Latent TB Infection Management in Zimbabwe TB Infection Management in Zimbabwe Dr Charles Sandy,...
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Transcript of Latent TB Infection Management in Zimbabwe TB Infection Management in Zimbabwe Dr Charles Sandy,...
Latent TB Infection Management in
Zimbabwe Dr Charles Sandy, Deputy Director (TB Control), Zimbabwe:
WHO Global Consultation on the Programmatic Management of
Latent Tuberculosis Infection, 27-28 April 2016
Country context Land locked country in Southern
Africa 14 million inhabitants
• Zimbabwe is one of 8 countries in Africa belonging to all the top 30 High burden lists of TB, TB/HIV, DR-TB in the world
• HIV drives TB, high rate of coinfection • Estimated PLHIV: 1.4 m (ZDHS
2011
• Drug resistant TB is an emerging public health problem
• Treatment outcomes remain suboptimal due to high mortality
NTP STRATEGIC GOALS
• By 2025 to have reduced the incidence of all forms of TB by 80% from 562/100000 in 2012 to 112/100 000
• By 2025 to have reduced mortality of all forms of TB by 80% from 132/100000 in 2012 to 26/100 000.
NTP STRATEGIC OBJECTVES
The intention of the NSP is to reach by 2017 the following targets: • Objective 1. To increase case notification rate of all forms of tuberculosis from 269/100
000 (35,566 patients) in 2013 to 313/100 000 (43,231 patients) by 2017.
• Objective 2. To increase treatment success rate for all forms of tuberculosis from 78% in 2012 to 87% by 2017.
• Objective 3. To increase the number of DR-TB cases detected annually from 393 in 2013 to 1 600 by 2017.
• Objective 4. To increase treatment success rate of Drug resistance TB from 59% in 2011 to 75% by 2017.
Strategic Focal Interventional Areas
• TB Care & Treatment: Prevention, Early intensified and active case finding
• TB/HIV: TB/HIV collaborative activities and integrated care
• MDR-TB: MDR-TB Prevention, Decentralized high quality MDR-TB Diagnosis, Care and Treatment
• Cross-cutting areas • Procurement Supply Management: Medicines & Laboratory
reagents uninterrupted supply and distribution, storage space
• Community systems strengthening - cross-cutting in all the strategies
TB Case Detection
Availability of Diagnostic Services 2015
Indicator Coverage
Smear Microscopy
• Number of laboratories 225
• Number of labs/100000 population 1.7
Xpert MTB/Rif
• Number of laboratories 108
• Number of labs/100000 population 0.8
X-ray Diagnosis
• Analogue (functional/available) 36/71
• Digital (functional/available) 14/16
Progress in TB Case Detection
319
298
269
235
212
97 94 96 94
116
2011 2012 2013 2014 2015
Rat
e p
er
10
0,0
00
po
pu
lati
on
Year
Trends in TB notification rates for all forms and bateriologically confirmed cases, 2011-2015
TNR all forms TNR bacteriologicaly confirmed
Contact Tracing Cascade- Smear Microscopy 2015
Number of presumptive TB clients identified (contacts)Number of presumptive TB clients with sputum
specimen sent to the laboratory (Contacts)Number of presumptive TB clients with Direct Smear
Microscopy results (Contacts)Number of presumptive TB clients with a smear
positive result (Contacts)
Sputum Smear Microscopy Screening
11244 9088 7670 676
Percentage 81% 84% 9%
11244
9088
7670
676
81%
84%
9%
0
2000
4000
6000
8000
10000
12000
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%A
xis
Titl
e
Axis Title
Axi
s Ti
tle
Percentage
Use of GeneXpert in Contact Tracing
Number of presumptive TB clientsidentified for Xpert MTB/ RIF
(Contacts)
Number of presumptive TB clientswith sputum specimen sent for Xpert
MTB/RI (Contacts)
Number of presumptive TB clientswith Xpert MTB/RIF results (Contacts)
Number of presumptive TB clientswith Xpert MTB positive
results(Contacts)
Number of presumptive with Xpert Rifresistance results(Contacts)
2349 3066 2499 345 69
Percentage 131% 82% 14% 20%
2349
3066
2499
345
69
131%
82%
14%
20%
0%
20%
40%
60%
80%
100%
120%
140%
0
500
1000
1500
2000
2500
3000
3500
Axi
s Ti
tle
Axi
s Ti
tle
Axis Title
Percentage
DR-TB Case Detection
0
50
100
150
200
250
300
350
400
450
500
0
20
40
60
80
100
120
2011 2012 2013 2014 2015
Co
un
t
Year
# of Instruments
# of Modules
0
50
100
150
200
250
300
350
400
450
500
2011 2012 2013 2014 2015
DR-TB Cases Diagnosed
DR-TB Cases put on Treatment
Fr
equ
ency
TB/HIV Integrated Management
85
90 91 92 96
77 74
69 72
68
0
20
40
60
80
100
120
2010 2011 2012 2013 2014
Per
cen
tage
HIV testing and co-infection rates among all forms of TB, 2010-2014
HIV testing
Co-infection
National Target 100%
87
94 95 96 96
44
60
75
81 86
2011 2012 2013 2014 2015
% o
f al
l TB
-HIV
co
-in
fect
ed c
ases
CPT Uptake ART Uptake
National Target 100%
ART among TB patients who are co-infected coverage comparing 2014 and 2015
Midlands
Masvingo
Matabeleland North
Manicaland
Mashonaland West
Matabeleland South
Mashonaland Central
Mashona and East
Chitungwiza
Bulawayo
TB/ART
0 - 79
80 - 89
90 - 100
National Target 100%
Midlands
Masvingo
Matabeleland North
Manicaland
Mashonaland West
Matabeleland South
Mashonaland Central
Mashona and East
Chitungwiza
Bulawayo
2014 2015
IPT provision
• Prior to Dec 2012 ,only limited to children under 5 years of age who are household contacts of smear-positive TB patients
• Following adaptation of the 2011 WHO guidelines on ICF/IPT in 2012 , the MOHCC commissioned a feasibility phase in ICF/IPT implementation in 10 selected sites across 5 provinces (Harare, Bulawayo; Mat North, Mat South and Midlands)
Reducing the Burden of TB among PLHIV
Roadmap in Implementation of the National ICF/IPT Programme
Adaptation processes of the
2011 WHO ICF/IPT
Guidelines
Revision of M&E Data Reporting and Recording
Tools
Stakeholder Sensitization meetings at
various levels on ICF/IPT
Capacity & Skills Building
of HCWs to provide ICF/IPT
services.
Feasibility Phase of ICF/IPT
implementation
Post Feasibility Phase of ICF/IPT Implementation
Jan 2012 – Dec 2013 (10 sites)
Jan 2014 – Dec 2015 ( 142 sites)
National Progress in IPT Implementation, Jan – Dec 2015
Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Dec
Number initiated on IPT 10425 9582 7167 12450 39624
Number completing IPT 5573 2502 8165 6559 22799
0
5000
10000
15000
20000
25000
30000
35000
40000
Fre
qu
en
cy (
n)
46 sites 83 sites 142 sites
TB Treatment Outcomes
2013 2014
Lost to follow up,
3%
Not Evaluated,
4% Failure, 1%
Died, 10%
Treatment Success,
82%
Lost to follow up,
5%
Not Evaluated,
2% Failure, 1%
Died, 9%
Treatment Success,
83%
National Target 90%
National TB Program Achievements/Impact
• Falling incidence of TB in line with international trends
• Case detection high at 70% but need to increase rapidly to 90%
• % of TB patients with Known HIV status high at 96%
• ART in TB high but still below universal coverage target
• Outcomes on treatment up • Success Rate 83% for Drug Sensitive TB
• 75% for Drug Resistant TB
• Prevalence coming down as evidenced by TBPS results
National TB Prevalence Survey 2014- Goal & Objectives • Goal: To estimate the prevalence of pulmonary TB among population
(aged 15 years or older) within Zimbabwe in 2014
• Main Objectives: 1. To establish the prevalence of bacteriologically-confirmed pulmonary TB
among adult population in Zimbabwe
2. To determine the prevalence of smear positive, culture positive TB
3. To determine the prevalence of symptoms suggestive of TB
4. To determine the prevalence of radiological abnormalities (chest X-ray) suggestive of TB
Screening outcomes
Symptom Chest X-ray Number S+ MTB + Xpert B+ MTB (smear negative)
Total (% All Survey Cases)
Positive Negative 1,162 0 8 (0.7) 8 (7.5)
Positive Positive 628 13 (2.1) 16 (2,6) 29 (27)
Negative Positive 2,797 9 (0.3) 54 (1,9) 63 (58.9)
Positive No CXR 42 1 1 2 (1.9)
Negative No CXR 1180 0 4 4 (3.7)
Missing Positive 6 0 1 1 (0.9)
Missing No CXR 4 0 0 0
Positive Missing 1 0 0 0
Total 5820 23 84 107
1) Symptoms alone were not specific for TB 2) A combination of symptoms and CXR abnormalities more specific 3) 58.9%of TB Survey Cases (63/107) were non symptomatic participants but had positive CXR screening 4) Smear and Xpert picked up 22% of all survey cases rest were smear negative
Key Message from TBPS
• High proportion of un-symptomatic TB in survey cases
• High utility of X-Ray as a screening tool
• High proportion of smear negative TB in survey cases
Summary of LTBI in Zimbabwe
• Systematic testing currently provided for people living with HIV, adult and child contacts of pulmonary TB cases and patients with silicosis. • Mantoux tuberculin skin test (TST) for children • Symptom screen and CXR plus Xpert in Adults
• Treatment of LTBI offered to people living with HIV, adult and child contacts of pulmonary TB cases • Treatment options available: 6-month isoniazid, or 9-month isoniazid, • IPT risks and benefits misunderstood by both HCWs and the Community for PLWHIV
• Screening offered for TB but no treatment of LTBI for prisoners, health-care workers • Symptom screen and CXR plus Xpert
• TB is stigmatized by HCWs and they do not seek care openly
• Mobile Chest radiography done for active TB case finding nth isoniazid, or 9-month isoniazid,
Conclusion
• Interventions for LTBI Management are being implemented in Zimbabwe but there is room for scale up