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IMPACT TB: Implementing proven community-based active case finding interventions in Vietnam and Nepal

Periodic Reporting for period 2 - IMPACT TB (IMPACT TB: Implementing proven community-based active case finding interventions in Vietnam and Nepal)

Reporting period: 2018-07-01 to 2019-12-31

Tuberculosis (TB) is the leading cause of death from a single infectious agent, with 2 million deaths and 10 million cases globally in 2016. The economic and social impacts of the continued TB pandemic are immense. Unless control efforts are stepped up, tuberculosis will kill 28 million people between 2015 and 2030 and cost the global economy almost US$1 trillion. The global health community has set ambitious targets within the END-TB strategy to reduce TB globally by 2035 to the level seen in developed countries today- less than 10 cases per 100,000. However, it is recognised that without significant advances these targets will be impossible to achieve. As for any infectious disease, we know that contact tracing and early diagnosis are important to interrupt transmission and prevent ongoing spread of the disease, but active case finding strategies for TB have limited evidence to inform best strategies and optimise allocation of limited resources.

The aim of IMPACT TB was to implement TB active case finding in communities in Vietnam and Nepal which have a high burden of tuberculosis. Embedded within this implementation was the systematic generation of evidence to inform global health policy on active case finding for TB in both low- and middle-income countries with a high burden of tuberculosis. These data are informing the development of evidence-based frameworks for scale-up of implementation by the respective National TB Programmes in consultation with relevant stakeholders and governments. This will facilitate programmatic adoption of realistic and optimised active case finding strategies by national TB control programmes. We compared two alternative implementation strategies in each country appropriate to the local level of current service delivery. For Vietnam, we compared implementation using salaried employees with volunteer counsellors. For Nepal, we compared two diagnostic testing strategies as a component of active case finding: traditional smear microscopy or Xpert molecular testing.

The IMPACT TB project successfully diagnosed and notified 1,306 TB cases in Vietnam and 1,201 TB cases in Nepal over two years of active case finding implementation. Strong additionality to the national TB programme was shown in both countries, demonstrating that systematic targeted active case finding can be a key strategy in closing the TB case notification gap and achieving the END TB strategy targets by 2035.
The IMPACT TB project successfully implemented active case finding over two years in 6 districts of Ho Chi Minh City, Vietnam and four districts of Nepal. Over 2,500 TB cases were diagnosed and enrolled to treatment by the project while significant contributions have also been made to both the local and global evidence base for active TB case finding implementation.

The project demonstrated that, in Vietnam, a middle income, high TB burden country both salaried and incentivised human resource models are effective for TB case finding and result in additional case detection (16% additionality in project districts in Ho Chi Minh City). The additionality in All Forms TB notifications disaggregated by human resource model in Vietnam was +8.8% [95% CI: +8.0%, +9.6%] from volunteer districts compared to +12.3% [95% CI: +11.4%, +13.2%] from salaried employee districts. These rates corresponded to 480 [95% CI: 439, 521] additional All Forms TB notifications in volunteer districts and 610 [95% CI: 565, 655] in salaried employee districts. Therefore, where resources allow, the salaried model should be implemented for scale-up to achieve maximum impact in increasing TB case notification. In Nepal, one of the world’s poorest countries, the project showed that active case finding using GeneXpert testing has substantially higher yields compared to traditional smear microscopy. The cost per case detected is however substantially higher at 513 USD per case detected using smear compared to 909 per case detected using GeneXpert.

The modeling work package has further shown that active case finding can make substantial contributions to the achievement of END-TB strategy goals in both Vietnam and Nepal, but that intensification of case finding alone is not sufficient to reduce the epidemic to less than 10 cases per 100,000 by 2035. To achieve this crucial target which has been adopted by the governments of both countries, TB prevention must be scaled up in concert with active case finding.

The results of IMPACT TB have been widely disseminated at both the national and international level and across trans-disciplinary fora. Internationally, consortium members have chaired symposia, participated in panels, given oral presentations and presented posters. Three manuscripts have been published in international peer reviewed open access journals with a further ten in draft. Policy dialogues were held in both Vietnam and Nepal in 2019 to disseminate research findings and engage a broad range of local and multilateral policymakers, as well as people affected by TB, community representatives and healthcare workers.
The results of IMPACT TB have been influential in changing national government policy on active case finding for TB in both Vietnam and Nepal. Both National TB programmes have committed to achieving the END-TB strategy targets by 2035 and are now implementing active TB case finding scale-up as a component of national strategic plans for TB. TB prevalence surveys were completed in both Vietnam and Nepal in 2019, and both countries were shown to have a substantially higher TB burden than previously estimated by WHO. This increases the scale of the challenge facing both countries to achieve TB elimination. IMPACT TB research findings will contribute to the planned update of WHO guidelines on active case finding for TB in 2020 and on associated systematic reviews.

IMPACT TB has innovated in several approaches. TB principally affects the most vulnerable members of a society from the lowest socioeconomic groups (“the poorest of the poor”). The project has adapted the WHO costing tool for conducting patient cost surveys into a longitudinal design. Longitudinal health economic surveys will evaluate not just baseline costs, but also the longer-term financial consequences for a household of having TB disease. This approach is innovative and will ensure that patient cost evaluations include the full extent of costs incurred, rather than just pre-diagnostic costs.

The health economic evaluations of IMPACT TB have demonstrated that active case finding for TB is an effective strategy to reduce the economic impact of TB on households and reduce the long-term consequences of the disease. This will support development of improved equity of access to TB services and patient-centric care through national TB Programmes. The modeling data of IMPACT TB provides strong evidence to support the scale-up of TB preventative therapy in high burden countries and both BNMT and FIT are now implementing work to understand the operational challenges and costs involved in scaling up prevention strategies in Vietnam and Nepal. IMPACT TB is strengthening and improving access to TB services, empowering communities, generating evidence and informing policy development to accelerate the END-TB strategy in low- and middle-income countries.
Prof Nhung, Director of the Vietnamese NTP, presenting at the IMPACT TB policy dialogue workshop
BNMT staff collecting sputum samples in Dhanusha, Nepal
Traditional Mithilla artwork in Nepal raising awareness of TB as part of World TB Day 2019
Gabriela Gomes leading the modelling working group during the 2019 IMPACT TB consortium meeting
Huy Huynh of FIT Vietnam being interviewed as part of PPM engagement
IMPACT TB team at the 2019 consortium meeting in Kathmandu, Nepal
District Project Coordinator in Nepal using a GeneXpert machine in Chitwan, Nepal