dr rph peters, md, phd, dlshtm clinical programme...
TRANSCRIPT
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Dr RPH Peters, MD, PhD, DLSHTM
Clinical Programme Specialist
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Janus – Roman God of transition
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TB epidemic in South Africa (1)
WHO Global Tuberculosis Report 2013
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TB epidemic in South Africa (2)
WHO Global Tuberculosis Report 2013
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TB epidemic in South Africa (3)
WHO Global Tuberculosis Report 2013
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What happened over time?
Churchyard GJ et al. S Afr Med J 2014
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• Why talk about strengthening TB system?
• Who to target?
• What to do?
• How to achieve the objectives?
Tuberculosis and HSS
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What is the goal of HSS?
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Can elimination be achieved?
Dye C et al. Annu. Rev. Public Health 2013
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TB-associated mortality in SA
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Impact TB on daily life
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• Patients and the community
• Healthcare workers
• Scientists
• Policy makers
• Biomedical Industry
• Pharmaceutical industry
• Advocacy groups
Who to target?
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What to do?
Dye C et al. Annu. Rev. Public Health 2013
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What to do?
• Patient education
• Impact of ART roll-out
• HIV/TB integration
• HCW skills development
• Early case detection of TB
• Xpert® MTB/RIF for diagnosis of TB
• Contact tracing
• Enhanced case management
• Other interventions & developments
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Patients delays
Lusignani S et al. BMC Infect Dis 2013
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People counselling required
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Implement lessons learnt…
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Is ART the answer?
Dodd PJ et al. PLoS One 2013
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Is ART the answer?
Dye C et al. Annu. Rev. Public Health 2013
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Is ART the answer?
Gupta A et al. PLoS One 2013
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Let’s expand our focus from
‘integration’ to ‘intensified effort’
Kaplan R et al. PLoS One 2013
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Healthcare workers knowledge
Engelbrecht M et al. S Afr J Epidemiol Infect Dis 2013
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Facility
Engelbrecht M et al. S Afr J Epidemiol Infect Dis 2013
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Early detection of TB (1)
• Symptom screening is implemented… but
do we really know what to look for?
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Early detection of TB (2)
Claassens MM et al. Int J Tuberc Lung Dis 2013
• 443/665 (64%) symptomatic
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Early detection of TB (3)
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Do we really know what to look for?
• How about TB in children?
• Maternal and infant TB?
• How about extrapulmonary TB?
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Xpert for diagnosis of TB (1)
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Xpert for diagnosis of TB (2)
Theron G et al. Lancet 2013
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Xpert for diagnosis of TB (3)
Hanrahan CF et al. PLoS One 2013
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Xpert for diagnosis of TB (3)
Yoon CJ et al. PLoS One 2013
All TB patients Smear-negative TB
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Xpert for diagnosis of TB (4)
Clinic-based
Xpert®
(n=264)
Laboratory-
based Xpert®
(n=154)
P-value
Median days to initiation of
TB treatment <1 (0-5) 7 (2-15) <0.001
TB case fatality rate at two
months 2/23 (8.7%) 1/16 (6.3%) 1.0
TB diagnosis at later stage
-Culture (MGIT)
-Chest X-ray
15 (5.7%)
8 (3.0%)
7 (2.7%)
5 (3.2%)
2 (1.3%)
3 (1.9%)
0.3
0.7
0.3
All cause mortality at two
months 6 (2.3%) 4 (2.6%) 1.0
Peters RP, In preparation
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Contact tracing for early detection
Middelkoop K et al. S Afr Med J 2014
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Creative ways of contact tracing
Mwansa J et al. PLoS One 2013
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Enhanced case management..
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Enhanced case management..
• Complicated cases?
• Adverse effects & drug interactions?
• Pharmacovigilance systems?
• Separate drugs vs. combination tablet?
• Drug levels (personalized medicine)?
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Complexity of TB Disease
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In summary (1)
• South Africa has one of the largest TB
epidemics in the world
• Progress made, but not on target
• Combined effort required:
– Patients and Healthcare workers
– Scientists
– Biomedical and pharmaceutical industry
– Advocacy groups and policy makers
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In summary (2)
• Increase awareness, skills and diagnostics
and therapeutic resources
• Implement common knowledge and
lessons learnt
• Expand basic scientific knowledge of TB
• Development of new drugs and vaccine
• Role of funding and public health
commitment
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