/ TB Infection Control Program Dr N Kapata Zambia National TB/Leprosy Control Programme Manager
Background Major public health problem Current (2014) notification rate is at 286/ 100,000 population. The estimated prevalence by WHO is at 388/100,000 Ranked 13 th highest incident country in the world MOH 2014; WHO 2013
In 2014, there were approximately 43, 000 TB cases notified nationally. Women accounted for an estimated 40% of all cases. Children accounted for about 8% of all cases Of those who were tested (90%) for HIV an estimated 60 % were HIV Positive MOH 2014
More than 50% of cases in age groups between 25 to 44 reproductive and indicating active transmission to children. MOH 2014
Majority of cases appear in group 25-44 years, Same age group affected by HIV/AIDS The rapid increases in Zambia from 1985 mainly attributed to the HIV population growth urban overcrowding improved case detection TB in Special Populations Chintu& Mwinga1999; Mwabet al, 2003; Kapata et al, 2011
TB Case Notifications 1964 to 2014 (All Forms) (Courtesy of MOH Report-2015) 600 500 400 300 200 100 0
TB Notifications by Province (Courtesy of TB CARE/ KNCV TB IC Report 2014)
TB Notifications (absolute) by age and gender 2013 (Courtesy of MOH Report-2014) 10000 9000 8000 8746 8096 7000 6000 5000 5614 5060 Males 4000 4292 Females 3000 2609 2894 3126 2000 1000 0 1522 1255 983 743 1007 1085 616 752 0-4 5-14 15-24 25-34 35-44 45-59 55-64 Over 65
Principles of TB Control Identify infectious TB cases Treat successfully these infectious cases Therefore cut transmission Detect 70% of all infectious cases and cure 85% WHO 1995; MOH/ NTP 2007
The Stop TB Strategy (2006) Six point Stop TB Strategy Builds on the successes of DOTS Addresses key challenges facing TB. To dramatically reduce TB global burden by 2015 Co-infected with HIV Drug-resistant TB WHO 2006; MOH 2011
Goal: To reducethe Prevalenceof TB by 50% relative to the estimated 1990 levels by 2016 and sustain the reduction in mortality rates MOH 2014 (RNTSP 2014 to 2016)
Impact Measurement Prevalence Declined from 665/ 100, 000 population in 1990 to 388/ 100, 000 population in 2012 455/ 100, 000 population National TB Prevalence survey (2013/2014) Baseline for subsequent impact measurement Mortality Reduced from 63/ 100, 000 in 1990 to 28/ 100,000 in 2012 Mortality data based on WHO estimates WHO 2013; MOH 2014 (EPI assessment report)
Re-organized structure of the NTP MCDMCH/MOH National TB & TB/HIV Coordinating Body -Subcommittees TB/HIV MDRTB Childhood TB TB in Mines NTP Central Level National AIDS/STI/TB Council Provincial TB/HIV Liaison Officers + Focal Point Persons District TB/HIV Coordinators Health Facility -TB/HIV Focal Persons/TB Corners/clinics Community Volunteers/ Community Based NGOs/ Treatments supporters
Program successes DOTS Expansion and Enhancement Treatment success rates improved from 50% in 2000 to 88%in 2013 Default rate from >15% in 2001 to < 3% in 2013 Failure rates from >10% in 2001 to < 1% in 2013 Death rate from >20% in 2001 to < 8% in 2013
Treatment success rate-all forms of TB by province (2012 cohort) (Courtesy of MOH Report-2014) 90% 87% 87% 87% 88% 89% 85% 85% 85% 80% 78% 78% 76% 75% 70% 65%
Drug Resistant TB The prevalence of MDR-TB in Zambia was estimated to be 1.8% in 2001. A second drug resistance survey was conducted in 2008 to determine trends; MDR-TB was 1.1% (CI 0.1-2.4) Isoniazid mono-resistance in new cases was 2.4% (CI 0.613-4.26) in retreatment cases, it was 4.4% (CI 0.3-8.6) Kapata et al, 2015
Rifampicin mono-resistance in new cases was 0.1% (CI <0.1-0.4) in retreatment cases, it was 0% (CI 0-3.8) There was no (Statistical) increase in MDR-TB prevalence in Zambia from 2001 to 2008 3 rd DRS Planned in 2015 Kapata et al, 2015; MOH 2014
Program successes Programmatic Management of DR-TB Successful with Green Light Committee (GLC) for the start up of Programmatic Management of Drug Resistant TB (PMDT) in 2010 PMDT Scale-up in progress with plans for decentralization Improved diagnostic capacity in three reference laboratories Quality assured Second line anti TB drugs available NTP 2015
Childhood TB Burden of TB in Children not well defined Poor diagnostic tools Low index of suspicion TB/HIV co-infection Paucibacillary nature of disease in children NTP 2015; Kapata et al, 2013
Childhood TB Notifications Only 8% of total notifications were children in 2014 Notification rate of childhood TB 69/ 100, 000 population Prevalence survey children < 15years old not included NTP 2015; Kapata et al, 2013
Program successes Improving diagnostics Use of XpertMTB/RIF Gastric aspirates improved yield Childhood TB technical working group Developed childhood TB guidelines
TB/HIV Collaborative Activities 1997: ProTEST Initiative Established by WHO to develop a more coherent response to TB in settings with high HIV prevalence Six projects in three Countries Malawi; South Africa; Zambia Results TB/HIV Collaborative activities was feasible & inexpensive WHO 2013; Terris-Prestholt et al 2008
2004: PICT Pilot in Livingstone Demonstrated that it was feasible to include HIV testing as part of routine care for TB 2005: Countrywide implementation based on WHO Policy on TB/HIV Collaborative activities National TB/HIV Coordinating Body Replicated at Provincial, District Levels & Facility levels CDC 2008; MOH 2010; Kapata et al 2012
TB/HIV Collaborative activities Established TB/HIV Collaborative bodies at all levels since 2005 Provider initiated counseling and testing for HIV offered to all TB patients (opt-out) Provision of Co-trimoxazolepreventive therapy to all TB/HIV co-infected patients Provision of ART to all TB/HIV co-infected patients MOH 2010; Kapata et al 2012
Program successes TB/HIV Collaborative activities TB Patients tested for HIV improved from < 20% in 2005 to > 85% in 2013 TB/HIV Patients put on Co-trimoxazolepreventive therapy from zeroin 2005 to > 80% in 2013 Provision of ART in TB/HIV ci-infected increased from < 20% in 2005 to > 60% in 2013 NTP 2015
HIV Testing in TB Patients 2009 to 2013 (Courtesy of MOH Report-2014) 100% 90% 80% 70% 60% 50% 40% % tested % HIV+ve (of tested) 30% 20% 10% 0% 2009 2010 2011 2012 2013
CPT and ART coverage in TB Patients 2009 to 2013 (Courtesy of MOH Report-2014) 100% 90% 80% 70% 60% 50% %CPT (of HIV+ve) %ART (of HIV+ve) 40% 30% 20% 10% 0% 2009 2010 2011 2012 2013
TB/HIV Collaborative activities Isoniazid preventive therapy Intensified case finding Infection control Three I s initiative (*Implementation intensified and scaled-up since 2012)
Isoniazid preventive therapy Demonstration/pilot studies implemented with GRZ through: ProTEST ZAMSTAR Study Guidelines developed Implementation started as part of USG supported Three I s initiative
Intensified case finding Guidelines developed Facilitated by scale-up of Xpert MTB/RIF assay Symptom screen Diagnostic evaluation Contact tracing
TB Infection Control Program TB IC -The development and implementation of basic infection control practices in facilities and communities where individuals are at risk of transmitting or contracting TB. TB IC Practices are Categorized into four
TB Infection Control Program i. Managerial activities Focal person Coordinating committee Comprehensive IC plan Health workers need to know how to protect themselves ii. Administrative controls Standard triage for infectious patients Responsible staff for triaging identified Cough etiquette promotion Minimizing time spent by patients at health facilities
TB Infection Control Program iii. Environmental Controls Adopt open window policy Redesigning consultation rooms & in-patient areas iv. Personal Protective Equipment Personal protective equipment should be used to prevent and /or minimize exposure Full face respirators or N-95 respirators Eye protection such as goggles; face shield
TB Infection Control Program Zambian Experience 2009: With PEPFAR and CDC Support the NTP through the TB/HIV Coordinating Body developed TB Infection Control guidelines To operationalize these guidelines, 8 facilities were selected purposively as Demonstration Projects MOH 2009
TB Infection Control Program Using CDC Support A TB Infection control training package was developed, composed of: 14 minute Video Slide presentations TB Infection control facility risk assessment tool Template for developing an infection control plan
TB Infection Control Program Training involved Behaviour change approaches Job aids Identifying focal persons; separating coughing patients; annual TB Screening for Health care workers Overall improvements in the 8 facilities Conclusion:TB Infection Control activities are feasible in a high TB/HIV burden; low resource setting
TB Infection Control Program USAID/TB CARE I Supported sites Improvement to TB/HIV treatment facilities Ventilation and airflow Renovation of waiting areas Demonstration Project Triage of patients flow PPEs Health Care workers Screening NTP 2015
Challenges Inadequate coordination of the National response for mitigation Structural and administrative (Re-structuring) Inadequate funding Inadequate impact evaluation system
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