Tuberculosis in hard-to-reach groups - programme grant

TB Reach - Improving the Management and Control of Tuberculosis among Hard to Reach Groups.

NIHR TB Programme Grant 2009-2014


To improve the management and control of tuberculosis (TB) among homeless people, prisoners and problem drug users (hard to reach groups) by developing and evaluating the effectiveness of novel approaches to case finding and management tailored to the needs of these groups. This will inform service commissioning and augment TB control in London throughout the programme and beyond.


Prisoners, homeless people and problem drug users in London have rates of TB exceeding those seen in many developing countries. They are “hard to reach” because they do not engage well with traditional hospital based services and have chaotic lifestyle factors that complicate management through insecure housing tenure, addiction issues and frequent contact with the criminal justice system. They have a disproportionate impact on TB transmission and control.


We propose a series of interconnected projects which spans the care pathway to evaluate novel interventions for hard to reach TB patients.

Study 1: Cross sectional survey of latent TB infection (using Interferon Gamma Release Assays), HIV, and hepatitis B and C in prisoners and homeless people. Long term follow up using data linkage with national enhanced tuberculosis surveillance (ETS) to assess the risk of progression to active disease.

Study 2: Evaluation of the effectiveness of the new prison X-ray screening system using teleradiology network of static digital X-ray units to reduce the risk from TB in prisons. Long term follow up using data linkage with national ETS will also be established.

Study 3: Cluster randomised controlled trial evaluating impact of peer educators to increase uptake of MXU screening for TB among homeless populations.

Study 4: Establishment and evaluation of a rapid diagnostic pathway for suspected TB cases. This pathway aims to reduce loss to follow up prior to confirmation or rejection of diagnosis of TB.

Study 5: Individually randomised controlled trial of clinic led directly observed therapy (DOT) versus community based DOT organised by a specialist team to inform optimal treatment delivery.

Study 6: Development of a dynamic transmission model to predict public health impact of the interventions and inform economic analysis comparing costs to the savings made through averting future cases.

The study team – The study is led by Professor John Watson (Head of Respiratory Disease at the Health Protection Agency Centre for Infections). The lead researcher is Dr. Andrew Hayward (Reader, UCL Centre for Infectious Disease Epidemiology), co-researcher Alistair Story (Manager, “Find&Treat”), the clinical lead is Dr. Marc Lipman (Clinical Lead – NCL Non-inpatient TB service), and Project Manager is Elizabeth Garber. Sara Hemming and Sue Yates are research nurses on the study. 

For further information about this study please contact the Chief Researcher, Dr. Andrew Hayward at a.hayward@ucl.ac.uk; or Project Manager, Elizabeth Garber at e.garber@ucl.ac.uk – UCL Centre for Infectious Disease Epidemiology.

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