Monitoring & evaluation LTBI management in the Netherlands. Key lessons.

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1 Monitoring & evaluation LTBI management in the Netherlands. Key lessons. Gerard de Vries, MD MSc PhD, Coordinator TB control the Netherlands, KNCV Tuberculosis Foundation/RIVM-CIb Global WHO Consultation meeting on LTBI, Seoul, Republic of Korea, 27 April 2016

2 Number of TB patients Number of TB patients (and TB incidence) in the Netherlands 2,500 2,000 1,500 1, Total Born in the Netherlands Foreign-born

3 National TB Control Plan Main new intervention is to screen immigrants and asylum seekers from high-risk countries for latent TB infection and provide preventive treatment. _publications/scientific/reports/2016/ maart/national_tuberculosis_control_p lan_2016_2020_towards_elimination

4 Organisational structure: 25 GGDs (Municipal Health Services) TB Departments Staffed with doctors, nurses and technical assistants They perform a.o. Notification Screening Contact investigation Note: TB control is increasingly organised at a regional level.

5 M&E: LTBI Register in the Netherlands Since 1993 in place, web-based since Data include: demographic characteristics target group diagnostic method patient management (preventive treatment regimen or radiological follow-up) completion of preventive treatment reason for interrupting preventive treatment.

6 M&E: LTBI case definition for reporting Cases eligible for preventive treatment according to the national guidelines are to be reported (voluntary), i.e. 1. a high likelihood of recent infection (<2 years ago); 2. pulmonary fibrotic lesions consistent with active TB in the past and without adequate treatment; 3. severe immunosuppressive disorders (e.g. HIV infection); 4. planned immunosuppressive therapy (anti-tnf-alpha therapy/organ transplantation).

7 Electronic reporting system Number Birth date Sex Postal code Country of birth CoB mother CoB father Diagnosis Test (TST, IGRA) BCG-vaccination HIV-test Other immunosuppression Reason LTBI screening Date start Rx Management (Rx or CXR) Rx regimen Treatment result Date completion

8 21 years of experience with M&E of LTBI in the Netherlands : 37,729 LTBI cases reported 28,931 (77%) started preventive treatment 85% completed treatment Increase in LTBI cases in foreignborn (49% of total in 2013) 61% of LTBI cases identified in contact investigation. 79% of notified LTBI cases in 2013 had confirmation with IGRA.

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10 Erkens et al. Results Preventive treatment initiation was highest in groups more likely to progress to active TB: immunosuppressed persons, children and TB contacts. Children and immunosuppressed persons were also more likely to complete preventive treatment, as were persons treated with the rifampicin or rifampicin/ isoniazid regimens.

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14 Countries with a low TB burden Testing Treatment Treatment completion

15 Measuring LTBI indicators in the Netherlands LTBI Testing LTBI Treatm. LTBI Rx Compl. TB incidence People living with HIV HIV clinics HIV clinics HIV clinics 36 Adult and child household contacts of PTB (Other contacts) 47 Silicosis x x x - Patients initiating anti-tnf treatment Patients with renal insufficiency/on dialysis Patients preparing for organ or hematologic transplantation Foreign-born hospitals hospitals hospitals 14 x x x 9 hospitals hospitals hospitals (33.8/100k

16 Measuring LTBI indicators in the Netherlands LTBI Testing LTBI Treatm. LTBI Rx Compl. TB incidence People living with HIV HIV clinics HIV clinics HIV clinics 36 Adult and child household contacts of PTB (Other contacts) 47 Silicosis x x x - Patients initiating anti-tnf treatment Patients with renal insufficiency/on dialysis Patients preparing for organ or hematologic transplantation Foreign-born hospitals hospitals hospitals 14 x x x 9 hospitals hospitals hospitals 5 LTBI Register 625 (33.8/100k

17 Measuring LTBI indicators in the Netherlands LTBI Testing LTBI Treatm. LTBI Rx Compl. TB incidence People living with HIV HIV clinics HIV clinics HIV clinics 36 Adult and child household contacts of PTB (Other contacts) 47 Silicosis x x x - Patients initiating anti-tnf treatment Patients with renal insufficiency/on dialysis Patients preparing for organ or hematologic transplantation Foreign-born hospitals hospitals hospitals 14 x x x 9 hospitals hospitals hospitals 5 LTBI Register 625 (33.8/100k

18 Key lessons Given the right infrastructure and organisation of services: At-risk groups for TB can be successfully screened and treated for LTBI. A system can be developed to monitor and evaluate LTBI screening and treatment.

19 GGDs Rob van Hest (GGD Rotterdam-Rijnmond / GGD Groningen) Wieneke Meijer (GGD Amsterdam) Lisette Timmermans (Limburg-Noord) All TB Departments of GGDs

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