1. World Health Organization Regional Office for the Western Pacific Expanding access to TB care: Review the progress Dr Nobuyuki Nishikiori, Coordinator Stop TB and Leprosy Elimination World Health Organization Regional Office for the Western Pacific The Ninth Technical Advisory Group and National TB Programme Managers Meeting Manila Philippines, 9-12 December 2014

2. World Health Organization, Western Pacific Regional Office Regional Strategy to Stop TB in the Western Pacific 2011-2015 Vision:Elimination of TB as a public health problem Strategic Priorities 1.Promoting universal and equitable access to quality TB diagnosis and treatment for all people 2.Strengthening TB Laboratory capacity 3.Scaling up the programmatic management of drug- resistant TB 4.Expanding TB-HIV collaborative activities 5.Strengthening TB programme management Goal: To reduce prevalence and mortality from all forms of TB by half by 2015, relative to 2000 level, in all countries with a high burden of TB, by moving to universal access to diagnosis and treatment of all forms of TB, including smear negative and M/XDR-TB.

3. World Health Organization, Western Pacific Regional Office Frameworks for analysis: Patient pathways Onion layer analysis

4. World Health Organization Regional Office for the Western Pacific Actions for improved case detection Minimizing physical, financial and social barriers Improved health communi- cation Engaging all care providers Improved diagnostic tools Patient pathway Symptoms recognized & patients take action Health care utilization Notification Infected Health services delay Access delay Patient delay Active TB TB Diagnosis TB Diagnosis Improved reporting system Regional Strategy to Stop TB in the Western Pacific (2011-2015), WHO WPRO Adapted and modified from “Action framework for higher and earlier TB case detection”, WHO

5. World Health Organization Regional Office for the Western Pacific Onion layer analysis – Where are missing TB cases? Whole onion. All TB cases Layer 6. No access Layer 5. Do not seek care Layer 4. Failed to be diagnosed Layer 3. Non-NTP provider non-reporting Layer 2. Initial loss to follow up and reporting failure The core. Notified TB cases L6. No access to health care L5. Patients do no seek care L4. Presenting to health facilities, but undiagnosed L3. Diagnosed by non-NTP, not notified L2. Diagnosed by NTP but not notified Notified cases ? % CDR=?%

6. (Layer 6) Health care coverage by province Distribution of children who got all vaccinations Distribution of women who were protected by TTI Distribution of women who went to ANC during pregnancy Distribution of women delivered at health facility

7. World Health Organization Regional Office for the Western Pacific Wong MK, Yadav RP, Nishikiori N, Eang MT. The association between household poverty rates and tuberculosis case notification rates in Cambodia, 2010. WPSAR 2013 Jan;4(1):25–33.

8. (Layer 5) Treatment seeking behaviour of people with TB symptoms in Philippines Nationwide TB Prevalence Survey 2007, Philippines Public Hospital Public clinic 9% Private Hospital 6% Private clinic 7% DOTS Center 9% 25% No Action 43% Self Medication 32% Sought Care People with TB Symptoms in the community (identified by survey)

9. World Health Organization Regional Office for the Western Pacific Financial hardship of TB patients and families A half of financial burden before diagnosis TB patients in low-and middle-income countries face expense equivalent to more than 50% of their annual income. On average, half of the costs are incurred before TB treatment has begun – in seeking diagnosis. Patients often have to resort to coping mechanisms that may be irreversible: –up to 75% of TB patients must take out a loan; –up to 50% sell household items; and –up to 66% rely on financial support from relatives. Addressing catastrophic patient cost is prerequisite for further advancing TB control

10. World Health Organization Regional Office for the Western Pacific Actions for improved case detection Contact investigation Children Household Workplace Contact investigation Children Household Workplace Clinical risk groups HIV Smokers Diabetics Previous TB Malnourished Drug abusers Clinical risk groups HIV Smokers Diabetics Previous TB Malnourished Drug abusers Risk populations Prisoners Urban poor dwellers Migrants Workplace (HCW) Elderly Risk populations Prisoners Urban poor dwellers Migrants Workplace (HCW) Elderly Active Case Finding (TB Screening) Minimizing physical, financial and social barriers Improved health communi- cation Engaging all care providers Improved diagnostic tools Patient pathway Symptoms recognized & patients take action Health care utilization Notification Infected Health services delay Access delay Patient delay Active TB TB Diagnosis TB Diagnosis Improved reporting system Regional Strategy to Stop TB in the Western Pacific (2011-2015), WHO WPRO Adapted and modified from “Action framework for higher and earlier TB case detection”, WHO

11. World Health Organization Regional Office for the Western Pacific TB high risk groups

12. World Health Organization Regional Office for the Western Pacific Mapping and prioritizing risk groups: Considerations in two dimensions TB high risk groups Increasing case detection Reducing transmission through early detection Mitigating institutional amplifiers Vulnerable and marginalized Targeted service provision to increase access to quality TB care Addressing health inequity Diabetes patients Tuberculosis risk Vulnerability / limited access to health care Smokers TB contacts PLHIV Prisoners Migrants Urban slum Elderly Remote areas Minorities Poor / malnourished

13. World Health Organization Regional Office for the Western Pacific Contact investigation Project  Policy in Philippines: –CATCH TB project in Metro Manila  informing CI policy –Policy on TB in children Viet Nam CI study –ACT1: Pilot in Hanoi completed –ACT2: A Nationwide intervention trial with periodic screening Community-based CI in Cambodia –2005-2011: experience in community based ACF among contacts and neighbours (adult and children) –Massive expansion 2012-2013 Enhanced CI in Mongolia –Piloting enhanced methods with home visit in 2013/2014

14. World Health Organization, Western Pacific Regional Office Cascade towards full implementation Global Policies Pilots Initiatives Country policies Scale up Experience Evidence Experience Evidence Documentation Evaluation Experience Evidence Experience Evidence Documentation Evaluation

15. World Health Organization, Western Pacific Regional Office Diabetes TB risk (relative to general pop) –Diabetes: 3.1 times higher TB risk –Dose response relation: poor control  higher TB risk Delayed sputum conversion, death during TB treatment, and relapse Cumulative hazards for active TB by diabetic status, among a cohort of clients (>65yrs) registered with an elderly health service in Hong Kong Leung, et al. 2008. "Diabetic control and risk of tuberculosis: a cohort study." Am J Epidemiol 167(12): 1486-1494. HbA1c >= 7%: annual incidence 422 per 100 000 No diabetes: annual incidence 214 per 100 000 DM prevalence*PAF** Cambodia4.2%8.1% China9.4%16.5% Lao6.2%11.5% Mongolia8.7%15.4% PNG13.3%21.8% Philippines5.8%10.9% Viet Nam6.9%12.7% * WHO Global Health Obserbertory, ** Population Attributable Fraction based on a relative risk of 3.1 for active TB among diabetics.

16. World Health Organization, Western Pacific Regional Office TB-DM collaborative framework Diabetes clinic TB DOTS clinic Case finding: Intensify detection of TB among DM patients Care delivery: Ensure TB infection control Ensure high quality TB treatment and management Outcome: Better control for DM by detecting and treating TB early Case finding: Intensify detection of TB among DM patients Care delivery: Ensure TB infection control Ensure high quality TB treatment and management Outcome: Better control for DM by detecting and treating TB early Case finding: Screen TB patients for diabetes Care delivery: Ensure high quality diabetes management Outcome: Better TB cure, less relapse by controlling DM Case finding: Screen TB patients for diabetes Care delivery: Ensure high quality diabetes management Outcome: Better TB cure, less relapse by controlling DM Effective Referral and coordination Establish mechanisms for collaboration (Stop TB, WHO WPRO, based on “Collaborative Framework for Care and Control of Tuberculosis and Diabetes”, WHO/IUATLD, 2011)

17. World Health Organization, Western Pacific Regional Office Migration: diverse populations, diverse issues Internal migrants Mainly rural to large cities Issues: access to services, care delivery Focus areas: Large cities and industrial areas Cross-border population movement Mostly economically driven (but inc refugees) Issues: legal issues (detention, repatriation), high-risk behaviours, health access and care delivery Focus areas: Mekong countries including China Floating population Homelessness, urban slums, mining communities, etc Issues: access to services, care delivery Focus areas: Large cities and development areas (mines, etc) Labour immigration Endemic to less endemic countries Issue: importation of infectious diseases, international referral, access to services Focus areas: Intermediate burden countries and areas Migration and TB (Stop TB, WHO WPRO)

18. World Health Organization, Western Pacific Regional Office Addressing TB among migrants WPRO’s TB & Migration Framework finalized in 2013 TB Elimination Framework now explicitly elaborate TB among migrants Various studies/supporting schemes in China (internal migrants) Cross-border project/information sharing (Lao PDR, Cambodia) Study on TB among foreigners (Malaysia) Hui Lu, Fei Yan, et al. WPSAR 2013Jiang SW, Li XX, et al. 2013

19. World Health Organization, Western Pacific Regional Office Progress in TB control in prisons Expansion of TB control in prisons and jails in Philippines Advanced ACF project in Palawan Visible reduction in TB burden in Mongolia (NTP Philippines) (NTP Mongolia) Global Fund (2005-) Joint Ministerial Order (2002-)

20. World Health Organization Regional Office for the Western Pacific Public-Private and Public-Public Mix inc Hospital Linkage PPM in general Steady progress in PPM in all countries in the Region Engaging hospitals What are expansion models after successful pilots in Viet Nam and Philippines Public health reform in China leading to increased roles of hospitals in China  Ensuring quality of care is continuous challenge

21. World Health Organization Regional Office for the Western Pacific National level coordination, planning and evaluation

22. World Health Organization, Western Pacific Regional Office National workshop on TB high risk and vulnerable populations Participants –All stakeholders: TB partners / Non-TB health programmes / Non-health sector partners Objectives: –Review global and in-country evidence; –Share experience of the work targeting TB high risk populations; –Discuss on potential areas of collaboration for improved access to TB services for TB high risk populations. Outcomes: –Strengthening and establishing partnerships (inc inter-ministerial discussion) –All partners’ effort harmonized under NTP

23. World Health Organization Regional Office for the Western Pacific What we can do for them? Don’t jump into ‘ACF only’ approach Information / communication Diagnosis Treatment Addressing the need  Group sensitive methods and contents  Campaign  Routine  Integrated screening (e.g. diabetes clinic)  Outreach (e.g. community-based)  Routine  Specific care delivery strategies  Specific enablers  Social support (welfare-link)

24. World Health Organization Regional Office for the Western Pacific Evaluation TB screening activities generating wealth of data Regular evaluation critical: –to assess TB burden among a target group –to make a rational decision on the continuation of the screening Still grave needs to expand global evidence base

25. World Health Organization Regional Office for the Western Pacific Contacts Prison Migrants Elderly Community-based Urban slum Diabetes Children

26. World Health Organization Regional Office for the Western Pacific

27. Summary Analysis of missing cases guide identification of priority actions –Patient pathway –Onion layer analysis Much progress made in addressing TB among high risk groups –At various stages in terms of policy, pilot, expansion cascade –Documentation and analysis critical to generate evidence to inform national and global policies Coordination and prioritization under NTP umbrella key for synergetic progress