TB in the Organization of Eastern Caribbean States (OECS)Auvergne.pdf · 2020. 3. 24. · OECS Country Profile TB Notified Cases 2013 vs 2018 2018 2013 34% Reduction in TB Cases Total

TB in the Organization of Eastern Caribbean States (OECS)

Cleophas d’Auvergne MD., MPA, Dip TB, (WHO/USAID), AAHIVS (HIV Specialist)

Disclaimer

I have no conflict of interest.

Learning Objectives

At the end of the session participants will be able to :

• Understand the Epidemiology of TB in the OECS

• Describe TB prevention and control activities in small island development states and identify possible strategies for TB Elimination.

Established in 1981 by the Treaty of Basseterre is an 11-membergrouping of islands spreading across the Caribbean from Anguilla,Montserrat, British Virgin Islands ( U.K British Overseas Territories)Guadeloupe, Martinique (French Department) Antigua and Barbuda,St. Kitts and Nevis, Dominica, St. Lucia, St. Vincent and the Grenadinesto Grenada, (Total Population 2017, 1.7 M)

Countries under Global Fund Grant St. Kitts and Nevis, Antigua andBarbuda, Dominica, St. Lucia, St. Vincent and the Grenadines, Grenadaall full Members (Total population 2019 , 627,713)

Income:• High income (Antigua& Barbuda, St. Kitts& Nevis, )• Middle Income (St. Lucia, St. Vincent, Grenada, Dominica)

US$ 1036 to US$ 4085 per capita

Life Expectancy : M 71.7 , F 76.8 Ave 74.2 years

Socio- Demographic profile

• Multi-Ethnic: African > Mixed> Indian > Caucasian > (Indigenous) Chinese

• Religion: Predominantly Christian

• Government: Unitary parliamentary constitutional Monarchy

• Economy: Tourism > Agriculture

• Unemployment rate: 17.1% (4.5-24)

TB Health Infrastructure

• GDP: US$ 2.60 (Total)

• Per capita: US$4,145 (Upper middle income)

• Health Care Budget as % GDP <10%

• National TB Budget: Integrated into Primary Health Care

• Most countries have TB service vs National TB Program

• Some countries have TB program management integrated with National HIV program management

Epidemiological Profile Region of the Americas

Source: Global Tuberculosis Control Report 2019

OECS TB-Trends

10.6

12.7

10.4 10.3 10.3

8.32

7.53

4.3

2.97

44.27

4.76

4

2.75

3.63

0

2

4

6

8

10

12

14

1990 1995 2000 2005 2010 2014 2015 2016 2017 2018

Rat

e p

er 1

00,0

00 p

op

ula

tio

n

OECS TB Trends 1990-2018

Estimated TB Incidence Estimated TB Mortality TB Notification Rate

2018 New TB cases = 23


Post 2015 END Strategy TB incidence target of <10/100,000 for 2035 have already been met.

OECS TB Demographic Profile 2018


4%

73%

23%

OECS TB Demographic Profile 2018

Children (0-14)

Men

Women

Socio-determinants of Health

Poverty UrbanizationUnemployment-

Youth

Air pollution

Climate change

Natural disasters

Suboptimal nutrition

Migration Education

“Air pollution is a silent Public Health Emergency” Dr. Tedros Adhanom Ghebreyesus WHO Director General 2018.

TB TB RISK FACTORS

Smoking Diabetes

HIV InfectionSubstance Abuse

PREVIOUS TB

OECS TB Case Detection

0

50

100

150

200

250

300

350

2014 2015 2016 2017 2018

% p

erce

nta

ge

OECS TB Trends-Case Detection 2014-2018

TB Case Detecton Rate TB/HIV Case detection Rate

Source: Global Tuberculosis Control Report 2019OECS M&E Reports 2019

TB Case detection rate have exceeded 70% target set by WHO

OECS TB Notification by Country

12

0

16

3

3

1

35

6

0

5

4

6

2

23

0 5 10 15 20 25 30 35 40

Antigua &Barbuda

St. Kitts & Nevis

St. Lucia

Dominica

St. Vincent&Grenadines

Grenada

Total

OECS Country Profile TB Notified Cases 2013 vs 2018

2018 2013

34% Reduction in TB CasesTotal of 23 new cases in 2018

Source: Global Tuberculosis Control Report 2014, 2019

Type of TB

0

5

10

15

20

25

Antigua &Barbuda St. Kitts & Nevis St. Lucia Dominica St.Vincent&Grenadines

Grenada Total

No

. of

Cas

es

Type of TB 2018

Pulmonary Non Pulmonary

13%

87%


Bacteriological Confirmation

40

0

100 100 100

50

78.2

0

20

40

60

80

100

120

Antigua &Barbuda St. Kitts & Nevis St. Lucia Dominica St.Vincent&Grenadines

Grenada Total

%

%BACTERIOLOGICALLY CONFIRMED AMONG PULMONARY CASES 2018


TB Treatment Outcomes

79%

4%

9%

4%4%

OECS 2016 TB Cohort

TreatmentSuccess

Failed

Died

Defaulted

Not Evaluated

Treatment Success for new and relapse TB patients:

WHO Target for TB Treatment Success = 85%

Rx Success OECS Cohort 2016 = 79%

Rx Success OECS Cohort 2018= 92%

Source: (OECS PUDR Report 2018 and 2019)

Source: OECS M&E report 2018

MDR-TB

0.3

0.16 0.16

0

0.2

0.4

0.6

0.8

1

1.2

1.4

ANTIGUA St. Kitts & Nevis St. Lucia Dominica St.Vincent&Grenadines

Grenada OECS

No

of

case

s

OECS MDR-TB- 2005-2017

Estimated MDR Cases Confirmed MDR-TB Cases Started on Treatment

Source: Global Tuberculosis Control Report 2012-2019

MDR-TB/HIV Testing(2018)

CountryNo. of notified

cases

% Notified TB Cases Tested with rapid diagnostics at time

of Diagnosis % Tested for HIV

Antigua &Barbuda 6 No data 100%

St. Kitts & Nevis 0 NA NA

St. Lucia 5 100% 100%

Dominica 4 No data 50%

St. Vincent&Grenadines 6 100% 100%

Grenada 2 0% 50%

OECS 23 40% 80%


TB/HIV

8.7

0

5

10

15

20

25

30

2013 2014 2015 2016 2017 2018

% p

erce

nta

ge

OECS TB/HIV coinfection rate 2013-2018

Source: OECS M&E Reports, 2019

TB/HIV Collaboration

3186

2547

2052 2 14

0

500

1000

1500

2000

2500

3000

3500

Estimate HIV PLHIV Diagnosed PLHIV screened forTB

Number TB casesdiagnosed

Number TB givenART

Number of HIV+given IPT

Reducing the Burden of TB in HIV Registered Patients OECS 2017

80 % PLHIV know their status

8% PLHIV screened for TB

1% TB/HIV case detection rate

100% TB/ARTTreatment for TB/HIV co-infected patients

< 1% PLHIV on IPT

Source: OECS TB/HIV Epidemiology Report 2018

Prevention

MethodsChallenges• TB is not taken as a serious disease because of

low prevalence

• Limited funding and human resource capacity for public education campaigns

• Limited knowledge of patients and health care providers on TB

• Weak infection control programs in congregated settings

OECS National Country Assessments 2017-2019. PAHO

Diagnosis-TB and LTBI

Methods

•

Challenges

• No available in-country TB culture and DST diagnosis

• Limited in-country Gene Xpert capacity

• Delays in Specimen collection and Transport

• Delays in reporting TB diagnosis

• Laboratory network not fully accredited


Treatment

Methods Challenges

• Initiating community, based TB treatment

• Limited accessing of Fixed Dose combinations for TB patients

• Updating clinical training of health care providers

• Treatment adherence and recapturing of treatment defaulters


Care and Support

Methods Challenges

• TB Stigma and Discrimination

• Non-existent TB support Groups

• Limited social financial assistance when hospitalized


TB Health information

Methods Challenges• TB registers are paper based and not

standardized

• The flow of information is defined but the system is fragmented

• Consolidation of patient characteristic i.ediagnosis, treatment and follow up to generate profile is lacking

• TB,TB/HIV Cohort analysis is weak

• Limited in-country M&E capacity


TB- Case findings

Methods Challenges• The flow of information is defined but the

system is fragmented• TB case definitions and classifications do not

always follow WHO recommendations• TB contact tracing performed but not always

recorded• Latent TB infection screening is poorly done

is hard to reach populations• TB case finding activities are usually passive

based on symptoms, but not always with a clear definition of a presumptive case.


Global Fund sponsored high impact TB interventions

Gene Xpert MTB/RIF: (Grenada, St. Lucia, St. Vincent& Grenadines, Antigua and Barbuda)OECS HIV/TB End of Project Report- Global Fund 2019

Global Fund sponsored high impact TB interventions

https://slucbs.org

System captures:TB/HIV Collaborative Activities:

HIV/TB on ART HIV/TB on CPT HIV screened for TB (Mantoux) HIV placed on IPT

https://slucbs.org/

OECS TB Elimination

0

1

2

3

4

5

6

7

8

9

2014 2015 2016 2017 2018 2027 2035 2042 2050

Per

10

0,00

0 p

op

ula

tio

n

OECS TB Elimination 2014-2050

Estimated TB Incidence WHO Global TB Strategy TB Notification rate

Pre- Elimination GAP TB

Elimination

OECS TB, TB/HIV Strategic

Interventions

GOVERNANCE

INFORMATION, EDUCATION, COMMUNICATION

SURVEILLANCE , MONITORING & EVALUATION.

RESEARCH & INNOVATION

STRATEGIC HEALTH INFORMATION

DIAGNOSIS , TREATMENT & CARE

OECS TB, TB/HIV Strategic for TB Elimination

Strategies for TB Elimination(Governance)

•Strengthen co-ordination of TB services with private sector and encourage public/ private sector mix

Increasing domestic funding for TB in National Health Budget through Regional Health Care Financing

Development of TB/HIV/Diabetes (Chronic Disease) Collaborative Committee

PUBLIC INFORMATION AND

EDUCATION ON TB & TB/HIV

INCREASED PUBLIC EDUCATION AND AWARENESS CAMPAIGNS OF TB USING PRINT, RADIO, TV AND SOCIAL MEDIA

PROMOTE WORLD TB DAY ESTABLISH INTER-MINISTERIAL AND INTERSECTORAL COLLABORATION ON TB,HIV EDUCATION IN COMMUNITIES AND SCHOOLS

OECS Strategies forTB,TB/HIV Elimination(IEC)

Optimize TB Diagnosis, Treatment and Care for all forms of TBOptimize

Scale up introduction of Gene Xpert and access to culture, DST and speciation diagnosis in all countries Scale up

Build capacity for supporting TB patients and educating them on human rights. Build

Expand OECS PPS pool procurement of TB medicines and diagnostic suppliesExpand

Provide appropriate treatment for TB , LTBI in high risk groups.Provide

Accelerate accreditation of hospitals within laboratory networkAccelerate

Optimize MDR-TB Prevention and CareOptimize

OECS Strategies for TB,TB/HIV EliminationDiagnosis and Treatment

Strategies for TB Elimination(Surveillance Monitoring and Evaluation- Case finding-contact investigation)

Ensure development and implementation of

regional TB outbreak Management Plan

Implement Port Health Policy for TB screening

of migrants and enhanced screening in

congregated settings i.eprisons

Upgrade and train stakeholders on contact

tracing, Standard Operating Procedures and infection control.

Strengthen human resource capacity for

Monitoring and Evaluation and TB

Program Management

Targeted systemic screening of high- risk groups using evidence

based research geographic mapping

Strategies for TB Elimination(Strategic Health Information)

Implement a comprehensive information system for TB &TB/HIV Surveillance, monitoring and evaluation (Strategic Health Information)

Implement

Upgrade paper- based TB, TB/HIV, MDR-TB records and registers complemented by a standardized integrated TB/HIV/STI case-based surveillance system.

Paper

Scale up training of case base surveillance system users. Scale up

Integrate TB information system into National Health Management Information system in public and private sector.

Integrate

Strategies for TB Elimination(Operational Research& Innovation)

Collaborate with partners such as Medical Schools and the Caribbean Health Research Council from CARPHA to strengthen operational research i.e TB Speciation, Needs Assessment, TB Treatment Outcomes, Geographic mapping, TB Cost Analysis.

TB Elimination as an OECS Region is possible

• Updating and Implementation of regional TB Policies and OECS Regional Strategic Plan

• Continued Focus on Health Systems Strengthening-Grant implementation- Global Fund

• Accelerated inter island collaboration through a common health space and agenda-• Regional Meetings OECS Heads of Ministers

• Joint advocacy efforts - UN General Assembly High level meetings

Thank you!

References

Global Tuberculosis Reports 2013-2019

M&E Quarterly Data: OECS Commission

Epidemiology of TB/HIV in OECS 2018. C. d’Auvergne

National TB Country Assessment Reports: PAHO (2017-2019)

OECS Infection Prevention and Control Summary Assessment: A. HART

Main results and findings of the TB assessments in OECS countries: Rafael Lopez PAHO

Air Pollution and Climate change: https://www.iass-potsdam.de/en/output/dossiers/air-pollution-and-climate-change

new WHO global TB strategy, 2016-35, a

The epidemiology of tuberculosis in the Pacific, 2000 to 2013. Kerri Viney etal

https://www.iass-potsdam.de/en/output/dossiers/air-pollution-and-climate-change

Documents

TB in the Organization of Eastern Caribbean States (OECS)Auvergne.pdf · 2020. 3. 24. · OECS Country Profile TB Notified Cases 2013 vs 2018 2018 2013 34% Reduction in TB Cases Total