in 1998, and in some parts of the capital almost 10% of the population are asylum seekers/refugees.  Two-thirds of the most socially deprived boroughs in the country are in London.

TB services in London are currently undergoing re-organisation, but without any additional resources.  In the absence of significant investments in TB control there can be little optimism about reversing the rising trend of tuberculosis.

John Watson

Tuberculosis in the United Kingdom


The epidemiology of tuberculosis in the UK has changed considerably in the last two decades.  Having been largely a disease occurring among older people in the indigenous white population reflecting infection acquired many years previously, it has become a disease of younger people in minority populations reflecting more recent transmission.  Since the late 1980ís reported case numbers of tuberculosis have increased steadily with substantial increases in urban areas such as London.  The emergence of co-infection with HIV and the occurrence of drug resistance (including multidrug resistance and outbreaks) have contributed to the changing epidemiology.  Re-emergence of Mycobacterium bovis infection in cattle has also led to increased concern.   Control methods, and surveillance, need to be continuously reviewed to keep up with the changing face of tuberculosis today. 

 Alex Pym

News from the Genome

The genera mycobacteria includes two important human pathogens

Mycobacterium tuberculosis and Mycobacterium lepra.  The former is
reputed to have the highest annual global mortality of all pathogens.
Their slow growth, virulence for humans and particular physiology
makes these organisms extremely difficult to work with.  However the
development of mycobacterial genomics following the completion of the
Mycobacterium tuberculosis genome sequence provides the basis for  a
powerful new approach for the understanding of these organisms.  Five
further genome sequencing projects of closely related mycobacterial
species with differing host range, virulence for humans and physiology
are underway. A comparative genomic analysis of these species has the
potential to define the genetic basis of these phenotypes which will
be invaluable for the development of urgently needed new vaccines and
drugs.  An overview of the current state of mycobacterial comparative
genomics will be given.

John Grange

Thirty Years in Tuberculosis: -

The 30 year period, 1970-2000, commenced with the introduction of
rifampicin but is ending with the highest ever prevalence of tuberculosis.
We need the humility to admit that we, the biomedical community, have failed
and our priority is to ask how we can rectify the failure. I will suggest
that our way forward is to open the doors of our subject to workers across a
very broad range of disciplines and to abandon the reductionist biomedical
model for an holistic one that embraces all disciplines from molecular
genetics to human rights activism. The foundation of TB Focus and TB Alert
is a significant step in this direction.
'State of the Union' assessment.

Professor Peter Ormerod

Problems in TB Control 

Pros   National Treatment Guidelines

           National Control & Prevention in update
           Audit being done. >85% treated by Chest Physicians
           Enhanced Surveillance started
           Continuous drug resistance monitoring (mycobnet)
           Rejoined IUATLD

Cons  Lack of TB nurse provision in high incidence areas (JTC Audit)
           No outcome data for country
           Poor system for New immigrant/refugee screening
           Shortages of BCG, tuberculin, isoniazid
           Funding/provision for MDR-TB