Dr LindiweMvusi INTERNATIONAL CLINICIANS COURSE ......Pop: 166 111 (professionals) 6000 (CHW) EstTB...
Transcript of Dr LindiweMvusi INTERNATIONAL CLINICIANS COURSE ......Pop: 166 111 (professionals) 6000 (CHW) EstTB...
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Dr Lindiwe Mvusi
INTERNATIONAL CLINICIANS COURSE FOR TB
AND HIV
15 AUGUST 2015
TB CONTROL AND MANAGEMENT
IN SOUTH AFRICA
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AIM OF TB PROGRAMME
Exposure to infectious TB case
Asymptomatic M.tb infection
Activation of innate immune response
Latent TB
infection
Active TB disease
Cured TB:
- Self-healed
- Drug-treatedDeath
No inhalation
of M. tb droplets
Activation of T cell response
Slide courtesy Ajit Lalvani
Confirm TB
Prevent exposure
Boost immune responsePrevent death
Addressing social
determinants
− Poverty
− Malnutrition
− Alcoholism
− Poor living
conditions
− Overcrowding2
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TB KEY POPULATIONS
• Household contacts
• Health care workers
• Mine workers
• Inmates and correctional services staff
• Mobile, migrant and refugee populations
• People living in informal settlements
• Smokers, drug and alcohol abusers
• People with diabetes and those who are
malnourished
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TB BURDEN 2013
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POPULATIONS AT RISK
• Household contacts
• Health care workers
• Mine workers
• Inmates and correctional services staff
• Mobile, migrant and refugee populations
• People living in informal settlements
• Smokers, drug and alcohol abusers
• People with diabetes and those who are
malnourished
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TB BURDEN (2)
WHO ESTIMATES OF TB BURDEN 2013
Incidence (All TB) 860 per 100 000
Prevalence (All TB) 715 per 100 000
Mortality (HIV +) 121 per 100 000
Case detection (All TB) 62%
MDR-TB among TB
cases
1.8% (New)
6.7% (Retreatment)
Estimated HIV
prevalence
12% (6.4 Million)
TB patients co-infected
with HIV
62%
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BACKGROUND
• High Incidence – 860 per
100 000
• High Prevalence – 715 per
100 000
• Total cases reported
annually > 300 000
• Co-morbidity with HIV: 62%
• ART uptake for TB cases:
66%
• TB Mortality high at 121 per
100 000 (HIV infected)
Estimated TB Incidence rates:2013
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MDR-TB AMONG NEW TB PATIENTS
• 26 023 Cases of RR-TB
and MDR-TB reported
in 2013
• 10 663 started on
treatment
• Poor treatment
outcomes - treatment
success rates below
60%
• High mortality rates
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TRENDS IN TB NOTIFICATIONS BY
PROVINCE: 2007-2012
0
20000
40000
60000
80000
100000
120000
140000
EC FS GP KZN LP MP NC NW WC
2007 2008 2009 2010 2011 2012
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INMATE POPULATION
WC FS / NC LMN GP EC KZN
RD Female 287 64 76 434 59 141
RD Male 9176 5866 6352 13147 5886 7297
Sentenced F 445 237 231 777 248 387
Sentenced M 15567 15425 16697 23213 12563 19281
TOTAL 25475 21615 22406 37580 18783 27122
0
5000
10000
15000
20000
25000
30000
35000
40000
Regions
RD Female
RD Male
Sentenced F
Sentenced M
DCS – 01 January 201411
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BURDEN OF DISEASE IN DCS
• Prevalence of undiagnosed TB amonginmates: 2.4 - 7.3%
• HIV prevalence among inmates: 25.3%Telisinghe T et al, 2011
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TB NOTIFICATIONS
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TB SCREENING AND TESTING
0
500000
1000000
1500000
2000000
2500000
3000000
2010 2011 2012
TB symptomatics tested for TB
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SCREENING TOOLS
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TB SYMPTOM SCREENING TOOL FOR ADULTS AND CHILDREN
PATIENT DETAILS
Surname: _________________________________ First Name: ____________________
Physical Address: _________________________ Age: ___________________________
Telephone Number: ________________________
Patient Folder Number: _____________________
MEDICAL HISTORY
Close contact of a person with infectious TB: Yes No Unknown
Type of index patient: DS-TB Rif Resistant TB
MDR-TB or
XDR-TB
Diabetic: Yes No Unknown
HIV Status: Pos Neg Unknown
Other:
TB SYMPTOM SCREEN
1. ADULTS
Symptoms Yes No
Cough of 2 weeks or more OR of any duration if HIV positive
Fever of more than two weeks
Unexplained weight loss >1.5kg in a month
Drenching night sweats
2. CHILDREN
Symptoms Yes No
Cough of 2 weeks or more which is not improving on treatment
Persistent fever of more than two weeks
Documented weight loss/ failure to thrive (check Road to Health Card )
Fatigue (less playful/ always tired)
If "Yes" to one or more of these questions, consider TB.
If the patient is coughing, collect sputum specimen and send it for Xpert testing.
If the patient is not coughing but has the other symptoms, clinically assess the patient or refer for further investigation.
Patient referred for assessment and investigation: Yes No
Date of referral: ___________________________ Facility name: __________________
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LINKAGE TO TREATMENT AND CARE
0
20000
40000
60000
80000
100000
120000
140000
160000
2010 2011 2012
Tested positive started on treatment
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RE-TREATMENT RATES: 2008-2012
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
2008 2009 2010 2011 2012
Relapse After failure After default Other
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NSP TREATMENT OUTCOMES TRENDS
1995 - 2011
0
10
20
30
40
50
60
70
80
1995 2000 2005 2010 2011
Cure Completion Death Failure Default N/E
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RSP TREATMENT OUTCOMES TRENDS
2000 - 2011
0
10
20
30
40
50
60
70
2000 2005 2010 2011
Cure Completion Death Failure Default N/E
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TB TREATMENT OUTCOMES 2000-2012
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DEATH NOTIFICATION
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TB AND HIV CARE 2005 - 2012
0
100000
200000
300000
400000
500000
600000
700000
800000
2005 2006 2007 2008 2009 2010 2011 2012
Known HIV status HIV pos On CPT On ART
Years
Nu
mb
er
rep
ort
ed
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COMBINATION INTERVENTIONS FOR
EFFECTIVE TB CONTROL
EARLY
ANTIRETROVIRAL
TREATMENT FOR HIV+
VACCINES
ISONIAZID PREVENTIVE
THERAPY
TB
SCREENING
XPERT
EARLY
TREATMENT
INITIATION
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CASE DETECTION STRATEGIES
• Previously passive
• Intensified case finding• HIV positive
• All PHC attendees - diabetic, smokers and
alcohol abusers, pregnant women
• Contacts
• Active case finding• High TB burden areas – campaigns, outbreak
investigations
• Health care workers
• Inmates
• Miners
• School children
• Hard to reach populations – migrant population
(farm workers, truckers), CSW
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4
• Opportunities• Primary health care
reengineering
− Ward based outreach
teams
• Integrated chronic
disease model
− Decongesting health
facilities
• Ideal clinic initiative
− Streamlining processes
and flow of patients
− Integration of services
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RISK GROUP PRIORITISATIONGROUP RATIONALE
Miners
Pop: 521 000
(including families 2
605 000)
Est Incidence 3000 per 100 000
TB Prevalence 2.3% (HIV-), 3.8% (HIV+)
Prevalence of LTBI: 89%
HIV Prevalence: 27%
Silicosis Prevalence: 18.3 – 19.9%
Rates of recurrence:
•HIV+: 19.7 cases per 100 person years•HIV-: 7.7 cases per 100 person years
Inmates
Pop: 150 000
(25 000 – 30 000
releases annually)
Prevalence of TB disease: 5.1% (HIV-positive)
Prevalence of TB disease: 1.6% (HIV-negative)
Prevalence of undiagnosed TB: 2.4 – 7.3%
HIV prevalence: 25.3%
TB Incidence: 4500 per 100 000
TB prevalence among new admissions 2.5 – 3.4%
PLWHA
5 510 000
TB Prevalence = 25.3% (95%CI 22.3-28.6%). (KZN)
TB Incidence = 6.89 per 100 person years (KZN)
TB prevalence at ART start: 30.1%
Cumulative incidence during ART: 27.5%(WC), 20.7%
(GP)
TB incidence rate on ART: 7.44 per 100 person years
(WC), 4.2 per 100 person years (GP)
Co-infection rates:
•DS-TB: 65%•MDRTB: 90% (KZN)•XDRTB: 98% (KZN)
12% yield in HIV clinic
12-19% yield in patients presenting for
ART initiation irrespective of symptoms
Assessing TB symptoms not helpful screen
for TB disease
6% yield in HH contacts of adult index
case, 15% of whom were HIV pos
5% yield among HIV+ and 0.5-0.7% among
HIV- (community based survey in
periurban setting
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GROUP RATIONALE
People living in
informal settlements
1 600 000
households (±4
people per HH)
Prevalence of LTBI: 52.7 – 54%
Force of infection: 7.3 – 7.9%
Prevalence LTBI: 45% 28% (5-10 yr old), 88.2% (31-35yrs)
ARTI: 3.9% (up to 5yrs)
Prevalence TB disease: 5.3 – 17.3% (HIV positive), 2.2 – 5.3% (HIV negative)
TB case notification rate: 1149 per 100 000 (1029 adults, 3588 children
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SCREENING IN HEALTH FACILITIES
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SCREENING IN COMMUNITIES
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Symptom Screening
in community
Positive symptom
screen
Referral to local Clinic/
CHC
Testing,
Diagnosis and
treatment
Back referral to
community for
continuity of care
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ALL PEOPLE WITH SYMPTOMS OF TB
Collect one spot specimen (sputum, gastric washing/ lavage, lymph node fine needle aspirate, pleural biopsy, cerebro spinal fluid).
Sputum collection must be under supervision
Xpert positive
Rifampicin susceptible
Xpert positive
Rifampicin unsuccessful
Xpert positive
Rifampicin resistant
Treat as Drug Susceptible TB
Start on Regimen 1
Treat as Drug susceptible TB
Start on Regimen 1Refer to MDR-TB treatment
initiation site
Conduct contact screening/
source investigation
Follow up the microscopy results
and record them in the patient’s
treatment record
If smear positive
Conduct contact screening/ source
investigation
Follow up the laboratory results and
record them in patient’s treatment
record
If drug susceptible TB and
smear positive
Record results
Continue treatment
Conduct contact screening/
source investigation
If Drug resistant TB, smear/
culture positive
Refer to MDR-TB treatment
initiation site
Conduct contact screening/
source investigation
If patient has Pulmonary TB
Collect one spot sputum specimen
for microscopy
Collect one spot specimen for
microscopy, LPA, or culture and DST
NOTE: If the Xpert test fails/ unsuccessful, a second spot specimen must be collected for a repeat
test.
DIAGNOSTIC ALGORITHMS (1)
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ALL PEOPLE WITH SYMPTOMS OF TB
Collect one specimen (sputum, gastric washing, lavage, lymph node fine needle aspirate, pleural biopsy).
Sputum collection must be under supervision
Xpert negative
If HIV positive If HIV negative
•Re-assess the patient clinically
•Do a chest x-ray (If available)
•Collect another specimen for culture and LPA or DST
•Treat with antibiotics
•Monitor response to treatment
after one week
If well and asymptomatic
•No further follow up is
required
•Advise to return when
symptoms recur
If still symptomatic and
sick
•Consider other diagnosis
•Refer to hospital for
further investigationFollow up and review LPA/ DST results
X-ray findings consistent
with TB
X-ray findings normal
(Or x-ray not available)
If drug resistant TB
•If on Regimen 1, stop treatment
•Refer to MDR-TB treatment
initiation Site
•Conduct contact screening/
source investigation
Consider the HIV status of the patient
Treat as Drug susceptible
TB
Start Regimen 1
If drug susceptible TB
•Continue treatment
•Start treatment if not
already on treatment
•Conduct contact
screening/ source
investigation
Treat with antibiotics
Re assess the patient after one week
NOTE: In patients with NTM, MTB will not be detected by Xpert, therefore a culture and speciation or
LPA must be conducted
DIAGNOSTIC ALGORITHMS (2)
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Thank you
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