Monitoring and evaluation of LTBI screening in the UK. Dr Dominik Zenner

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1 Monitoring and evaluation of LTBI screening in the UK Dr Dominik Zenner

2 Outline Background UK epidemiology A new strategy for England LTBI screening in the UK The programme Monitoring Evaluation Preliminary data Conclusions 2

3 UK epidemiology: a whistle stop tour In 2013 UK TB incidence 12.3/100,000 73% occurred among people born outside the UK 85% of these occur more than two years post entry Time between entry to the UK & TB diagnosis for non-uk born TB cases by year, UK, 2013 Three-year average tuberculosis case rates per 100,000 by local area, UK, Source: Enhance Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS) Data as at: May Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England Source: Enhance Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI), Office for National Statistics (ONS). Data as at: May Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England 3

4 The TB strategy for England Improving access and early diagnosis High quality diagnostics High quality treatment and care services Contact tracing Vaccination Tackling drug resistance Tackling TB in underserved populations New entrant screening for LTBI Effective Surveillance and Monitoring Workforce strategy 4

5 The national LTBI screening programme Primary care based screening Secondary care based treatment National protocols and pathways Fully-funded Monitoring and evaluation Eligibility criteria a) Born or spent >6 m in high TB incidence country (>150/100,000 or SSA) b) Entered the UK within the last 5 years (including entry via other countries) c) Aged between years. d) No history of TB or LTBI e) Not previously screened for LTBI in UK 5

6 New registration Identification from existing databases Eligible for national LTBI screening programme 1 Identified at registration Invitation letter 3 Suspected active TB? 2 Appointment in primary care Signs, symptoms, investigations 4 Suspected underlying illness (e.g. immunosuppression / HIV) Yes? Consider further tests (e.g. HIV) & refer TB clinic Inform and advise Negative Negative Or declined No Offer IGRA test* Repeat IGRA Indeterminate Positive Indeterminate Further assessment and treatment for active or latent TB as appropriate Review indication for LTBI screening using NICE guidance (e.g. if outside age group) *Also offer HIV test according to BHIVA/ HPA recommendations Consider Hepatitis B/C testing where appropriate 1 Full eligibility criteria a) Born or spent >6 months in high TB incidence country (150 cases per 100,000 or more/ Sub-Saharan Africa) b) Entered the UK within the last 5 years (including where entry was via other countries (e.g. within EU/EEA) c) Aged between years. d) No history of TB (either treated or untreated) e) Never screened for LTBI in UK 2 TB contacts should be referred to the local TB service. TB-suggestive symptoms include a) Cough > 3 weeks b) Haemoptysis (cough with blood) c) Night sweats d) Unexplained weight loss e) Unexplained fever f) Lymph node swelling (especially cervical) 3 The invitation letter advises patients to seek clinical care if they have symptoms of TB 4 The recommended investigations prior to referral will depend on local arrangements, but might include CXR and sputum collection as appropriate NB colours of the boxes denote location and responsibilities: blue systematic call (PHE or GP); Yellow - Primary Care; Orange Secondary Care 6

7 Data capturing 7

8 8

9 LTBI screening monitoring Process indicators to ensure the programme runs and delivers well 1. Screening acceptance 2. LTBI positivity 3. Treatment uptake 4. Treatment completion 5. Toxicity By geography, demography, service provider and intervention type Three national indicators for LTBI 1. The number of local authorities that have a systematic new entrant LTBI screening initiative in place 2. Proportion of eligible new entrants covered by screening programmes who accept LTBI screening 3. Proportion of individuals who complete LTBI treatment amongst those who start treatment 9

10 Screening intervention evaluation Outcome assessment of effectiveness and cost effectiveness Prevalence of active cases Incidence of active cases Deaths a. Overall b. TB-related Costs of the programme Of those offered screening Stratified by geography, demography, service provider and treatment status Case ascertainment through probabilistic matching to UK national TB surveillance Estimating effectiveness prevalent cases diagnosed early incident reactivation cases prevented Estimating cost per case detected and prevented Modelling impact on incidence in England 10

11 Early monitoring data By March: 3,272 IGRA tests done among 9,468 eligible individuals (34.5%) LTBI rate 26.5%, Treatment referral rate increased from 47% to 66.9% 11

12 Summary TB rates in the UK are 12.3/100,000 and the majority of cases occur amongst migrants from high incidence countries LTBI re-activation is key driver of incidence in UK LTBI screening for new migrants is a key intervention of the new TB strategy for England Funded roll-out of new LTBI screening programme based on the experience of previous successful small area pilots Monitoring and evaluation is key and national LTBI surveillance is being developed The strategy has three key (process) indicators. Systematic data collection will allow detailed monitoring incl. geographical and demographic stratification. Matching LTBI surveillance to the national TB notification system will allow evaluation of effectiveness and cost effectiveness. 12

13 Thank you You may never know what results come of your action, but if you do nothing there will be no result MK Gandhi 13

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