Active TB cases Finding in The Integrated HIV Care Program Dr Sai Ko Ko Zaw The Union Office in Myanmar No.36, 27 street between 73 & 72 streets, Chan Aye Thar Zan Township, Mandalay, Myanmar Tel/Fax: +95 2 71082 Email: skkzaw@theunion.org 1
Outlines • Magnitude of TB problem in Myanmar • Active TB case finding at Integrated HIV Care (IHC) clinics • Challenges & Solutions • Ways forwards
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Magnitude of TB problem in Myanmar Estimated TB Burden 2011* Prevalence
506/100,000 population
Incidence
381/100,000 population
Mortality
48/100,000 population
*Data:www.who.int/tb/data
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Active TB case finding (ACF) at Integrated HIV Care (IHC) clinics in Mandalay, Myanmar
The photo was taken with written consent and agreed to use in public
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Active TB case finding at the Integrated HIV Care (IHC) clinics • • • • •
IHC program had started in 2005 “In, By, With” public sectors Screening for HIV in all TB patients Introduced WHO-3Is activities in 2009 ACF using GeneXpert Jan 2012 (Program to increase catchment of TB suspects – PICTS ) • Up to July 2013, in 20 townships of Myanmar 17,422 HIV patients (Active Follow up) 15,395 HIV patients on ART (Active Follow up) 5
HIV screening among TB diagnosed patients in Mandalay seven townships ( Jan- July 2013) Adult TB patients in Register
1340
Adult TB patients tested for HIV
1251 (93%)
Adult TB patients HIV + among tested
239 (19%)
Adult TB-HIV co-infected put on CPT
239 (100%)
Adult TB-HIV co-infected started ART at clinics in reporting period*
273
*not only from Mandalay Township but also from other hospitals/GP/INGOs such MMA & PSI
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ACF in IHC clinics: Education Posters about TB symptoms at HIV clinics
HE at HIV clinic of THC 7
ACF in IHC clinics :TB screening & IPT initiation protocol for HIV clinics Patients with known HIV infection attending HIV care
Symptom Screen Each Visit (Ask TB screening questions, Record results on Daily OPD register)
≥ 1 symptom
MO Refers for TB evaluation (using cross referral form)
No symptoms Assess IPT Eligibility (using stamp inside patient booklet)
If diagnosed TB – Treat TB If not TB – Return patient to HIV care
IPT Eligible • • •
Initiate IPT Counseling Prescribe IPT Register for IPT 8
TB screening questions Does patient have any: • • • • •
Cough Fever Weight loss Night sweats Enlarge Lymph Node
Photo of five symptoms
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Any symptom, refer for detailed TB & clinical evaluation Daily OPD and TB screening register
Date______________________
S. No
Name
Age
Sex
Township
Q1 Cough (any) (√/X)
Q2 Fever
Q3 Weight loss
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U Myint
44 M
CATZ
X
X
X
12
Bo Htwe
24 M
MHAM
X
X
√
For asymptomatic patients, Stamp inside ‘Patient OPD booklet’ For “IPT Evaluation” (Recommendation 1)
Q4 Night sweats
Q5 Lymph node enlarged
X X
Current TB Rx / Prior TB Tx / Current IPT / Prior IPT
X X
X X
Referred for Referred for IPT TB eval evaluation (√/X) (√/X)
X
√
√
X
Patients with any symptoms should be referred for TB evaluation (Recommendation 2)
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Refer from HIV clinic
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Feedback From MGH TB OPD
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TB screening activities and Refer for further evaluation at Pre-ART clinics and ART clinics (MU 1 & MU 2) in Jan-July 2013 ART Clinics Pre-ART clinic (MU1 &MU2)
Total visits of the clinics screened for TB Refer For TB diagnosis evaluation Refer for IPT evaluation IPT started
1795
8111
101 (6%)
92 (1%)
917
997
105 (11%)
116 (12%) 13
Patients’ flow For TB evaluation IHC Clinics
Sputum Examination NAP Clinic
Chest X Ray Machine TB OPD MGH
TSHC
GeneXpert Machines Link with Pathological examination Refer for other EPTB investigations
MGH 14
Known HIV (+) Child TB suspects
New TB suspect
Sputum Smear Examination Ss +
Ss -
TB Diagnosis algorithm in PICTS program
Antibiotics trial s/s +
Cat I +
Chest X Ray Abnormal
Normal HIV (-)
EPTB investigations according to need
Gene Xpert
Reconsider TB or EP TB Dx
Negative
Positive MTB+R+
Decision by Clinician
MTB + R-
LPS and DST No TB Tx
Cat I -, GXP + TB Tx
DR TB Treatment15 a/t National Guidelines
Cascades of TB diagnosis for HIV infected patients at MGH TB OPD in Jan 2012 - July 2013
949 1000
Alternative Diagnosis/ Outcomes?
800 600
317 (33%) 400
154 (49%)
200 0 Refer for TB Dx Evaluation
TB diagnosed (All Forms)
Bact/Pathological comfirmed TB cases 16
Proven TB cases in 2012 versus 2013
18 (17%)
94 (44%)
120 (56%)
85 (83%)
Bact/Patho comfirmed TB Cases
Bact/Patho comfirmed TB Cases
Clinically Diagnosed TB Cases
Clinically Diagnosed TB Cases
2012
2013 up to July 17
Routine Contacts tracing and modified activity with PICTS program • Done by BHS and Community TB Care volunteers as soon as patients enrolled in Township TB registers • Two kinds contact tracing in Mandalay - Initial Home Visit ( screening of cough >3wk in Household members) - Extended Contacts Tracing ( screening of 5 TB -/s in household, neighbours, at work places) 18
Routine Contacts tracing and modified activity with PICTS program
Total Number of registered TB patient (Jan-June 2013) Total number of TB patient had home visit
Total number of contact identified
Initial Home Visit
Extended Contact Tracing
1610
1610
1585 (98%) 1528 (95%) 7649
28210
Total number of contact evaluated
6270 (81%) 23989 (85%)
Total number of TB suspects
792 (12%)
1272 (5.3%)
545
1018
13 (1.6%)
84 (7%) 19
Total number of TB Suspects examined for sputum for ATB Total number of contact put on anti-TB treatment
Challenges • Screening Tools and Diagnostic Tools (sensitivity/specificity?) • Screening Algorithm for public sectors in specific context • Individual Clinical Care and Management • Need to strengthen recording system 20
Solutions • Developing a better Algorithm • Regular Monitoring and Supervision • Training of recording and reporting for staff • Health education to HIV infected patients at clinics 21
Way Forwards IHC Program
TB
HIV
PICTS Program
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Thanks!
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