Post on 20-Mar-2020
transcript
Dr RPH Peters, MD, PhD, DLSHTM
Clinical Programme Specialist
Janus – Roman God of transition
TB epidemic in South Africa (1)
WHO Global Tuberculosis Report 2013
TB epidemic in South Africa (2)
WHO Global Tuberculosis Report 2013
TB epidemic in South Africa (3)
WHO Global Tuberculosis Report 2013
What happened over time?
Churchyard GJ et al. S Afr Med J 2014
• Why talk about strengthening TB system?
• Who to target?
• What to do?
• How to achieve the objectives?
Tuberculosis and HSS
What is the goal of HSS?
Can elimination be achieved?
Dye C et al. Annu. Rev. Public Health 2013
TB-associated mortality in SA
Impact TB on daily life
• Patients and the community
• Healthcare workers
• Scientists
• Policy makers
• Biomedical Industry
• Pharmaceutical industry
• Advocacy groups
Who to target?
What to do?
Dye C et al. Annu. Rev. Public Health 2013
What to do?
• Patient education
• Impact of ART roll-out
• HIV/TB integration
• HCW skills development
• Early case detection of TB
• Xpert® MTB/RIF for diagnosis of TB
• Contact tracing
• Enhanced case management
• Other interventions & developments
Patients delays
Lusignani S et al. BMC Infect Dis 2013
People counselling required
Implement lessons learnt…
Is ART the answer?
Dodd PJ et al. PLoS One 2013
Is ART the answer?
Dye C et al. Annu. Rev. Public Health 2013
Is ART the answer?
Gupta A et al. PLoS One 2013
Let’s expand our focus from
‘integration’ to ‘intensified effort’
Kaplan R et al. PLoS One 2013
Healthcare workers knowledge
Engelbrecht M et al. S Afr J Epidemiol Infect Dis 2013
Facility
Engelbrecht M et al. S Afr J Epidemiol Infect Dis 2013
Early detection of TB (1)
• Symptom screening is implemented… but
do we really know what to look for?
Early detection of TB (2)
Claassens MM et al. Int J Tuberc Lung Dis 2013
• 443/665 (64%) symptomatic
Early detection of TB (3)
Do we really know what to look for?
• How about TB in children?
• Maternal and infant TB?
• How about extrapulmonary TB?
Xpert for diagnosis of TB (1)
Xpert for diagnosis of TB (2)
Theron G et al. Lancet 2013
Xpert for diagnosis of TB (3)
Hanrahan CF et al. PLoS One 2013
Xpert for diagnosis of TB (3)
Yoon CJ et al. PLoS One 2013
All TB patients Smear-negative TB
Xpert for diagnosis of TB (4)
Clinic-based
Xpert®
(n=264)
Laboratory-
based Xpert®
(n=154)
P-value
Median days to initiation of
TB treatment <1 (0-5) 7 (2-15) <0.001
TB case fatality rate at two
months 2/23 (8.7%) 1/16 (6.3%) 1.0
TB diagnosis at later stage
-Culture (MGIT)
-Chest X-ray
15 (5.7%)
8 (3.0%)
7 (2.7%)
5 (3.2%)
2 (1.3%)
3 (1.9%)
0.3
0.7
0.3
All cause mortality at two
months 6 (2.3%) 4 (2.6%) 1.0
Peters RP, In preparation
Contact tracing for early detection
Middelkoop K et al. S Afr Med J 2014
Creative ways of contact tracing
Mwansa J et al. PLoS One 2013
Enhanced case management..
Enhanced case management..
• Complicated cases?
• Adverse effects & drug interactions?
• Pharmacovigilance systems?
• Separate drugs vs. combination tablet?
• Drug levels (personalized medicine)?
Complexity of TB Disease
In summary (1)
• South Africa has one of the largest TB
epidemics in the world
• Progress made, but not on target
• Combined effort required:
– Patients and Healthcare workers
– Scientists
– Biomedical and pharmaceutical industry
– Advocacy groups and policy makers
In summary (2)
• Increase awareness, skills and diagnostics
and therapeutic resources
• Implement common knowledge and
lessons learnt
• Expand basic scientific knowledge of TB
• Development of new drugs and vaccine
• Role of funding and public health
commitment