Addressing poverty through quality TB control and research

1. Addressing poverty through quality TB control and research 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

2. Latest global TB estimates and notification - 2008 Estimated number of cases Cases reported DOTS All forms of TB Greatest number of cases in Asia; greatest rates per capita in Africa 9.4 million (8.9 – 9.9) 5.7 million (80 per 100,000) 4.3 million 2.6 million (61%) New Smear positive Multidrug-resistant TB (MDR-TB) 30,000 500,000 HIV-associated TB 1.4 million (15%)

3. Decelerated case detection trend 100% (?) 40% ss- / EP 95% MDR Children? Women/men? Vulnerable? -HIV? -poor? -migrants? -contacts? -smokers? -diabetics? -alcoholics? -infants? Gap: 40% sm+

4. What policy?Analysis of missing cases

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

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

7. Increasing access

8. Analysis of the pathway, and risk of delay DOTS / MDR-TB Expansion Community engagement HSS ACSM TB/Poverty HR PPM TB/HIV Minimize access barriers Effective TB screening in health services and on broader indication Pediatr. TB Health education PAL Lab str. Symptoms recognised Access delay Health care utilisation Improve diagnostic quality, new tools Patient delay Health services delay Active case finding Active TB Diagnosis Improve referral and notification systems Infected Notification New diagnostic tools TB determinants Infection control TB/HIV

9. OPD attendees 30% 70% Chest symptoms Non-chest symptoms 90% 10% Person with persistent cough (cough>=2wks) Acute respiratory symptoms (PAL services) Option: CXR for screeningabnormality  Smear exam Point of care diagnosis Smear examination 90% 10% Negative Positive Positive Negative TB Comprehensive care (inc. TB diagnosis)Monitoring of TB occurrence among CRD (PAL services) TB PAL services

10. Symptom screening alone may not work • Vietnam prevalence survey 2006-07: • 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?

11. "Early" case detection: time to consider targeted active case finding?

12. 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.

15. 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.

16. Which groups to target for active case finding?

17. Analysis of the pathway, and risk of delay DOTS / MDR-TB Expansion Community engagement HSS ACSM TB/Poverty HR PPM TB/HIV Minimize access barriers Effective TB screening in health services and on broader indication Pediatr. TB Health education PAL Lab str. Symptoms recognised Access delay Health care utilisation Improve diagnostic quality, new tools Patient delay Health services delay Active case finding Active TB Diagnosis Improve referral and notification systems Infected Notification New diagnostic tools TB determinants Infection control TB/HIV

18. Approaches to analyses and prioritization

19. 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

20. Policies: what can be implemented? * Reacheable populations and feasible: country specific 0=unfeasible, 1=very difficult, 2=somewhat difficult, 3=relatively easy

21. Policies: what can be implemented? * Reacheable populations and feasible: country specific 0=unfeasible, 1=very difficult, 2=somewhat difficult, 3=relatively easy

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

23. 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