TB or not TB? Strategy and Policy

1. TB or not TB? Strategy and Policy Grace Smith HPA Regional Centre for Mycobacteriology, West Midlands Public Health Laboratory, Birmingham Heartlands Hospital

2. GLOBAL STRATEGY TO STOP TB NICE STRATEGY for ENGLAND AND WALES CMO’s ACTION PLAN CONNECTING FOR HEALTH HPA TB PROGRAMME

3. Actions for Life - Towards aWorld Free of Tuberculosis:A focus on the global plan to stop TB 2006-2015 • On January 27th 2006, The Stop TB • Partnership launched its Global Plan to Stop TB • for 2006-2015. • The Plan requires $56 billion to • carry out its aims - less than $1 per day of • healthy life gained, with 14 million lives saved • by 2015. • With this money, the Plan aims to • halve deaths from TB in the next ten years and • provide treatment for 50 million people. • Ultimate aim of the Stop TB Partnership is to • eliminate TB as a global health problem by 2050

4. The First Global Plan:2001-2005 • Patients treated DOTS programmes being doubled over 5 years, from 2 million in 2000 to 4 million in 2004. • Improvement in case detection - both India and China, which account for 35% of the world's TB cases, are now close to the target of 70% case detection.

5. Global Plan to Stop TBfor 2006-2015. • Based on WHO's Stop Tuberculosis Strategy, builds on the 2001-2005 Plan. • Seeks to deliver more on the ground and emphasises the issues of HIV/TB co-infection and multi drug resistant TB through adapting the use of DOTS.

6. Global Plan to Stop TB for 2006-2015. Barriers • Increasing the accessibility of quality anti-TB drugs • Addressing the social burdens of the disease for patients. • Health services also need to be adequately resourced and committed to eliminating TB.

7. Global Plan to Stop TB for 2006-2015.Targets • More effective tools for fighting TB: • Diagnostic tests at the point of care by 2012 • A safe, effective and affordable vaccine by 2015 • a shorter treatment regime of 1-2 months by 2015. • The Global plan is available at the Stop TB Partnership Web Site: www.stoptb.org/globalplan/.

8. Meeting the Millennium Development Goal on TuberculosisHow will Britain Help Deliver on the Global Plan to Stop TB, 2006-2015? Key Challenges • Lack of funding for the plan, • Limited research • Inequitable access to new tools and diagnostics, • Lack of awareness of TB amongst the public, TB patients, parliamentarians, policy-makers and the media, • The additional burden of TB/HIV co-infection, • High levels of poverty • Poor health infrastructure and resources in the developing world. If the targets of the Global Plan are to be met, greater awareness of the Global TB epidemic and the Plan be is necessary alongside a three-fold increase in financial investment in TB control over the lifespan of the plan.

9. What should the UK be doing to ensure fulfilment of the Global Plan to StopTB, 2006 – 2015? • If the global plan to stop TB is to be met, • TB needs to be a far greater political priority in both the UK and the developing world. • This commitment should extend to long-term and sustained financing, • To the development of new tools and diagnostics, available for all, • To support for the strengthening of human resource capacity and health systems. • In addition there must be greater collaboration between the pharmaceutical industry and patients, civil society and the development of public-private partnerships if the ambitious targets of the Global Plan areto be met.

10. Stopping Tuberculosis in England An Action Plan from the Chief Medical Officer October 2004

11. The TB Programme goals Long-term goal is a reduction, and ultimately elimination, of tuberculosis in this country. Working towards this goal, the immediate aims of our national TB programme are to: • reduce the risk of people being newly infected with tuberculosis in England • provide high quality treatment and care for all people with TB • maintain low levels of drug resistance, particularly multidrug resistant (MDR) TB

12. Rising to the challenge:a can-do philosophy • In the United States of America (USA) tuberculosis re-emerged during the 1980s and early1990s. The disease was out of control. • With a clear plan, a national focus, and a build up of infrastructure and resources at local, state and national levels, the tide was turned. • Between 1992 and 2002, TB cases decreased by 45 per cent and rates of TB halved to five per 100,000 population, the lowest ever recorded. • Control of TB in this country can be achieved with a similar level of commitment to that shown in the USA.

13. In the short term the total number of new TB cases reported each year may rise because: • Firstly ,of infection acquired abroad • Secondly, of latent infection acquired in the past ,but reactivated with waning immunity • Thirdly, increasing size of some of the population groups most at risk

14. What will success look like? Within the next three years: • a progressive decline (of at least two per cent per year) in rates of TB in population groups born in England • a reduction in the incidence of disease among people who entered the country and became resident here within the previous five years • no more than seven per cent of new cases resistant to the anti-TB drug isoniazid and two per cent multidrug resistant • a reduction in the number of human cases of bovine (cattle) TB in people under the age of 35 years and born in the UK

15. Targets Evidence and experience show that TB control is likely to be achieved if: • all patients with suspected pulmonary TB are seen by the TB team within two weeks of first presentation to health care • at least 65 per cent of patients with pulmonary TB have the diagnosis confirmed by laboratory culture of the organism • all patients diagnosed with TB have the outcome of their treatment recorded, • and at least 85 per cent successfully complete their treatment

16. Recommended actions 1: Increased awareness 2: Strong commitment and leadership 3:High quality surveillance 4: Excellence in clinical care 5: Well organised and co-ordinated patient services 6: First class laboratory services 7: Highly effective disease control at population level 8: An expert workforce 9: Leading edge research 10: International partnership

17. Key DH and HPA groups involved in the implementation ofthe National TB Action Plan Department of Health Overall Strategy and Policy TB Action Plan Stakeholders Group TB Action Plan Steering Group Chair Dr David Harper HPA TB Programme Board Chair Prof Pete Boriello Working Groups-Fixed Term Strategy and Policy (Specific Issues) • Monitoring and Laboratory Standards Group • Dr Grace Smith • Commisioning Group • Prof Rod Griffiths • Delivery Group • Dr John Moore-Gillon Diagnostics and Molecular Epidemiolgy Forum (DAME) HPA Operational Groups,LaRS ,Surveillance Operational and Delivery Issues

18. NICE guidelinesClinical diagnosis and management of tuberculosis,and measures for its prevention and control March 2006 www.nice.org.uk. Key Priorities: • Managing Active TB • Improving Adherence • New Entrant Screening • BCG Vaccination

19. Diagnosing active TBRespiratory TB Take a chest X-ray – if this suggests TB, arrange further tests. ● Send at least three sputum samples (including one early morning sample) for culture and microscopy. ● Samples should be spontaneously produced if possible. If not possible: – in adults, use induction of sputum or bronchoscopy and lavage – in children, consider induction of sputum if it can be done safely, or gastric washings if not. ● Take samples before starting treatment if possible, or within 7 days of starting. ● Start treatment without waiting for culture results if the patient has clinical signs and symptoms of TB, and complete treatment even if culture results are negative. ● Send autopsy samples for culture if respiratory TB was a possibility.

20. Active non-respiratory TB ● Discuss the advantages and disadvantages of biopsy and needle aspiration with the patient. ● If non-respiratory TB is a possibility, place all or part of any of the following samples in a dry potand send for TB culture: – lymph node biopsy or pus aspirated from lymph nodes – pleural biopsy – any surgical or radiological sample sent for routine culture – histology, aspiration and autopsy samples. ● If the histology and clinical picture are consistent with TB, start the appropriate treatment regimen without waiting for culture results ● Continue drug treatment even if culture results are negative. ● Do a chest X-ray to check for coexisting respiratory TB in all patients with non-respiratory TB,and consider other investigations

21. Laboratory tests ● Use rapid diagnostic tests on primary specimens only if: – rapid confirmation of TB in a sputum smear-positive patient would alter their care, or – before conducting a large contact-tracing initiative. ● If clinical signs and other laboratory findings are consistent with TB meningitis, start treatment even if a rapid diagnostic test is negative. ● If a risk assessment suggests a patient has multidrug-resistant (MDR) TB: – do rapid diagnostic tests for rifampicin resistance – start infection control measures and treatment for MDR TB while waiting for the results

22. Tuberculosis Surveillance Developments

23. Tuberculosis Surveillance Developments Current Service collects and reports : • Notified cases • Laboratory reports of new isolates ,drug resistance and molecular typing profiles • Clinical reports • Outcome reports at 12 months

24. The HPA intends to create a new web-based system for TB surveillance within the next financial year: Improve the completeness, timeliness, accuracy and accessibility of epidemiological information on case reports (Enhanced Tuberculosis Surveillance) and laboratory results. Develop a mechanism for linking case reports and laboratory data so that they are available immediately at the local and regional levels and can be collated nationally in a timely and accurate manner. Link the national molecular typing database to routine surveillance so it can be used for public health purposes. Tuberculosis Surveillance Developments

25. Information for Action:Tuberculosis Strain Typing • Molecular typing methods introduced in all RCMs in last 2 years, using a common method and applied to all new clinical isolates pf Mtb. • National Microbial Typing Database for rapid comparison of strains is under development-. first phase of this project is approaching completion. • Both are initiatives of the HPA TB Diagnosis and Molecular Epidemiology (DAME) Working Group.

26. National projects that will ensure that NHS information systems support the clinical and public health activities required to deliver the National Action Plan for TB. National Knowledge Service Pilot on Tuberculosis Tuberculosis Do Once and Share Project. Connecting for Health:Initiatives in TB

27. Set up after the Kennedy Enquiry “To improve the level of information available to clinical staff and patients” Provides evidence-based best practice information to healthcare professionals through 'Map of Medicine' clinical algorithms. Pilot is tailored for those working with at risk population groups such as the homeless, and areas of professional or public concern such as TB in pregnancy. (www.hpa.org.uk/tbknowledge/) National Knowledge Service Pilot on Tuberculosis

28. >40 projects that will develop care pathways for specific diseases or conditions based on current best practice. Establish a National Community of Interest that will ensure that local, regional and national initiatives on TB, care pathways and information management are coordinated Stakeholders include clinical TB networks, Health Protection Units and also Department of Health Steering Group and working groups charged with delivering the National Action Plan for Tuberculosis. www.connectingforhealth.nhs.uk/delivery/serviceimplementation/kps/doas Tuberculosis Do Once and Share Project

29. POTENTIAL BARRIERS (Domestic) • Other initiatives in the NHS; “Choose and Book”, “Payment by results”, Pathology Modernisation, “Connecting for Health” • Wide variation in incidence of disease across the country. • Funding for new tests • Working across traditional boundaries.

30. Global Barriers • Increasing the accessibility of quality anti-TB drugs • Addressing the social burdens of the disease for patients. • Health services also need to be adequately resourced and committed to eliminating TB.