Framework for improved, early case detection Knut Lönnroth DEWG meeting October 2009

Decelerated case detection trend Gap: 37% ss+ 50% ss- / EP 97% MDR Children? Women/men? Vulnerable? -HIV? -poor? -migrants? -contacts? -smokers? -diabetics? -alcoholics? -infants? 100% (?)

Early case detection Source: Dye C. Int J Tuberc Lung Dis 2000; 4(12):S146–S152 Shorten delay from onset of infectiousness to start of treatment to average 2 month, and get 30% annual reduction in TB incidence (in theory)

How to shorten delay? Optimize diagnostic approaches – lab strengthening, better X-ray diagnosis, new tools, etc Identify and involve the health providers people go to first – PPM concept Communication strategy to improve health seeking Reduce access barriers, especially for vulnerable groups, and improve health systems -  Universal access! But will this be enough?

Who is a "TB suspect"? Vietnam prevalence survey : –23% of new smear positive case reported no symptoms –47% did not have symptoms corresponding to "TB suspect" definition Cambodia prevalence survey, 2002 –15% of bacteriologically confirmed cases had no symptoms –61% did not have symptoms corresponding to "TB suspect" definition Zambia prevalence survey, 2005: –35% of bacteriologically confirmed cases had no cough –57% of bacteriologically confirmed cases did not fulfil "TB suspect" definition Review of risk factors: contacts, HIV, smokers, diabetics, alcoholics, elderly, infants, previously treated: –all are suspects?

Consequences More active "passive" case finding: Screening question for "chronic coughers" in health facilities maybe insufficient:  expand the diagnostic algorithm and consider "clinical" risk groups (HIV, diabetes, smokers, alcoholics, malnourished, previously treated, infants, elderly)? But, many will not be detected, or detected late, if waiting for them to seek care:  active screening of risk populations outside health services (contacts, slums dwellers, migrants, prisons, homeless, etc)? Feasible and cost-effective? Will new diagnostic tools make it more feasible? Where is it relevant to start now?

WARNING: Before moving ahead with new things: - don't forget the basics! - get the evidence right!

How to assess the country- specific needs?

Analysis of missing cases

Active TB Symptoms recognised Health care utilisation Diagnosis Notification Health education Improve referral and notification systems Improve diagnostic quality, new tools Infected Patient delay Health services delay Access delay Effective TB screening in health services and on broader indication ACSM DOTS / MDR-TB Expansion HR PAL Lab str. HSS Community 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

Other entry points for analyses: By provider:  PPM Situational analysis tool By geographical area:  assess routine programme data, OR, prevalence surveys By risk group:  mapping of risk populations and risk factors Exercise 1 for this meeting: draft set of key questions cutting across all above

Exercise 1: Assess Questions Answer Burden of TB, what are the trends, Geographical difference within the country? Is the country moving towards TB elimination? Concentrated to certain risk populations only? Case detection gap, in different subgroups? Treatment delay? Geographical coverage of the NTP? Cover essential parts of the health system, and all important health providers? Quality and outreach of diagnostic services? Screening people with HIV for TB? Screening other "clinical risk groups":diabetes, smoking, alcoholics, malnourished, etc? Contact investigation? Active screening for TB of other risk populations (slums, migrants, prisons, etc)? Main access barriers? Weaknesses of the general health system that hampers access to quality TB services? Knowledge and attitudes towards TB and NTP? Stigma?

How to prioritise?

Exercise 2: Prioritize (among 17 listed action) Importance 0=not relevant in the setting 1=somewhat important 2=Important 3= Critical Implementation gap 0=Sufficiently implemented 1=In place, but further scale up required 2=Limited implementation 3=Not implemented Priority Score Multiply values in column 2 and 3 Top five priorities for further action Scoring should take into account cost and feasibility Mark only the five most important actions, rank them from 1-5 Add comments, as required, both for prioritized and non-prioritized actions

Thailand Impo- rtance Imple- mentati -on gap Prio- rity score Top 5 priorities Geographical DOTS coverage313 Basic lab network of good quality313 Culture / DST services313 High quality diagnosis of EP TB2362 High quality diagnosis of TB in children 3393 (High score, but need to cooperation with other sectors) Screen people living with HIV313 Screen other clinical risk groups, e.g. diabetics, alcoholics, etc 212 Access barriers, especially for the poor and vulnerable 212 Engage all health care providers3261 (Critical to complete scale up academia and private) Health communication and social mobilization 313

Exercise for DEWG 2009

Priority, importance, implementation gap

When considering feasibility

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, TA  yet others, just political commitment Still lot of work required to develop framework and tools for setting priorities  your advice and help please! (and thanks for the comments so far)  All this for discussion in the group work tomorrow