Download full presentation pack. - London Health Programmes

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
Country
• Operational policy guidance
• National guidance
• Define standard indicators
• M and E system
• Implementation manual
• Training manual
• Training manual
• NGOs supported
• Advocacy and visibility
• NGOs provided TA
WHO’s new area of work
Resource mobilisation
DR Congo, Ethiopia, Kenya, South Africa, Tanzania
World Tuberculosis Day, 2012
Urban Tuberculosis Control in
the European Union
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
EU/EEA 2010
14.6/100,000
100.0
80.0
60.0
40.0
20.0
0.0
Norway
Iceland
United kingdom
Sweden
Spain
Slovenia
Slovakia
Romania
Portugal
Poland
Netherlands
Malta
Luxembourg
Lithuania
Latvia
Italy
Ireland
Hungary
Greece
Germany
France
Finland
Estonia
Denmark
Czech Republic
Cyprus
Bulgaria
Belgium
Austria
Source: Surveillance report, TB Surveillance and Monitoring in Europe 2012 (2010 data)
Pattern of TB situation in big cities
differs across the EU
Figure 1: TB notification rates in a selection
of countries and big cities of EU/EEA, in 2009.
< 20 cases
per 100,000
population
≥ 20 cases
per 100,000
population
Riga / Latvia
Copenhagen / Denmark
16.9 / 6.0
43.0 / 43.2
Rotterdam / Netherlands
Vilnius / Lithuania
21.3 / 7.0
31.9 / 62.1
London / United Kingdom
44.4 / 14.8
Warsaw / Poland
17.8 / 21.6
Paris / France
23.4 / 8.2
Milan / Italy
Bucharest / Romania
81.0 / 108.2
33.2 / 6.5
Sofia / Bulgaria
Barcelona / Spain
31.9 / 38.3
24.3 / 16.6
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.
Pattern of TB situation in big cities
differs across the EU
Low-incidence countries
High-incidence countries
TB case load appears to
accumulate disproportionately to
big cities.
TB case load appears more
generalised in the population and
evenly distributed in the country.
2-5 times higher notification rates
in big cities compared to the
country overall.
Equal or lower 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
The most vulnerable and
excluded groups carry the most
significant burden of disease and
have the poorest access to
services.
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
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
Advocacy
Support
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
[email protected]
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
Rate per 100,000 population
70
60
50
40
30
20
10
0
2004
2005
2006
2007
2008
2009
2010
Year of Notification
London Total
North Central
North East
North West
South East
South West
2011
TB case rates by PCT of residence, 2011
Enfield
Barnet
Harrow
Haringey
Waltham
Forest
Redbridge
Havering
Hillingdon
Brent
Camden
City &
Islington Hackney
Westminster
Kensington &
Chelsea
Hammersmith
& Fulham
Ealing
Hounslow
Tower
Hamlets
Barking &
Dagenham
Newham
Southwark
Greenwich
Bexley
Lambeth
Richmond &
Twickenham
Kingston
Wandsworth
Lewisham
Sutton &
Merton
Bromley
Croydon
Newham – 158 /100,000
Brent – 123 /100,000
North Central
North East
North West
South East
89%
South West
Wandsworth
85% 86%
Sutton & Merton
77%
Richmond & Twickenham
Kingston
87% 85%
Croydon
77%
Southwark
Lewisham
89%
Lambeth
89%
Greenwich
83% 84% 84%
Bromley
Bexley
Westminster
81% 82%
Kensington & Chelsea
Hounslow
Hillingdon
78%
Harrow
85% 86%
Hammersmith & Fulham
77%
Ealing
81% 82%
Brent
88%
Waltham Forest
Tower Hamlets
85% 85%
Redbridge
Newham
83%
Havering
91%
City & Hackney
89% 89%
Barking & Dagenham
81%
Islington
80%
Haringey
Enfield
Camden
90%
Barnet
Treatment completion among TB cases reported in 2010
100%
87%
81%
76%
85% Rx
completion
target
70%
60%
2010
84%
completion
50%
40%
30%
20%
10%
0%
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
TB drug resistance, 2010
12
Proportion of TB cases (%)
10
8
8.4% INH-R
6
1.6% MDR
4
2
0
1999
2001
Any resistance
2003
2005
Isoniazid resistant
2007
2009
Multi-drug resistant
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
Financial considerations – costs
• 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 – savings
Cost of TB Treatment
Case Finding vs. Do Nothing
£ Millions
25
20
15
2012
2013
2014
2015
2016
Net TB costs - with case finding
2017
2018
2019
2020
2021
Net TB costs - do nothing
42
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
Rate per 100,000 population
70
60
50
40
30
20
10
0
2004
2005
2006
2007
2008
2009
2010
Year of Notification
London Total
North Central
North East
North West
South East
South West
* Rates based upon 2010 ONS PCT population estimates
2011
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
140
120
100
80
Hackney
Tower Hamlets
60
Newham
40
20
Screening programme
0
2005
2006
2007
2008
2009
2010
Migrant from high TB prevalence* country
aged 5-35 years
Sputum, CXR, blood (FBC, ESR, CRP) and
make follow up appointment with GP
yes
TB symptoms?
+ve
Refer TB team
no
IGRA
*TB prevalence >40/100,000 - see map
-ve
Letter to reassure
If no BCG scar, do BCG
Migrant from high TB prevalence* country
aged over 35 years
yes
Sputum, CXR, blood (FBC, ESR, CRP) and
make follow up appointment with GP
TB symptoms?
no
Reassure, give TB leaflet
*TB prevalence >40/100,000 - see map
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……
Contact tracing
GP
Radiology
Accident + Emergency
TB service
Self-referrals
New entrants
Ophthalmology
ENT
Gastroenterology
HIV
GUM
Orthopaedics
Neurology
Occupational Health
Find and Treat
MXU
Cardiothoracics
Surgery
Dermatology
Cytopathology
Histopathology
Neurosurgery
Rheumatology
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
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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
Ensure
comprehensive case
management
Provide staff with a
forum for open
discussion
Provide ongoing
training and
education for staff
Improve promptness
of appropriate
interventions
Strengthen
the
prevention
and control
of TB
Maintain reliability of
data on the TB
Surveillance System
Providing immediate
analysis of treatment
outcomes and
contact investigation
efforts, measured
against previous
cohorts
Identifying, tracking
and following up on
important case
management issues
highlighted through
the review
Assess efforts
compared to local
and national TB
control targets
The cohort review process
Preparation
Presentation
Training
Setting targets
Data -TB register
Identify cohort
Case
management
• Preparing forms
for presentation
• Analysis
• Detailed patient
outcome
• Outcome of
group of patients
• Analysis of
outcomes
• Assessed against
national, regional
and local service
objective
•
•
•
•
•
Cohort co-ordinator
Follow- up
• Treatment
• Case
Management
• Data
• Education and
Training
• Commissioning
Cohort chair
A group of all TB cases counted in a specific
time frame are reviewed in a group setting
Case manager
Social care team
Evaluation 2011
Outcomes
Cases ≥1 risk factor
Proportion of sputum smear
positive PTB with ≥ 1 risk
factor receiving DOT
Proportion of cases lost to
follow up
Treatment completion rate all
cases
The proportion of TB cases
with sputum smear positive
pulmonary disease with at
least one contact
2009
2010
19%
20%
42%
67%
2.5%
0%
82% (77%)
79% (64%)
90% (84)
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%
98%
Assessed efforts compared to local and national
targets
96%
Identified, tracked and followed up important case
management issues
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


Thank you for
listening
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.
www.thetruthabouttb.org
www.tbalert.org
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: [email protected]
• Website: www.londonhp.nhs.uk
• Follow us on Twitter (@londonhp)
#Londontbplan
• Join us on Facebook (London Health
Programmes)
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