Universal access to TB care what is the challenge, what policy, what is being implemented Cancun 3 December 2009 Léopold BLANC and TBS team TBS/STB/WHO Addressing poverty through quality TB control and research

Latest global TB estimates and notification Estimated number of cases Cases reported DOTS 5.7 million 5.7 million (80 per 100,000) 9.4 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? 100% (?) Gap: 40% sm+

What policy? Analysis of missing cases

India: contribution of PPM providers India: contribution of PPM providers Courtesy: RNTCP, India

The Philippines: increase in case detection in PPM implementation areas 7% 11% 14% Courtesy: 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 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

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 screening abnormality  Smear exam Point of care diagnosis Negative PAL services Positive TB

Symptom screening alone may not work Vietnam prevalence survey : –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.

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 populations Prisons Urban slums Poor areas MigrantsWorkplaceElderlyMinorities Risk groups HIV/AIDS Previous TB MalnourishedSmokersDiabetics Drug abusers

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

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? RRPreva- lence PolicyFor Diag. or for TTT Place of identification Reach able?* PPM0-25% Incr. yesDiag/tttHealth care3 PALIncr. ?yesDiagHealth care3 Community participation Incr. ?yesDiag/tttPop.2-3 HIV>201%yesDiag/tttHealth care3 Miners15(?)?Diag/tttInstitution3 Prisoners20(?)0.5%yesDiagInstitution3 Contacts-5/caseyesDiagHealth care3 * Reacheable populations and feasible: country specific 0=unfeasible, 1=very difficult, 2=somewhat difficult, 3=relatively easy

Policies: what can be implemented? RRPreva- lence PolicyFor Diag. or for TTT Place of identification Reach able?* Diabetics34%noDiag/tttHC (Pop.)3 - 1 Malnourished3.420%noDiag/tttPop. (HC)1 Smokers2.720%noDiagPop. (HC)1 Slums4(?)10%noDiagDefined pop.2 Migrants3(?)5%yesDiagPop.2 Alcoholics2.95%noTtt/diagPop. (HC, inst.)1 - 3 * Reacheable populations and feasible: country specific 0=unfeasible, 1=very difficult, 2=somewhat difficult, 3=relatively easy

Conclusion: Interventions for early and increased case finding 1.Expand setting-specific, proven approaches Detecting more cases: Detecting more cases:Scale up PPM Scale up PAL Detecting cases early: Detecting cases early: Screening of HIV infected Introduce contact screening Mobilize communities 2. Develop and implement new approaches Targeted active case finding: Targeted active case finding: Identified risk groups Identified risk populations 3. 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