Prevention of Tuberculosis in Kuwait Samir M. Bahnasy, MBBCh,, MSc TMH, DPH, Dr PH, Consultant Epidemiologist

Talk outline Background Descriptive Epidemiology Epidemiological Statistics Prevention Prospective achievements

Background Tuberculosis is one of the oldest diseases known to affect man. It might involve almost any part of the body, though to a variable extent, pulmonary type is the most frequent. Pulmonary tuberculosis represents an important global health problem due to its close relation to the socio-economic standard of the population, chronic nature, and the need for long-term treatment. It represents the most important form as it is the most common one and patients with pulmonary tuberculosis are the principal sources of other forms of tuberculosis infection.

Background In the beginning of l980s, tuberculosis was so well controlled in developed countries. The progressive decline in the incidence of tuberculosis suggested that eradication of the disease was possible. However in 1985, the steady annual decrease in the number of cases leveled off, and then the rate began to rise. This upside-down change might be attributed to a range of factors such as the pandemic of (HIV) infection, population growth, migration,

Background socioeconomic changes ,and (MDR) to the anti-TB drugs as a result of inadequately supported and / or disorganized treatment services. In 1993, the World Health Organization declared a state of global emergency for TB due to the steady worldwide increase in the disease. Along with HIV and malaria, TB has been declared a global enemy. An effective TB control program requires early diagnosis and immediate initiation of treatment.

Background Delay in diagnosis is significant with regard to not only disease prognosis at the individual level but also transmission within the community and the reproductive rate of the TB epidemic. The goal of TB control programs is to arrest transmission within the community. Achieving this goal takes considerable time, because most individuals in endemic areas are already infected, constituting a reservoir that continuously contributes to the pool of infectious cases.

Background WHO Global Tuberculosis Program had developed a new strategy to meet the needs of global tuberculosis control “DOTS” (Directly Observed Treatment Short course). DOTS strategy with its five components (Political commitment, Good quality diagnosis, Good quality drugs, Short-course chemotherapy, and Systematic monitoring and accountability) is a patient friendly strategy implemented by patient oriented supervisors. DOTS is currently the standard approach to care. Though expensive, it is probably less costly than admission and high cure rates have been achieved.

Descriptive Epidemiology More common in developing countries. Poverty - Crowding living conditions - Reduce access to health care Race/ethnicity Migration Population density (rural vs. urban) Substance abuse/alcoholism Nutritional status

Descriptive Epidemiology In developed countries is more frequent among immigrants, drug users, HIV, homeless, and those living in inner cities. HIV alone does not explain the increase of TB. Higher among males than females. The leading cause of death among women due to infectious diseases worldwide. The main cause of deaths occurred among young people and adults due to infectious diseases.

Descriptive Epidemiology Responsible for the highest number of orphans at the global level compared to other infectious diseases. In developed countries more frequent in old age (shift in age). Age-specific incidence varies over countries and socioeconomic conditions: Elders in Developed countries Young adults in developing countries* * Mainly those in their most productive years of life

Epidemiological Statistics Overall, 1/3 of the world population is currently infected with M. tuberculosis. 16 million TB infected (including TB/HIV). 1% of the world's population are infected with tuberculosis every year. every second , one person in the world get infection with TB. 5 – 10% of persons exposed to TB infection progress to TB diseased. 12 million new cases, 80% in 22 high-burden countries.

Epidemiological Statistics 2 million deaths. Over 1/4 million deaths due to TB/HIV. TB is the main cause of deaths occurred among HIV/AIDS patients, where it accounts about 15% of all deaths. More than 100,000 children die from TB each year. 95 % of all TB cases and 98 % of TB deaths occur in developing countries.

Epidemiological Statistics 75 % of TB cases in developing countries are in the economically productive age (15-50 years). 3.2% of all TB cases nationwide occurred among residents of correctional facilities. Multi-drug resistance (MDRTB) present in 102 of 109 countries surveyed from 1994-2003. If TB is left unchecked in the next 20 years, almost one billion people will become newly infected, 200 million will develop the disease, and 35 million will die of it.

Epidemiological Statistics In Kuwait, tuberculosis is an important public health concern. In year 2010, 957 persons ( both Kuwaiti and non Kuwaiti ) were diagnosed as TB cases (all forms). 358 cases of them were infectious ( smear positive ). Incidence rate of TB cases (all forms) was about 26.8, and of smear positive cases was 10.8 (4.6 for Kuwaiti and 13.6 for non Kuwaiti).

Epidemiological Statistics TB case notifications in Kuwait (2001-2010) 2009 2008 2007 2006 2005 2004 2003 2002 2001 387 386 345 294 284 187 247 201 206 174 Smear positive 163 155 158 94 76 95 65 73 91 72 Smear negative 407 391 363 277 234 242 288 283 250 Extra-pulmonary 957 932 866 645 644 516 554 562 580 496 Total New Cases

Epidemiological Statistics Incidence rate of TB cases (all forms) in Kuwait (2001-2010) 2009 2008 2007 2006 2005 2004 2003 2002 2001 26.8 27.1 25.2 21.2 21.1 21.0 23.3 24.3 25.6 21.8 (IR per 100 000)

Incidence rate Of TB cases (all forms) in Kuwait (2001-2010) (IR per 100 000)

Epidemiological Statistics Incidence rate Of smear positive pulmonary TB in Kuwait (2001-2010) 2009 2008 2007 2006 2005 2004 2003 2002 2001 4.6 3.8 4.2 3.3 3.6 2.5 4.3 3.7 2.8 Kuwaiti 13.6 14.7 12.7 11.8 12.1 10.9 14.2 12.2 10.8 Non Kuwaiti 11.2 10.0 9.0 9.3 7.6 10.3 8.6 9.1 Total (IR per 100 000)

Incidence rate Of smear positive pulmonary TB in Kuwait (2001-2010) (IR per 100 000)

The increasing TB incidence rate in Kuwait can be attributed to: Increased number of expatriates seeking residency in Kuwait from south-east Asia (40-50% of worldwide TB cases). Sustained efforts in the area of screening and early case detection of TB cases.

Levels of Prevention and Their Goals Prevention efforts focus on the following three goals: Primary prevention – preventing TB infection Secondary prevention – preventing TB disease Tertiary prevention – preventing TB morbidity and mortality

Prevention Designing and implementation of health education programs for all community sectors to educate the public in mode of transmission and methods of control and regarding the importance of early diagnosis and continued adherence to treatment. Reduce or eliminate those social conditions that increase the risk of infection. Set up TB prevention and control programs in institutional settings, closed communities and minorities.

Prevention Screening Early identification through efficient screening programs and successful treatment of persons with TB disease is the most effective means of preventing disease transmission. Screening programs can also detect persons with LTBI who are at high risk for progressing to TB disease.

Prevention Screening Infectious or potentially infectious ??? Infectious TB: all cases of respiratory (pulmonary or laryngeal) TB which are sputum smear-positive and culture-positive (if culture is available). Potentially infectious TB: all cases of respiratory (pulmonary or laryngeal) TB which are sputum smear-negative and culture-positive (susceptible, MDR-TB or XDR-TB). Non-infectious TB: all cases of respiratory TB which have two consecutive negative sputum-smear and negative culture (if culture is available) results.

Prevention Screening In Kuwait, TB screening is enhanced in last years particularly among expatriates with applying strict measures for early case detection, diagnosis and management. Active Surveillance for TB cases. Enhancing effective collaboration between TB and HIV/AIDS prevention and control programs. Monitoring national tuberculosis programs to prevent the emergence of (MDR) & (XDR-TB)

Prevention Management of close contacts of open TB cases. Preventive chemotherapy (isoniazid for 6-12 months) has been effective in preventing the progression of LTBI to TB disease. Eliminate bovine TB among diary cattle, pasteurize or boil milk. Applying measures to prevent silicosis among those working in industrial plants and mines.

Vaccination, BCG (Bacille Calmette-Guerin) Prevention Vaccination, BCG (Bacille Calmette-Guerin) BCG vaccine is the most vaccine in use worldwide. It has been used for the first time to protect against human tuberculosis in 1921, and since this date until today, the BCG is the only vaccine for prevention of TB. WHO estimated that more than one billion people worldwide have been vaccinated with BCG. BCG vaccines is safe, where no mention of having caused a serious problem since the beginning of its use until now.

Vaccination, BCG (Bacille Calmette-Guerin) Prevention Vaccination, BCG (Bacille Calmette-Guerin) BCG vaccine is live attenuated vaccine, which is derived from the bovine strain of tuberculosis bacteria (mycobacterium bovis). BCG gives immunity to some extent against tuberculosis and its influence extends for years. IT reduces the risk of progression TB infection to serious forms of tuberculosis such as TB meningitis and miliary TB. TST is not contraindicated for persons vaccinated with BCG.

Vaccination, Bacille Calmette-Guerin (BCG) Prevention Vaccination, Bacille Calmette-Guerin (BCG) Cannot distinguish between TST reactions caused by BCG and those caused by natural mycobacterial infection, but ≥ 20-mm indurations is usually NOT caused by BCG In Kuwait, Since 1/1/2005, all children in Kuwait must be vaccinated by BCG by the end of third month of life. BCG vaccination coverage had reached about 99%.

WHO guidelines for air travel Prevention WHO guidelines for air travel People with infectious or potentially infectious TB should postpone all travel by commercial air transportation of any flight duration until they become non infectious. Those people must be received 2 weeks of adequate treatment, and they must be sputum smear negative on at least two occasions (2 consecutive negative sputum-culture results – if MDR or XDR).

WHO guidelines for air travel Prevention WHO guidelines for air travel The public health authority must be Informed when an infectious or potentially infectious TB patient has a history of commercial air travel within the previous 3 months. The concerned airline must be Informed of infectious and potentially infectious passengers travelling against medical advice and request that boarding be denied.

WHO guidelines for air travel Prevention WHO guidelines for air travel If patient has exceptional circumstances, it must be ensure that the airline(s) and all involved authorities have agreed the procedures for travel. The public health authority must be informed of all exceptional circumstances.

Prevention DOTS (and DOTS- plus) is currently the standard approach to care, - Achieve high cure rates of up to 95%, - Low cost compared to other methods of treatment, - Prevents the emergence of new cases of TB, - Prevents the emergence of drug-resistant TB through a commitment to full and complete treatment until complete cure. In Kuwait, the National tuberculosis Program (NTP) has adopted DOTS strategy since 1998, and expanded it rapidly and achieved high population coverage.

Prospective achievements Developing sufficient, sustainable, human and financial resources to meet the challenge of stopping tuberculosis. Comprehensiveness of services for management of high-risk groups. A high quality of DOTS activities, using existing mechanisms and new initiatives.

Prospective achievements Implementing the Practical Approach to Lung Health (PAL), and assessing its potential impact on TB case detection and on the rationalization of drug prescriptions. Involvement of drug resistance surveillance. DST (Drug Sensitivity Testing) & Molecular epidemiology in the form of PCR and DNA finger printing. Restrictions and legislations to control TB drugs in private sectors.

Thank you