Slide 1

World Tuberculosis Day

The London TB Plan Event #LondonTBplan Key TB functions and efforts of WHOHaileyesus GetahunStop TB DepartmentWHO/HQ, Geneva. WHO core functions in global TB control Provide global leadershipDevelopment of policy, norms and standards3. Technical support and coordination Monitoring and evaluationPromoting research6. Facilitate partnerships

3Impact of WHO policies (1995 - 2010)DOTS/Stop TB strategy46 million people treated

7 million total lives saved

0.23 - 0.28 million child lives saved

1.5 million women saved

TB/HIV activities: saved 1 million lives (2005-2010)

TB/HIV lives savedNGOs for Community based TB activitiesGlobal Operational policy guidance

Define standard indicators

Implementation manual

Training manual

Advocacy and visibilityCountryNational guidance

M and E system

Training manual

NGOs supported

NGOs provided TA

WHOs new area of workResource mobilisation

DR Congo, Ethiopia, Kenya, South Africa, Tanzania Urban Tuberculosis Control in the European UnionWorld Tuberculosis Day, 2012Tuberculosis ProgrammeEuropean Centre for Disease Prevention and ControlStockholm, Sweden, 19 March, 2012From surveillance to public health actionFrom surveillance to public health action ECDCs added valueAction Plan and Monitoring FrameworkSurveillance and Monitoring

Identifying and assessing needs

Public Health Action

RAISEAWARENESSThe epidemiological patterns of TB are heterogeneous within EUThe epidemiological patterns of TB are heterogeneous within EU0.020.040.060.080.0100.0AustriaBelgiumBulgariaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUnited kingdomIcelandNorwayEU/EEA 201014.6/100,000Source: Surveillance report, TB Surveillance and Monitoring in Europe 2012 (2010 data)11Pattern of TB situation in big cities differs across the EUDisclaimer: Survey performed by the Metropolitan TB network, www.metropolitantb.org Please note that ECDC does not collect city-level TB surveillance data and take no responsibility for accuracy of data collected for this survey. Figure 1: TB notification rates in a selection of countries and big cities of EU/EEA, in 2009.43.0 / 43.231.9 / 62.181.0 / 108.231.9 / 38.317.8 / 21.6Riga / LatviaVilnius / LithuaniaWarsaw / PolandBucharest / RomaniaSofia / Bulgaria16.9 / 6.0Copenhagen / Denmark21.3 / 7.0Rotterdam / Netherlands23.4 / 8.2Paris / France44.4 / 14.8London / United Kingdom24.3 / 16.6Barcelona / Spain33.2 / 6.5Milan / Italy< 20 cases per 100,000 population 20 cases per 100,000 populationPattern of TB situation in big cities differs across the EUHigh-incidence countriesTB case load appears more generalised in the population and evenly distributed in the country.Equal or lower notification rates in big cities compared to the country overall. Low-incidence countriesTB case load appears to accumulate disproportionately to big cities.2-5 times higher notification rates in big cities compared to the country overall.Two different epidemiological settings

Accumulation of TB among vulnerable groups in urban settingsAccumulation of TB among vulnerable groupsTB disproportionately affects the socially and economically disadvantaged

Vulnerable groups in urban settingsHigh-risk groupsRefugees, asylum seekers, migrantsHomeless peoplePrisonersIllicit drug usersAlcoholicsHIV-seropositive peopleOther vulnerable groupsChildrenElderlyCharacteristics of urban settingsHigh population densityComplex social structureThe most vulnerable and excluded groups carry the most significant burden of disease and have the poorest access to services. Interaction between individual risk factors and urban characteristics create specific opportunities for TB transmission

Reaching out to vulnerable groups in urban settingsProviding guidance, advocate and monitorECDCs added valueAction and outputs from ECDC of relevance for urban TB control

European UnionGuidanceSupportAdvocacy

Reaching out to vulnerable groups in urban settings Going beyond standard public health strategies

Every patients right. Novel interventions. Collaborate between cities. Share best practices.Working together to eliminate TB in the EUContact the ECDC TB Programme

http://ecdc.europa.euTB - the factsThe epidemiology of TB in Londonand the need for changeDr Sarah Anderson HPA Regional Epidemiologist - Londonsarah.anderson@hpa.org.uk

22nd March 2012TB in London 20113588 cases46 per 100,000 population (c.f. nationally 13.6)3 times national rate, some boroughs 10x42% of national burden Case numbers doubled in 15 yrs 85% cases non-UK born More than one in ten have 1 social risk factor, with high case loads of complex patients in some areas

22TB Epidemiology in London sarah.anderson@hpa.org.ukTB rates in London, 1982-2010

TB rate by sector of residence, 2004 2011

85% non-UK born24

TB case rates by PCT of residence, 2011Newham 158 /100,000Brent 123 /100,000Provisional TB rates by PCT, London 2011 (calculated using ONS 2010 mid-year estimates)- Hot spots not exclusively inner-city; some suburban well-established communities- 1/3 of cases = NWL residents = rate of 64 /100,000 in 2011 Highest rates Newham 158 /100,000 , Brent 123 /100/000

25Treatment completion among TB cases reported in 2010

85% Rx completion target

2010 84% completionProportion of new TB notifications in London residents completing treatment within 1 year of notification by PCT of residenceLondon total 84%26Treatment comprises anti-TB drugs for at least six months occasionally causes unpleasant side effects completion essential - but variable completion rates development of drug resistant TB means using more specialist anti-TB drugs with more side effects, worse outcomes and greater cost

TB drug resistance, 20108.4% INH-R1.6% MDR

Almost 1 in ten culture confirmed cases resistant

INH-R relatively stable over last ten years at around 8-9%, but remains above 7% CMO target (Action Plan)MDR increased from 40/100,000 - see map *TB prevalence >40/100,000 - see map TB symptoms?yesSputum, CXR, blood (FBC, ESR, CRP) and make follow up appointment with GP no Migrant from high TB prevalence* country aged over 35 yearsReassure, give TB leafletEvaluation plannedNumbers of practices screening with IGRANumbers of IGRA testsDemography of those tested% positive IGRA testsNumbers with LTBINumbers receiving chemoprophylaxisWelcome to the Health and Social Care BillHackney PCT dissolved, Clinical Commissioning Groups set upPublic Health shifted to Hackney councilCCG funding cutCouncil freeze on all new activity

How will providers need to work differently?Integrating TB care to achieve best possible outcomesOnn Min KonMarc LipmanIs this TB?

Multifaceted disease and approachTB a complex disease with multiple presentations50% extrapulmonary80% reactivation diseaseDrug resistanceSpecialist careHigh risk groupsImmunosuppressedHIVDiabetesRenal disease Iatrogenic HomelessnessDrug and alcohol abusePrisonChildrenWhere patients come fromTB serviceGPENTCardiothoracicsSelf-referralsCytopathologyHistopathologyNew entrantsOrthopaedicsRadiologyOccupational HealthContact tracingAccident + EmergencySurgeryOphthalmologyRheumatologyGastroenterologyNeurologyDermatologyFind and TreatMXUNeurosurgeryGUMHIV

Where patients come from

TB disease in London, 2010Case 129 UK born male drug userPrior TB treatment 1 year previouslyOffered DOTOnly took a few weeks then lost to follow upMissed multiple clinicsFound in hostel by Find and Treat in WestminsterContacted Outreach TB CNSSputum samples taken smear AFB positive +++

Admitted to inpatient TB treatment centreAbsconded on multiple occasionsPublic Health OrderPolice involvedPrivate security funded by PCTDrug interaction issuesCase 1 1 year DOT via pharmacy (local Boots) linked to methadoneDrug Project team or hostel key worker attend appointmentsCompleted treatment with CXR correlate and microbiological cureComplex case multi Agency integrationCase managed by TB CNSClinical overview specialist TB serviceSuccessful outcome resulted fromMulti Agency approachClose collaboration Clinical staffHostelPharmacistDrug projectGPPCTFind and TreatHow can we ensure that this happens in every case?Avoiding variability in service provisionFive local delivery boards established to act as a single providers of TB services - mirror current networks to maintain strong clinical relationships and referral patterns Delivery boards will ensure standardised pathways and protocols are developed to promote consistent, high quality care for patientsWorkforce development group will ensure appropriate skill mix and best value for money is achieved

Case 248 Indian femaleMDR TB 2 prior treatments in original hospitalNow: CXR cavities, BAL smear positive

3rd line TB treatment requiredInpatient treatment for 3 months Adverse events ++Child infectedAvoiding variability in service provisionNICE recommends that treatment of complex cases is managed by clinicians with substantial experience in drug-resistant TB in hospitals with appropriate isolation facilities and in close conjunction with the HPAWhat is medically complex TB?MDR or extensively drug resistant TBPaediatric TB disease Chronic renal disease or renal transplant TBPatients co-infected with HIV/TBSpinal TBNeurological TBService configuration

Level 1 generic primary & community servicesCase finding of active TB in newly registered patients Targeted testing and potential treatment of latent TB in newly GP registered or recently arrived people (to UK in last five years) from high risk countries in high incidence boroughs Community DOT delivery (via community pharmacists, primary care, third sector and community organisations) Accessing social support services for diagnosed TB patients with social risk factors

May be provided by the acute, community, or third sector and include prison health services

Level 2 - recognised TB services Diagnose and treat patients with uncomplicated TBAssess new patientsPerform appropriate investigations for the diagnosis of TB Start and maintain treatment for TB including supporting patient and their families/carers over this timeWork with HPA in cluster investigation of possible linked cases, as well as the public health management of infectious drug resistant TB cases

Providers may be acute (hospital) or community services and should be available at times and locations appropriate to the needs of the communityLevel 3 - very specialist servicesProvide the same functions as level 2 services and also have the clinical expertise & specialist facilities to manage medically complex TB

Provide joint management with level 2 services and/or accept transfer of these patients when requiredPatients requiring inpatient treatment at a level 3 service should be considered for transfer back to a level 2 service closer to patients home or for treatment within the home as soon as practicableAdding value to the modelCase 3 33 male from SlovakiaHomeless / alcoholicUnwell/ coughing monthsMXU screen Abnormal CXRSmear negative, culture positive TBNo Recourse to Public FundsCase 3 Admitted briefly to hospitalHostel in Camden for street homeless Europeans3 x a week DOT TB outreach workerEvicted as drinkingAttended Day CentreThen clinic DOT with incentive fundsBrief imprisonmentMoved to CambridgeMedication passed by friend to himF+T saw him in CambridgeLocal team took over and completedPan London Provided ServicesPan London with local integrationHousing HPA DOT F+TMicrobiology servicesMycobacterial Reference UnitLarge scale contact tracingNew entrant/ new registration screeningDiagnostic clinicSpecialist componentNegative pressure facilitiesMDR/Level 3 requirementBCGNeed to work across the borders to tackle TBClinical accountability and expertise

IssuesPolitical will vitalUncertain commissioning landscapeSignificant co-ordination requiredHow are level 3 providers selected?Who pays?

This may be TB!

Session two Q&A

Dr Chris Griffiths Dr Onn Min Kon Dr Marc Lipman

84The Benefits of Cohort ReviewSurinder TamneTB Specialist Nurse Health Protection Agency Colindale

cohort review process :talk outline

86

HistoryIn the SixtiesDr. Karel Styblo pioneered the first Cohort Review model in TanzaniaLow techEnsured ACCOUNTABILITY for care deliveryAfter visiting and reviewing the New York City TB Program, the Medical Director of the program implemented a cohort review process TB cases decreased from 3811 to 953 (75%)Treatment completion rates increased from 62.8% to over 86%Improved quality of patient information, enhanced patient treatment, ensured accountability2008 London DOT survey by F&T on behalf on LTBWG (formerly London nurses network)Identified, variation in practice across London, assessment subjective rather than objective led, need for standardised approach in case management 2009 Field visit by London team - Trained in CR 2010 Pilot in NCL2011 Evaluation

87The purpose of cohort review88The cohort review processA group of all TB cases counted in a specific time frame are reviewed in a group setting Cohort chairMedical reviewerEpidemiologist Case managerSocial care teamCohort co-ordinatorData support analystPublic health specialistA group of all TB cases counted in a specific time frame are reviewed in a group settingA cohort is a group of TB cases identified over a specific period of time, usually 3 monthsCases are reviewed 6 months after they are reportedIndividual outcomes are assessedPatients demographic informationPatients status: clinical, lab, radiologyAdherence to treatment, completionResults of contact investigation

Group outcomes are also assessed: against national, regional and local service objective and also tracks progressEveryone leaves the meeting knowing the results

89Evaluation 2011Outcomes 2009 2010 Cases 1 risk factor19% 20%Proportion of sputum smear positive PTB with 1 risk factor receiving DOT 42%67%Proportion of cases lost to follow up 2.5%0%Treatment completion rate all cases82% (77%)90% (84)The proportion of TB cases with sputum smear positive pulmonary disease with at least one contact 79% (64%) 100% ( 84%)Ref Evaluation of the implementation of Cohort Review by North Central London TB Service http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1296687649609

Aim: To evaluate the impact implementing a CR process had on the TB service. Method: Quantitative: Comparison of key indicators relating to case management and contact tracing of TB cases before and after implementation of CR. Qualitative: Review the staff experience of CR within the TB service including external partners and observers. Consider the service issues raised and measures taken to address these issues

90Evaluation 2011Staff feedback

Highlighted gaps in service96% Promptness of interventions improved

86%

Immediate analysis of treatment and contact investigation outcomes

91%

Assessed efforts compared to local and national targets

98%

Identified, tracked and followed up important case management issues

96%

Provided on-going staff training and education

94%

Ref Evaluation of the implementation of Cohort Review by North Central London TB Service http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1296687649609

Anonymous web-based survey sent to 88 persons with 80% completed. Positive experience 90% Neutral experience 6% Negative experience 2%

The gap between what we think know and what we actually is sometimes very largeCR helps to fill that gap!

96% of responders found CR highlighted gaps in service most often collaboration with other TB services (69%), patient care (63%) collaboration with allied services (51%), service organisation (45%)

91Benefits

Time & commitment, initial increase in workloadImproved outcomesCost neutralInitial increase in workload over time is reduced due to better organisation and documentation

92

Working together: How the third sector supports TB controlLondon TB Plan Event22nd March 2012Mike Mandelbaum, TB Alert

www.thetruthabouttb.org

www.thetruthabouttb.org

www.tbalert.org94Involving Community Based Organisations in TB ProgrammesMost effective and sustainable way to raise awareness among vulnerable populations

CBOs have knowledge of, access to, and trust of communities they support

TB services mainly delivered through medical model of health CBOs are not involved in TB service delivery and in strategic networks

Lack of knowledge, capacity and resources (funding, materials, etc.) to deliver TB services

TB may not currently be seen as a priority in their community

www.thetruthabouttb.org

www.tbalert.org95A description of what you are going to talk about explain that this normally takes 15-20 mins (best to time yourself first!) and there will be time for questions afterwardswww.thetruthabouttb.org

www.thetruthabouttb.org

www.tbalert.org96TB training workshops for community based organisationsTo provide the TB knowledge and skills to become active and credible partners to statutory agencies

Initially: to engage people and communities affected by TB through awareness raisingSymptomsTB is curableGo to a doctor for free treatment

Delivered nationwide in partnership with NHS/HPU agencies

13 workshops. 250 delegates. 2/3rds third sector; 1/3rd statutory sector

www.thetruthabouttb.org

www.tbalert.org97A description of what you are going to talk about explain that this normally takes 15-20 mins (best to time yourself first!) and there will be time for questions afterwardsExamples of third sector partnershipsJoint designing and branding of TB awareness leaflets for specific populations at risk TB/HIV co-infection (African Health Policy Network)TB in people dependent on alcohol and drugs (Westminster Drug Project)TB in Somali Communities (Bristol NHS, Embrace-UK)

TB awareness project in Liverpool funded by local PCT (Asylum Link working with refugees and asylum seekers)

TB awareness integrated in strategic goals (BHA, Manchester)

TSOs running World TB Day events (62 in 2011; 99 in 2012)www.thetruthabouttb.org

www.tbalert.org982012-14: Local TB PartnershipsFuture: Third sector organisations become service delivery partners at appropriate points along the TB pathway

LTBPs: Partnerships of third sector organisations and statutory stakeholders that plan how third sector organisations and people affected by TB can contribute to local TB care and control programmes.

Representative of and owned by locally affected communitiesRecognised by statutory stakeholders as a legitimate and necessary TB partnershipsWork with statutory stakeholders to plan and build the role of third sector organisations and PATB in local TB care and control programmesWork with statutory stakeholders to improve the design and delivery of local TB services

www.thetruthabouttb.org

www.tbalert.org99Involving communities and PATBThe principle will be no decisions about me without me.

services are more responsive to patients and designed around them, rather than patients having to fit around services.

People arent hard to reach. It just requires a bit more thought and effort to make sure their needs are taken into account.

www.thetruthabouttb.org

www.tbalert.org100Professor Ibrahim Abubakar PhD, FFPH, FRCP (Edin)Head of TB Section HPAProfessor of Infectious Disease Epidemiology 101Session three Q&A

Surinder Tamne Mike Mandelbaum Prof Ibrahim Abubakar

102Contact the LHP TB team at: Email: tb@londonhp.nhs.ukWebsite: www.londonhp.nhs.ukFollow us on Twitter (@londonhp) #LondontbplanJoin us on Facebook (London Health Programmes)

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