TB or not TB? Strategy and Policy

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TB or not TB? Strategy and Policy

• Grace Smith
• HPA Regional Centre for Mycobacteriology, West
  Midlands Public Health Laboratory,
• Birmingham Heartlands Hospital

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GLOBAL STRATEGY TO STOP TB
NICE
STRATEGY for ENGLAND AND WALES
CMOs ACTION PLAN
CONNECTING FOR HEALTH
HPA TB PROGRAMME
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Actions for Life - Towards aWorld Free of
TuberculosisA focus on the global plan to stop
TB 2006-2015

• On January 27th 2006, The Stop TB
• Partnership launched its Global Plan to Stop TB
• for 2006-2015.
• The Plan requires 56 billion to
• carry out its aims - less than 1 per day of
• healthy life gained, with 14 million lives saved
• by 2015.
• With this money, the Plan aims to
• halve deaths from TB in the next ten years and
• provide treatment for 50 million people.
• Ultimate aim of the Stop TB Partnership is to
• eliminate TB as a global health problem by 2050

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The First Global Plan2001-2005

• Patients treated DOTS programmes being doubled
  over 5 years, from 2 million in 2000 to 4 million
  in 2004.
• Improvement in case detection - both India and
  China, which account for 35 of the world's TB
  cases, are now close to the target of 70 case
  detection.

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Global Plan to Stop TBfor 2006-2015.

• Based on WHO's Stop Tuberculosis Strategy, builds
  on the 2001-2005 Plan.
• Seeks to deliver more on the ground and
  emphasises the issues of HIV/TB co-infection and
  multi drug resistant TB through adapting the use
  of DOTS.

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Global Plan to Stop TB for 2006-2015. Barriers

• Increasing the accessibility of quality anti-TB
  drugs
• Addressing the social burdens of the disease for
  patients.
• Health services also need to be adequately
  resourced and committed to eliminating TB.

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Global Plan to Stop TB for 2006-2015.Targets

• More effective tools for fighting TB
• Diagnostic tests at the point of care by 2012
• A safe, effective and affordable vaccine by 2015
• a shorter treatment regime of 1-2 months by 2015.
• The Global plan is available at the Stop TB
  Partnership Web Site www.stoptb.org/globalplan/.

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Meeting the Millennium Development Goal on
TuberculosisHow will Britain Help Deliver on the
Global Plan to Stop TB, 2006-2015?

• Key Challenges
• Lack of funding for the plan,
• Limited research
• Inequitable access to new tools and diagnostics,
• Lack of awareness of TB amongst the public, TB
  patients, parliamentarians, policy-makers and the
  media,
• The additional burden of TB/HIV co-infection,
• High levels of poverty
• Poor health infrastructure and resources in the
  developing world.
• If the targets of the Global Plan are to be met,
  greater awareness of the Global TB epidemic and
  the Plan be is necessary alongside a three-fold
  increase in financial investment in TB control
  over the lifespan of the plan.

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What should the UK be doing to ensure fulfilment
of the Global Plan to StopTB, 2006 2015?

• If the global plan to stop TB is to be met,
• TB needs to be a far greater political priority
  in both the UK and the developing world.
• This commitment should extend to long-term and
  sustained financing,
• To the development of new tools and diagnostics,
  available for all,
• To support for the strengthening of human
  resource capacity and health systems.
• In addition there must be greater collaboration
  between the pharmaceutical industry and patients,
  civil society and the development of
  public-private partnerships if the ambitious
  targets of the Global Plan areto be met.

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Stopping Tuberculosis in England An Action Plan
from the Chief Medical Officer October 2004
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The TB Programme goals
Long-term goal is a reduction, and ultimately
elimination, of tuberculosis in this
country. Working towards this goal, the
immediate aims of our national TB programme are
to reduce the risk of people being newly
infected with tuberculosis in England provide
high quality treatment and care for all people
with TB maintain low levels of drug resistance,
particularly multidrug resistant (MDR) TB
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Rising to the challengea can-do philosophy

• In the United States of America (USA)
  tuberculosis re-emerged during the 1980s and
  early1990s. The disease was out of control.
• With a clear plan, a national focus, and a build
  up of infrastructure and resources at local,
  state and national levels, the tide was turned.
• Between 1992 and 2002, TB cases decreased by 45
  per cent and rates of TB halved to five per
  100,000 population, the lowest ever recorded.
• Control of TB in this country can be achieved
  with a similar level of commitment to that shown
  in the USA.

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In the short term the total number of new TB
cases reported each year may rise because
Firstly ,of infection acquired abroad
Secondly, of latent infection acquired in the
past ,but reactivated with waning immunity
Thirdly, increasing size of some of the
population groups most at risk
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What will success look like?

• Within the next three years
• a progressive decline (of at least two per cent
  per year) in rates of TB in population groups
  born in England
• a reduction in the incidence of disease among
  people who entered the country and became
  resident here within the previous five years
• no more than seven per cent of new cases
  resistant to the anti-TB drug isoniazid and two
  per cent multidrug resistant
• a reduction in the number of human cases of
  bovine (cattle) TB in people under the age of 35
  years and born in the UK

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Targets

• Evidence and experience show that TB control is
  likely to be achieved if
• all patients with suspected pulmonary TB are
  seen by the TB team within two weeks of first
  presentation to health care
• at least 65 per cent of patients with pulmonary
  TB have the diagnosis confirmed by laboratory
  culture of the organism
• all patients diagnosed with TB have the outcome
  of their treatment recorded,
• and at least 85 per cent successfully complete
  their treatment

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Recommended actions

• 1 Increased awareness
• 2 Strong commitment and leadership
• 3High quality surveillance
• 4 Excellence in clinical care
• 5 Well organised and co-ordinated patient
  services
• 6 First class laboratory services
• 7 Highly effective disease control at population
  level
• 8 An expert workforce
• 9 Leading edge research
• 10 International partnership

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Key DH and HPA groups involved in the
implementation ofthe National TB Action Plan
Department of Health
Overall Strategy and Policy
TB Action Plan Stakeholders Group
TB Action Plan Steering Group Chair Dr David
Harper
HPA TB Programme Board Chair Prof Pete Boriello
Working Groups-Fixed Term
Strategy and Policy (Specific Issues)

• Monitoring and Laboratory Standards Group
• Dr Grace Smith

• Commisioning Group
• Prof Rod Griffiths

• Delivery Group
• Dr John Moore-Gillon

Diagnostics and Molecular Epidemiolgy Forum (DAME)
HPA Operational Groups,LaRS ,Surveillance
Operational and Delivery Issues
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NICE guidelinesClinical diagnosis and
management of tuberculosis,and measures for its
prevention and control

• March 2006 www.nice.org.uk.
• Key Priorities
• Managing Active TB
• Improving Adherence
• New Entrant Screening
• BCG Vaccination

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Diagnosing active TBRespiratory TB
Take a chest X-ray if this suggests TB, arrange
further tests. ? Send at least three sputum
samples (including one early morning sample) for
culture and microscopy. ? Samples should be
spontaneously produced if possible. If not
possible in adults, use induction of sputum or
bronchoscopy and lavage in children, consider
induction of sputum if it can be done safely, or
gastric washings if not. ? Take samples before
starting treatment if possible, or within 7 days
of starting. ? Start treatment without waiting
for culture results if the patient has clinical
signs and symptoms of TB, and complete treatment
even if culture results are negative. ? Send
autopsy samples for culture if respiratory TB was
a possibility.
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Active non-respiratory TB

• ? Discuss the advantages and disadvantages of
  biopsy and needle aspiration with the patient.
• ? If non-respiratory TB is a possibility, place
  all or part of any of the following samples in a
  dry potand send for TB culture
• lymph node biopsy or pus aspirated from lymph
  nodes
• pleural biopsy
• any surgical or radiological sample sent for
  routine culture
• histology, aspiration and autopsy samples.
• ? If the histology and clinical picture are
  consistent with TB, start the appropriate
  treatment regimen without waiting for culture
  results ? Continue drug treatment even if culture
  results are negative.
• ? Do a chest X-ray to check for coexisting
  respiratory TB in all patients with
  non-respiratory TB,and consider other
  investigations

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Laboratory tests

• ? Use rapid diagnostic tests on primary specimens
  only if
• rapid confirmation of TB in a sputum
  smear-positive patient would alter their care, or
• before conducting a large contact-tracing
  initiative.
• ? If clinical signs and other laboratory findings
  are consistent with TB meningitis, start
  treatment even
• if a rapid diagnostic test is negative.
• ? If a risk assessment suggests a patient has
  multidrug-resistant (MDR) TB
• do rapid diagnostic tests for rifampicin
  resistance
• start infection control measures and treatment
  for MDR TB while waiting for the results

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Tuberculosis Surveillance Developments
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Tuberculosis Surveillance Developments

• Current Service collects and reports
• Notified cases
• Laboratory reports of new isolates ,drug
  resistance and molecular typing profiles
• Clinical reports
• Outcome reports at 12 months

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Tuberculosis Surveillance Developments

• The HPA intends to create a new web-based system
  for TB surveillance within the next financial
  year
• Improve the completeness, timeliness, accuracy
  and accessibility of epidemiological information
  on case reports (Enhanced Tuberculosis
  Surveillance) and laboratory results.
• Develop a mechanism for linking case reports and
  laboratory data so that they are available
  immediately at the local and regional levels and
  can be collated nationally in a timely and
  accurate manner.
• Link the national molecular typing database to
  routine surveillance so it can be used for public
  health purposes.

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Information for ActionTuberculosis Strain
Typing

• Molecular typing methods introduced in all RCMs
  in last 2 years, using a common method and
  applied to all new clinical isolates pf Mtb.
• National Microbial Typing Database for rapid
  comparison of strains is under development-.
  first phase of this project is approaching
  completion.
• Both are initiatives of the HPA TB Diagnosis and
• Molecular Epidemiology (DAME) Working Group.

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Connecting for HealthInitiatives in TB

• National projects that will ensure that NHS
  information systems support the clinical and
  public health activities required to deliver the
  National Action Plan for TB.
• National Knowledge Service Pilot on Tuberculosis
• Tuberculosis Do Once and Share Project.

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National Knowledge Service Pilot on Tuberculosis

• Set up after the Kennedy Enquiry To improve the
  level of information available to clinical staff
  and patients
• Provides evidence-based best practice information
  to
• healthcare professionals through 'Map of
  Medicine'
• clinical algorithms.
• Pilot is tailored for those working with at risk
• population groups such as the homeless,
• and areas of professional or public concern
  such as TB in pregnancy.
• (www.hpa.org.uk/tbknowledge/)

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Tuberculosis Do Once and Share Project

• gt40 projects that will develop care pathways for
  specific diseases or conditions based on current
  best practice.
• Establish a National Community of Interest that
  will ensure that local, regional and national
  initiatives on TB, care pathways and information
  management are coordinated
• Stakeholders include clinical TB networks, Health
  Protection Units and also Department of Health
  Steering Group and working groups charged with
  delivering the National Action Plan for
  Tuberculosis.
• www.connectingforhealth.nhs.uk/delivery/serviceimp
  lementation/kps/doas

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POTENTIAL BARRIERS (Domestic)

• Other initiatives in the NHS Choose and Book,
  Payment by results, Pathology Modernisation,
  Connecting for Health
• Wide variation in incidence of disease across the
  country.
• Funding for new tests
• Working across traditional boundaries.

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Global Barriers

• Increasing the accessibility of quality anti-TB
  drugs
• Addressing the social burdens of the disease for
  patients.
• Health services also need to be adequately
  resourced and committed to eliminating TB.