Tuberculosis Surveillance Review4th Quarter, 2017

Inter-Provincial Quarterly Review Meeting

25-26 June, 2018

Dr. Raja Muhammad Ayub

M&E and Surveillance Specialist

CMU – GF Grant

PAKISTANPopulation 193 M

Disease Burden

Incidence Rate268 per 100,000(174-383)

Estimated Incident TB cases518,000 (335,000–741,000)

Estimated incident RR/MDR cases15000(12000–18000)

% of TB cases with MDR/RR-TBNew cases: 4.2%Previously Tx: 16%

Reference:

1. WHO Global TB Report 2017

Incidence & Mortality : Global TB report 2017

Notified New + Relapse (N+R) & Bacteriologically Confirmed Cases

117985 130316 133646 137718 144161

293860309278

323856

356390 359000

0

50000

100000

150000

200000

250000

300000

350000

400000

2013 2014 2015 2016 2017

B+ Incident

31278 34297 33808 36335 35637

8120885732 87000

9591890264

0

20000

40000

60000

80000

100000

120000

Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017

B+ Incident

Case notification

Type 2016 2017

Total new cases 344,233 344,784

Relapse 12,157 14,511

N+R (incident) 356,390 359,295

Treatment after failuare 1,414 1,482

Treatment after default 1,494 1,708

Others 6,366 6,494

Total 366,061 368,979

CNR Incident (N+R) and CNR B+

172178 180

199190

66 71 70 75 72

0

50

100

150

200

250

Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017

CNR Incident CNR B+

171167

174189

188

69 7072 73 73

0

50

100

150

200

250

2013 2014 2015 2016 2017

CNR Incident CNR B+

Sub-National CNR N+R & B+

88102

88

195

163

231

157

136

190

3240

2315

51

89

67

34

72

0

50

100

150

200

250

AJK BAL FATA GB KP PUN SND ICT PAK

Q4-2017

CNR Incident CNR B+

85

107

77

216

161

204

139

155

181

2941

22 19

51

79

62

39

69

0

50

100

150

200

250

AJK BAL FATA GB KP PUN SND ICT PAK

Q4-2016

CNR Incident CNR B+

Percentage breakup of Incident Cases (B+, C-Dx, EP)

39 40 39 38 38

42 41 41 42 42

19 19 20 20 20

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017

B+ C.DX EP

Contact Screening of B+ TB Cases

38419 35025 40715 39179 37806

117971 136465 128325 142596 132169

Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Screened UnScreened

Gender Distribution among Incident Cases Quarter 4th, 2017

57%

45% 45%48%

50%54%

57% 61%

51%

43%

55% 55%52%

50%46%

43% 39%

49%

0%

10%

20%

30%

40%

50%

60%

70%

<5 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65> PAK

Male Female

Percentage of Children among all Incident Cases

10% 9% 11% 12% 12%

90% 91% 89% 88% 88%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2013 2014 2015 2016 2017

12% 11% 13% 13% 12%

88% 89% 87% 87% 88%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017

Childhood Incident TB (0-14) Notification 4th Quarter, 2017

6%

15%

30%

47%

32%

6%

16%

6%

12%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

AJK BAL FATA GB KP PUN SND ICT PAK

0-14 Notification

Percentage of Previously Treated cases in Notified Cases (including Relapse)

4%

5%

6%

6%

7%

0%

1%

2%

3%

4%

5%

6%

7%

8%

2013 2014 2015 2016 2017

6%

7%6%

7%

7%

0%

1%

2%

3%

4%

5%

6%

7%

8%

Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017

Percentage of Previously Treated cases in Notified Cases (including Relapse)

6%

4%

7%

1%

4%

6%

13%

14%

7%

0%

2%

4%

6%

8%

10%

12%

14%

16%

AJK BAL FATA GB KP PUN SND ICT PAK

Percentage of PPM case Notification in Notified Cases

18% 18%

22%

28%

32%

10%

15%

20%

25%

30%

35%

2013 2014 2015 2016 2017

28%

30%32%

32%32%

10%

15%

20%

25%

30%

35%

Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017

Model-wise contribution of Private sector

PPM-1, 56%

PPM -2, 29%

PPM-3, 13%

PPM-4, 2%

Q4-2017

PPM-1, 58%

PPM -2, 27%

PPM-3, 13%

PPM-4, 3%

Q4-2016

Sub-National Private Sector Contribution

11%

21%

0%

10%

28% 28%

44%

23%

32%

14%

19%

0%

10%

27%

31%

36%

16%

29%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

AJK BAL FATA GB KP PUN SND ICT PAK

Q4-2017 Q4-2016

Treatment Outcomes of Incident TB Cases

28% 28% 26% 26% 26%

65% 65% 67% 67% 67%

3% 3% 3% 3% 3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017

Cure Completed Lost to Follow-up

Treatment Outcomes of B+ Incident TB Cases

68% 68% 69% 69% 68%

24% 23% 23% 23% 24%

3% 3% 3% 3% 3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017

Cure Completed Lost to Follow-up

Treatment Outcomes of Previously Treated TB Cases (excluding Relapse)

30% 32%26% 31% 30%

50% 48% 56%53% 50%

9% 10% 8% 8%9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017

Cure Complete Lost to Follow-up

RR-TB Enrollment

209 498888

1570

2662 2621 2881 3081

0

2000

4000

6000

8000

10000

12000

14000

16000

2010 2011 2012 2013 2014 2015 2016 2017

Incident cases among notified PTB cases (15000)

National Disease Burden & Enrolment 2017

TB Notification

MDR IncidenceNew: 4.2%Re-Tx: 16%

Enrolment % of Enrolment

against Incidence

New PTB 274,834 11,499

3081 20%Re-Tx PTB 22,102 3,090

Total 296,936 15,079

Province-wise Disease Burden & Enrolment 2017

Province/Region

New Cases Notified

A

Est. RR-TB in New Cases

B = A x 4.2%

Re-Tx Cases Notified

C

Est. RR-TB in Re-Tx Cases

D = C x 16%

Est. Total RR-TB Cases

RR = B + D

Total Enrolment

EN

Percentage Enrolment

EN / RR x 100

Punjab 175519 7372 10956 1753 9125 1319 14%

Azad Kashmir 3826 161 316 51 211 10 5%

Islamabad 1149 48 123 20 68 50 74%

Khyber-Pakhtunkhwa & FATA 28127 1181 1893 303 1484 271 18%

Gilgit Baltistan 2023 85 27 4 89 2 2%

Sindh 56557 2375 8345 1335 3711 1357 37%

Balochistan 7633 321 442 71 391 72 18%

PAKISTAN 274834 11543 22102 3536 15079 3081 20%

Province-wise RR-TB Target vs EnrolmentQuarter 4, 2017

595

17 4

114

6

314

23

1072

311

2 1048

1

329

14

715

0

200

400

600

800

1000

1200

PUN AJK ICT KP & FATA GB SND BAL PAK

Target Enrolment

52% 12% 285% 42% 17% 103% 61% 67%

Treatment Outcome of RR-TB 2015 Cohort

Success63%

Died18%

Failed6%

Lost to Follow-up

11%

Not Evaluated2%

Treatment Outcome of RR-TB 2010-15 Cohorts

1652

1731

1122

670

387

151

903

838

430

235

114

57

66

93

18

25

3

2

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2015

2014

2013

2012

2011

2010

Successful UnSuccessful Not Evaluated

Screening of HIV in Notified TB Cases

285396298980

316577331780

366061368979

2012 2013 2014 2015 2016 2017

All Notified

10423

8306

10715

1216213092

26150

2012 2013 2014 2015 2016 2017

Screened for HIV

17

49

90

59

71

127

2012 2013 2014 2015 2016 2017

Reactive cases

4% 3% 3% 8% 4% 7%

Interpretations

• Slow decline in TB incidence• Static case notification ( 2016 Vs 2017 )• Low % of contact investigation• Low case detection of DS & DR-TB cases

– 160000 missing DS-TB cases– 12000 missing DR-TB cases– Low Childhood TB case notification (AJK, Punjab, ICT) , while very high in

GB, FATA and KP– Low previously treated case notification in all country except Sindh and

ICT

• Low bacteriological confirmation among notified DS-TB cases• High death and lost to follow-up in DR-TB patients• HIV screening low in DS-TB cases

Surveillance, Data & M&E Issues

• Late conduction of quarterly surveillance meetings

• Timeliness– By the 30th day to CCM, By the 45th day to GF

• Incomplete Information– Presumptive and contact information

• Late submission of Hard copies and mismatch– Required for Data validation and LFA review

• In the post devolution scenario, weak M&E coordination at national and provincial interface

Progress Update

• DHIS2

– Core team training Round 1 & 2 conducted

– Server configuration for TB in process

– Malaria DHIS2 instance moving to NTP server

– TOT and end user training planned from June onwards

• Revised R&R tools used from Quarter 1, 2018 onwards.

Thank you for your attention