2. Key TB functions and efforts of
WHO
Haileyesus Getahun
Stop TB Department
WHO/HQ, Geneva.
3. WHO core functions in global TB control
1. Provide global leadership
2. Development of policy,
norms and standards
3. Technical support and
coordination
4. Monitoring and evaluation
5. Promoting research
6. Facilitate partnerships
4. Impact of WHO policies (1995 - 2010)
• DOTS/Stop TB strategy
46 million people treated
7 million total lives saved
0.23 - 0.28 million child
lives saved
1.5 million women saved
• TB/HIV activities: saved
1 million lives (2005-2010)
TB/HIV lives saved
5. NGOs for Community based TB activities
Global
• Operational policy guidance
• Define standard indicators
• Implementation manual
• Training manual
• Advocacy and visibility
Country
• National guidance
• M and E system
• Training manual
• NGOs supported
• NGOs provided TA
WHO’s new area of work
7. Urban Tuberculosis Control in
the European Union
World Tuberculosis Day, 2012
Tuberculosis Programme
European Centre for Disease Prevention and Control
Stockholm, Sweden, 19 March, 2012
9. From surveillance to public health action –
ECDC’s added value
Action Plan and
Monitoring Framework
Surveillance and
Monitoring –
Identifying and
assessing needs
Public Health Action
11. The epidemiological patterns of TB are
heterogeneous within EU
0.0
20.0
40.0
60.0
80.0
100.0
Austria
Belgium
Bulgaria
Cyprus
Czech
Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Ireland
Italy
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Poland
Portugal
Romania
Slovakia
Slovenia
Spain
Sweden
United
kingdom
Iceland
Norway
EU/EEA 2010
14.6/100,000
Source: Surveillance report, TB Surveillance and Monitoring in Europe 2012 (2010 data)
12. Pattern of TB situation in big cities
differs across the EU
Disclaimer: Survey performed by the Metropolitan TB network, www.metropolitantb.org Please note that ECDC does not
collect city-level TB surveillance data and take no responsibility for accuracy of data collected for this survey.
Figure 1: TB notification rates in a selection
of countries and big cities of EU/EEA, in 2009.
43.0 / 43.2
31.9 / 62.1
81.0 / 108.2
31.9 / 38.3
17.8 / 21.6
Riga / Latvia
Vilnius / Lithuania
Warsaw / Poland
Bucharest / Romania
Sofia / Bulgaria
16.9 / 6.0
Copenhagen / Denmark
21.3 / 7.0
Rotterdam / Netherlands
23.4 / 8.2
Paris / France
44.4 / 14.8
London / United Kingdom
24.3 / 16.6
Barcelona / Spain
33.2 / 6.5
Milan / Italy
< 20 cases
per 100,000
population
≥ 20 cases
per 100,000
population
13. Pattern of TB situation in big cities
differs across the EU
High-incidence countries
TB case load appears more
generalised in the population and
evenly distributed in the country.
Equal or lower notification rates in
big cities compared to the country
overall.
Low-incidence countries
TB case load appears to
accumulate disproportionately to
big cities.
2-5 times higher notification rates
in big cities compared to the
country overall.
Two different
epidemiological
settings
15. Accumulation of TB among
vulnerable groups
TB disproportionately affects the
socially and economically
disadvantaged
Socio-economic
determinants
Differential exposure
and susceptibility
Vulnerable groups
Health inequalities
16. Vulnerable groups in urban settings
High-risk groups
- Refugees, asylum seekers, migrants
- Homeless people
- Prisoners
- Illicit drug users
- Alcoholics
- HIV-seropositive people
Other vulnerable groups
- Children
- Elderly
Characteristics of urban settings
- High population density
- Complex social structure
The most vulnerable and
excluded groups carry the most
significant burden of disease and
have the poorest access to
services.
Interaction between
individual risk factors
and urban
characteristics create
specific opportunities
for TB transmission
18. Providing guidance, advocate and monitor
ECDC’s added value
Action and outputs from ECDC of relevance
for urban TB control
European Union
Guidance
Support
Advocacy
19. Reaching out to vulnerable groups
in urban settings
Going beyond standard public
health strategies
Every patient’s right.
Novel interventions.
Collaborate between cities.
Share best practices. Working together to
eliminate TB in the
EU
21. TB - the facts
The epidemiology of TB in London
and the need for change
Dr Sarah Anderson
HPA Regional Epidemiologist - London
sarah.anderson@hpa.org.uk
22nd March 2012
22. TB in London – 2011
• 3588 cases
• 46 per 100,000 population (c.f. nationally 13.6)
• 3 times national rate, some boroughs 10x
• 42% of national burden
• Case numbers doubled in 15 yrs
• 85% cases non-UK born
• More than one in ten have ≥1 social risk factor, with high
case loads of complex patients in some areas
23. TB rates in London, 1982-2010
TB rates in London, 1982-2010
24. TB rate by sector of residence, 2004 – 2011
0
10
20
30
40
50
60
70
2004 2005 2006 2007 2008 2009 2010 2011
Rate
per
100,000
population
Year of Notification
London Total North Central North East
North West South East South West
27. Treatment
• comprises anti-TB drugs for at least six months
• occasionally causes unpleasant side effects
• completion essential - but variable completion rates
• development of drug resistant TB means using more
specialist anti-TB drugs with more side effects, worse
outcomes and greater cost
28. 0
2
4
6
8
10
12
1999 2001 2003 2005 2007 2009
Proportion
of
TB
cases
(%)
Any resistance Isoniazid resistant Multi-drug resistant
TB drug resistance, 2010
8.4% INH-R
1.6% MDR
Almost 1 in ten culture confirmed cases resistant
29. Case for Change - TB in London
TB is an infectious disease that is treatable and curable
however it remains a major public health issue
The number of TB cases has increased by 50% over the
last ten years and more than doubled over the last 20 years
In 2010, more cases of TB diagnosed in London than HIV
TB rates vary widely across the capital
30. Key issues for TB
Latent TB Active transmission
80% of active cases are from latent
TB, activated years after the patient
has become infected
More prevalent in social risk groups
including drug and alcohol users,
homelessness, prisoners and people
with mental health issues
No systematic screening – majority
identified only when disease
reactivates
Poor treatment completion rates lead
to high rates of drug resistant TB
which is costly and time consuming for
the patient and NHS
Prophylactic treatment can be
unpleasant and lengthy.
Patients from high risk groups often
present late, resulting in complications
and onward transmission of the
disease to others
31. Current service provision
5 TB networks across London with variability in
commissioning, service planning, protocols and education
Service resources, capacity and delivery does not align with
TB rates
Poor awareness of TB among health professionals
Variable uptake and administration of neonatal vaccination
32. Case for Change
The ‘Case for change’ document
- provides the evidence to support the need for change and
- highlights the risks for London if these problems are not
addressed:
• further fragmentation in TB services
• varied quality of care for patients
• increased rates of active, latent and drug resistant TB
• greater cost to the system for TB services and treatment for patients
Development of ‘Model of Care’ to address the
TB problem in London with the ultimate goal
of reducing rates of TB in London
33. The London Model of Care
Dr William Lynn
Clinical Lead, TB project
London Health Programmes
2012
34.
35. Background to the model
• Developed by the TB community involving nurses,
consultants, GPs, the Health Protection Agency and TB
networks and overseen by both a clinical working group
and project board with strong public health expertise and
service user representation
• Stakeholder events along with meetings, national and
public media, 1:1 interviews
• Over 200 individuals provided feedback including GPs,
patients, voluntary and community organisations, public
health and government committees
• There was widespread support for the plans
35
36. Model of Care
• Recommendations in the model are targeted at three
aspects of the patient pathway:
– Improving detection and diagnosis of the disease
– Better coordinated commissioning
– Addressing variability of provision
36
37. Improving detection and diagnosis
• Raise awareness in communities with higher rates of TB
disease
• Raise awareness and knowledge of TB among health
and social care workers
• Explore the potential of active and latent TB case finding
focusing on new registrations in primary care
- to pilot in specific area(s) for first year
37
38. Improving the commissioning of TB services
• Develop a London TB Commissioning Board to address
current system fragmentation
• The board would bring together the functions of health
care commissioning, health protection and public health
to ensure a co-ordinated, multi-agency approach to TB
control
• Robust commissioning of TB services will include sound
planning, standard setting and strong performance
management
38
39. Improving the commissioning of TB services
• Continue to commission the Find and Treat service to
work with hard to reach groups in the community
• Streamline funding process for patients with no recourse
to public funds
• Ensure three levels of service provision
• Level 1 - Generic primary and community care
• Level 2 - Recognised TB services
• Level 3 - Specialist TB services
39
40. Variability of service provision
• Encourage providers of TB services to work together as
delivery boards that mirror current networks to maintain
strong clinical relationships and referral patterns
• Delivery boards will ensure standardised pathways and
protocols are developed to promote consistent, high
quality care for patients
• Workforce development group will ensure appropriate
skill mix and best value for money is achieved.
40
41. • Annual NHS spend on healthcare in London
£13.9billion
• Annual spend on TB in London £18-20 million
• Annual costs of the TB plan £7.2 million
– Including additional diagnostic and treatment costs from active
case finding
41
Financial considerations – costs
42. Financial considerations – savings
42
15
20
25
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
£
Millions
Net TB costs - with case finding Net TB costs - do nothing
Cost of TB Treatment
Case Finding vs. Do Nothing
43. Next steps and challenges
• Commissioning
– current PCT clusters, CCGs and proposed CSSs
• Addressing variability
– Cohort review
• Pan-London protocols
– Established commissioning intentions
• Case finding pilot(s)
– Implementation and evaluation
43
45. TB screening in primary
care: can we move
forward?
Chris Griffiths, QMUL
46. Figure 1: London TB rate per 100,000* population by sector
of residence – reported to the London TB Register
* Rates based upon 2010 ONS PCT population estimates
0
10
20
30
40
50
60
70
2004 2005 2006 2007 2008 2009 2010 2011
Rate
per
100,000
population
Year of Notification
London Total North Central North East
North West South East South West
47. Screening for TB in primary care
Do we meet the criteria?
• Condition
– Important health problem, epidemiology understood
• Test
– Simple, safe, acceptable, precise, clear policy on
managing positive results
• Treatment
– Effective treatment
• Screening programme
– High quality trials, complete screening programme
needs to be clinically and socially acceptable, with
benefits outweighing harms, monitoring in place
53. TB symptoms?
yes
Sputum, CXR, blood (FBC, ESR, CRP) and
make follow up appointment with GP
no
IGRA
Migrant from high TB prevalence* country
aged 5-35 years
+ve
Refer TB team
Letter to reassure
If no BCG scar, do BCG
-ve
*TB prevalence >40/100,000 - see map
54. *TB prevalence >40/100,000 - see map
TB symptoms?
yes
Sputum, CXR, blood (FBC, ESR, CRP) and
make follow up appointment with GP
no
Migrant from high TB prevalence* country
aged over 35 years
Reassure, give TB leaflet
55. Evaluation planned
• Numbers of practices screening with IGRA
• Numbers of IGRA tests
• Demography of those tested
• % positive IGRA tests
• Numbers with LTBI
• Numbers receiving chemoprophylaxis
56. Welcome to the
Health and Social Care Bill
• Hackney PCT dissolved, Clinical
Commissioning Groups set up
• Public Health shifted to Hackney council
• CCG funding cut
• Council freeze on all new activity
57. How will providers need to work
differently?
Integrating TB care to achieve best
possible outcomes
Onn Min Kon
Marc Lipman
60. Multifaceted – disease and approach
• TB – a complex disease with multiple presentations
• 50% extrapulmonary
• 80% reactivation disease
• Drug resistance
• Specialist care
• High risk groups
– Immunosuppressed
• HIV
• Diabetes
• Renal disease
• Iatrogenic
– Homelessness
– Drug and alcohol abuse
– Prison
– Children
61. Where patients come from……
TB service
GP
ENT
Cardiothoracics
Self-referrals
Cytopathology
Histopathology
New entrants Orthopaedics
Radiology
Occupational Health
Contact tracing
Accident + Emergency
Surgery
Ophthalmology
Rheumatology
Gastroenterology
Neurology
Dermatology
Find and Treat
MXU
Neurosurgery
GUM
HIV
64. Case 1
• 29 UK born male drug user
• Prior TB treatment 1 year previously
• Offered DOT
• Only took a few weeks then lost to follow up
• Missed multiple clinics
• Found in hostel by Find and Treat in Westminster
• Contacted Outreach TB CNS
• Sputum samples taken – smear AFB positive +++
• Admitted to inpatient TB treatment centre
• Absconded on multiple occasions
• Public Health Order
• Police involved
• Private security funded by PCT
• Drug interaction issues
65. Case 1
• 1 year DOT via pharmacy (local Boots) linked to methadone
• Drug Project team or hostel key worker attend appointments
• Completed treatment with CXR correlate and microbiological
‘cure’
• Complex case – multi Agency integration
• Case managed by TB CNS
• Clinical overview – specialist TB service
66. Successful outcome resulted from
• Multi Agency approach
• Close collaboration
– Clinical staff
– Hostel
– Pharmacist
– Drug project
– GP
– PCT
– Find and Treat
67. How can we ensure that this
happens in every case?
68. Avoiding variability in service provision
• Five local delivery boards established to act as a single
providers of TB services - mirror current networks to
maintain strong clinical relationships and referral
patterns
• Delivery boards will ensure standardised pathways and
protocols are developed to promote consistent, high
quality care for patients
• Workforce development group will ensure appropriate
skill mix and best value for money is achieved
69. Case 2
• 48 Indian female
• MDR TB 2 prior treatments in original hospital
• Now: CXR cavities, BAL smear positive
• 3rd line TB treatment required
• Inpatient treatment for 3 months
• Adverse events ++
• Child infected
70. Avoiding variability in service
provision
• NICE recommends that “treatment of complex
cases is managed by clinicians with substantial
experience in drug-resistant TB in hospitals
with appropriate isolation facilities and in
close conjunction with the HPA”
71. What is medically complex TB?
• MDR or extensively drug resistant TB
• Paediatric TB disease
• Chronic renal disease or renal transplant TB
• Patients co-infected with HIV/TB
• Spinal TB
• Neurological TB
73. Level 1 – generic primary &
community services
• Case finding of active TB in newly registered patients
• Targeted testing and potential treatment of latent TB in newly
GP registered or recently arrived people (to UK in last five
years) from high risk countries in high incidence boroughs
• Community DOT delivery (via community pharmacists,
primary care, third sector and community organisations)
• Accessing social support services for diagnosed TB patients
with social risk factors
• May be provided by the acute, community, or third sector and
include prison health services
74. Level 2 - recognised TB services
• Diagnose and treat patients with uncomplicated TB
• Assess new patients
• Perform appropriate investigations for the diagnosis of TB
• Start and maintain treatment for TB including supporting
patient and their families/carers over this time
• Work with HPA in cluster investigation of possible linked
cases, as well as the public health management of infectious
drug resistant TB cases
• Providers may be acute (hospital) or community services and
should be available at times and locations appropriate to the
needs of the community
75. Level 3 - very specialist services
• Provide the same functions as level 2 services and
also have the clinical expertise & specialist facilities
to manage medically complex TB
• Provide joint management with level 2 services
and/or accept transfer of these patients when
required
• Patients requiring inpatient treatment at a level 3
service should be considered for transfer back to a
level 2 service closer to patient’s home or for
treatment within the home as soon as practicable
77. Case 3
• 33 male from Slovakia
• Homeless / alcoholic
• Unwell/ coughing ‘months’
• MXU screen
• Abnormal CXR
• Smear negative, culture positive TB
• No Recourse to Public Funds
78. Case 3
•Admitted briefly to hospital
•Hostel in Camden for ‘street homeless’ Europeans
•3 x a week DOT
• TB outreach worker
•Evicted as drinking
•Attended Day Centre
•Then clinic DOT with incentive funds
•Brief imprisonment
•Moved to Cambridge
•Medication passed by friend to him
•F+T saw him in Cambridge
•Local team took over and completed
80. Pan London with local integration
• Housing
• HPA
• DOT
• F+T
• Microbiology services
• Mycobacterial Reference Unit
• Large scale contact tracing
• New entrant/ new registration screening
• Diagnostic clinic
• Specialist component
• Negative pressure facilities
• MDR/Level 3 requirement
• BCG
Need to work across the ‘borders’ to tackle TB
Clinical accountability and expertise
81. Issues
• Political will vital
• Uncertain commissioning landscape
• Significant co-ordination required
• How are level 3 providers selected?
• Who pays?
88. The purpose of cohort review
Strengthen
the
prevention
and control
of TB
Ensure
comprehensive case
management
Improve promptness
of appropriate
interventions
Maintain reliability of
data on the TB
Surveillance System
Providing immediate
analysis of treatment
outcomes and
contact investigation
efforts, measured
against previous
cohorts
Assess efforts
compared to local
and national TB
control targets
Identifying, tracking
and following up on
important case
management issues
highlighted through
the review
Provide ongoing
training and
education for staff
Provide staff with a
forum for open
discussion
89. The cohort review process
Preparation
• Training
• Setting targets
• Data -TB register
• Identify cohort
• Case
management
• Preparing forms
for presentation
Presentation
• Analysis
• Detailed patient
outcome
• Outcome of
group of patients
• Analysis of
outcomes
• Assessed against
national, regional
and local service
objective
Follow- up
• Treatment
• Case
Management
• Data
• Education and
Training
• Commissioning
A group of all TB cases counted in a specific
time frame are reviewed in a group setting
Cohort chair
Case manager Social care team
Cohort co-ordinator
90. Evaluation 2011
Outcomes 2009 2010
Cases ≥1 risk factor 19% 20%
Proportion of sputum smear
positive PTB with ≥ 1 risk
factor receiving DOT
42% 67%
Proportion of cases lost to
follow up
2.5% 0%
Treatment completion rate all
cases
82% (77%) 90% (84)
The proportion of TB cases
with sputum smear positive
pulmonary disease with at
least one contact
79% (64%) 100% ( 84%)
Ref Evaluation of the implementation of Cohort Review by North Central London TB Service
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1296687649609
91. Evaluation 2011Staff feedback
Highlighted gaps in service 96%
Promptness of interventions improved 86%
Immediate analysis of treatment and contact
investigation outcomes
91%
Assessed efforts compared to local and national
targets
98%
Identified, tracked and followed up important case
management issues
96%
Provided on-going staff training and education 94%
Ref Evaluation of the implementation of Cohort Review by North Central London TB Service
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1296687649609
95. www.thetruthabouttb.org www.tbalert.org
Involving Community Based
Organisations in TB Programmes
• Most effective and sustainable way to raise awareness among
vulnerable populations
• CBOs have knowledge of, access to, and trust of communities they
support
• TB services mainly delivered through ‘medical model of health’ –
CBOs are not involved in TB service delivery and in strategic networks
• Lack of knowledge, capacity and resources (funding, materials, etc.) to
deliver TB services
• TB may not currently be seen as a priority in their community
97. www.thetruthabouttb.org www.tbalert.org
TB training workshops for
community based organisations
• To provide the TB knowledge and skills to become active and credible
partners to statutory agencies
• Initially: to engage people and communities affected by TB through
awareness raising
– Symptoms
– TB is curable
– Go to a doctor for free treatment
• Delivered nationwide in partnership with NHS/HPU agencies
• 13 workshops. 250 delegates. 2/3rds third sector; 1/3rd statutory sector
98. www.thetruthabouttb.org www.tbalert.org
Examples of third sector partnerships
• Joint designing and branding of TB awareness leaflets for specific
populations at risk
– TB/HIV co-infection (African Health Policy Network)
– TB in people dependent on alcohol and drugs (Westminster Drug
Project)
– TB in Somali Communities (Bristol NHS, Embrace-UK)
• TB awareness project in Liverpool funded by local PCT (Asylum Link
– working with refugees and asylum seekers)
• TB awareness integrated in strategic goals (BHA, Manchester)
• TSOs running World TB Day events (62 in 2011; 99 in 2012)
99. www.thetruthabouttb.org www.tbalert.org
2012-14: Local TB Partnerships
Future: Third sector organisations become service delivery partners at
appropriate points along the TB pathway
LTBPs: Partnerships of third sector organisations and statutory stakeholders
that plan how third sector organisations and people affected by TB can
contribute to local TB care and control programmes.
• Representative of and owned by locally affected communities
• Recognised by statutory stakeholders as a legitimate and necessary TB
partnerships
• Work with statutory stakeholders to plan and build the role of third sector
organisations and PATB in local TB care and control programmes
• Work with statutory stakeholders to improve the design and delivery of local
TB services
100. www.thetruthabouttb.org www.tbalert.org
Involving communities and PATB
• “The principle will be no decisions about me without me.”
• “…services are more responsive to patients and designed
around them, rather than patients having to fit around
services.”
• People aren’t ‘hard to reach’. It just requires a bit more thought
and effort to make sure their needs are taken into account.
101. Professor Ibrahim Abubakar PhD, FFPH, FRCP (Edin)
Head of TB Section HPA
Professor of Infectious Disease Epidemiology
101
103. Contact the LHP TB team at:
• Email: tb@londonhp.nhs.uk
• Website: www.londonhp.nhs.uk
• Follow us on Twitter (@londonhp)
#Londontbplan
• Join us on Facebook (London Health
Programmes)
103
