LTBI monitoring and evaluation in the Netherlands

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1 LTBI monitoring and evaluation in the Netherlands 17 th Wolfheze Workshops 2015, Den Haag Connie Erkens MD MPH Senior TB consultant

2 Content presentation Epidemiology Target groups for programmatic LTBI management Monitoring and evaluation of LTBI management Summary of key LTBI programmatic results

3 TB incidence per 100,000 Key facts TB epidemiology TB cases registered: TB incidence: 4.9 per 100,000 - Pulmonary TB cases: 451, 45% SS+ - Children <15 years: 49 (6%) - MDR-TB: 6 -New LTBI cases notified: 1300 Immigration increases Average annual decline % Source: RIVM New Previously treated Total

4 Target groups for LTBI screening and preventive treatment Sector Frequency National policy since TB contacts public TB services Ad hoc before 1993 Health care workers at risk for TB exposure hospital services Periodical: 6 months 1 year Other professionals at risk for TB exposure public TB services Periodical: 6 months 1 year Long term travelers to endemic countries public TB services Ad hoc, upon return Patients initiating anti-tnf treatment curative services Ad hoc, before treatment People living with HIV curative services Ad hoc, upon diagnosis of HIV Immigrants with X-ray abnormalities suspect for inactive & untreated TB public TB services Ad hoc, after screening on entry Homeless persons / illicit drug users public TB services Optional: ad hoc / periodically before 1993 before 1993 before (optional since 2007) 2015

5 LTBI screening algorithm in immune competent individuals Symptom assessment and TST <5mm = negative 5mm NO LTBI IGRA negative positive Further examinations to confirm diagnosis TB Any signs and symptoms for TB Medical examination AND Chest X-ray No signs and symptoms for TB LTBI Rule out contraindications for preventive treatment

6 * Introduced in 2009 Organization of LTBI management Screening performed by MPHS TB unit, military medical services or hospital clinician (clinical risk groups and HCWs) HCWs and military personal with LTBI are notified & referred to MPHSs Standard preventive treatment (PT): 6H, 3RH* or 4R* If contra-indications for PT> 2 years X-ray follow-up TB nurse provides support during PT if needed Cases managed or supported by MPHSs are recorded in webbased LTBI register

7 LTBI register Voluntary case-based registration by MPHSs since 1993 Nation wide coverage Web based data collection integrated with TB notification register Data: Age, gender, etnicity Target group for LTBI screening Diagnostic test used Case management (Rx or follow-up) Preventive treatment regimen Treatment outcome

8 Monitoring and evaluation indicators Number of new cases with LTBI eligible for PT diagnosed (+ by target group, age group and etnicity) % of eligible cases with LTBI starting PT diagnosed with IGRA % of eligible cases with LTBI starting PT (+ by age group and target group) % of eligible cases with LTBI completing PT (+ by PT regimen, age group and target group) % cases with serious adverse events (SAE) (+ by per PT regimen and age group)

9 Key results

10 Number of LTBI cases by ethnicity In total 37,736 LTBI cases registered since 1993 Before 2005: Mainly ethnic Dutch Since IGRA were introduced in 2007, both number and proportion of foreign born (BCG-vaccinated population) increased

11 Acceptance of preventive treatment (PT) Overall acceptance = 70% Acceptance is related to: Age: % % % Target groups: TB contact 75% HCW 65% Traveler 70%

12 Preventive treatment regimens used After introduction in 2009, shorter treatment regimens were adopted quickly

13 Preventive treatment outcome by regimen RH=91% 4R=89% 6H=84% Overall 84% persons completed PT successfully, but completion rate is better in shorter R-containing regimens

14 Progression to TB immune competent and normal chest X-ray only cases developed TB after start of preventive treatment: 1.4% of those not started on PT developed active TB (vs 0.3% of those treated)

15 Limitations of LTBI register to be addressed: Register does not capture coverage of screening of target groups for LTBI Underregistration of clinical risk groups with LTBI diagnosed and managed in curative clinical services Clinical risk groups cannot be distinguished from one and other Serious adverse events only recorded for those who interrupted PT >underestimation Risk factors for TB and comorbidity are not recorded

16 Discussion How to determine preventive treatment coverage and eligibility (=the denominator of the target group eligible) for LTBI treatment? Does the denominator group include: - Those not screened for LTBI among the target groups? - Those with contra-indications for PT (comorbidity, age>45 years, alcohol users, MDR TB contact etc.)?

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