Latent TB Infection in the WHO European Region and recommendations on LTBI s M&E framework 18 th Wolfheze workshops / 15 th NTP managers meeting, 31 May 02 June 2017 Dr Andrei DADU Technical officer, Joint TB, HIV/AIDS and Hepatitis Programme
Why Do We Have Drug Resistance on raise? Inadequate treatment Incorrect regimen (lack of drugs or knowledge) Poor adherence Treatment failure / relapse with drug resistant TB Transmission of drug resistant TB It is far easier to prevent TB in those infected without disease than to treat a full blown case of drug resistant TB
Scale-up of programmatic management of LTBI is critical in order to end the global TB epidemic as stated in the WHO s End TB Strategy. LTBI management contributes to the End TB Strategy targets Incidence of TB, projections to 2050 Mitigation of risk e.g. HIV prevention/art or prevention of infection by vaccine or infection control have limited impact on the trajectory of drop in TB incidence and so is the case with treatment of active TB alone However identification and treatment of latent infection in combination with active TB treatment can potentially accelerates reduction in TB incidence and achieve the End TB Strategy target Dye C et al., Prospects for Tuberculosis Elimination. Ann Rev Public Health 2013. 34:271-86
WHO LTBI Guidelines GLOBAL TB PROGRAMME Guidelines on the management of latent tuberculosis infection (high and upper middle-income countries with TB incidence <100/100, 000) WHO guidelines 2014 http://apps.who.int/iris/bitstream/10665/136471/1/9789241548908_eng.pdf Recommendations for investigating contacts of persons with infectious tuberculosis in low- and middle-income countries WHO guidelines 2012 http://apps.who.int/iris/bitstream/10665/77741/1/9789241504492_eng.pdf Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource-constrained settings WHO guidelines 2011 (to be updated 2015) http://whqlibdoc.who.int/publications/2011/9789241500708_eng.pdf
Published: October 25, 2016 Revised LTBI estimates 1 MDR is found in each 4 TB in Europe L MDR-TB I *: All ages = 31 millions 0-14 years = 610 thousands 0-4 years = 260 thousands * Provisional estimates / unpublished
MDR-TB and their contacts Estimated of all new RR/MDR-TB emerging RR/MDR-TB 120,000 Contacts of 0-4 years old 260,000 Estimated RR/MDR in all notified TB 74,000 Detected RR/MDR cases among all TB notified cases 47,000 148,000 94,000 Modified from JA Seddon et al, Lancet 2012
Target countries for LTBI packages er/lower-middle income per/upper-middle income TB >=100 or lower/lower-middle income TB <100 and upper/upper-middle income TB Incidence>=100 or lower/lower-middle income TB incidence<100 and upper/upper-middle income
A snapshot of the WHO s key recommendations
PILAR 1> INTEGRATED, PATIENT CENTRED CARE AND PREVENTION E. LTBI PROGRAMMATIC MANAGEMENT AND VACCINATION AGAINST TB
LTBI in the TB Action Plan in EUR 2016-2020) TB Action Plan in EUR 2016-2020): MS to adopt and adapt their national policies to align with the most up-to-date WHO recommendations on diagnosis and treatment of latent TB infection for high-risk populations. MS to ensure that WHO policy recommendations on BCG vaccination for infants are implemented and BCG revaccination is discontinued. MS to ensure that people accessing harm-reduction services for drug misuse will be provided the option of TB preventive therapy.
LTBI treatment enrollment rate among PLHIV (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 70% 50% 40% 39% 33% 19% 14% 10% 9% 36% 36% 90% in 2015: 36% IPT coverage among those newly enrolled into HIV care vs. in 2011 4.8% as a baseline 10% 3% 0% 0%
LTBI in Global TB data collection form (EUR section only) National policy is available but rarely implemented and not reported Country X, 2015 data Total pop. = 3 mln 0-4 years pop. = 200 000 Contacts, estimates = 4 000 Actually screened = unk LTBI eligible = unk IPT enrolment = unk
LTBI in Global TB data collection form (only for EUR) Conutry Y, 2015 data Total pop. = 4 mln 0-4 years pop. = 700 000 No LTBI national policy 0-4 years contacts, est. = 4 600* * By A.Dadu based on Houben & Dodd 0-4 years screened = 514 (14%) 0-4 year LTBI eligible = 496 0-4 year IPT enrolment = 136 (27%) National policy is available but rarely implemented PLHIV, IPT enrolment = 19%
National policy on systematic screening for LTBI TB incidence > 20/100k 36 countries responded 23 targeting risk groups not recommended 3 TB incidence < 20/100k 8 countries responded 2 3 3 2 2 2 2 2 2 2 1 1 1 Community contacts Previous treatment for TB Military School children
Challenges: policy implementation and practices Low enrolment rate in to the LTBI treatment among PLHIV (the beginning of the countrywide implementation) LTBI management miss-practices at country level (screening/detection); High RR/MDR prevalence among TB cases in the EECA countries: 9 out of top 10 global high MDR-TB burden countries; Weak LTBI [surveillance] and [response monitoring] in countries and therefore poor data at regional level; Poor cascade analysis understanding contacts children (weak cascade analysis) Estimates/Projections modelling and Drugs forecasting HCW commitment/engagement due to high overload on tasks and responsibilities Country health system that prevent the LTBI rolleout Challenges in LTBI resources mobilization Refugees and other categories of migrants influx across the boarders;
TAG 2017 recommendations LTBI management Adapt and disseminate criteria for prioritization of at-risk population among those for whom systematic LTBI testing and treatment is recommended, in agreement with the 2014 WHO policy document; Create an implementation guide for contact tracing, screening and management of contacts. Evaluate the opportunity for recommending active search of the contacts (children to be prioritized); Analyse bottlenecks in implementation of LTBI testing and treatment among PLHIV and children under the age of 5 who are household contacts, and propose solutions; Develop a framework for recording and reporting of LTBI data that allows measurements of contact and LTBI indicators, using WHO guidance document on LTBI M&E with reference to both global and national core indicators; Develop a regional position paper/expert opinion document on the use of Interferon Gamma Release Assays (IGRA) in LTBI detection; Develop a regional position paper/expert opinion document on rifapentine-containing regimens and assist Member States and partners facilitate the registration of the drug with European Medicine Agency and/or country drug regulatory authorities ; Promote research and assessment on LTBI.