LTBI monitoring and evaluation in the Netherlands

17th Wolfheze Workshops 2015,

Den Haag

Connie Erkens MD MPH

Senior TB consultant

Content presentation

• Epidemiology

• Target groups for programmatic LTBI management

• Monitoring and evaluation of LTBI management

• Summary of key LTBI programmatic results

Source: RIVM

- TB cases registered: 823

- TB incidence: 4.9 per 100,000

- Pulmonary TB cases: 451 , 45% SS+

- Children <15 years: 49 (6%)

- MDR-TB: 6

Key facts TB epidemiology 2014

-New LTBI cases notified: 1300 TB incid

ence p

er

100,0

00

New Previously treated

Total

Average annual decline 1993-2014

2.8%

Immigration increases

Target groups for LTBI screening and preventive treatment

Sector Frequency National policy since

TB contacts public TB services Ad hoc before 1993

Health care workers at risk for TB exposure hospital services Periodical: 6 months – 1 year

before 1993

Other professionals at risk for TB exposure public TB services

Periodical: 6 months – 1 year

before 1993

Long term travelers to endemic countries public TB services

Ad hoc, upon return

before 1993

Patients initiating anti-TNF treatment curative services

Ad hoc, before treatment

2004

People living with HIV curative services

Ad hoc, upon diagnosis of HIV

2008

Immigrants with X-ray abnormalities suspect for inactive & untreated TB

public TB services

Ad hoc, after screening on entry

2014 (optional since 2007)

Homeless persons / illicit drug users public TB services

Optional: ad hoc / periodically

2015

LTBI screening algorithm in immune competent individuals

Symptom assessment and

TST

≥ 5mm

<5mm = negative

NO LTBI

IGRA

positive

negative

LTBI

Medical examination

AND Chest X-ray

No signs and symptoms for TB

Any signs and symptoms for TB

Further examinations

to confirm diagnosis TB

Rule out contra- indications for

preventive treatment

Organization of LTBI management

• Screening performed by MPHS TB unit, military medical services or

hospital clinician (clinical risk groups and HCWs)

• HCWs and military personal with LTBI are notified & referred to MPHSs

• Standard preventive treatment (PT): 6H, 3RH* or 4R*

• If contra-indications for PT> 2 years X-ray follow-up

• TB nurse provides support during PT if needed

• Cases managed or supported by MPHSs are recorded in webbased LTBI

register

* Introduced in 2009

LTBI register

• Voluntary case-based registration by MPHSs since 1993

• Nation wide coverage

• ‘Web based’ data collection integrated with TB notification register

• Data:

• Age, gender, etnicity

• Target group for LTBI screening

• Diagnostic test used

• Case management (Rx or follow-up)

• Preventive treatment regimen

• Treatment outcome

• www.tbc-online.nl

Monitoring and evaluation indicators

• Number of new cases with LTBI eligible for PT diagnosed (+

by target group, age group and etnicity)

• % of eligible cases with LTBI starting PT diagnosed with

IGRA

• % of eligible cases with LTBI starting PT (+ by age group

and target group)

• % of eligible cases with LTBI completing PT (+ by PT

regimen, age group and target group)

• % cases with serious adverse events (SAE) (+ by per PT

regimen and age group)

• www.tbc-online.nl

Key results 2005-2013

Number of LTBI cases by ethnicity

In total 37,736 LTBI cases

registered since 1993

Before 2005:

Mainly ethnic Dutch

Since IGRA were introduced in

2007, both number and

proportion of foreign born

(BCG-vaccinated population)

increased

Acceptance of preventive treatment (PT)

Overall acceptance = 70%

Acceptance is related to:

Age:

0-14 94%

15-44 76%

45+ 56%

Target groups:

TB contact 75%

HCW 65%

Traveler 70%

Preventive treatment regimens used

After introduction in 2009, shorter treatment regimens were adopted quickly

Preventive treatment outcome by regimen 2005-2013

Overall 84% persons completed PT successfully, but completion rate is better in shorter R-containing regimens

4R=89%

3RH=91%

6H=84%

Progression to TB immune competent and normal chest X-ray only 2005-2013

129 cases developed TB after start of preventive treatment: 1.4% of those not started on PT developed active TB (vs 0.3% of those treated)

Limitations of LTBI register to be addressed:

• Register does not capture coverage of screening of target groups

for LTBI

• Underregistration of clinical risk groups with LTBI diagnosed and

managed in curative clinical services

• Clinical risk groups cannot be distinguished from one and other

• Serious adverse events only recorded for those who interrupted

PT >underestimation

• Risk factors for TB and comorbidity are not recorded

Discussion

How to determine preventive treatment coverage and ‘eligibility’ (=the

denominator of the target group eligible) for LTBI treatment?

Does the denominator group include:

- Those not screened for LTBI among the target groups?

- Those with contra-indications for PT (comorbidity, age>45 years, alcohol

‘users’, MDR TB contact etc.)?