Prevalence Survey Session

• Progress Report – Ikushi

• Results and Lessons - Surveys in Asia – Irwin

• African Surveys – First Survey in Africa – Ethiopia – Zeleke

– Most recently completed survey- Zambia- Pascalina

– Yields and lessons – Views of advisors- Marina and Eveline

– Voices from NTP managers

• Before moving to Discussion– Survey and surveillance: Challenges in urban areas:

Thai experience – Noi

TB prevalence survey

Global

• Assessing the impact of the efforts (MDGs related target)

Country

• More accurate estimate of country TB epidemiology by direct measurement

• Knowing sizes and characteristics of remaining cases in community – to develop better country strategy on TB care and control

What we measure and what we learn

Size of TB burden (prevalence) and its change

TB patients in

Community

Cure by

Treatment

Incident

Cases

Self Cure

Death

4 |

TB prevalence survey: Active screening methods

with epidemiological sampling

TB prevalence survey: Active screening methods

with epidemiological sampling

Photography: Nile Bowie, Jacques Sebert & Sean Brokenshire/MSF

Symptom identification Sputum collection Smear & Microscopy

Chest X-rayCulture

1. Census collection 2. Interview

3. Chest X-Ray 4. Data check 5. Specimen collection

Central activities

• Financing

• Logistics and Supervision

• Laboratory

• Central Chest X-ray reading

• Data management with data from different sources and different timings

• Case management

• Diagnostic panel

• Analysis

the TB epidemic in

Japan

Transmission nearly

stopped

High case rates in old

individuals

2 orders of magnitude

Annual

decline of

>10%

Case Notification – ALL TB

HBCs in Asia

Met 70/85 % Global Target

Progress since Oct 2013

• Field Data Collection completed in Ghana, Sudan, Malawi, Indonesia and Zambia

• Field Data Collection launched in Mongolia, Zimbabwe and Uganda

• Results published in peer review journal: China, Ethiopia and Cambodia

• Two Analytical WS in Geneva, November 2013 and June 2014

• Technical exchanges between countries

Surveys in Pre-Task Force Era (2000-08)*Published Symptom CXR Diagnosis Remarks

China 2000* Y Fluoroscopy Smear/Culture CXR for screening

positive

Cambodia 2002* Y Direct CXR Smear/Culture

Thailand 2003 Y MMR Smear/Culture Incomplete MMR

feedback

Indonesia 2004* Y (home) NA Smear Culture for

limited clusters

Eretria 2005* NA NA Smear Follow up and

CXR for 1 S+

Malaysia 2006 Y (home) Direct CXR

(at facility)

Smear/Culture Low attendance

at facility

Vietnam 2007* Y Digital Scan

or MMR

Smear/Culture

Philippines 2007* NA Direct CXR Smear/Culture

Bangladesh 2008* NA NA Smear Culture for S+

Completed Surveys with WHO TF

*published Symp Chest X-ray Culture/Smear NAA test HIV

Myanmar 2009 Yes Direct Yes/FM-ZN

China 2010 Yes Direct Yes

Lao PDR 2011 Yes Direct Yes (NAA S+/C- slide)

Cambodia 2011 Yes Direct Yes/LED FM-ZN

Ethiopia 2011 Yes Direct Yes (1culture)/LEDFM

Pakistan 2011 Yes Direct DR Yes (1 culture) (NAA S+/C- slide)

Nigeria 2012 Yes Direct CR Yes

Gambia 2012 Yes Direct DR Yes (MGIT)/LEDFM

Rwanda 2012 Yes Direct DR Yes/ LED FM Spot

Tanzania 2012 Yes Direct CR Yes (1culture)/ LEDFM (GXP S+ slide) Spot

Thailand 2012 Yes Direct DR Yes (GXP S+/C- slide)

Ghana 2013 Yes Direct DR Yes (MGIT)/LEDFM-ZN GXP for S+

Indonesia 2013 Yes Direct DR Yes (1-2 culture) GXP for S+

Malawi 2013 Yes Direct Yes/LED FM GXP for S+

Sudan 2013 Yes Direct DR Yes/ LED FM LPA for S+

Zambia 2014 Yes Direct DR Yes (MGIT)/ LED FM GXP for S+ Spot

Lab positive: who are patients?

With typical signs and symptoms

Atypical (lower lung, mild symptoms…)

Sub-clinical: Early Disease? Active Infection? Harbouring germs? Cross-

Contamination?

Surveys in old days We are

counting

We are

observing

High Burden in ASEAN countriesCountry

Year (* Provisional)Smear Positive TB Bact. Positive TB

(including S+ TB)

Philippines 2007 10y- 260 (170-360) 660 (510-880)

Viet Nam 2007 15y- 197 (149-254) 307 (248-367)****1 culture , CXR TB suspects

Myanmar 2009 15y- 242 (186-315) 613 (502-748)

Cambodia 2011 15y- 271 (212-348) 831 (707-977)

Lao PDR 2011 15y- 278(199-356) 595(457-733)

Thailand 2012Non-Bangkok

15y- 101 (56-181) 242 (182-322)

Indonesia 2013* 15y- 257 (210-303) 758(589-959)

African surveys since 2011

Prevalence/100 000 aged 15y-

Smear + TB B + TB Remarks

Ethiopia 2011 108 (73-143) 277 (208-347) Published

Nigeria 2012 318 (225-412) 524 (378-670) Published

Gambia 2012 90 (53-127) 212 (152-272) Finalised

Rwanda 2012 74 (48-99) 119 (79-160) Finalised

Tanzania 2012 210 (158-262) 316 (245-387) Reported

(re-evaluation) 250? In process

Ghana 2013 Finalizing

Malawi 2013 Finalizing

Sudan 2013 Finalizing

Zambia 2014 Finalizing

General Findings

• More accurate estimate of TB burden

• Higher TB prevalence compared with the notification: B+ prevalence double or more of the annual notification

• Concrete Decline of TB Prevalence toward MDG

– 1. By better case management, DOTS

– 2. By earlier and more case detection

– 3. By TB/HIV collaborative efforts

• Probable very slow declining TB incidence

– Very small or no decrease of prevalence of “S+ without chronic cough” , Smear negative “CXR active”

Key Findings: High TB Prevalence

– Diagnosing program performance • By “known” cases due to poor case management

• By Symptomatic S+ much more than notified:

Basic DOTS has not penetrated into community

• By chronic cases who missed opportunity to be

diagnosed – diagnostic capacity of health system

– HIV negative/ smear negative, women

• By sub-set of population: Elderly, Remote

villages, Urban Poor

Expected Surveys in 2015 (GFC*)

• Mongolia Phase II

• Uganda*

• Bangladesh*

• Kenya*

• Nepal

• DPRK

• Philippines*

• Viet Nam*

• Mozambique*

Prevalence Survey Sub-Group: Global

Task Force on TB Impact Measurement • Sensitizing WS/ Feasibility Assessment

• Protocol Review

• Participation in periodic reviews

• Guidance on analysis

• Re-estimation of TB burden

• Data repository (survey databank)

• Coordination of required TA: Survey Design, Data management, Laboratory, Radiology, Field Management, Analysis

• International training workshop

• Facilitation of country- country collaboration

Thank you