Transcript Epidemiology of DRTB in Harare City - UZ-UCSF

Epidemiology of DRTB in Harare City
• Background on DRTB in Zimbabwe and Harare
• Descriptive Epidemiology
• Analytic Epidemiology
• Recommendations
• Case management – pre-2011, 2011 to date
Background
• National PMDT started in January 2011 at two pilot sites – Bulawayo
and Harare Cities with regional coordinators
• Decentralisation of programmatic management of drug resistant
tuberculosis to districts and provinces was rolled out in January 2013
and was continued in 2014
• Less and less patients from the other provinces were referred to
Harare for initiation of treatment and follow up
• Sporadic referrals and transfers from provinces and districts
continued to be received due to various reasons and challenges
surrounding access to decentralised sites
What is DRTB?
Forms of DRTB
• RRTB
• MDRTB
• Mono resistant DRTB
• PDRTB
• XDRTB
• TDRTB
DRTB Notification trends – Harare City 2011
to 2015
Year
Number of cases
Population
2011
35
Northern region
2012
44
Northern region
2013
26
Harare Province
2014
45
Harare Province
2015
19
Harare City
Notification rate
DRTB notification trends - Harare City
45
44
35
26
19
2011
2012
2013
2014
2015
Notification trends
• 2011 -2012 Increase attributed to enrolment of pool of undiagnosed
cases and patients on treatment waiting list
• 2012 – 2013 Decrease in line with fall in NTP TB notifications
• 2013 – 2014 Rapid increase due to introduction Expert MTB RIF
• 2014 -2015 Decrease due to decentralization
Demographic characteristics
Gender distribution 2014
2013
%Enrolled
change
2014
% Enrolled
MALE
39
62.9%
(10%)
27
53%
FEMALE
23
37.1%
10%
24
47%
TOTAL
62
100%
(17.7%)
51
100%
Age distribution 2013 versus 2014
Figure 3: Age distribution of DRTB patients in Harare City
0.5
0.45
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
0 to 4
5 to 14
15 to 24
25to 34
2014
35to 44
2103
45to 54
55to 64
65+
Age distribution
• Majority of the DRTB patients were aged between 15 to 54 years
• Contributing at least 90% of all enrolled patients in both 2014 and
2013
• The age 22 to 50 years is the most infected with HIV infection and
reflects HIV/TB co-infection and co-morbidity pattern
• Opinion on HIV as risk factor for DRTB (Lukole et al, 2015 (Uganda),
Gomez-Gomez, A et al, 2015 (Mexico) vs Ehl Sahly et al, 2006 (USA)
• There were two elderly patients above 55 years in both 2014 and
2013
• There were no under-five children enrolled in 2013 and 2014.
Socio-Ecological factors in Harare
• HIV
• Overcrowding
• Poverty
• Malnutrition
• High mobility
• Poor access to DOT sites
• DM
• Institutional conditions
History of previous TB drug treatment at Wilkins DRTB clinic 2013 vs 2014
91.50%
60.80%
35.20%
8.50%
0
Previously treated with FLDS
New
2013
3.90%
Previously treated with SLDs
2014
History of previous TB medicines treatment
• Higher previous FLDs treatment and more new registration categories
in 2013 vs 2014 suggesting earlier case finding in 2014
• More exposure to SLDs suggest PMDT evolution, return after default,
and XDRTB surveillance
Risk groups in Harare, 2013 -2014
Figure 6: DRTB risk groups at Wilkins Hospital clinic 2013 vs 2014
Other
Failure of treatment from private sector
Exposure to high DRTB burden region
Relapse
Exposure to high DRTB burden institutions
2013 %age
Return after default
2014 %age
Sputum Positive end of IP
DRTB Contact
Failed CAT 1
Failed CAT 2
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
Risk groups
Increased mix of diagnoses and risk categories in 2014 than 2013
reflecting increased HCW KAP on risk groups and case finding
PMDT Indicators
• Enrolment
• Detection
• Interim outcomes
• Final Outcomes
DRTB Enrolment City of Harare
Year
2011
2012
2013
2014
2015
Confirmed Enrolled
35
35
44
44
59
59
37
37
20
19
Catchment
Northern region
Northern region
Northern region
Harare Province
Harare City
DRTB enrolment by quarter, City of Harare, 2015
8
7
7
6
6
7
6
7
6
5
4
3
2
1
0
0
Q1
Q2
DRTB Enrolment by quarter 2015 Enrolled
Q3
0
Q4
DRTB Enrolment by quarter 2015 Confirmed
Enrolment
• 20 presumptive TB patients were tested and confirmed to have DRTB
in 2015.
• Almost all (19/20) confirmed patients were enrolled on DRTB
treatment.
• Average enrolment was 5 DRTB patients per quarter.
• None were neither confirmed nor enrolled in Q4 2015. Fourth
quarters have been associated with low diagnosis and enrolment of
DRTB patients in Zimbabwe
Detection of DRTB – Gene XPERT Utilisation
(City of Harare, 2015)
Q12015
Q2 2015
Q32015
Q4 2015
Total
%age
XPERT MTB Tests
done
MTB+VE
1291
1798
2033
1851
6973
100%
80
105
152
130
467
6.7%
RR+VE
4
2
7
1
14
3.0%
Detection
• 6973 Xpert MTB RIF test were done in 2015 which yielded 14 (3.0%)
rifampicin resistant positive results and 467 MTB positive cases
(6.7%).
• However there was under-reporting of Xpert testing in most districts.
Resistance pattern of DRTB Cases seen at WIDH –
cumulative, Q3 2012
Resistance pattern
N
%
Rifampicin Mono-resistance
14
20%
Poly Drug Resistance
5
7.1%
Multi-Drug Resistance
45
64.3%
No DST results
6
8.6%
TOTAL
70
100%
Drug sensitivity testing results, Northern region & Harare, 2012
No DST results
8.60%
Multi-Drug Resistance
64.30%
Poly Drug Resistance
7.10%
Rifampicin Mono-resistance
20%
0%
10%
20%
30%
40%
50%
60%
70%
DRTB/HIV Collaboration
Q1 2015
6
Number
confirmed
Number with 2
HIV positive
results
Number on
2
ART
Number on
2
CPT
Q2 2015
7
Q3 2015
7
Q4 2015
0*
Total
20
%age
100%
7
2
4
15
75%
6
2
3
13
86.7%
6
2
4
14
93.3%
6 months interim outcomes, Q2 2013 Cohort
• All patients enrolled were alive and on treatment at six months in 2014
compared to a similar Q2-cohort in 2013.
• There were no defaulters nor deaths among the Q2 2014 cohort compared
to the same cohort in 2013.
• There was one death, one defaulter, and one patient with sputum results
unknown in the Q2 2013 cohort.
• No patients remained sputum positive between the two cohorts with 100%
sputum negativity among all alive on treatment patients.
• Six months interim outcomes are reported on the patients who have
completed six months on of treatment hence the cohort that started nine
months ago.
Figure 9: 24 Months DRTB treatment outcomes, Q1 2011 Cohort, Harare City
9
8
8
8
7
6
5
4
3
2
1
0
0
Alive on Treatment
Defaulted
0
0
Died
Culture Negative
0
Culture PositiveSputum results unknown
24 months treatment outcomes
All eight patients enrolled in the first quarter of 2011 (Q1 2011) were
alive and on treatment after 24 months. All eight out of the eight
patients were culture negative. No patient in this cohort died nor
defaulted treatment. None was culture positive nor had sputum results
unknown. All eight patients had cured and had treatment stopped at
24 months.
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