TB in the Organization of Eastern Caribbean States (OECS)Auvergne.pdf · 2020. 3. 24. · OECS...
Transcript of TB in the Organization of Eastern Caribbean States (OECS)Auvergne.pdf · 2020. 3. 24. · OECS...
TB in the Organization of Eastern Caribbean States (OECS)
Cleophas d’Auvergne MD., MPA, Dip TB, (WHO/USAID), AAHIVS (HIV Specialist)
Disclaimer
I have no conflict of interest.
Learning Objectives
At the end of the session participants will be able to :
• Understand the Epidemiology of TB in the OECS
• Describe TB prevention and control activities in small island development states and identify possible strategies for TB Elimination.
Established in 1981 by the Treaty of Basseterre is an 11-membergrouping of islands spreading across the Caribbean from Anguilla,Montserrat, British Virgin Islands ( U.K British Overseas Territories)Guadeloupe, Martinique (French Department) Antigua and Barbuda,St. Kitts and Nevis, Dominica, St. Lucia, St. Vincent and the Grenadinesto Grenada, (Total Population 2017, 1.7 M)
Countries under Global Fund Grant St. Kitts and Nevis, Antigua andBarbuda, Dominica, St. Lucia, St. Vincent and the Grenadines, Grenadaall full Members (Total population 2019 , 627,713)
Income:• High income (Antigua& Barbuda, St. Kitts& Nevis, )• Middle Income (St. Lucia, St. Vincent, Grenada, Dominica)
US$ 1036 to US$ 4085 per capita
Life Expectancy : M 71.7 , F 76.8 Ave 74.2 years
Socio- Demographic profile
• Multi-Ethnic: African > Mixed> Indian > Caucasian > (Indigenous) Chinese
• Religion: Predominantly Christian
• Government: Unitary parliamentary constitutional Monarchy
• Economy: Tourism > Agriculture
• Unemployment rate: 17.1% (4.5-24)
TB Health Infrastructure
• GDP: US$ 2.60 (Total)
• Per capita: US$4,145 (Upper middle income)
• Health Care Budget as % GDP <10%
• National TB Budget: Integrated into Primary Health Care
• Most countries have TB service vs National TB Program
• Some countries have TB program management integrated with National HIV program management
Epidemiological Profile Region of the Americas
Source: Global Tuberculosis Control Report 2019
OECS TB-Trends
10.6
12.7
10.4 10.3 10.3
8.32
7.53
4.3
2.97
44.27
4.76
4
2.75
3.63
0
2
4
6
8
10
12
14
1990 1995 2000 2005 2010 2014 2015 2016 2017 2018
Rat
e p
er 1
00,0
00 p
op
ula
tio
n
OECS TB Trends 1990-2018
Estimated TB Incidence Estimated TB Mortality TB Notification Rate
2018 New TB cases = 23
Source: Global Tuberculosis Control Report 2019
Post 2015 END Strategy TB incidence target of <10/100,000 for 2035 have already been met.
OECS TB Demographic Profile 2018
Source: Global Tuberculosis Control Report 2019
4%
73%
23%
OECS TB Demographic Profile 2018
Children (0-14)
Men
Women
Socio-determinants of Health
Poverty UrbanizationUnemployment-
Youth
Air pollution
Climate change
Natural disasters
Suboptimal nutrition
Migration Education
“Air pollution is a silent Public Health Emergency” Dr. Tedros Adhanom Ghebreyesus WHO Director General 2018.
TB TB RISK FACTORS
Smoking Diabetes
HIV InfectionSubstance Abuse
PREVIOUS TB
OECS TB Case Detection
0
50
100
150
200
250
300
350
2014 2015 2016 2017 2018
% p
erce
nta
ge
OECS TB Trends-Case Detection 2014-2018
TB Case Detecton Rate TB/HIV Case detection Rate
Source: Global Tuberculosis Control Report 2019OECS M&E Reports 2019
TB Case detection rate have exceeded 70% target set by WHO
OECS TB Notification by Country
12
0
16
3
3
1
35
6
0
5
4
6
2
23
0 5 10 15 20 25 30 35 40
Antigua &Barbuda
St. Kitts & Nevis
St. Lucia
Dominica
St. Vincent&Grenadines
Grenada
Total
OECS Country Profile TB Notified Cases 2013 vs 2018
2018 2013
34% Reduction in TB CasesTotal of 23 new cases in 2018
Source: Global Tuberculosis Control Report 2014, 2019
Type of TB
0
5
10
15
20
25
Antigua &Barbuda St. Kitts & Nevis St. Lucia Dominica St.Vincent&Grenadines
Grenada Total
No
. of
Cas
es
Type of TB 2018
Pulmonary Non Pulmonary
13%
87%
Source: Global Tuberculosis Control Report 2019
Bacteriological Confirmation
40
0
100 100 100
50
78.2
0
20
40
60
80
100
120
Antigua &Barbuda St. Kitts & Nevis St. Lucia Dominica St.Vincent&Grenadines
Grenada Total
%
%BACTERIOLOGICALLY CONFIRMED AMONG PULMONARY CASES 2018
Source: Global Tuberculosis Control Report 2019
TB Treatment Outcomes
79%
4%
9%
4%4%
OECS 2016 TB Cohort
TreatmentSuccess
Failed
Died
Defaulted
Not Evaluated
Treatment Success for new and relapse TB patients:
WHO Target for TB Treatment Success = 85%
Rx Success OECS Cohort 2016 = 79%
Rx Success OECS Cohort 2018= 92%
Source: (OECS PUDR Report 2018 and 2019)
Source: OECS M&E report 2018
MDR-TB
0.3
0.16 0.16
0
0.2
0.4
0.6
0.8
1
1.2
1.4
ANTIGUA St. Kitts & Nevis St. Lucia Dominica St.Vincent&Grenadines
Grenada OECS
No
of
case
s
OECS MDR-TB- 2005-2017
Estimated MDR Cases Confirmed MDR-TB Cases Started on Treatment
Source: Global Tuberculosis Control Report 2012-2019
MDR-TB/HIV Testing(2018)
CountryNo. of notified
cases
% Notified TB Cases Tested with rapid diagnostics at time
of Diagnosis % Tested for HIV
Antigua &Barbuda 6 No data 100%
St. Kitts & Nevis 0 NA NA
St. Lucia 5 100% 100%
Dominica 4 No data 50%
St. Vincent&Grenadines 6 100% 100%
Grenada 2 0% 50%
OECS 23 40% 80%
Source: Global Tuberculosis Control Report 2019
TB/HIV
8.7
0
5
10
15
20
25
30
2013 2014 2015 2016 2017 2018
% p
erce
nta
ge
OECS TB/HIV coinfection rate 2013-2018
Source: OECS M&E Reports, 2019
TB/HIV Collaboration
3186
2547
2052 2 14
0
500
1000
1500
2000
2500
3000
3500
Estimate HIV PLHIV Diagnosed PLHIV screened forTB
Number TB casesdiagnosed
Number TB givenART
Number of HIV+given IPT
Reducing the Burden of TB in HIV Registered Patients OECS 2017
80 % PLHIV know their status
8% PLHIV screened for TB
1% TB/HIV case detection rate
100% TB/ARTTreatment for TB/HIV co-infected patients
< 1% PLHIV on IPT
Source: OECS TB/HIV Epidemiology Report 2018
Prevention
MethodsChallenges• TB is not taken as a serious disease because of
low prevalence
• Limited funding and human resource capacity for public education campaigns
• Limited knowledge of patients and health care providers on TB
• Weak infection control programs in congregated settings
OECS National Country Assessments 2017-2019. PAHO
Diagnosis-TB and LTBI
Methods
•
Challenges
• No available in-country TB culture and DST diagnosis
• Limited in-country Gene Xpert capacity
• Delays in Specimen collection and Transport
• Delays in reporting TB diagnosis
• Laboratory network not fully accredited
OECS National Country Assessments 2017-2019. PAHO
Treatment
Methods Challenges
• Initiating community, based TB treatment
• Limited accessing of Fixed Dose combinations for TB patients
• Updating clinical training of health care providers
• Treatment adherence and recapturing of treatment defaulters
OECS National Country Assessments 2017-2019. PAHO
Care and Support
Methods Challenges
• TB Stigma and Discrimination
• Non-existent TB support Groups
• Limited social financial assistance when hospitalized
OECS National Country Assessments 2017-2019. PAHO
TB Health information
Methods Challenges• TB registers are paper based and not
standardized
• The flow of information is defined but the system is fragmented
• Consolidation of patient characteristic i.ediagnosis, treatment and follow up to generate profile is lacking
• TB,TB/HIV Cohort analysis is weak
• Limited in-country M&E capacity
OECS National Country Assessments 2017-2019. PAHO
TB- Case findings
Methods Challenges• The flow of information is defined but the
system is fragmented• TB case definitions and classifications do not
always follow WHO recommendations• TB contact tracing performed but not always
recorded• Latent TB infection screening is poorly done
is hard to reach populations• TB case finding activities are usually passive
based on symptoms, but not always with a clear definition of a presumptive case.
OECS National Country Assessments 2017-2019. PAHO
Global Fund sponsored high impact TB interventions
Gene Xpert MTB/RIF: (Grenada, St. Lucia, St. Vincent& Grenadines, Antigua and Barbuda)OECS HIV/TB End of Project Report- Global Fund 2019
Global Fund sponsored high impact TB interventions
https://slucbs.org
System captures:TB/HIV Collaborative Activities:
HIV/TB on ART HIV/TB on CPT HIV screened for TB (Mantoux) HIV placed on IPT
OECS TB Elimination
0
1
2
3
4
5
6
7
8
9
2014 2015 2016 2017 2018 2027 2035 2042 2050
Per
10
0,00
0 p
op
ula
tio
n
OECS TB Elimination 2014-2050
Estimated TB Incidence WHO Global TB Strategy TB Notification rate
Pre- Elimination GAP TB
Elimination
OECS TB, TB/HIV Strategic
Interventions
GOVERNANCE
INFORMATION, EDUCATION, COMMUNICATION
SURVEILLANCE , MONITORING & EVALUATION.
RESEARCH & INNOVATION
STRATEGIC HEALTH INFORMATION
DIAGNOSIS , TREATMENT & CARE
OECS TB, TB/HIV Strategic for TB Elimination
Strategies for TB Elimination(Governance)
•Strengthen co-ordination of TB services with private sector and encourage public/ private sector mix
Increasing domestic funding for TB in National Health Budget through Regional Health Care Financing
Development of TB/HIV/Diabetes (Chronic Disease) Collaborative Committee
PUBLIC INFORMATION AND
EDUCATION ON TB & TB/HIV
INCREASED PUBLIC EDUCATION AND AWARENESS CAMPAIGNS OF TB USING PRINT, RADIO, TV AND SOCIAL MEDIA
PROMOTE WORLD TB DAY ESTABLISH INTER-MINISTERIAL AND INTERSECTORAL COLLABORATION ON TB,HIV EDUCATION IN COMMUNITIES AND SCHOOLS
OECS Strategies forTB,TB/HIV Elimination(IEC)
Optimize TB Diagnosis, Treatment and Care for all forms of TBOptimize
Scale up introduction of Gene Xpert and access to culture, DST and speciation diagnosis in all countries Scale up
Build capacity for supporting TB patients and educating them on human rights. Build
Expand OECS PPS pool procurement of TB medicines and diagnostic suppliesExpand
Provide appropriate treatment for TB , LTBI in high risk groups.Provide
Accelerate accreditation of hospitals within laboratory networkAccelerate
Optimize MDR-TB Prevention and CareOptimize
OECS Strategies for TB,TB/HIV EliminationDiagnosis and Treatment
Strategies for TB Elimination(Surveillance Monitoring and Evaluation- Case finding-contact investigation)
Ensure development and implementation of
regional TB outbreak Management Plan
Implement Port Health Policy for TB screening
of migrants and enhanced screening in
congregated settings i.eprisons
Upgrade and train stakeholders on contact
tracing, Standard Operating Procedures and infection control.
Strengthen human resource capacity for
Monitoring and Evaluation and TB
Program Management
Targeted systemic screening of high- risk groups using evidence
based research geographic mapping
Strategies for TB Elimination(Strategic Health Information)
Implement a comprehensive information system for TB &TB/HIV Surveillance, monitoring and evaluation (Strategic Health Information)
Implement
Upgrade paper- based TB, TB/HIV, MDR-TB records and registers complemented by a standardized integrated TB/HIV/STI case-based surveillance system.
Paper
Scale up training of case base surveillance system users. Scale up
Integrate TB information system into National Health Management Information system in public and private sector.
Integrate
Strategies for TB Elimination(Operational Research& Innovation)
Collaborate with partners such as Medical Schools and the Caribbean Health Research Council from CARPHA to strengthen operational research i.e TB Speciation, Needs Assessment, TB Treatment Outcomes, Geographic mapping, TB Cost Analysis.
TB Elimination as an OECS Region is possible
• Updating and Implementation of regional TB Policies and OECS Regional Strategic Plan
• Continued Focus on Health Systems Strengthening-Grant implementation- Global Fund
• Accelerated inter island collaboration through a common health space and agenda-• Regional Meetings OECS Heads of Ministers
• Joint advocacy efforts - UN General Assembly High level meetings
Thank you!
References
Global Tuberculosis Reports 2013-2019
M&E Quarterly Data: OECS Commission
Epidemiology of TB/HIV in OECS 2018. C. d’Auvergne
National TB Country Assessment Reports: PAHO (2017-2019)
OECS Infection Prevention and Control Summary Assessment: A. HART
Main results and findings of the TB assessments in OECS countries: Rafael Lopez PAHO
Air Pollution and Climate change: https://www.iass-potsdam.de/en/output/dossiers/air-pollution-and-climate-change
new WHO global TB strategy, 2016-35, a
The epidemiology of tuberculosis in the Pacific, 2000 to 2013. Kerri Viney etal