report of the intercountry workshop on quality of

Report of the Intercountry Workshop on Quality of Surveillance and Revision of Estimates of TB Burden

Cairo, Egypt

27-29 October, 2009

Country participants AFGANISTAN, ISLAMIC REPUBLIC OF Dr Said Dauod Mahmoodi Head of Surveillance and M&E National TB Programme Ministry of Public Health Kabul Email: [email protected] BAHRAIN Dr Said El Safar TB Consultant for Chest Diseases Salmaniyia Medical Complex Ministry of Health Manama Tel: +973 39777025 / +97317253666 Email: [email protected] DJIBOUTI Ms Assia Haissama Responsible of the TB Data follow-up National TB Programme Ministry of Health Djibouti Email: [email protected] EGYPT Dr Amal Galal Surveillance Officer National TB Control Programme Ministry of Health Cairo Tel: +2012 7708809 Fax: +2020 23428867 Email: [email protected] / [email protected] IRAQ Dr Mohammed Rahim Abbas Tbena Surveillance Manager National TB Programme Respiratory and Chest Diseases Centre Ministry of Health Baghdad Email: [email protected]

ISLAMIC REPUBLIC OF IRAN Dr Mahshid Nasehi National TB Programme Manager Disease Control Department Ministry of Health and Medical Education Teheran Tel: +9821 66708949 Fax: +9821 66708949 / +9821 66700143 Email: [email protected]

JORDAN Dr Nadia Ismail Abu Sabrah National TB Deputy Manager Surveillance Officer Directorate of Chest Diseases Ministry of Health Amman Tel: +962 799070668 Fax: +962 65520177 Email: [email protected] LEBANON Dr Mtanios Saade National TB Programme Manager Ministry of Public Health Beirut Tel: +961 3216729 Fax: +961 1445734 Email: [email protected] LIBYAN ARAB JAMAHIRIYA Dr Mohamed Furjani National TB Manager National Communicable and Infectious Diseases Prevention and Control Centre Tripoli Tel: +218 928658846 / +218 912204207 Email: [email protected]

MOROCCO Dr Naima Benchaikh National TB Programme Manager Directorate of Epidemiology and Diseases Control Ministry of Health 71 Avenu Ibn Sina, Agdul Rabat Tel: +212 537671261 Fax: +212 537671298

Email: [email protected] OMAN Dr Ali Al Lawati Specialist & In-charge of TB Control Programme Ministry of Health Muscat Tel: +968 99849933 Email: [email protected] PAKISTAN Dr Razia Kaniz Fatima Monitoring & Evaluation Officer National TB Programme Manager Ministry of Health Islamabad Tel: +9251 9257236 Fax: +9251 9257228 Email: [email protected] QATAR Dr Mohd Mohd Al Hajri Specialist, Community Medicine Programme Primary Health Care Supreme Council of Health Doha Tel: +974 5564063 Email: [email protected] / [email protected] SAUDI ARABIA Dr Naila Anwar Abu Aljadayel Director of Chest Diseases National TB Manager Ministry of Health Riyadh 11176 Tel: 00966-505620517 Fax: 00966-1-4028941 E-mail: [email protected] / [email protected] SOMALIA Dr Rumbidzai Pairamanzi Monitoring & Evaluation Coordinator World Vision International Somalia P. 0. Box 56527 00200 Nairobi Tel: +254 728027532 Email: [email protected]

SUDAN Dr Samia Ali Alagaab TB Surveillance Officer National TB Programme Federal Ministry of Health Khartoum Tel: +249 12346703 Email: [email protected] SYRIAN ARAB REPUBLIC Dr Kinaz Shaban Alshaikh Director of TB Department TB Surveillance Focal Point Ministry of Health Damascus Tel: +93 3273602 Email: [email protected]

TUNISIA Dr Mohamed Zaher Ahmadi Head of Department Primary Health Care Ministry of Public Health Sidi Bousid Tunis Tel: +216 98954274 Fax: +216 76632534 Email: [email protected] UNITED ARAB EMIRATES Dr Kalthoom Mohammed Al Belooshi National TB Manager

Ministry of Health RAK – P.O.BOX 463 Abu Dhabi Tel: +97 1504874666 Email: [email protected] UNITED ARAB EMIRATES (Cont’d) Dr Kifah Saleh Al Saqeldi TB Programme Coordinator Ministry of Health Dubai Tel: +971 505285654 Fax: +971 473968391 Email: [email protected] / kefah [email protected]

YEMEN, REPUBLIC OF Mr Abdelbari Al Hammadi Monitoring and Evaluation Officer National TB Control Programme Ministry of Public Health and Population Algarda zone, Taif st, Sana’a Tel: +967 1619213 / +967777083987 Fax: +967 71619213 OTHER ORGANIZATIONS

Dr Ryuichi Komatsu Team Leader, Strategic Information The Global Fund to Fight AIDS, Tuberculosis and Malaria Ch. Blandonnet Geneva SWITZERLAND Tel: +41 587911700 Fax: +41 587911701 Email: [email protected] Dr Laura Fay Anderson Scientist Epidemiology Health Protection Agency G1 Colindale Avenue London UNITED KINGDOM Tel: +44 208327 6165 Email: [email protected]

Dr Brian Williams TB Consultant 11B chemin Jacques-Attenville, 1218 Grand-Saconnex Geneva SWITZERLAND Tel: +41 796 005495 E-mail: [email protected] WHO Secretariat Dr Akihiro Seita, Coordinator, TB, AIDS and Malaria, WHO/EMRO, Abdul Razak El Sanhouri St., Cairo, Egypt Tel: 22765258 Fax: +20222765249 E-mail [email protected]

Dr Samiha Baghdadi, Medical Officer Stop TB, WHO/EMRO, Abdul Razak El Sanhouri St., Cairo, Egypt Tel: 22765258 Fax: +20222765259 E-mail: [email protected] Dr Amal Bassili, Technical Officer Stop TB, WHO/EMRO Abdul Razak El Sanhouri St., Cairo, Egypt Tel: 22765275 Fax: +20222765259 E-mail: [email protected] Dr Ana Bierrenbach, Technical Officer, Tuberculosis Monitoring and Evaluation (TME), Stop TB Department, WHO/HQ, Geneva, Switzerland, Tel:+41 22 7911248 Fax: +41 22 791 1589, E-mail: [email protected] Dr Philippe Glaziou, Technical Officer, Tuberculosis Monitoring and Evaluation (TME), Stop TB Department, WHO/HQ, Geneva, Switzerland, Tel:+41 22 7911028 Fax: +41 22 791 1589, E-mail: [email protected]

Dr Mehran Seyed Hosseini, Technical Officer, Tuberculosis Monitoring and Evaluation (TME), Stop TB Department, WHO/HQ, Geneva, Switzerland, Tel:+41 22 7911959 Fax: +41 22 791 1589, E-mail: [email protected]

Mr Tom Hiatt, Assistant, HQ/TME Tuberculosis Monitoring and Evaluation, Geneva, Switzerland, Tel: +41 227915041, Fax: +41 22 791 1589, E-mail: [email protected] Dr Lailuma Nuzhat, TB Officer, WHO/Afghanistan, E-mail: [email protected]

Dr R.Taghizadeh, National Professional Officer, TB Programme, WHO/Iran ,12th floor, Ministry of Health building, Symaye-e-Iran, Tehran, Iran, Tel: +98 21 8836397980, Email: [email protected] Dr Peter Metzger, Medical Officer, Stop Tuberculosis, WHO/Pakistan, P.O. Box 1013 NIH Chak Shehzad, Islamabad, E-mail: [email protected]

Dr Ejaz Qadeer, Stop Tuberculosis, WHO/Pakistan, P.O. Box 1013 NIH Chak Shehzad, Islamabad, E-mail: [email protected]

Dr Ireneaus Sindani, Medical Officer, Stop Tuberculosis, WHO/Somalia, P.O. BOX 63565 – 00619, Nairobi, Kenya, Tel: +254 722788510, E-mail: [email protected] Dr Ayid Munim, Medical Officer, Stop Tuberculosis, WHO/Sudan, Tel: 00249912167507 Fax: 0024983776282 E-mail: [email protected]

Dr Philip Ejikon, Medical Officer, Stop Tuberculosis, WHO/S.Sudan, Tel: +249 926136422, E-mail: [email protected] / [email protected]

Mr Essam Ghoneim, Audio Visual Technician, WHO/EMRO, Abdul Razak El Sanhouri St., Cairo, Egypt Tel: 22765190. E-mail: [email protected]

Ms Sherine Abdel Malek, Secretary, Division of Communicable Disease Control, WHO/EMRO, Abdul Razak El Sanhouri St., Cairo, Egypt Tel: 22765535. Fax: +20222765249. E-mail: [email protected] Ms Ghada Oraby, Secretary, Division of Communicable Disease Control, WHO/EMRO, Abdul Razak El Sanhouri St., Cairo, Egypt Tel: 22765681. Fax: +20222765249. E-mail: [email protected]

Background In October 2009 representatives of 17 countries from the Eastern Mediterranean Region gathered in Cairo to participate in a workshop designed to evaluate detailed tuberculosis (TB) surveillance data and methods for estimating the burden of TB. Prior to the workshop, detailed national and sub-national data were requested from countries. During the workshop, these and other data were analysed and assessed in order to better understand the underlying epidemiology of TB in each country and to make informed estimates of the burden of TB and its trend over time. A major goal of the workshop was to familiarize countries with the methods used by WHO to estimate the TB burden, to revise these estimates using available surveillance data, and to facilitate improved surveillance and data collection at the national and sub-national levels in the future. Methods Using standard Excel templates, representatives from each country were asked to provide national and sub-national data on TB case notifications, infrastructure and case-finding efforts for the years 1995 - 2008. Requested data were as follows:

• Population by age and sex • TB case notifications by case type (smear-positive, smear-negative,

extrapulmonary) • TB case notifications by age and sex • Active case finding efforts • Number of new and re-treatment TB cases reported by non-NTP/non-MoH

providers • Number of foreign-born or non-citizen new and re-treatment TB cases reported • MDR-TB • TB/HIV • Lab infrastructure • Number of dispensaries and hospitals • Number of non-NTP providers and hospitals • Number of staff • Other (chronic respiratory cases, TB suspects examined, slides examined, %

culture-positive/smear-positive) No country was able to provide all of the above data for all years requested. However, data availability has improved in recent years. For details on the data provided by each country, see Annex. Data were then compiled into a single data file using STATA software, and country-specific graphs were generated using R software. These data were then used to complete workbooks designed to answer the following questions:

1. Are TB notifications as complete as possible? 2. Are TB notifications reliable (limited misclassifications)? 3. What proportion of incident cases are missing from routine notifications and

why? 4. How have TB notifications changed over time?

5. Do changes in notifications over time reflect operational changes (e.g., improved case finding)?

6. Do changes in notifications over time reflect changes in the underlying epidemiology?

7. What specific studies/activities are suggested to improve TB surveillance and programme monitoring & evaluation?

Question 1: Completeness of National Data Countries were asked about the completeness of their notifications data in terms of aggregating sub-national reporting data to produce national notifications. Countries provided information on systems used to monitor the completeness of reporting at various administrative levels and to provide reasons for any unusual fluctuations across geographies or over time. For example, there may be programmatic reasons for the variation across administrative units such as differences in the recording and reporting system, lab capacity or case definitions used. There could also be epidemiological reasons for sub-national variation in notifications, such as differences in HIV prevalence and population density. Table 1. Data completeness and reliability

Country Are there any missing reports? Are TB cases classified correctly?

Afghanistan No

Yes, but some misclassification problems due to variable notification policy/practice and EP dx capacity

Bahrain No

Yes with some variation due to differences in notification policy/practice

Djibouti No Yes

Egypt No Yes

Iran No Yes

Iraq No, though in previous years case reports had been tripled Yes

Jordan No (case finding has increased in recent years) Yes

Morocco No Yes

Oman No

Yes, but some difference in EP dx capacity and in notification policy/practices

Pakistan No Misclassification problems due to dx capacity

Qatar No Yes

Saudi Arabia No Yes

Somalia

No, but some fluctuations due to change in recording/reporting system Yes

Sudan No

Yes, but significant variation over time due to dx capacity and variations in notification policy/practice

Syria

Changes in recording/reporting system, dx capacity and case definitions led to fluctuations in notifications

Tunisia No Yes

United Arab Emirates No Some misclassification problems

Yemen No, but some changes in case definition Yes Most countries in the region report having systems in place to monitor the completeness of reporting from various administrative levels to the national level. Unusual fluctuations in notifications seem to be due to changes in recording and reporting systems such as the expansion of DOTS and the addition of new reporting units. Countries noting sub-national variations in notifications reported a mixture of reasons - in some cases, true variation in incidence across provinces or administrative units and, in other cases, variation in reporting quality. Question 2: Reliability of Data Following from this, the data were reviewed for their reliability in terms of case classification. Countries were asked about the proportion of all cases that are new, the proportion of new cases that are pulmonary and the proportion of pulmonary cases

that are smear-positive. There are data to suggest normal ranges for these proportions. It is expected that about 85-90% of new cases are pulmonary and 65-80% of pulmonary cases are smear-positive. Reasons for any significant deviations from these expected ranges were sought. Again, these factors could be due to reporting issues or epidemiological factors. Regionally, the proportion of all cases that are new is reported to be unusually high at 96% in 2007. This pattern has consistently been reflected in the notifications going back to 1995. This would suggest insufficient investigation of past treatment history, and it is unclear why the ratio of new cases to all TB cases would be so high in this region compared to others. The reported proportion of all new cases that are pulmonary is lower than expected in the Eastern Mediterranean Region at 78% for 2007. Again, similar proportions can be seen in the historical data. This suggests an unusually high level of extra-pulmonary TB in the region, but we have no epidemiological explanation for this phenomenon. Some experts suggest a high rate of M. bovis, but there are little data to support this. One would expect higher levels of extra-pulmonary TB in areas of high HIV prevalence or where children represent a significant proportion of the reported cases, but neither of these is the case in this region. And finally the proportion of pulmonary cases that are smear-positive is remarkably low in the region at 51%. This could be explained by weak lab infrastructure or overuse of clinical diagnosis. This section of the workshop attempted to assess whether the pattern seen in each country was representative of the underlying epidemiology or if the classifications of notifications needed to be corrected. As such, the patterns were analysed at the sub-national (where possible), national and regional levels and assessed for reliability in the context of what is known about the natural history of TB and TB epidemiology. Further questions were asked regarding the availability of data on HIV prevalence in TB patients and the prevalence of drug resistance.

Table 2. System to monitor TB/HIV and MDR-TB

Country TB/HIV MDR-TB

Afghanistan No No

Bahrain Yes Yes

Djibouti Yes Yes

Egypt No Yes

Iran Yes Yes

Iraq Yes No

Jordan Yes Yes

Morocco Yes Yes

Oman Yes Yes

Pakistan Yes No

Qatar Yes Yes

Saudi Arabia Yes Yes

Somalia

Sudan Yes No

Syria No Yes

Tunisia Yes Yes

United Arab Emirates No No

Yemen No No Question 3: Assessment of Missing Cases In order to answer the third question, workshop attendees were guided through the use of "the onion" model which highlights the various layers at which patients may be missed by the surveillance system. TB incidence can theoretically be measured directly from population-based incidence surveys or when the performance of national routine TB surveillance systems is so high that they capture all or almost all incident cases. However, incidence surveys are too resource intensive and impractical for any country to consider, and there are no widely endorsed criteria that allow to know with sufficient confidence whether surveillance systems capture all or almost all incident cases. In some countries and under specific conditions (e.g. existence of a case-based database of TB notified cases), incidence may be indirectly derived from direct measurements of TB mortality (from Vital Registration Systems) or incidence may be derived from direct measurements of TB prevalence (from population-based surveys). However, indirectly derived estimates of incidence are very uncertain. In the past, incidence estimates have often been derived from findings of tuberculin surveys. However, the method is judged too uncertain to be applied: it relies on several key assumptions that are very difficult to validate and the diagnostic value (diagnosis of infection) of the tuberculin test is poor. In all other countries, TB incidence can only be estimated by eliciting expert opinion. To obtain the best informed judgement about incidence, experts are asked to consider the various ways through which TB cases may not be captured by routine surveillance, using the so-called "onion" model. Ideally, a sample of experts should be interviewed using methods that would allow the quantification of systematic biases, but logistical limitations attached to regional workshops result in only one or two national experts being involved, with additional input from WHO experts from Country and Regional Offices.

Figure 1. The "onion" Countries were invited to make assessments of the percent of all cases that were unreported at each layer for three years - 1997, 2003 and 2008 - with ranges around each estimated proportion. Although conceptually simple, quantification of the fraction of TB cases missing from each layer is challenging. In some cases, it helps to have an understanding of the overall healthcare system, the distribution of public and private healthcare facilities and providers and how reporting practices differ between public and private sectors. Summing layers 2 to 6 of the onion gives us an estimate of the fraction of incident cases that are not represented within the national notifications, and the upper and lower bounds of these layers is the range of uncertainty around this fraction. The remaining proportion of cases represents an estimated case detection rate for each country. In addition, data on access to health from Demographic and Health Surveys and on the overall performance of health systems as measured by the infant mortality ratio were used to substantiate opinion on the proportion of cases with no or very limited access to health care. For example, the case detection rate for Sudan was adjusted due to the country's low access to health care and its very high infant mortality rate.

2. Cases diagnosed by the NTP

or by providers collaborating

with the NTP, but not

recorded/reported

3. Cases diagnosed by public

or private providers, but not

reported

5. Cases with access to

health services that do not

go to health facilities

6. Cases with no access

to health care

1. Cases recorded in TB

notification data

4. Cases presenting to

health facilities, but not

diagnosed

HSS to minimize

access barriers

Communication and

social mobilization;

contact tracing, active

case-finding

Improve

diagnostic

quality or

tools

Health system

strengthening (HSS)

Practical Approach

to Lung Health

(PAL)

Supervision and

investment in

recording and

reporting systems

Country representatives interpreted their data and external evidence with help from facilitators. At the end of the workshop, agreement was reached about estimates for one or more reference years and the trend in incidence for most countries.

Table 3. Percentage of undetected TB cases, as estimated by countries, 2008

Country No access

Have access,

but don't go

Go, but not

diagnosed by

health facility

Diagnosed by

NTP, but not

notified

Diagnosed by

non-NTP, but

not notified Total

Afghanistan 15 (13-17) 5 (3-7) 5 (3-7) 5 (4-6) 15 (14-17) 38 (34-45)

Bahrain 0 (0-0) 6 4 0 (0-0) 4.5 14

Djibouti 6 (5-7) 6 (2-10) 9 (7-11) 3 (2-4) 1 (0-2) 23 (15-30)

Egypt 2 (0-5) 1 (0-2) 2 (0-5) 2 (0-5) 13 (5-20) 19 (5-34)

Iran 5 (3-7) 5 (3-7) 10 (8-12) 2 (1-3) 21 (19-23) 37 (31-44)

Iraq 11 (10-12) 3 (2-4) 4 (2-6) 3 (2-4) 5 (4-6) 24 (19-29)

Jordan 1 (0-2) 4 (2-6) 4 (3-6) 0 (0-1) 0 (0-1) 9 (5-15)

Lebanon 1 (0-1) 1 (0-2) 5 (0-6) 1 (0-1) 1 (0-2) 9 (0-12)

Morocco 2 (0-5) 2 (1-4) 1 (0-2) 1 (0-2) 2 (1-4) 8 (2-16)

Oman 0 (0-0) 8 (5-10) 5 (1-5) 0 (0-0) 1.1 (0-2.2) 14 (6-16)

Pakistan 10 (5-15) 5 (3-6) 5 (3-6) 10 (5-15) 30 (15-45) 51 (28-70)

Qatar 1 (0-1.5) 4 (2.5-7) 13 (7-19) 0 (0-0) 2 (1-3) 19 (10-28)

Saudi Arabia 0 (0-0) 5 (1-8) 7 (2-14) 5 (1-10) 5 (1-10) 20 (5-37)

Somalia 12 (10-14) 5 (4-6) 3 (2-4) 5 (3-8) 6 (3-8) 28 (20-35)

Sudan 11.4 (7-17.6) 3.2 (2.1-6.1) 3.1 (2.1-4.4) 2.5 (2-3) 6.1 (4.4-7) 24 (17-33)

Syria 7 (5-8) 7 (5-8) 5 (4-6) 3 (2-4) 4 (4-5) 24 (19-28)

Tunisia 2 (1-3) 1 (0.5-2) 2 (1-3) 0.5 (0-1) 0.5 (0-1) 6 (2-10)

United Arab Emirates 3 (1-5) 9 (6-18) 11 (8-24) 0 (0-0) 15 (7-21) 33 (20-50)

Yemen 10 (5-15) 3 (2-5) 7 (5-10) 3 (0-5) 5 (3-7) 27 (14-35) Few countries estimated more than 10% of the population without access to healthcare services. Exceptions were Afghanistan, Iraq and Sudan. Also, few countries provided estimates that suggest appropriate diagnosis may be a hurdle to case detection. There is active private sector care in the region which is reflected in the estimates of non-NTP diagnoses that are not reported. Notable countries are Iran and Pakistan. Overall, the estimated fraction of cases that are not reported varies from 5 to 51% by country, with the largest proportion of estimated unreported cases coming from non-NTP diagnoses. In the Eastern Mediterranean Region, resulting estimates of case detection rate ranged from 49 to 94% for 2008, the most recent year of data. The year in which case-finding efforts were assumed to be the most robust - usually the most recent year - was used as the reference year for the new estimate of TB incidence. Applying the case detection rate to reported notifications gives the new incidence estimate for the reference year.

Table 4. Case detection rates, based on undetected TB cases as estimated by countries

Country 1997 2003 2008

Afghanistan 44 51 62

Bahrain 27 27 86

Djibouti 59 69 77

Egypt 69 74 81

Iran 55 57 63

Iraq 76 68 76

Jordan 84 88 91

Lebanon 90 91 91

Morocco 91 91 92

Oman 81 86 86

Pakistan 24 36 49

Qatar 64 78 81

Saudi Arabia 26 51 80

Somalia 52 60 72

Sudan 69 77 76

Syria 60 74 76

Tunisia 87 92 94

United Arab Emirates 65 53 67

Yemen 60 68 73 Based on the review of notifications data, countries were asked to indicate sources of data that could be used to assess the extent of TB cases missed in each layer of the onion model. These include mortality data from vital registration and laboratory registries, among other sources. Many countries reported availability of these data for assessment. Table 5. Country availability of data to assess undetected cases

Country

Mortality

(vital

registration)

Laboratory

registries

Separate

NTP list

Hospital

registries

HIV

notification

data with

information

on TB

diagnoses

Pharmacy

registries

Health

insurance

registries

Demographic

Health Surveys Other

Afghanistan

Bahrain x x x x ARI

Djibouti x x x x x

Egypt x x x x x x

Military, universities, prisons, refugees, private providers

Iran x x

Iraq

Jordan

Morocco

Oman x x x x x

Pakistan x x x Prevalence survey

Qatar x x x x ARI

Saudi Arabia x x x x x x x x Active case finding in high-risk groups

Somalia

Sudan x x x x

Syria x x x

Tunisia

United Arab Emirates

Yemen Additional studies that could help to quantify the missing cases were also suggested. It is hoped that countries will use these data in the future to generate more informed estimates of the fraction of cases that goes unreported each year.

Table 6. Country plans for studies to assess missing TB cases

Country

Inventory

studies

using

existing

sources of

data

Inventory

studies

using

newly

collected

sources of

data

Studies of

diagnostic

procedures

performed

on TB

suspects

Yield of

patients

found as

a result

of ACSM

Yield of

patients

found

following

training

staff on

PAL

Yield of

patients

found while

screening

high-risk

populations

Yield of

patients

found

while

contact

tracing

Yield of

patients found

because of

improvements

in diagnostic

quality or tools

Yield of

patients

found as a

result of

PPM

TB disease

prevalence

studies

Capture-

recapture

studies

Studies of

post-mortem

registration

of TB Other

Afghanistan

Bahrain x x x x x x

Djibouti x x x x x

Egypt x x x x x x x x x x

Iran x x x x x x

Iraq

Jordan

Morocco

Oman x

Pakistan x x x x x x x x x x

Qatar x x x x x

Saudi Arabia x x

Somalia

Sudan x x x x x x

Syria x x x

Tunisia


Yemen Questions 4-6: Changes in Notifications over Time The next section of the workbook was designed to assess how the factors already mentioned and others have affected notifications over time in order to understand the trend in TB incidence in each country. In TB epidemiology one would not expect to see incidence change by more than 10% year-over-year, almost regardless of the interventions or lack thereof. As such, where notifications truly reflect underlying incidence, we would not expect to see notifications change by more than this either. However, in addition to changes in true incidence of disease, there are a number of other factors that may cause notifications to change over time. These include the rigor of case-finding efforts, the reach of the NTP and its expansion over time, and other factors mentioned previously such as changes in lab capacity or recording and reporting policies. This section of the workbook was designed to answer 4 questions:

1. Have notifications been increasing, decreasing or stable over time? 2. Were there any changes in case-finding effort and/or recording and reporting

that might have affected notifications over time? 3. How have factors that may influence TB incidence changed over time, and

have they had any impact on underlying TB incidence? 4. Based on the information above, what is the best assessment of how true

underlying incidence changed over time, if at all? Countries were asked about the trends in notifications of new cases over several self-defined periods of time, including pulmonary, extra-pulmonary, SS+ and SS- notifications. Then they were asked about changes over time in factors that could affect case detection, such as the number of labs doing smear or culture, number of NTP staff, and expenditure on TB control, and the periods during which these factors increased or decreased. From this, the group was able to make judgements regarding the impact these factors might have had on case detection and, therefore, notifications. Then, countries were asked about factors that might influence underlying TB incidence such as HIV prevalence, gross domestic product (GDP) and various risk factors for TB.

They were also asked about the age distribution of notified cases as this tells us something about transmission. If the average age of TB cases is increasing, more TB is likely due to reactivation of latent infection rather than new infection/transmission. This information was used to assess whether any changes in notifications might be due to true changes in incidence. Nearly every country in the region noted improvements made in the recording and reporting systems over the years. Also, in most countries the direction of change in notifications has varied over the years - increasing during some periods, decreasing or stable during others. There is no obvious reason why the incidence would be changing in this way, but it may be possible to attribute some of the divergent trends to reporting practices or other factors. However, where the trend has been consistent and epidemiologically plausible over time this may reflect the trend in underlying incidence. Few countries were able to identify any factors that may have attributed to an increase in TB incidence. HIV prevalence is relatively low in the region and so is not thought to be a contributing factor. Changing economic conditions may be leading to reductions in incidence in some cases, while increased immigration may be adding to the disease burden in others. For example, some Gulf countries receive immigrants from countries with a much higher risk of TB than the local population. However, it is difficult to quantify the impact these factors may have had.

Table 7. Do changes in TB notifications reflect changes in TB incidence?

Country

Have TB notifications been

increasing, decreasing or

stable over time?

Were there any changes in

case-finding effort and/or

recording and reporting

that might have affected

notifications over time?

How have factors that

may influence TB

incidence changed over

time and have they had

an impact on underlying

TB incidence?

Based on the information

discussed in questions 1

through 3, how do you

think true underlying

incidence has changed

over time?

Afghanistan Increase 1998-2006

Improved case detection and expansion of recording and reporting system since 1998 Unknown Unknown

Bahrain

Increase (1997-2000), Stable (2000-03), Increase (2003-04), then stable

Expanded R&R since 2001; began notifying SS- & EP cases in 2003

Immigration may have increased incidence Unknown

Djibouti

Decrease (1995-2004), Increase (2004-2007) Labs increased in 2006

Egypt

Decrease (1995-?), Stable (?-2003), Decrease (2003-07)

Expanded R&R and began notifying SS-, EP and pediatric cases in 1995; changed to electronic system and began checking for duplicates and misclassifications in 2004

Iran

Increase (1990-92), decrease (1992-2003), stable (2003-07)

Improvements in dx capacity, classification of cases and recording and reporting began in 1995 No

Iraq

Increase (1995-98), decrease (1998-2007)

Expanded recording & reporting system, changed to electronic system, increased training; NTP staff and expenditures increased in 2008

GDP changes may have decreased incidence

Jordan

Decrease (1995-2004), increase (2004-06), stable (2006-08)

Active case finding since 2002; expansion of recording & reporting system since 2006

GDP changes may have decreased incidence

Decreasing among nationals over the last 10 years, but some increase in refugees

Morocco Decrease (1996-2007)

Active case finding, expansion of recording & reporting system since 1991 Unknown

Oman

Decrease (1994-2000), stable (2000-03), increase (2003-07)

Expansion of recording & reporting system since 1991 No

Pakistan

Increase (1996-98), decrease (1998-2000), increase (2000-08)

Expansion of recording & reporting system Unknown

Qatar

Decrease pre 1995, increase (1995-2004), stable 2004-08)

Influx of foreign workers may have increased incidence

Saudi Arabia

Decrease (2000-03), stable (2003-05), increase (2005-08)

Active case finding, expansion of recording & reporting system since 1998 No

Somalia


Expansion of recording & reporting system since 2004 Unknown

Sudan


Expansion of recording & reporting system since 1995 Unknown Stable

Syria


Expansion of recording & reporting system since 2001 Unknown

Tunisia

Decrease 1995-2003), increase 2003-07) Unknown


Decrease (2000-04), stable (2004-08) No No

Yemen Decrease (2004-08) No No

Using the data and expert opinions gathered from countries and the external evidence of health system coverage and other proxies, we assessed, and in some cases challenged, the reliability of country-driven estimates for the reference years. Once estimates of incidence were made for the reference years, we moved on to evaluate trends. In evaluating the possible underlying trend in incidence over time, there were three approaches to calculating the manner in which TB incidence may be changing year-over-year. The first step was to look at the historical notifications. For countries in which notifications were deemed to be a reliable representation of the trend in incidence over several years, the mirror method was used. This simply means that the trend in notifications mirrors the trend in estimated incidence. This trend is applied to the estimate of incidence for the reference year. In most cases, this is used for countries with consistent notifications patterns such as Jordan and Lebanon which both show incrementally declining and then stabilizing rates. Where historical notifications do not appear to reflect underlying incidence, but estimated incidence for the three years evaluated using the onion model is thought be reliable, those three point estimates were used to determine the trend with a mathematically smoothed line characterizing the year-over-year change. This is the method used, for example, in Yemen where reported cases were stable and then declining. Mapping the trend to three years with reasonable estimates shows a steady decline in incidence due to control efforts. And finally, where data were less reliable and the impact of programmatic changes and/or factors that may be affecting the underlying epidemiology were difficult to characterize or quantify, a flat trend was assumed. Having first decided that we had at least one reliable assessment of case detection for a reference year, we then assumed that the incidence rate is not changing over time (or we had no better knowledge to say that it was decreasing or increasing). This is the case in Afghanistan where notifications were not thought to reflect incidence. Here, notifications have been increasing significantly while there have been considerable improvements in case-finding efforts and expansion of the DOTS programme, but there is no information on determinants of TB. In this case, we used the most recent estimate of case detection to estimate incidence and kept the rate constant throughout the years. Another example is Iraq where notifications have varied considerably over the years, but it is difficult to understand the effects of war, internal security issues and displacement on either the functioning of the TB control programme or the epidemiology of the disease in such circumstances. In these situations, no attempt is made to estimate year-over-year changes in incidence and the estimated rate is held constant. However, in the case of Iraq, the best estimate of case detection was for 2003 and this was the reference year used. Prior to 1997, the trend in incidence was assumed to be flat for all countries as we did not analyse data from these years and did not have enough information to inform estimates of trends before this. Confidence intervals were also estimated in an attempt to acknowledge the uncertainty bounds around the estimates. The upper bounds were more uncertain in

some countries, and bounds around estimates for past years are generally more uncertain. Question 7: Suggestions/Recommendations Countries provided information on planned studies and improvements to the TB surveillance system. Following the detailed analyses, suggestions and recommendations were made regarding additional future studies and improvements to be made to support more robust TB surveillance in the future. Table 8. Planned Activities

Afghanistan

Bahrain

Djibouti

Egypt

Iran

Iraq

Jordan

Morocco

Oman

Pakistan

Qatar

Saudi Arabia

Somalia

Sudan

Syria

Tunisia


Yemen

1. Improve recording and reporting capacity:

i. Improve coverage of R&R Yes No Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yesii. Improve supervision of R&R activities,

from data collection to validation,

analysis and findings Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yesiii. Introduce a new or improve the

existing electronic recording and

reporting system Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes2. Improve capacity to analyse TB

notification and other supporting data at

the:

i. National level Yes No Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes

ii. Sub-national level Yes No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes

3. Improve feedback of data analysis and

interpretation to TB staff and other

healthcare working at the peripheral level Yes No Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes4. Implement a study to identify and

eliminate duplicate and misclassified records

at the national level No No No Yes No Yes No Yes No Yes Yes Yes5. Perform data quality assessment (e.g.,

using data quality assessment tool) Yes No No Yes No Yes No Yes Yes Yes Yes Yes

6. Perform studies comparing number of TB

cases with number of suspects examined

and/or number of suspects examined with

number of chronic respiratory cases

attending the healthcare facilities Yes No Yes No No Yes Yes Yes Yes Yes Yes

7. Perform contact investigation studies Yes No Yes Yes Yes No Yes Yes Yes Yes Yes

8. Perform cross-validation of TB notification

data with other sources of TB data:

i. Pre-existing sources of data No No Yes Yes Yes No Yes No Yes Yes Yes

ii. Prospectively collected TB data No No Yes Yes No Yes Yes Yes

9. Capture-recapture studies Yes No No Yes Yes Yes No Yes No No Yes Yes10. Perform a national survey to estimate

the prevalence of drug-resistant TB Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes11. Perform a national survey of the

prevalence of HIV among registered TB

patients Yes No Yes Yes Yes Yes No Yes Yes Routine12. Introduce routine culture and drug

susceptibility testing for all new reported

cases and link them to the national TB

notification system Yes No No Yes Yes No No No Yes13. Implement routine culture and drug

susceptibility testing for all reported

retreatment cases and link them to the

national TB notification system Yes No Yes No Yes Yes Yes No No Yes Yes Yes Yes14. Perform a national survey of the

prevalence of TB disease Yes Yes No No Yes No No No Yes No Yes15. Perform studies to assess TB burden in

high-risk populations Yes No No No Yes Yes No No Yes Yes Yes16. Perform studies to quantify the effect of

risk factors for TB and their population

attributable fraction Yes No Yes No Yes Yes No No No Yes Yes

17. Other No No

TB among immigrants No No

Detailed country data Country-specific tables and graphs explaining the estimates can be found in the Annex. Conclusions The workshops with country representatives were designed to share information and data on TB epidemiology and the external factors that influence it at the country level. With this information, it is hoped that the estimates of TB burden will improve as more informed analyses are conducted. It is clear from the workshop and discussions that TB surveillance is improving dramatically. Eventually, it is hoped that, as routine surveillance continues to improve, country notifications will provide a more complete and accurate reflection of true incidence. Until that time, the annex that follows

outlines the process by which the revised estimates of incidence are made for each country.

Annex

1. Afghanistan Summary

• Considerable increase in notifications year-over-year alongside DOTS expansion and increased case finding efforts

• Increase in labs (2002-04), staff (2002-08), expenditures (2002-08) • Difficult to characterize how epidemiology is changing - not enough robust

surveillance data to estimate trend • Proportion of all cases that are new is higher than expected • Proportion of all TB that is pulmonary is lower than expected

Table 1: Data provided by country prior to workshop Data National Sub-national

Population – 2005–2008 Population by age and sex – – TB case notifications by type – 2001–2008 TB case notifications by age and sex – 2005–2008 Active case finding – – Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – –

Number of new and re-treatment TB cases reported among foreign-born individuals or non-citizens – –

MDR-TB – – TB/HIV – – Labs – – Number of dispensaries and hospitals – – non-NTP providers and collaborators – – Staff – – Other (chronic respiratory cases, TB suspects, slides examined, % culture-positive/smear-positive)

– –

Figure 1. Percentage change in new TB case notifications over time (red lines indicate 10% change)

-20%

0%

20%

40%

60%

80%

100%

120%

140%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7

Table 2. Contribution of different types of TB in notifications 1995 2000 2007

Percentage Country Region Country Region Country Region

New / all TB – 98% 97% 96% 96% 96%

New pulmonary / new TB

– 74% 76% 70% 78% 78%

New smear-positive / new pulmonary TB

– 51% – 51% – 51%

Relapse / all retreatment – 93% 100% 96% 100% 68%

Failure / all retreatment – 2% 0% 2% 0% 20%

Default / all retreatment – 93% 0% 1% 0% 11%

Other retreat / all retreatment

– 2% 0% 1% 0% 0%

Figure 2. Contribution of different TB case types over time

92%

93%

94%

95%

96%

97%

98%

99%

1995 1999 2003 2007

New

/All

AFG EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

AFG EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

ss+/Pulm

AFG EM R

Table 3: Case detection rate of new TB cases (%)

Year Country estimates from the workshop Point estimate (lower-upper bound)

1997 3 (2–3)

2003 30 (27–32)

2008 62 (55–66)

Table 4. Comparison of changes in notifications with case finding efforts and TB determinants Assessment Country's assessment

Have TB notifications been increasing, decreasing or stable over time?

Increasing

Were there any changes in case-finding effort that might have affected notifications over time?

Yes

Were there any changes in recording and reporting that might have affected notifications over time?

Yes

How have factors that may influence TB incidence changed over time, and have they had an impact on underlying TB incidence?

Unknown

Table 5. Method to estimate TB incidence and trend Assumptions Method

Estimate of incidence for reference year

• Data source 55% case detection in 2008

• Value (per 100 000 population) 189

Trend in TB incidence

• Data source Flat trend

Table 6. Current versus revised estimate of incidence and case detection rate

Estimated rate of new TB cases

Estimated rate of new ss+ TB cases

Case detection rate, new TB cases

Case detection rate, new ss+ TB cases

Year Previous Revised Previous Revised Previous Revised Previous Revised

1995 170 190 76 79 – – – –

1996 170 190 76 79 – – – –

1997 170 190 76 79 4 4 4 4

1998 170 190 76 79 9 8 12 12

1999 170 190 76 79 10 9 11 11

2000 170 190 76 79 20 18 18 18

2001 170 190 76 79 28 25 29 28

2002 170 190 76 79 37 33 39 37

2003 170 190 76 79 36 32 37 36

2004 170 190 76 79 45 41 45 44

2005 170 190 76 79 52 47 52 51

2006 170 190 76 79 58 53 63 62

2007 170 190 76 79 63 58 64 63

2008 190 79 55 61

Table 7. Revised estimate of new TB cases with the confidence limits

Year Estimated

incidence rate Lower bound

Upper bound

1995 190 150 230

1996 190 150 230

1997 190 150 230

1998 190 150 230

1999 190 150 230

2000 190 150 230

2001 190 150 230

2002 190 150 230

2003 190 150 230

2004 190 150 230

2005 190 150 230

2006 190 150 230

2007 190 150 230

2008 190 150 230

Table 8. Estimated incidence rate and notification rate, per 100 000 population

0

50

100

150

200

250

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Notification rate Estimated incidence rate Lower bound Upper bound

2. Bahrain

Summary

• Considerable variation in notifications year-over-year which cannot be due to changes in incidence alone, though notifications stabilize after 2004

• Increased non-NTP notifications since 2000, began notifying retreatment cases in 2002, smear-negative, extrapulmonary and pediatric cases in 2003

• Notifications more reliable post-2004 when changes to recording and reporting system were made

• Notable presence of non-national cases (Nepalese and Ethiopian), though most of these are not notified

• Proportion of all cases that are new is higher than expected • Proportion of pulmonary TB that is smear-positive is lower than expected


Population – – Population by age and sex – – TB case notifications by type – – TB case notifications by age and sex – – Active case finding – – Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – –



– –


-100%

-50%

0%

50%

100%

150%

200%

250%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7

Table 2. Contribution of different types of TB in notifications 1995 2000 2007


New / all TB 100% 98% 100% 96% 99% 96% New pulmonary / new TB

27% 74% 83% 70% 61% 78%


55% 51% 55% 51% 55% 51%

Relapse / all retreatment – 93% – 96% 100% 68%

Failure / all retreatment – 2% – 2% 0% 20%

Default / all retreatment – 93% – 1% 0% 11% Other retreat / all retreatment

– 2% – 1% 0% 0%


91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

101%

1995 1999 2003 2007

New

/All

BHR EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

BHR EM R

0%

20%

40%

60%

80%

100%

120%

1995 1999 2003 2007

ss+/Pulm

BHR EM R


Year Country estimates from the workshop

Point estimate

1997 27

2003 27

2008 86



Alternately increasing and stable


No


Yes


Shifts in foreign-born population from countries with high TB prevalence






• Data source Mirror notifications since 2004







1995 58 40 26 13 13 19 11 22

1996 57 40 25 13 15 21 21 40

1997 55 40 25 13 14 19 15 28

1998 52 40 24 13 25 33 17 30

1999 49 40 22 13 46 57 15 25

2000 47 40 21 13 67 80 17 27

2001 46 40 20 13 62 71 17 26

2002 45 40 20 13 62 70 12 19

2003 43 40 19 13 87 94 12 17

2004 42 40 19 13 81 86 51 73

2005 42 45 19 15 93 86 74 94

2006 41 43 19 14 91 86 72 92

2007 41 45 18 15 97 86 79 96

2008 46 15 86 121


Year Estimated


Upper bound

1995 40 32 48

1996 40 32 48

1997 40 32 48

1998 40 32 48

1999 40 32 48

2000 40 32 48

2001 40 32 48

2002 40 32 48

2003 40 38 48

2004 40 34 48

2005 45 38 54

2006 43 37 52

2007 45 39 54

2008 46 39 55


0

10

20

30

40

50

60

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Notif ication rate Estimated incidence rate

Low er bound Upper bound

3. Djibouti

Summary

• Large fluctuations in notifications over time • In 2001 NTP staff were reduced with resulting reduction in notifications • 2002-04 many immigrant workers left which was thought to reduce incidence • 2006-07 new TB programme put into place • Given fluctuations in notifications and programmatic changes over time, there is

insufficient data with which to make an assessment of trend • The proportion of new cases that are pulmonary is extraordinarily low, even

when compared to the already low regional average • The proportion of pulmonary cases that is smear-positive is unusually high


Population – 1999–2007 Population by age and sex 1999–2007 1999–2007 TB case notifications by type 1995–2007 1999–2007 TB case notifications by age and sex 2001–2007 2001–2007 Active case finding – – Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – –

Number of new and re-treatment TB cases reported among foreign-born individuals or non-citizens 1995–2007 2000–2006

MDR-TB – – TB/HIV 2006–2007 – Labs 1999–2007 1999–2007 Number of dispensaries and hospitals 1999–2007 1998–2007 non-NTP providers and collaborators 2006–2007 1998–2007 Staff 2006–2007 1998–2007 Other (chronic respiratory cases, TB suspects, slides examined, % culture-positive/smear-positive)

2006–2007 2006–2007


-25%

-20%

-15%

-10%

-5%

0%

5%

10%

15%

20%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7

Table 2. Contribution of different types of TB in notifications

1995 2000 2007


New / all TB 94% 98% 95% 96% 93% 96%


63% 74% 50% 70% 51% 78%


94% 51% 94% 51% 94% 51%

Relapse / all retreatment 60% 93% 74% 96% 73% 68%

Failure / all retreatment 9% 2% 14% 2% 21% 20%

Default / all retreatment 31% 93% 13% 1% 6% 11%


0% 2% 0% 1% 0% 0%


86%

88%

90%

92%

94%

96%

98%

100%

1995 1999 2003 2007

New

/All

DJI EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

DJI EM R

0%

20%

40%

60%

80%

100%

1995 1999 2003 2007

ss+/Pulm

DJI EM R



1997 59 (53–64)

2003 69 (63–75)

2008 77 (70–85)



Decreasing, then increasing


Yes


Unknown


Unknown






• Data source Flat







1995 640 620 290 340 – – – –

1996 650 620 290 340 79 84 93 79

1997 670 620 300 340 86 93 97 84

1998 680 620 300 340 81 89 82 72

1999 700 620 310 340 84 94 72 64

2000 710 620 310 340 76 88 61 56

2001 730 620 320 340 77 91 55 51

2002 740 620 330 340 56 68 50 48

2003 760 620 330 340 55 67 46 45

2004 780 620 340 340 48 60 40 40

2005 790 620 350 340 49 62 40 41

2006 810 620 360 340 45 59 40 41

2007 830 620 360 340 46 62 40 42

2008 620 340 70 47


Year Estimated


Upper bound

1995 620 500 740

1996 620 500 740

1997 620 500 740

1998 620 500 740

1999 620 500 740

2000 620 500 740

2001 620 500 740

2002 620 500 740

2003 620 500 740

2004 620 500 740

2005 620 500 740

2006 620 500 740

2007 620 500 740

2008 620 500 740


0

100

200

300

400

500

600

700

800

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



4. Egypt Summary

• Notifications have been stable or declining over time • Increase in labs 2004-07; began notifying cases in refugees and from prisons in

2002; active case finding began in 2008 • Culture is only available in 18 of 28 governorates • Used data from capture-recapture study to estimate incidence; results were

55% (95%CI 46%-68%) all forms and 66% (95%CI 55%-75%) smear-positive case detection in the NTP (insert reference)

• Incidence is likely to be declining - used exponential 5.5% decline that had been used in previous methods to estimate trend

• The proportion of new cases that are pulmonary is lower than expected


Population – 2007 Population by age and sex – 1996–2007 TB case notifications by type – 1995–2008 TB case notifications by age and sex – 1997–2007 Active case finding – – Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – –

Number of new and re-treatment TB cases reported among foreign-born individuals or non-citizens – 2007–2008

MDR-TB – – TB/HIV – – Labs – 2003–2007 Number of dispensaries and hospitals – – non-NTP providers and collaborators – – Staff – – Other (chronic respiratory cases, TB suspects, slides examined, % culture-positive/smear-positive)

– –


-40%

-30%

-20%

-10%

0%

10%

20%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 96% 98% 94% 96% 94% 96%


74% 74% 72% 70% 70% 78%


31% 51% 31% 51% 31% 51%





0% 2% 0% 1% 0% 0%


82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

1995 1999 2003 2007

New

/All

EGY EM R

60%

65%

70%

75%

80%

85%

1995 1999 2003 2007

Pulm

/New

EGY EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

1995 1999 2003 2007

ss+/Pulm

EGY EM R



1997 69 (47–84)

2003 74 (63–91)

2008 81 (66–95)



Decreasing, stable, then decreasing


Yes


Yes


Unknown



• Data source Capture-recapture study



• Data source 5.5% exponential decline







1995 37 32 17 13 50 55 42 50

1996 36 31 16 13 55 62 51 61

1997 34 29 15 12 65 73 56 68

1998 33 27 15 12 60 68 52 63

1999 32 27 14 11 57 64 55 67

2000 31 26 14 11 52 59 50 61

2001 30 25 14 10 52 59 49 60

2002 29 24 13 10 56 64 54 67

2003 28 23 12 10 59 67 58 71

2004 26 22 12 9 62 70 64 77

2005 25 21 11 9 63 70 64 76

2006 24 20 11 9 56 62 58 70

2007 24 20 11 8 55 62 61 74

2008 19 8 60 78


Year Estimated


Upper bound

1995 32 26 37

1996 31 25 36

1997 29 24 33

1998 27 23 32

1999 27 22 31

2000 26 21 30

2001 25 21 29

2002 24 20 28

2003 23 19 27

2004 22 18 26

2005 21 17 25

2006 20 17 24

2007 20 16 23

2008 19 16 22


0

5

10

15

20

25

30

35

40

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



5. Iran (Islamic Republic of)

Summary

• Notifications have generally been stable or decreasing over time • Improvements in diagnosis and increased emphasis on lab confirmation led to

decline in notifications in 1995-98 • The proportion of new cases that are pulmonary is lower than expected


Population – 1995–2008 Population by age and sex – 1996–2008 TB case notifications by type 1995–2001 1995–2008 TB case notifications by age and sex 1995–2001 2006–2008 Active case finding – – Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – –


MDR-TB – – TB/HIV 1995–1997 2006–2008 Labs – 2004–2008 Number of dispensaries and hospitals – – non-NTP providers and collaborators – – Staff – – Other (chronic respiratory cases, TB suspects, slides examined, % culture-positive/smear-positive)

1995–1999 2003–2008


-15%

-10%

-5%

0%

5%

10%

15%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 92% 98% 96% 96% 95% 96%


74% 74% 72% 70% 72% 78%


77% 51% 77% 51% 77% 51%





33% 2% 0% 1% 0% 0%


84%

86%

88%

90%

92%

94%

96%

98%

100%

1995 1999 2003 2007

New

/All

IRN EM R

60%

65%

70%

75%

80%

85%

1995 1999 2003 2007

Pulm

/New

IRN EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

ss+/Pulm

IRN EM R



1997 55 (47–63)

2003 57 (52–66)

2008 63 (56–69)



Increasing, decreasing, then stable


Yes


Yes


No






• Data source Cubic spline using estimated incidence from 1997, 2003 and 2008







1995 40 36 18 15 65 71 48 57

1996 39 36 17 15 58 63 49 57

1997 35 36 16 15 57 55 53 55

1998 32 34 15 14 56 53 54 54

1999 31 33 14 14 59 55 59 60

2000 31 32 14 13 58 56 58 61

2001 30 30 13 13 59 58 61 65

2002 29 29 13 12 59 59 61 65

2003 27 27 12 11 59 58 62 66

2004 25 26 11 11 59 57 63 65

2005 24 24 11 10 56 54 62 64

2006 23 23 10 10 59 57 67 70

2007 22 21 10 9 60 60 68 73

2008 20 8 65 78


Year Estimated


Upper bound

1995 36 29 43

1996 36 29 43

1997 36 29 43

1998 34 28 41

1999 33 26 40

2000 32 25 38

2001 30 24 36

2002 29 23 34

2003 27 22 33

2004 26 21 31

2005 24 19 29

2006 23 18 27

2007 21 17 26

2008 20 16 24


0

5

10

15

20

25

30

35

40

45

50

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



6. Iraq Summary

• Large fluctuations in notifications over time • Previously had been significant over-reporting for political reasons; evidence of

inflated notifications from 1996 to 2000 • Decline in notifications from 2003 to 2007 due to the internal security situation

created by war, with millions displaced either externally and internally • In 2008 there was some improvement due to revitalization of TB care in some

governorates • Notifications are not a reliable guide to underlying trend - insufficient data with

which to estimate trend • The proportion of new cases that are pulmonary is lower than expected • The proportion of pulmonary cases that is smear-positive is also unusually low


Population – 1997–2008 Population by age and sex – 1997–2008 TB case notifications by type 2008 2000–2008 TB case notifications by age and sex 2008 2000–2008 Active case finding 2008 2008 Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – –


MDR-TB 2008 2004–2008 TB/HIV 2008 2008 Labs – – Number of dispensaries and hospitals – – non-NTP providers and collaborators – – Staff – – Other (chronic respiratory cases, TB suspects, slides examined, % culture-positive/smear-positive)

2008 2008


-80%

-60%

-40%

-20%

0%

20%

40%

60%

80%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 100% 98% 94% 96% 93% 96%


93% 74% 70% 70% 69% 78%


19% 51% 19% 51% 19% 51%





0% 2% 0% 1% 0% 0%


86%

88%

90%

92%

94%

96%

98%

100%

102%

1995 1999 2003 2007

New

/All

IRQ EM R

0%

20%

40%

60%

80%

100%

1995 1999 2003 2007

Pulm

/New

IRQ EM R

0%

10%

20%

30%

40%

50%

60%

70%

1995 1999 2003 2007

ss+/Pulm

IRQ EM R



1997 155 (147–173)

2003 68 (64–75)

2008 46 (43–51)



Increasing, then decreasing


Yes


Yes


Unknown






• Data source Flat







1995 56 64 25 27 80 72 59 57

1996 56 64 25 27 234 211 183 178

1997 56 64 25 27 206 186 141 136

1998 56 64 25 27 221 199 149 144

1999 56 64 25 27 219 196 161 155

2000 56 64 25 27 69 62 51 48

2001 56 64 25 27 73 65 55 52

2002 56 64 25 27 81 71 59 56

2003 56 64 25 27 77 68 53 50

2004 56 64 25 27 68 60 49 46

2005 56 64 25 27 60 52 44 41

2006 56 64 25 27 50 44 40 37

2007 56 64 25 27 48 42 37 35

2008 64 27 47 39


Year Estimated


Upper bound

1995 64 51 77

1996 64 51 77

1997 64 51 77

1998 64 51 77

1999 64 51 77

2000 64 51 77

2001 64 51 77

2002 64 51 77

2003 64 51 77

2004 64 51 77

2005 64 51 77

2006 64 51 77

2007 64 51 77

2008 64 51 77


0

20

40

60

80

100

120

140

160

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



7. Jordan Summary

• Notifications have been either decreasing or stable over time • Recording and reporting system has been expanded since 2006 and active case

finding has been increasing since 2002 • Workshop participants believe TB is declining among native Jordanians, but

increasing numbers of non-nationals have been entering the country with latent infection and progressing to active disease (as much as 25% of TB cases)

• Efforts underway to improve screening of non-nationals • Proportion of new cases that are pulmonary is unusually low • Proportion of pulmonary cases that are smear-positive is unusually low


Population – 2000–2008 Population by age and sex – 2004–2008 TB case notifications by type – 2000–2008 TB case notifications by age and sex – 2000–2008 Active case finding – 2000–2008 Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – 2003–2008

Number of new and re-treatment TB cases reported among foreign-born individuals or non-citizens – 2000–2008

MDR-TB – – TB/HIV – 2001–2008 Labs – – Number of dispensaries and hospitals – 2000–2008 non-NTP providers and collaborators – 2000–2008 Staff – 2000–2008 Other (chronic respiratory cases, TB suspects, slides examined, % culture-positive/smear-positive)

– 2000–2008


-25%

-20%

-15%

-10%

-5%

0%

5%

10%

15%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 99% 98% 99% 96% 97% 96%


80% 74% 52% 70% 54% 78%


47% 51% 47% 51% 47% 51%





0% 2% 0% 1% 73% 0%


90%

92%

94%

96%

98%

100%

1995 1999 2003 2007

New

/All

JOR EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

JOR EM R

0%

10%

20%

30%

40%

50%

60%

70%

1995 1999 2003 2007

ss+/Pulm

JOR EM R



1997 84 (75–91)

2003 88 (80–94)

2008 91 (85–95)



Decreasing, then increasing, then stable


Yes


Yes


Influx of non-nationals, GDP













1995 13 14 4 6 86 84 106 75

1996 13 13 4 5 84 84 99 73

1997 11 10 3 4 78 84 87 69

1998 10 10 3 4 81 85 76 59

1999 9 9 3 4 86 85 77 56

2000 9 7 3 3 73 86 70 60

2001 8 8 2 3 87 87 78 57

2002 8 7 2 3 79 87 75 61

2003 7 7 2 3 80 88 91 73

2004 8 7 2 3 79 89 73 59

2005 8 7 2 3 86 89 66 50

2006 8 7 2 3 83 90 78 62

2007 7 6 2 3 76 90 81 70

2008 6 3 91 67


Year Estimated


Upper bound

1995 14 12 17

1996 13 11 15

1997 10 9 12

1998 10 8 12

1999 9 8 11

2000 7 6 9

2001 8 7 10

2002 7 6 8

2003 7 6 8

2004 7 6 8

2005 7 7 9

2006 7 6 8

2007 6 6 8

2008 6 6 7


0

2

4

6

8

10

12

14

16

18

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



8. Lebanon Summary

• Notifications have generally been either decreasing or stable over time, but increasing slightly since 2006

• Country representatives believe that underlying incidence has been decreasing as reflected in notifications, but that the slight increase since 2006 is due to an increasing number of non-nationals from TB endemic countries

• Proportion of new cases that are pulmonary is unusually low • Proportion of pulmonary cases that are smear-positive is also unusually low


Population 1995–2007 2004–2008 Population by age and sex 2004–2007 – TB case notifications by type 1995–2007 2004–2008 TB case notifications by age and sex 1995–2007 2004–2008 Active case finding – – Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – –

Number of new and re-treatment TB cases reported among foreign-born individuals or non-citizens 2002–2007 –


– –


-20%

-15%

-10%

-5%

0%

5%

10%

15%

20%

25%

30%

35%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 100% 98% 99% 96% 99% 96%


74% 74% 62% 70% 55% 78%


27% 51% 27% 51% 27% 51%





0% 2% 0% 1% 0% 0%


91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

101%

1995 1999 2003 2007

New

/All

LBN EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

LBN EM R

0%

10%

20%

30%

40%

50%

60%

70%

1995 1999 2003 2007

ss+/Pulm

LBN EM R



1997 90 (82–100)

2003 91 (87–100)

2008 91 (88–100)



NA


NA


NA


NA













1995 46 31 14 13 62 90 40 43

1996 41 26 12 11 57 90 44 51

1997 35 21 11 9 56 90 54 63

1998 32 19 10 8 55 90 63 75

1999 29 20 9 8 62 90 75 79

2000 27 17 8 7 56 91 65 77

2001 23 15 7 6 59 91 64 72

2002 20 12 6 5 57 91 63 74

2003 18 11 5 4 55 91 63 77

2004 17 11 5 4 59 91 71 81

2005 17 11 5 4 59 91 64 73

2006 18 10 5 4 52 91 51 65

2007 19 13 6 5 62 91 61 65

2008 14 6 91 66


Year Estimated


Upper bound

1995 31 28 38

1996 26 23 31

1997 21 19 26

1998 19 17 23

1999 20 18 24

2000 17 15 20

2001 15 13 18

2002 12 11 15

2003 11 10 13

2004 11 10 13

2005 11 10 13

2006 10 9 12

2007 13 11 15

2008 14 12 16


0

5

10

15

20

25

30

35

40

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



9. Morocco Summary

• Notifications have been in a fairly steady decline over time • Efforts to detect cases were intensified between 1990 and 1995 • NTP staff and expenditure increases began in 1996; key indicators have been

relatively stable since • Country representatives noted that they would like to improve collaboration

with private providers and the military in order to strengthen notifications • Proportion of new cases that are pulmonary is unusually low





– –


-15%

-10%

-5%

0%

5%

10%

15%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 100% 98% 100% 96% 100% 96%


61% 74% 55% 70% 55% 78%


78% 51% 78% 51% 78% 51%

Relapse / all retreatment – 93% – 96% – 68%

Failure / all retreatment – 2% – 2% – 20%

Default / all retreatment – 93% – 1% – 11%


– 2% – 1% – 0%


90%

92%

94%

96%

98%

100%

102%

1995 1999 2003 2007

New

/All

M AR EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

M AR EM R

0%

20%

40%

60%

80%

100%

1995 1999 2003 2007

ss+/Pulm

M AR EM R



1997 91 (83–97)

2003 91 (83–97)

2008 92 (84–98)



Decreasing


Yes


Yes


Unknown






• Data source Cubic spline using estimates from 1997, 2003 and 2008







1995 130 150 57 63 87 73 92 83

1996 130 150 56 61 93 80 93 86

1997 120 140 55 57 89 80 93 89

1998 120 130 53 55 88 78 90 86

1999 110 120 51 51 92 86 92 92

2000 110 110 50 46 89 91 89 97

2001 110 110 50 46 88 88 88 95

2002 110 110 48 45 95 95 91 98

2003 100 100 46 43 87 88 93 100

2004 97 97 44 41 88 89 93 100

2005 95 95 43 40 90 91 98 105

2006 94 94 42 39 90 90 94 102

2007 92 93 41 39 89 88 92 98

2008 93 39 92 96


Year Estimated


Upper bound

1995 150 120 182

1996 150 120 174

1997 140 110 164

1998 130 110 159

1999 120 110 147

2000 110 100 131

2001 110 97 132

2002 110 100 128

2003 100 90 123

2004 97 86 116

2005 95 86 114

2006 94 85 112

2007 93 82 112

2008 93 85 111


0

20

40

60

80

100

120

140

160

180

200

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



10. Oman Summary

• Notifications have been fairly steady over time with some fluctuation year-over-year

• Contact tracing is done and prophylactic therapy for infected contacts with follow-up for two years implemented

• Non-nationals are screened in their home countries before immigration and subsequently followed every two years after entry

• Country representatives believe the notifications reflect the trend in underlying incidence

• Proportion of new cases that are pulmonary is unusually low Table 1: Data provided by country prior to workshop Data National Sub-national




– –


-20%

-15%

-10%

-5%

0%

5%

10%

15%

20%

25%

30%

35%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 100% 98% 98% 96% 98% 96%

New pulmonary / new TB 71% 74% 64% 70% 68% 78%


69% 51% 69% 51% 69% 51%




Other retreat / all retreatment – 2% 0% 1% 0% 0%


88%

90%

92%

94%

96%

98%

100%

102%

1995 1999 2003 2007

New

/All

OM N EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

OM N EM R

0%

20%

40%

60%

80%

100%

1995 1999 2003 2007

ss+/Pulm

OM N EM R



1997 81 (75–87)

2003 86 (81–94)

2008 86 (84–94)



Decreasing, then stable, then increasing


No


Yes


No













1995 14 13 6 4 91 95 99 141

1996 13 14 6 5 100 95 121 158

1997 13 14 6 5 98 95 121 160

1998 12 13 6 4 100 95 121 156

1999 12 11 6 4 85 95 91 140

2000 12 14 6 5 108 95 123 148

2001 13 13 6 4 94 95 112 154

2002 12 12 5 4 101 95 117 150

2003 12 11 5 4 89 95 85 124

2004 11 12 5 4 105 95 128 158

2005 12 10 5 3 85 95 95 144

2006 12 13 6 4 107 95 129 156

2007 13 13 6 4 99 95 125 164

2008 13 4 95 140


Year Estimated


Upper bound

1995 13 13 16

1996 14 13 17

1997 14 13 17

1998 13 12 16

1999 11 11 13

2000 14 13 17

2001 13 12 15

2002 12 12 15

2003 11 10 13

2004 12 11 14

2005 10 10 13

2006 13 13 16

2007 13 12 15

2008 13 13 16


0

2

4

6

8

10

12

14

16

18

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



11. Pakistan Summary

• Notifications have been increasing over time which is thought to be a reflection of expansion of DOTS services and increased case detection

• Number of labs increased between 2004 and 2006; number of NTP staff increased in 2004

• Significant proportion of TB cases are diagnosed in the private sector and not reported to the NTP; 1000 of 42 000 GPs engaged with NTP contribute 15% of notifications; drugs available in private pharmacy

• Others diagnosed by public non-NTP sector - military, police, prisons - and not notified

• Some NTP diagnosed cases also not reported due to weaknesses in the recording and reporting system

• Notifications not a reliable guide to underlying trend - insufficient data with which to estimate trend

• Proportion of pulmonary cases that are smear-positive is unusually low Table 1: Data provided by country prior to workshop Data National Sub-national

Population 2001–2008 2001–2009 Population by age and sex – – TB case notifications by type 2001–2008 2001–2008 TB case notifications by age and sex 2001–2008 2001–2008 Active case finding – – Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – –


MDR-TB – – TB/HIV – – Labs 2004–2008 2004–2008 Number of dispensaries and hospitals – – non-NTP providers and collaborators – – Staff – – Other (chronic respiratory cases, TB suspects, slides examined, % culture-positive/smear-positive)

– –


-150%

-100%

-50%

0%

50%

100%

150%

200%

250%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 98% 98% 97% 96% 97% 96%



40% 51% 40% 51% 40% 51%




Other retreat / all retreatment 0% 2% 0% 1% 0% 0%


91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

1995 1999 2003 2007

New

/All

PAK EM R

0%

20%

40%

60%

80%

100%

120%

1995 1999 2003 2007

Pulm

/New

PAK EM R

0%

10%

20%

30%

40%

50%

60%

70%

1995 1999 2003 2007

ss+/Pulm

PA K EM R



1997 0 (0–0)

2003 14 (8–20)

2008 49 (30–72)



Increasing, decreasing, then increasing again


Yes


Yes


Unknown













1995 180 230 82 97 6 4 2 2

1996 180 230 82 97 2 1 2 1

1997 180 230 82 97 – – – –

1998 180 230 82 97 36 27 13 11

1999 180 230 82 97 8 6 5 4

2000 180 230 82 97 4 3 3 2

2001 180 230 82 97 13 10 9 7

2002 180 230 82 97 19 15 13 11

2003 180 230 82 97 25 19 17 14

2004 180 230 82 97 33 25 25 20

2005 180 230 82 97 50 37 37 30

2006 180 230 82 97 61 45 50 40

2007 180 230 82 97 78 58 66 53

2008 230 97 60 58


Year Estimated


Upper bound

1995 230 190 280

1996 230 190 280

1997 230 190 280

1998 230 190 280

1999 230 190 280

2000 230 190 280

2001 230 190 280

2002 230 190 280

2003 230 190 280

2004 230 190 280

2005 230 190 280

2006 230 190 280

2007 230 190 280

2008 230 190 280


0

50

100

150

200

250

300

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



12. Qatar Summary

• Notifications have shown some fluctuation since 1995, but have basically stabilized

• The NTP has wide coverage and both nationals and non-nationals have access to TB care

• Proportion of new cases reported as pulmonary is remarkably low • Proportion of pulmonary cases that are smear-positive is also unusually low





– –


-20%

-15%

-10%

-5%

0%

5%

10%

15%

20%

25%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 100% 98% 100% 96% 100% 96%



31% 51% 31% 51% 31% 51%

Relapse / all retreatment 100% 93% – 96% – 68%

Failure / all retreatment 0% 2% – 2% – 20%

Default / all retreatment 0% 93% – 1% – 11%

Other retreat / all retreatment 0% 2% – 1% – 0%


91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

101%

1995 1999 2003 2007

New

/All

QAT EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

QAT EM R

0%

10%

20%

30%

40%

50%

60%

70%

1995 1999 2003 2007

ss+/Pulm

QA T EM R



1997 64 (51–78)

2003 78 (67–89)

2008 81 (72–90)



Decreasing, increasing, then stable


Unknown


Unknown


Influx of foreign workers













1995 76 60 34 20 76 96 33 58

1996 71 60 32 20 67 80 27 43

1997 64 60 29 20 59 64 24 36

1998 63 67 28 22 71 67 43 55

1999 66 63 30 21 66 69 33 47

2000 66 63 30 21 69 72 29 41

2001 64 59 29 19 68 74 41 61

2002 60 53 27 18 67 76 34 53

2003 56 48 25 16 67 78 52 81

2004 57 43 25 14 63 79 38 65

2005 58 46 26 15 70 80 46 72

2006 61 42 27 14 68 81 51 83

2007 63 43 28 14 76 81 49 71

2008 55 18 81 87


Year Estimated


Upper bound

1995 60 58 72

1996 60 48 72

1997 60 48 72

1998 67 53 80

1999 63 51 76

2000 63 50 75

2001 59 47 71

2002 53 43 64

2003 48 39 58

2004 43 34 52

2005 46 37 55

2006 42 34 51

2007 43 35 52

2008 55 44 66


0

10

20

30

40

50

60

70

80

90

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



13. Saudi Arabia Summary

• Notifications have been quite stable over time • Number of labs and staff, NTP expenditure, and active case finding all began

increasing in 1998 • Proportion of new cases reported as pulmonary is unusually low





– –


-15%

-10%

-5%

0%

5%

10%

15%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB – 98% 97% 96% 96% 96%

New pulmonary / new TB – 74% 69% 70% 66% 78%


– 51% – 51% – 51%






82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

1995 1999 2003 2007

New

/All

SA U EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

SAU EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

ss+/Pulm

SA U EM R



1997 26 (11–55)

2003 51 (29–74)

2008 80 (63–95)



Decreasing, stable, then increasing


Yes


Yes


No













1995 43 31 19 10 – – – –

1996 45 31 20 10 – – – –

1997 46 31 21 10 35 53 39 80

1998 48 30 22 10 34 55 39 85

1999 48 30 22 10 36 58 38 84

2000 47 27 21 9 35 61 36 85

2001 46 25 21 8 34 63 38 97

2002 44 23 20 8 35 66 39 99

2003 43 21 19 7 35 69 38 104

2004 42 20 19 7 34 72 38 111

2005 43 20 19 7 35 75 38 111

2006 44 20 20 7 35 79 40 121

2007 45 19 20 6 36 82 40 125

2008 19 6 86 137


Year Estimated


Upper bound

1995 31 25 37

1996 31 25 37

1997 31 25 37

1998 30 24 35

1999 30 24 36

2000 27 22 33

2001 25 20 30

2002 23 19 28

2003 21 17 26

2004 20 16 24

2005 20 16 24

2006 20 16 24

2007 19 16 23

2008 19 16 22


0

5

10

15

20

25

30

35

40

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



14. Somalia Summary

• Notifications have increased since 1995, but it is thought that this is due more to programme expansion than increasing TB incidence

• Number of labs increased 1998-2008; number of staff increased 1996-2009; NTP expenditures increased 2004-09

• Variations in sub-national data • One of two countries in the region most affected by HIV • As most of the increase in notifications is thought to be due to programme

expansion, we have no way of knowing if or how true underlying incidence may be changing

• The proportion of new cases that are pulmonary is more in line with expectations than the regional average

• The smear-positive proportion of all cases is also within the expected range, unlike that of the region as a whole


Population – 1995–2008 Population by age and sex – – TB case notifications by type – 1995–2008 TB case notifications by age and sex – 1995–2008 Active case finding – 1995–2008 Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – –


MDR-TB – 1995–2008 TB/HIV – 1995–2008 Labs – – Number of dispensaries and hospitals – – non-NTP providers and collaborators – – Staff – – Other (chronic respiratory cases, TB suspects, slides examined, % culture-positive/smear-positive)

– 1995–2008


-20%

-10%

0%

10%

20%

30%

40%

50%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 95% 98% 94% 96% 96% 96%



69% 51% 69% 51% 69% 51%






75%

80%

85%

90%

95%

100%

1995 1999 2003 2007

New

/All

SOM EM R

0%

20%

40%

60%

80%

100%

1995 1999 2003 2007

Pulm

/New

SOM EM R

0%

20%

40%

60%

80%

100%

1995 1999 2003 2007

ss+/Pulm

SOM EM R



1997 27 (24–29)

2003 60 (54–66)

2008 72 (65–80)





Yes


Yes


Unknown













1995 290 290 130 160 14 13 19 15

1996 280 290 130 160 22 21 36 28

1997 280 290 120 160 25 23 39 29

1998 270 290 120 160 24 22 39 28

1999 260 290 120 160 27 23 43 30

2000 260 290 120 160 32 27 47 32

2001 250 290 110 160 38 32 57 39

2002 240 290 110 160 41 33 59 39

2003 240 290 110 160 51 41 63 41

2004 230 290 100 160 64 50 79 50

2005 220 290 100 160 70 54 86 53

2006 220 290 98 160 64 49 83 51

2007 210 290 95 160 60 45 74 44

2008 290 160 49 46


Year Estimated


Upper bound

1995 290 230 340

1996 290 230 340

1997 290 230 340

1998 290 230 340

1999 290 230 340

2000 290 230 340

2001 290 230 340

2002 290 230 340

2003 290 230 340

2004 290 230 340

2005 290 230 340

2006 290 230 340

2007 290 230 340

2008 290 230 340


0

50

100

150

200

250

300

350

400

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



15. Sudan Summary

• Notifications have been reasonably stable over time, though they do not reflect cases occurring in areas affected by war, notably south Sudan

• We do not know what is happening to TB incidence in the areas affected by war

• One of two countries in the region most affected by HIV • Number of labs and staff and expenditures have been increasing since 1995,

with significant increases beginning in 2003 • Notifications from non-NTP providers began in 2003 • Notifications not a reliable guide to underlying trend - insufficient data with

which to estimate trend • The proportion of new cases that are pulmonary is more in line with

expectations than the regional average • The smear-positive proportion of all cases is also within the expected range,

unlike that of the region as a whole Table 1: Data provided by country prior to workshop Data National Sub-national

Population – 1995–2008 Population by age and sex – 1995–2008 TB case notifications by type – 1995–2008 TB case notifications by age and sex – 2003–2008 Active case finding – 1995–2008 Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers – –



– 1995–2008


-30%

-20%

-10%

0%

10%

20%

30%

40%

50%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 97% 98% 91% 96% 93% 96%



77% 51% 77% 51% 77% 51%






86%

88%

90%

92%

94%

96%

98%

100%

1995 1999 2003 2007

New

/All

SDN EM R

0%

20%

40%

60%

80%

100%

1995 1999 2003 2007

Pulm

/New

SDN EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

ss+/Pulm

SDN EM R



1997 69 (57–76)

2003 77 (67–84)

2008 76 (67–83)





Yes


Yes


Unknown



• Data source 49% case detection










1995 190 120 85 66 25 39 35 43

1996 200 120 87 66 34 54 34 43

1997 200 120 89 66 34 54 39 51

1998 200 120 91 66 34 56 37 49

1999 210 120 93 66 40 66 36 49

2000 210 120 95 66 35 60 39 54

2001 220 120 97 66 32 57 34 47

2002 220 120 99 66 32 57 30 43

2003 230 120 100 66 31 57 31 45

2004 230 120 100 66 32 59 32 48

2005 240 120 110 66 32 60 33 50

2006 240 120 110 66 32 62 30 47

2007 250 120 110 66 31 61 30 47

2008 120 66 49 40


Year Estimated


Upper bound

1995 120 95 140

1996 120 95 140

1997 120 95 140

1998 120 95 140

1999 120 95 140

2000 120 95 140

2001 120 95 140

2002 120 95 140

2003 120 95 140

2004 120 95 140

2005 120 95 140

2006 120 95 140

2007 120 95 140

2008 120 95 140


0

20

40

60

80

100

120

140

160

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



16. Syrian Arab Republic Summary

• Notifications have shown a general decline over time • Recording and reporting has been expanded since 2001 • Labs increased in 2002; staff decreased 2004-06 • Limited involvement of non-NTP providers in notifying cases; notifications from

non-NTP providers fluctuates • Current electronic reporting system is constrained by limited internet access • Syria recently completed a capture-recapture study which allows for better

estimation of case detection and incidence • Proportion of new cases reported as pulmonary is lower than expected • Proportion of pulmonary cases that are smear-positive is also unusually low


Population 1995–2007 1997–2007 Population by age and sex 1995–2007 1997–2007 TB case notifications by type 1995–2007 1995–2007 TB case notifications by age and sex 1996–2007 1995–2007 Active case finding 1995–2007 1995–2007 Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers 1995–2007 1995–2007

Number of new and re-treatment TB cases reported among foreign-born individuals or non-citizens 1995–2007 1995–2007

MDR-TB 2001–2007 1997–2007 TB/HIV 1995–2008 2001–2007 Labs 1995–2007 1995–2007 Number of dispensaries and hospitals 1995–2007 2000–2007 non-NTP providers and collaborators 1995–2007 1995–2007 Staff 1995–2007 1995–2007 Other (chronic respiratory cases, TB suspects, slides examined, % culture-positive/smear-positive)

1995–2007 1995–2007


-15%

-10%

-5%

0%

5%

10%

15%

20%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 99% 98% 94% 96% 94% 96%



46% 51% 46% 51% 46% 51%






88%

90%

92%

94%

96%

98%

100%

1995 1999 2003 2007

New

/All

SYR EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

SYR EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

1995 1999 2003 2007

ss+/Pulm

SYR EM R



1997 60 (56–72)

2003 71 (65–76)

2008 76 (72–81)





Yes


Yes


Unknown



• Data source Capture-recapture



• Data source ?







1995 53 46 16 19 57 66 55 46

1996 51 43 16 18 68 80 65 56

1997 53 41 16 17 61 79 57 54

1998 53 39 16 16 65 89 63 62

1999 52 37 16 15 65 92 62 64

2000 49 35 15 15 62 89 63 66

2001 46 33 14 14 64 90 63 65

2002 44 31 13 13 62 88 62 64

2003 42 29 13 12 65 91 68 70

2004 39 28 12 12 64 89 71 72

2005 36 26 11 11 64 86 65 64

2006 33 25 10 10 61 80 68 65

2007 31 24 9 10 66 85 61 57

2008 22 9 79 56


Year Estimated


Upper bound

1995 46 37 55

1996 43 35 52

1997 41 33 49

1998 39 34 47

1999 37 34 44

2000 35 31 42

2001 33 29 39

2002 31 27 37

2003 29 27 35

2004 28 25 33

2005 26 23 32

2006 25 20 30

2007 24 20 28

2008 22 18 27


0

10

20

30

40

50

60

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



17. Tunisia Summary

• Notifications have shown a general decline over time with a slight increase in the last few years

• Proportion of new cases reported as pulmonary is lower than expected - postulated that the excess of extrapulmonary TB may be due to bovine TB

• Proportion of pulmonary TB that is smear-positive is more in line with expectations than the regional average





– –


-120%

-100%

-80%

-60%

-40%

-20%

0%

20%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB 100% 98% 97% 96% 99% 96%



75% 51% 75% 51% 75% 51%






91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

101%

1995 1999 2003 2007

New

/All

TUN EM R

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1995 1999 2003 2007

Pulm

/New

TUN EM R

0%

20%

40%

60%

80%

100%

1995 1999 2003 2007

ss+/Pulm

TUN EM R



1997 87 (80–94)

2003 92 (87–97)

2008 94 (90–98)



Decreasing, then increasing


No


Unknown


Unknown













1995 31 29 14 12 84 93 98 116

1996 31 29 14 12 85 92 80 92

1997 30 29 13 12 – – – –

1998 28 27 13 11 84 88 101 114

1999 27 26 12 11 85 89 93 105

2000 25 24 11 10 84 90 101 116

2001 24 23 11 9 84 91 103 120

2002 23 21 11 9 82 91 90 107

2003 23 22 11 9 85 92 84 98

2004 24 22 11 9 84 93 88 105

2005 24 23 11 9 85 93 83 98

2006 25 23 11 10 83 93 80 96

2007 26 24 12 10 85 94 78 92

2008 24 10 94 99


Year Estimated


Upper bound

1995 29 27 35

1996 29 26 35

1997 29 23 35

1998 27 24 33

1999 26 23 31

2000 24 22 29

2001 23 20 27

2002 21 20 26

2003 22 20 26

2004 22 20 26

2005 23 21 27

2006 23 21 27

2007 24 23 29

2008 24 22 29


0

5

10

15

20

25

30

35

40

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



18. United Arab Emirates Summary

• Notifications have been stable since 1999, before which they fluctuated considerably, in some years not reporting at all

• Health authorities fragmented in the country, and thus notifications not consistent nationally

• Significant sub-national variation in notifications, case definitions and case management

• No full-time NTP staff or separate budget for NTP • Active case finding among non-nationals, HIV+, and TB contacts • Cases unreported from non-NTP providers • Limited diagnostic quality and tools • Low rate of supervised DOTS • Insufficient surveillance data with which to estimate trend over time • Proportion of new cases reported as pulmonary is lower than expected





– –


-60%

-40%

-20%

0%

20%

40%

60%

80%

100%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB – 98% 100% 96% 95% 96%

New pulmonary / new TB – 74% 65% 70% 83% 78%


– 51% – 51% – 51%



Default / all retreatment – 93% – 1% 0% 11%

Other retreat / all retreatment – 2% – 1% 0% 0%


82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

102%

1995 1999 2003 2007

New

/All

ARE EM R

0%

20%

40%

60%

80%

100%

120%

1995 1999 2003 2007

Pulm

/New

ARE EM R

0%

20%

40%

60%

80%

100%

120%

1995 1999 2003 2007

ss+/Pulm

ARE EM R



1997 0 (0–0)*

2003 81 (60–96)

2008 67 (50–80) *No notifications received in 1997



Decreasing, then stable


No


No


No













1995 23 4 10 1 – – – –

1996 22 4 10 1 89 474 – –

1997 21 4 10 1 – – – –

1998 20 4 9 1 130 644 – –

1999 19 4 9 1 11 52 12 74

2000 18 4 8 1 19 86 27 166

2001 18 4 8 1 12 52 25 147

2002 18 4 8 1 14 60 20 116

2003 17 4 8 1 18 75 27 148

2004 17 4 7 1 14 56 19 106

2005 16 4 7 1 15 61 21 111

2006 16 4 7 1 13 51 17 90

2007 16 4 7 1 14 54 18 93

2008 4 1 50 82


Year Estimated


Upper bound

1995 4 3 5

1996 4 3 5

1997 4 3 5

1998 4 3 5

1999 4 3 5

2000 4 4 5

2001 4 3 5

2002 4 3 5

2003 4 3 5

2004 4 3 5

2005 4 3 5

2006 4 3 5

2007 4 3 5

2008 4 3 5


0

5

10

15

20

25

30

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



19. Yemen Summary

• Notifications were stable and then decreasing over time • Country representatives believe this reflects the true decline in underlying

incidence due to TB control efforts • Labs and staff increased 2004-2007 • Significant proportion of cases not reported by non-NTP providers • Country representatives noted that national surveillance system is weak and

that they will implement a new recording and reporting system next year Table 1: Data provided by country prior to workshop Data National Sub-national

Population 2004–2008 2004–2008 Population by age and sex 2004–2008 2004–2008 TB case notifications by type 2004–2008 2004–2008 TB case notifications by age and sex 2004–2008 2004–2008 Active case finding – 2008 Number of new and re-treatment TB cases reported by non-NTP/non-MoH providers 2004–2008 –

Number of new and re-treatment TB cases reported among foreign-born individuals or non-citizens 2004–2008 –

MDR-TB – – TB/HIV 2006 2006 Labs 1995–2008 2004–2008 Number of dispensaries and hospitals 2004–2008 2004–2008 non-NTP providers and collaborators – – Staff 2008 2004–2008 Other (chronic respiratory cases, TB suspects, slides examined, % culture-positive/smear-positive)

– –


-15%

-10%

-5%

0%

5%

10%

15%

1995

–199

6

1996

–199

7

1997

–199

8

1998

–199

9

1999

–200

0

2000

–200

1

2001

–200

2

2002

–200

3

2003

–200

4

2004

–200

5

2005

–200

6

2006

–200

7


1995 2000 2007


New / all TB – 98% – 96% 96% 96%

New pulmonary / new TB – 74% – 70% 71% 78%


– 51% – 51% – 51%



Default / all retreatment – 93% – 1% 0% 11%

Other retreat / all retreatment – 2% – 1% 0% 0%


92%

93%

94%

95%

96%

97%

98%

99%

1995 1999 2003 2007

New

/All

YEM EM R

60%

65%

70%

75%

80%

85%

1995 1999 2003 2007

Pulm

/New

YEM EM R

0%

10%

20%

30%

40%

50%

60%

70%

1995 1999 2003 2007

ss+/Pulm

YEM EM R



1997 60 (48–62)

2003 68 (58–73)

2008 73 (65–86)



Decreasing


Yes


Unknown


Unknown






• Data source Cubic spline using estimated incidence from 1997, 2003 and 2008







1995 31 32 9 13 9 9 4 3

1996 30 31 9 13 5 5 10 7

1997 29 29 9 12 – – – –

1998 28 28 8 12 2 2 3 2

1999 27 27 8 11 – – – –

2000 26 26 8 11 10 10 15 11

2001 25 25 8 10 8 8 12 9

2002 24 24 7 10 – – – –

2003 23 23 7 10 4 4 6 4

2004 22 22 7 9 3 3 2 1

2005 21 21 6 9 4 4 3 2

2006 21 21 6 9 5 5 7 5

2007 20 20 6 8 4 4 5 4

2008 19 8 5 5


Year Estimated


Upper bound

1995 32 25 38

1996 31 25 37

1997 29 23 35

1998 28 22 33

1999 27 21 32

2000 26 21 31

2001 25 20 30

2002 24 19 29

2003 23 19 28

2004 22 18 27

2005 21 17 25

2006 21 16 25

2007 20 16 24

2008 19 15 23


0

5

10

15

20

25

30

35

40

45

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008



report of the intercountry workshop on quality of

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