Overview of recent WHO guidelines:

Transcription

1 Overview of recent WHO guidelines: 1. Systematic screening for active TB 2. Framework on TB and diabetes 3. Nutritional care for people with TB Knut Lönnroth, Global TB Programme, WHO Divonne NSP workshop Feb

2

3 Key principle: prioritize Indiscriminate mass screening should be avoided. The prioritization of risk groups for screening should be based on assessments made for each risk group of; the potential benefits and harms; the feasibility of the initiative; the acceptability of the approach; the number needed to screen; and the cost effectiveness of screening. 3

4 Strong recommendations = Should be screened in all settings 1. Household contacts and other close contacts should be systematically screened for active TB. 2. People living with HIV should be systematically screened for active TB at each visit to a health facility. 3. Systematic screening for active TB should be done in current and former workers in workplaces with silica exposure 4

5 Conditional recommendations = prioritization needed 4. Systematic screening for active TB should be considered in prisons and other penitentiary institutions. (including staff) (disagreement in the group, many wanted a strong recommendation if prevalence >100/100,000) 5. Systematic screening for active TB should be considered in people with untreated fibrotic CXR lesion. 6. In settings where the TB prevalence is 100/100,000 in the general population, systematic screening for active TB should be considered among people who are seeking care or who are in care and belong to selected risk groups (see remarks, including staff) 5

6 Risk factor Relative Risk of TB Poor health outcomes related to risk factor Underweight (BMI <18.5) Gastrectomy or jejunoileal bypass 3.2 (95% CI, ) Increased risk of death and TB relapse; systematic reviews, no pooled estimate No pooled estimate Gastrectomy: Range 2 5. Gastric bypass: Range Increased risk of death associated with undernutrition (see Underweight ) Diabetes mellitus 3.1 (95% CI, ) Pooled relative risk of TB treatment failure or death from systematic review: 1.69 (95% CI, ) and relapse: 3.89 Alcohol dependence (95% CI, ) 2.9 (95% CI, ) Higher risk of TB treatment failure and relapse (six studies) and death during treatment (seven studies); systematic review, no pooled estimate Tobacco smoking 2.0 (95% CI, ) Increased risk of death; systematic review, no pooled estimate Chronic renal failure or haemodialysis Intravenous drug use Solid organ transplantation Old age Previously treated TB No pooled estimate; range No pooled estimate No pooled estimate; range, No pooled estimate, prevalence surveys report increased risk with age No pooled estimate Increased risk of death; systematic review, no pooled estimate Increased risk of death; systematic review, no pooled estimate No published data Increased risk of death; systematic review, no pooled estimate Retreatment cases have higher risk of poor outcomes and higher risk of MDR-TB Pregnancy No pooled estimate Infants of mothers with TB have increased risks of premature birth, 6

7 Conditional recommendations, cont. 7. A. Systematic screening may be considered for geographically defined sub-populations with extremely high levels of undetected TB (>1% prevalence) B. Systematic screening may be considered also for other subpopulations with very poor health care access, such as urban slum dwellers, homeless people, people living remote areas with poor access, indigenous populations, migrants, and other vulnerable groups. 7

8 Algorithm options Algorithm Screening Diagnosis Prevalence = 1% (1,000/100,000) 100,000 persons screened (1,000 true C+ cases) % of true cases detected True positive False positive Positive predictive value 1 2 Cough >2-3 w 1.Cough >2-3 w 2.CXR Any symptom 1.Any symptom 2.CXR SSM 21% % GXP 32% % SSM 19% % GXP 29% % SSM 47% % GXP 71% % SSM 42% % GXP 64% % 3 CXR: Any abn. CXR: TB abn. SSM 60% % GXP 90% % SSM 53% % GXP 80% %

9

10 The TB/diabetes Framework, building on TB/HIV policy TB control need The TB/HIV approach Applied to DM/TB 1. TB screening in risk groups, for early and comprehensive TB diagnosis 1. Screening people living with HIV for TB 1. Screen people with DM for TB, at least in high TB burden settings 2. Quality care for TB comorbidities to improved health outcomes among people with TB 3. Better prevention of TB by reducing population prevalence of TB risk factors 4. Health Systems Strengthening through synergistic collaboration 2. HIV screening among people with TB, quality treatment and care, including ARV 3. Scale up quality HIV treatment and care, and reduce HIV prevalence 4. Collaborative structure, sensible integration 2. DM screening among people with TB, provision of high quality DM treatment, adapt "DOTS" model 3. Broad DM prevention and care efforts, TB programmes can help advocate 4. Collaborative structure, sensible integration

11 The recommendations Document available at:

12

13 Focus on nutritional rehabilitation Evidence summary: Proper TB treatment helps restore normal weight and nutrition. However, the time to full nutritional recovery can be long and many TB patients are still undernourished after TB treatment is completed. There is no good evidence that nutritional care improves TB-specific treatment outcomes, once proper treatment with TB medicines is provided. However, proper nutritional care improves nutritional recovery for people who are undernourished, and therefore helps reduce future health risks. Potentially impact on access, adherence, poverty mitigation, but very little high quality research.

14 Assessment and counselling Recommendation 1: All individuals with active TB should receive: a) an assessment of their nutritional status and b) appropriate counselling based on their nutritional status at diagnosis and throughout treatment. Nutritional assessment and counseling Severe malnutrition (BMI <16.0 kg/m 2 ) or Moderate malnutrition: Children <5 years Pregnant women Persons with MDR-TB Moderate malnutrition (BMI kg/m 2 ) Re-assess after 2 months TB treatment Moderate/severe malnutrition No or mild malnutrition (BMI 17 kg/m 2 ) Standard TB treatment only Loosing weight during TB treatment Nutritional intervention adjusted to age, pregnancy, co-morbidities Evaluate TB treatment response; Adherence? MDR-TB? Co-morbidity?

15 Key principles 1. All people with active TB should receive TB diagnosis, treatment and care according to WHO guidelines and international standards of care. 2. An adequate diet, containing all essential macro and micro nutrients, is necessary for the wellbeing and health of all people, including those with TB infection and/or TB disease. 3. Because of the clear bi-directional causal link between malnutrition and active TB, nutrition screening, assessment and management are integral components of TB treatment and care. 4. Poverty and food insecurity are both causes and consequences of TB infection and disease, and those involved in TB care therefore play an important role in recognizing and addressing these wider socioeconomic issues. 5. TB is commonly accompanied by co-morbidities such as HIV, diabetes mellitus, smoking and alcohol or substance abuse which have their own nutritional implications, and these should be fully considered during nutrition screening, assessment and counselling.

16 Severe malnutrition Recommendation 2: Adults, including pregnant and lactating women, children and adolescents (5 to 19 years), with active TB, including MDR-TB, and severe malnutrition, should be treated in accordance with the WHO recommendations for treatment of severe malnutrition. (Strong recommendation) Recommendation 3: Children less than 5 years of age with active TB and severe malnutrition should be treated in accordance with the WHO recommendations for the management of severe malnutrition in children less than 5 years. (Strong recommendation)

17 Moderate malnutrition Recommendation 4: Adults, including lactating women, children and adolescents (5 to 19 years) with active TB and moderate malnutrition who fail to regain normal BMI after two months TB treatment, as well as those who are losing weight during TB treatment should be evaluated for adherence and co-morbid conditions. They should also receive nutrition assessment and counselling, and if indicated, be provided with locally available nutrientrich or fortified supplementary foods as necessary to restore normal nutritional status. (Conditional recommendation). Recommendation 5: Children under 5 years of age with active TB and moderate malnutrition should be managed in accordance with the WHO recommendations for the management of moderate malnutrition in children aged less than 5 years. This includes provision of locally available nutrient-rich or fortified supplementary foods in order to restore appropriate weight-for-height. (Strong recommendation) Recommendation 6: Pregnant women with active TB and moderate malnutrition or with inadequate weight gain should be provided with locally available nutrient-rich or fortified supplementary food as necessary to achieve an average weekly minimum weight gain of approximately 300 g per week in the second and third trimesters. (Strong recommendation) Recommendation 7: Patients with active MDR-TB and moderate malnutrition should be provided with locally available nutrient-rich or fortified supplementary food as necessary to restore normal nutritional status. (Strong recommendation)

18 Micronutrient supplementation Recommendation 8: A daily multiple micronutrient supplement at 1x recommended dietary allowance (RDA) should be provided in situations where fortified or supplementary food should have been provided in accordance with the moderate malnutrition recommendations above, but is unavailable. (Conditional recommendation) Recommendation 9: All pregnant women with active TB should be provided with a pre-natal multiple micronutrient supplement such as UNIMAP (UN international multiple micronutrient preparation) containing 14 micronutrients in RDA amounts appropriate for pregnant women, in addition to routine supplementary calcium, in accordance with WHO antenatal recommendations for pregnant women without TB. All lactating women with active TB should be provided with a multiple micronutrient supplement such as UNIMAP containing 14 micronutrients. (Conditional recommendation).

19 Contact investigation Recommendation 10: In settings where contact tracing is implemented, household contacts of people with active TB should have a nutrition screening and assessment as part of contact investigation. If malnutrition is identified, it should be managed according to WHO recommendations. (Conditional recommendation)

20 Thanks