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Assessment of LTBI Policies and Practices in WHO European Region
Photo: Riccardo Venturi
17th Wolfheze Workshops and 13th WHO National TB Programme Managers' meeting The Hague, The Netherlands Wednesday 27th May, 2015
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I. Low-Incidence Countries
II. High-incidence countries
III. National policy on preventive therapy for contacts of MDR-TB
IV. Systematic screening for LTBI and ACF
GLOBAL TB PROGRAMME
Presentation Outline
• Backgrounds, objectives, and methodology
• LTBI Survey Results:
(Estimated TB incidence<100/100,000 and upper/upper-middle income)
(Estimated TB incidence >=100 or lower/lower-middle income)
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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
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LTBI Survey Objectives
GLOBAL TB PROGRAMME
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
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LTBI Survey Methodology
GLOBAL TB PROGRAMME
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%)
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Target countries for LTBI
GLOBAL TB PROGRAMME
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
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GLOBAL TB PROGRAMME
I. LTBI Survey Results for Low-Incidence Countries
(Estimated incidence<100/100,000 and upper/upper-middle income)
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National policy on systematic screening for LTBI
GLOBAL TB PROGRAMME
83% of countries have a national policy for LTBI screening (30/36)
% of countries targeting risk groups conditionally recommended
% of countries targeting risk groups strongly recommended N=36
Denominator: All countries which responded to the survey including those without a national policy
N=36
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National policy on systematic screening for LTBI
GLOBAL TB PROGRAMME
% of countries targeting risk groups not recommended N=36
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4 1
4 3
3
HIV
N=15
6 4
2
Compromised immune status
N=12
Screening Frequency for LTBI
GLOBAL TB PROGRAMME
13 8
2 1
12 8
1 1
N=24
N=22
Ad hoc research Periodically < 1year Annually Periodically > 1 year Unknown
Household or close contacts, aged>=5years
Household or close contacts, Children< 5years
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Initial Screening methods for LTBI
GLOBAL TB PROGRAMME
1 1
4 2 1
6
HIV
N=15
16 1 5
2 2
N=26
7
3 4 2 1
5 N=22
TST IGRA Parallel testing with TST and IGRATST followed by IGRA for confirmation Other More than one optionUnknown
2
3 2
2
2 1
Compromised immune system
N=12
Household or close contacts, aged>=5years
Household or close contacts, children<5years
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Tools used to exclude active TB
GLOBAL TB PROGRAMME
What does ‘other’ include?
What does ‘combination of the above’ include, Symptom + Chest X-ray?
N=30
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Preventive treatment regimens
GLOBAL TB PROGRAMME
Single regimen
Multiple regimen
Recommended preventive treatment regimens (multiple answers)
N=30
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Monitoring and Evaluation for LTBI
GLOBAL TB PROGRAMME
39% of countries are monitoring and evaluating LTBI activities (14/36)
Monitoring and Evaluation Indicators
N=14
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GLOBAL TB PROGRAMME
II. LTBI Survey Results for High-Incidence Countries
(TB >=100 or lower/lower-middle income)
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National policy on systematic screening for LTBI
GLOBAL TB PROGRAMME
62% of countries have a national policy for LTBI screening (5/8)
% of countries targeting risk groups strongly recommended
% of countries targeting risk groups not recommended N=8
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Screening frequency and methods and for LTBI
GLOBAL TB PROGRAMME
Screening Frequency
Screening Method
Data for HIV not shown as only 1 country targeting this risk group
Household or close contact, aged>=5 years
Household or close contact, children<5 years
Household or close contact, aged>=5 years
Household or close contact, children<5 years
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Preventive treatment regimens
GLOBAL TB PROGRAMME
Recommended preventive treatment regimens N=5
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Monitoring and Evaluation for LTBI
GLOBAL TB PROGRAMME
62% of countries are monitoring and evaluating LTBI activities (5/8)
Monitoring and Evaluation Indicators N=5
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GLOBAL TB PROGRAMME
III. Survey Results: National policy on preventive therapy for contacts of
MDR-TB
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Monitoring and Evaluation for LTBI
GLOBAL TB PROGRAMME
Among low incidence countries, 36% have a national policy on preventive therapy for contacts of MDR-TB (13/36)
Yes 23%
No 69%
Unanswered 8%
Yes 92%
No 8%
Is preventive treatment recommended? Is clinical follow-up recommended?
Among high incidence countries, only one indicated to have the policy. Clinical follow-up, but not preventive treatment, was recommended (1/8).
N=13 N=13
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GLOBAL TB PROGRAMME
IV. Survey Results: systematic screening for LTBI and ACF
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GLOBAL TB PROGRAMME
Incidence<100 and upper/upper middle countries
TB Incidence>=100 or lower income
Risk Groups targeted for LTBI and ACF (Low vs. High incidence)
50% 50%
Immigrants from high TB burden countries
11% 11%
6% 72%
Household or close contacts, children<5years
31%
47%
22%
Immigrants from high TB burden countries
17%
33% 11%
39%
HIV
87%
13%
HIV
50%
12%
38%
Household or close contacts, children<5years
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GLOBAL TB PROGRAMME
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.
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GLOBAL TB PROGRAMME
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
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GLOBAL TB PROGRAMME
Plenary Discussion
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GLOBAL TB PROGRAMME
Yes 23%
No 67%
Unknown 10%
Are rifampicin containing preventive regimens recommended for use in persons living with HIV?
N=30 Low TB burden countries
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GLOBAL TB PROGRAMME
Yes 40%
No 60%
Are rifampicin containing preventive regimens recommended for use in persons living with HIV?
N=5 High TB burden countries
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No policy on LTBI Albania, Belarus, Hungary, Latvia, Luxembourg,Montenegro
Child contact not eligible Lithuania and Denmark
Adult contact not eligible Denmark, Finland, Lithuania, Serbia and Turkmenistan
Compromised status eligible Denmark , Estonia, France, Greece, Iceland, Israel, Italy, Netherlands, Poland, Slovenia, Sweden, Switzerland, Turkey, UK
TNF eligible Belgium Czech Finland Germany Ireland Serbia
Transplantation eligible Czech
Chronic renal diseases eligible Greece ,Israel ,Slovakia ,Slovenia Turkey
Miner eligible
Estonia
Among low incidence countries: Strongly recommended
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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 Belgium, Estonia, Portugal, Romania, Slovakia
Drug user Estonia, Portugal
Homeless Slovakia, Slovenia
Among low incidence countries: Conditionally recommended
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Diabetes Slovakia
Community contact Not eligible Armenia, Azerbaijan, Denmark, Estonia, Finland, Kazakhstan, Lithuania, Serbia
General population Turkmenistan
Slums Slovakia
Tribal population Slovenia
Hospital and Health care settings Greece, Turkey
Untreated fibrotic lesion Greece, Iceland
Pregnancy Azerbaijan, Turkmenistan
VCT attendees Estonia
Psychiatric facilities Estonia
Shelter residents Estonia, Romania, Slovenia
Nursing home resident Slovakia ,Estonia
Home for elderly Slovakia ,Estonia
Military Germany, Greece ,Netherland
Teachers Azerbaijan, Greece
School children Russia
Immigrants from low TB burden countries(outside Schengen)
Greece
Immigrants from low TB burden countries (within Schengen)
Norway
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National policy not available Georgia, Uzbekistan, Moldova
Targeting HIV Ukraine
Not targeting contacts while having national policy
Armenia
Community contacts Kirgizstan, Tajikistan, Ukraine. All are targeting child and adult contacts as well
Previous treatment for TB Ukraine
Military Armenia
School children Tajikistan Ukraine
High incidence countries