universal access to tb care what is the challenge, what policy, what is being implemented cancun 3...
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Universal access to TB carewhat is the challenge,
what policy,what is being implemented
Cancun 3 December 2009
Léopold BLANC and TBS teamTBS/STB/WHO
Addressing poverty through quality TB control and research
Latest global TB estimates and notification - 2008
Estimated number of
cases
Cases reported
DOTS
5.7 million5.7 million(80 per (80 per 100,000)100,000)
9.4 million9.4 million (8.9 – 9.9)(8.9 – 9.9)
2.6 million (61%)
4.3 million
All forms of TB Greatest number of cases in Asia; greatest rates per capita in Africa
Multidrug-resistant TB (MDR-TB)
New Smear positive
500,000
30,000
HIV-associated TB 1.4 million (15%)
Decelerated case detection trend
40% ss- / EP
95% MDR
Children?
Women/men?
Vulnerable?
-HIV?
-poor?
-migrants?
-contacts?
-smokers?
-diabetics?
-alcoholics?
-infants?
-
10
20
30
40
50
60
70
801
99
5
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
case d
ete
cti
on
rate
(%
)
DOTS sm+
All sm+
100% (?)Gap: 40% sm+
What policy?Analysis of missing cases
India: contribution of PPM providers India: contribution of PPM providers
India: 14 intensified urban PPM districts (2nd quarter 2008): Summary of contribution by different health
sectors
58% 60%69%
24% 24% 7%
9% 7% 11%
5%
4%
3%
1%1% 1% 8%
5%3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TB suspectsreferred (n=103465)
New S+ casesdetected (n=9281)
No. of patientsprovided DOT
(n=7704)
NGO
Private
Corporate
Medical Colleges
Govt, other thanhealth dept
Health dept
Courtesy: RNTCP, India Courtesy: RNTCP, India
The Philippines: increase in case detection in PPM implementation areas
7%
11% 11%14%
0%
5%
10%
15%
20%
2004 2005 2006 2007
2.5M7 units
30 M 168 units14 M
70 units 6 M
28 units
7%
11% 11%
14%
Courtesy: PhilCATCourtesy: PhilCAT
Increasing access
Active TB
Symptoms recognised
Health care utilisation
Diagnosis
Notification
Health education
Improve referral and notification
systems
Improve diagnostic
quality, new tools
Infected
Patie
nt d
elay
Health services delay
Access delay
Effective TB screening in health services and on
broader indication
ACSMDOTS / MDR-TB
Expansion
HR
PAL
Lab str.
HSSCommunity engagement
Contact investig-Children
-Other risk groups
-All household
-Workplace
-Wider
Clinical risk groups-HIV
-Previous TB
-Malnourished
-Smokers
-Diabetics
-Drug abusers
Risk populations-Prisons
-Urban slums
-Poor areas
-Migrants
-Workplace
-Elderly
TB/HIV
Pediatr. TB
TB determinants
TB/HIV Infection control
Analysis of the pathway, and risk of delay
Active case finding
TB/Poverty
Minimize access barriers
New diagnostic tools
PPM
OPD attendees
Non-chest symptoms
70%30%
Chest symptoms
90%10%
Acute respiratory symptoms (PAL services)
Person with persistent cough (cough>=2wks)
Smear examination
Positive Negative
Comprehensive care (inc. TB diagnosis)Monitoring of TB occurrence among CRD (PAL services)
TB
90%10%
Option: CXR for screeningabnormality Smear exam
Point of care diagnosis
Negative
PAL services
Positive
TB
Symptom screening alone may not work
• Vietnam prevalence survey 2006-07:– 23% of new smear positive case reported no symptoms– 47% did not have symptoms corresponding to "TB suspect"
definition (Cough more than 3 weeks) Official report of the prevalence survey
• Cambodia prevalence survey, 2002– 15% of bacteriologically confirmed cases had no symptoms– 61% did not have symptoms corresponding to "TB suspect"
definition (Cough more than 3 weeks) Official report of the prevalence survey
• Zambia prevalence survey, 2005:– 35% of bacteriologically confirmed cases had no cough– 57% of bacteriologically confirmed cases did not fulfil "TB suspect"
definition (Cough more than 3 weeks) Plos one 4(5), 2009
• Review of risk factors: contacts, HIV, smokers, diabetics, alcoholics, elderly, infants, previously treated: – all are suspects?
"Early" case detection: time to consider targeted
active case finding?
Contact investigation: what does the literature tell us?
• In low income, high TB incidence countries (27 studies):
– Up to 5% household contacts have active TB – Approximately 2.5% of household contacts have bacteriologically
confirmed TB– Approximately 50% of household contacts have LTBI
• In high income, low TB incidence countries (30 studies)
– About 3% of contacts have active TB– 33% of contacts have LTBI
• The number of active TB cases that could be potentially identified among close contacts would be: 300,000 to 340,000 per year globally.
Distribution of registered new TB patients (any type) between those who sought care in health facilities and those who were screened for TB as household contacts, Morocco, 1993-2004
0
5000
10000
15000
20000
25000
30000
35000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Identified among household contacts Identified among patients who sought care
5.4% 8.8%
5.6% 5.3% 8.5% 4.7% 4.6% 5.2% 7.2% 3.8 4.1% 2.8%
27,626
30,316 29,829
31,77130,227
29,09729,854
28,85228,285
28,673
26,78226,132
Proportion among registered TB cases, any type, of those who were identified in household contacts, by age group,
Morocco, 1993-2004
0
5
10
15
20
25
30
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
%
Less than 10 years 10 years and more
17.6
4.6
21.4
23.3
7.9
4.5
17.6
4.6
24.2
7.6
19.5
3.9
21.7
3.8
22.4
4.2
16.9
6.7
16.7
3.3
15.3
3.6
11.5
2.5
What are the estimates?
• WHO estimates: around 4.3 million SS+ worldwide
• If we assume that: – i) each of these SS+ patients has at least 3 close contacts
and – ii) the prevalence of active TB among close contacts is
2.5%
• The number of active TB cases that could be potentially identified among close contacts would be: 300,000 to 340,000 per year at global level.
Which groups to target for active case finding?
Risk populationsRisk populations
PrisonsPrisons
Urban slumsUrban slums
Poor areasPoor areas
MigrantsMigrants
WorkplaceWorkplace
ElderlyElderly
MinoritiesMinorities
Risk groupsRisk groups
HIV/AIDSHIV/AIDS
Previous TBPrevious TB
MalnourishedMalnourished
SmokersSmokers
DiabeticsDiabetics
Drug abusersDrug abusers
Active TB
Symptoms recognised
Health care utilisation
Diagnosis
Notification
Health education
Improve referral and notification
systems
Improve diagnostic
quality, new tools
Infected
Patie
nt d
elay
Health services delay
Access delay
Effective TB screening in health services and on
broader indication
ACSMDOTS / MDR-TB
Expansion
HR
PAL
Lab str.
HSSCommunity engagement
Contact investig-Children
-Other risk groups
-All household
-Workplace
-Wider
Clinical risk groups-HIV
-Previous TB
-Malnourished
-Smokers
-Diabetics
-Drug abusers
Risk populations-Prisons
-Urban slums
-Poor areas
-Migrants
-Workplace
-Elderly
TB/HIV
Pediatr. TB
TB determinants
TB/HIV Infection control
Analysis of the pathway, and risk of delay
Active case finding
TB/Poverty
Minimize access barriers
New diagnostic tools
PPM
Approaches to analyses and prioritization
Entry points for analyses:
• By provider: PPM Situational analysis tool
• By geographical area: assess routine programme sub-national data,
OR, prevalence surveys
• By risk group: mapping of risk populations and risk factors
Policies: what can be implemented?
RR Preva-lence
Policy For Diag. or for TTT
Place of identification
Reachable?*
PPM 0-25%
Incr.
yes Diag/ttt Health care 3
PAL Incr. ? yes Diag Health care 3
Community participation
Incr. ? yes Diag/ttt Pop. 2-3
HIV >20 1% yes Diag/ttt Health care 3
Miners 15(?) ? Diag/ttt Institution 3
Prisoners 20(?) 0.5% yes Diag Institution 3
Contacts - 5/case yes Diag Health care 3
* Reacheable populations and feasible: country specific0=unfeasible, 1=very difficult, 2=somewhat difficult, 3=relatively easy
Policies: what can be implemented?
RR Preva-lence
Policy For Diag. or for TTT
Place of identification
Reachable?*
Diabetics 3 4% no Diag/ttt HC (Pop.) 3 - 1
Malnourished 3.4 20% no Diag/ttt Pop. (HC) 1
Smokers 2.7 20% no Diag Pop. (HC) 1
Slums 4(?) 10% no Diag Defined pop. 2
Migrants 3(?) 5% yes Diag Pop. 2
Alcoholics 2.9 5% no Ttt/diag Pop. (HC, inst.) 1 - 3
* Reacheable populations and feasible: country specific0=unfeasible, 1=very difficult, 2=somewhat difficult, 3=relatively easy
Conclusion: Interventions for early and increased case finding
1.1. Expand setting-specific, proven approachesExpand setting-specific, proven approaches
Detecting more cases:Detecting more cases: Scale up PPMScale up PAL
Detecting cases early:Detecting cases early: Screening of HIV infectedIntroduce contact screeningMobilize communities
2. Develop and implement new approaches2. Develop and implement new approaches
Targeted active case finding: Targeted active case finding: Identified risk groupsIdentified risk populations
3. Introduce new tools rapidly as they become available3. Introduce new tools rapidly as they become available
Conclusions
• Clear need for earlier case detection and more active strategies: Dust off "active case finding" debate Additional research needs.
• Countries are different – needs are different: situation assessment in each setting
• And, different needs for different actions: some areas need basic research and new tools others, further guidance development others scaling up interventions yet others, just political commitment
• Still lot of work required to develop framework and tools for setting priorities