Intensified TB case finding among PLHIV and vulnerable population Identifying contacts Gunta Kirvelaite Riga East Clinical hospital, Centre for tuberculosis and lung diseases. Head of outpatient department. MDR TB physician. WHO Collaborating Centre for Research and training in Management of MDR TB Latvia 1
Intensified case finding 2
Components of TB-HIV Framework Surveillance TB/HIV co-infection Intensified case finding Interventions Treatment and care 3
Several terms have been used for the screening of patients for active TB. The terms intensive case finding, active case finding, and enhanced case finding are used and all refer to strategies to identify and treat people with TB who have not sought diagnostic services on their own initiative. Intensified case finding (ICF) in the 3Is policy is an activity intended to detect possible TB cases among PLHIV as early as possible-- - means the regular screening for evidence of TB in people PLHIV, at high risk of HIV, or living in congregate settings for symptoms and signs of TB followed promptly with diagnosis and treatment. 4
Results from studies of intensified case finding published between January, 1994, and April, 2009. In 78 eligible studies, the number of people with TB detected during intensified case finding varied substantially between countries and target groups of patients. Median prevalence of newly diagnosed TB was 0.7% in population-based surveys, 2.2% in contact-tracing studies, 2.3% in mines, 2.3% in programs preventing mother-to-child transmission of HIV, 2.5% in prisons, 8.2% in medical and antiretroviral treatment clinics, and 8.5% in voluntary counseling and testing Yield services. of HIV-associated tuberculosis during intensified case finding in resource-limited settings: a systematic review and meta-analysis. K. Kranzer at all The Lancet February 2010, Pages 93 102 5
Figure 2. Prevalence of tuberculosis among individuals screened in different settings in countries with generalized epidemics of HIVVCT=voluntary counseling and testing. PMTCT=prevention of mother-to-child transmission. Yield of HIV-associated tuberculosis during intensified case finding in resource-limited settings: a systematic review and meta-analysis. K. Kranzer at all The Lancet February 2010, Pages 93 102 6
Intensified case finding among patients attending HIV care services reached just 2.2% of the 33 million people estimated to be living with HIV in 2007 Yield of HIV-associated tuberculosis during intensified case finding in resource-limited settings: a systematic review and meta-analysis. K. Kranzer at all The Lancet February 2010, Pages 93 102 7
Implementation challenges WHO 2011 IPT/ICF Recommendations Chronic cough alone is insensitive predictor of TB Screening tools are not standardised and vary Demand from countries for TB screening algorithm Concerns that IPT causes drug resistance Ruling out TB is major barrier to implementing IPT 8
As part of the guidelines development process, a comprehensive systematic primary patient data meta-analysis, including 12 observational studies involving over 8 000 PLHIV, was used to develop the best screening rule to identify adults and adolescents living with HIV who are unlikely to have active TB disease. Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource- constrained settings (2011) Department of HIV/AIDS Stop TB Department WHO, Geneva, Switzerland WHO 2011 9
All people living with HIV, wherever they receive care, should be regularly screened for TB using a clinical algorithm at every visit to a health facility or contact with a health worker. Screening for TB is important, regardless of whether they have received or are receiving IPT or ART. Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource- constrained settings (2011) Department of HIV/AIDS Stop TB Department WHO, Geneva, Switzerland WHO 2011 10
Intensified case-finding for and prevention of tuberculosis in adults and adolescents living with HIV 2.1 Adults and adolescents living with HIV should be screened for TB with a clinical algorithm and those who do not report any one of the symptoms of current cough, fever, weight loss or night sweats are unlikely to have active TB and should be offered IPT. Adults and adolescents living with HIV and screened for TB with a clinical algorithm and who report any one of the symptoms of current cough, fever, weight loss or night sweats may have active TB and should be evaluated for TB and other diseases. Both-Strong recommendations, moderate quality of evidence Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource- constrained settings (2011) Department of HIV/AIDS Stop TB Department WHO, Geneva, Switzerland WHO 2011 11
The analysis found that the absence of all the symptoms of current cough, night sweats, fever or weight loss can identify a subset of PLHIV who have a very low probability of having TB disease. This best screening rule has a sensitivity of 79% and a specificity of 50%. Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource- constrained settings (2011) Department of HIV/AIDS Stop TB Department WHO, Geneva, Switzerland WHO 2011 12
At 5% TB prevalence among PLHIV, the negative predictive value was 97.7% (95%CI 97.4 98.0). This high negative predictive value ensures that those who are negative on screening are unlikely to have TB and hence can reliably start IPT. Assessment of the evidence showed that the addition of abnormal findings on chest radiography to the four-symptom-based rule increases the sensitivity from 79% to 91%. Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource- constrained settings (2011) Department of HIV/AIDS Stop TB Department WHO, Geneva, Switzerland WHO 2011 13
2.2.7 Algorithm for TB screening in adults and adolescents living with HIV in HIV-prevalent and resource-constrained settings Adults and adolescents living with HIV Screen for TB with any one of the following symptoms Ɨ : Current cough Fever Weight loss Night sweats Screen for TB regularly Ɨ Chest radiography can be done if available, but is not required to classify patients into TB and non-tb groups. In high HIV-prevalence settings with a high TB prevalence among people living with HIV, strong consideration must be given to adding other sensitive investigations. Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource- constrained settings (2011) Department of HIV/AIDS Stop TB Department WHO, Geneva, Switzerland WHO 2011 14
ICF among PLHIV, 2005-2009 * Data as per June 2010 15
Intensified TB case finding, diagnosis of TB and IPT provision among PLWHA, 2006 350 300 250 200 150 100 50 0.96% Number of people receiving the intervention as % of estimated PLWHA in reporting Countries 12% 0.08% 0 Screened for TB (44, 52%) Diagnosed with TB (58, 58%) Started on IPT (25, 38%) (Number of Countries reporting; % of total estimated HIV+ TB patients accounted for by those Countries) 16
Risk groups for TB 1. people who associate with others with active TB disease 2. poor and medically underserved 3. homeless people 4. those who come from countries with high TB incidence rates 5. people in congregate settings, such as nursing homes or prisons 6. alcoholics and IDUs 7. people with medical conditions that impair their immunity, such as HIV or AIDS, or who are undergoing treatments likely to impair their immune systems 8. the elderly 9. health care workers and others who come in contact with high-risk populations, e.g. prison guards American Lung Association of Washington 17
TB risk group Nr 1= HIV HIV-infected people have a high attack rate a shortened incubation period for TB are susceptible to re-infection, including re-infection with drug-resistant strains. Interventions to prevent progression of latent TB infection to active disease HIV Epidemic TB Epidemic HIV can fuel the TB epidemic in several ways. 18
Populations at high risk of HIV and TB IDUs 1 IDUs are at risk of HIV infection, TB and, in some settings, MDR-TB; more than two thirds of newly diagnosed HIV infections are among IDUs; sexual partners of IDUs are at risk of HIV; IDUs often engage in sex work to support their injecting habit, which increases the risk of HIV transmission to the general population. 19
Populations at high risk of HIV and TB Sex workers 2 Sex workers (SWs) are at higher risk of HIV because of behavior; unsafe sex; unsafe injecting drug-use practices; SWs may represent a significant channel of HIV transmission to the general population. 20
Populations at high risk of HIV and TB Prisoners Prisoners are at high-risk of TB - crowded facilities; come from populations at high risk of HIV: illicit nature of drug use; sex work ; the high rates of property crime to support drug use by IDUs; The risk of TB infection and disease is consistently higher among prison inmates than among the general population, and this increases with the length of detention. 21 21 3
Populations at high risk of HIV and TB Migrants Both European and non-european migrants contribute to the TB and HIV epidemics; difficulties in communication, accessing healthcare services, sex barriers, 4 The often uncertain legal status of migrants pose particular problems for TB control and HIV prevention and care in this group. 22
Populations at high risk of HIV and TB HC users and HC workers 5 Healthcare users and health workers often have greater risk of being exposed to M. Tuberculosis; TB is most likely to be nosocomially transmitted from people with unrecognized pulmonary TB who have not started any anti-tb treatment and have not been isolated; Nosocomial TB transmission among HIVinfected patients has caused outbreaks with high case-fatality rates. 23
Intensified case-finding Early diagnosis of both conditions can limit transmission, decrease the related morbidity and mortality, improve people's quality of life; Investigation of PLWHA with respiratory symptoms consistent with TB should always include sputumsmear microscopy and culture for M. tuberculosis where available. 24
Riga s experience in TB case finding 25
Management of TB (MDR TB) case finding Examination of TB risk groups is important to diagnose this illness timely; Some risk groups are particularly important to examine, yet inconvenient, because they are the part of population that does not count health care as a priority or simply lack information regarding tuberculosis: potential clients of night shelters, visitors of soup kitchens, drug users, persons affected with HIV, sex workers. 26
TB case-finding among potential shelters clients To detect TB cases among potential shelters clients To decrease spread of TB among homeless people and community X-ray examination of shelter clients for TB is included in the epidemiology safety law Objectives for shelters potential clients examination: x- ray examination; sputum collection from clients with cough; admission of detected TB patients; results evaluation. Collaboration with shelter administration, social workers and medical staff 27
Shelters clients have been examined since 1998 1300 1445 1500 1000 698 734 668 731 634 724 examined 500 11 10 1,6% 1,4% 13 2% 6 0,8% 11 1,7% 13 1,8% 12 0,9% 0 2003 2005 2007 2010 17 17 1,8% 2011 TB cases TB gadījumi 28
TB cases finding among soup kitchens visitors To detect TB among soup kitchens visitors To decrease spread of TB among poorest part of city inhabitants and community Objectives for soup kitchens clients voluntary examination: to select clients with cough who were not examined for TB; to motivate them to see doctor or cough up sputum for examination; to select patients for repeated examinations; to organize admission for detected TB patients; to evaluate results. 29
Soup kitchens 2002-2009 800 600 400 200 0 776 727 638 615 672 408 483 270 5 17 13 19 9 5 3 6 2002 2004 2006 2008 2009 ss+ 1 c+ 5 3 of them did not start treatment (1 MDR) 3 started treatment 30
Soup kitchens Trained nurse; list of soup kitchens and their working hours bus. 31
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TB cases finding among PLWHA To provide voluntary TB testing for PLHIV and risk groups for HIV To decrease spread of TB among people from HIV/TB risk groups and community Objectives for voluntary examination of HIV/TB risk groups: to spread information about HIV/TB risk; to select clients with cough not examined for TB; to motivate them to see doctor or cough up sputum for examination; to select patients for repeated examinations; to evaluate results. 42
During 2003-2009 voluntary examination for TB detection and informing about TB/HIV has been successfully started for risk groups in collaboration with HIV harm reduction programs and LTC: drug abusers, PLHIV, sex workers, persons working in the field of HIV/ AIDS. Trained nurse in TB and voluntary consulting and testing (VCT) informing, consulting; training in cough hygiene. 43
Performing early TB case finding and spreading information in highrisk environments gives better chance to detect infectious TB (MDR TB) cases and motivate them to start treatment 44 44
Identifying contacts 45
No safe exposure time to airborne M. tuberculosis has been established. A single bacterium can initiate an infection leading to TB disease for people with suppressed immunity. The likelihood of TB disease after an exposure is influenced by medical condition that impair immune competence, and these conditions constitute a critical factor in assigning contact priorities. However, we must focus our resources on finding exposed persons who are more likely to be infected or to become ill with TB disease after contact with infectious TB patient. 46
The Infectious Period Determining the infectious period focuses the investigation on those contacts most likely to be at risk for infection and sets the timeframe for testing contacts. 47
TB sympto ms Guidelines for estimating the beginning of the period of infectiousness of persons with TB, by index case characteristic (CDC 2005) Characteristic AFB sputum smear positive Cavitary chest radiograph Recommended minimum beginning of likely period of infectiousness Yes No No 3 month before symptoms or first positive findings (abnormal chest x-ray) Yes Yes Yes 3 month before symptoms or first positive findings (abnormal chest x-ray) No No No 4 weeks before date of suspected diagnosis No Yes Yes 3 months before first positive finding consistent with TB The exposure period for individual contacts is determined by how much time they spent with the index patient during the infectious period. 48
The majority of TB contacts have not been tested for HIV infection. Contacts of HIV-infected index TB patients are more likely to be HIV infected than contacts of HIV-negative patients. Voluntary HIV counseling, testing, and referral for contacts are key steps in providing optimal care, especially in relation to TB/HIV. 49
HIV Epidemic TB Epidemic 50