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Guidance on programmatic management of
latent TB infection: applicability for TB control
in migrants
Marieke J. van der We...
Background
TB notifications by country, EU/EEA, 2014
58 008 TB cases in 29 EU/EEA countries
12.8 per 100 000 population (r...
Background
Towards TB elimination in EU/EEA
With current mean annual change in the TB notification rate (-6%), the
EU/EEA ...
Towards TB elimination: An action
framework for low-incidence countries
Priority action area
1. Ensure political commitmen...
Towards TB elimination: An action
framework for low-incidence countries
Priority action area
1. Ensure political commitmen...
ECDC guidance document on programmatic
management of latent TB infection: PROCESS
Expert
meeting
• Inventory of expert opi...
Step 1: Expert meeting
Components identified for guidance
• diagnostic tests for LTBI
• preventive treatment regimens
• ri...
Step 2: Systematic literature reviews
8
Step 2: Systematic literature reviews
1. What is the prevalence of LTBI among risk groups?
2. What is the risk of progress...
Step 2: Systematic literature reviews
1. What is the prevalence of LTBI among risk groups?
2. What is the risk of progress...
Mathematical modelling and cost-
effectiveness studies
11
Erasmus MC. Report: Assessment of introducing programmatic laten...
ECDC guidance document on programmatic
management of latent TB infection: PROCESS
Expert
meeting
• Inventory of expert opi...
ECDC guidance: Applicability for TB control
in migrants
13
Total population
Infectious diseases
LTBI
Migrants
ECDC guidance: Applicability for TB control
in migrants
14
Total population
Infectious diseases
LTBI
Migrants
ECDC guidance: Applicability for TB control
in migrants
15
Total population
Infectious diseases
LTBI
Migrants
Acknowledgements
Erasmus MC
Jan A.C. Hontelez
Joost Vanhommerig
Suzanne Verver
Rui Cai
Rinke Hoekstra
Jan Hendrik Richardu...
Trend in origin of TB cases in the EU/EEA,
2007-2013
17
0.0
5.0
10.0
15.0
20.0
25.0
0
10000
20000
30000
40000
50000
60000
...
Conflict of interest disclosure
X I have no, real or perceived, direct or indirect conflicts of interest that relate to th...
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Guidance on programmatic management of latent TB infection: applicability for TB control in migrants

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ECDC presentation at the Union Conference, Liverpool, 27 October 2016.
Marieke van der Werf, ECDC.

Published in: Health & Medicine
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Guidance on programmatic management of latent TB infection: applicability for TB control in migrants

  1. 1. Guidance on programmatic management of latent TB infection: applicability for TB control in migrants Marieke J. van der Werf, Netta Beer, Sake J. de Vlas, Teymur Noori, Marije Vonk Noordegraaf-Schouten Liverpool, 27 October 2016
  2. 2. Background TB notifications by country, EU/EEA, 2014 58 008 TB cases in 29 EU/EEA countries 12.8 per 100 000 population (range 2.5–79.7) 2 Not reporting 20 to 49 per 100 000 10 to 19 per 100 000 5 to 9 per 100 000 < 5 per 100 000 ≥ 50 per 100 000
  3. 3. Background Towards TB elimination in EU/EEA With current mean annual change in the TB notification rate (-6%), the EU/EEA will achieve TB elimination by 2092. To reach elimination by 2050, TB rates need to decline by 12% annually. 3 1 10 100 1000 2010 2020 2030 2040 2050 2060 2070 2080 2090 TBnotificationsper1million Decline needed to reach TB elimination by 2050 Current mean annual decline
  4. 4. Towards TB elimination: An action framework for low-incidence countries Priority action area 1. Ensure political commitment, funding and stewardship for planning and essential services of high quality. 2. Address the most vulnerable and hard-to-reach groups. 3. Address special needs of migrants and cross-border issues. 4. Undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment. 5. Optimize the prevention and care of drug-resistant TB. 6. Ensure continued surveillance, programme monitoring and evaluation and case based-data management. 7. Invest in research and new tools. 8. Support global TB prevention, care and control. 4
  5. 5. Towards TB elimination: An action framework for low-incidence countries Priority action area 1. Ensure political commitment, funding and stewardship for planning and essential services of high quality. 2. Address the most vulnerable and hard-to-reach groups. 3. Address special needs of migrants and cross-border issues. 4. Undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment. 5. Optimize the prevention and care of drug-resistant TB. 6. Ensure continued surveillance, programme monitoring and evaluation and case based-data management. 7. Invest in research and new tools. 8. Support global TB prevention, care and control. 5
  6. 6. ECDC guidance document on programmatic management of latent TB infection: PROCESS Expert meeting • Inventory of expert opinions on components of LTBI control collected through a questionnaire and two interactive rounds Systematic reviews • Systematic literature reviews on scientific evidence for relevant components of LTBI control Modelling • Mathematical modelling and cost-effectiveness studies on LTBI control Expert panel meeting • Expert panel meeting to discuss the results of the systematic reviews and modelling Guidance • Development of guidance with options for introducing programmatic LTBI control in the European Union 6
  7. 7. Step 1: Expert meeting Components identified for guidance • diagnostic tests for LTBI • preventive treatment regimens • risk group specific interventions • combining LTBI control with other health programmes 7Sandgren et al. Euro Surveill. 2016 Aug 25;21(34).
  8. 8. Step 2: Systematic literature reviews 8
  9. 9. Step 2: Systematic literature reviews 1. What is the prevalence of LTBI among risk groups? 2. What is the risk of progression of LTBI to active TB disease among risk groups? 3. What is the incidence of active TB among risk groups? 4. Among individuals at risk of LTBI, which investigations and clinical parameters are most predictive of the absence of active TB? 5. Among persons at high risk of latent tuberculosis infection (LTBI) who are not on tuberculosis preventive therapy, which test(s) alone or in combination with other proxies for LTBI, when positive, can best identify individuals most at risk of progression to incident tuberculosis (TB) disease? 6. Systematic literature review and meta-analysis on the best treatment options for latent tuberculosis infection 7. What is the best way to monitor and manage hepatic toxicity and other adverse events in individuals receiving treatment for LTBI? 8. Does treatment for LTBI lead to significant development of resistance against the drugs used? 9. What is the effectiveness of anti-tuberculosis drugs (any regimen) in preventing active TB in contacts of MDR-TB patients? 10. For each recommended LTBI treatment regimen, what are the initiation and completion rates? 11. For each recommended LTBI treatment regimen, what are the determinants of treatment initiation, adherence and completion? 12. In individuals who are eligible for LTBI treatment, what are the interventions with demonstrated efficacy to improve LTBI treatment initiation, adherence and completion? 13. Will duration of protection from LTBI treatment be a barrier to LTBI management implementation? 14. What is the cost-effectiveness of LTBI management interventions? 9
  10. 10. Step 2: Systematic literature reviews 1. What is the prevalence of LTBI among risk groups? 2. What is the risk of progression of LTBI to active TB disease among risk groups? 3. What is the incidence of active TB among risk groups? 4. Among individuals at risk of LTBI, which investigations and clinical parameters are most predictive of the absence of active TB? 5. Among persons at high risk of latent tuberculosis infection (LTBI) who are not on tuberculosis preventive therapy, which test(s) alone or in combination with other proxies for LTBI, when positive, can best identify individuals most at risk of progression to incident tuberculosis (TB) disease? 6. Systematic literature review and meta-analysis on the best treatment options for latent tuberculosis infection 7. What is the best way to monitor and manage hepatic toxicity and other adverse events in individuals receiving treatment for LTBI? 8. Does treatment for LTBI lead to significant development of resistance against the drugs used? 9. What is the effectiveness of anti-tuberculosis drugs (any regimen) in preventing active TB in contacts of MDR-TB patients? 10. For each recommended LTBI treatment regimen, what are the initiation and completion rates? 11. For each recommended LTBI treatment regimen, what are the determinants of treatment initiation, adherence and completion? 12. In individuals who are eligible for LTBI treatment, what are the interventions with demonstrated efficacy to improve LTBI treatment initiation, adherence and completion? 13. Will duration of protection from LTBI treatment be a barrier to LTBI management implementation? 14. What is the cost-effectiveness of LTBI management interventions? 10
  11. 11. Mathematical modelling and cost- effectiveness studies 11 Erasmus MC. Report: Assessment of introducing programmatic latent tuberculosis control in the European Union and candidate countries. Work package 5: Cost-effectiveness analysis BRHR = behaviour-related high-risk individuals
  12. 12. ECDC guidance document on programmatic management of latent TB infection: PROCESS Expert meeting • Inventory of expert opinions on components of LTBI control collected through a questionnaire and two interactive rounds Systematic reviews • Systematic literature reviews on scientific evidence for relevant components of LTBI control Modelling • Mathematical modelling and cost-effectiveness studies on LTBI control Expert panel meeting • Expert panel meeting to discuss the results of the systematic reviews and modelling Guidance • Development of guidance with options for introducing programmatic LTBI control in the European Union 12
  13. 13. ECDC guidance: Applicability for TB control in migrants 13 Total population Infectious diseases LTBI Migrants
  14. 14. ECDC guidance: Applicability for TB control in migrants 14 Total population Infectious diseases LTBI Migrants
  15. 15. ECDC guidance: Applicability for TB control in migrants 15 Total population Infectious diseases LTBI Migrants
  16. 16. Acknowledgements Erasmus MC Jan A.C. Hontelez Joost Vanhommerig Suzanne Verver Rui Cai Rinke Hoekstra Jan Hendrik Richardus Sake J. de Vlas ECDC Andreas Sandgren Netta Beer Teymur Noori 16 Pallas, Health research and consultancy B.V. Marije Vonk Noordegraaf-Schouten Femke van Kessel Anke Stuurman Anouk Oordt-Speets Radbout UMC Rob Baltussen
  17. 17. Trend in origin of TB cases in the EU/EEA, 2007-2013 17 0.0 5.0 10.0 15.0 20.0 25.0 0 10000 20000 30000 40000 50000 60000 70000 2007 2008 2009 2010 2011 2012 2013 Percentage No.ofcases Year TB cases of non-EU/EEA origin TB cases of EU/EEA origin TB cases of unknown/not specified origin % of non-EU/EEA TB cases among all TB Ködmön et al. Eurosurveillance March 2016
  18. 18. Conflict of interest disclosure X I have no, real or perceived, direct or indirect conflicts of interest that relate to this presentation.  I have the following, real or perceived direct or indirect conflicts of interest that relate to this presentation: Affiliation / financial interest Nature of conflict / commercial company name Tobacco-industry and tobacco corporate affiliate related conflict of interest Grants/research support (to myself, my institution or department): Honoraria or consultation fees: Participation in a company sponsored bureau: Stock shareholder: Spouse/partner: Other support or other potential conflict of interest: This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of interest going back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgment. It remains for audience members to determine whether the speaker’s interests or relationships may influence the presentation. Drug or device advertisement is strictly forbidden.

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