Systematic TB screening: Operational research - Enhanced contact

investigation of smear-positive tuberculosis patients in Mongolia

J. Narantuya, Technical officer on HIV, AIDS, STIs, Tuberculosis and Hepatitis, WHO Mongolia

The ninth Technical Advisory Group and National TB Managers meeting

Manila, Philippines9-12 December 2014

CONTENT

• Background• Objectives• Methods• Implementation• Preliminary results• Policy implications and future directions• Acknowledgement

BACKGROUND

• Prevalence of TB in 2013 (includes HIV+TB) 254 per 100,00 population (Global TB report, WHO 2014)

• Current practice is passive contact investigation

• Contact investigation form is not used

OBJECTIVES

1. General objective

• To assess impact of enhanced contact investigation through introduction of active home-visit and new recording and reporting forms in Ulaanbaatar, Mongolia

2. Specific objectives

To describe screening coverage of household TB contacts

To determine prevalence of TB disease and latent TB infection among household contacts

To determine secondary attack rate of pulmonary TB among household contacts

To identify risk factors for TB disease and latent TB infection among household contacts

To develop standard operating procedures (SOPs) for contact investigation

METHODS

• Study design– Cluster randomized control trial

• Study area and population– 8 districts of Ulaanbaatar city (capital) have been

selected randomly: 4 intervention and 4 control districts– Target population: New smear positive pulmonary TB

patients who are diagnosed and notified at district TB dispensary and their contacts

– 460 index cases and 1536 contacts were planned

METHODS

• Eligibility criteria– Newly diagnosed smear-positive TB patients– A household contact is defined as any person staying in the same

household with index case for more than 3 months before the date of diagnosis of index cases

– Informed consent

• Excluding criteria: – index patients who are less than 15 years of age;– index patients who have a history of TB in the family– index cases who have no household contact (living alone).

IMPLEMENTATION

IMPLEMENTATION

• Training of health providers• Advocacy meetings with district health authorities • Newly developed individual contact investigation

form• Questionnaires: – For index case– For household– For contacts

• Diagnostic tools:– Sputum smear microscopy– Tuberculin skin test– X-ray

PRELIMINARY RESULTS: Index cases and contacts

Index (N=499)• All smear-positive cases

> 15 years in 8 districts• Male 278 (55.7%)

• Housing– House 157 (31.4%)– Apartment 149 (29.8%)– Ger 172 (34.4%)

Contacts (N=1437)• Average 3.8 per index• Male 632 (44.0%)

Yield by (contact) age group

Children Adults

Risk factors (determinants of yield)Risk factor analysis• Index factors• Household factors• Individual factors

Index factors (preliminary)• Index aged 30-49• Unemployed• Cough > 8 weeks• X-ray cavity

POLICY IMPLICATIONS and FUTURE DIRECTIONS

• Include active contact investigation in the national guidelines

• Introduce new contact investigation form and use it by health providers

• Involve primary health providers and social workers • Consider to implement active contact investigation • Strengthen collaboration between:

– Primary health care providers (Family group practice)– District TB dispensaries– Local governors’ office

ACKNOWLEDGEMENT

• Dr Gantungalag, National TB Programme• Dr Nobuyuki Nishikiori, STB, WPRO• Dr Fukushi Morishita, STC• TB surveillance and research department,

NCCD• District health departments in Ulaanbaatar• TB doctors at the district TB dispensaries• Primary health care providers (FGPs) in

selected districts

THANK YOU!