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
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