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May 23-26, 2012 in Bucharest, Romania “TB and M/XDR-TB: from clinical management to control and elimination” ERS School Exercise: Investigation of a microepidemic in adults and children Giovanni Sotgiu Martina Sester Lia D´Ambrosio Session IV: Control, elimination and research priorities

Exercise: Outline Description of the problem. Organization of CT activities (different groups). Discussion focused on the output (and pos/neg feedback)

TB Contact Tracing: definition Investigational activity aimed at identifying individuals with TB and LTBI Ultimate goal STOP transmission TB control programme

et al. Euro Surveill. 2011;16(40):pii=19984

Case description On 18 July 2011, a case of pulmonary and extra-pulmonary (splenic) TB was diagnosed in a four month old infant at the children’s hospital ‘Bambino Gesù’ in Rome, Italy Borgia et al. Euro Surveill. 2011;16(40):pii=19984

Let’s work together! Identify which steps should be implemented

Let’s work together! Prepare a questionnaire!

TB Contact Tracing: diagnostic algorithm Medical history Erkens et al (2010) Eur Resp J 36: 925

TB Contact Tracing: organization Risk assessment Erkens et al (2010) Eur Resp J 36: 925

TB Contact Tracing: organization Risk assessment Erkens et al (2010) Eur Resp J 36: 925

TB Contact Tracing: organization

Risk group approach: other vulnerable contacts Concentric-circles approach: evidence of recent transmission among the high priority contacts.  Contacts with TST or IGRA conversions.  Young children with a positive TST or IGRA.  Contact with TB.  The observed prevalence of infection is higher than the expected prevalence. TB Contact Tracing: organization

Identify the best diagnostic techniques

Diagnosis of active tuberculosis Patient history Chest X-ray Culture Acid-fast bacilli staining Nucleic acid amplification testing

APC T cell antigens/ peptides cytokine induction cytokine induction activation/ cytokine induction cytokine induction ELISAELISPOT assayFlow-cytometry cytokine activation marker Skin test Immunodiagnosis of latent M. tuberculosis infection T.SPOT.TBQuantiFERON TB gold IGRA IFN-  release assay PPD ESAT-6/CFP-10/TB7.7

TB Contact Tracing: organisation Identify the best diagnostic techniques, consider – Sensitivity/specificity of TST vs. IGRA – TB prevalence – Age of tested individuals – Logistics – Costs What is the scientific evidence for your decision

TB Contact Tracing: organization Identify the best treatment

Options Which regimen is universally recommended? Which alternatives do we want to consider? Is the evidence of alternative regimens sufficient?

Do we need a coordination? Any coordination body? Which competences represented? Which steps? Do we need international review? How to organise it? Can you estimate the costs of the operation? – Diagnostics – Treatment – Consultations – Communication – Coordination – Legal – Other?

M&E: how to organise it? Other specific indicators here?

ACSM: How to organise it?