1. 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.

2. ‘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.

3. 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

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

5. 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

6. 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

7. 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?)

8. 4 million “missing” cases
Case notification gap
4 million “missing” cases
WHO Global TB Report 2017

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

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

11. 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.

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

13. 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.

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

15. False-positive smears are common

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

17. 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

18. 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

19. 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): e doi: /journal.pmed

20. 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

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