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Guidance on use of emergency inhalers in schools

Guidance on the use of emergency salbutamol inhalers in schools September 2014 Title: Guidance on the use of emergency salbutamol inhalers in schools
Author: SCLGCP/CMHI/IDC/14100
Document Purpose: Guidance
Publication date: September 2014
Target audience: Schools, school governors, parents, pharmacists
Contact details:
Pat Parris Disabled and Ill Child Services Team Social Care, Local Government and Care Partnerships Directorate 310, Department of Health, Richmond House 79, Whitehall, London, SW1A 2NS You may re-use the text of this document (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit Crown copyright Published to gov.uk, in PDF format only. Guidance on the use of emergency salbutamol inhalers in schools Prepared by the Disabled and Ill Child Services Team, Department of Health
HOW TO RECOGNISE AN ASTHMA ATTACK . 5
WHAT TO DO IN THE EVENT OF AN ASTHMA ATTACK . 6
Executive summary . 7 1. About this guidance . 8 2. Introduction . 9 3. Arrangements for the supply, storage, care and disposal of the inhaler . 10 4. Children who can use an inhaler . 13 5. Responding to asthma symptoms and an asthma attack . 14 7. Useful links . 19 HOW TO RECOGNISE AN ASTHMA

The signs of an asthma attack are

• Persistent cough (when at rest) • A wheezing sound coming from the chest (when at rest) • Difficulty breathing (the child could be breathing fast and with effort, using all accessory muscles in the upper body) • Nasal flaring • Unable to talk or complete sentences. Some children will • May try to tell you that their chest ‘feels tight' (younger children may express this as tummy ache)
CALL AN AMBULANCE IMMEDIATELY AND COMMENCE
THE ASTHMA ATTACK PROCEDURE WITHOUT DELAY IF
THE CHILD

• Appears exhausted • Has a blue/white tinge around lips • Is going blue • Has collapsed Guidance on the use of emergency salbutamol inhalers in schools WHAT TO DO IN THE EVENT OF AN
ASTHMA ATTACK

• Keep calm and reassure the child
• Encourage the child to sit up and slightly forward • Use the child's own inhaler – if not available, use the emergency inhaler • Remain with the child while the inhaler and spacer are • Immediately help the child to take two puffs of salbutamol via • If there is no immediate improvement, continue to give two puffs at a time every two minutes, up to a maximum of 10 puffs • Stay calm and reassure the child. Stay with the child until they feel better. The child can return to school activities when they feel better • If the child does not feel better or you are worried at ANYTIME before you have reached 10 puffs, CALL 999 FOR AN AMBULANCE • If an ambulance does not arrive in 10 minutes give another 10 puffs in the same way Guidance on the use of emergency salbutamol inhalers in schools Executive summary From 1st October 2014 the Human Medicines (Amendment) (No. 2) Regulations 2014 will allow
schools to keep a salbutamol inhaler for use in emergencies.
The emergency salbutamol inhaler should only be used by children, for whom written
parental consent for use of the emergency inhaler has been given, who have either been
diagnosed with asthma and prescribed an inhaler, or who have been prescribed an
inhaler as reliever medication.

The inhaler can be used if the pupil's prescribed inhaler is not available (for example, because it
is broken, or empty).
This change applies to all primary and secondary schools in the UK. Schools are not required to
hold an inhaler – this is a discretionary power enabling schools to do this if they wish. Schools
which choose to keep an emergency inhaler should establish a policy or protocol for the use of
the emergency inhaler based on this guidance.
Keeping an inhaler for emergency use will have many benefits. It could prevent an unnecessary
and traumatic trip to hospital for a child, and potentially save their life. Parents are likely to have
greater peace of mind about sending their child to school. Having a protocol that sets out how
and when the inhaler should be used will also protect staff by ensuring they know what to do in
the event of a child having an asthma attack.
The protocol could be incorporated into a wider medical conditions policy which will be required
by Supporting Pupils from 1st September 2014. The protocol should include the following – on
which this guidance provides advice:
• arrangements for the supply, storage, care, and disposal of the inhaler and spacers in line with the schools policy on supporting pupils with medical conditions • having a register of children in the school that have been diagnosed with asthma or prescribed a reliever inhaler, a copy of which should kept with the emergency inhaler • having written parental consent for use of the emergency inhaler included as part of a child's individual healthcare plan • ensuring that the emergency inhaler is only used by children with asthma with written parental consent for its use • appropriate support and training for staff in the use of the emergency inhaler in line with the schools wider policy on supporting pupils with medical conditions • keeping a record of use of the emergency inhaler as required by Supporting pupils and informing parents or carers that their child has used the emergency inhaler • having at least two volunteers responsible for ensuring the protocol is followed Guidance on the use of emergency salbutamol inhalers in schools 1. About this guidance From 1st October 2014 the Human Medicines (Amendment) (No. 2) Regulations 2014 will allow schools to keep a salbutamol inhaler, if they wish, for use in emergencies. This will be for any pupil with asthma, or who has been prescribed an inhaler as reliever medication. The inhaler can be used if the pupil's prescribed inhaler is not available (for example, because it is broken, or empty). This change applies to all primary and secondary schools in the UK. Schools are not required to hold an inhaler – this is a discretionary power enabling schools to do this if they wish. Please note that only those institutions described in regulation 17 of the Human Medicines (Amendment) (No. 2) Regulations 2014, which amends regulation 213 of the Human Medicines Regulations 2012 may legally hold emergency asthma inhalers containing salbutamol. This guidance is non-statutory, and has been developed by the Department of Health with key stakeholders, to capture the good practice which schools in England should observe in using emergency inhalers and which should form the basis of any school protocol or policy. The guidance has been updated to take account of issues raised during the public consultation, and the Department is grateful to all who submitted comments and suggestions, which we have endeavoured to incorporate. This guidance does not apply to schools in Wales, Northern Ireland and Scotland, which as devolved administrations have responsibility for issuing their own guidance for schools which wish to make use of this power (and have their own distinct policies on how staff may support children's health needs in the school setting). The principles of safe usage of inhalers in this guidance however are universal and based on recognised good practice. The Children and Families Act 2014 requires governing bodies of English schools to make arrangements for supporting pupils at school with medical conditions. This duty came into force on 1st September 2014 and will be supported by the statutory guidance Supporting pupils at school with medical conditions. Statutory guidance for governing bodies of maintained schools and proprietors of academies in England, referred to hereafter as Supporting pupils. This guidance is therefore designed to be read in conjunction with Supporting pupils, and every school's protocol or policy on use of the inhaler should have regard to it. Supporting Pupils expects schools to: • develop policies for supporting pupils with medical conditions and review them regularly; • develop individual healthcare plans for pupils with medical conditions that identify the child's medical condition, triggers, symptoms, medication needs and the level of support needed in an emergency. • have procedures in place on managing medicines on school premises; • ensure staff are appropriately supported and trained. 2 Including maintained schools, independent schools, independent educational institutions, pupil referral units and alternative provision academies. Maintained nursery schools are also eligible to hold an emergency salbutamol inhaler. Guidance on the use of emergency salbutamol inhalers in schools Asthma is the most common chronic condition, affecting one in eleven children. On average, there are two children with asthma in every classroom in the UK.There are over 25,000 emergency hospital admissions for asthma amongst children a year in the UK. Children should have their own reliever inhaler at school to treat symptoms and for use in the event of an asthma attack. If they are able to manage their asthma themselves they should keep their inhaler on them, and if not, it should be easily accessible to them. However, an Asthma UK survey found that 86% of children with asthma have at some time been without an inhaler at school having forgotten, lost or broken it, or the inhaler having run out. However, before 1 October 2014, it was illegal for schools to hold emergency salbutamol inhalers for the use of pupils whose own inhaler was not available. In 2013 in response to this, and following advice from the Commission of Human Medicines 2013 the Medicines and Healthcare Products Regulatory Agency (MHRA) recommended changes to legislation to enable schools to hold emergency salbutamol inhalers. A public consultation was held (the results can be found at . There was overwhelming support for changing the regulations to allow schools to hold an emergency inhaler. The regulations which enable this come into force on 1st October 2014. The MHRA also recommended that the use of emergency inhalers be supported by appropriate protocols and this guidance provides advice on what such a protocol should contain. Any school which chooses to hold an emergency inhaler may wish to consider including a cross-reference to the asthma policy in the school's policy for supporting pupils with medical conditions. The use of an emergency asthma inhaler should also be specified in a pupils individual healthcare plan where appropriate. There are a number of resources which provide information on asthma, and how it can be treated listed in section 7 together with contact details for support organisations. This guidance is not intended to be a detailed guide to the diagnosis or treatment of asthma in general. If any member of staff has reason to suspect a child has asthma or a respiratory condition, they should notify the parents, so they can take the child to a doctor. Section 5 gives advice on what to do in an emergency. A school's medical conditions policy or asthma policy may already cover elements of the emergency inhaler protocol, for example ensuring appropriate support and training for teachers. Policies will likely already cover elements such as arrangements for storage, care and disposal of medication, ensuring written consent for administration or supervision of administration of medication, keeping a record of administration of medication, and informing parents in relation to children's own inhalers, and could simply be expanded to cover the emergency inhaler. 4 Asthma UK, ‘Asthma Facts and FAQs', 5 The NHS Atlas of Variation in Healthcare for Children and Young People gives the numbers of emergency admissions of children and young people for asthma in each former PCT / local authority area


Guidance on the use of emergency salbutamol inhalers in schools 3. Arrangements for the supply, storage, care and disposal of the inhaler Supply

Schools can buy inhalers and spacers (these are enclosed plastic vessels which make it easier
to deliver asthma medicine to the lungs) from a pharmaceutical supplier, provided the general
advice relating to these transactions are observed. Schools can buy inhalers in small quantities
provided it is done on an occasional basis and is not for profit.

Fig. 1 – a child being helped to use an inhaler with spacer.

A supplier will need a request signed by the principal or head teacher (ideally on appropriately
headed paper) stating:
- the name of the school for which the product is required; - the purpose for which that product is required, and - the total quantity required.
Schools may wish to discuss with their community pharmacist the different plastic spacers
available and what is most appropriate for the age-group in the school. Community pharmacists
can also provide advice on use of the inhaler. Schools should be aware that pharmacies cannot
provide inhalers and spacers free of charge and will charge for them.
The emergency kit

An emergency asthma inhaler kit should include:
- a salbutamol metered dose inhaler; - at least two single-use plastic spacers compatible with the inhaler; - instructions on using the inhaler and spacer/plastic chamber; - instructions on cleaning and storing the inhaler; - manufacturer's information; - a checklist of inhalers, identified by their batch number and expiry date, with monthly checks recorded; - a note of the arrangements for replacing the inhaler and spacers (see below); - a list of children permitted to use the emergency inhaler (see section 4) as detailed in their individual healthcare plans; Guidance on the use of emergency salbutamol inhalers in schools - a record of administration (i.e. when the inhaler has been used).
Schools should consider keeping more than one emergency asthma kit, especially if covering
more than one site, to ensure that all children within the school environment are close to a kit.
The experience of some respondents to the consultation on this guidance suggested a stock of
5 spacers would be adequate for a typical school.
Salbutamol

Salbutamol is a relatively safe medicine, particularly if inhaled, but all medicines can have some
adverse effects. Those of inhaled salbutamol are well known, tend to be mild and temporary
and are not likely to cause serious harm. The child may feel a bit shaky or may tremble, or they
may say that they feel their heart is beating faster.
The main risk of allowing schools to hold a salbutamol inhaler for emergency use is that it may
be administered inappropriately to a breathless child who does not have asthma. It is essential
therefore that schools ensure that the inhaler is only used by children who have asthma or who
have been prescribed a reliever inhaler, and for whom written parental consent has been given.
Section 5 provides essential information on the safe use of an inhaler.
Storage and care of the inhaler

A school's asthma policy should include staff responsibilities for maintaining the emergency
inhaler kit. It is recommended that at least two named volunteers amongst school staff should
have responsibility for ensuring that:
• on a monthly basis the inhaler and spacers are present and in working order, and the inhaler has sufficient number of doses available; • that replacement inhalers are obtained when expiry dates approach; • replacement spacers are available following use; • the plastic inhaler housing (which holds the canister) has been cleaned, dried and returned to storage following use, or that replacements are available if necessary. Schools will wish to ensure that the inhaler and spacers are kept in a safe and suitably central location in the school, such as the school office, or staffroom, which is known to all staff, and to which all staff have access at all times, but in which the inhaler is out of the reach and sight of children. The inhaler and spacer should not be locked away. The inhaler should be stored at the appropriate temperature (in line with manufacturer's guidelines), usually below 30C, protected from direct sunlight and extremes of temperature. The inhaler and spacers should be kept separate from any child's inhaler which is stored in a nearby location and the emergency inhaler should be clearly labelled to avoid confusion with a child's inhaler. An inhaler should be primed when first used (e.g. spray two puffs). As it can become blocked again when not used over a period of time, it should be regularly primed by spraying two puffs. To avoid possible risk of cross-infection, the plastic spacer should not be reused. It can be given to the child to take home for future personal use. The inhaler itself however can usually be reused, provided it is cleaned after use. The inhaler canister should be removed, and the plastic inhaler housing and cap should be washed in warm Guidance on the use of emergency salbutamol inhalers in schools running water, and left to dry in air in a clean, safe place The canister should be returned to the
housing when it is dry, and the cap replaced, and the inhaler returned to the designated storage
place.
However, if there is any risk of contamination with blood (for example if the inhaler has been
used without a spacer), it should also not be re-used but disposed of.
Disposal

Manufacturers' guidelines usually recommend that spent inhalers are returned to the pharmacy
to be recycled. Schools should be aware that to do this legally, they should register as a lower-
tier waste carrier, as a spent inhaler counts as waste for disposal. Registration only takes a few
minutes online, and is free, and does not usually need to be renewed in future years.

6 This advice is in line with the British Thoracic Society's The use of placebo inhaler devices, peak flow meters and inspiratory flow meters in clinical practice. Practical Recommendations Guidance on the use of emergency salbutamol inhalers in schools 4. Children who can use an inhaler The emergency salbutamol inhaler should only be used by children: - who have been diagnosed with asthma, and prescribed a reliever inhaler; - OR who have been prescribed a reliever inhaler; AND for whom written parental consent for use of the emergency inhaler has been given.
This information should be recorded in a child's individual healthcare plan.
A child may be prescribed an inhaler for their asthma which contains an alternative
reliever medication to salbutamol (such as terbutaline). The salbutamol inhaler should
still be used by these children if their own inhaler is not accessible – it will still help to
relieve their asthma and could save their life.

There should already be procedures in place to ensure that schools are notified of children that
have additional health needs and this information, will enable them to compile an asthma
register. Some schools will already have such a register as part of an asthma policy or medical
conditions policy.
The asthma register is crucial as in larger schools and secondary schools in particular, there
may be many children with asthma, and it will not be feasible for individual members of staff to
be aware of which children these are (in primary settings, where a teacher has responsibility for
a single class each year this is more reasonable). Consequently, schools should ensure that the
asthma register is easy to access, and is designed to allow a quick check of whether or not a
child is recorded as having asthma, and consent for an emergency inhaler to be administered. A
school may wish to include – with parental consent - a photograph of each child, to allow a
visual check to be made.
As part of the school's asthma policy, when the emergency inhaler is to be used, a check
should be made that parental consent has been given for its use, in the register. Schools should
have in their asthma policy a proportionate and flexible approach to checking the register.
The school should seek written consent from parents of children on the register for them to use
the salbutamol inhaler in an emergency. A draft consent form is at Annex B. Schools will want to
consider when consent for use of the inhaler is best obtained. Options include:
• obtaining consent at the same time as for administering or supervising administration of a child's own inhaler under an asthma policy or medical conditions policy, or as part of development of an individual healthcare plan • obtaining consent at the same time as seeking consent for the flu vaccination or other vaccinations Keeping a record of parental consent on the asthma register will also enable staff to quickly check whether a child is able to use the inhaler in an emergency. Consent should be updated regularly – ideally annually - to take account of changes to a child's condition. Guidance on the use of emergency salbutamol inhalers in schools 5. Responding to asthma symptoms and an asthma attack Salbutamol inhalers are intended for use where a child has asthma. The symptoms of other
serious conditions/illnesses, including allergic reaction, hyperventilation and choking from an
inhaled foreign body can be mistaken for those of asthma, and the use of the emergency inhaler
in such cases could lead to a delay in the child getting the treatment they need.
For this reason the emergency inhaler should only be used by children who have been
diagnosed with asthma, and prescribed a reliever inhaler, or who have been prescribed an
reliever inhaler AND whose parents have given consent for an emergency inhaler to be used.
It is recommended that each school's asthma policy includes general information on how to
recognise and respond to an asthma attack, and what to do in emergency situations. Staff
should be aware in particular of the difficulties very young children may have in explaining how
they feel. Often guidance provided to schools by local authorities will provide this information.
Some schools will already have this information in an asthma policy or medical conditions
policy.
Asthma UK has produced demonstration films on using a metered-dose inhaler and
spacers suitable for staff and children.

Education for Health is a charity providing asthma training with the most up to date
guidelines and best practice
http:/


Common ‘day to day' symptoms of asthma are:
• Cough and wheeze (a ‘whistle' heard on breathing out) when exercising • Shortness of breath when exercising • Intermittent cough
These symptoms are usually responsive to use of their own inhaler and rest (e.g. stopping
exercise). They would not usually require the child to be sent home from school or to need
urgent medical attention.

Signs of an asthma attack include
:
• Persistent cough (when at rest) • A wheezing sound coming from the chest (when at rest) • Being unusually quiet • The child complains of shortness of breath at rest, feeling tight in the chest (younger children may express this feeling as a tummy ache) • Difficulty in breathing (fast and deep respiration) • Nasal flaring • Being unable to complete sentences • Appearing exhausted Guidance on the use of emergency salbutamol inhalers in schools • A blue / white tinge around the lips If a child is displaying the above signs of an asthma attack, the guidance below on responding to an asthma attack should be followed. CALL AN AMBULANCE IMMEDIATELY AND COMMENCE THE ASTHMA ATTACK PROCEDURE WITHOUT DELAY IF THE CHILD • Appears exhausted Has a blue/white tinge around lips
Responding to signs of an asthma attack

• Keep calm and reassure the child • Encourage the child to sit up and slightly forward. • Use the child's own inhaler – if not available, use the emergency inhaler • Remain with child while inhaler and spacer are brought to them • Immediately help the child to take two puffs of the salbutamol via the spacer immediately • If there is no immediate improvement, continue to give two puffs every two minutes up to a maximum of 10 puffs, or until their symptoms improve. The inhaler should be shaken between puffs. • Stay calm and reassure the child. Stay with the child until they feel better. The child can return to school activities when they feel better • If the child does not feel better or you are worried at ANYTIME before you have reached 10 puffs, CALL 999 FOR AN AMBULANCE • If an ambulance does not arrive in 10 minutes give another 10 puffs in the same way • The child's parents or carers should be contacted after the ambulance has been • A member of staff should always accompany a child taken to hospital by ambulance and stay with them until a parent or carer arrives.
Recording use of the inhaler and informing parents/carers

Use of the emergency inhaler should be recorded. This should include where and when the
attack took place (e.g. PE lesson, playground, classroom), how much medication was given,
and by whom. Supporting pupils requires written records to be kept of medicines administered
to children.
Guidance on the use of emergency salbutamol inhalers in schools The child's parents must be informed in writing so that this information can also be passed onto the child's GP. The draft letter at Annex B may be used to notify parents. Guidance on the use of emergency salbutamol inhalers in schools Any member of staff may volunteer to take on these responsibilities, but they cannot be required
to do so. These staff may already have wider responsibilities for administering medication
and/or supporting pupils with medical conditions.
In the following advice, the term ‘designated member of staff' refers to any member of staff who
has responsibility for helping to administer an emergency inhaler, e.g. they have volunteered to
help a child use the emergency inhaler, and been trained to do this, and are identified in the
school's asthma policy as someone to whom all members of staff may have recourse in an
emergency.
Schools will want to ensure there are a reasonable number of designated members of staff to
provide sufficient coverage. In small schools, it may be that all members of staff are designated
members of staff.
Schools should ensure staff have appropriate training and support, relevant to their level of
responsibility. Supporting Pupils requires governing bodies to ensure that staff supporting
children with a medical condition should have appropriate knowledge, and where necessary,
support.
It would be reasonable for ALL staff to be:
• trained to recognise the symptoms of an asthma attack, and ideally, how to distinguish them from other conditions with similar symptoms; • aware of the asthma policy; • aware of how to check if a child is on the register; • aware of how to access the inhaler; • aware of who the designated members of staff are, and the policy on how to access As part of the asthma policy, the school should have agreed arrangements in place for all members of staff to summon the assistance of a designated member of staff, to help administer an emergency inhaler, as well as for collecting the emergency inhaler and spacer. These should be proportionate, and flexible – and can include phone calls being made or responsible secondary school-aged children asking for the assistance of another member of staff and/or collecting the inhaler (but not checking the register), and procedures for supporting a designated member's class while they are helping to administer an inhaler. The school's policy should include a procedure for allowing a quick check of the register as part of initiating the emergency response. This does not necessarily need to be undertaken by a designated member of staff, but there may be value in a copy of the register being held by at least each designated member. If the register is relatively succinct, it could be held in every classroom. Designated members of staff should be trained in: • recognising asthma attacks (and distinguishing them from other conditions with similar symptoms) • responding appropriately to a request for help from another member of staff; Guidance on the use of emergency salbutamol inhalers in schools • recognising when emergency action is necessary; • administering salbutamol inhalers through a spacer; • making appropriate records of asthma attacks. The Asthma UK films on using metered-dose inhalers and spacers are particularly valuable as training materials. Children with inhalers will also be able to demonstrate to their teacher how they use it; the school nurse may also be able to advise on appropriate use. In a number of areas, local asthma teams have provided training for school staff in supporting children with asthma, including use of the inhaler, and schools could contact their local NHS Hospital Trust for information on how children with asthma are supported, and improving links between the NHS and the school. It is recommended that schools should also ensure that: • a named individual is responsible for overseeing the protocol for use of the emergency inhaler, and monitoring its implementation and for maintaining the asthma register; • at least two individuals are responsible for the supply, storage care and disposal of the inhaler and spacer. Liability and indemnity Supporting pupils requires that governing bodies ensure that when schools are supporting pupils with medical conditions, they have appropriate levels of insurance in place to cover staff, including liability cover relating to the administration of medication. Local Authorities may provide schools which are administering inhalers with appropriate indemnity cover; however schools will need to agree any such indemnity cover directly with the relevant authority or department. Guidance on the use of emergency salbutamol inhalers in schools For convenience both hot links and full URLs are given below.
Education for Health

School Asthma Cards

Getting it right for children, young people and families. Maximising the contribution of the school
nursing team: Vision and Cal to Action (March 2012).
Guidance on the use of emergency salbutamol inhalers in schools USE OF EMERGENCY SALBUTAMOL INHALER [Insert school name] Child showing symptoms of asthma / having asthma attack
1. I can confirm that my child has been diagnosed with asthma / has been prescribed an inhaler [delete as appropriate]. 2. My child has a working, in-date inhaler, clearly labelled with their name, which they will bring with them to school every day. 3. In the event of my child displaying symptoms of asthma, and if their inhaler is not available or is unusable, I consent for my child to receive salbutamol from an emergency inhaler held by the school for such emergencies. Date: ……………………………………………… Parent's address and contact details: Guidance on the use of emergency salbutamol inhalers in schools SPECIMEN LETTER TO INFORM PARENTS OF EMERGENCY SALBUTAMOL INHALER USE [Delete as appropriate] This letter is to formal y notify you that………………………………….has had problems with his / her breathing today. This happened when……………………………………………………………………………………………. A member of staff helped them to use their asthma inhaler. They did not have their own asthma inhaler with them, so a member of staff helped them to use the emergency asthma inhaler containing salbutamol. They were given ……… puffs. Their own asthma inhaler was not working, so a member of staff helped them to use the emergency asthma inhaler containing salbutamol. They were given ……… puffs. [Delete as appropriate] Although they soon felt better, we would strongly advise that you have your seen by your own doctor as soon as possible. Yours sincerely,

Source: https://www.educationforhealth.org/wp-content/uploads/2015/03/guidance_on_use_of_emergency_inhalers_in_schools_September_2014__3_.pdf

x-ray structure of tmp kinase from mycobacterium tuberculosis complexed with tmp at 1.95 Å resolution

doi:10.1006/jmbi.2001.4843 available online at on J. Mol. Biol. (2001) 311, 87±100 X-ray Structure of TMP Kinase from Mycobacterium tuberculosis Complexed with TMP at 1.95 AÊ ResolutionI. Li de la SierraH. , A. M. , O. Baà 1Unite de Biochimie Structurale The X-ray structure of Mycobacterium tuberculosis TMP kinase at 1.95 AÊ resolution is described as a binary complex with its natural substrate