Appendix 3 Sample size and cost of surveys
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1 Appendix 3 Sample size and cost of surveys Here we estimate the sample sizes needed to carry out prevalence of infection and disease, incidence of disease and verbal autopsy surveys in the 22 high burden countries. These calculations only take into account the random errors associated with the sample size and do not take into account any systematic errors. A good rule of thumb is to double the sample size to allow for the design effect and incomplete data. In the case of tuberculin surveys, in particular, there is often a substantial contribution to the positive reactors from exposure to environmental mycobacteria. If, for example, half of the reactors were the result of exposure to environmental bacteria then one would have to double the sample size. In the case of incidence surveys it would be necessary to carry out two surveys, one year apart, and follow up individuals from one survey to the next. In the case of verbal autopsy surveys of death the number is the number of deaths that would have to be investigated. These calculations assume that we want to be able to detect a decrease of 25%. This number is chosen since, over a period of five years, this would correspond to a decline of about 5% per year. The incidence and prevalence are for all forms of TB as estimated in the current Global Report, 1 TB deaths as estimated in the current Global Report, 1 total deaths from the world-wide-web, and ARI from the study by Trunz et al. 2 assuming that the children in the sample are between 5 and 10 years old. Tuberculin From Table 1 it appears that tuberculin surveys can be done with sample sizes of between 1k and 3k in all countries if the data are uncontaminated by exposure to environmental mycobacteria. Recent studies in India, Kenya, Tanzania and Somalia suggest that this is unlikely to be the case and the sample size needs to be increased by a factor of three or more. About 3k to 10k is probably a realistic sample size. Prevalence of disease Prevalence surveys require sample sizes of 20k to 100k in all countries except Brazil and Russia where they would need more than 100k people. Incidence of disease Incidence surveys require larger sample sizes (and need to be repeated) but in addition to Brazil and Russia the sample size would have to be greater than 200k in China, India, Myanmar, Thailand and Vietnam. Since incidence is about 50% of prevalence where there is little HIV, sample sizes are typically about twice those for prevalence surveys and two prevalence surveys are needed to determine incidence. Incidence surveys are also logistically more difficult since they depend on following this very large number of individuals.
2 Table 1. Sample sizes for surveys in the high burden countries. ARI (%) Prevalence of infection at 7.5 yrs Prevalence of disease Incidence of disease (/yr) TB mortality (/yr) Crude death rate (/yr) Proportion deaths due to TB Afghanistan Bangladesh Brazil Cambodia China DR Congo Ethiopia India Indonesia Kenya Mozambique Myanmar Nigeria Pakistan Philippines Russian Fed South Africa Thailand Uganda UR Tanzania Viet Nam Zimbabwe
3 Death surveys Cause of death surveys using verbal autopsy can also be done with less than 10k deaths in all countries except Brazil and Russia. Table 2. Costs associated with prevalence surveys. Type Reference Cost Sample size (k) Cost per person tested (US$) Disease Bangladesh Cambodia c Eritrea a Indonesia a Kenya Tanzania 5 1,100 Vietnam a,d Vietnam b,d 3 1, Infection Kenya 5, Somalia Vietnam d a. No radiography; b. MMR; c. CXR; d. Still being planned. 1 Sebhatu, M. Determining the tuberculosis burden in Eritrea: Report of the tuberculosis prevalence survey in Eritrea Ministry of Health and National AIDS and Tuberculosis Control Division, NATCoD, (2006) 2 Ministry of Health, Tuberculosis Prevalence Survey in Cambodia 3 Development plan of the National Tuberculosis Control Programme for the period , Hanoi S.R. Vietnam, Ministry of Health 4 Report of the Study of the Prevalence of TB Infection in Somalia, Munim A, Rajab Y, Barker A, Daniel M, Williams B. 5 Marieke van der Werf, personal communication. 6 Reneé L Herminez, personal communication. Costs A number of countries have recently carried out or are planning to carry out prevalence of infection and prevalence of disease surveys but few countries provide detailed data on their cost. From the limited available data (Table 2) the cost of prevalence-of-disease surveys ranges from about US$4 to US$15 per person surveyed depending mainly on whether or not radiography is included in the screening, as noted explicitly in the plans for the survey in Vietnam. The cost of recent tuberculin surveys ranges from US$2 to US$5 per child tested. Verbal autopsy surveys may be expected to cost about US$1 to US$5 per person surveyed but more need to be done to establish the actual costs. In estimating survey costs we have also double the size of the prevalence surveys and the mortality surveys to allow for the design effect and loss to follow up and we have again 3/5
4 doubled the size of the incidence surveys since each survey needs an initial sample which must then be followed up a year or more later. The estimated costs of surveys for each of the high burden countries are given in Table 3. Table 2. Approximate costs of various surveys. For the prevalence of infection surveys in Table 1 the sample size has been multiplied by 2 and the cost is assumed to be US$2 to 5 per person tested. For the prevalence of diseases and incidence of disease surveys the sample size has been multiplied by 2 and 4, respectively, and the cost is assumed to be US$5 to 15 per person surveyed. For the cause of death surveys the sample sizes has been multiplied by 2 and the cost is assumed to be US$1 to 5 per person tested. Prevalence of infection Prevalence of disease Incidence of disease (US$M) TB deaths from VA Afghanistan Bangladesh Brazil Cambodia China DR Congo Ethiopia India Indonesia Kenya Mozambique Myanmar Nigeria Pakistan Philippines Russian Fed South Africa Thailand Uganda UR Tanzania Viet Nam Zimbabwe The average cost of the prevalence of infection surveys ranges from about US$10k to US$20k. The average cost of prevalence of disease surveys ranges from about US$600k to US$ 1.7M with the lower estimate for surveys without radiography and the upper estimate for surveys with radiography. In the case of Brazil, however, where the prevalence of infection is low the cost of a prevalence survey with radiography could reach US$7M. The average cost 4/5
5 of incidence of disease surveys ranges from about US$1.6M to US$4.9M again with the lower estimate for surveys without radiography and the upper estimate for surveys with radiography. The average cost of cause of death surveys ranges from US$90k to US$260k depending on the cost of doing verbal autopsies. References 1. World Health Organization. Global Tuberculosis Control: Surveillance, Planning, Financing. World Health Organization, Geneva (2006). 2. Trunz, B. B., Fine, P. & Dye, C. Effect of BCG vaccination on childhood tuberculous meningitis and miliary tuberculosis worldwide: a meta-analysis and assessment of cost-effectiveness. Lancet 367, (2006). 5/5
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