Tuberculosis and its symptoms
TB is a curable disease caused by the tubercle bacillus Mycobacterium tuberculosis or M tuberculosis. This usually affects the lungs but can affect other parts of the body, such as the lymphatic system, the bones and, rarely, the brain. In recent years cases of TB in England and Wales have started to decline – there were around 5,000 cases in 2017 compared to nearly 9,000 in 2011. London accounts for the highest proportion of cases reported (39 per cent in 2016). The risk of an individual becoming infected is still low, however.
TB develops slowly in the body and it usually takes several months for symptoms to appear. Symptoms which may suggest the presence of TB include fever and night sweats, a persistent cough, weight loss and blood in the sputum.
Transmission of tuberculosis
TB is usually transmitted by air when infected persons with TB in the lungs sneeze, cough or spit. Although anyone can be infected by TB, it is not easily transmitted since only some infected persons are infectious to other people. People who are most at risk of being infected are those who share accommodation with individuals who are either already infected or have close contact with others so infected.
Certain categories of people have a greater chance of becoming infected with TB. These are children, the elderly, people with diabetes, people on steroids, people who are HIV-positive, people in overcrowded poor housing, people with chronic poor health, and those who are dependent on drugs or alcohol.
Control of tuberculosis
In 2005 the Joint Committee on Vaccination and Immunisation (JCVI) carried out a review of all the available scientific and epidemiological data. It recommended that the national schools-based programme – involving immunisation between the ages of ten and 14 – should be discontinued. Those at high risk are now identified in a selective programme.
As a result of the JCVI recommendations, the following risk groups should be offered the BCG vaccination, usually in infancy:
- all infants (0-12 months) living in areas of the UK were the incidence of TB is 40 per 100,000 or greater
- all infants with a parent or grandparent who was born in a country with a TB incidence of 40/100,000 or greater
- those aged 16 or younger, who are not already vaccinated and have a parent or grandparent who was born in a country with a TB incidence of 40/100,000 or greater
- those aged 16 or under who have been in contact with a person with known TB
- those aged 16 or under who were born in, or have lived for a prolonged period in, a country with a high prevalence of TB
- those aged 35 or under working in occupations involving an elevated risk of TB infection, eg health care
- those aged 16 or under who are due to work or live in a country with a high prevalence of TB for more than three months.
Children who would otherwise have been offered BCG vaccination through the schools’ programme should be screened for risk factors, tested and vaccinated as appropriate. The primary care trust (PCT) is responsible for implementing the immunisation strategy for tuberculosis. Those who are uncertain as to their level of risk should seek advice from their general practitioner.
Control of tuberculosis in schools
Schools in areas where TB rates are higher, in particular in inner city areas such as London, should be aware of the symptoms of TB and be extra vigilant with regard to matters such as long-term unexplained illness, and liaise with their health authority where appropriate. School staff in such schools should seek medical advice if they identify themselves as suffering symptoms of TB.
Teachers are not regarded as being at high occupational risk of contracting tuberculosis. Most teachers will have been immunised as children although the BCG vaccine does not offer complete protection against the disease. New entrants to the UK from countries with a high prevalence of TB may be screened at the point of arrival but it is more likely that they would be identified for screening when registering with a GP.
Pre-employment health questionnaires completed by teachers taking up their first post or transferring between posts will generally include questions about symptoms of pulmonary tuberculosis. Candidates who tick the boxes relating to chronic cough, unexplained weight loss, fever etc are likely to be referred for further investigation as such symptoms could indicate active TB. Such teachers can then be treated and prevented from spreading the disease.
Steps to be taken where tuberculosis is confirmed in schools
As with other cases of suspected infectious diseases, where it is suspected that students or school staff are suffering symptoms of tuberculosis, head teachers should make arrangements in accordance with any employer guidelines so that the individual is examined by a health professional.
Where any case of TB is diagnosed affecting a school student or teacher, the law requires that the ‘proper officer’ of the local authority must be notified by the registered medical practitioner making the diagnosis. In practice this is the Consultant in Communicable Disease Control (CCDC) – employed not by the local authority, but the local health protection team (HPT). The CCDC will, nevertheless, work in close conjunction with the local authority’s environmental/public health services directorate in providing advice and assistance to school staff and parents.
Action by the authority and/or the HPT is likely to include contact tracing within the school concerned and screening of students and staff to identify anyone else who is suffering from the disease or who has been infected without showing evidence of contracting the disease. Close contacts are at greatest risk of contracting the disease. Anyone deemed to be at risk will be asked to undertake testing and will receive treatment as necessary.
Infectious individuals will cease to be infectious approximately two weeks after commencing medical treatment. Provided that they are taking medication as prescribed and are known to be responding to treatment (indicated by obtaining ‘smear negative’ sputum), they are likely to be allowed to resume contact with other students or school staff at that point.
Any instances of school staff contracting TB at work must also be reported by the employer to the Health and Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), see: gov.uk/riddor/specified-injuries.htm
Checklist for safety representatives
In many areas, tuberculosis is unlikely to pose a major risk. As with other infectious diseases, prevention is better than cure – so in the first instance, safety reps should check their employer’s policies on infectious diseases and hygiene control to determine both their adequacy and the extent to which they are properly implemented. It is important that such procedures are regularly reviewed to take account of risks affecting the school community. Factors which might increase the risk include:
- an increase in the number of those who may never have been vaccinated against the disease
- contact with those who have lived in foreign countries where incidence of the disease is much higher
- a recent case or cases of TB locally
- a higher than average rate of TB per head of population in the area.
If you work in a school located in an area where there is believed to be a high incidence of TB, and staff could be put at risk as a result of contact during the course of their work, the first step is to seek an agreement with your employer on what precautions may need to be taken.
TB, like any infection that can be contracted through work, is covered by the Control of Substances Hazardous to Health (COSHH) regulations.
Your employer is required to:
- carry out a risk assessment if any members of staff are likely to come into contact with TB in the course of their work
- put in place preventative measures to reduce the risk
- provide staff with information and training
- keep risk assessments up to date.
Employers should also provide health checks for staff if appropriate.
Where a member of the school community, or someone they live with, develops TB, you should try to work with the head teacher to identify which employees, if any, are likely to be placed at greater risk as a result of their work. Where this is so, the head teacher should, in following local authority policy:
- ensure that there is a programme for ensuring that all workers are notified of the risk of TB, how to identify any early signs and what they should do if they think they may be infected
- if the work involves direct contact with clients who may have TB, ensure that there are arrangements in place for obtaining infection control advice
- consider whether or not vaccination for high-risk staff is appropriate.
Safety representatives have a legal right to be consulted on the risk assessment process and the development of health and safety policies.