Second workshop on systematic screening for TB disease and preventive treatment in the WHO European region: WHO virtual workspace, 15–16 April 2021

SECOND WORKSHOP ON SYSTEMATIC SCREENING FOR TB DISEASE AND PREVENTIVE TREATMENT IN THE WHO EUROPEAN REGION WHO virtual workspace, 15–16 April 2021 ABSTRACT The Second Workshop on Systematic Screening for TB Disease and Preventive Treatment in the WHO European Region was held virtually on 15 and 16 April 2021. This is the continuation of a series of workshops hosted by the WHO Regional Office for Europe, in collaboration with the WHO Global TB Programme, with the aim of scaling up the uptake and implementation of the latest WHO recommendations on tuberculosis (TB) preventive and curative action across the Region and encouraging investment into: 1) operationalizing the implementation of WHO recommendations; 2) implementing operational research to address evidence gaps; and 3) applying the best innovative practices across TB patient pathways. On 15 and 16 April 2021, over 250 participants met virtually to update each other, share experiences and discuss the prevention of TB through systematic screening and preventive treatment in the WHO European Region. This report summarizes the main discussion points from each of the four sessions from the workshop. Keywords TUBERCULOSIS PREVENTIVE TREATMENT SYSTEMATIC SCREENING WORLD HEALTH ORGANIZATION EUROPE Document number: WHO/EURO:2021-2805-42563-59176 © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. 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SECOND WORKSHOP ON SYSTEMATIC SCREENING FOR TB DISEASE AND PREVENTIVE TREATMENT IN THE WHO EUROPEAN REGIONWHO virtual workspace, 15–16 April 2021 3 Contents Acronyms and abbreviations ................................................................................................................................ 4 Acknowledgements .................................................................................................................................................. 5 Executive summary .................................................................................................................................................. 6 Introduction ................................................................................................................................................................ 7 Background ............................................................................................................................................................ 7 Modus operandi of the workshop................................................................................................................... 8 Workshop web-repository ................................................................................................................................ 8 Workshop objectives .......................................................................................................................................... 8 Opening remarks....................................................................................................................................................... 9 Session1 Global policy updates and practical guidance for their application in the WHO European Region ....................................................................................................................................................... 9 Impact of the COVID-19 pandemic ................................................................................................................. 9 Updated WHO consolidated guidelines on TB ......................................................................................... 10 Session 2 Implementation of WHO’s guidelines on TB screening and prevention: country cases........................................................................................................................... 11 Current policies and practices on systematic screening for TB in the WHO European Region ............................................................................................................................ 11 Country experiences ........................................................................................................................................ 11 Session 3 Digital technologies for TB screening and prevention............................................................ 12 Mobile applications for TB ............................................................................................................................. 12 Computer-aided detection (CAD) ................................................................................................................ 13 Session 4 Operational research and capacity-building .............................................................................. 14 Implementation research on diagnostic algorithms.............................................................................. 14 Support for the implementation and scale-up of digital technologies for TB................................ 14 Regional operational research projects ..................................................................................................... 14 Discussions and conclusions .............................................................................................................................. 15 Post-event satisfaction survey ...................................................................................................................... 15 Part 1 Technical content ............................................................................................................................ 16 Part 2 Administration and management .............................................................................................. 16 Annex 1 Programme ............................................................................................................................................. 17 Annex 2 List of participants ................................................................................................................................ 20 Annex 3 Survey on systematic screening for active TB in the WHO European Region ................... 29 Annex 4 Post-event satisfaction survey .......................................................................................................... 35 4 Acronyms and abbreviations CAD computer-aided detection CXR chest X-ray GDPR General Data Protection Regulations IGRA interferon-gamma release assays MoH Ministry of Health NNS number needed to screen NTP National Tuberculosis Programme OCF optimized case finding PI principal co/investigator PMTP Programmatic Management of TB Prevention TB tuberculosis TPT TB preventive treatment TST tuberculin skin test UCL University College London USAID United States Agency for International Development WHO WHO Regional Office for Europe 5 Acknowledgements The World Health Organization (WHO) Regional Office for Europe would like to thank the people from the national tuberculosis (TB) control programmes and the TB focal officers from the WHO European Region, partners and people affected by the disease for their participation in the Second Workshop on Systematic Screening for TB Disease and TB Preventive Treatment in the WHO European Region, 15–16 April 2021. The event organizing committee thank and acknowledge the contributions of members of the faculty and invited speakers for their delivery of the content provision: Dr Daniela CIRILLO (Head, Emerging Bacterial Pathogens Unit, San Raffaele Scientific Institute (HSR), Milano, Italy), Dr Andrei DADU (Medical Officer, TB Unit, Joint TB, HIV and Viral Hepatitis Programme, WHO Regional Office for Europe), Mr Sabyasachi DAS (Dure Technologies), Dr Saskia DEN BOON (Technical Officer, Global TB Programme, WHO headquarters), Dr Lucica DITIU (Executive Director, Stop TB Partnership), Dr Dennis FALZON (Team Lead, Global TB Programme, WHO headquarters), Dr Thomas HIATT (WHO Regional Office for the Western Pacific), Dr Avinash KANCHAR (Medical Officer, Global TB Programme, WHO headquarters), Dr Tereza KASAEVA (Director, Global TB Programme, Communicable Diseases Cluster, WHO headquarters), Mr Oleksandr KOROTYCH (Consultant, Research and Innovations, WHO Regional Office for Europe), Dr Giorgi KUCHUKHIDZE (Epidemiologist, WHO Regional Office for Europe), Professor Troels LILLEBÆK (Statens Serum Institut, Denmark), Professor Knut LONNROTH (Professor of Social Medicine, Karolinska Institutet), Dr Irada MAMMADOVA (Ministry of Justice, Azerbaijan, WHO Collaborating Centre for TB in Prisons), Dr Liliia MASIUK (TB Project Manager, Alliance Ukraine, Alliance for Public Health), Professor Alberto MATTEELLI (Associate Professor, Clinic of Infectious and Tropical Diseases, University of Brescia and Brescia Spedali Civili General Hospital, WHO Collaborating Centre for TB/HIV and TB Elimination, Italy), Dr Cecily MILLER (Medical Officer, Global TB Programme, WHO headquarters), Dr Lele RANGAKA (University College London (UCL), United Kingdom), Dr Morten RUHWALD (Senior Scientist, Head of Tuberculosis, FIND), Dr Vanessa VERONESE (Special Programme for Research & Training in Tropical Diseases (TDR), WHO), Dr Askar YEDILBAYEV (TB Team Lead, Joint TB, HIV and Viral Hepatitis Programme, WHO Regional Office for Europe), and Professor Lyazzat YERALIYEVA (Deputy Director of Clinical and Scientific Work, National Scientific Centre of Phthisiopulmonology, Ministry of Health, Kazakhstan). This report was written by: Andrei DADU,1 Nina BJERGLUND ANDERSEN1 and Giorgi KUCHUKHIDZE,1 and edited by Askar YEDILBAYEV,1 Dennis FALZON2 and Alberto MATTEELLI.3 1 WHO Regional Office for Europe 2 Global TB Programme, WHO headquarters 3 Clinic of Infectious and Tropical Diseases, University of Brescia and Brescia Spedali Civili General Hospital, Italy This work was supported by United States Agency for International Development (USAID) within the framework of WHO’s Regional Platform Project to End TB in east Europe. 6 Executive summary As countries strive to mitigate the COVID-19 pandemic, it is important to ensure that essential services, such as TB care and all operations dealing with long-standing health challenges, continue to protect the lives of people with TB and other diseases or health conditions. Efforts directed at TB prevention, diagnosis and treatment should thus be maintained without any interruption so that no one is left behind. The WHO guidance on TB preventive treatment (TPT) and on systematic screening for TB disease released in 2020 and 2021, respectively, present new evidence and critical steps in programmatic management that follow the cascade of TB prevention and care. Delivering these services effectively and safely necessitates a programmatic approach to implementing a comprehensive package of interventions. The WHO Regional Office for Europe, in collaboration with the WHO’s Global TB Programme, is continuing the series of regional workshops with the aim of scaling up the uptake and implementation of the latest WHO recommendations on preventive and curative action across the Region, and encouraging investment into: 1) operationalizing the implementation of WHO recommendations; 2) implementing operational research to address evidence gaps; and 3) applying the best innovative practices across the TB patient pathways. On 15 and 16 April 2021, over 250 participants met virtually to update each other, share experiences and discuss TB prevention through systematic screening and preventive treatment in the WHO European Region. This report summarizes the main discussion points of each of the four sessions of the workshop. The main points made during these discussions and the closing session of the workshop are outlined below. 1. Systematic screening and preventive treatment of TB need to be high on the agenda of the Global End TB Strategy – we will not reach Regional targets unless we scale-up screening and preventive treatment. 2. The key elements in systematic treatment and preventive treatment are design, algorithms, population groups, gradual roll-outs, good monitoring and evaluation systems, and letting local data guide the activities. 3. National plans for screening and preventive treatment are needed and require continuous updating. 4. Integrating TPT into existing screening is beneficial, but can slow down the process. Many countries in the Region are lagging behind on this integration. Integration is relevant in most settings, including in prisons and among migrant populations. 5. Counselling of close contracts is also inadequate in many countries and more focus should be put on it. 6. Screening and TPT for people living with HIV has progressed but is still a challenge for many countries in the Region. 7 Introduction Background The End TB Strategy – with its vision of a world free of TB, and an end to the global TB epidemic by 2035 – was launched by WHO in 2014 and was operationalized for the WHO European Region by the Tuberculosis Action Plan 2016–2020. During the last decade, the Region has had the fastest rates of decline in TB incidence (about 5% a year) and TB mortality (about 10% a year) in the world. Nonetheless, TB still represents a major public health threat, despite the significant impact of efforts by Member States, WHO and partners. As countries strive to mitigate the COVID-19 pandemic, it is important to ensure that essential services, such as TB care and all operations dealing with long-standing health challenges, continue to protect the lives of people with TB and other diseases or health conditions. Efforts directed at TB prevention, diagnosis and treatment should thus be maintained without any interruption so that no one is left behind. WHO guidance on TPT1 and on systematic screening for TB disease2 released in 2020 and 2021, respectively, present new evidence and critical steps in programmatic management that follow the cascade of TB prevention and care. Delivering these services effectively and safely necessitates a programmatic approach to implementing a comprehensive package of interventions, which means: • identifying individuals at highest risk of TB; • testing for TB infection and disease in certain risk groups; • starting TPT in people at risk of progressing to TB disease; • starting TB treatment in people with TB; • supporting medication adherence, and managing adverse events; • monitoring programmatic performance.The approach to programmatic management of systematic screening for TB disease and TPT varies across the Region, with best practices observed in west Europe and more attention required in eastern Europe and central Asia, the Regions that have a high burden of drug-resistant TB. Therefore, to enable more targeted discussions during the workshop, WHO provided a survey to examine the main bottlenecks in TB screening and to foster opportunities for systematic screening for active TB in the WHO European Region (Annex 3). The survey was designed to collect basic information about present and future practices in systematic screening for active TB in each country. The results of this survey were reported and discussed during the workshop. The WHO Regional Office for Europe, in collaboration with the WHO’s Global TB Programme, is continuing the series of regional workshops with the aim of scaling up the uptake and implementation of the latest WHO recommendations on preventive and curative action across the Region, and encouraging investment into: 1) operationalizing the implementation of WHO recommendations; 2) implementing operational research to address evidence gaps; and 3) applying the best innovative practices across the TB patient pathways. 1 WHO consolidated guidelines on tuberculosis: Module 1: Prevention: Tuberculosis preventive treatment. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/who-consolidated- guidelines-on-tuberculosis-module-1-prevention-tuberculosis-preventive-treatment, accessed 24 May 2021). 2 WHO consolidated guidelines on tuberculosis Module 2: Screening – Systematic screening for tuberculosis disease. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/9789240022676, accessed 24 May 2021). 8 The focus of these workshops is on ensuring universal and free-of-charge access to diagnosis and treatment of TB infection and disease among vulnerable and hard-to-reach populations; improving surveillance, response monitoring and outcome/impact evaluation; and strengthening case-based data management. Modus operandi of the workshop On the 15 and 16 April 2021 approximately 255 participants meet virtually to update each other, share experiences and discuss the prevention of TB through systematic screening and preventive treatment in the WHO European Region. The workshop was aimed at bringing national counterparts and partners up to date on the latest global guidelines and operational implementation aids of TB prevention at regional and country levels, and increase awareness of the digital health tools and practices available for the programmatic management of systematic screening and TPT. The participants of the meeting included: • national TB counterparts and relevant focal point officers in screening, prevention and health; • international and national partners of WHO and country TB programmes; • other interested stakeholders (the event was live-streamed and open to all interested parties). Due to the COVID-19 pandemic, the workshop was run virtually; the workshop ran over 2 days, with two sessions on each day. The workshop was conducted in English and Russian with simultaneous interpretation and consisted of both presentations and discussions. Approximately 300 participants from the 51 countries of the European Region and participants from outside Europe registered for this event (see Annex 2).3 After the workshop, a post-event satisfactory survey was provided for all participants, the results of which are presented in Annex 4.4 Workshop web-repository The workshop material was made available prior to the event on a web-repository5 in accordance with WHO’s paper-free policy. The workshop was streamed live via social media and the recording remains available for further viewing. 6 This report summarizes the main discussion points of each of the four sessions of the workshop. The workshop programme, the list of participants, and the pre- and post-event surveys are provided in Annexes 1–4. Workshop objectives 1) To discuss the latest WHO TB consolidated guidelines: Module 1: Prevention: Tuberculosis preventive treatment, and Module 2: Screening – Systematic screening for tuberculosis disease; 2) To share best practices for the application of digital health tools for screening and TPT; 3 Online event registration can be found at: https://eurotb.net/TB-screening-registration 4 Second regional workshop on Systematic screening for TB disease and TB Prevention in the WHO European Region, post-event questionnaire can be found at: http://eurotb.net/TB-screening-evaluation. Survey results are at: http://eurotb.net/TB-screening-satisfaction 5 The event web repository can be found at: https://eurotb.net/TB-screening-files 6 Workshop recordings can be found at: http://eurotb.net/TB-screening-day1 and http://eurotb.net/TB-screening- day2 9 3) To review the impact of the COVID-19 crisis on the achievement of the UN High-Level Meeting and End TB Strategy targets that depend on screening and TPT: current challenges and future opportunities. Opening remarks Opening remarks were given by Alberto MATTEELLI, the Chair of the meeting; Tereza KASAEVA, Director of the Global TB Programme of WHO; Lucica DITIU, Executive Director of the Stop TB Partnership; and Askar YEDILBAYEV, TB Unit Lead at the WHO Regional Office for Europe. The speakers thanked the participants for joining the workshop and congratulated them on the impressive progress made in TB prevention. However, compared with the aims of the Political Declaration of the United Nations General Assembly in September 2018, the Region is still lagging behind. Regular and systematic screening and preventive treatment of TB are essential elements if overall progress in the global burden of TB is to be seen. The COVID-19 pandemic has not made the job easier, and the progress made in the work against TB over the last 10 years is at risk of being lost. The updated guidance on TB prevention provides a real opportunity to fight back; however, the guidance requires implementation and funding, and the involvement of all relevant stakeholders including civil society. Despite being responsible for the setbacks in TB progress, COVID-19 also provides an opportunity for positioning TB on the political agenda. Contact investigation, screening and testing for COVID-19 are also opportunities for TB prevention. Session1 Global policy updates and practical guidance for their application in the WHO European Region Session 1 provided the participants with an overview of: 1) the impact of the COVID-19 pandemic on coverage and continuity of TB prevention and care services in the WHO European Region; 2) the most recent global guidelines on systematic screening and TPT. Impact of the COVID-19 pandemic The COVID-19 pandemic has affected the coverage and continuity of TB preventive and care services in the WHO European Region. A survey based on preliminary monthly reported data by 29 Member States found that monthly TB notification rates in 2020 had decreased compared with 2020. The largest decrease was registered in April 2020 which registered only 48% of the notifications that were registered in the April 2019. In the second quarter of 2020, there was an average decrease in TB notification rates of 35.5% compared with the same period in 2019. Restrictions on movement seem to be responsible for some of this decrease. 10 Updated WHO consolidated guidelines on TB New and updated WHO consolidated guidelines on TB were released in 2020 and 2021. These updates include Module 1: Prevention: Tuberculosis preventive treatment7 and Module 2: Screening – Systematic screening for TB disease.8 Module 1: Prevention: Tuberculosis preventive treatment was the first module to be released from the new WHO consolidated TB guidelines. The primary target group for the guidelines are the national TB and HIV programmes, or the equivalent personnel working in ministries of health, and other policy-makers working on TB and HIV and infectious diseases in public and private sectors and in the community. The guidelines include a set of 18 recommendations on TB prevention, which cover four critical steps in programmatic management that follow the cascade of TB prevention and care. The main changes introduced include conditional recommendations for 1-month daily rifapentine and isoniazid regimens and 4-month daily rifampicin regimens as alternative treatment options in all high-TB burden settings. The advice for both isoniazid preventive treatment in pregnancy and on the concomitant use of rifapentine and dolutegravir have been updated to reflect findings from the latest studies. The guidelines are complemented by an operational handbook, providing details on TPT that are critical to the implementation of different elements of programmatic management of TPT; for example, contact tracing, drug dosages, safety monitoring and programme indicators.9 The update of Module 2: Screening – Systematic Screening for TB disease is based on the most recent evidence and evaluations of novel screening tools and technologies. The guidelines include a set of 17 new and updated recommendations for the screening of TB accompanied by a complementary implementation guide, covering six critical steps in programmatic management of TB. The guidelines recommend that contacts of TB patients, people living with HIV, people exposed to silica, prisoners and other key populations should be prioritized for TB screening. Different screening tools are recommended, including: symptom screening, chest radiography, computer-aided detection (CAD) software, WHO-approved molecular rapid diagnostic tests, and C-reactive protein. 7WHO consolidated guidelines on tuberculosis: Module 1: Prevention: Tuberculosis preventive treatment. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/who-consolidated- guidelines-on-tuberculosis-module-1-prevention-tuberculosis-preventive-treatment, accessed 24 May 2021). 8WHO consolidated guidelines on tuberculosis Module 2: Screening – Systematic screening for tuberculosis disease. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/9789240022676, accessed 24 May 2021). 9 WHO operational handbook on tuberculosis. Module 2: Screening. Systematic screening for tuberculosis disease. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/340256/9789240022614-eng.pdf, accessed 24 May 2021). 11 Session 2 Implementation of WHO’s guidelines on TB screening and prevention: country cases Session 2 provided the participants with an overview of: 1) current policies and practices on systematic screening for TB in the European Region; 2) country experiences with systematic screening for TB. Current policies and practices on systematic screening for TB in the WHO European Region A regional survey on current policies and practices on systematic screening for TB in the Region was carried out in 2020. Out of 53 Member States, 20 responded to the survey, and the respondents included representatives from civil society and people working at the regional level. The survey showed that most countries are familiar with, and actively use, WHO guidelines on systematic screening. Most countries are working with subpopulations, people living with HIV and prison populations. The most commonly used tools and algorithms for systematic screening are chest X-rays (CXRs) and any TB symptom. Ten countries use rapid tests and one country (Georgia) uses CAD. The most common model of screening is through health centres. Many of the respondents also described the use of outreach programmes. Six countries mentioned that they require technical support from WHO and its partners to revise the national protocols and guidelines on systematic screening and TPT (Armenia, Belarus, Republic of Moldova, Romania, Switzerland and Tajikistan). Country experiences Kazakhstan described the process of developing national guidelines on screening and preventive treatment. This process was guided by the then new WHO guidelines, and focused on patient-oriented care. The development included a situation analysis of existing screening activities and the identification of challenges involved in screening household contacts, people living with HIV and prisoners. The process had a focus on a broad engagement of stakeholders, including civil society. Denmark presented programmatic considerations of TB screening and prevention in migrants (former asylum seekers, quota refugees, and family-reunified to refugees) and socially marginalized groups. Denmark’s experiences demonstrate the need to adapt screening modalities to specific risk groups and local conditions – one size does not fit all. It is important to be aware of the origin of migrants and that the risks are high after their arrival, making it relevant to screen for active TB. However, it is important to be aware of the high long-term risk and ensure screening for active TB disease and continuous access to health care for the groups at risk. For socially marginalized groups, culture screening proved to be useful in a Danish setting and led to reduced morbidity, reduced transmission and detection of isoniazid resistance and nontuberculous mycobacteria. Ukraine presented its experiences with the implementation of intensified case-finding among close contacts and household contacts, based on experiences of identifying HIV cases in key 12 populations. The main conclusions were that collaborations between stakeholders improves TB detection in hard-to-reach populations. Higher levels of TB drug-resistance in contacts residing within the general population heralds a real risk of transmission of MDR-TB from the general population to key populations. The optimized case-finding (OCF) strategy among key populations is highly effective in detecting TB cases and linking them to care. The presenters advocate the scale-up of the OCF strategy in Ukraine and beyond. Data from Sweden, England, the Netherlands and Italy were presented as part of the E-DETECT project, focusing on the detection of TB infection among migrants in low-incidence countries. The project showed that screening can be cost-effective with the correct targeting, but also very non-cost-effective in cases of too broad screening, and screening without intention to offer preventive treatment. The project has also demonstrated that linkage to care can be done effectively, but requires a lot of planning (and resources). The data can be used to estimate TB infection prevalence by age group and incidence in country of origin among migrants in similar countries; for example, for planning and modelling of effectiveness and cost–effectiveness. Azerbaijan presented programmatic considerations of TB screening and prevention in prisons. Three types of screening were used: screening on entry within the first 24 hours after imprisonment; annual mass screening; and passive screening among prisoners with clinical TB symptoms. Despite entry screening, the annual mass screenings identify many new cases. A particular risk group is people living with HIV, with the risk being 20 times greater than among prisoners who are not HIV-positive. A preventive TB strategy among HIV-infected prisoners has led to a reduction of mortality among HIV-infected prisoners. Session 3 Digital technologies for TB screening and prevention Session 3 provided the participants with an overview of: 1) the mobile applications available for TB screening, management and care; 2) the potentials of CAD systems. Mobile applications for TB WHO’s Prevent TB mobile application is a digital platform for monitoring and providing the TB continuum of care.10 The mobile app facilitates field operations for different user groups including outreach workers, testing counsellors and treatment supporters. The app allows client registration, screening and referrals, and testing and treatment for presumptive cases and household contacts. The app improves the quality of services and communication across different stakeholders. Real-time alerts help providers track clients, thus reducing lost to follow-up cases. The tool is based on a global template that can be adapted to the specific country setting. It is also possible to use the tool in cross-border settings. Reporting on screening activities in the Region is not yet included in the data collection at the global level. The Prevent TB app will soon include key data elements to capture and report on a global indicator. A local adaptation of the Prevent TB mobile application has been developed in the Philippines. The app consists of four different applications: 1) Care TB, which is a companion tool for health 10 Prevent TB Digital Platform. Geneva: World Health Organization; 2021 (https://www.who.int/tb/prevent-tb- digital-platform/en/, accessed 24 May 2021). 13 care workers and patients; 2) Lead TB, which contains monitoring and survey tools and makes it possible to share reports; 3) Guide TB, an e-learning app with the latest version of TB documents and algorithms; and 4) Race TB, an app that supports a national TB campaign. The platforms are General Data Protection Regulations (GDPR) compliant and can be replicated for other settings and health conditions; for example, COVID-19 or HIV. The development of the apps was an incremental process over 3 years. WHO owns the code, but has donated in to the Department of Health of the Philippines. In Georgia, a tool to include the registration of contacts of TB cases and people on preventive treatment is under development. It consists of an app and a web-based database. The tool will be available in June. Screen TB is an online tool to aid prioritization of risk groups and selection of screening algorithms.11 The tool generates estimates of the yield of screening interventions, the cost and cost–effectiveness. It also allows for comparisons of estimates across risk groups and screening algorithms. The estimates are based on: 1) the size of the risk group and prevalence of TB; 2) the portion of the risk group that can be reached; and 3) the sensitivity and specificity of the screening algorithm. In addition, the tool compiles data from multiple sources, including WHO and other global data repositories; published literature including systematic reviews and user-provided data. Currently, the tool has a number of limitations; for example, it is based on numerous assumptions and does not account for overlaps between risk groups. These limitations mean that the tool is not suitable for detailed planning. Screen TB is currently being updated based on recent guideline revisions and will include new tools and algorithms and a section for screening people living with HIV. Computer-aided detection (CAD) The development of software for CAD systems that interpret digital CXR images is a fast-moving field. CAD has the potential to capture differential diagnosis on CXRs as it provides objective, quantitative and fast results. CAD performance for TB detection seems to be at least comparable to the performance of experienced human readers, but variability in results is seen between different countries and types of CAD software. CAD can be used to prioritize workflows, for automated reporting and for quality control, in cases in which the radiologist looks at the CXR images first. CAD is a new area for policy-makers and regulators.12 A CAD calibration toolkit aimed to support national TB programmes and other implementers of calibrated CAD is available.13 The toolkit supports new users of CAD to understand threshold scores and their programmatic implications within the context of a TB screening or triage programme. It describes a simplified operational research protocol to collect and analyse the required data necessary to determine the appropriate CAD threshold for a specific CAD implementation. And finally, it supports the analysis, interpretation and application of the resulting CAD diagnostic performance data and provides cost estimates to determine the most appropriate CAD thresholds based on local context and use. 11 ScreenTB – target prioritization and strategy selection for tuberculosis screening (active case finding). Geneva: World Health Organization; 2021 (https://wpro.shinyapps.io/screen_tb/, accessed 24 May 2021). 12Computer-aided detection (CAD) of TB. Geneva: FIND; 2021 (https://www.finddx.org/tb-archive/cad/, accessed 24 May 2021). 13Calibrating computer-aided detection (CAD) for TB. TDR; 2021 (https://tdr.who.int/activities/calibrating- computer-aided-detection-for-tb, accessed 24 May 2021). 14 Session 4 Operational research and capacity-building Session 4 provided the participants with an overview of: 1) implementation research on digital algorithms; 2) relevant toolkits; 3) Regional operational research activities; 4) data collection for TPT. Implementation research on diagnostic algorithms Diagnostic algorithms for screening for active TB in symptomatic or non-symptomatic people can be used: 1) to detect TB disease early and increase the probability of treatment success, decrease sequelae, and reduce the social burden; 2) to reduce TB transmission in community settings by removing people with prevalent disease and shortening the duration of infectiousness; 3) to reduce the incidence of TB infections, and consequently the incidence and prevalence of TB disease; and 4) for screening in target populations. New diagnostic algorithms are being developed at high speed. Countries should concentrate on adopting algorithms suitable to address existing performance gaps, the epidemiological context, health system settings and infrastructure, including laboratory networks, priority groups to be screened and the technology already in place, and not to focus on implementing tools just because they are new. Support for the implementation and scale-up of digital technologies for TB Since 2016, WHO has published several guidelines to support the implementation of digital technologies for TB. One of the key challenges for digital technologies is that evidence of effectiveness varies and there is little information on implementation-related outcomes. The Implementation Research for Digital Technologies and TB (IR4DTB) is a toolkit available online for evaluating the implementation and scale-up of digital innovations across the TB continuum of care.14 This toolkit provides guidance to countries on implementation research for use of digital innovations within TB programmes and to support the strengthening of the evidence base on the optimal implementation of digital innovations for TB. It is organized around four digital functions: patient care; programme management; surveillance and monitoring; and e-Learning. Each module contains a series of subsections, which are linked to clear objectives, and are designed to contribute to development of IR proposal. The module concludes with a checklist allowing users to track their progress against the required components of a study proposal. Regional operational research projects The introduction of fully-oral shorter regimens for MDR/RR-TB under operational research conditions (ERI-TB Initiative) is underway in 14 Member States in the Region. The primary operational research objective is to determine treatment outcomes of patients who are treated with a novel (modified) shorter MDR-TB regimen. Secondary objectives are to assess the safety of a novel (modified) shorter MDR-TB regimen monitoring of adverse event rates; and to 14Implementation Research for Digital Technologies and TB (IR4DTB). TDR; 2021 (https://www.ir4dtb.org/, accessed 24 May 2021). 15 determine the proportion of patients with TB recurrence during the 12 months after successful treatment with a novel (modified) shorter MDR-TB regimen. Preventive treatment for DR-TB contacts has become possible with the availability of short and ultra-short regimens for the treatment of TB infection to halt progression to disease. In addition, initial evidence exists to support preventive treatment for DR-TB contacts, and trials are underway. However, slow roll-out of the new treatment, the existing challenges to programmatic scalability, and adherence to treatment creates prevention gaps. There is a range of opportunities for operational research in the entire cascade of care. Nine high-MDR-TB burden countries in the Region are participating in the introduction of RR- TB preventive treatment regimens under operational research conditions. The objectives are to facilitate introduction of RR-TB preventive treatment under operational research conditions; to foster good clinical care for people with RR-TB infection through operational research; to build and strengthen countries’ research capacities; and to contribute to global knowledge for the generation of new policy guidance for TPT. Discussions and conclusions The event had three main outcomes. • National counterparts and partners were updated on the latest global guidelines and the latest operational implementation aids for regional and country levels. • National counterparts and partners were made aware of the digital health tools and practices for use in the programmatic management of systematic screening and TPT. • The WHO Regional Office for Europe documented country requests for the provision of technical support to update national policies on systematic screening and TPT. The main points made during these discussions and the closing session of the workshop are outlined below. 1. Systematic screening and preventive treatment of TB need to be high on the agenda of the Global End TB Strategy – we will not reach Regional targets unless we scale-up screening and preventive treatment. 2. The key elements in systematic treatment and preventive treatment are design, algorithms, population groups, gradual roll-outs, good monitoring and evaluation systems, and letting local data guide the activities. 3. National plans for screening and preventive treatment are needed and require continuous updating. 4. Integrating TPT into existing screening is beneficial, but can slow down the process. Many countries in the Region are lagging behind on this integration. Integration is relevant in most settings, including in prisons and among migrant populations. 5. Counselling of close contracts is also inadequate in many countries and more focus should be put on it. 6. Screening and TPT for people living with HIV has progressed but is still a challenge for many countries in the Region. Post-event satisfaction survey The satisfaction survey provided the participants with an opportunity to rate the content, the mode of delivery and its quality on a scale of 1–5, where 1 is very unsatisfied and 5 is very satisfied. The survey was offered to all participants after the event in a letter/email which acknowledged their participation. The survey questions were divided into two sections: the first section was on the presentation of the technical content, which followed the structure of the event programme, and the second section was on the mode of delivery, including the 16 administration and management of the virtual workspace established for this event. The survey had 123 respondents. All respondents (100%) said that the workshop met their expectations in general. The average score for the technical content, including the lectures, Q&A sessions and panel discussions was 4.81 (range 3–5), and the average score for the administration and management was 4.87 (range 4–5). Part 1 Technical content Out of the four technical session the most appreciated session was “Session 3 Digital technologies for TB screening and prevention” with an average score of 4.82 (range 3–5). The top three presentations were: 1) Regional operational research on modified fully-oral shorter treatment regimens for RR/MDR-TB: a model for the implementation of innovations (score 4.93); 2) Local adaptation of the Prevent TB mobile application (score 4.93); 3) The global guidelines on TB preventive treatment: Module 1, consolidated guidelines and operational handbook (score 4.91); 4) Introduction to computer-aided detection (CAD) products for tuberculosis (score 4.90). Part 2 Administration and management The set up, administration and management of the event received an overall average score of 4.86; the highest individual score was for simultaneous interpretation (4.90). Several technical areas were requested for discussion in a similar format in the future. These are the five areas mentioned most frequently: 1) paediatric TB: diagnostic tools, case-finding, treatment, TPT; 2) COVID/TB: mitigation impact, sustaining access to TB diagnostics, treatment and care; 3) laboratory diagnosis: updates on molecular, early diagnosis, Mantoux tuberculin skin test TST, interferon-gamma release assays IGRA, other; 4) TB services delivery roll-out and integration into primary health care using people-centred models of service delivery; 5) digital health in TB prevention and care: CAD, data connectivity, Screen TB, etc. 17 Annex 1 Programme WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE WELTGESUNDHEITSORGANISATION REGIONALBÜRO FÜR EUROPA ORGANISATION MONDIALE DE LA SANTÉ BUREAU RÉGIONAL DE L'EUROPE ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО Second workshop on systematic screening for TB disease and programmatic management of TB prevention (PMTP) in the WHO European Region WHO virtual workspace 15 and 16 April 2021 Original: English PROGRAMME (PROVISIONAL) Day 1. Thursday, 15 April 2021 Session 1 Global policy updates and practical guidance for their application in the WHO European Region Chair: Alberto MATTEELLI; Facilitator: Askar YEDILBAYEV Time Title Speaker 11:00 5 mins Welcome Tereza KASAEVA (WHO/GTB) Lucica DITIU (STOP TB) Askar YEDILBAYEV (WHO/EURO-TB) 11:05 5 mins End TB in the WHO European Region – the progress to date and the commitments for 2021–2030 Askar YEDILBAYEV (WHO/EURO-TB) 11:10 5 mins Impact of the COVID-19 pandemic on the coverage and continuity of TB prevention and care services in the WHO European Region: back to the future Giorgi KUCHUKHIDZE (WHO/EURO-TB) 11:15 30 mins The global guidelines on systematic screening for TB disease: Module 2, consolidated guidelines and operational handbook Cecily MILLER Saskia DEN BOON (WHO/GTB) 11:45 15 mins The global guidelines on TB preventive treatment: Module 1, consolidated guidelines and operational handbook Avinash KANCHAR (WHO/GTB) 12:00 30 mins Questions and answers (about 10 live questions) 12:30 30 mins Bio-break 18 Session 2 Implementation of WHO’s guidelines on TB screening and prevention: country cases Chair: Knut LONNROTH and Alberto MATTEELLI; Facilitator: Andrei DADU Time Title Speaker 13:00 15 mins Current policies and practices on systematic screening for TB in the WHO European Region Andrei DADU (WHO/EURO-TB) 13:20 15 mins Development of the National Guideline on screening and TB preventive treatment: why Kazakhstan need these updates and how we did it Lyazzat YERALIYEVA (NTP/Kazakhstan) 13:30 10 mins Programmatic considerations of TB screening and prevention in migrants and risk groups: experiences from Denmark Troels LILLEBÆK (SSI/Denmark) 13:40 10 mins Lessons learned from the programmatic implementation of intensified case-finding among close and household contacts of index TB patients Liliia MASIUK (APH/Ukraine) 13:50 10 mins Migrant TB and detection of TB infection in low-incidence countries: experiences from the E-DETECT project Knut LONNROTH (KI/Sweden) 14:00 10 mins Programmatic considerations of TB screening and prevention in prison conditions Irada MAMMADOVA (MoJ/Azerbaijan) 14:10 30 mins Panel discussions (about six interventions) 19 Day 2. Friday, 16 April 2021 Session 3 Digital technologies for TB screening and prevention Chair: Dennis FALZON; Facilitator: Giorgi KUCHUKHIDZE Time Title Speaker 11:00 15 mins WHO’s Prevent TB mobile application Sabyasachi DAS (Dure Technologies) 11:15 10 mins Local adaptation of the Prevent TB mobile application: example from the Philippines Thomas HIATT (WHO/Philippines) 11:25 10 mins Screen TB – an online tool for the prioritization of risk groups and comparison of screening algorithms Cecily MILLER (WHO/GTB) 11:35 20 mins Introduction to computer-aided detection (CAD) products for tuberculosis Morten RUHWALD (FIND) 11:55 20 mins A toolkit for the local calibration of computer-aided detection (CAD) software to enhance TB screening Vanessa VERONESE (WHO/TDR) 12:15 15 mins Questions and answers (about 10 live questions) 12:30 30 mins Bio-break Session 4 Operational research and capacity-building Chair: Dennis FALZON; Facilitator: Andrei DADU Time Title Speaker 13:00 15 mins Implementation research on diagnostic algorithms: what is needed? Daniela CIRILLO (WHO CC/Milano, Italy) 13:15 15 mins Supporting the implementation and scale-up of digital technologies for TB: the IR4DTB toolkit Vanessa VERONESE (WHO/TDR) 13:30 30 mins Regional operational research on modified fully-oral shorter treatment regimens for RR/MDR-TB: a model for the implementation of innovations Askar YEDILBAYEV Oleksandr KOROTYCH (WHO/EURO-TB) 14:00 15 mins Research gaps in TPT among MDR-TB contacts and considerations for operational research Lele RANGAKA (UCL/UK) 14:15 15 mins Regional data collection for TB preventive treatment among contacts of MDR-TB patients Andrei DADU (WHO/EURO-TB) 14:30 15 mins Questions and answers (about 10 live questions) 14:45 15 mins Summary and closure Alberto MATTEELLI Askar YEDILBAYEV 20 Annex 2 List of participants Participants Country/Region Last Name First Name Organization Albania MEMA Donika Institute of Public Health MESI Artan WHO Country Office, Albania MUKAJ Elina NTP TAFAJ Silva University Hospital Shefqet Ndroqi Armenia HOVHANNESYAN Arax WHO KHACHATRYAN Lilit Global Fund Projects Coordinating Team, Ministry of Health KHACHATRYAN Naira National TB Programme SERGEEVA Naira Ministry of Health ULUMYAN Anik National Centre for Pulmonology Australia KALON Stobdan PATH Austria DE COLOMBANI Pierpaolo Freelance consultant Azerbaijan ALIKHANOVA Natavan Global Drug Facility/Stop TB Partnership HUSEYNOV Samir Main Medical Department, Ministry of Justice MAMMADOV Famil Main Medical Department, Ministry of Justice TAGHIYEVA Sevinj Main Medical Department, Ministry of Justice Belarus KLIMUK Dmitriy State Institution “Republican Scientific and Practical Centre of Pulmonology and Phthisiology” SKRAHINA Alena Republican Research and Practical Centre for Pulmonology and Tuberculosis ZHURKIN Dzmitry Republican Research and Practical Centre for Pulmonology and Tuberculosis Belgium MAEX Margo Sciensano Burkina Faso DJIBOUGOU Arthur Centre Muraz Canada AL IMRAN Anm Aquity Global Inc. Croatia ŽMAK Ljiljana Croatian National Institute for Public Health Denmark BJERGLUND ANDERSEN Nina Public Health Science Communication GOZALOV Ogtay WHO Regional Office for Europe HASANOVA Sayohat WHO Regional Office for Europe KOCH Anders Statens Serum Institute, International Reference Laboratory of Mycobacteriology 21 KOSBAYEVA Aliya WHO KRAEF Christian Rigshospitalet, Copenhagen MOZALEVSKIS Antons WHO Regional Office for Europe NORDHOLM Anne Christine Statens Serum Institut, International Reference Laboratory of Mycobacteriology PODLEKAREVA Daria Rigshospitalet, Copenhagen RUNDSTROEM Maria WHO Regional Office for Europe Estonia GURBANOVA Elmira Tartu University Clinic Finland VASANKARI Tuula Filha and University of Turku France DORIN Camille Ministère de la santé Georgia ADAMASHVILI Natalia National Centre for Disease Control and Public Health ASATIANI Alexander WHO Consultant AVALIANI Teona National Centre for Tuberculosis and Lung Diseases BUZIASHVILI Mariana National Centre for Tuberculosis and Lung Diseases KIPIANI Maia National Centre for Tuberculosis and Lung Diseases LOMTADZE Nino National Centre for Tuberculosis and Lung Diseases SEREBRYAKOVA Lela Independent consultant SOLOMONIA Nelly National Centre for Tuberculosis and Lung Diseases TOGONIDZE Tamar National Centre for Tuberculosis and Lung Diseases Germany HAECKER Brit DZK – German Central Committee Against Tuberculosis HAUER Barbara Robert Koch Institute MAURER Florian SRL Borstel Hungary BAKOS Ágnes National Korányi Institute for Pulmonology India ANAND Anchita Dure Technologies BAL Himadri Bhusan National Reference Laboratory-TB, ICMR-Regional Medical Research Centre, Bhubaneswar BHATNAGAR Nitish Dure Technologies Ravi Reckitt DAS Aritra Dure Technologies GANDHI Ravdeep PATH GHOSH Pujya Center for Health Research and Innovation JAIN Neeraj PATH NARALE Naveen Dure NATH Ravindra Vardhman Mahavir Medical College and Safdarjung Hospital 22 RODDAWAR Venkatesh PATH SAXENA Rishabh SINGH Tushar Dure Technologies SISTLS Jyotsna Reckitt SRIVASTAVA Prasoon Dure Technologies YAMIN Nida Dure Technologies Indonesia RIANI Mia University of Hasanuddin, Makassar SIDABUTAR Evalina IOM Italy COSMARO Lella Fondazione LILA Milano – Italian League for Fighting AIDS Japan OKADA Kosuke Japan Anti-Tuberculosis Association (JATA) ONOZAKI Ikushi Research Institute of Tuberculosis, Japan Anti-TB Association SUGAMOTO Tetsihiro Tuberculosis Prevention Association YAMADA Norio Research Institute of Tuberculosis, JATA Kazakhstan AYDINYAN Lusine Stop TB Partnership BEKTRUSINOV Bakhytzhan National Scientific Centre of Phthisiopulmonology, Ministry of Health DJAZYBEKOVA Panagul National Scientific Centre of Phthisiopulmonology, Ministry of Health ERIMBETOV Kulakhmet National Scientific Centre of Phthisiopulmonology, Ministry of Health ISMAILOV Shakhmurat Project Implementation Unit for the Global Fund OSMANOVA Nadira Abt Associates PAK Svetlana KNCV in Central Asia PUSHKINA Tatyana Abt Association SEICAS Rita Stop TB Partnership TOXANBAYEVA Bekzat Abt Associates ZHANGIREYEV Aman West Kazakhstan Medical University of Marat Ospanov Kosovo15 GECAJ Aferdita Community Development Fund GJOCAJ Majlinda Ministry of Health ZHURI Gazmend WHO Kyrgyzstan ABDRAHMANOVA Elmira National Centre for Phthisiology BAITELIEVA Altynai Kyrgyz State Medical Academy named of I.K. Akhunbaev 15 In accordance with United Nations Security Council Resolution 1244 (1999). 23 BURINSCHI Victor National Tuberculosis Programme ERKINBAEV Mambet Osh Regional Centre for Tuberculosis Control GONCHAROVA Olga National TB Centre GUBANKOVA IRINA National Centre for Phthisiology KOZUKEEV Turat International Committee of the Red Cross KULZHABAEVA Aizat KNCV Kyrgyzstan TESHABAYEVA Aysalkyn National Centre for Phthisiology TOKTOGONOVA Atyrkul National Centre for Phthisiology ZHDANOVA Elena National Centre for Phthisiology Latvia KUKSA Liga WHO Collaborating Centre RIMSANE Ieva Center for Disease Prevention and Control Malta ABELA Anabel Mater Dei Hospital Montenegro LUCIC Stevan Special Hospital for TB and Lung Diseases Myanmar KYAW Thi Thi United Nations Office for Project Services THEIN Ye Win WHO Country Office Netherlands TURUSBEKOVA Nonna TBC Consult Nigeria ORANETO Rosemary Health Poland GRZEMSKA Małgorzata Retired WHO staff member Portugal RODRIGUES Mónica University of Coimbra Republic of Moldova ALEXANDRU Sofia PPI Insitute of Phthisiopneumology ANA Ciobanu WHO Regional Office for Europe AXENTII Ecaterina Phthisiopneumology Institute “Chiril Draganiuc” BIVOL Stela PAS Center CELAN Cristina Center for Health Policies and Studies CORLOTEANU Andrei National Tuberculosis Programme CRUDU Valeriu Phthisiopneumology Institute “Chiril Draganiuc” CONDRAȚCHI Diana Phthisiopneumology Institute “Chiril Draganiuc” DOLTU Svetlana The Health and Community Development Center AFI: Act for Involvement IATCO Ala Union for HIV Prevention and Harm Reduction MALIC Alina Nicolae Testemitanu State University of Medicine and Pharmacy 24 NICOLAESCU Svetlana Centre for Health Policies and Studies PLESCA Valeriu National Centre of Management in Health RUCSINEANU Oxana Societatea Moldovei Împotriva Tuberculozei (SMIT) VICTORIA Petrica Public Institution "Unit for Coordination, Implementation and Monitoring of Health Projects" VILC Valentina Phthisiopneumology Institute “Chiril Draganiuc” Romania IBRAIM Elmira Marius Nasta Institute of Pulmonology MIHAILESCU Lucia Freelance consultant NEDELCU RAMONA Marius Nasta Institute of Pulmonology SOCACI Adriana Victor Babeş Clinical Hospital Timisoara Russia BELILOVSKY Evgeny Moscow Research and Clinical Centre for TB Control, Moscow Health Department BOGORODSKAYA Elena State Budgetary Institution of Healthcare of the City of Moscow, Moscow City Scientific and Practical Center for Tuberculosis Control DEMIHOVA Olga Central TB Research Institute, Russian Academy of Sciences FELKER Irina FSBI "Novosibirsk Research Institute of Tuberculosis", Ministry of Health GOLIUSOV Aleksandr WHO Country Office HAMITOV Bulat Branch of GAUZ “Republican Clinical Anti-Tuberculosis Dispensary” — “Leninogorsk Anti-Tuberculosis Dispensary” KARAVANOV Yuri Moscow Scientific and Practical Centre for Tuberculosis Control KHURIEVA Nina Department of International Affairs, Federal Research Institute for Health Organization and Informatics of MOH of the Russian Federation MIKHEEVA IRINA Central Research Institute of Epidemiology PIROG Alla Phthisiopulmonology Centre POLUNINA Tatiana WHO Regional Office for Europe 25 POLYAKOVA Angela Federal State Budgetary Scientific Institution “Central Research Institute of Tuberculosis” RUSSKIKH Anastasiia National Medical Research Centre of Phthisiopulmonology and Infectious Diseases SAYFULIN Marat State Budgetary Institution of Health Care of the Astrakhan Region “Regional Clinical Anti-Tuberculosis Dispensary” SEVASTIANOVA Elina Federal State Budgetary Scientific Institution “Central Research Institute of Tuberculosis” STAVITSKAYA Natalia FSBI “Novosibirsk Research Institute of Tuberculosis”, Ministry of Health VOLIK Mikhail WHO Regional Office for Europe YEGEUBAYEVA Saltanat WHO Country Office YURASTOVA Lyudmila WHO Regional Office for Europe Slovakia SOLOVIC Ivan National Institute for TB, Lung Diseases and Thoracic Surgery South Africa ABDULLAH Fareed South African Medical Research Council CASTRO Youmnah SRHR Africa Trust CHINGANDU Annette Wits Health Consortium Spain BROUN Denis Cipla GARCÍA-GARCÍA José-María SEPAR Sociedad Española de Neumología y Cirugía Torácica VAZQUEZ María C Ministry of Health Sri Lanka MANATHUNGE Ariyaratne National STD/AIDS Control Programme Switzerland BANDA Mazuwa WHO, Global HIV/AIDS Programme BECCHERLE Maurizio Dure Technologies Pvt SA CASSINI Alessandro WHO, Infection Prevention and Control Global Unit CHUIKINA Viktoriya Global Fund GRANICH Reuben Vestergaard JEONG Eunsun University of Geneva JOSHI Surabhi WHO, Division of Health Information MATAS Tomas WHO, Global TB Programme MERLE Corinne Special Programme for Research & Training in Tropical Diseases MUZAFAROVA Nigorsulton Stop TB Partnership/Global Drug Facility 26 POLITI Claudio WHO, Polio Transition Programme SOLTAN Viorel Stop TB Partnership YADAV Vipin Dure Technologies YOUSSEF FOX Mayada WHO headquarters ZIGNOL Matteo WHO, Global TB Programme Tajikistan BAYDULLOEVA Zamira Local Health System Sustainability Project DILOROM Abbasova UNDP HIV Project ISMOILOVA Jamilya Abt Associates JUMAEV Shamsiddin Regional HIV Centre, Kulob KHOLOV Davron Tuberculosis Dispensary МАКСУМОВА Zumrat ICAP Global Health MAHMUDOVA Parvina WHO, Country Office MAKHMUDOVA Mavlyuda Stop TB Partnership/Global Drug Facility MARETBAYEVA Shinar USAID Eliminating TB in Central Asia Project MIRGAYOSIEVA Shamsiya USAID Eliminating TB in Central Asia Project|Abt Associates YUNUSOV Fathudin National TB programme ZIYOEVA Sayora UNDP Thailand PANAKADAN Salil UNAIDS Turkey SERT Beren YENICE Mine TB Department, General Directorate of Public Health of MoH Turkmenistan VALIYEVA Sona WHO, Country Office Uganda BAGONZA Amos Infectious Diseases Institute NUWAGABA Norman Baylor College of Medicine Children's Foundation Ukraine BARNARD Tetiana USAID BILOGORTSEVA Olga National Institute of Phthisiology and Pulmonology BOGDANOV Aleksey PATH BOGOMAZ Ganna Municipal Non-Commercial Institute of Phthisiopulmonological Medical Centre of Kherson Regional Council CHEBANENKO Denis Dnipro National Medical University DENYSOVA Kateryna USAID DIUZHEVA Olena PATH DOCENKO Yaroslava National Institute of Tuberculosis and Pulmonology DRAVNIECE Gunta PATH DYMOV Georgii WHO Country Office 27 FREYVALD Valentin Dnipro State Medical University GORENKO Galina Kirovograd Regional Phthisiopulmonology Medical Center of Kirovograd Regional Council HONCHARENKO Nataliya Kyiv TB Centre ISMAGILOVA Tatyana 100% LIFE IVANENKO Tamara PATH IVANOVA Olena PATH KALANCHA Yuliia TB European Coalition KOLISNYK Nataliia State Institution “Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine” LYTVYNENKO Nataliia National TB Institute MAKOIDA Iryna Ivano-Frankivsk National Medical University MIRONCHUK Yulia Department of Phthisiology and Pulmonology, ZSMU MOTRYCH Inna WHO Green Light Committee MUSAT Viacheslav Municipal Non-Commercial Institute of Phthisiopulmonological Medical Centre of Kherson Regional Council PAVLENKO Olena PATH ROGANOVA Yana Médecins Sans Frontières SMETANINA Oksana PATH TERLEEVA Yana National TB Programme, TRUSH Olena Médecins Sans Frontières TSAPYK Oksana Kirovograd Regional Phthisiopulmonology Medical Center of Kirovograd Regional Council VARCHENKO Iurii Public Health Centre, Ministry of Health ZAITSEVA Olha Public Health Centre, Ministry of Health ZHEREBKO Nina РАТН United Arab Emirates KELLEHER Dara Qure.ai United Kingdom HAMADA Yohhei University College London JANAGLE Neena Lucane Pharma LIPMAN Marc University College London MCKEOWN Paul Health Protection Surveillance Centre NIKOLAYEVSKYY Vladyslav QIAGEN 28 TIBERI Simon Barts Health NHS Trust/Queen Mary University of London ZENNER Dominik Queen Mary University of London United States BOUEY Paul Save the Children US CARAULAN Liliana Centre for Health Policies and Studies, Moldova DUZEY Olya Duzey Property Management KAK Neeraj Aquity MAKHMUDOVA Sholpan USAID/Central Asia, Kazakhsrtab MAZITOV Rais WHO Regional Office for Europe MENON Ravi Consultant THAKKAR Shital Dure Technologies, India Uzbekistan MELTZER Anna USAID USMANOVA Ruzilya Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology Faculty members Name of presenter/speaker Affiliation Dr Daniela CIRILLO Head, Emerging Bacterial Pathogens Unit, San Raffaele Scientific Institute (HSR), Milano, Italy Dr Andrei DADU Medical Officer, TB Unit, Joint TB, HIV and Viral Hepatitis Programme, WHO Regional Office for Europe Sabyasachi DAS Dure Technologies Dr Saskia DEN BOON Technical Officer, Global TB Programme, WHO headquarters Dr Lucica DITIU Executive Director, Stop TB Partnership Dr Dennis FALZON Team Lead, Global TB Programme, WHO headquarters Thomas HIATT WHO Regional Office for the Western Pacific Dr Avinash KANCHAR Medical Officer, Global TB Programme, WHO headquarters Dr Tereza KASAEVA Director, Global TB Programme, WHO headquarters Oleksandr KOROTYCH Consultant, Research and Innovations, WHO Regional Office for Europe Dr Giorgi KUCHUKHIDZE Epidemiologist, WHO Regional Office for Europe Professor Troels LILLEBÆK Statens Serum Institut, Denmark Dr Knut LONNROTH Professor of Social Medicine, Karolinska Institutet Dr Irada MAMMADOVA Ministry of Justice, Azerbaijan, WHO Collaborating Centre on TB in Prisons Dr Liliia MASIUK TB Project Manager, Alliance Ukraine, Alliance for Public Health Professor Alberto MATTEELLI Associate Professor, Clinic of Infectious and Tropical Diseases, University of Brescia and Brescia Spedali Civili General Hospital, WHO Collaborating Centre for TB/HIV and TB Elimination, Italy Dr Cecily MILLER Medical Officer, Global TB Programme, WHO headquarters Dr Morten RUHWALD Senior Scientist, Head of Tuberculosis, FIND 29 Vanessa VERONESE Special Programme for Research & Training in Tropical Diseases (TDR), WHO Dr Askar YEDILBAYEV TB Team Lead, Joint TB, HIV and Viral Hepatitis Programme, WHO Regional Office for Europe Professor Lyazzat YERALIYEVA Deputy Director of Clinical and Scientific Work, National Scientific Centre of Phthisiopulmonology, Ministry of Health, Kazakhstan Annex 3 Survey on systematic screening for active TB in the WHO European Region Early detection of TB is essential to improve health outcomes for people with TB and to reduce TB transmission effectively. The World Health Organization has updated the guideline “WHO consolidated guidelines on tuberculosis Module 2: Screening – Systematic screening for tuberculosis disease” and developed a handbook WHO operational handbook on tuberculosis. Module 2: screening – systematic screening for tuberculosis disease (2021) on systematic screening for active tuberculosis. These present new evidence and critical steps in programmatic management that follow the cascade of TB prevention and care. To examine the main bottlenecks and foster opportunities of systematic screening for active TB in the WHO European Region a survey is conducted. The survey is designed to collect basic information about present and future practices on systematic screening for active TB in your country. Your collaboration in completing this questionnaire is greatly appreciated. Your replies to the following questions should not take more than 15 minutes. The collected information will be analysed and presented in the second regional workshop on Systematic screening for TB disease and TB Prevention in the WHO European Region, that will be take place on 15–16 April 2021. Thank you in advance, The TB team at WHO Regional Office for Europe Questionnaire Date: Country: Name respondent: Organization: Function: Email: 1. Are you familiar with WHO recommendations on systematic screening for TB? a. 2013, “Systematic screening for active tuberculosis: Principles and recommendations” (WHO/HTM/TB/2013.04) and 2015, “Systematic screening for active tuberculosis: an operational guide” (WHO/HTM/TB/2015.16) 1. Yes 2. No b. “WHO consolidated guidelines on tuberculosis Module 2: Screening – Systematic screening for tuberculosis disease” (2021) and WHO operational handbook on tuberculosis. Module 2: screening – systematic screening for tuberculosis disease (2021) 1. Yes 2. No 30 2. In the table below, please indicate the status (Yes, No, Not applicable) of adoption (1a–1d) and feasibility of implementation (2a–2c) of each of WHO recommendations on systematic screening for active tuberculosis: 31 Recommendation 1a. The recommendation has been integrated into national guidelines identically as in WHO guidelines 1b. The recommendation has been adopted and integrated into national guidelines, with changes to reflect local context 1c. The recommendation has NOT been integrated into national guidelines 1d. The recommendation is not applicable to the local context 2a. The screening practice is routinely conducted 2b. The screening practice is NOT routinely conducted 2c. The screening practice is not applicable to the local context Recommendation 1. Systematic screening for TB disease may be conducted among the general population in areas with an estimated TB prevalence of 0.5% or higher Recommendation 2. Systematic screening for TB disease may be conducted among subpopulations with structural risk factors for TB. These include urban poor communities, homeless communities, communities in remote or isolated areas, indigenous populations, migrants, refugees, internally displaced persons and other vulnerable or marginalized groups with limited access to health care Recommendation 3. People living with HIV should be systematically screened for TB disease at each visit to a health facility Recommendation 4. Household contacts and other close contacts of individuals with TB disease should be systematically screened for TB disease Recommendation 5. Systematic screening for TB disease should be conducted in prisons and penitentiary institutions Recommendation 6. Current and former workers in workplaces with silica exposure should be systematically screened for TB disease Recommendation 7. In settings where the TB prevalence in the general population is 100/100 000 population or higher, systematic screening for TB disease may be conducted among people with a risk factor for TB who are either seeking health care or who are already in care Recommendation 8. People with an untreated fibrotic lesion seen on chest X-ray may be systematically screened for TB disease 32 3. Are there recommendations that in your opinion are missing from the current TB screening guidelines? (one choice) 1. Yes 2. No 3. Do not know b. If Yes, what are they? Please, specify ________________________ 4. If any of the above screening recommendations are routinely conducted in your country, what screening tools are used? (multiple choice) 1. Screening for cough 2. Screening of any symptom compatible with TB 3. CXR (chest radiograph/chest X-ray) screening 4. CAD (computer-aided detection of TB-related abnormalities on chest radiography) technologies for screening 5. Molecular WHO-recommended rapid diagnostics for screening (e.g. Xpert) 6. Tests of TB infection 7. C-reactive protein (for HIV) 8. Other (specify) _____________ 5. If any of above screening recommendations is routinely conducted in your country, what algorithms are used? (multiple choice) 1. Algorithms that begin with screening for cough 2. Algorithms that begin with screening for any symptom compatible with TB 3. Algorithm that begins with screening with CXR (chest radiograph/chest X-ray), with or without symptoms 4. Algorithm that begins with screening with mWRDs (molecular WHO-recommended rapid diagnostics) 5. Other (specify) _______________ 6. Please, indicate what models for screening programme are used in your country? (multiple choice) 1. Screening health centre attendees 2. Workplace screening 3. Screening in the home 4. Mobile outreach screening campaign 5. Community-based screening events (health fairs) 6. Other, specify ________________________________ 33 7. What indicators that assess the performance of the TB screening are used in your country? Name of indicators Yes No Not applicable The number of people eligible for screening The number of people screened (considering the first screening and second screening separately) The proportion of those eligible for screening who were screened The number of people with presumptive TB who were identified The number of people undergoing diagnostic investigation The number of people diagnosed with TB, stratified by type of TB The proportion of those undergoing diagnostic investigation who have TB The NNS (number needed to screen) to detect one person with TB The proportion of initial defaulters (that is, the number of people diagnosed with TB who do NOT start treatment divided by number of people diagnosed with TB) The treatment success rate and the death rate (using standard cohort analyses) 8. Please specify the services, programmes and stakeholders that collaborate with systematic screening programmes for tuberculosis (TB) in your country: (multiple choice) 1. Health services 2. Social services 3. Other government services 4. Civil society organizations 5. Private health care providers 6. Other, specify ____________________________ 9. Are you familiar with WHO’s online tool for prioritizing risk groups for screening and for selecting algorithms ScreenTB? 1. Yes 2. No 10. Are you familiar with WHO’s Prevent TB Digital Platform PreventTB? 1. Yes 2. No 11. Do you need a support in revising and updating the current national policy on contact screening in line with the new recommendations adopted in 2021 “WHO consolidated guidelines on tuberculosis Module 2: Screening – Systematic screening for tuberculosis disease” and “WHO operational handbook on tuberculosis. Module 2: screening – systematic screening for tuberculosis disease“? 1. Yes → question 12 2. No → question 1312. If Yes, please specify the period when you plan to revise and update the national policy on contact screening 1. Q2, 2021 2. Q3, 2021 3. Q4, 2021 4. Q1, 2022 5. Q2, 2022 6. Q3, 2022 7. Q4, 2022 34 13. Please present your willingness to co/act in the capacity of the principal co/investigator (PI) on the following global and regional priority research questions: Proposed research questions Yes No The effectiveness of systematic screening interventions for TB disease to address individual and community outcomes Among people with TB disease, does TB screening identify people at an earlier stage of disease compared with passive case-finding? Is there a difference in TB treatment outcomes between people with TB identified through screening interventions compared with people with TB identified through passive case-finding? For people with TB disease and their families, does receiving a diagnosis and undergoing a course of treatment after case detection through screening have a different cost of illness and risk of adverse social consequences compared with receiving a diagnosis and undergoing a course of treatment after diagnosis through passive case-finding? For people being screened who do not have TB disease, what are the consequences of TB screening? Does TB screening used in addition to passive case-finding affect subsequent health-seeking behaviour compared with passive case-finding alone? Does TB screening initially increase the number of people with TB detected compared with passive case-finding alone? Does TB screening affect the epidemiology of TB in a community, including the prevalence, incidence and transmission, compared with passive case-finding alone? Which are the most cost-effective TB case-finding screening methods among high-risk populations? Diagnostic accuracy and performance of screening tools Among people living with HIV, what is the performance of a range of screening tools compared with a microbiological reference standard? Among the general population and high-risk groups eligible for TB screening, what is the performance of a range of screening tools compared with a microbiological reference standard? Among children and adolescents eligible for TB screening, what is the performance of a range of screening tools compared with a composite or microbiological reference standard? What is the performance of computer-aided detection (CAD) software for automated reading of digital chest radiographs (CXRs) for the detection of TB disease in the screening- and the triage use cases? Among the general population and high-risk groups eligible for TB screening, what is the performance of molecular WHO-recommended rapid diagnostic tests (mWRDs) for screening for TB disease compared with a microbiological reference standard? What is the optimal screening algorithm for active TB and latent TB infection among people living with HIV? TB screening interventions Among the general public and high-risk populations, what is the number needed to screen (NNS) to detect one person with TB disease? Among contacts of people with TB disease, what is the NNS to detect one person with TB disease? What are the estimated relative risks of TB associated with a range of risk factors? What are the costs and cost–effectiveness of implementing TB screening interventions? What are the perceptions and attitudes of communities towards TB screening programmes? How are outbreak investigations among high-risk populations and in high-risk settings being mapped and reported? 14. Please provide any other comments to inform the revision of WHO’s TB screening guidelines and implementation guidance. Thank you for your time! 35 Annex 4 Post-event satisfaction survey Questions Average score Min. Max. 1. Did welcoming/intro inspire you/convince you to stay on this workshop? 4.81 3 5 2. End TB in the WHO European Region – the progress up to date and the commitments for 2021–2030. 4.86 3 5 3. Impact of the COVID-19 pandemic on the coverage and continuity of TB prevention and care services in the WHO European Region: back to the future. 4.79 3 5 4. The global guidelines on systematic screening for TB disease: Module 2, consolidated guidelines and operational handbook. 4.81 3 5 5. The global guideline on TB Prevention treatment: Module 1, consolidated guidelines and operational handbook. 4.91 3 5 6. Current policies and practices on systematic screening for TB in the WHO European Region. 4.86 3 5 7. Questions and answers 4.57 2 5 Session 1: Average 4.80 3 5 8. Development of the National Guideline on screening and TB preventive treatment: why Kazakhstan need these updates and how we did it. 4.78 3 5 9. Programmatic consideration of TB screening and prevention in migrants and risk groups: experiences from Denmark. 4.86 3 5 10. Lessons learned from the programmatic implementation of intensified case-finding among close and household contacts of index TB patients. 4.70 3 5 11. Migrant TB and detection of TB infection in low-incidence countries: experiences from the E-DETECT project. 4.86 4 5 12. Programmatic consideration of TB screening and prevention in prisons conditions. 4.76 3 5 13. Panel discussions 4.71 3 5 Session 2: Average 4.77 3 5 14. WHO’s Prevent TB mobile application. 4.85 3 5 15. Local adaptation of the Prevent TB mobile application: example from the Philippines. 4.93 3 5 16. ScreenTB – an online tool for prioritization of risk groups and comparison of screening algorithms. 4.76 3 5 17. Introduction to computer-aided detection (CAD) products for tuberculosis. 4.90 4 5 18. A toolkit for the local calibration of computer-aided detection (CAD) software to enhance TB screening. 4.76 3 5 19. Questions and answers 4.79 3 5 Session 3: Average 4.82 3 5 20. Implementation research on diagnostic algorithms: what is needed? 4.83 3 5 36 21. Supporting the implementation and scale-up of digital technologies for TB: The IR4DTB toolkit 4.78 3 5 22. Regional operational research on modified fully-oral shorter treatment regimens for RR/MDR-TB: a model for the implementation of innovations. 4.93 4 5 23. Research gaps in TPT among MDR-TB contacts and considerations for operational research. 4.86 4 5 24. Regional data collection for TB preventive treatment among contacts of MDR-TB patients. 4.85 4 5 25. Questions and answers 4.51 1 5 Session 4: Average 4.80 4 5 26. Did the conclusions captured the essence of the entire workshop and inspired you to engage in regional collaboration of the screening and prevention. 4.93 4 5 Technical sessions: Average 4.81 3 5 27. How did you find the web-cloud repository and online registration. 4.86 4 5 28. How did you found ZOOM as a platform for tele-workshop. 4.86 2 5 29. How was the translation. 4.90 4 5 Administration and management: Average 4.87 4 5 Number (%) 30. Would you like to receive the recording to watch again / share? 98 (80%) 31. Did the workshop meet your expectations in general? 123 (100%) 32. On which other aspects of TB care and prevention would expect WHO to organize the workshops on? a) Paediatric TB: diagnostic tools, case-finding, treatment, TPT. 6 b) COVID/TB: mitigation impact, sustaining access to TB diagnostics, treatment and care. 3 c) Laboratory diagnosis updates on: molecular, early diagnosis, TST, IGRA, other. 3 d) TB services delivery roll-out and integration into primary health care using people-centred models of service delivery. 3 e) Digital health in TB prevention and care: CAD, data connectivity, Screen TB, other. 2 f) Mental health and TB collaborative activities. 2 g) TB/HIV/HEP integrated care. 1 h) Active drug safety monitoring and management. 1 i) Operational research: Planning and implementation. 1 j) Extrapulmonary TB: diagnosis and treatment. 1 37 k) Planning and management of TB prevention and care services. 1 l) Live TB surveillance and outbreak management. 1 m) Addressing need of vulnerable and at-risk populations: TB risk factors and determinants. 1 33. Any other comments/recommendations to improve our support. “A lot of useful information, best practices presented” “Beautiful event. Wait again” “Congrats, everything was perfect” “Excellent webinar” “Excellent work” “Very interesting, practical topics. Great presenters! All materials and recording shared in real time. Translation ensured. Many thanks” “Great conference. Very efficient learning platform; Lots of important data. Good translation format into Russian” “It was exciting to be able to attend some of the meeting. I am sorry that I wasn't able to hear more of it but will hope to catch up on some of the other sessions post event. Well done! Thanks” “It was very informative and helpful! THANK YOU” “It was very interesting, a lot of useful information” “It would be good to hear about follow-up on pilots and other experimental activities promoted by WHO, especially mentioned in the workshops, to know what the result is” “It would be perfect if the presentations include more practical activities in the fight against TB” “Keep up the good work” “More often” “Thank you for the invitation, the opportunity to take a full-fledged part in the international forum on TB, and I also convey a special thanks to the translation service – it was great. All the participants of the scientific and practical meeting – wishes of peace, health and success” “Thank you very much for the great workshop” “The workshop was excellent, and time is needed to consider the materials” “Give more time for the speaker and also Q&A” “Very good event! Thank you and congratulations” “Very important webinar. Considering COVID-19 effects on jeopardizing the TB targets, I would like just to bring some data to you to highlight the important role of new tools and TB screening improvement in Albania which are essential to reach all those TB cases not diagnosed as result of pandemic. So, a significant reduction 2020 versus 2019 in the number of visits by 50%, reduction of the number of TB cases to 45%, laboratory tests decreased with 38% and increasing of MDR-TB cases are some of the figures to understand the role of screening” “Thanks, meanwhile … Pay attention to the huge amount of antibiotics including fluoroquinolones used for COVID patient's treatment could affect even more during next few years the TB-DR/ and/or AMR situation in general” “Would like to thank the organizers of the forum for the invitation to take part, all the speakers for the preparation and desire to share new data, the first-time service for the highly professional work! All – health, peace and success” 38 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. 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