World Tuberculosis Day

1. World Tuberculosis Day The London TB Plan Event #LondonTBplan

2. Key TB functions and efforts of WHO Haileyesus Getahun Stop TB Department WHO/HQ, Geneva.

3. WHO core functions in global TB control • Provide global leadership • Development of policy, norms and standards • 3. Technical support and coordination • Monitoring and evaluation • Promoting research • 6. Facilitate partnerships

4. Impact of WHO policies (1995 - 2010) • DOTS/Stop TB strategy • 46 million people treated • 7 million total lives saved • 0.23 - 0.28 million child lives saved • 1.5 million women saved • TB/HIV activities: saved 1 million lives (2005-2010) TB/HIV lives saved

5. NGOs for Community based TB activities Global Country National guidance M and E system Training manual NGOs supported NGOs provided TA • Operational policy guidance • Define standard indicators • Implementation manual • Training manual • Advocacy and visibility WHO’s new area of work

6. Resource mobilisation DR Congo, Ethiopia, Kenya, South Africa, Tanzania

7. Urban Tuberculosis Control in the European Union World Tuberculosis Day, 2012 Tuberculosis ProgrammeEuropean Centre for Disease Prevention and Control Stockholm, Sweden, 19 March, 2012

8. From surveillance to public health action

9. From surveillance to public health action –ECDC’s added value Action Plan and Monitoring Framework RAISE AWARENESS Surveillance and Monitoring – Identifying and assessing needs Public Health Action

10. The epidemiological patterns of TB are heterogeneous within EU

11. The epidemiological patterns of TB are heterogeneous within EU 100.0 EU/EEA 2010 14.6/100,000 80.0 60.0 40.0 20.0 0.0 Italy Malta Spain Latvia France Poland Austria Cyprus Greece Ireland Finland Estonia Iceland Norway Sweden Belgium Bulgaria Slovakia Portugal Slovenia Hungary Romania Germany Lithuania Denmark Netherlands Luxembourg Czech Republic United kingdom Source: Surveillance report, TB Surveillance and Monitoring in Europe 2012 (2010 data)

12. Pattern of TB situation in big cities differs across the EU Figure 1: TB notification rates in a selection of countries and big cities of EU/EEA, in 2009. < 20 cases per 100,000 population ≥ 20 cases per 100,000 population Riga / Latvia 43.0 / 43.2 Copenhagen / Denmark 16.9 / 6.0 Vilnius / Lithuania Rotterdam / Netherlands 31.9 / 62.1 21.3 / 7.0 London / United Kingdom Warsaw / Poland 44.4 / 14.8 17.8 / 21.6 Paris / France 23.4 / 8.2 Bucharest / Romania 81.0 / 108.2 Milan / Italy 33.2 / 6.5 Sofia / Bulgaria 31.9 / 38.3 Barcelona / Spain 24.3 / 16.6 Disclaimer: Survey performed by the Metropolitan TB network, www.metropolitantb.org Please note that ECDC does not collect city-level TB surveillance data and take no responsibility for accuracy of data collected for this survey.

13. Pattern of TB situation in big cities differs across the EU Low-incidence countries TB case load appears to accumulate disproportionately to big cities. 2-5 times higher notification rates in big cities compared to the country overall. High-incidence countries TB case load appears more generalised in the population and evenly distributed in the country. Equal or lower notification rates in big cities compared to the country overall. Two different epidemiological settings

14. Accumulation of TB among vulnerable groups in urban settings

15. Accumulation of TB among vulnerable groups • TB disproportionately affects the socially and economically disadvantaged

16. Vulnerable groups in urban settings • High-risk groups • Refugees, asylum seekers, migrants • Homeless people • Prisoners • Illicit drug users • Alcoholics • HIV-seropositive people • Other vulnerable groups • Children • Elderly • Characteristics of urban settings • High population density • Complex social structure The most vulnerable and excluded groups carry the most significant burden of disease and have the poorest access to services. Interaction between individual risk factors and urban characteristics create specific opportunities for TB transmission

17. Reaching out to vulnerable groups in urban settings

18. Providing guidance, advocate and monitorECDC’s added value • Action and outputs from ECDC of relevance for urban TB control European Union Guidance Support Advocacy

19. Reaching out to vulnerable groups in urban settings • Going beyond standard public health strategies • Every patient’s right. • Novel interventions. • Collaborate between cities. • Share best practices. Working together to eliminate TB in the EU

20. Contact the ECDC TB Programme http://ecdc.europa.eu

21. TB - the factsThe epidemiology of TB in Londonand the need for change Dr Sarah Anderson HPA Regional Epidemiologist - London sarah.anderson@hpa.org.uk 22nd March 2012

22. TB in London – 2011 • 3588 cases • 46 per 100,000 population(c.f. nationally 13.6) • 3 times national rate, some boroughs 10x • 42% of national burden • Case numbers doubled in 15 yrs • 85% cases non-UK born • More than one in ten have ≥1 social risk factor, with high case loads of complex patients in some areas

23. TB rates in London, 1982-2010

24. TB rate by sector of residence, 2004 – 2011

25. TB case rates by PCT of residence, 2011 Newham – 158 /100,000 Brent – 123 /100,000

26. Treatment completion among TB cases reported in 2010 85% Rx completion target 2010 84% completion

27. Treatment • comprises anti-TB drugs for at least six months • occasionally causes unpleasant side effects • completion essential - but variable completion rates • development of drug resistant TB means using more specialist anti-TB drugs with more side effects, worse outcomes and greater cost

28. TB drug resistance, 2010 8.4% INH-R 1.6% MDR Almost 1 in ten culture confirmed cases resistant

29. Case for Change - TB in London TB is an infectious disease that is treatable and curable however it remains a major public health issue The number of TB cases has increased by 50% over the last ten years and more than doubled over the last 20 years In 2010, more cases of TB diagnosed in London than HIV TB rates vary widely across the capital

30. Key issues for TB

31. Current service provision 5 TB networks across London with variability in commissioning, service planning, protocols and education Service resources, capacity and delivery does not align with TB rates Poor awareness of TB among health professionals Variable uptake and administration of neonatal vaccination

32. Case for Change The ‘Case for change’ document • provides the evidence to support the need for change and • highlights the risks for London if these problems are not addressed: • further fragmentation in TB services • varied quality of care for patients • increased rates of active, latent and drug resistant TB • greater cost to the system for TB services and treatment for patients Development of ‘Model of Care’ to address the TB problem in London with the ultimate goal of reducing rates of TB in London

33. The London Model of Care Dr William Lynn Clinical Lead, TB project London Health Programmes 2012

35. Background to the model Developed by the TB community involving nurses, consultants, GPs, the Health Protection Agency and TB networks and overseen by both a clinical working group and project board with strong public health expertise and service user representation Stakeholder events along with meetings, national and public media, 1:1 interviews Over 200 individuals provided feedback including GPs, patients, voluntary and community organisations, public health and government committees There was widespread support for the plans

36. Model of Care • Recommendations in the model are targeted at three aspects of the patient pathway: • Improving detection and diagnosis of the disease • Better coordinated commissioning • Addressing variability of provision

37. Improving detection and diagnosis Raise awareness in communities with higher rates of TB disease Raise awareness and knowledge of TB among health and social care workers Explore the potential of active and latent TB case finding focusing on new registrations in primary care - to pilot in specific area(s) for first year

38. Improving the commissioning of TB services Develop a London TB Commissioning Board to address current system fragmentation The board would bring together the functions of health care commissioning, health protection and public health to ensure a co-ordinated, multi-agency approach to TB control Robust commissioning of TB services will include sound planning, standard setting and strong performance management

39. Improving the commissioning of TB services • Continue to commission the Find and Treat service to work with hard to reach groups in the community • Streamline funding process for patients with no recourse to public funds • Ensure three levels of service provision • Level 1 - Generic primary and community care • Level 2 - Recognised TB services • Level 3 - Specialist TB services

40. Variability of service provision Encourage providers of TB services to work together as delivery boards that mirror current networks to maintain strong clinical relationships and referral patterns Delivery boards will ensure standardised pathways and protocols are developed to promote consistent, high quality care for patients Workforce development group will ensure appropriate skill mix and best value for money is achieved.

41. Financial considerations – costs • Annual NHS spend on healthcare in London £13.9billion • Annual spend on TB in London £18-20 million • Annual costs of the TB plan £7.2 million • Including additional diagnostic and treatment costs from active case finding

42. Financial considerations – savings Cost of TB Treatment Case Finding vs. Do Nothing

43. Next steps and challenges • Commissioning • current PCT clusters, CCGs and proposed CSSs • Addressing variability • Cohort review • Pan-London protocols • Established commissioning intentions • Case finding pilot(s) • Implementation and evaluation

44. Session One Q&A Dr Emma Huitric Sarah Anderson Dr William Lynn

45. TB screening in primary care: can we move forward? Chris Griffiths, QMUL

46. Figure 1: London TB rate per 100,000* population by sector of residence – reported to the London TB Register * Rates based upon 2010 ONS PCT population estimates

47. Screening for TB in primary careDo we meet the criteria? • Condition • Important health problem, epidemiology understood • Test • Simple, safe, acceptable, precise, clear policy on managing positive results • Treatment • Effective treatment • Screening programme • High quality trials, complete screening programme needs to be clinically and socially acceptable, with benefits outweighing harms, monitoring in place

49. TB Notification rates East LondonSource: HPA 2011 Screening programme