Issues in management of "TB suspects" in PHC settings

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Issues in management of "TB suspects" in PHC
settings

• Task force on TB suspects' management
• WHO/EMRO
• 12th EMRO NTP Managers Meeting
• Tunis, 6 9 April 2007

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Key background

• Respiratory conditions are very common 20 35
  of patients in PHC setting
  
• Among respiratory illnesses
• 80 to 90 are ARIs
• 10 to 20 are CRDs
• 2 and less are pulmonary TB

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Overall distribution of respiratory conditions

• PHC Total number ARI
  TB CRD Others
  
  
• settings of RD cases cases
  suspects cases
  
• --------------------------------------------------
  --------------------------------------------------
  ------
  
• With MO
• Overall 25585 80.3
  5.0 12.3
  2.4
  
• --------------------------------------------------
  --------------------------------------------------
  ------
  
• Without MO
• Overall 3814 88.1
  4.3 5.9
  1.6
  
• --------------------------------------------------
  --------------------------------------------------
  ------

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Distribution of chronic RD cases in PHC
facilities with MO

• Country Nbr. of Asthma
  COPD/BC Other
  
• chronic RD cases
• --------------------------------------------------
  --------------------------------------------------
  ------
  
• Thailand 229
  22.7 77.3
  0.0
  
• Morocco 29
  69.0 31.0
  0.0
  
• Kyrgyzstan 408
  10.3 89.7
  0.0
  
• Peru 87
  71.3 28.7
  0.0
  
• Argentina 353
  91.8 8.2
  0.0
  
• Chile 1308
  81.7 17.3
  1.7
  
• Nepal 225
  6.2 93.8
  0.0
  
• Ivory Coast 44
  22.7 77.3
  0.0
  
• Guinea 242
  16.7 34.5
  48.8
  
• Morocco 231
  53.7 14.0
  30.3
  
• --------------------------------------------------
  --------------------------------------------------
  ------
  
• OVERALL 3156 55.4
  37.6 6.8

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Proportion of SS pulmonary TB cases among
overall respiratory patients in PHC facilities
with medical officer

• Country Total Nbr. of RD
  Nbr SS cases Proportion
  
  
• -------------------------------------------------
  --------------------------------------------------
  ------
  
• Bolivia 1033
  4
  0.4
  
• Chile 5912
  6
  0.1
  
• Guinea 2564
  74
  2.9
  
• Kyrgyzstan 893
  7
  0.8
  
• Morocco 3625
  7
  0.2
  
• Syria 1099
  0
  0.0
  
• Thailand 2047
  12
  0.6
  
• Tunisia 1475
  1
  0.0

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Sputum smear examination request in patients with
respiratory symptoms for more than 2 weeks

• Count SSE request Total
  Proportion
  
• --------------------------------------------------
  --------------------------------------
  
• Bolivia 48
  113 42.5
  
• Kyrgyzstan 12
  68 17.6
  
• Syria 3
  66 4.5
  
• Tunisia 8
  160 5.0
  
• --------------------------------------------------
  --------------------------------------------------
  ------

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SSE not done among patients to whom SSE was
requested

• Country SSE requested SSE not done
  Proportion
  
• --------------------------------------------------
  -------------------------
  
• Bolivia 91
  23 25.3
  
• Guinea 270
  60 17.6
  
• Kyrgyzstan 45
  10 22.2
  
• Morocco 85
  17 20.0
  
• Syria 16
  4 25.0
  
• Tunisia 8
  3 37.5

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What do these data tell us?

• Respiratory conditions are common in PHC
  settings
  
• TB is a rare condition among them
• Probable misunderstanding of definition of "TB
  suspect" by PHC workers ( disease category??)
  
• Non negligible proportion of respiratory cases
  that meet the definition of "TB suspect" are not
  screening for TB
  
• Many respiratory patients in whom SSE was
  requested do not reach TB laboratory
  

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What should be done?

• "TB suspect" should not be considered as a
  disease category but as a cut off from which
  respiratory patients should be screened for TB
  
• All respiratory patients with symptoms more than
  2-3 weeks should be screened for TB whatever the
  diagnosis established, including CRD cases
  
• TB component should be systematically included in
  the management package of CRD cases (asthma,
  COPD/CB, and others)
  
• Establishment of a tracking system to monitor
• the identification, in PHC, of respiratory
  patients
  
• eligible for TB screening
• the follow-up of patients who were
  requested
  
• to undergo TB screening.

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Option Risk groups (e.g. VCT, prisons), CHW,
Chronic disease programs (e.g. DM)
OPD register(HMIS register)
OPD attendees
70
30
Chest symptoms
OPD register(HMIS register)
Non-chest symptoms
90
10
OPD register(HMIS register)(TB suspect register)
Person with persistent cough (cough2wks)
Acute respiratory symptoms
Option CXR for screening(abnormality ? Smear
exam
Monitor
Smear examination
Lab register
90
10
Negative
Lab register
Positive
Comprehensive care (inc. TB diagnosis)Monitoring
of TB occurrence among CRD
TB
TB register
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Utilization of HMIS register in tracking
respiratory patients referred to TB laboratory
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Example from Pakistan (reported by Dr A. Seita)

• National policy SM
• Cough 3 weeks registered by HMIS (code 105)
• However,
• Limited implementation of suspect management
• Almost no date available
• Limited suspect of suspects
• 402 respiratory patients ? 11 suspects only
  (3)
  
• Lost of suspects
• 8 suspects sent to lab ? only 3 found in lab
  register
  
• Need for SM system
• Use HMIS register
• Monitoring

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• Thank you
• for
• you attention