Where do we go from here?

1. Where do we go from here? Philip Hopewell, MD Curry International Tuberculosis Center University of California San Francisco

2. New York Times, March 20, 2018 ‘We’re Losing the Fight’: Tuberculosis Batters a Venezuela in Crisis

3. Recent findings and events • Data from recent TB prevalence surveys • Examinations of the cascade of TB care • Detailed national and sub-national descriptions of pathways to care • Shorter, effective regimens for LTBI • Ministerial meeting on TB • UN General Assembly meeting on TB

4. Recent national TB prevalence surveys in Asia and Africa WHO Global Tuberculosis Programme Katherine Floyd, Philippe Glaziou, Irwin Law, IkushiOnozaki, BabisSismanidis

5. Surveys 1990–2017 Completed (16*) *since Task Force subgroup active Field operations completed, analysis ongoing (1) Field operations ongoing (3) Planned (8) • 27 surveys between 2009 and 2015/16 • 20/22 global focus countries(not Mali or Sierra Leone) • + 7 more: Lao PDR, Gambia, Sudan, Zimbabwe, Mongolia, DPR Korea, Nepal

6. Consistent methods since 2009 HIV test offered in most African surveys *Since 2013: + rapid molecular test for at least: 1. All smear-positive specimens; 2. Smear-negative specimens if culture failed

7. Lessons from prevalence surveys • TB is more prevalent than we have thought. • Cough is an insensitive indicator of TB. • Microscopy is only 40-50% sensitive (compared with culture). • False-positive smears are common. • Many cases are treated in the private sector. • Many “smear positive cases” cannot be confirmed by culture. (Is problem with smear or with culture?)

8. Case notification gap 4 million “missing” cases WHO Global TB Report 2017

9. Estimated TB prevalence before and after prevalence surveys WHO Global TB Report 2017

10. Incidence estimates before and after surveys 2012-2015 WHO Global TB report 2016

11. Kenya Releases Results of National TB Prevalence Survey: March 24, 2017 NAIROBI —  Kenya on Friday recognized World Tuberculosis Day by releasing results of a TB study by the country's ministry of health — the first of its kind since Kenya's independence. TB remains high in Kenya, and experts say the country lags in the fight against the disease. The report states that there are more TB cases in Kenya than previously estimated, with a TB prevalence of 558 per 100,000 people.

12. Prevalence survey, Kenya Translates to approx. 138,105 incident cases/year compared with 82,000 reported 2015 (40% missing)

13. Many prevalent cases don’t report cough

14. Sensitivity of microscopy 60% Kenya 32% Range ~30-60% sensitivity

15. False-positive smears are common

16. Cascade of Care: India -28% -12% -7% -5% -6%

17. 13-Country Patient Pathway Summary 6. Location of Notification (Among Estimated Burden) 7. Treatment Outcomes (Among Estimated Burden) 2. Coverage of Microscopy Among Health Facilities 3. Access to Microscopy at Initial Care Seeking 4. Coverage of Treatment Among Health Facilities 5. Access to Treatment at Initial Care Seeking 1. Initial General Care Seeking Patterns Sector Level 43% Missing 43% Missing 21% Informal Private Sector 21% L0 L0 0% L0 0% 90% L3 40% Private Sector 12% L2 29% 42% Patients may iterate through the diagnosis pathway multiple time before being initiated on treatment. 20% L1 7% Tx Not Succes. 5% Private 23% 19% 52% Public Sector 48% TxSucces. 7% L0 4% 2% L3 39% Public Sector 88% 89% 15% L2 7% Private 10% Private 71% 69% 23% Public Sector 17% L1 19% Public Sector 67% 43% 8% L0 L0 L0 2% 10% DRAFT VERSION 1.0

18. Where do we go from here? (1) • Fix the front end of the care cascade (access and diagnostic capacity) • Strengthen primary care services • Align services with care seeking patterns • Fully engage the private sector • Purchase, deploy, and fully utilize rapid molecular testing that includes drug susceptibility testing (at least RIF) • Hold the health care system to a high standard • Integrated view of public and private as part of overall system • Integration of TB services into primary and referral levels of care • Improve information systems • Apply performance criteria to all

19. Criteria for assessment of health system/facility performance • Access and responsiveness • Availability • Timeliness of services • Hospitality • Quality • Comprehensiveness • Accuracy • Adherence to standards • Outcomes • Treatment success • Coverage • Morbidity/mortality • Accountability, transparency, regulation • Data accessibility and quality • Public health functions • Reform capacity • Fairness and equity • Financial barriers to care • Availability commensurate with need • Efficiency • Cost • Redundancy • Fragmentation • Delays Basu S, et al. Comparative Performance of Private and Public Healthcare Systems in Low- and Middle- Income Countries: A Systematic Review. PLoS Med 9(6): e1001244. doi:10.1371/journal.pmed.1001244

20. Where do we go from here? (2) • Improved approaches to case-finding and prevention • Identification of high risk populations for screening • Utilize more sensitive screening tests and algorithms • Chest radiography (digital radiography) • CRP followed by radiograph or rapid molecular test • Begin implementation of treatment for LTBI in persons with high risk of TB • 12 dose INH/rifapentine • 30 day INH/rifapentine

21. Individual and community-centered care AA Information systems Universal coverage Access Social protection Technical assistance Ending TB Funding Quality Multi-stakeholder involvement Innovation Accountability Equity, rights Leadership