global tb programme systematic screening for active tb – from guideline to operational manual a...
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GLOBAL TB PROGRAMME
Systematic screening for active TB – from guideline to operational manual
A TBCARE 1 (USAID) project by ATS, FHI360, KNCV, MSH, TBREACH and WHO
The Union Conference 2014
Knut Lönnroth
Global TB Programme, WHO 1
GLOBAL TB PROGRAMME
Key principles
• First ensure health systems preparedness
• Indiscriminate mass screening should be avoided.
• Prioritize risk groups for screening based on assessments of benefits, risks, feasibility, and cost.
• Chose among screening and diagnostic algorithms, based on accuracy, feasibility and cost
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Strong recommendations = Should be screened in all settings
1. Household contacts and other close contacts should be systematically screened for active TB.
2. People living with HIV should be systematically screened for active TB at each visit to a health facility.
3. Systematic screening for active TB should be done in current and former workers in workplaces with silica exposure
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Conditional recommendations = prioritization needed
4. Systematic screening for active TB should be considered in prisons and other penitentiary institutions. (including staff)
5. Systematic screening for active TB should be considered in people with untreated fibrotic CXR lesion.
6. In settings where the TB prevalence is ≥100/100,000 in the general population, systematic screening for active TB should be considered among people who are seeking care or who are in care and belong to selected risk groups (see remarks, including staff)
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Conditional recommendations, cont.
7. A. Systematic screening may be considered for geographically defined sub-populations with extremely high levels of undetected TB (>1% prevalence)
B. Systematic screening may be considered also for other sub-populations with very poor health care access, such as urban slum dwellers, homeless people, people living remote areas with poor access, indigenous populations, migrants, and other vulnerable groups.
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Operational guide
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Planning & implementation cycle
1. Situation assessment /
6. Monitoring and evaluation
2. (Re-)Define goals and specific
objectives
3. (Re-) prioritization of
risk-groups
4. Choose screening and
diagnostic algorithms
5. Planning, budgeting,
implementation
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1. Situation assessment
• TB epidemiology and case detection gaps
• Map risk groups and special access barriers
• Preparedness of NTP, health system, partners
• Existing regulatory and human rights frameworks
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2. Setting goals and specific objectives
Primary aim: detect active TB early:a) Reducing the risk of poor treatment
outcomes and the adverse social and economic consequences.
b) Equitable access
c) Reducing TB transmission
Secondary:d) Rule out active disease to help identify
people who are eligible for treatment of latent TB infection.
e) Identifying people who are at particularly high risk of developing active disease in the future and thus may require repeat screening
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3. Prioritization of risk-groups; criteria:
1. Benefits vs. harm for the individual
2. Total yield of true TB cases
3. Impact on transmission
4. Equity aspects
5. Feasibility and acceptability
6. Number needed to screen
7. Cost effectiveness and cost benefit
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4. Choosing algorithms
• Accuracy and yield of the screening and diagnostic tests
• TB prevalence in the risk groups
• Profile of the prioritized risk groups
• Availability, feasibility, capacity for using different tests
• Cost and cost-effectiveness
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5. Planning, budgeting and implementing
• Planning, HR and commodity requirements, budgeting
• Ethical considerations (informed consent etc)
• Partner and community involvement
• Resource mobilization
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6. Monitoring, evaluation and re-programming
• Reality check; adjust, re-prioritize, discontinue?
• Define indicators to monitor: Yield, NNS, confirmed vs. non-confirmed cases Contribution to case notification Cost and cost per case
• Minimum recording and reporting requirements Number screened Number screened positive Number cases detected (by type)
• Research: Accuracy of algorithms Operational challenges Improve acceptability and minimize harm Effectiveness and cost effectiveness
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Next steps for the operational guide
1. Finalization (December 2014) and dissemination
2. Continued support for field testing and evaluation
3. Compilation of additional case studies – create a web repository
4. Research to refine approaches and algorithms
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Acknowledgements
NTPs• Cambodia• China• Ghana• Myanmar• Rwanda• South Africa• Uzbekistan • TBREACH project
countries
TBCARE 1 Partners• ATS• FHI360• KNCV• MSH• TBREACH/Stop TB
Partnership