Where do we go from here? Philip Hopewell, MD Curry International Tuberculosis Center University of California San Francisco Good morning (ur afternoor or evening depending on where you are watching this World TB Day program. World TB Day presents us with a good marker, a tie to take stock of where we are in global TB care and control and where we want to go from here.

‘We’re Losing the Fight’: Tuberculosis Batters a Venezuela in Crisis New York Times, March 20, 2018 ‘We’re Losing the Fight’: Tuberculosis Batters a Venezuela in Crisis This is not where we want to go. As described in this article in the New York Times a few days ago, tuberculosis is poised to resurge as it has in Venezuela if/when we let up on the pressure we apply in addressing the disease. Until relatively recently, Venezuela had a very good tuberculosis control program but the current economic crisis has led to striking resurgence in the disease in a country with little ability to fight back.

Recent findings and events Data from recent TB prevalence surveys Examinations of the cascade of TB care Detailed national and sub-national descriptions of pathways to care Shorter, effective regimens for LTBI Ministerial meeting on TB UN General Assembly meeting on TB Part of the reason to take stock and deciode where we go from here is the relatively recent availability of important data

Recent national TB prevalence surveys in Asia and Africa WHO Global Tuberculosis Programme Katherine Floyd, Philippe Glaziou, Irwin Law, Ikushi Onozaki, Babis Sismanidis

Surveys 1990–2017 27 surveys between 2009 and 2015/16 1991 1992 1993 1994 1995 1996 1997 1998 1999 China Thailand Myanmar R. Korea Philippines 2000 2001 2002 2003 2004 2005 2006 2007 2008 China Cambodia Eritrea Indonesia Philippines BNG Viet Nam 2009 2010 2011 2012 2013 2014 2015 2016 2017 Myanmar China Cambodia Gambia Ghana Indonesia Mongolia DPR Korea Ethiopia Nigeria Malawi Zambia Uganda Mozambique Namimbia Lao PDR Rwanda Sudan Zimbabwe Bangladesh Nepal Pakistan Tanzania Kenya South Africa Thailand Philippines Viet Nam All the national TB prevalence surveys since 2009 with the task force guidance adopted symptom and direct chest x-ray screening and smear and culture based diagnosis. Recent surveys introduced NAA (Xpert or LPA) and HIV tests. Other countries indicating interest: Africa- Botswana, Lesotho, Swaziland, Senegal, Ivory Coast, Angola, and repeat survey in Ethiopia. Asia- Afghanistan, East Timor and very importantly India South America- Bolivia and Peru. Completed (16*) *since Task Force subgroup active Field operations completed, analysis ongoing (1) Field operations ongoing (3) Planned (8) 27 surveys between 2009 and 2015/16 20/22 global focus countries (not Mali or Sierra Leone) + 7 more: Lao PDR, Gambia, Sudan, Zimbabwe, Mongolia, DPR Korea, Nepal

Consistent methods since 2009 HIV test offered in most African surveys *Since 2013: + rapid molecular test for at least: 1. All smear-positive specimens; 2. Smear-negative specimens if culture failed

Lessons from prevalence surveys TB is more prevalent than we have thought. Cough is an insensitive indicator of TB. Microscopy is only 40-50% sensitive (compared with culture). False-positive smears are common. Many cases are treated in the private sector. Many “smear positive cases” cannot be confirmed by culture. (Is problem with smear or with culture?)

4 million “missing” cases Case notification gap 4 million “missing” cases WHO Global TB Report 2017

Estimated TB prevalence before and after prevalence surveys WHO Global TB Report 2017

Incidence estimates before and after surveys 2012-2015 WHO Global TB report 2016

Kenya Releases Results of National TB Prevalence Survey: March 24, 2017 NAIROBI —  Kenya on Friday recognized World Tuberculosis Day by releasing results of a TB study by the country's ministry of health — the first of its kind since Kenya's independence. TB remains high in Kenya, and experts say the country lags in the fight against the disease. The report states that there are more TB cases in Kenya than previously estimated, with a TB prevalence of 558 per 100,000 people.

Prevalence survey, Kenya Translates to approx. 138,105 incident cases/year compared with 82,000 reported 2015 (40% missing)

Many prevalent cases don’t report cough Nigeria and Indonesia – here 2/3-3/4 (65-75%) of S+ cases in community have screening positive symptoms, chronic cough; programmes can do much more here with available tools. Myanmar and Cambodia surveys reported where those who did not report screening positive symptoms whether they had sought care.

Sensitivity of microscopy 60% Kenya 32% Range ~30-60% sensitivity

False-positive smears are common

Cascade of Care: India -28% -12% -7% -5% -6%

13-Country Patient Pathway Summary 1. Initial General Care Seeking Patterns L0 0% 90% 42% 23% 2% 89% 71% 43% 2. Coverage of Microscopy Among Health Facilities L0 0% 29% 19% 4% 88% 69% 67% 10% 4. Coverage of Treatment Among Health Facilities 43% Missing 5% Private 52% Public Sector 6. Location of Notification (Among Estimated Burden) 43% Missing 7% Tx Not Succes. 48% Tx Succes. 7. Treatment Outcomes (Among Estimated Burden) 10% Private 19% Public Sector 3. Access to Microscopy at Initial Care Seeking 7% Private 23% Public Sector 5. Access to Treatment at Initial Care Seeking Patients may iterate through the diagnosis pathway multiple time before being initiated on treatment. 39% Public Sector 40% Private Sector 21% Informal Private Sector Sector 8% L0 17% L1 15% L2 20% 12% 21% L3 7% Level DRAFT VERSION 1.0

Where do we go from here? (1) Fix the front end of the care cascade (access and diagnostic capacity) Strengthen primary care services Align services with care seeking patterns Fully engage the private sector Purchase, deploy, and fully utilize rapid molecular testing that includes drug susceptibility testing (at least RIF) Hold the health care system to a high standard Integrated view of public and private as part of overall system Integration of TB services into primary and referral levels of care Improve information systems Apply performance criteria to all

Criteria for assessment of health system/facility performance Access and responsiveness Availability Timeliness of services Hospitality Quality Comprehensiveness Accuracy Adherence to standards Outcomes Treatment success Coverage Morbidity/mortality Accountability, transparency, regulation Data accessibility and quality Public health functions Reform capacity Fairness and equity Financial barriers to care Availability commensurate with need Efficiency Cost Redundancy Fragmentation Delays Basu S, et al. Comparative Performance of Private and Public Healthcare Systems in Low- and Middle- Income Countries: A Systematic Review. PLoS Med 9(6): e1001244. doi:10.1371/journal.pmed.1001244

Where do we go from here? (2) Improved approaches to case-finding and prevention Identification of high risk populations for screening Utilize more sensitive screening tests and algorithms Chest radiography (digital radiography) CRP followed by radiograph or rapid molecular test Begin implementation of treatment for LTBI in persons with high risk of TB 12 dose INH/rifapentine 30 day INH/rifapentine

Individual and community-centered care AA Information systems Universal coverage Access Social protection Technical assistance Ending TB Quality Funding Multi-stakeholder involvement Innovation Accountability Equity, rights Leadership