Dr. Mao Tan Eang, NTP Director National Center for TB and Leprosy Control, Cambodia

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

2. Contents • TB situation in Cambodia • Rationale for screening risk groups • Process of prioritizing risk groups • Choice of screening algorithms • Outcomes of screening

3. 1. TB situation in Cambodia

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

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

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

7. 2. RATIONALE FOR SCREENING RISK GROUPS

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

9. Analysis and actions for improved case detection Analysis of TB patient pathway Minimizing physical, financial and social barriers Symptoms recognized & patients take action Health care utilization Engaging all care providers Access delay Patient pathway Improved health communi-cation Improved diagnostic algorithms and tools Health services delay Patient delay Active TB TB Diagnosis Active case finding strategies • Contact investigation • Children • Other risk groups • All household • Workplace • Clinical risk groups • HIV • Previous TB • Malnourished • Smokers • Diabetics • Drug abusers • Risk populations • Prisons • Urban poor settlements • Migrants • Workplace (HCW) • Elderly Improved reporting system Infected Notification

10. 3. PROCESS OF PRIORITIZING RISK GROUPS

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

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

14. 4. Choice of screening and diagnostic algorithms

15. Screening + diagnostic algorithm(CENAT-TB REACH project) • Using provider-driven active case finding

16. Screening + diagnostic algorithm(CENAT-Global Fund in geo-targeted areas) • Using community-driven fast track mechanism • Using provider-driven enhanced case finding • Planned to be conducted from 2015 using NFM budget

17. 5. Outcomes of screening

18. Results for last two years(CENAT-TB REACH project) 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)

20. 1 year budget (for 2.8m population)(CENAT-TB REACH project) Source: Cost-effectiveness of a TB active case finding in Cambodia. Am. J. Trop. Med. Hyg., 2014.

21. Implementation in pictures CENAT-TB REACH Project

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

27. Thanks for Your Attention 27