Photo: Riccardo Venturi Assessment of LTBI Policies and Practices in WHO European Region

Transcription

1 Photo: Riccardo Venturi Assessment of LTBI Policies and Practices in WHO European Region 17th Wolfheze Workshops and 13th WHO National TB Programme Managers' meeting The Hague, The Netherlands Wednesday 27 th May, 2015

2 Presentation Outline Backgrounds, objectives, and methodology LTBI Survey Results: I. Low-Incidence Countries II. (Estimated TB incidence<100/100,000 and upper/upper-middle income) High-incidence countries (Estimated TB incidence >=100 or lower/lower-middle income) III. National policy on preventive therapy for contacts of MDR-TB IV. Systematic screening for LTBI and ACF

3 WHO LTBI Guidelines Guidelines on the management of latent tuberculosis infection (high and upper middle-income countries with TB incidence <100/100, 000) WHO guidelines Recommendations for investigating contacts of persons with infectious tuberculosis in low- and middle-income countries WHO 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)

4 LTBI Survey Objectives 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

5 LTBI Survey Methodology 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%)

6 Target countries for LTBI TB >=100 or lower/lower-middle income TB Incidence>=100 or lower/lower-middle income TB <100 and upper/upper-middle income TB incidence<100 and upper/upper-middle income

7 I. LTBI Survey Results for Low- Incidence Countries (Estimated incidence<100/100,000 and upper/upper-middle income)

8 National policy on systematic screening for LTBI 83% of countries have a national policy for LTBI screening (30/36) N=36 % of countries targeting risk groups strongly recommended N=36 % of countries targeting risk groups conditionally recommended Denominator: All countries which responded to the survey including those without a national policy

9 National policy on systematic screening for LTBI N=36 % of countries targeting risk groups not recommended

10 Screening Frequency for LTBI N=15 HIV Household or close contacts, Children< 5years N= Ad hoc research Periodically < 1year Annually Periodically > 1 year Unknown N=22 Household or close contacts, aged>=5years Compromised immune status N=

11 Initial Screening methods for LTBI HIV N= Household or close contacts, children<5years N= TST IGRA Parallel testing with TST and IGRA TST followed by IGRA for confirmation Other More than one option Unknown N=22 Household or close contacts, aged>=5years Compromised immune system N=

12 Tools used to exclude active TB N=30 What does other include? What does combination of the above include, Symptom + Chest X-ray?

13 Preventive treatment regimens N=30 Recommended preventive treatment regimens (multiple answers) Single regimen Multiple regimen

14 Monitoring and Evaluation for LTBI 39% of countries are monitoring and evaluating LTBI activities (14/36) N=14 Monitoring and Evaluation Indicators

15 II. LTBI Survey Results for High- Incidence Countries (TB >=100 or lower/lower-middle income)

16 National policy on systematic screening for LTBI 62% of countries have a national policy for LTBI screening (5/8) N=8 % of countries targeting risk groups strongly recommended % of countries targeting risk groups not recommended

17 Screening frequency and methods and for LTBI Household or close contact, aged>=5 years Household or close contact, children<5 years Screening Frequency Household or close contact, aged>=5 years Household or close contact, children<5 years Data for HIV not shown as only 1 country targeting this risk group Screening Method

18 Preventive treatment regimens N=5 Recommended preventive treatment regimens

19 Monitoring and Evaluation for LTBI 62% of countries are monitoring and evaluating LTBI activities (5/8) N=5 Monitoring and Evaluation Indicators

20 III. Survey Results: National policy on preventive therapy for contacts of MDR-TB

21 Monitoring and Evaluation for LTBI Among low incidence countries, 36% have a national policy on preventive therapy for contacts of MDR-TB (13/36) Is preventive treatment recommended? Unanswered 8% N=13 N=13 Yes 23% Is clinical follow-up recommended? No 8% No 69% Yes 92% Among high incidence countries, only one indicated to have the policy. Clinical follow-up, but not preventive treatment, was recommended (1/8).

22 IV. Survey Results: systematic screening for LTBI and ACF

23 Risk Groups targeted for LTBI and ACF (Low vs. High incidence) Incidence<100 and upper/upper middle countries HIV Household or close contacts, children<5years Immigrants from high TB burden countries 39% 11% 17% 33% 72% 11% 11% 6% 22% 47% 31% TB Incidence>=100 or lower income HIV Household or close contacts, children<5years Immigrants from high TB burden countries 13% 87% 38% 12% 50% 50% 50%

24 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.

25 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

26 Plenary Discussion

27 Are rifampicin containing preventive regimens recommended for use in persons living with HIV? N=30 Low TB burden countries Unknown 10% Yes 23% No 67%

28 Are rifampicin containing preventive regimens recommended for use in persons living with HIV? N=5 High TB burden countries No 60% Yes 40%

29 Among low incidence countries: Strongly recommended No policy on LTBI Child contact not eligible Adult contact not eligible Compromised status eligible TNF eligible Transplantation eligible Chronic renal diseases eligible Miner eligible Albania, Belarus, Hungary, Latvia, Luxembourg,Montenegro Lithuania and Denmark Denmark, Finland, Lithuania, Serbia and Turkmenistan Denmark, Estonia, France, Greece, Iceland, Israel, Italy, Netherlands, Poland, Slovenia, Sweden, Switzerland, Turkey, UK Belgium Czech Finland Germany Ireland Serbia Czech Greece,Israel,Slovakia,Slovenia Turkey Estonia

30 Among low incidence countries: Conditionally 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 Drug user Homeless Belgium, Estonia, Portugal, Romania, Slovakia Estonia, Portugal Slovakia, Slovenia

31 Diabetes Community contact Not eligible General population Slums Tribal population Hospital and Health care settings Untreated fibrotic lesion Pregnancy VCT attendees Psychiatric facilities Shelter residents Nursing home resident Home for elderly Military Teachers School children Immigrants from low TB burden countries(outside Schengen) Immigrants from low TB burden countries (within Schengen) Slovakia Armenia, Azerbaijan, Denmark, Estonia, Finland, Kazakhstan, Lithuania, Serbia Turkmenistan Slovakia Slovenia Greece, Turkey Greece, Iceland Azerbaijan, Turkmenistan Estonia Estonia Estonia, Romania, Slovenia Slovakia,Estonia Slovakia,Estonia Germany, Greece,Netherland Azerbaijan, Greece Russia Greece Norway

32 High incidence countries National policy not available Georgia, Uzbekistan, Moldova Targeting HIV Not targeting contacts while having national policy Community contacts Previous treatment for TB Military School children Ukraine Armenia Kirgizstan, Tajikistan, Ukraine. All are targeting child and adult contacts as well Ukraine Armenia Tajikistan Ukraine