TB prevention in vulnerable populations in low burden countries - - PowerPoint PPT Presentation

TB prevention in vulnerable populations in low burden countries

The network

Objectives and approach

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Outreach programme of TB screening and strengthen care integration in Romania (WP4)

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Who to screen?

• Vulnerable populations
• Prisoners
• People who use drugs
• Homeless individuals
• Roma population

Characteristics TB patients Romania,2017

Total Prisoners Drug users Homeless Estimated population 19.6m 28,000 10,000 5,000-15,000 Number of TB cases 12,310 107 57 117 Estimated TB incidence (per 100,000) 62.8 382 570 500-1500 (Bucharest) Urban residence 44% 48% 88% 69% Previous history of TB 20% 24% 23% 45% HIV infection 2.2% 20% 82% 5.4% Drug resistance against rifampicine 4.6% 4.6% 11.8% 14.0% Treatment outcome (2016)

• Successful

81% 92% 46% 62%

• Died

8.6% 3.7% 25.0% 13.4%

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Equip mobile digital radiography unit (MXU) Training

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Revised algorithm

CXR

CAD4TB ‘abnormal’ >60 CAD4TB ‘normal’ ≤50 GeneXpert, on the spot / in the van

TB

Human reading CXR Start treatment

7%

(10%) 90%

77%

Culture (MGIT) in the lab CAD4TB ‘subnormal’ 51-60 Human reading CXR

16%

GX, Culture

TB

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Screening main results to date

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Early LTBI and active TB drtrction in migrants

Daniela M. Cirillo1 and Alberto Matteelli2

1 IRCCS San Raffaele Scientific Institute , Milano Italy 2 University of Brescia, Brescia, Italy, WHO

Collaborating Centre for TB/HIV and TB Elimination

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

WP5 - Mig igrant TB detection, prevention and treatment

To create a network with local partners to agree a detailed protocol for migrant screening. To establish active TB screening in temporary migrants in Italy. To start screening for active and latent TB in more settled migrants in Italy. To collect data and produce evidences aiming at impacting European policy.

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Activ ive TB TB screening strategy

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Study flow

900

At least protocol-defined TB symptom

15 Pos 557 Neg

601

Sputum Collected

299

Sputum NOT Collected

3867 Screening 2967

No TB symptom

3 Pos 26 Neg

29

Sputum Collected

2938

Sputum NOT Collected

29 Emptysample 159 Sputumcollection notoffered 140 Sputumcollection notattend/Refused

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Considering confirmed cases, estimated screening yield for active TB among asylum seekers is 387 per 100.000 persons

100 200 300 400 500 600 700 800 900

Vanino et al; 20172]Active PTBand

• EPTP. Reception centres, Bologna

(Italy) Aldrige at al;2016; active pulmonary TB; UK [3] Pre-entry screening Italian Guidelines on TB screening in migrants; 2010 [4] Schepisi et al, 2016 active pulmonary TB, Italy (Rome, Milan) [5] CARA and CSPA centres in Sicily (Italy)

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Dia iagnostic ic perf rform rmance of f Xpert MTB TB/RIF vs s Xp Xpert MTB TB/RIF IFUlt ltra compared to MGIT IT cult lture

Sensitivity (95% CI) Specificity (95% CI) GeneXpert MTB/RIF-Ultra* 81.82% (52.30-94.86) 98.75% (97.45-99.39) GeneXpert MTB/RIF^ 54.55% (28.01-78.73) 99.47% (98.46-99.82)

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

• Retrospective study (2015-2016): TB incidence and prevalence,

LTBI rate, screening uptake and treatment completion (LTBI)

• Prospective study (2017-2018): TB incidence and prevalence, LTBI

rate, screening uptake, treatment completion (LTBI) different health care delivery system (centralized), pilot evaluation of a novel, e-Health recording system

Screening for LTBI in a replacement area, Brescia:

results of a retrospective analysis 2015-2016

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Methods: retrospective study (2015-2016)

• LTBI screening is offered at a first site, and screening positive individuals

are referred to a second site for chest Xray.

• LTBI screening was based on the administration of the tuberculin skin test

(TST), with 5 IU of PPD

• TST was considered positive with induration of >10 mm
• Individuals with positive TST and no radiological abnormalities were

considered and eventually offered preventive therapy (INH 6Mo). Additional investigation are conducted on a third site

This project has received funding from the European Union’s Health Programme (2014-2020) under grant agreement No 709624

2567 2498 2303 1460 843 403 397 190 93

102 143

500 1000 1500 2000 2500 3000 Candidates for LTBI screening TST performed TST read TST results Screening completed Eligible for treatment Treatment prescribed Treatment outcome available AS number LTBI positive treatment not prescribed/treatment outcome

36.6% TST positive 49% screening Completion (TST+) 47.9% started treatment 65% completion rate

Results (data censoring May 2017)

This project has received funding from the European Union’s Health Programme (2014-2020) under grant agreement No 709624

• LTBI screening (TST) performed at a centralized site and asylum

seekers are asked to return for reading.

• Those with positive TST are immediately tested with IGRA and

Chest X-ray performed at the same site.

• Those with a positive IGRA and negative chest X-ray are

considered for and eventually offered preventive therapy (HR 3Mo).

18

Brescia: screening for LTBI I in in a replacement area

Results of a prospective analysis is 2018

This project has received funding from the European Union’s Health Programme (2014-2020) under grant agreement No 709624

• 144 asylum seekers tested
• 141 completed the screening process

✓Screening pick-up increased by 100% from 49% to 98%

• Of 43 eligible asylum seekers 39 initiated treatment

✓ Treatment initiation rate increased by 84% from 48% to 90%

19

Screening for LTBI in in a replacement area

Results of a prospective analysis is 2018 (8 months)

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

WP5 - Key achievements to date

app based + Xpert ULTRA can be used to screen for active TB among migrants when chest Xray is not feasible incidence of TB among migrants is higher than incidence in Country of Origin, transmission occurs in centers LTBI screening and treatment uptake initially affected by significant losses, mainly attributable to the fragmentation of health care services coupled with the absence of a recording and reporting system Changes in the health care structure allows achieving high screening completion and treatment initiation rates

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

WP6 main objective: Collating, analyzing and evaluating multi country migrant TB screening data

Screening for LTBI:

To determine:

• screening coverage
• results of the initial LTBI

screening

• LTBI treatment uptake and

completion

• To estimate reactivation

rates of active TB amongst LTBI screening cohort (after the project period).

Screening for active TB

To determine:

• screening coverage,

target groups and reasons for chest X-ray screening for active TB

• results of the initial

chest X-ray screening

• TB treatment uptake

and completion ➢What approaches are feasible, effective and cost-effective?

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020) Preliminary results of IGRA/TST screening and coverage of LTBI treatment in the Multi Country Migrant Screening data within the E-DETECT TB work package 6 Percentage screened positive with IGRA/TST divided by gender, age group and TB incidence in country of birth Gender Age group (years) TB incidence in country

• f birth

Male Female 12-17 18-34 35-54 ≥55 <150 ≥ 150 England (by IGRA) 26 % 19/ 9% 17% 30% 32% NA 19%* The Netherlands (by IGRA) 28% 18% 24% 21% 32% 44% 13% 24% Stockholm,Sweden (by IGRA) 23% 24% 15% 25% 37% 47% 21% 24% Italy (by TST) 59% 24% 33% 34% 44% NA 26% 36% Percentage of those screened positive with IGRA/TST that started LTBI treatment divided by gender, age group and TB incidence in country of birth Gender Age group (years) TB incidence in country

• f birth

Male Female 12-17 18-34 35-54 ≥55 <150 ≥ 150 England . . . . . . . . The Netherlands 78% 71% 92% 77% 68% 72% 68% 76% Stockholm,Sweden 30% 20% 76% 23% 6% 6& 11% 31% Italy 48% 50% 29% 49% 10% NA 43% 50% *England presents data for country of nationality

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

19 26 18 28 24 23 24 59 10 20 30 40 50 60 70 80 90 100 Female Male Female Male Female Male Female Male . England, by IGRA The Netherlands, by IGRA Stockhom Sweden, by IGRA Italy, by TST %

Percentage screened positive with IGRA/TST, by gender

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

9 17 30 32 24 21 32 44 15 25 37 47 33 34 44 10 20 30 40 50 60 70 80 90 100 12- 17 18- 34 35- 54 ≥55 12- 17 18- 34 35- 54 ≥55 12- 17 18- 34 35- 54 ≥55 12- 17 18- 34 35- 54 ≥55 . England; by IGRA The Netherlands, IGRA Stockholm Sweden, by IGRA Italy, by TST % Age group

Percentage screened positive with IGRA/TST, by age group

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

71 78 20 30 50 48 10 20 30 40 50 60 70 80 90 100 Female Male Female Male Female Male . The Netherlands, by IGRA Stockhom Sweden, by IGRA Italy, by TST % Gender

Percentage of those screened positive with IGRA/TST that started LTBI treatment, by gender

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

71 78 11 31 43 50

10 20 30 40 50 60 70 80 90 100

<150 ≥150 <150 ≥150 <150 ≥150 . The Netherlands, by IGRA Stockholm Sweden, by IGRA Italy, by IGRA/TST % TB incidence/100 000 in country of birth/nationality

Percentage of those screened positive with IGRA/TST that started LTBI treatment, by TB incidence in country of birth

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

WP7 P7 lea ead: Dr Dr Dom Domin inik Zenner Ms s Fatim ima Wurie ie, Dr Dr Sar Sarah And nderson, , Dr Dr Ger Gerard de de Vrie ies, , Prof

• f Knut Lön

Lönnroth an and Prof

• f Ibr

Ibrahim im Abubakar

WP7 Aims and and obj

• bjectiv

ives

Su Support t th the e deve velopment of f acti ction pla lans in in member r states, in in clo close coll llaboration with ith ECDC and WHO, by takin ing bes est t pra ractic ice appro roaches fro from countr tries wher ere E-DETECT TB B partn rtners have ve deve veloped nati tional and in inter ernational l stra trategies by:

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

EU EU/E /EEA-wid ide TB TB Str trategy Too

• olk

lkit it: Core com

• mponents

ts of

• f na

natio ional l str trategic ic pla lans (NS (NSPs) for

• r TB

TB pr preventio ion and and con

• ntrol

l to

• inform

rm EU EU/E /EEA cou

• untry

try-le level l prio priorit itis isatio ion

▪ An overview of the available TB control tools together + EU/EEA-wide evidence and provide information on barriers and enablers to implementation. ▪ A menu of choices to support national TB programme representatives and national focal points to be equipped to successfully develop and implement locally-relevant strategies in their own context. ▪ Developed with Member States for Member States to support strategy development and implementation and it is ready to be piloted

Addressing vulnerable high risk populations in Europe: what can we learn from intercountry collaboration

Next steps for:  further implementation in other countries  country collaboration in generating further body of evidence for the effectiveness of TB prevention in these target groups for TB prevention.

For group discussion

 What are the preconditions for active case finding and LTBI management in vulnerable groups?  How to ensure and monitor the cascade of care?  What is the merit of international collaboration in monitoring and evaluating the effectiveness of active case finding and LTBI management? How can it be achieved?  Are the WHO and ECDC new LTBI guidelines sufficient to guide countries to further implementation?  Is there a need for additional guidance and/or operationalisation? 

This presentation is part of the project E-DETECT TB (709624) which has received funding from the European Union’s Health Programme (2014-2020)

Thank you for listening!

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Lucia Barcellini Giovanna Stancanelli Emanuele Borroni Bruno Cacopardo Staff of CARA Mineo Staff of La Siculiana Prefettura di Catania Alberto Matteelli Valentina Marchese