Latent TB Infection Management in Zimbabwe TB Infection Management in Zimbabwe Dr Charles Sandy, Deputy Director (TB Control), Zimbabwe: WHO Global Consultation on the Programmatic

Latent TB Infection Management in

Zimbabwe Dr Charles Sandy, Deputy Director (TB Control), Zimbabwe:

WHO Global Consultation on the Programmatic Management of

Latent Tuberculosis Infection, 27-28 April 2016

Country context Land locked country in Southern

Africa 14 million inhabitants

• Zimbabwe is one of 8 countries in Africa belonging to all the top 30 High burden lists of TB, TB/HIV, DR-TB in the world

• HIV drives TB, high rate of coinfection • Estimated PLHIV: 1.4 m (ZDHS

2011

• Drug resistant TB is an emerging public health problem

• Treatment outcomes remain suboptimal due to high mortality

NTP STRATEGIC GOALS

• By 2025 to have reduced the incidence of all forms of TB by 80% from 562/100000 in 2012 to 112/100 000

• By 2025 to have reduced mortality of all forms of TB by 80% from 132/100000 in 2012 to 26/100 000.

NTP STRATEGIC OBJECTVES

The intention of the NSP is to reach by 2017 the following targets: • Objective 1. To increase case notification rate of all forms of tuberculosis from 269/100

000 (35,566 patients) in 2013 to 313/100 000 (43,231 patients) by 2017.

• Objective 2. To increase treatment success rate for all forms of tuberculosis from 78% in 2012 to 87% by 2017.

• Objective 3. To increase the number of DR-TB cases detected annually from 393 in 2013 to 1 600 by 2017.

• Objective 4. To increase treatment success rate of Drug resistance TB from 59% in 2011 to 75% by 2017.

Strategic Focal Interventional Areas

• TB Care & Treatment: Prevention, Early intensified and active case finding

• TB/HIV: TB/HIV collaborative activities and integrated care

• MDR-TB: MDR-TB Prevention, Decentralized high quality MDR-TB Diagnosis, Care and Treatment

• Cross-cutting areas • Procurement Supply Management: Medicines & Laboratory

reagents uninterrupted supply and distribution, storage space

• Community systems strengthening - cross-cutting in all the strategies

TB Case Detection

Availability of Diagnostic Services 2015

Indicator Coverage

Smear Microscopy

• Number of laboratories 225

• Number of labs/100000 population 1.7

Xpert MTB/Rif

• Number of laboratories 108

• Number of labs/100000 population 0.8

X-ray Diagnosis

• Analogue (functional/available) 36/71

• Digital (functional/available) 14/16

Progress in TB Case Detection

319

298

269

235

212

97 94 96 94

116

2011 2012 2013 2014 2015

Rat

e p

er

10

0,0

00

po

pu

lati

on

Year

Trends in TB notification rates for all forms and bateriologically confirmed cases, 2011-2015

TNR all forms TNR bacteriologicaly confirmed

Contact Tracing Cascade- Smear Microscopy 2015

Number of presumptive TB clients identified (contacts)Number of presumptive TB clients with sputum

specimen sent to the laboratory (Contacts)Number of presumptive TB clients with Direct Smear

Microscopy results (Contacts)Number of presumptive TB clients with a smear

positive result (Contacts)

Sputum Smear Microscopy Screening

11244 9088 7670 676

Percentage 81% 84% 9%

11244

9088

7670

676

81%

84%

9%

0

2000

4000

6000

8000

10000

12000

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%A

xis

Titl

e

Axis Title

Axi

s Ti

tle

Percentage

Use of GeneXpert in Contact Tracing

Number of presumptive TB clientsidentified for Xpert MTB/ RIF

(Contacts)

Number of presumptive TB clientswith sputum specimen sent for Xpert

MTB/RI (Contacts)

Number of presumptive TB clientswith Xpert MTB/RIF results (Contacts)

Number of presumptive TB clientswith Xpert MTB positive

results(Contacts)

Number of presumptive with Xpert Rifresistance results(Contacts)

2349 3066 2499 345 69

Percentage 131% 82% 14% 20%

2349

3066

2499

345

69

131%

82%

14%

20%

0%

20%

40%

60%

80%

100%

120%

140%

0

500

1000

1500

2000

2500

3000

3500

Axi

s Ti

tle

Axi

s Ti

tle

Axis Title

Percentage

DR-TB Case Detection

0

50

100

150

200

250

300

350

400

450

500

0

20

40

60

80

100

120

2011 2012 2013 2014 2015

Co

un

t

Year

# of Instruments

# of Modules

0

50

100

150

200

250

300

350

400

450

500

2011 2012 2013 2014 2015

DR-TB Cases Diagnosed

DR-TB Cases put on Treatment

Fr

equ

ency

TB/HIV Integrated Management

85

90 91 92 96

77 74

69 72

68

0

20

40

60

80

100

120

2010 2011 2012 2013 2014

Per

cen

tage

HIV testing and co-infection rates among all forms of TB, 2010-2014

HIV testing

Co-infection

National Target 100%

87

94 95 96 96

44

60

75

81 86

2011 2012 2013 2014 2015

% o

f al

l TB

-HIV

co

-in

fect

ed c

ases

CPT Uptake ART Uptake

National Target 100%

ART among TB patients who are co-infected coverage comparing 2014 and 2015

Midlands

Masvingo

Matabeleland North

Manicaland

Mashonaland West

Matabeleland South

Mashonaland Central

Mashona and East

Chitungwiza

Bulawayo

TB/ART

0 - 79

80 - 89

90 - 100

National Target 100%

Midlands

Masvingo

Matabeleland North

Manicaland

Mashonaland West

Matabeleland South

Mashonaland Central

Mashona and East

Chitungwiza

Bulawayo

2014 2015

IPT provision

• Prior to Dec 2012 ,only limited to children under 5 years of age who are household contacts of smear-positive TB patients

• Following adaptation of the 2011 WHO guidelines on ICF/IPT in 2012 , the MOHCC commissioned a feasibility phase in ICF/IPT implementation in 10 selected sites across 5 provinces (Harare, Bulawayo; Mat North, Mat South and Midlands)

Reducing the Burden of TB among PLHIV

Roadmap in Implementation of the National ICF/IPT Programme

Adaptation processes of the

2011 WHO ICF/IPT

Guidelines

Revision of M&E Data Reporting and Recording

Tools

Stakeholder Sensitization meetings at

various levels on ICF/IPT

Capacity & Skills Building

of HCWs to provide ICF/IPT

services.

Feasibility Phase of ICF/IPT

implementation

Post Feasibility Phase of ICF/IPT Implementation

Jan 2012 – Dec 2013 (10 sites)

Jan 2014 – Dec 2015 ( 142 sites)

National Progress in IPT Implementation, Jan – Dec 2015

Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Dec

Number initiated on IPT 10425 9582 7167 12450 39624

Number completing IPT 5573 2502 8165 6559 22799

0

5000

10000

15000

20000

25000

30000

35000

40000

Fre

qu

en

cy (

n)

46 sites 83 sites 142 sites

TB Treatment Outcomes

2013 2014

Lost to follow up,

3%

Not Evaluated,

4% Failure, 1%

Died, 10%

Treatment Success,

82%

Lost to follow up,

5%

Not Evaluated,

2% Failure, 1%

Died, 9%

Treatment Success,

83%

National Target 90%

National TB Program Achievements/Impact

• Falling incidence of TB in line with international trends

• Case detection high at 70% but need to increase rapidly to 90%

• % of TB patients with Known HIV status high at 96%

• ART in TB high but still below universal coverage target

• Outcomes on treatment up • Success Rate 83% for Drug Sensitive TB

• 75% for Drug Resistant TB

• Prevalence coming down as evidenced by TBPS results

National TB Prevalence Survey 2014- Goal & Objectives • Goal: To estimate the prevalence of pulmonary TB among population

(aged 15 years or older) within Zimbabwe in 2014

• Main Objectives: 1. To establish the prevalence of bacteriologically-confirmed pulmonary TB

among adult population in Zimbabwe

2. To determine the prevalence of smear positive, culture positive TB

3. To determine the prevalence of symptoms suggestive of TB

4. To determine the prevalence of radiological abnormalities (chest X-ray) suggestive of TB

Screening outcomes

Symptom Chest X-ray Number S+ MTB + Xpert B+ MTB (smear negative)

Total (% All Survey Cases)

Positive Negative 1,162 0 8 (0.7) 8 (7.5)

Positive Positive 628 13 (2.1) 16 (2,6) 29 (27)

Negative Positive 2,797 9 (0.3) 54 (1,9) 63 (58.9)

Positive No CXR 42 1 1 2 (1.9)

Negative No CXR 1180 0 4 4 (3.7)

Missing Positive 6 0 1 1 (0.9)

Missing No CXR 4 0 0 0

Positive Missing 1 0 0 0

Total 5820 23 84 107

1) Symptoms alone were not specific for TB 2) A combination of symptoms and CXR abnormalities more specific 3) 58.9%of TB Survey Cases (63/107) were non symptomatic participants but had positive CXR screening 4) Smear and Xpert picked up 22% of all survey cases rest were smear negative

Key Message from TBPS

• High proportion of un-symptomatic TB in survey cases

• High utility of X-Ray as a screening tool

• High proportion of smear negative TB in survey cases

Summary of LTBI in Zimbabwe

• Systematic testing currently provided for people living with HIV, adult and child contacts of pulmonary TB cases and patients with silicosis. • Mantoux tuberculin skin test (TST) for children • Symptom screen and CXR plus Xpert in Adults

• Treatment of LTBI offered to people living with HIV, adult and child contacts of pulmonary TB cases • Treatment options available: 6-month isoniazid, or 9-month isoniazid, • IPT risks and benefits misunderstood by both HCWs and the Community for PLWHIV

• Screening offered for TB but no treatment of LTBI for prisoners, health-care workers • Symptom screen and CXR plus Xpert

• TB is stigmatized by HCWs and they do not seek care openly

• Mobile Chest radiography done for active TB case finding nth isoniazid, or 9-month isoniazid,

Conclusion

• Interventions for LTBI Management are being implemented in Zimbabwe but there is room for scale up