Implementation of Management information system in Ukraine

.

PATH Project team “TB Control partnership in Ukraine”

TBTeam-Kyiv@path.org

• To provide an overview of management-information systems and show how TB data can be used for appropriate decision making in TB Programs

Goal of the presentation

Outline

1. TB-epidemiology overview

2. Overview of Ukraine

3. Definitions and examples:– Management information system (MIS)

– Monitoring and evaluation (M&E)

– Cohort analysis (ChA)

4. Main indicators for TB-program M&E

5. Examples of decision-making in TB program

2 billion the world’s of population are infected by Mycobacterium Tuberculosis (MBT)8.9 million new TB cases each year – (Every 4 Seconds. = one new TB case)

• 3.9 million of them are smear+ (highly infectious)

• 80% of cases are registered in African, South-East Asia, and Western Pacific regions (22 high-burden countries)

• 8.3 % (741,000) HIV prevalence among new adult TB cases

• 3.2 % primary MDR prevalence1.7 million. deaths due to TB (EACH 20 SEC. = ONE DEATH DUE TO TB)

Estimated TB Burden in the world, 2004

Ref: Global TB control report, 2006

Estimated TB incidence rate, 2004

Ref: Global TB control report, 2006

AFR29%

AMR4%

EMR7%

EUR5%

SEAR33%

WPR22%

Growth of TB in Africa and Eastern Europe

0

50

100

150

200

250

300

1980 1985 1990 1995 2000

Sta

nd

ard

ize

d n

oti

fic

ati

on

ra

te

Africa - high HIV

Eastern Europe

Africa - low HIV

v

Ref: Global TB control report, 2006

Estimated HIV prevalence among new adult TB cases, 2004

Ref: DRS Report

9.4Estonia

Ivanovo(Russia)

Latvia

Henan (China)

Iran

Liaoning(China)

Domenican Rep

3.1

57.8

10.4

99.3

12.2

Tomsk(Russia)

13.7

Israel

14.2

6.6

5.3

Ivory Coast

4.9

Ecuador

14.2

14.2

Kazakhstan13.2

Uzbekistan

Lithuania

Prevalence of primary MDR, 1994-2002MDR-TB is rampant in the former Soviet Union and ChinaMDR-TB is rampant in the former Soviet Union and China

Ukraine- An Overview

• 2nd largest country in Europe (603,700 km2)

• independent from the USSR since 1991

• 27 regions and 490 districts

• population – 48 million

– 67% living in urban areas

• gross national income per person US$ 5,430

• life expectancy 67 years

– 62 years among male and 73 among female

• population growth rate = -0.7 %

Definition (MIS)

• Management information system (MIS) is an ongoing process of information collection and analysis with periodical interpretation and dissemination of public-health data

• Data for decision-making process in controlling the public-health problems

• “Information for action”

Ref: Principle of Epidemiology, second edition, CDC

Epidemiological approach of the MIS in public health

Problem Action

By surveillance (define burden)what kind of problem?where is the problem?when was happen?among whom?

Descriptiveepidemiology By operational research

(define exposure):why does this happen? how does this happen?

Analytic epidemiology By operational research

(define efficacy and efficiency of intervention):what works?

Prognostic(experimental) epidemiology

Implementation :How better to implement interventions?

Field epidemiologySupervision, Monitoring and Evaluation

PATH!PATH!MOH? MOH? TBI?TBI?

Region / Oblast levelRegion / Oblast level

Quarterly (at data of 10 of first MM of the next Q)

District levelDistrict level

Structure of TB MIS (by DOTS) in Ukraine implemented by PATH

Quarterly (at data of 15 of first MM of the next Q)

• Standard DOTS recording and reporting forms

• M&E guidelines• IT technologies

– Equipment; – Software; – Electronic communication

• e-mail• chat• listserv

• Training

Inputs => Process => Output

Definition of MONITORING

• MONITORING is the observation of TB program performance to ascertain whether activities are accomplished as planned. (It aims to identify problems quickly so that they can be solved without delay)

– Internal – self-analysis of activities – External - by upper level

• Direct – field visits• Indirect – at distance (examining periodic reports)

• Is a daily management activity

Definition of EVALUATION

• EVALUATION refers to the periodic assessment of progress towards operational targets and epidemiological objectives.– Includes measurement of indicators, such as

percentage of patients cured, to assess progress in achieving targets and objectives.

– Is undertaken after some interval (3, 6, or 12 months, or longer), allowing sufficient time to measure program results.

– Process evaluation – Outcome (cohort analysis) and impact

evaluations (TB-burden evaluation)

Definition: COHORT ANALYSIS

• COHORT ANALYSIS – review and interpretation of patient outcomes using a set cohort, that is, a cohort (or group of individuals) that started treatment during the same time period (usually during the same quarter)

• KEY MANAGEMENT TOOL FOR EVALUATING THE EFFECTIVENESS OF TB CONTROL PROGRAM

• Cohort structure is defined by main determinants used for case management

Ref: Compendium of indicators for M&E of the NTP, WHO 2004

TB determinants and case definitions

Smear- Positive

Pulmonary No New Case Smear-

Negative TB Case

Extra- Pulmonary

Yes

Defaulter Relapse Case Failure Case Chronic Case

Severity Smear

Microscopy Site of

Disease

Previous Treatment

Case as: Severe Case if: meningitis miliary pericarditis peritonitis bilat./extensive pleural effusion spinal intestinal genito-urinary

Smear-Pos. if: 2 sputum +

or 1 sputum + and X-ray suspect and physician

or 1 sputum + and culture +

Pulmonary if: lung parenchyma New = previous treatment lasted less than 1 month

Defaulter = stopped treatment after 2 months Relapse = previously received full treatment and was cured

Failure = still positive after 5 months of treatment Chronic = positive after full re-treatment course

Cohort analysis

In a foot race: In a TB programme:

A group of people start together a 10 km foot race

➨A group of TB patients start treatment within one quarter

How many people did complete the race and who was the champion (results)?

➨How many patients did complete their treatment and what was the outcomes?

Core package of the TB MIS

• Lab request/report (TБ-05 and ТБ-06)

TB case management card (TB-01)

• Referral/transfer form (TБ-09)

• Lab register (TB-04 and ТB-04c)

TB cases register (TB-03)

Quarterly report about registration of new cases & relapses (TB-07)

Smear conversion report (TB-10)

Quarterly report about treatment outcomes (TB-08)

For

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em

ent

For

TB

pro

gra

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onito

ring

at

dist

rict

leve

l

For

TB

pro

gra

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valu

atio

n at

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last

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Indicators for cohort analysis

Indicators Targets

Diagnosis Rate of re-treatments < 30 %

Rate of extra-pulmonary TB ≈ 10-15 %

Rate of S+ among PTB ≈ 65 %

Rate of S+ among all new TB cases ≈ 50 %

Primary MDR -

HIV prevalence among new TB cases -

Treatment Smear conversion rate >85 %

Cure rate (cured + tr. completed) among new PTB+

> 85 %

Lethality rate among new PTB+ < 5 %

Failure rate among new PTB+ < 5 %

Defaults rate among new PTB+ < 3 %

Incidence increasing since 1990 г. – 250 %

Mortality increasing since 1990 – 280 %

each hour 4 Ukrainians get disease and 1 dies due to TB

Primary MDR * – 0.6 – 11.9%

HIV Prevalence among new TB cases * – 3.5 – 12%

Ref:• Ukrainian journal of chemotherapy• Ukrainian journal of pulmonology

84.1

23.4

0

50

100

1968

1970

1972

1974

1976

1978

1980

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1986

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1998

2000

2002

2004

0

5

10

15

20

25

incidence mortality

TB epidemic in Ukraine

0

20

40

60

80

100

120

140

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

per

100

,000

age group 0-14; control

age group 15-24; RR = 7.1

age group 25-44; RR = 12.5

age group 45-64 ; RR = 9.8

age group 65 and Hi; RR = 4,7

Age Distribution of TB Incidence and Risk to acquire TB, Ukraine, 1995-2004

Efficiency of case finding system in Ukraine, 2003

 WHO

estimatesOfficial MOH

data TB

Incidence (all cases)

92 77.5 TB

Incidence (PTB+)

41 26.8

Just FYI53% of Ukraine population receive annual X-rays

Registered new PTB + incidence compared with estimates, by PATH Project’s cites

0

10

20

30

40

50

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

pe

r 1

00

,00

0 Crimea (reg 29.7 / est 45.5 = -21%)

Dnepropetrovsk (reg 20.8 / est 31.8 = -22%)

Donetsk (reg 27.6 / est 42.2 = -26%)

Zaporizhye (reg 39.1 / est 59.8 = -27%)

Kharkivska (reg 28.4 / est 43.4 = -28%)

Kherson (reg 43.6/ est 66.7 = -23%)

Kyiv (reg 22.4 / est 34.3 = -20%)

Sevastopol (reg 27.6 / est 42.2 = -31%)

TB control targets (detection)

Detect 70 %

of estimated TB cases

Estimated TB cases

Real TB cases

Cases presented to PHC

Cases referred to TB Program

Cases correctly diagnosed

Reported and treated by DOTS TB cases

Structure of TB reservoir and management, where we are losing TB

70 %

An onion with a thin hull

TB control targets (treatment)

Cure 85 % of detected

Convergence towards DOTS targets

Treatment outcomes among new PTB+Cohort analysis, Donetska oblast, 2002-2004, by years

Source: PATH TB MIS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2002 2003 2004

cured treatment completed transferred

death with TB failure default

N=236 N=718 N=954

Program failure

0

2

4

6

8

10

EUR SEAR WPR AFR AMR EMR

(%)

Ref: Global TB control report, 2003

Failures rate in cohorts of 2001, world by regions

Lethality rate in cohorts of 2001, world by regions

Ref: Global TB control report, 2003

0

2

4

6

8

AFR EUR AMR SEAR EMR WPR

(%)

Lethality rate among new cases, Ukraine, 1999-2004

0%

2%

4%

6%

8%

10%

12%

1999 2000 2001 2002 2003 2004

!! Target for TB Program

!!! Centrilised first line TB drugs providing

Source: medical statistics centre of MOH of Ukraine

HIV prevalence among new TB cases, Donetska oblast, 2000-2005

Source: Donetska oblast MIS

2.8% 5.6% 7.3% 9.9%

91.1%94.4%97.2% 92.7%

0%

50%

100%

2000 2003 2004 2005

HIV-

HIV+

MDR Prevalence, Donetska oblast, 2005

Source: Donetska oblast TB service

7.3%20.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

new cases relapses

MDR-

MDR+

Anxiety

• High level of: Failure rates (2004 average = 15%) Defaulter rates (2004 average = 14%) Lethality (2004 average = 14%) HIV prevalence among newly detected TB cases

(growth up to 9.6 %) Primary MDR prevalence (10.7%)? Quality of drugs

Suggested solution

Social and pecuniary support for previously treated TB cases during continuation phase

Building up coordination mechanism among HIV and TB Programs- Joint planning of TB/HIV

- Clinical surveillance of TB/HIV

Reduction of HIV-burden among TB patients- HIV testing and counseling; HIV prevention

- ART for TB/HIV patients

Reduction of TB-burden among PLHA- Active TB case detection

- Treatment of LTBI (prophylaxis with Isoniazid)

? Implementation of DOTS PLUS (needs assessment of preparedness and detailed implementation plan)

73927520

8040

7460

72307100

6000

6500

7000

7500

8000

8500

January February March April May June

ab

s n

um

be

r

P<

0.0

05

Health-seeking of people with TB symptoms to PHC and TB service, Donetsk, 2003

Information campaignSource: health administration

Economical TB Burden, Ukraine, 2003

• Number of death due to TB, by age groups = 10,421*

• Life expectancy = 67 years

• YPLL (years of potential life lost) due to TB

– 198,389 years

• Gross national income (GNI) lost per capita

– USD 4,800**

• Financial TB burden = USD 952,267,200

Ref:

* medical statistics centre of MOH of Ukraine

** World Bank/WDI-2004

TB death and GNI lost, Ukraine, 2003

0

500

1,000

1,500

2,000

2,500

3,000

3,500d

ea

th c

ase

s

0

50

100

150

200

250

300

350

400

Mill

ion

s$

TB death

gross national income lost

Definition of epidemiological TB burden

Incidence per 100.000

Lethality in cohorts per 100

Prevalence per 100.000

Mortality per 100.000

Invalidity per 10.000

Область Заболеваемость (всего)

Заболеваемость (0-14)

Смертность (всего)

Летальность (всего)

Распространенность (всего)

Распространенность (0-14)

Инвалидность

Cherkassy 56 7.8 9.8 12.8 227.9 24.4 0.7Chernigov 72 7.4 19.9 15.2 289.3 18.3 2.9Chernovtsy 56.5 11.1 14 18.6 230.4 31.5 1.6Crimean 76.7 13 22.2 11.3 301.4 34.7 2.1Dnepropetrovsk 83.8 10.4 27.6 2.9 376.9 31.9 1.4Donetsk 97.8 14.8 33.2 9.2 370.2 36.1 4.3I vano-Frankovsk 69.7 6.7 14.6 8.4 291.6 15.2 1.9Khar'kov 94.7 11.1 17.9 12.1 313.2 32.8 1.5Kherson 150.1 11.8 45.6 37.3 489.2 28.7 4.5Khmel'nitskiy 54.7 4.6 11.4 12.4 261.4 21.4 1.9Kiev 62.4 7.7 19.5 18.4 264.7 18.3 1.9Kiev city 43.7 9.3 9.6 38.4 158 18 0.9Kirovograd 83.7 8.9 23.9 23.5 302 20.7 2.4Lugansk 102.1 11.4 29.8 19.1 318.3 29.2 2.3L'viv 72.4 6.9 17.4 12.5 294.6 18.6 3.7Nikolayev 112.4 8.4 24.2 15.6 308.5 16.8 2.8Odessa 81 8.4 30.9 27.8 332.3 27.3 2.5Poltava 48 3.7 20 8.9 220.2 16.2 1.4Rovno 69 9.6 15.1 10.6 275.3 24.6 1.9Sevastopol city 60.6 10.1 17.7 10.7 247.5 26.2 0.7Sumy 50.1 6.4 18.4 4.6 248.7 14.4 0.9Ternopl' 62.6 9.3 15.2 16.6 232.9 16.2 1.3Vinnitsa 69.7 10.3 12.9 20.6 263.9 19.5 1.7Volyn 60.5 5.3 26.6 10.4 271.5 16.9 2.8Zakarpats'ka 55.6 2.3 20 6.4 234 9.3 2.2Zaporozh'ye 97.8 8.6 24.1 7.3 272.2 25 1.7Zhitomir 78.8 8.4 14.8 19.3 325.1 39 1.5

TB figures by regions, Ukraine 2003

Adjusted TB figures, Ukraine, 2003

oblasts incidence

total

incidence

0-14

mortality

total

mortality

0-14

letality

rate total

prevalence

total

prevalence

0-14

invalidity

rate

sum TB burden index

Cherkassy 0.37 0.53 0.21 0.33 0.47 0.63 0.16 2.75 1.67

Chernigov 0.48 0.50 0.44 0.40 0.59 0.47 0.64 3.55 2.17

Chernovtsy 0.38 0.75 0.31 0.48 0.47 0.81 0.36 3.62 2.20

Crimean 0.51 0.88 0.49 0.29 0.62 0.89 0.47 4.21 2.57

Dnepropetrovsk 0.56 0.70 0.61 0.08 0.77 0.82 0.31 3.91 2.38

Donetsk 0.65 1.00 0.73 0.24 0.76 0.93 0.96 5.33 3.25

I vano-Frankovsk 0.46 0.45 0.32 0.22 0.60 0.39 0.42 2.90 1.76

Khar'kov 0.63 0.75 0.39 0.32 0.64 0.84 0.33 3.97 2.42

Kherson 1.00 0.80 1.00 0.97 1.00 0.74 1.00 6.56 4.00

Khmel'nitskiy 0.36 0.31 0.25 0.32 0.53 0.55 0.42 2.80 1.70

Kiev 0.42 0.52 0.43 0.48 0.54 0.47 0.42 3.31 2.02

Kiev city 0.29 0.63 0.21 1.00 0.32 0.46 0.20 3.15 1.92

Kirovograd 0.56 0.60 0.52 0.61 0.62 0.53 0.53 4.02 2.45

Lugansk 0.68 0.77 0.65 0.50 0.65 0.75 0.51 4.57 2.79

L'viv 0.48 0.47 0.38 0.33 0.60 0.48 0.82 3.60 2.19

Nikolayev 0.75 0.57 0.53 0.41 0.63 0.43 0.62 3.97 2.42

Odessa 0.54 0.57 0.68 0.72 0.68 0.70 0.56 4.50 2.74

Poltava 0.32 0.25 0.44 0.23 0.45 0.42 0.31 2.45 1.49

Rovno 0.46 0.65 0.33 0.28 0.56 0.63 0.42 3.38 2.06

Sevastopol city 0.40 0.68 0.39 0.28 0.51 0.67 0.16 3.14 1.91

Sumy 0.33 0.43 0.40 0.12 0.51 0.37 0.20 2.40 1.46

Ternopl' 0.42 0.63 0.33 0.43 0.48 0.42 0.29 3.02 1.84

Vinnitsa 0.46 0.70 0.28 0.54 0.54 0.50 0.38 3.44 2.09

Volyn 0.40 0.36 0.58 0.27 0.55 0.43 0.62 3.26 1.99

Zakarpats'ka 0.37 0.16 0.44 0.17 0.48 0.24 0.49 2.36 1.44

Zaporozh'ye 0.65 0.58 0.53 0.19 0.56 0.64 0.38 3.58 2.18

Zhitomir 0.52 0.57 0.32 0.50 0.66 1.00 0.33 4.00 2.44

Epidemiological TB Burden in Ukraine, 2003 Where intervention is more required?

2003-2005

2006

2003

Decision making based on eight unrepresentative rating indicators (system established during WWII)

Decision making based on new M&E indicators

PATH’s TB Project coverage, Ukraine

Increase of TB incidence and mortality rates, Ukraine, 1991-2004

-10%

-5%

0%

5%

10%

15%

20%

25%

30%

35%

19

91

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% o

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Incidence Mortality

31.8

84.1

80.9

8.1

23.4

22.9

0

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per

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25

per

100

,000

Incidence Mortality

Standardizing of case management by DOTS

Stage 1 of DOTS implementation, pilot sites

Centralized TB drugs supplying

Stage 3 of DOTS implementation, throughout the country

PATH get involved in to TB control in Ukraine

Interpretation

Providing task-oriented, efficient technical support to reduce morbidity and mortality in Ukraine

Recommendation/Conclusion

TB Burden Evaluation should be performed every 3 to 5 years to determine the extent (prevalence) of the problem

Quarterly Cohort Analysis provides specific and sensitive surveillance data for TB program evaluation and monitoring

MIS is one of the most important components of TB Program, providing information on intervention efficiency