Framework for improved, early case detection

Knut Lönnroth

DEWG meeting

October 2009

Decelerated case detection trend Gap:

37% ss+

50% ss- / EP

97% MDR

Children?

Women/men?

Vulnerable? -HIV?

-poor?

-migrants?

-contacts?

-smokers?

-diabetics?

-alcoholics?

-infants?

-

10

20

30

40

50

60

70

80

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

case

det

ecti

on

rat

e (%

)

DOTS sm+

All sm+

100% (?)

Early case detection

Source: Dye C. Int J Tuberc Lung Dis

2000; 4(12):S146–S152

Shorten delay from onset of infectiousness to start of treatment to average 2 month, and get 30% annual reduction in TB incidence (in theory)

How to shorten delay?

• Optimize diagnostic approaches – lab strengthening, better X-ray diagnosis, new tools, etc

• Identify and involve the health providers people go to first – PPM concept

• Communication strategy to improve health seeking

• Reduce access barriers, especially for vulnerable groups, and improve health systems - Universal access!

• But will this be enough?

Who is a "TB suspect"?• Vietnam prevalence survey 2006-07:

– 23% of new smear positive case reported no symptoms– 47% did not have symptoms corresponding to "TB suspect"

definition

• Cambodia prevalence survey, 2002– 15% of bacteriologically confirmed cases had no symptoms– 61% did not have symptoms corresponding to "TB suspect"

definition

• Zambia prevalence survey, 2005:– 35% of bacteriologically confirmed cases had no cough– 57% of bacteriologically confirmed cases did not fulfil "TB

suspect" definition

• Review of risk factors: contacts, HIV, smokers, diabetics, alcoholics, elderly, infants, previously treated: – all are suspects?

Consequences• More active "passive" case finding: Screening

question for "chronic coughers" in health facilities maybe insufficient: expand the diagnostic algorithm and consider "clinical" risk

groups (HIV, diabetes, smokers, alcoholics, malnourished, previously treated, infants, elderly)?

• But, many will not be detected, or detected late, if waiting for them to seek care: active screening of risk populations outside health services

(contacts, slums dwellers, migrants, prisons, homeless, etc)?

• Feasible and cost-effective?

• Will new diagnostic tools make it more feasible?

• Where is it relevant to start now?

WARNING:

Before moving ahead with new things:

- don't forget the basics!

- get the evidence right!

How to assess the country-specific needs?

Analysis of missing cases

Active TB

Symptoms recognised

Health care utilisation

Diagnosis

Notification

Health education

Improve referral and notification

systems

Improve diagnostic

quality, new tools

Infected

Patie

nt d

elay

Health services delay

Access delay

Effective TB screening in health services and on

broader indication

ACSMDOTS / MDR-TB

Expansion

HR

PAL

Lab str.

HSSCommunity engagement

Contact investig-Children

-Other risk groups

-All household

-Workplace

-Wider

Clinical risk groups-HIV

-Previous TB

-Malnourished

-Smokers

-Diabetics

-Drug abusers

Risk populations-Prisons

-Urban slums

-Poor areas

-Migrants

-Workplace

-Elderly

TB/HIV

Pediatr. TB

TB determinants

TB/HIV Infection control

Analysis of the pathway, and risk of delay

Active case finding

TB/Poverty

Minimize access barriers

New diagnostic tools

PPM

Other entry points for analyses:

• By provider: PPM Situational analysis tool

• By geographical area: assess routine programme data, OR, prevalence surveys

• By risk group: mapping of risk populations and risk factors

• Exercise 1 for this meeting: draft set of key questions cutting across all above

Exercise 1: AssessQuestions Answer

• Burden of TB, what are the trends, • Geographical difference within the country? • Is the country moving towards TB elimination? • Concentrated to certain risk populations only?

• Case detection gap, in different subgroups?

• Treatment delay?

• Geographical coverage of the NTP?• Cover essential parts of the health system, and all important health providers?

• Quality and outreach of diagnostic services?

• Screening people with HIV for TB? • Screening other "clinical risk groups":diabetes, smoking, alcoholics, malnourished, etc?

• Contact investigation?• Active screening for TB of other risk populations (slums, migrants, prisons, etc)?

• Main access barriers? • Weaknesses of the general health system that hampers access to quality TB services?

• Knowledge and attitudes towards TB and NTP? • Stigma?

How to prioritise?

Exercise 2: Prioritize (among 17 listed action)

Importance

0=not relevant in the setting

1=somewhat important

2=Important

3= Critical

Implementation gap

0=Sufficiently implemented

1=In place, but further scale up required

2=Limited implementation

3=Not implemented

Priority Score

Multiply values in column 2 and 3

Top five priorities for further action

Scoring should take into account cost and feasibility

Mark only the five most important actions, rank them from 1-5

Add comments, as required, both for prioritized and non-prioritized actions

ThailandImpo-rtance

Imple-mentati-on gap

Prio-rity

score

Top 5 priorities

Geographical DOTS coverage 3 1 3

Basic lab network of good quality 3 1 3

Culture / DST services 3 1 3

High quality diagnosis of EP TB 2 3 6 2

High quality diagnosis of TB in children

3 3 9 3 (High score, but need to cooperation with other sectors)

Screen people living with HIV 3 1 3

Screen other clinical risk groups, e.g. diabetics, alcoholics, etc

2 1 2

Access barriers, especially for the poor and vulnerable

2 1 2

Engage all health care providers 3 2 6 1 (Critical to complete scale up academia and private)

Health communication and social mobilization

3 1 3

Exercise for DEWG 2009Average priority score

October 2009, 19 countries

0.0

1.0

2.0

3.0

4.0

5.0

6.0

New t

ools.

Cultu

re

Conta

ct in

vest

igatio

n

TB in ch

ildre

n

Acces

s ba

rrier

s

Scree

n HIV

High

risk

popu

latio

nsPPM

PAL

Basic

lab

netw

ork

Oth

er ri

sk g

roup

s

ACSMHSS

Diagn

ostic

algo

rithm

Diagn

osis

of EPTB

Existin

g diag

nostic

alg

orith

m

DOTS

cove

rage

Ave

rage

sco

re (

impo

rtan

ce x

impl

emen

tatio

n ga

p)

Priority, importance, implementation gap

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

New t

ools.

Cultur

e

Conta

ct inv

estig

ation

TB in c

hildr

en

Acces

s bar

riers

Scree

n HIV

High ri

sk p

opul

ation

sPPM

PAL

Basic

lab n

etwor

k

Other

risk

gro

ups

ACSMHSS

Diagno

stic a

lgorit

hm

Diagno

sis o

f EPTB

Existin

g di

agno

stic

algor

ithm

DOTS cov

erag

eImpo

rtan

ce a

nd im

plem

enta

tion

gap

(low

impl

emen

tatio

n =

high

sco

re)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

Prio

rity

scor

e (im

port

ance

* im

plem

enta

tion

gap)

Importance

Implementation gap

Priority

When considering feasibilityPriority score vs. listed among top 5 priorities

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

New

tools.

Culture

TB

in children

Contact investigation

Access barriers

Screen H

IV

High risk populations

PP

M

PA

L

Basic lab netw

ork

AC

SM

Other risk groups

HS

S

Diagnostic algorithm

Diagnosis of E

PT

B

Exist diagn algor

DO

TS

coverageP

riorit

y sc

ore

and

coun

t in

14 c

ount

ries

Priority scoreAmong the top 5 priorities after considering feasibility (14 countries)

Conclusions

• 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, TA yet others, just political commitment

• Still lot of work required to develop framework and tools for setting priorities your advice and help please! (and thanks for the comments so far)

All this for discussion in the group work tomorrow