Understanding delays and TB transmission Nim Arinaminpathy Imperial College London IDM Symposium 20 Apr 2017 Tuberculosis today 2 An estimated 96 million cases of TB occurred globally in 2014 ID: 603883
Download Presentation The PPT/PDF document "Looking under the streetlight?" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Looking under the streetlight?
Understanding delays and TB transmission
Nim
Arinaminpathy
Imperial College London
IDM Symposium
, 20
Apr 2017Slide2
Tuberculosis today
2
An estimated 9.6 million cases of TB occurred globally in 201425% of this burden occurred in India alone, the highest of any countryGlobal Tuberculosis Report, 2015Slide3
End TB StrategySlide4
4
At present No transmission-blocking vaccine
, but cost effective chemotherapySlide5
We need to understand where transmission is happeningSlide6
TB control in India: a brief retrospective
DOTS: treatment outcomes and case detectionPublic-sector services (Revised National TB Control Programme) scaled up from 1997
But problems remainVast and unregulated private sector2012 NSP: “The extension of RNTCP services to patients diagnosed and treated in the private sector”Slide7
A possible mechanism
Public-Private Interface Agency (PPIA)Pilot PPM scheme funded by Bill and Melinda Gates FoundationEngage with private providers, incentivising to improve:Quality of TB diagnosisNotification to public sectorTreatment outcomes
Financial incentives vs Training and engagementSlide8
The settingSlide9
The setting
What is the potential epidemiological impact of a PPIA at scale?Slide10
Uninfected
Latent
infection
Active disease,
Pre-care-seeking
βI
d
Treatment
initiation
Treatment
c
ompletion
Cure, HIGH
relapse risk
Cure, LOW
relapse risk
(Default)
(Success)
Patient
delay
Diagnostic
delay
Quality of
TB treatmentSlide11
Uninfected
Latent
infection
Active disease,
Pre-care-seeking
βI
d
Treatment
initiation
Treatment
c
ompletion
Cure, HIGH
relapse risk
Cure, LOW
relapse risk
(Default)
(Success)
Patient
delay
Diagnostic
delay
Quality of
TB treatment
Pathway
surveysSlide12
Key data inputsSlide13
Uninfected
Latent
infection
Active disease,
Pre-care-seeking
βI
d
Treatment
initiation
Treatment
c
ompletion
Cure, HIGH
relapse risk
Cure, LOW
relapse risk
(Default)
(Success)
Patient
delay
Diagnostic
delay
Quality of
TB treatment
ARTI,
Prevalence
Pathway
surveysSlide14
Potential epidemiological impact
Arinaminpathy et al, In prepSlide15
Uninfected
Latent
infection
Active disease,
Pre-care-seeking
βI
d
Treatment
initiation
Treatment
c
ompletion
Cure, HIGH
relapse risk
Cure, LOW
relapse risk
(Default)
(Success)
Patient
delay
Diagnostic
delay
Quality of
TB treatmentSlide16
Uninfected
Latent
infection
Active disease,
Pre-care-seeking
βI
d
Treatment
initiation
Treatment
c
ompletion
Cure, HIGH
relapse risk
Cure, LOW
relapse risk
(Default)
(Success)
Patient
delay
Diagnostic
delay
Quality of
TB treatment
~ 1 – 2 months
(reported)Slide17
Uninfected
Latent
infection
Active disease,
Pre-care-seeking
βI
d
Treatment
initiation
Treatment
c
ompletion
Cure, HIGH
relapse risk
Cure, LOW
relapse risk
(Default)
(Success)
Patient
delay
Diagnostic
delay
Quality of
TB treatment
~ 1 – 2 months
(reported)
~
4 – 5 months
(fitted)
M.A.N.E.Slide18
What the data suggests (i)Slide19
What the data suggests (ii)
19
Gujarat prevalence survey
, 2011Slide20
What the data suggests (ii)
Gujarat prevalence survey, 2011
Courtesy of
Dr
Kiran
Rade
,
Central
TB DivisionSlide21
We need to understand where transmission is happeningSlide22
Chest
symptomatics seeking careSlide23
Chest
symptomatics seeking care
Key burden indicators(ARTI
etc
)
Cross-sectional (prevalence) surveysSlide24
Chest
symptomatics seeking care
Some TB cases never contacting the healthcare system?
Most patients wait for several months before seeking care?
Key burden indicators
(ARTI
etc
)
Cross-sectional (prevalence) surveysSlide25
We may be missing transmission as long as we’re missing the sociological perspective
Increasing awareness?Addressing stigma?Lowering barriers to care?
What would be the impact on TB incidence?
Is there evidence that TB patients defer
careseeking
?
Upcoming work with NIRT (Chennai), FMR (Mumbai)
Also evidence
from other prevalence surveys in the
region
Ongoing
work: modelling TB in
WHO/SEARO
What is going on?Slide26
India’s next National Strategic Plan
…but more ‘real’ evidence now needed...Slide27
Thank youSlide28
Spare slidesSlide29
Many reasons for engaging the private sector
Surveillance: India’s public TB programme covers only estimated ~60% of TB casesBurden of TB managed by the private sector is much higher than previously recognised (Arinaminpathy et al, 2016)Extending public-sector quality of care to the private sector
’Saving lives’ through improved outcomesFree TB drugs and adherence supportReducing opportunities for transmission ….?
Not without demand generationSlide30
Movement in a fragmented healthcare system
Kapoor, Raman,
Sachdeva, Satyanarayana (2012) PLoS ONE
30Slide31
FQ
LTFQ
Chemist
Public
FQ
LTFQ
Chemist
Public
Mumbai
Patna
Aside: fresh views on
patient pathways
Arinaminpathy
et al, In prepSlide32
Gujarat prevalence survey
Mumbai model, cross-sectionNot yet visited a provider
69%36%Have sought care, but not on treatment
17%
21%
Have sought care, been diagnosed, and
on treatment
11%
42%
Of microbiologically positive TB
What the data suggests (ii)
Patient delay
Diagnostic delaySlide33
Increasing awareness?
Addressing stigma?What are the barriers to patient careseeking?And how might they be addressed?
What would be the impact on TB incidence?Demand generation: what does it mean?Slide34
What the data suggests (i)
Early TB symptoms are too subtle for patients to report
Diagnosed patients are ‘telling the truth’: there is another population that never access care
Of several
careseeking
episodes, only the most recent is reported