6249919.ppt

6249919.ppt
World Tuberculosis Day The London TB Plan Event #LondonTBplan
Key TB functions and efforts of WHO Haileyesus Getahun Stop TB Department WHO/HQ, Geneva.
WHO core functions in global TB control 1. Provide global leadership 2. Development of policy, norms and standards 3. Technical support and coordination 4. Monitoring and evaluation 5. Promoting research 6. Facilitate partnerships
Impact of WHO policies (1995 - 2010) • DOTS/Stop TB strategy  46 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 saved
NGOs for Community based TB activities Global • Operational policy guidance • Define standard indicators • Implementation manual • Training manual • Advocacy and visibility Country • National guidance • M and E system • Training manual • NGOs supported • NGOs provided TA WHO’s new area of work
Resource mobilisation DR Congo, Ethiopia, Kenya, South Africa, Tanzania
Urban Tuberculosis Control in the European Union World Tuberculosis Day, 2012 Tuberculosis Programme European Centre for Disease Prevention and Control Stockholm, Sweden, 19 March, 2012
From surveillance to public health action
From surveillance to public health action – ECDC’s added value Action Plan and Monitoring Framework Surveillance and Monitoring – Identifying and assessing needs Public Health Action
The epidemiological patterns of TB are heterogeneous within EU
The epidemiological patterns of TB are heterogeneous within EU 0.0 20.0 40.0 60.0 80.0 100.0 Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden United kingdom Iceland Norway EU/EEA 2010 14.6/100,000 Source: Surveillance report, TB Surveillance and Monitoring in Europe 2012 (2010 data)
Pattern of TB situation in big cities differs across the EU Disclaimer: 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 / 43.2 31.9 / 62.1 81.0 / 108.2 31.9 / 38.3 17.8 / 21.6 Riga / Latvia Vilnius / Lithuania Warsaw / Poland Bucharest / Romania Sofia / Bulgaria 16.9 / 6.0 Copenhagen / Denmark 21.3 / 7.0 Rotterdam / Netherlands 23.4 / 8.2 Paris / France 44.4 / 14.8 London / United Kingdom 24.3 / 16.6 Barcelona / Spain 33.2 / 6.5 Milan / Italy < 20 cases per 100,000 population ≥ 20 cases per 100,000 population
Pattern of TB situation in big cities differs across the EU High-incidence countries TB 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 countries TB 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 settings
Accumulation of TB among vulnerable groups TB disproportionately affects the socially and economically disadvantaged Socio-economic determinants Differential exposure and susceptibility Vulnerable groups Health inequalities
Vulnerable groups in urban settings High-risk groups - Refugees, asylum seekers, migrants - Homeless people - Prisoners - Illicit drug users - Alcoholics - HIV-seropositive people Other vulnerable groups - Children - Elderly Characteristics of urban settings - High population density - Complex social structure The 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 settings
Providing guidance, advocate and monitor ECDC’s added value Action and outputs from ECDC of relevance for urban TB control European Union Guidance Support Advocacy
Reaching out to vulnerable groups in urban settings Going beyond standard public health strategies  Every patient’s right.  Novel interventions.  Collaborate between cities.  Share best practices. Working together to eliminate TB in the EU
Contact the ECDC TB Programme http://ecdc.europa.eu
TB - the facts The epidemiology of TB in London and the need for change Dr Sarah Anderson HPA Regional Epidemiologist - London sarah.anderson@hpa.org.uk 22nd March 2012
TB in London – 2011 • 3588 cases • 46 per 100,000 population (c.f. nationally 13.6) • 3 times national rate, some boroughs 10x • 42% 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
TB rates in London, 1982-2010 TB rates in London, 1982-2010
TB rate by sector of residence, 2004 – 2011 0 10 20 30 40 50 60 70 2004 2005 2006 2007 2008 2009 2010 2011 Rate per 100,000 population Year of Notification London Total North Central North East North West South East South West
Hillingdon Barnet Redbridge Harrow Havering Barking & Dagenham Bexley Newham Hammersmith &Fulham Haringey Brent Ealing Greenwich Bromley Lewisham Tower Hamlets City& Hackney Islington Camden Westminster Kensington & Chelsea Richmond & Twickenham Waltham Forest Southwark Lambeth Wandsworth Croydon Sutton & Merton Kingston Hounslow Enfield TB case rates by PCT of residence, 2011 Newham – 158 /100,000 Brent – 123 /100,000
Treatment completion among TB cases reported in 2010 89% 89% 81% 77% 83% 91% 88% 85% 85% 81% 82% 85% 86% 78% 89% 81% 82% 77% 83% 84% 84% 81% 89% 87% 85% 77% 85% 86% 76% 89% 87% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Barnet Camden Enfield Haringey Islington Barking & Dagenham City & Hackney Havering Newham Redbridge Tower Hamlets Waltham Forest Brent Ealing Hammersmith & Fulham Harrow Hillingdon Hounslow Kensington & Chelsea Westminster Bexley Bromley Greenwich Lambeth Lewisham Southwark Croydon Kingston Richmond & Twickenham Sutton & Merton Wandsworth NorthCentral NorthEast NorthWest SouthEast SouthWest 85% Rx completion target 2010 84% completion
Treatment • 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
0 2 4 6 8 10 12 1999 2001 2003 2005 2007 2009 Proportion of TB cases (%) Any resistance Isoniazid resistant Multi-drug resistant TB drug resistance, 2010 8.4% INH-R 1.6% MDR Almost 1 in ten culture confirmed cases resistant
Case for Change - TB in London TB is an infectious disease that is treatable and curable however it remains a major public health issue The number of TB cases has increased by 50% over the last ten years and more than doubled over the last 20 years In 2010, more cases of TB diagnosed in London than HIV TB rates vary widely across the capital
Key issues for TB Latent TB Active transmission 80% of active cases are from latent TB, activated years after the patient has become infected More prevalent in social risk groups including drug and alcohol users, homelessness, prisoners and people with mental health issues No systematic screening – majority identified only when disease reactivates Poor treatment completion rates lead to high rates of drug resistant TB which is costly and time consuming for the patient and NHS Prophylactic treatment can be unpleasant and lengthy. Patients from high risk groups often present late, resulting in complications and onward transmission of the disease to others
Current service provision 5 TB networks across London with variability in commissioning, service planning, protocols and education Service resources, capacity and delivery does not align with TB rates Poor awareness of TB among health professionals Variable uptake and administration of neonatal vaccination
Case for Change The ‘Case for change’ document - provides the evidence to support the need for change and - highlights the risks for London if these problems are not addressed: • further fragmentation in TB services • varied quality of care for patients • increased rates of active, latent and drug resistant TB • greater cost to the system for TB services and treatment for patients Development of ‘Model of Care’ to address the TB problem in London with the ultimate goal of reducing rates of TB in London
The London Model of Care Dr William Lynn Clinical Lead, TB project London Health Programmes 2012
Background to the model • Developed by the TB community involving nurses, consultants, GPs, the Health Protection Agency and TB networks and overseen by both a clinical working group and project board with strong public health expertise and service user representation • Stakeholder events along with meetings, national and public media, 1:1 interviews • Over 200 individuals provided feedback including GPs, patients, voluntary and community organisations, public health and government committees • There was widespread support for the plans 35
Model of Care • Recommendations in the model are targeted at three aspects of the patient pathway: – Improving detection and diagnosis of the disease – Better coordinated commissioning – Addressing variability of provision 36
Improving detection and diagnosis • Raise awareness in communities with higher rates of TB disease • Raise awareness and knowledge of TB among health and social care workers • Explore the potential of active and latent TB case finding focusing on new registrations in primary care - to pilot in specific area(s) for first year 37
Improving the commissioning of TB services • Develop a London TB Commissioning Board to address current system fragmentation • The board would bring together the functions of health care commissioning, health protection and public health to ensure a co-ordinated, multi-agency approach to TB control • Robust commissioning of TB services will include sound planning, standard setting and strong performance management 38
Improving the commissioning of TB services • Continue to commission the Find and Treat service to work with hard to reach groups in the community • Streamline funding process for patients with no recourse to public funds • Ensure three levels of service provision • Level 1 - Generic primary and community care • Level 2 - Recognised TB services • Level 3 - Specialist TB services 39
Variability of service provision • Encourage providers of TB services to work together as delivery boards that 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 patients • Workforce development group will ensure appropriate skill mix and best value for money is achieved. 40
• Annual NHS spend on healthcare in London £13.9billion • Annual spend on TB in London £18-20 million • Annual costs of the TB plan £7.2 million – Including additional diagnostic and treatment costs from active case finding 41 Financial considerations – costs
Financial considerations – savings 42 15 20 25 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 £ Millions Net TB costs - with case finding Net TB costs - do nothing Cost of TB Treatment Case Finding vs. Do Nothing
Next steps and challenges • Commissioning – current PCT clusters, CCGs and proposed CSSs • Addressing variability – Cohort review • Pan-London protocols – Established commissioning intentions • Case finding pilot(s) – Implementation and evaluation 43
Session One Q&A Dr Emma Huitric Sarah Anderson Dr William Lynn 44
TB screening in primary care: can we move forward? Chris Griffiths, QMUL
Figure 1: London TB rate per 100,000* population by sector of residence – reported to the London TB Register * Rates based upon 2010 ONS PCT population estimates 0 10 20 30 40 50 60 70 2004 2005 2006 2007 2008 2009 2010 2011 Rate per 100,000 population Year of Notification London Total North Central North East North West South East South West
Screening for TB in primary care Do we meet the criteria? • Condition – Important health problem, epidemiology understood • Test – Simple, safe, acceptable, precise, clear policy on managing positive results • Treatment – Effective treatment • Screening programme – High quality trials, complete screening programme needs to be clinically and socially acceptable, with benefits outweighing harms, monitoring in place
TB Notification rates East London Source: HPA 2011 0 20 40 60 80 100 120 140 2005 2006 2007 2008 2009 2010 Hackney Tower Hamlets Newham Screening programme
TB symptoms? yes Sputum, CXR, blood (FBC, ESR, CRP) and make follow up appointment with GP no IGRA Migrant from high TB prevalence* country aged 5-35 years +ve Refer TB team Letter to reassure If no BCG scar, do BCG -ve *TB prevalence >40/100,000 - see map
*TB prevalence >40/100,000 - see map TB symptoms? yes Sputum, CXR, blood (FBC, ESR, CRP) and make follow up appointment with GP no Migrant from high TB prevalence* country aged over 35 years Reassure, give TB leaflet
Evaluation planned • Numbers of practices screening with IGRA • Numbers of IGRA tests • Demography of those tested • % positive IGRA tests • Numbers with LTBI • Numbers receiving chemoprophylaxis
Welcome to the Health and Social Care Bill • Hackney PCT dissolved, Clinical Commissioning Groups set up • Public Health shifted to Hackney council • CCG funding cut • Council freeze on all new activity
How will providers need to work differently? Integrating TB care to achieve best possible outcomes Onn Min Kon Marc Lipman
Is this TB?
Multifaceted – disease and approach • TB – a complex disease with multiple presentations • 50% extrapulmonary • 80% reactivation disease • Drug resistance • Specialist care • High risk groups – Immunosuppressed • HIV • Diabetes • Renal disease • Iatrogenic – Homelessness – Drug and alcohol abuse – Prison – Children
Where patients come from…… TB service GP ENT Cardiothoracics Self-referrals Cytopathology Histopathology New entrants Orthopaedics Radiology Occupational Health Contact tracing Accident + Emergency Surgery Ophthalmology Rheumatology Gastroenterology Neurology Dermatology Find and Treat MXU Neurosurgery GUM HIV
Where patients come from……
TB disease in London, 2010
Case 1 • 29 UK born male drug user • Prior TB treatment 1 year previously • Offered DOT • Only took a few weeks then lost to follow up • Missed multiple clinics • Found in hostel by Find and Treat in Westminster • Contacted Outreach TB CNS • Sputum samples taken – smear AFB positive +++ • Admitted to inpatient TB treatment centre • Absconded on multiple occasions • Public Health Order • Police involved • Private security funded by PCT • Drug interaction issues
Case 1 • 1 year DOT via pharmacy (local Boots) linked to methadone • Drug Project team or hostel key worker attend appointments • Completed treatment with CXR correlate and microbiological ‘cure’ • Complex case – multi Agency integration • Case managed by TB CNS • Clinical overview – specialist TB service
Successful outcome resulted from • Multi Agency approach • Close collaboration – Clinical staff – Hostel – Pharmacist – Drug project – GP – PCT – Find and Treat
How can we ensure that this happens in every case?
Avoiding variability in service provision • Five 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 patients • Workforce development group will ensure appropriate skill mix and best value for money is achieved
Case 2 • 48 Indian female • MDR TB 2 prior treatments in original hospital • Now: CXR cavities, BAL smear positive • 3rd line TB treatment required • Inpatient treatment for 3 months • Adverse events ++ • Child infected
Avoiding variability in service provision • NICE 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 HPA”
What is medically complex TB? • MDR or extensively drug resistant TB • Paediatric TB disease • Chronic renal disease or renal transplant TB • Patients co-infected with HIV/TB • Spinal TB • Neurological TB
Service configuration
Level 1 – generic primary & community services • Case 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 TB • Assess new patients • Perform appropriate investigations for the diagnosis of TB • Start and maintain treatment for TB including supporting patient and their families/carers over this time • Work 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 community
Level 3 - very specialist services • Provide 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 required • Patients requiring inpatient treatment at a level 3 service should be considered for transfer back to a level 2 service closer to patient’s home or for treatment within the home as soon as practicable
Adding value to the model
Case 3 • 33 male from Slovakia • Homeless / alcoholic • Unwell/ coughing ‘months’ • MXU screen • Abnormal CXR • Smear negative, culture positive TB • No Recourse to Public Funds
Case 3 •Admitted briefly to hospital •Hostel in Camden for ‘street homeless’ Europeans •3 x a week DOT • TB outreach worker •Evicted as drinking •Attended Day Centre •Then clinic DOT with incentive funds •Brief imprisonment •Moved to Cambridge •Medication passed by friend to him •F+T saw him in Cambridge •Local team took over and completed
Pan London Provided Services
Pan London with local integration • Housing • HPA • DOT • F+T • Microbiology services • Mycobacterial Reference Unit • Large scale contact tracing • New entrant/ new registration screening • Diagnostic clinic • Specialist component • Negative pressure facilities • MDR/Level 3 requirement • BCG Need to work across the ‘borders’ to tackle TB Clinical accountability and expertise
Issues • Political will vital • Uncertain commissioning landscape • Significant co-ordination required • How 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 84
The Benefits of Cohort Review Surinder Tamne TB Specialist Nurse Health Protection Agency Colindale
cohort review process :talk outline History Purpose Process Evaluation Benefits
History
The purpose of cohort review Strengthen the prevention and control of TB Ensure comprehensive case management Improve promptness of appropriate interventions Maintain reliability of data on the TB Surveillance System Providing immediate analysis of treatment outcomes and contact investigation efforts, measured against previous cohorts Assess efforts compared to local and national TB control targets Identifying, tracking and following up on important case management issues highlighted through the review Provide ongoing training and education for staff Provide staff with a forum for open discussion
The cohort review process Preparation • Training • Setting targets • Data -TB register • Identify cohort • Case management • Preparing forms for presentation Presentation • Analysis • Detailed patient outcome • Outcome of group of patients • Analysis of outcomes • Assessed against national, regional and local service objective Follow- up • Treatment • Case Management • Data • Education and Training • Commissioning A group of all TB cases counted in a specific time frame are reviewed in a group setting Cohort chair Case manager Social care team Cohort co-ordinator
Evaluation 2011 Outcomes 2009 2010 Cases ≥1 risk factor 19% 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 cases 82% (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
Evaluation 2011Staff feedback Highlighted gaps in service 96% 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
Benefits  
www.thetruthabouttb.org www.tbalert.org www.thetruthabouttb.org Working together: How the third sector supports TB control London TB Plan Event 22nd March 2012 Mike Mandelbaum, TB Alert
www.thetruthabouttb.org www.tbalert.org Involving Community Based Organisations in TB Programmes • Most 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.org www.thetruthabouttb.org
www.thetruthabouttb.org www.tbalert.org TB training workshops for community based organisations • To 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 raising – Symptoms – TB is curable – Go 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.org Examples of third sector partnerships • Joint 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.org 2012-14: Local TB Partnerships Future: 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 communities • Recognised by statutory stakeholders as a legitimate and necessary TB partnerships • Work with statutory stakeholders to plan and build the role of third sector organisations and PATB in local TB care and control programmes • Work with statutory stakeholders to improve the design and delivery of local TB services
www.thetruthabouttb.org www.tbalert.org Involving communities and PATB • “The 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 aren’t ‘hard to reach’. It just requires a bit more thought and effort to make sure their needs are taken into account.
Professor Ibrahim Abubakar PhD, FFPH, FRCP (Edin) Head of TB Section HPA Professor of Infectious Disease Epidemiology 101
Session three Q&A Surinder Tamne Mike Mandelbaum Prof Ibrahim Abubakar 102
Contact the LHP TB team at: • Email: tb@londonhp.nhs.uk • Website: www.londonhp.nhs.uk • Follow us on Twitter (@londonhp) #Londontbplan • Join us on Facebook (London Health Programmes) 103

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