world health organization regional office for the western pacific expanding access to tb care:...

World Health Organization Regional Office for the Western PacificWorld Health Organization Regional Office for the Western Pacific

Expanding access to TB care: Review the progress

Dr Nobuyuki Nishikiori, CoordinatorStop TB and Leprosy EliminationWorld Health OrganizationRegional Office for the Western Pacific

The Ninth Technical Advisory Group and National TB Programme Managers Meeting

Manila Philippines, 9-12 December 2014

World Health Organization, Western Pacific Regional Office

Regional Strategy to Stop TB in the Western Pacific 2011-2015

Vision: Elimination of TB as a public health problem

Strategic Priorities

1. Promoting universal and equitable access to quality TB diagnosis and treatment for all people

2. Strengthening TB Laboratory capacity

3. Scaling up the programmatic management of drug-resistant TB

4. Expanding TB-HIV collaborative activities

5. Strengthening TB programme management

Goal: To reduce prevalence and mortality from all forms of TB by half by 2015, relative to 2000 level, in all countries with a high burden of TB, by moving to universal access to diagnosis and treatment of all forms of TB, including smear negative and M/XDR-TB.


Frameworks for analysis:

Patient pathwaysOnion layer analysis

World Health Organization Regional Office for the Western Pacific

Actions for improved case detectionMinimizing physical, financial and social

barriers

Improved health

communi-cation

Engaging all care providers

Improved diagnostic

tools

Patient pathway

Symptoms recognized & patients take

action

Health care utilization

Notification

Infected

Health services delay

Access delay

Pat

ient

del

ay

Active TB TBDiagnosis

Improved reporting

system

Regional Strategy to Stop TB in the Western Pacific (2011-2015), WHO WPROAdapted and modified from “Action framework for higher and earlier TB case detection”, WHO


Onion layer analysis – Where are missing TB cases?

Whole onion. All TB cases

Layer 6. No access

Layer 5. Do not seek care

Layer 4. Failed to be diagnosed

Layer 3. Non-NTP provider non-reporting

Layer 2. Initial loss to follow up and reporting failure

The core. Notified TB cases

L6. No access to health care

L5. Patients do no seek care

L4. Presenting to health facilities, but

undiagnosed

L3. Diagnosed by non-NTP, not

notified

L2. Diagnosed by NTP but not notified

Notified cases

? %

? %

? %

? %

? %

CDR=?%

(Layer 6) Health care coverage by province

Distribution of children who got all vaccinations

Distribution of women who were protected by TTI

Distribution of women who went to ANC during pregnancy

Distribution of women delivered at health facility


Wong MK, Yadav RP, Nishikiori N, Eang MT. The association between household poverty rates and tuberculosis case notification rates in Cambodia, 2010. WPSAR 2013 Jan;4(1):25–33.

(Layer 5) Treatment seeking behaviour of people with TB symptoms in Philippines

Nationwide TB Prevalence Survey 2007, Philippines

Public

Hospital

Public

HospitalPublic clinic

Public clinic

9%

Private Hospital

Private Hospital

6%

Private clinic

Private clinic

7%

DOTS Center

DOTS Center

9%

25%No Action

43%Self Medication

32% Sought Care

People with TB Symptoms in the community (identified by survey)


Financial hardship of TB patients and familiesA half of financial burden before diagnosis

• TB patients in low-and middle-income countries face expense equivalent to more than 50% of their annual income.

• On average, half of the costs are incurred before TB treatment has begun – in seeking diagnosis.

• Patients often have to resort to coping mechanisms that may be irreversible: – up to 75% of TB patients must take out a loan; – up to 50% sell household items; and – up to 66% rely on financial support from relatives.

• Addressing catastrophic patient cost is prerequisite for further advancing TB control


Actions for improved case detection

Contact investigation

•Children•Household•Workplace

Clinical risk groups

•HIV•Smokers•Diabetics•Previous TB•Malnourished•Drug abusers

Risk populations•Prisoners•Urban poor dwellers•Migrants•Workplace (HCW)•Elderly

Active Case Finding (TB Screening)

Minimizing physical, financial and social

barriers

Improved health

communi-cation

Engaging all care providers

Improved diagnostic

tools

Patient pathway

Symptoms recognized & patients take

action

Health care utilization

Notification

Infected

Health services delay

Access delay

Pat

ient

del

ay

Active TB TBDiagnosis

Improved reporting

system

Regional Strategy to Stop TB in the Western Pacific (2011-2015), WHO WPROAdapted and modified from “Action framework for higher and earlier TB case detection”, WHO


TB high risk groups


Mapping and prioritizing risk groups: Considerations in two dimensions

TB high risk groups• Increasing case

detection• Reducing

transmission through early detection

• Mitigating institutional amplifiers

Vulnerable and marginalized

• Targeted service provision to increase access to quality TB care

• Addressing health inequity

Diabetes patients

Tub

erc

ulo

sis

ris

k

Vulnerability / limited access to health care

Smokers

TB contacts

PLHIVPrisoners

Migrants

Urban slum

Elderly

Remote areas

Minorities

Poor / malnourished


Contact investigation• Project Policy in Philippines:

– CATCH TB project in Metro Manila informing CI policy

– Policy on TB in children • Viet Nam CI study

– ACT1: Pilot in Hanoi completed– ACT2: A Nationwide intervention

trial with periodic screening

• Community-based CI in Cambodia– 2005-2011: experience in

community based ACF among contacts and neighbours (adult and children)

– Massive expansion 2012-2013• Enhanced CI in Mongolia

– Piloting enhanced methods with home visit in 2013/2014


Cascade towards full implementation

Global Policies

Pilots Initiatives

Country policies

Scale up

ExperienceEvidence

DocumentationEvaluation

ExperienceEvidence

DocumentationEvaluation


Diabetes

• TB risk (relative to general pop)– Diabetes: 3.1 times higher TB risk– Dose response relation:

poor control higher TB risk

• Delayed sputum conversion, death during TB treatment, and relapse

Cumulative hazards for active TB by diabetic status, among a cohort of clients (>65yrs) registered with an elderly health service in Hong Kong

Leung, et al. 2008. "Diabetic control and risk of tuberculosis: a cohort study." Am J Epidemiol 167(12): 1486-1494.

HbA1c >= 7%:annual incidence 422 per 100 000

No diabetes: annual incidence 214 per 100 000

DM prevalence* PAF**

Cambodia 4.2% 8.1%

China 9.4% 16.5%

Lao 6.2% 11.5%

Mongolia 8.7% 15.4%

PNG 13.3% 21.8%

Philippines 5.8% 10.9%

Viet Nam 6.9% 12.7%

* WHO Global Health Obserbertory, ** Population Attributable Fraction based on a relative risk of 3.1 for active TB among diabetics.


TB-DM collaborative framework

Diabetes clinic TB DOTS clinic

Case finding:•Intensify detection of TB among DM patientsCare delivery:•Ensure TB infection control•Ensure high quality TB treatment and management

Outcome:•Better control for DM by detecting and treating TB early

Case finding: •Screen TB patients for diabetes

Care delivery:•Ensure high quality diabetes management

Outcome: •Better TB cure, less relapse by controlling DM

Effective Referral and coordination

Establish mechanisms for

collaboration

(Stop TB, WHO WPRO, based on “Collaborative Framework for Care and Control of Tuberculosis and Diabetes”, WHO/IUATLD, 2011)


Migration: diverse populations, diverse issues

Internal migrants• Mainly rural to large cities• Issues: access to services , care delivery• Focus areas: Large cities and industrial areas

Cross-border population movement• Mostly economically driven (but inc refugees)• Issues: legal issues (detention, repatriation),

high-risk behaviours, health access and care delivery

• Focus areas: Mekong countries including China

Floating population• Homelessness, urban slums, mining

communities, etc• Issues: access to services, care delivery• Focus areas: Large cities and development areas

(mines, etc)

Labour immigration• Endemic to less endemic countries• Issue: importation of infectious diseases,

international referral, access to services• Focus areas: Intermediate burden countries and

areas

Migration and TB

(Stop TB, WHO WPRO)


Addressing TB among migrants

• WPRO’s TB & Migration Framework finalized in 2013

• TB Elimination Framework now explicitly elaborate TB among migrants

• Various studies/supporting schemes in China (internal migrants)

• Cross-border project/information sharing (Lao PDR, Cambodia)

• Study on TB among foreigners (Malaysia)

Hui Lu, Fei Yan, et al. WPSAR 2013 Jiang SW, Li XX, et al. 2013


Progress in TB control in prisons

• Expansion of TB control in prisons and jails in Philippines

• Advanced ACF project in Palawan • Visible reduction in TB burden in Mongolia

2007 2008 2009 20100

200

400

600

800

1000

7514

402

685

Progress in TB case detection in prisons, Philippines

Pilot Sites (7 prisons and jails)Non-Pilot sites

Num

ber o

f TB

case

s

(NTP Philippines)(NTP Mongolia)

Global Fund (2005-)

Joint Ministerial Order (2002-)


Public-Private and Public-Public Mixinc Hospital Linkage

PPM in general• Steady progress in PPM in all countries

in the Region

Engaging hospitals• What are expansion models after

successful pilots in Viet Nam and Philippines

• Public health reform in China leading to increased roles of hospitals in China

Ensuring quality of care is continuous challenge


National level coordination, planning and evaluation


National workshop on TB high risk and vulnerable populations

• Participants– All stakeholders: TB partners / Non-TB

health programmes / Non-health sector partners

• Objectives: – Review global and in-country evidence; – Share experience of the work targeting

TB high risk populations; – Discuss on potential areas of

collaboration for improved access to TB services for TB high risk populations.

• Outcomes: – Strengthening and establishing

partnerships (inc inter-ministerial discussion)

– All partners’ effort harmonized under NTP


What we can do for them?Don’t jump into ‘ACF only’ approach

• Information / communication

• Diagnosis

• Treatment

• Addressing the need

Group sensitive methods and contents

Campaign Routine Integrated screening (e.g. diabetes

clinic) Outreach (e.g. community-based) Routine Specific care delivery strategies Specific enablers Social support (welfare-link)


Evaluation

• TB screening activities generating wealth of data• Regular evaluation critical:

– to assess TB burden among a target group– to make a rational decision on the continuation of the

screening

• Still grave needs to expand global evidence base


Contacts

Contacts

Prison

Prison

Migrants

Elderly

Elderly

Elderly

Community-based

Urban slum

Urban slum

Diabetes

Diabetes

Diabetes

Children


Summary

• Analysis of missing cases guide identification of priority actions – Patient pathway– Onion layer analysis

• Much progress made in addressing TB among high risk groups– At various stages in terms of policy, pilot, expansion cascade– Documentation and analysis critical to generate evidence to

inform national and global policies

• Coordination and prioritization under NTP umbrella key for synergetic progress

world health organization regional office for the western pacific expanding access to tb care:...

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forms of tb

coordinatorstop tb

elimination of tb

tb caseslayer

quality tb diagnosis

high burden of tb