Assessment of LTBI Policies and Practices in WHO European Region

Photo: Riccardo Venturi

17th Wolfheze Workshops and 13th WHO National TB Programme Managers' meeting The Hague, The Netherlands Wednesday 27th May, 2015

I. Low-Incidence Countries

II. High-incidence countries

III. National policy on preventive therapy for contacts of MDR-TB

IV. Systematic screening for LTBI and ACF

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Presentation Outline

• Backgrounds, objectives, and methodology

• LTBI Survey Results:

(Estimated TB incidence<100/100,000 and upper/upper-middle income)

(Estimated TB incidence >=100 or lower/lower-middle income)

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WHO LTBI Guidelines

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)

Recommendations for investigating contacts of persons with infectious tuberculosis in low- and middle-income countries WHO guidelines 2012

Guidelines on the management of latent tuberculosis infection (high and upper middle-income countries with TB incidence <100/100, 000) WHO guidelines 2014

http://whqlibdoc.who.int/publications/2011/9789241500708_eng.pdf

http://apps.who.int/iris/bitstream/10665/77741/1/9789241504492_eng.pdf

http://apps.who.int/iris/bitstream/10665/136471/1/9789241548908_eng.pdf

LTBI Survey Objectives

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Conduct baseline assessment of LTBI policies and practices Will allow measurement of implementation

of LTBI guidelines Identify challenges and opportunities to

scale-up LTBI implementation Network and strengthen collaborative efforts

within EURO

LTBI Survey Methodology

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Countries in WHO European regions

N=55

TB incidence<100/100,000 and upper/upper-middle

income N=45

TB incidence>=100/100,000 or lower/lower-middle

income N=10

Participated in the survey N=36 (80%)

Participated in the survey N=8 (80%)

Target countries for LTBI

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TB Incidence>=100 or lower/lower-middle income

TB incidence<100 and upper/upper-middle income

TB >=100 or lower/lower-middle income TB <100 and upper/upper-middle income

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I. LTBI Survey Results for Low-Incidence Countries

(Estimated incidence<100/100,000 and upper/upper-middle income)

National policy on systematic screening for LTBI

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83% of countries have a national policy for LTBI screening (30/36)

% of countries targeting risk groups conditionally recommended

% of countries targeting risk groups strongly recommended N=36

Denominator: All countries which responded to the survey including those without a national policy

N=36

National policy on systematic screening for LTBI

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% of countries targeting risk groups not recommended N=36

4 1

4 3

3

HIV

N=15

6 4

2

Compromised immune status

N=12

Screening Frequency for LTBI

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13 8

2 1

12 8

1 1

N=24

N=22

Ad hoc research Periodically < 1year Annually Periodically > 1 year Unknown

Household or close contacts, aged>=5years

Household or close contacts, Children< 5years

Initial Screening methods for LTBI

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1 1

4 2 1

6

HIV

N=15

16 1 5

2 2

N=26

7

3 4 2 1

5 N=22

TST IGRA Parallel testing with TST and IGRATST followed by IGRA for confirmation Other More than one optionUnknown

2

3 2

2

2 1

Compromised immune system

N=12

Household or close contacts, aged>=5years

Household or close contacts, children<5years

Tools used to exclude active TB

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What does ‘other’ include?

What does ‘combination of the above’ include, Symptom + Chest X-ray?

N=30

Preventive treatment regimens

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Single regimen

Multiple regimen

Recommended preventive treatment regimens (multiple answers)

N=30

Monitoring and Evaluation for LTBI

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39% of countries are monitoring and evaluating LTBI activities (14/36)

Monitoring and Evaluation Indicators

N=14

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II. LTBI Survey Results for High-Incidence Countries

(TB >=100 or lower/lower-middle income)

National policy on systematic screening for LTBI

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62% of countries have a national policy for LTBI screening (5/8)

% of countries targeting risk groups strongly recommended

% of countries targeting risk groups not recommended N=8

Screening frequency and methods and for LTBI

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Screening Frequency

Screening Method

Data for HIV not shown as only 1 country targeting this risk group

Household or close contact, aged>=5 years

Household or close contact, children<5 years

Household or close contact, aged>=5 years

Household or close contact, children<5 years

Preventive treatment regimens

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Recommended preventive treatment regimens N=5

Monitoring and Evaluation for LTBI

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62% of countries are monitoring and evaluating LTBI activities (5/8)

Monitoring and Evaluation Indicators N=5

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III. Survey Results: National policy on preventive therapy for contacts of

MDR-TB

Monitoring and Evaluation for LTBI

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Among low incidence countries, 36% have a national policy on preventive therapy for contacts of MDR-TB (13/36)

Yes 23%

No 69%

Unanswered 8%

Yes 92%

No 8%

Is preventive treatment recommended? Is clinical follow-up recommended?

Among high incidence countries, only one indicated to have the policy. Clinical follow-up, but not preventive treatment, was recommended (1/8).

N=13 N=13

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IV. Survey Results: systematic screening for LTBI and ACF

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Incidence<100 and upper/upper middle countries

TB Incidence>=100 or lower income

Risk Groups targeted for LTBI and ACF (Low vs. High incidence)

50% 50%

Immigrants from high TB burden countries

11% 11%

6% 72%

Household or close contacts, children<5years

31%

47%

22%

Immigrants from high TB burden countries

17%

33% 11%

39%

HIV

87%

13%

HIV

50%

12%

38%

Household or close contacts, children<5years

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Conclusions

Should additional risk groups be considered ? Should interventions be discouraged in other risk groups ? Should screening algorithms and frequency

be adapted to each risk group? Why is there a low level of implementation

of LTBI management in PLHIV.

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Acknowledgements

• Working Group members: Knut Lonnroth (WHO Geneva) Masoud Dara / Andrei Dadu (WHO-Regional Office for Europe) Marieke van der Werf (ECDC) Connie Erkens (secretary) / Susan van den Hof (KNCV)

• NTP Manager/Country Correspondents/ Program Coordinators in WHO European regions

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Plenary Discussion

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Yes 23%

No 67%

Unknown 10%

Are rifampicin containing preventive regimens recommended for use in persons living with HIV?

N=30 Low TB burden countries

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Yes 40%

No 60%

Are rifampicin containing preventive regimens recommended for use in persons living with HIV?

N=5 High TB burden countries

No policy on LTBI Albania, Belarus, Hungary, Latvia, Luxembourg,Montenegro

Child contact not eligible Lithuania and Denmark

Adult contact not eligible Denmark, Finland, Lithuania, Serbia and Turkmenistan

Compromised status eligible Denmark , Estonia, France, Greece, Iceland, Israel, Italy, Netherlands, Poland, Slovenia, Sweden, Switzerland, Turkey, UK

TNF eligible Belgium Czech Finland Germany Ireland Serbia

Transplantation eligible Czech

Chronic renal diseases eligible Greece ,Israel ,Slovakia ,Slovenia Turkey

Miner eligible

Estonia

Among low incidence countries: Strongly recommended

Immigrants from high burden countries

• France, Greece ,Iceland, Israel Norway, UK, Slovakia

• Ireland, Slovenia, and Sweden

are targeting only refugees but not immigrants

• There is no country which target

immigrants only within Schengen

Prisoners eligible Belgium, Estonia, Portugal, Romania, Slovakia

Drug user Estonia, Portugal

Homeless Slovakia, Slovenia

Among low incidence countries: Conditionally recommended

Diabetes Slovakia

Community contact Not eligible Armenia, Azerbaijan, Denmark, Estonia, Finland, Kazakhstan, Lithuania, Serbia

General population Turkmenistan

Slums Slovakia

Tribal population Slovenia

Hospital and Health care settings Greece, Turkey

Untreated fibrotic lesion Greece, Iceland

Pregnancy Azerbaijan, Turkmenistan

VCT attendees Estonia

Psychiatric facilities Estonia

Shelter residents Estonia, Romania, Slovenia

Nursing home resident Slovakia ,Estonia

Home for elderly Slovakia ,Estonia

Military Germany, Greece ,Netherland

Teachers Azerbaijan, Greece

School children Russia

Immigrants from low TB burden countries(outside Schengen)

Greece

Immigrants from low TB burden countries (within Schengen)

Norway

National policy not available Georgia, Uzbekistan, Moldova

Targeting HIV Ukraine

Not targeting contacts while having national policy

Armenia

Community contacts Kirgizstan, Tajikistan, Ukraine. All are targeting child and adult contacts as well

Previous treatment for TB Ukraine

Military Armenia

School children Tajikistan Ukraine

High incidence countries