Reimagining Global Health Zero TB Karachi : What models do Search-Treat-Prevent Implementors want? Aamir Khan MD, PhD Executive Director, IRD Zero TB CITIES is a global initiative targeted at creating “islands of elimination” with strong local ownership in high burden settings Zero TB implements evidence-based Search, Treat & Prevent approaches from around the world shown to be successful in controlling TB Zero TB Cities and districts – Current, new and potential: Almaty, Kazakhstan** Manila, Philippines** Balti, Moldova Melbourne, Australia** Chennai, India Mexicali, Mexico Dhaka, Bangladesh* Mthata, South Africa** Geissen, Germany Mumbai, India** Hai Phong, Vietnam Muscat, Oman** Hanoi, Vietnam Odessa, Ukraine Ho Chi Mihn City, Vietnam Pattaya, Thailand** Indore, India** Peshawar, Pakistan Karachi, Pakistan Quetta, Pakistan** Kathmandu, Nepal** Shenzhen, China* Kisumu, Kenya Sofia, Bulgaria** Lagos, Nigeria ** Tbilisi, Georgia** Lima (Carabayllo), Peru Ulaanbaatar, Mongolia Vladimir, Moscow * First of multiple cities planned ** Discussions of alignment underway Pakistan’s Zero TB Initiative Global Fund Support 2016-2017 USD 40m – Zero TB Karachi +32 districts 2018-2020 USD 40m – Zero TB Karachi, Peshawar, Quetta + 32 districts >3m 55 mobile >61,000 3 Zero TB >1.5m ~1200 screened X-ray vans/ patients Cities / 32 Chest X-ray staff on verbal 70 fixed with TB districts screens symptoms X-rays notified 12 Active Case Finding ≠ ‘Active Case Finding’ • What is the focus and intensity of case finding? – Which populations are targeted for systematic screening? • Low-income communities, outpatients, prison inmates, factory workers • Adults vs children – How does one measure intensity of ACF? • Number of bacteriological tests done • Yield of patients from screening at specific settings • Proportion of target population screened or tested – Cost of CAD and GeneXpert cartridges as impediment to scale Zero TB Karachi: All Forms TB Notifications 2008 – 2018* 30000 25,064 25,339 25000 20,560 19,336 20000 18,693 18,270 17,545 18,115 16,104 15,993 15000 14,470 Notifications 10000 5000 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 *Q4 2018 numbers are self counted from TB03 registers Zero TB Karachi: Mobile Chest X-ray Screening among Adults Jan 2018 – Dec 2018 Other X-ray based Chest X-ray / Computer Aided Detection Screening (CAD > 70) Case-finding Models Large Community Community GP-Linked Household Screening Site Hospital Camps Camps Prisons Factories Camps Contacts OPDs (Not for Profit) (Social Enterprise) Screened 197,346 86,622 111,909 10,071 10,221 41,276 5,069 Presumptive 17, 839 6,147 9,584 597 686 5,174 - B+ve (Rif+ Included) 1,708 396 172 23 5 57 16 Cases 2,332 475 669 106 13 283 49 Yield from 13% 8% 7% 18% 2% 6% - presumptive Yield from screened 1.2 % 0.5 % 0.6 % 1 % 0.1 % 0.7 % 1 % Number Needed to 85 182 167 95 786 146 103 Screen (NNS) Childhood TB Screening: Karachi, Lahore, Peshawar: July 2016 – June 2018 Zero TB Karachi Lahore Zero TB Peshawar Screened 212,132 81,705 36,966 13,631 Presumptive 3,997 2,909 (6%) (5%) (8%) 1,568 758 297 TB Diagnosed (12%) (19%) (14%) Zero TB Karachi: Childhood TB as a Proportion of All Forms Case Notifications 2010 – 2018 30000 100% 25,480 90% 25000 80% 70% 20000 60% 15000 50% 40% Notifications 10000 30% 20% Notifications of all Proportion 5000 12% 13% 9% 10% 11% 9% 6% 7% 6% 10% 3,298 0 0% 2010 2011 2012 2013 2014 2015 2016 2017 2018 Karachi Karachi Peads % Peads Zero TB Karachi: GeneXpert Cartridge Use 2014 - 2018 55000 48,324 50000 46,490 45000 42,417 40000 35,492 35000 28,476 30000 26,643 25,983 25000 22,263 22,541 20000 14,766 15000 11,149 13,449 12,049 10,818 10,379 9,159 10000 3,863 5,868 3,162 3,889 Number of GeneXpert Tests GeneXpert of Number 5000 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2014 2015 2016 2017 2018 Karachi: Quarterly tests and trend of MTB+/Rif+ Detected Q3 2013 – Q12019 60000 35.0 31.0 30.0 50000 24.7 25.0 24.0 23.7 25.0 40000 18.2 20.0 17.2 17.2 30000 15.0 15.0 15.0 16.1 13.6 15.0 12.1 11.1 20000 10.5 9.2 11.5 11.7 8.6 8.7 8.0 10.0 6.5 6.4 7.0 9.0 5.7 7.7 10000 7.0 7.1 6.3 6.6 6.3 6.2 5.0 6.0 6.1 5.7 5.7 5.5 4.5 5.0 4.9 4.6 4.9 4.6 5.1 0 0.0 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2013 2014 2015 2016 2017 2018 2019 Total Xpert Test % Total MTB+ Det/Total Tested % RR + Det/Total MTB+Detected Karachi Residents: DR-TB Enrolments and Proportion of New Cases 2009 – May 2019 350 100% 319 312 90% 300 80% 244 250 70% 202 60% 200 TB Enrolments TB 176 - 50% 150 40% 38% 34% 40% 32% 32% 118 29% 100 89 30% 19% 73 Cases of New Proportion Number of DR of Number 66 57 20% 50 14 5% 10% 7% 3% 2% 0 0% 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Total Karachi Residents % New Karachi City: Active Case Finding Resources Invested and Case Notifications 2010 - 2018 250 6000 5000 200 4000 150 3000 100 2000 Case Notifications 100,000per Notifications Case 50 1000 100,000 per Invested Resources 0 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 Adult DSTB Case Notificaton Rates All Ages B+ DSTB Case Notification Rate Xpert Tests/Population *100000 XRAYs/Population *100000 XRAYs/Population = Fixed and mobile Contact Tracing and Prevention • What is the focus and coverage of contact tracing and prophylaxis? • Household contact tracing vs all contact tracing • Drug susceptible vs drug resistant TB contacts – Uptake of prevention regimens among contacts • 3HP vs others – Cost of Rifapentine as impediment to scale Drug Susceptible TB Prevention Regimen: 6 months INH vs 3HP Zero TB Karachi 2017 6 months INH 3HP Indicators N % N % Contacts offered treatment 1258 956 Contacts started treatment 1029 82 715 75 Contacts refused after initiating treatment 247 24 41 6 Contacts completed treatment 171 17 194 27 Contacts not completing treatment 125 12 28 4 Contacts with unknown outcomes 3 0 2 0 Contacts still on treatment 483 47 464 65 TB Prevention Cascade – Drug Resistant TB Total contacts (N=800) <5 years 5-17 years >17 years (N=94) (N=258) (N=448) Screened Screened Screened (N=88, 93%) (N=238, 93%) (N=411, 93%) Evaluated Evaluated Evaluated (N=76, 86%) (N=196, 82%) (N=389, 95%) PT eligible (N=76, 100%) PT eligible (N=96, 49%) PT eligible (N=42, 11%) Eligibility reason: Eligibility reason: Eligibility reason: Age (n=76) TST+ (n=5) Malnourished (n=41) Malnourished (n=91) Diabetes (n=1) Initiated Initiated Initiated (N=61, 80%) (N=85, 89%) (N=25, 60%) Completed Completed Completed (N=46, 75%) (N=58, 68%) (N=17, 68%) Zero TB Karachi: Cumulative probabilities for evaluation, prescription, uptake and completion of treatment for presumed DR-TB infection treatment by age group (N=792, Karachi Zero TB, unpublished Amyn Malik, Mercedes Becerra, Hamidah Hussain et al) Prevention Cascade (CP) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% Cumulative Probability Cumulative 20.0% 10.0% 0.0% <5 years 5-17 years >17 years Total Evaluated Prescribed Uptake Completion Modeling Zero TB Karachi Impact • Modeling from 2013 (David Dowdy and Andrew Azman) • Significant declines in 5-year mortality and incidence (2013 Dowdy paper) • Modeling from Zero TB baseline (Sourya Shreshta and David Dowdy) • Targeted case finding can double reductions in TB incidence • But what is the combined impact of targeted Active Case Finding and targeted Preventive Therapy? (Sourya Shreshta and David Dowdy) Korangi Town: All Ages All Forms Notifications 2010 – Q4 2018 5000 4,642 20% decrease in 4500 4,305 notifications 4,123 reported from 4000 3,735 Korangi Town 3500 3,392 3000 2,850 2,598 2500 2,223 Notification 2000 1500 1,314 1,043 1000 793 500 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Korangi Town includes 5 BMUs: Indus Hospital, SZC Korangi, SGH Korangi, Sindh Anti TB Association, and Baldia Maternity Home Korangi Town: Active Case Finding Resources Invested and Case Notifications 2010 - 2018 600 25000 500 20000 400 15000 300 10000 200 5000 Case Notifications per 100,000 Notifications Case 100 100,000 per Invested Resources 0 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 All Ages B+ DSTB Case Notification Rate Adult Case Notificaton Rates Xpert Tests/Population *100000 XRAYs/Population *100000 XRAYs/Population = Fixed and mobile Karachi : All Forms TB Yield through Community Chest X-ray Camps 2017 and 2018 2017 * * Korangi Town 2018 * Zero TB Interventions in Korangi: CXRs and Increasing NNS Q1 2017 – Q4 2018 25000 160 CXRs NNS (All Forms) NNS (B+) 140 2017 Q1 -- -- -- 20000 120 2017 Q2 8,294 25 47 15000 100 2017 Q3 18,639 39 97 80 NNS 2017 Q4 21,909 62 137 10000 60 2018 Q1 21,004 65 91 Number Number of CXRs 40 5000 2018 Q2 16,251 56 82 20 2018 Q3 19,293 67 89 0 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2018 Q4 23,749 92 117 2017 2018 Chest X-Rays NNS (All Forms) NNS (B+) NNS: Number Needed to Screen # of CXRs/# of cases ZTB Interventions include GHD performed CXRs (community and facility), CHS run community camps and CHS center CXRs Indus Hospital: All Forms Notifications and Proportion of Korangi Residents 2008 – 2018 4500 76% 80% 4000 68% 70% 61% 3500 57% 60% 3000 48% 45% 50% 43% 43% 2500 43% 40% 39% 40% 2000 Notifications 30% 1500 20% 1000 Residents of Korangi Proportion 500 10% 0 0% 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Korangi Town Residents Other Town Residents % of Korangi Residents Korangi Adult Tuberculosis Case Notification Rate Korangi Pediatric Tuberculosis Case Notification Rate 500 compared to the rest of Karachi 90 compared to the rest of Karachi 450 80 400 70 350 60 300 50 250 40 200 Rate per Rate 100,000 per Rate 100,000 30 150 20 100