Latent TB Infection in the WHO European Region

and recommendations on LTBI’s M&E framework

18th Wolfheze workshops / 15th NTP managers meeting,

31 May – 02 June 2017

Dr Andrei DADU

Technical officer,

Joint TB, HIV/AIDS and Hepatitis Programme

Why Do We Have Drug Resistance on raise?• Inadequate treatment

– Incorrect regimen (lack of drugs or knowledge)

– Poor adherence

Treatment failure / relapse with drug resistant TB

Transmission of drug resistant TB

• It is far easier to prevent TB in those infected without disease than to treat a full blown case of drug resistant TB

Dye C et al., Prospects for Tuberculosis Elimination. Ann Rev Public Health 2013. 34:271-86

Scale-up of programmatic management of LTBI is critical in order to end

the global TB epidemic as stated in the WHO’s End TB Strategy.

LTBI management contributes to the End

TB Strategy targets

• Mitigation of risk e.g. HIV prevention/ART

or prevention of infection by vaccine or

infection control have limited impact on the

trajectory of drop in TB incidence

• and so is the case with treatment of active

TB alone

• However identification and treatment of

latent infection in combination with active

TB treatment can potentially accelerates

reduction in TB incidence and achieve the

End TB Strategy target

Incidence of TB, projections to 2050

GLOBAL TB PROGRAMME

WHO LTBI 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)

Recommendations for investigating contacts of persons with infectious

tuberculosis in low- and middle-income countries

WHO guidelines 2012

Guidelines on the management of latent tuberculosis infection (high and upper

middle-income countries with TB incidence <100/100, 000)

WHO guidelines 2014

http://whqlibdoc.who.int/publications/2011/9789241500708_eng.pdf

http://apps.who.int/iris/bitstream/10665/77741/1/9789241504492_eng.pdf

http://apps.who.int/iris/bitstream/10665/136471/1/9789241548908_eng.pdf

Revised LTBI estimates

Published: October 25, 2016

1 MDR is found in each 4 TB in Europe

L MDR-TB I *:

All ages = 31 millions

0-14 years = 610 thousands

0-4 years = 260 thousands

* Provisional estimates / unpublished

120,000Estimated of all new RR/MDR-TB emerging

74,000Estimated RR/MDR in all notified TB

47,000Detected RR/MDR cases among all TB notified cases

MDR-TB and their contacts

260,000

Contacts of 0-4 years oldRR/MDR-TB

148,000

94,000Modified from JA Seddon et al, Lancet 2012

TB Incidence>=100 or lower/lower-middle income

TB incidence<100 and upper/upper-middle income

TB >=100 or lower/lower-middle income

TB <100 and upper/upper-middle income

TB Incidence>=100 or lower/lower-middle income

TB incidence<100 and upper/upper-middle income

Target countries for LTBI packages

A snapshot of the WHO’s key recommendations

E. LTBI PROGRAMMATIC MANAGEMENT AND VACCINATION AGAINST TB

PILAR 1> INTEGRATED, PATIENT CENTRED CARE AND PREVENTION

LTBI in the TB Action Plan in EUR 2016-2020)TB Action Plan in EUR 2016-2020):

• MS to adopt and adapt their national policies to align with the most up-to-date WHO recommendations

on diagnosis and treatment of latent TB infection for high-risk populations.

• MS to ensure that WHO policy recommendations on BCG vaccination for infants are implemented and

BCG revaccination is discontinued.

• MS to ensure that people accessing harm-reduction services for drug misuse will be provided the option

of TB preventive therapy.

LTBI treatment enrollment rate among PLHIV (%)

in 2015: 36% IPT coverage

among those newly enrolled into

HIV care

vs.

in 2011 4.8% as a baseline

70%

50%

40% 39%

33%

19%14%

10% 9%

3%0%

36% 36%

90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LTBI in Global TB data collection form (EUR section only)

Country X, 2015 dataTotal pop. = 3 mln0-4 years pop. = 200 000Contacts, estimates = 4 000Actually screened = unkLTBI eligible = unkIPT enrolment = unk

National policy is available but rarely implemented and not reported

LTBI in Global TB data

collection form (only for EUR)Conutry Y, 2015 data

Total pop. = 4 mln

0-4 years pop. = 700 000

No LTBI national policy

0-4 years contacts, est. = 4 600** By A.Dadu based on Houben & Dodd

0-4 years screened = 514 (14%)

0-4 year LTBI eligible = 496

0-4 year IPT enrolment = 136 (27%)

PLHIV, IPT enrolment = 19%

National policy is available but rarely implemented

targeting risk groups not recommended

23

3 3 2 2 2 2 2 2 2 1

National policy on systematic screening for LTBI

3

1 1

2

Communitycontacts

Previoustreatment for TB

Military School children

TB incidence > 20/100k 36 countries responded

TB incidence < 20/100k 8 countries responded

Challenges: policy implementation and practices

• Weak LTBI [surveillance] and [response monitoring] in

countries and therefore poor data at regional level;

• Poor cascade analysis understanding contacts children

(weak cascade analysis)

• Estimates/Projections modelling and Drugs forecasting

• HCW commitment/engagement due to high overload on

tasks and responsibilities

• Country health system that prevent the LTBI rolleout

• Challenges in LTBI resources mobilization

• Low enrolment rate in to the LTBI treatment

among PLHIV (the beginning of the

countrywide implementation)

• LTBI management miss-practices at country

level (screening/detection);

• High RR/MDR prevalence among TB cases in

the EECA countries: 9 out of top 10 global high

MDR-TB burden countries;

• Refugees and other categories of migrants

influx across the boarders;

TAG 2017 recommendations

LTBI management

• Adapt and disseminate criteria for prioritization of at-risk population among those for whom systematic LTBI testing and treatment is recommended, in agreement with the 2014 WHO policy document;

• Create an implementation guide for contact tracing, screening and management of contacts. Evaluate the opportunity for recommending active search of the contacts (children to be prioritized);

• Analyse bottlenecks in implementation of LTBI testing and treatment among PLHIV and children under the age of 5 who are household contacts, and propose solutions;

• Develop a framework for recording and reporting of LTBI data that allows measurements of contact and LTBI indicators, using WHO guidance document on LTBI M&E with reference to both global and national core indicators;

• Develop a regional position paper/expert opinion document on the use of Interferon Gamma Release Assays (IGRA) in LTBI detection;

• Develop a regional position paper/expert opinion document on rifapentine-containing regimens and assist Member States and partners facilitate the registration of the drug with European Medicine Agency and/or country drug regulatory authorities ;

• Promote research and assessment on LTBI.