TB REACH McGill 2018 -AKhan - TeachEpi – A …GlblTBGlobal TB Burden) 10.4 million new TB cases People living (2016 Estimates pg with TB (prevalence) 6.3 million TB cases notifdfied

TB REACHTB REACHImplementing Active CaseImplementing Active Case Finding and Innovation to find the Missing Millions

Amera KhanStop TB Partnershipamerak@stoptb [email protected]

McGill Summer Institute – June 21, 2018 – Montreal, Canada

Presentation Overview• The Missing Millions• Case Finding Approachesg pp• TB REACH Overview• TB REACH Activities for Finding the g

Unreached, Undiagnosed, and Unreported • Lessons Learned• Wave 6: Innovation Highlights• Questions

The Missing Million and Case Finding Approaches

Gl b l TBGlobal TB Burden

)

10.4 millionnew TB cases

People living (2016 Estimates)

p gwith TB (prevalence)

6.3 millionf dTB cases notified

*WHO Global Report 2017

Where are the Missing People with TB?

• 10 countries account for ¾ of the “missing” peoplemissing people

• 3 countries account for ~1/2

o India (25%)o Indonesia (16%)

Ni i (8%)o Nigeria (8%)

*WHO Global Report 2017

Why are there Missing People with TB?

UNREACHEDAccess

UNREPORTEDLinkages

UNDIAGNOSEDServicesAccess

Despite a great expansion of TB

i f 1990

LinkagesMany people are receiving care for TB

ServicesIn many settings, people who are sick with TB have access toservices from 1990-

2005, many people have limited access

in the Private Sector, but are not notified to NTPs

with TB have access to health services, yet they are not identified

to careNTPs as needing to be

tested, or are tested but not properly diagnosedp p y g

What are Case Finding Approaches? (1)Passive Case Finding

f f

What are Case Finding Approaches? (1)

• Waiting for sick individuals to seek care for symptoms that may be TB. Health worker then needs to recognize symptoms, appropriately diagnose treat refer and/or notifyappropriately diagnose, treat, refer, and/or notify

Patient Initiated Pathway to TB Care

doi: 10.1093/inthealth/ihu055

What are Case Finding Approaches? (2)Active Case Finding (ACF)Special efforts initiated by health services to find and reach underserved or high-risk

What are Case Finding Approaches? (2)

Special efforts initiated by health services to find and reach underserved or high risk groups for TB. Renewed interest in implementing these approaches to find the missing millions

Examples include • Community engagement and outreach activities (ex. mobile x-ray screenings)• Contact investigations• Contact investigations • Any other systematic effort used to screen and diagnose TB that doesn’t rely on

patient initiation of care

While there are mixed results and research gaps on ACF intervention potential benefits of ACF

Di d i li d i f h i i• Diagnose and treat patients earlier, reducing further transmission.• Interventions may also achieve substantial population-level TB control

doi: 10.1093/inthealth/ihu055

TB REACH Overview

What is TB REACH? (1)( )• Established in 2010 • Funded by Global Affairs Canada, withFunded by Global Affairs Canada, with 

additional support from USAID, BMGF, and the Indonesia Health Fundand the Indonesia Health Fund

• Grant‐making platform to test and scale‐up innovative ACF approaches to:up innovative ACF approaches to:

o Increase the number of people diagnosed and treated for TB 

o Decrease the time to appropriate treatment

o Improve treatment success rates

What is TB REACH? (2)( )• TB REACH good platform to help bridge research 

and programmatic implementation gap of new toolstools 

• One of the earliest supporters of Genexpert(supported projects before WHO recommendations which helped formrecommendations which helped form understanding of programmatic challenges) 

• TB REACH projects undergo rigorous independent M&E to determine impactindependent M&E to determine impact

• Selected projects have opportunity to have OR technical assistance from McGill

• Ultimate TB REACH oal is to identif s essf l ACF• Ultimate TB REACH goal is to identify successful ACF approaches and innovations and have them sustained and scaled up by national governments, the private sector and/or donor agencies (such asthe private sector,  and/or donor agencies (such as Global Fund))

TB REACH, Where are We Now?5 F di W i l t d i 20105 Funding Waves implemented since 2010

Awarded 180 Grants in 48 Countries Worth Over USD 111 MillionWorth Over USD 111 Million

(42 New Wave 6 Projects have been selected and will be launched in July)

12

What Have We Accomplished? Waves 1-4Waves 1-4

• Over 33 million people screened for TB

• Over 1.9 million people diagnosed and

reportedreported

• 89% of people diagnosed with TB

successfully linked to proper care and

treatmenttreatment

• Over 900,000 lives saved

13

Wave 5 grants progress not included

TB REACH Funds Projects Targeting a Diversity of Populations and a Diversity of Innovative p y

Approaches

New DiagnositcsAwareness Raising

Systematic ScreeningSputum Transfer

by DonkeySputum Transfer

by Drone gSystematic Screeningby Donkey by Drone

Social SupportCommunity Outreach Engage Private SectormHealth Digital Adherence

TB REACH: Finding the UNREACHED

Reaching Tribal Populations Asha Kalp, India

• Asha Kalp works with the Sahariyatribal communities in rural Northern India

• This extremely impoverished group has a documented TB burden that is over 10 times higher gthan India's national average.

• Group has limited access to government-run health services gdue to language, stigma and geographic barriers

• Nearest TB Diagnostic CenterNearest TB Diagnostic Center 30km away

Asha Kalp Activities• Young men with motorbikes hired as

community health workers. • No formal health training• No formal health training • Paid for gas and a small salary.• Provided a backpack filled with sputum• Provided a backpack filled with sputum

containers, paper registers, and now tablets for data collection

• Each visit 10-12 villages in their assigned area to help screen, transport sputum, and provide treatment supportand provide treatment support

Asha Kalp- ResultsS d 196 439 Di d 2 465• Screened 196,439 Diagnosed 2,465Additionality ~1000

• Lessons learned•Involvement and engagement of community members, local TB program, and other partners key

•Challenges with accessing chest xray in distant clinics, malnutrition, and migrant populations

•Because project success project and great need of the Saharyia tribe, State TB program and NIRTH are taking over the project and

di it t di t i t i thexpanding it to more districts in the area

Kahama Community TB Outreach Program SHEDPHA, T iTanzania• Accelerated case finding among miners, female

sex workers MSM and childrensex workers, MSM, and children• High-risk vulnerable populations that face stigma

and access barriers to care• Door to Door campaigns and proactive

engagement with mining communities• 47,202 screened; 595 diagnosed, 555 on47,202 screened; 595 diagnosed, 555 on

treatment• Challenges

• Govt policy against MSM 300400500

• Govt policy against MSM • Weather and poor infrastructure affect transport• Lab staff overwhelmed with additional sample 0

100200

Q3 Q1 Q3 Q1 Q3 Q1 Q3 Q1

Evaluation 

processing and CHW demanding more moneyQ Q Q Q Q Q Q Q

2015 2016 2017 2018pop

TB REACH: Focus on Unreported-Engaging Private Sectorg g g

INDUS Hospital: Screening in Private Clinics i P ki t M ltif t d A h

CommunicationsCommunications Mass Screening Algorithms

Mass Screening Algorithms

BehavioralEconomicsBehavioralEconomics

in Pakistan: Multifaceted ApproachInformaticsInformatics

Local cable TV adverts Community screeners Performance incentives Medical Records

Video Instructions• Systematic screening in private GP Clinics • Signboards, TB and radio advertisements

C it thl t d i ti (50• Community screener monthly costs and incentives(50 USD)

• Smear negative patient referred to mobile x-ray unitsVid d l t f b tt t l• Video development for better sputum samples

• Development of electronic medical records• 100% increase of people on TB treatment in Karachi

00%

400600800

tients 

ed

0200400

S+ TB Pa

tde

tecte

0Q1 Q3 Q1 Q3 Q1 Q3 Q1 Q3 Q1 Q3 Q1

2008 2009 2010 2011 20122013

SS

2008 2009 2010 2011 20122013

• 1.2 million screened, 32, 971 persons suspected of TB, 3668 diagnosed (AF)diagnosed (AF)

• Increase in case notifications by 78.6%• 82% increase in treatment initiation

Social Enterprise Model (SEM)B l d h i dd bBangladesh icddr,b◉3 TB screening centres sell CXR and use revenue to subsidize private sectoruse revenue to subsidize private sector TB engagement programme◉In 2017 scaled up to 9 centres in 3 cities◉In 2017 scaled up to 9 centres in 3 cities with support from TB REACH, Global Fund and USAID / Challenge TB◉Successful but challenge will be continued funding and political support

icddr,b Impact22% I

5 9666,517

7,030

)

8,000• 22% Increase in B+ TB at the city level

5,750 5,966

2%)

26%

)

UE]

(39%

)

6,000

ient

s

y• 39% of all TB

notifications coming from 3

ALU

E](2

VALU

E](2

[VAL

U

2 000

4,000TB

Pat

icoming from 3 testing centers

• GF, USAID, d TB

0

[VA [V

0

2,000and TB REACH all supporting 0

2013 2014 2015 2016

Bac+ TB Case Notifications (Dhaka Metro) Detected by icddr,b SEM

pp gscale up.

Multi-Pronged Private Sector Approach REACH INDIAREACH, INDIA

Promising Results for some key unique activitiesPromising Results for some key unique activities• Contact Screening and Private sector

• Providing voucher for CXR at private laboratories to all HHCs regardless oflaboratories to all HHCs regardless of symptoms.

• REACH Pharmacy Engagement. Other pharmacy projects have had challengesprojects have had challenges

• Sick people do not always pick up their own medicine

• Large loss to follow up when sick people• Large loss to follow up when sick people referred for testing

• Sputum collection is challenging due to privacy concernsprivacy concerns

TB REACH: UNDIAGNOSED- Focus onTB REACH: UNDIAGNOSED Focus on Diagnostics

Diagnostics in ACF: Ch t X R C t A t t d R diChest X-Ray Computer Automated Reading

TB REACH Chest x-ray Computer Automated ReadingDOI: 10.1183/13993003.02159-2016

• Used CXR and Xpert MTB/RIF testing in network of over 2000 private

y p gBangledesh-Private Sector Engagement

practitioners and 133 DOTS centers• 18 036 individuals enrolled; TB prevalence by Xpert was 15%. • The radiologist graded 49% of CXRs as abnormal, 91% sensitivity and

58% specificity. • CAD4 similar sensitivity, but lower specificity (41%), saving fewer (36%)

Xpert tests. The AUC for CAR was 0.74 (95% CI 0.73–0.75). CAD4 f d li d ith i i• CAD4 performance declined with increasing age

• . The radiologist grading was superior across all sub-analyses and was less costlyless costly

TB REACH Chest x-ray Computer Automated ReadingDOI: 10.1183/13993003.02159-2016

• BUT we are seeing improvements in newer CAR versions and in other

y p gCAD4, QureAI, and ACF activities

ACF interventions• We are looking at CAD4TB performance as screening tool to identify

l ith t d TB i it b d ACF i Z bipeople with suspected TB in community-based ACF in Zambia• Preliminary analysis of QureAi performance in Nepal ACF activities

seems to be promisingseems to be promising• CAR may be best suited for high throughput ACF interventions where

access to radiologist is difficultaccess to radiologist is difficult• More implementation results from TB REACH in various populations

and settings coming soon!and settings coming soon!

Coming Soon: Results from Batching Samples Assessment: ACF in Elderly in Cambodia, CATACATAAnd Cameroon• Cambodia, ACF Mobile x-ray targeting elderly (group has the highest

documented TB prevalence in Cambodia )documented TB prevalence in Cambodia.) • Operational research assessing the impact that batching samples for

Xpert testing can have on the cost of diagnostic testing.p g g g• Cameroon looking at batching smear-positive samples for detection of

rifampicin resistance using Xpert MTB/RIF

DNA Genotek’s OMNIgene•SPUTUM (OM-SPD) in Ethiopia• Evaluate impact of OM-SPD added in the field before transport

using 800 samples from people with suspected MDR-TB tested by g p p p p yLED-FM, Xpert MTB/RIF, culture (LJ & MGIT), and LPA

Way Forward

WAVE 6: Even More Exciting Projects Underway!!WAVE 6: Even More Exciting Projects Underway!!

42 new TB REACH projects have been selected Anticipated to start in JulyHighlights include• India PATH Private sector engagement using bout• India, PATH Private sector engagement using bout

QureAi and TrueNat (Molbio)• Vietnam, Mobile X-ray for elderly using CAD4, Xpert-, y y g , p

Ultra and Lam• Marshall slands-ACF and 3HP LTBI treatment.

A i CRP b d TB i d thAssessing CRP-based TB screening can reduce the cost and therefore facilitate scale-up of TB case finding and prevention.and prevention.

Planning ACF Activities General Principals and Considerations

• Use local epidemiology data to identify target popl and understand underreporting• Use local epidemiology data to identify target popl and understand underreporting • Review care cascade data to identify where losing patients • Conduct patient pathway analysis to understand how best to align patient care

ki d TB i i ti t t d hseeking and TB services in a patient-centered approach• Select screening and diagnostic algorithms based on local context/capabilities • Consider potential risks and benefits of interventionp• Consider available infrastructure, resources, and costs • Conduct research to determine the feasibility and acceptability of the intervention

for both patient/community and health servicesfor both patient/community and health services• Need a clear plan of notifying additional TB patients found and linking them to

treatmentH it i d l ti l• Have a monitoring and evaluation plan

DOI: https://doi.org/10.5588/ijtld.13.0199; https://doi.org/10.5588/ijtld.13.0059

WAVE 6: Additional Focus on TreatmentWAVE 6: Additional Focus on Treatment Outcomes

• 17 projects focused on Treatment Outcomes• 14 looking at Digital Adherenceg g

• 99 DOTS•EvriMEDEvriMED•WeChat•SureAdhere•SureAdhere•And other technologies

Lessons Learned• Assessment of where the current gaps and

barriers are is critical – and will vary by setting.L l d liti l t t tt i t ti• Local and political context matter, interventions may perform differently in different settings

• Effective partnering and community p g yengagement skills Key

• To find more cases, number of people tested must increaseus c ease

• Many identified TB cases will not be ‘additional’B tt t t i i l ti l h th• Better tests in isolation only reach those attending the health facility

Lessons Learned • Must do things differently and reach more people to• Must do things differently and reach more people to

advance• 40-50% of B+ cases may not complain of symptoms• Most of those without symptoms need more than

smear to detect (CXR-Xpert)• ACF/screening with smear can produce false positive• ACF/screening with smear can produce false positive

results; need more than smear• We need to not only focus on impact but look at ACF

ti iti ith i l t ti i h tactivities with an implementation science approach to better understand how to improve approaches (political context, acceptability, feasibility, cost, etc.)

• Need to have better understanding role incentives play in ACF activities and if this is sustainable model

• It will cost money to have impact• It will cost money to have impact

Coming SoonTB REACH and partners

developing “lessons from thedeveloping lessons from the field” guides to implementing

ACFACF. Wave 7: Expected to launch p

early 2019W l k f d tWe look forward to

your ideas!your ideas!

Thank YouThank You

The Stop TB Partnership's TB REACH initiative has been supported by the Government of Canada since its inception in 2010.

Additional funding support has been provided by the