1. Screening for TB among risk groups in Cambodia Dr. Mao Tan Eang, NTP Director National Center for TB and Leprosy Control, Cambodia TAG Meeting, 9-12 December 2014 Manila

2. Contents 1.TB situation in Cambodia 2.Rationale for screening risk groups 3.Process of prioritizing risk groups 4.Choice of screening algorithms 5.Outcomes of screening 2

3. 1. TB SITUATION IN C AMBODIA 3

4. TB situation in Cambodia (2012) Total population: 14.96 million Among the 22 high burden countries for TB Prevalence of all forms: 764 / 100,000 pop ( decline from 1670 in 1990 to 764/100,000 pop in 2012) Incidence of all forms: 411 / 100,000 pop Death rate: 63 / 100,000 pop ( decline from 157 in 1990 to 63/100,000 pop in 2012) MDG goals (prevalence, death) achieved since 2011 Prevalence declining by about 5% per year HIV prevalence among adult population 0.7% in 2013 4

5. TB Case Notification, 1982-2013 DOTS expansion to HC started in 2001

6. Incidence-notification gap 6 1/3 rd missing cases Incidence declined around 3.2% per year between 2000 and 2012 Impact of DOTS expansion to HC, started in 2001

7. 2. RATIONALE FOR SCREENING RISK GROUPS 7

8. Rationale for active screening of risk groups Case-finding has plateaued in Cambodia Epidemic is concentrating in high risk groups The country needs to maximize its resources High risk groups are the most vulnerable and hard-to-reach To complement passing case finding Passive vs Active? ACF is kind of provider pushed to create demand Systematic screening helps find the missing cases 8

9. Contact investigation Children Other risk groups All household Workplace Contact investigation Children Other risk groups All household Workplace Clinical risk groups HIV Previous TB Malnourished Smokers Diabetics Drug abusers Clinical risk groups HIV Previous TB Malnourished Smokers Diabetics Drug abusers Risk populations Prisons Urban poor settlements Migrants Workplace (HCW) Elderly Risk populations Prisons Urban poor settlements Migrants Workplace (HCW) Elderly Active case finding strategies Minimizing physical, financial and social barriers Improved health communi- cation Engaging all care providers Improved diagnostic algorithms and 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 Analysis and actions for improved case detection Analysis of TB patient pathway

10. 3. PROCESS OF PRIORITIZING RISK GROUPS 10

11. 11 Step 1: Select “high poverty + low case notification” areas This is called “geo-targeting”.

12. Step 2: Target risk groups in geo-targeted areas of the country Community-based mechanisms Contacts of known smear positive TB People who are 55+ years old Institution-based mechanisms People living with HIV Diabetics who are attending diabetic clinics Prison inmates and detained migrants 12

13. Major highest risk groups for TB in Cambodia 1.Contacts (pop size~ 120,000) 2.Elderly (pop size~ 900,000) 3.PLHIV (pop size~ 70,000) 4.Prison inmates (pop size~ 20,000) 5.Diabetics (pop size~ 700,000) 13

14. 4. C HOICE OF SCREENING AND DIAGNOSTIC ALGORITHMS 14

15. Screening + diagnostic algorithm (CENAT-TB REACH project) High risk groups screened for four TB symptoms If any one of four symptoms for >2 weeks, Xray Xray positives undergo Xpert testing Xpert negatives undergo clinical evaluation 15 Using provider-driven active case finding

16. Screening + diagnostic algorithm (CENAT-Global Fund in geo-targeted areas) Highest risk groups screened for four TB symptoms If any one of four symptoms >2 weeks, Xpert Xpert negatives undergo clinical evaluation 16 Using community-driven fast track mechanism Using provider-driven enhanced case finding Planned to be conducted from 2015 using NFM budget

17. 5. O UTCOMES OF SCREENING 17

18. Results for last two years (CENAT-TB REACH project) Smear positive index cases 13,882 Symptomatic contacts screened with Xrays 74,098 Xray positive tested with Xpert 7,603 Xpert positive 1,745 All forms 3,727 18 Number screened to get 1 bacteriologically positive case (NNS) = 42 Number screened to get 1 cases (NNS) ( all forms)= 20

19. Contributions and cost of systematic screening Currently, systematic screening contributes to 7-10% of all case notifications in Cambodia But, if it is organized in larger scale, it may have a contribution up to 25 % or more of total cases notified Systematic screening is cost effective at least in high prevalence country like Cambodia (for CENAT-TB-REACH,cost per case detected for all forms was around USD 182, excluding drugs) 19

20. 1 year budget (for 2.8m population) (CENAT-TB REACH project) CategoryEconomic cost % Training$9,5003% Salaries for core staff$24,5007% Capital equipment$64,30218% Consumables$93,02926% Per diems$138,79238% Transport$18,0005% Enablers$15,1334% Total economic cost$363,257100% 20 Source: Cost-effectiveness of a TB active case finding in Cambodia. Am. J. Trop. Med. Hyg., 2014.

21. I MPLEMENTATION IN PICTURES 21 CENAT-TB REACH P ROJECT

22. Preparation visits (10 to 15 days before field operation) Transportations to the sites ACF field operation

23. Reception (registration) Conduct interview (Re-screening TB symptoms

24. CXR taking and film developing TB screening and diagnosis by CXR (Xray reading on spot)

25. TB suspects examined by Xpert for TB

26. Conclusion/ Lessons learned ACF activities in small scale has been conducted in Cambodia since 2005;larger scale activities just started since 2012 (20 to 25 ODs out of total 82) Diagnostic algorithms has been revised with major improvement, especially multiple symptom approach( cough, fever, night sweats, weigh loss, lymph note ) not just cough, and plus Xray together with Xpert MTB/RIF Active case finding complement routine service case finding with good contribution; in Cambodia if we have more resources to conduct ACF,contribution to cases notified could be up to 25% or more Without ACF the new and more ambitious global TB target may not be reached, we need ACF to help passing cases finding ACF is cost-effective at least in high TB burden settings or groups ACF maybe less cost-effective in less prevalent settings Number needed to screen to get one case is very important

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