1. GLOBAL TB PROGRAMME Systematic screening for active TB – operational manual and tool to help prioritization Wolfheze 2015 Knut Lönnroth, Global TB Programme WHO 1

2. GLOBAL TB PROGRAMME Strong recommendations = Should be screened in all settings 1.Household contacts and other close contacts should be systematically screened for active TB. 2.People living with HIV should be systematically screened for active TB at each visit to a health facility. 3.Systematic screening for active TB should be done in current and former workers in workplaces with silica exposure 2

3. GLOBAL TB PROGRAMME Conditional recommendations = prioritization needed 4.Systematic screening for active TB should be considered in prisons and other penitentiary institutions. (including staff) 5.Systematic screening for active TB should be considered in people with untreated fibrotic CXR lesion. 6.In settings where the TB prevalence is ≥100/100,000 in the general population, systematic screening for active TB should be considered among people who are seeking care or who are in care and belong to selected risk groups (see remarks, including staff) 3

4. GLOBAL TB PROGRAMME Conditional recommendations, cont. 7.A. Systematic screening may be considered for geographically defined sub-populations with extremely high levels of undetected TB (>1% prevalence) B. Systematic screening may be considered also for other sub- populations with very poor health care access, such as urban slum dwellers, homeless people, people living remote areas with poor access, indigenous populations, migrants, and other vulnerable groups. 4

5. GLOBAL TB PROGRAMME Operational guide

6. GLOBAL TB PROGRAMME Planning & implementation cycle 1. Situation assessment / 6. Monitoring and evaluation 2. (Re-)Define goals and specific objectives 3. (Re-) prioritization of risk-groups 4. Choose screening and diagnostic algorithms 5. Planning, budgeting, implementation

7. GLOBAL TB PROGRAMME Tool for prioritization of risk groups (slides from Cecily Miller, UCSF)  Estimates the following for each risk group and each algorithm:  Case-finding yield (true and false positive)  Number needed to screen to detect one true case  Total cost  Cost per true case detected  Allows for comparison of estimates  Across risk groups  Across screening algorithms

8. GLOBAL TB PROGRAMME Step 1– Select the country  User begins by selecting the country for exploration:  Country selection auto-populates data on:  Total population size  TB prevalence per 100,000  HIV prevalence  Household size (when available) Cambodia

9. GLOBAL TB PROGRAMME Step 2 – Select risk groups PLHIV Contacts Miners Diabetics

10. GLOBAL TB PROGRAMME Step 3 – Estimating risk group size 2 ways to specify population size of each risk group: 1.Estimate size of risk group as % of country population (default) 2.Estimate absolute size of risk group PLHIV Contacts Miners Diabetics

11. GLOBAL TB PROGRAMME Step 4 – Estimating TB prevalence in each risk group 2 ways to specify TB prevalence within risk groups: 1.Enter or estimate relative risk of TB in risk group compared to general population (default) 2.Enter or estimate absolute TB prevalence per 100k PLHIV Contacts Miners Diabetics

12. GLOBAL TB PROGRAMME Step 5 – Reachability & acceptability Contacts PLHIV Miners Diabetics  Enter the % of the risk group expected to be reachable  Enter the % of the risk group expected to accept screening  Findings from acceptability systematic review pre-filled as suggested values

13. GLOBAL TB PROGRAMME Algorithms (default, with changeable values for sensitivity and specificity) 1a. Cough screen  Sputum smear microscopy 1b. Cough screen  Xpert 1c. Cough screen  CXR  Sputum smear microscopy 1d. Cough screen  CXR  Xpert 2a. Any symptom screen  Sputum smear microscopy 2b. Any symptom screen  Xpert 2c. Any symptom screen  CXR  Sputum smear microscopy 2d. Any symptom screen  CXR  Xpert 3a. CXR  Sputum smear microscopy 3b.CXR  Xpert Note: - Clinical diagnosis / empirical treatment not considered for persons negative on diagnostic test in current version - Culture can be included, by replacing Xpert assumptions

14. GLOBAL TB PROGRAMME Step 6 – costs  User estimates cost of per person screened: 1.Test cost 2.Operational cost

15. GLOBAL TB PROGRAMME https://wpro.shinyapps.io/screen_tb/

16. GLOBAL TB PROGRAMME Total potential yield

17. GLOBAL TB PROGRAMME

18. GLOBAL TB PROGRAMME No. of true and false positive cases Cough  smear microscopy Cough  CXR  Xpert CXR  Xpert Algorithm CXR  Xpert Cough  CXR  Xpert Cough  smear microscopy

19. GLOBAL TB PROGRAMME Costs per true case, across algorithms:

20. GLOBAL TB PROGRAMME Incremental cost-effectiveness

21. GLOBAL TB PROGRAMME Tool considerations & limitations  Focus on pulmonary TB (bacteriologically confirmable)  The tool is exploratory, not for detailed planning purposes  Tool estimates are based on several assumptions  The uncertainty of each estimate compounds the uncertainty of the overall estimates  Does not model the impact on transmission and TB incidence  Does not estimate patient cost (only provider)  Algorithm options developed mostly for low- and middle- income countries

22. GLOBAL TB PROGRAMME Thank you Acknowledgements Cecily Miller Nobu Nishikiori Anja van't Hoog Screening operational guide review committee https://wpro.shinyapps.io/screen_tb/ Send feedback to lonnrothk@who.intlonnrothk@who.int & nishikiorin@wpro.who.int. nishikiorin@wpro.who.int