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