Transcript TB or not TB? Strategy and Policy

TB or not TB?
Strategy and Policy
Grace Smith
HPA Regional Centre for Mycobacteriology, West Midlands
Public Health Laboratory,
Birmingham Heartlands Hospital
GLOBAL
STRATEGY
TO
STOP
TB
STRATEGY for
ENGLAND
AND WALES
HPA TB
PROGRAMME
NICE
CMO’s
ACTION
PLAN
CONNECTING
FOR HEALTH
Actions for Life - Towards a
World Free of Tuberculosis:
A focus on the global plan to stop TB 2006-2015
•On January 27th 2006, The Stop TB
Partnership launched its Global Plan to Stop TB
for 2006-2015.
•The Plan requires $56 billion to
carry out its aims - less than $1 per day of
healthy life gained, with 14 million lives saved
by 2015.
• With this money, the Plan aims to
halve deaths from TB in the next ten years and
provide treatment for 50 million people.
•Ultimate aim of the Stop TB Partnership is to
eliminate TB as a global health problem by 2050
The First Global Plan:
2001-2005
• Patients treated DOTS programmes being
doubled over 5 years, from 2 million in
2000 to 4 million in 2004.
• Improvement in case detection - both India
and China, which account for 35% of the
world's TB cases, are now close to the
target of 70% case detection.
Global Plan to Stop TB
for 2006-2015.
• Based on WHO's Stop Tuberculosis
Strategy, builds on the 2001-2005 Plan.
• Seeks to deliver more on the ground and
emphasises the issues of HIV/TB coinfection and multi drug resistant TB
through adapting the use of DOTS.
Global Plan to Stop TB for 2006-2015.
Barriers
• Increasing the accessibility of quality antiTB drugs
• Addressing the social burdens of the
disease for patients.
• Health services also need to be
adequately resourced and committed to
eliminating TB.
Global Plan to Stop TB for 2006-2015.
Targets
•
•
•
•
More effective tools for fighting TB:
Diagnostic tests at the point of care by 2012
A safe, effective and affordable vaccine by 2015
a shorter treatment regime of 1-2 months by
2015.
• The Global plan is available at the Stop TB
Partnership Web Site:
www.stoptb.org/globalplan/.
Meeting the Millennium Development Goal on Tuberculosis
How will Britain Help Deliver on the Global Plan to Stop TB,
2006-2015?
Key Challenges
• Lack of funding for the plan,
• Limited research
• Inequitable access to new tools and diagnostics,
• Lack of awareness of TB amongst the public, TB patients,
parliamentarians, policy-makers and the media,
• The additional burden of TB/HIV co-infection,
• High levels of poverty
• Poor health infrastructure and resources in the developing world.
If the targets of the Global Plan are to be met, greater awareness of
the Global TB epidemic and the Plan be is necessary alongside a
three-fold increase in financial investment in TB control over the
lifespan of the plan.
What should the UK be doing to ensure
fulfilment of the Global Plan to Stop
TB, 2006 – 2015?
• If the global plan to stop TB is to be met,
• TB needs to be a far greater political priority in both the
UK and the developing world.
• This commitment should extend to long-term and
sustained financing,
• To the development of new tools and diagnostics,
available for all,
• To support for the strengthening of human resource
capacity and health systems.
• In addition there must be greater collaboration between
the pharmaceutical industry and patients, civil society
and the development of public-private partnerships if the
ambitious targets of the Global Plan areto be met.
Stopping Tuberculosis in England
An Action Plan from the Chief Medical
Officer
October 2004
The TB Programme goals
Long-term goal is a reduction, and ultimately
elimination, of tuberculosis in this country.
Working towards this goal, the immediate aims of our
national TB programme are to:
• reduce the risk of people being newly infected with
tuberculosis in England
• provide high quality treatment and care for all people
with TB
• maintain low levels of drug resistance, particularly
multidrug resistant (MDR) TB
Rising to the challenge:
a can-do philosophy
• In the United States of America (USA) tuberculosis reemerged during the 1980s and early1990s. The disease
was out of control.
• With a clear plan, a national focus, and a build up of
infrastructure and resources at local, state and national
levels, the tide was turned.
• Between 1992 and 2002, TB cases decreased by 45 per
cent and rates of TB halved to five per 100,000
population, the lowest ever recorded.
• Control of TB in this country can be achieved with a
similar level of commitment to that shown in the USA.
In the short term the total number of new TB cases
reported each year may rise because:
• Firstly ,of infection acquired abroad
• Secondly, of latent infection acquired in the past ,but
reactivated with waning immunity
• Thirdly, increasing size of some of the population
groups most at risk
What will success look like?
Within the next three years:
• a progressive decline (of at least two per cent per
year) in rates of TB in population groups born in
England
• a reduction in the incidence of disease among
people who entered the country and became
resident here within the previous five years
• no more than seven per cent of new cases
resistant to the anti-TB drug isoniazid and two
per cent multidrug resistant
• a reduction in the number of human cases of
bovine (cattle) TB in people under the age of 35
years and born in the UK
Targets
Evidence and experience show that TB control is likely to
be achieved if:
• all patients with suspected pulmonary TB are seen by the
TB team within two weeks of first presentation to health
care
• at least 65 per cent of patients with pulmonary TB have
the diagnosis confirmed by laboratory culture of the
organism
• all patients diagnosed with TB have the outcome of their
treatment recorded,
• and at least 85 per cent successfully complete their
treatment
Recommended actions
1: Increased awareness
2: Strong commitment and leadership
3:High quality surveillance
4: Excellence in clinical care
5: Well organised and co-ordinated patient services
6: First class laboratory services
7: Highly effective disease control at population level
8: An expert workforce
9: Leading edge research
10: International partnership
Key DH and HPA groups involved in the implementation of
the National TB Action Plan
Department
of Health
Overall
Strategy and
Policy
Strategy
and
Policy
(Specific
Issues)
TB Action Plan
Stakeholders
Group
TB Action Plan Steering
Group
Chair Dr David Harper
HPA TB Programme Board
Chair Prof Pete Boriello
Working Groups-Fixed Term
Delivery Group
• Dr John MooreGillon
Operational and
Delivery Issues
Commisioning Group
•Prof Rod Griffiths
Monitoring and
Laboratory Standards
Group
•Dr Grace Smith
Diagnostics
and Molecular
Epidemiolgy
Forum (DAME)
HPA Operational
Groups,LaRS
,Surveillance
NICE guidelines
Clinical diagnosis and management of tuberculosis,
and measures for its prevention and control
March 2006 www.nice.org.uk.
Key Priorities:
•
•
•
•
Managing Active TB
Improving Adherence
New Entrant Screening
BCG Vaccination
Diagnosing active TB
Respiratory TB
Take a chest X-ray – if this suggests TB, arrange further tests.
● Send at least three sputum samples (including one early morning sample)
for culture and microscopy.
● Samples should be spontaneously produced if possible. If not possible:
– in adults, use induction of sputum or bronchoscopy and lavage
– in children, consider induction of sputum if it can be done safely, or gastric
washings if not.
● Take samples before starting treatment if possible, or within 7 days of
starting.
● Start treatment without waiting for culture results if the patient has clinical
signs and symptoms of TB, and complete treatment even if culture results are
negative.
● Send autopsy samples for culture if respiratory TB was a possibility.
Active non-respiratory TB
● Discuss the advantages and disadvantages of biopsy and needle
aspiration with the patient.
● If non-respiratory TB is a possibility, place all or part of any of the
following samples in a dry potand send for TB culture:
– lymph node biopsy or pus aspirated from lymph nodes
– pleural biopsy
– any surgical or radiological sample sent for routine culture
– histology, aspiration and autopsy samples.
● If the histology and clinical picture are consistent with TB, start the
appropriate treatment regimen without waiting for culture results ●
Continue drug treatment even if culture results are negative.
● Do a chest X-ray to check for coexisting respiratory TB in all patients
with non-respiratory TB,and consider other investigations
Laboratory tests
● Use rapid diagnostic tests on primary specimens only if:
– rapid confirmation of TB in a sputum smear-positive
patient would alter their care, or
– before conducting a large contact-tracing initiative.
● If clinical signs and other laboratory findings are
consistent with TB meningitis, start treatment even
if a rapid diagnostic test is negative.
● If a risk assessment suggests a patient has multidrugresistant (MDR) TB:
– do rapid diagnostic tests for rifampicin resistance
– start infection control measures and treatment for MDR
TB while waiting for the results
Tuberculosis Surveillance
Developments
Tuberculosis Surveillance
Developments
Current Service collects and reports :
• Notified cases
• Laboratory reports of new isolates ,drug
resistance and molecular typing profiles
• Clinical reports
• Outcome reports at 12 months
Tuberculosis Surveillance
Developments
The HPA intends to create a new web-based system for TB
surveillance within the next financial year:
• Improve the completeness, timeliness, accuracy and
accessibility of epidemiological information on case
reports (Enhanced Tuberculosis Surveillance) and
laboratory results.
• Develop a mechanism for linking case reports and
laboratory data so that they are available immediately at
the local and regional levels and can be collated
nationally in a timely and accurate manner.
• Link the national molecular typing database to routine
surveillance so it can be used for public health
purposes.
Information for Action:
Tuberculosis Strain Typing
• Molecular typing methods introduced in all RCMs in last
2 years, using a common method and applied to all new
clinical isolates pf Mtb.
• National Microbial Typing Database for rapid comparison
of strains is under development-. first phase of this
project is approaching completion.
• Both are initiatives of the HPA TB Diagnosis and
Molecular Epidemiology (DAME) Working Group.
Connecting for Health:
Initiatives in TB
National projects that will ensure that NHS
information systems support the clinical and
public health activities required to deliver the
National Action Plan for TB.
• National Knowledge Service Pilot on
Tuberculosis
• Tuberculosis Do Once and Share Project.
National Knowledge Service
Pilot on Tuberculosis
• Set up after the Kennedy Enquiry “To improve the level
of information available to clinical staff and patients”
• Provides evidence-based best practice information to
healthcare professionals through 'Map of Medicine'
clinical algorithms.
• Pilot is tailored for those working with at risk
population groups such as the homeless,
and areas of professional or public concern such as TB
in pregnancy.
(www.hpa.org.uk/tbknowledge/)
Tuberculosis Do Once and
Share Project
• >40 projects that will develop care pathways for specific
diseases or conditions based on current best practice.
• Establish a National Community of Interest that will
ensure that local, regional and national initiatives on TB,
care pathways and information management are
coordinated
• Stakeholders include clinical TB networks, Health
Protection Units and also Department of Health Steering
Group and working groups charged with delivering the
National Action Plan for Tuberculosis.
• www.connectingforhealth.nhs.uk/delivery/serviceimplem
entation/kps/doas
POTENTIAL BARRIERS
(Domestic)
• Other initiatives in the NHS; “Choose and
Book”, “Payment by results”, Pathology
Modernisation, “Connecting for Health”
• Wide variation in incidence of disease
across the country.
• Funding for new tests
• Working across traditional boundaries.
Global Barriers
• Increasing the accessibility of quality antiTB drugs
• Addressing the social burdens of the
disease for patients.
• Health services also need to be
adequately resourced and committed to
eliminating TB.