Dr Lindiwe Mvusi

INTERNATIONAL CLINICIANS COURSE FOR TB

AND HIV

15 AUGUST 2015

TB CONTROL AND MANAGEMENT

IN SOUTH AFRICA

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

3

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

4

TB BURDEN 2013

5

6

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

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%

7

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

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

9

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

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

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

12

TB NOTIFICATIONS

TB SCREENING AND TESTING

0

500000

1000000

1500000

2000000

2500000

3000000

2010 2011 2012

TB symptomatics tested for TB

SCREENING TOOLS

15

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: __________________

LINKAGE TO TREATMENT AND CARE

0

20000

40000

60000

80000

100000

120000

140000

160000

2010 2011 2012

Tested positive started on treatment

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

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

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

TB TREATMENT OUTCOMES 2000-2012

20

DEATH NOTIFICATION

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

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

2

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

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

2

5

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

SCREENING IN HEALTH FACILITIES

2

7

SCREENING IN COMMUNITIES

2

8

Symptom Screening

in community

Positive symptom

screen

Referral to local Clinic/

CHC

Testing,

Diagnosis and

treatment

Back referral to

community for

continuity of care

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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