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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. Latest global TB estimates and notification - 2008.

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Addressing poverty through quality tb control and research
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


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%)


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+


What policy analysis of missing cases
What policy?Analysis of missing cases



The philippines increase in case detection in ppm implementation areas
The Philippines: increase in case detection in PPM implementation areas

14%

11%

11%

7%

Courtesy: PhilCAT


Increasing access

Increasing access implementation areas


Analysis of the pathway, and risk of delay implementation areas

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


OPD attendees implementation areas

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


Symptom screening alone may not work
Symptom screening alone implementation areas 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?


Early case detection time to consider targeted active case finding

"Early" case detection: implementation areas time to consider targeted active case finding?


Contact investigation what does the literature tell us
Contact investigation: what does the literature tell us? implementation areas

  • 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.


What are the estimates
What are the estimates? implementation areas

  • 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.



Analysis of the pathway, and risk of delay implementation areas

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



Entry points for analyses
Entry points for analyses: implementation areas

  • 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


Policies what can be implemented
Policies: implementation areas what can be implemented?

* Reacheable populations and feasible: country specific

0=unfeasible, 1=very difficult, 2=somewhat difficult, 3=relatively easy


Policies what can be implemented1
Policies: implementation areas what can be implemented?

* Reacheable populations and feasible: country specific

0=unfeasible, 1=very difficult, 2=somewhat difficult, 3=relatively easy


Conclusion interventions for early and increased case finding
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


Conclusions
Conclusions finding

  • 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


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