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Report

Teaser, summary, work performed and final results

Periodic Reporting for period 1 - IMPACT TB (IMPACT TB: Implementing proven community-based active case finding interventions in Vietnam and Nepal)

Teaser

Summary

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. For every dollar invested in TB case finding and treatment, there is a return of US$30 through direct and indirect benefit to the patient, family and society in general.

The aim of this project is to assess the facilitators and barriers to scale-up two proven active TB case-finding and comprehensive patient care models in Nepal and Vietnam as examples of these low and lower-middle income country settings. We will use these data to develop an evidence-based framework 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 will compare two alternative implementation strategies in each country appropriate to the local level of current service delivery. For Vietnam, we will compare implementation using salaried employees with volunteer counsellors. For Nepal, we will compare two diagnostic testing strategies as a component of active case finding: traditional smear microscopy or Xpert molecular testing. We will determine the health economic impact of active case detection under the different models and model the long-term epidemiological impact and cost-effectiveness.

The research seeks to achieve the following objectives:
1) Implementation of active case finding with comprehensive patient support in 6 districts of Ho Chi Minh City, Vietnam detecting 1,450 additional cases in 2 years.
2) Implementation of active case finding with comprehensive patient support in 4 districts of the Central Development Region of Nepal, detecting 1,050 additional cases in 2 years.
3) Health economic evaluation of alternative implementation models in low (Nepal) and middle income (Vietnam) scenarios to inform policy.
4) Consultation with policy makers, stakeholders and end-users to evaluate facilitators and barriers to scale-up at health system and individual level and development of an evidence-based framework for scale-up for each country.
5) Transmission modelling of epidemic impact and long-term cost-effectiveness.

Work performed

The IMPACT TB project commenced in January 2017. The project website, www.impacttbproject.org, was established and twitter account started to disseminate awareness and project information (@impact_TB). During the first six months, the project held policy dialogue workshops in Vietnam and Nepal (reports available on website), obtained ethical approvals from all relevant authorities in Vietnam and Nepal as well as from the Liverpool School of Tropical Medicine Research Ethics Committee. Study specific data collection tools were developed. Active Case Finding for tuberculosis at the field sites in Vietnam and Nepal commenced in June 2017 and has been operational for one year.

The adapted WHO patient costing questionnaire has been piloted and modified to be appropriate to the local context. Data collection is ongoing and will be available for analysis in Q2 of 2018. Mathematical models are being developed which will inform future plans for laboratory network strengthening for TB diagnosis.

An IMPACT TB 18-month review and planning meeting was held in June 2017 in Ho Chi Minh City, Vietnam with the participation of all consortium partners, local stakeholders and representation from the Vietnamese and Nepalese National TB Programmes. Active case finding activities will continue until June 2019, at which time data will be prepared for analysis. Manuscripts are currently being prepared for submission on the development of the heterogeneous models, patient pathway models and preliminary patient cost assessment work. In the second half of the project we anticipate completion of active case finding, data collection, cleaning and analysis and drafting of manuscripts for publication.

Final results

IMPACT TB has innovated in several approaches. TB principally affects the most vulnerable members of a society from the lowest socioeconomic groups (â€œthe poorest of the poorâ€). 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 novel mathematical modelling frameworks (homogeneous and heterogeneous settings) have been developed and are being optimised for each setting using national TB programme data. The results of this analysis are being drafted for submission to an open-access peer reviewed journal. A patient pathway model is being developed for districts in Nepal using unique methods developed at LSTM, and a model developed for optimal deployment of TB diagnostic services, based on geographical variation, population densities and transport networks. This will inform optimal scale-up of TB services at the district level as Nepal transitions to the Federal system.

In the second half of the project, IMPACT TB will generate a number of peer-reviewed open-access publications and make the translated tools available to other researchers. The project will also generate policy briefs for active case finding scale-up in collaboration with the national TB programmes of Vietnam and Nepal, WHO representatives, Global Fund, and other experts and stakeholders. We anticipate these policy briefs being available in the final phase of the project, as they are dependent on results from the active case finding implementation. IMPACT TB has made a significant contribution to early career research capacity building in leading European Institutions, and in our developing country partners. The project has scaled-up access to early TB diagnosis and treatment for 2.5 million people in both Nepal and Vietnam and will continue to strengthen evidence to inform optimal scale-up of active case finding within resource-scarce health systems. 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.