Application of the Onion model to assess the extent of missing tuberculosis cases by the National Programmes

Transcription

1 Application of the Onion model to assess the extent of missing tuberculosis cases by the National Programmes Dr Amal Bassili Stop TB unit, WHO, Regional Office for the Eastern Mediterranean Surveillance Workshop Cairo Sheraton Cairo, Egypt, October, /3/2010 1

2 Background In 2007, the estimated number of smear positive pulmonary tuberculosis was 259,885 cases while the notified number of cases was 155, 481 The Region achieved a case detection rate (CDR) of 60% and did not achieve the global target of 70% This would mean that as many as 103,954 smear positive TB patients (i.e. 40% of the total) may not have had access to appropriate TB care 2/3/2010 2

3 Background: Causes of low case detection Suboptimal quality of TB care: for example, laboratory diagnosis is not always extensive or accurate. Management of TB suspects is not yet well established. Health care providers in public and private sectors are not fully involved. Complex emergencies are affecting TB care in countries particularly those with a high burden of TB. Awareness of TB is not always high in the community, and TB is often heavily stigmatized. the care-seeking behavior of patients and the health systems responses are extremely dynamic and complex, and do not follow any stereotyped patterns. 2/3/2010 3

4 Methodology of the guide A guide with a stepwise approach was developed aiming at evaluating the efficiency of case finding activities. This guide was tested and then used in several programme review missions in the countries of the EMR. The approach is based on the patient s pathway to care from the community to the diagnostic and treatment centres for TB. The below hypothetical Onion-shaped model depicts this approach. Each layer of this Onion describes one step taken by the patient, from outer-most layer to inner-most layer, in the pathway to care and also indicates the relevant programmatic activities according to the Stop TB strategy. 2/3/2010 4

5 Estimated TB incidence Undetected TB cases in community Undetected cases at private health facilities Undetected cases at public health facilities Undetected cases at outpatient units of TBMU Undetected cases at laboratory of TBMU Step 1: ACSM Step 2: Public-Private mix, Suspect management Step 3: Public-Public mix, Suspect management Step 4: Suspect management Step 5:Laboratory diagnosis Diagnosed & reported cases by TBMU Step 6: DOT with Treatment support Monitoring and Evaluation Drug management Contact management HIV/TB MDR-TB Onion model to detect the undetected TB cases 2/3/2010 5

6 Methodology of the guide In order to measure the performance of activities in the layers of the model, a set of indicators was developed for each layer of the model All the indicators were reported in the WHO compendium of indicators. Several sources were used to collect the necessary data: Global TB Data Collection Form of WHO, programme review mission reports, countries reports, operational research studies, and the web-based quarterly reporting system from the countries of the Region to the WHO EMRO, the EMRO DOTS Quarterly online (DQ online). 2/3/2010 6

7 Methodology of the guide For each step, the recommended level (target) was in principle defined and the performance of the indicator was evaluated using a 4-point Likert scale (1 worst and 4 best) If the indicator could not be evaluated due to lack of information or due to the absence of the related activities, a zero score was given. 2/3/2010 7

8 Methodology of the guide All the indicators were given the same weight except the following: TB suspect register coverage, and the treatment success rate. These were given double weight. a good coverage of suspect register in the TBMUs and PHCs enhances timely identification of TB suspects at their first point of care in the health system. successful treatment is the most effective measure to control the disease. While this indicator is not implicated in the case finding process, it is strongly correlated with the programme performance. The sale of anti-tb drugs in private pharmacies was given a triple weight, provided it is supported by evidence. Experience has shown that,whenever the sale of anti-tb drugs is banned in the private pharmacies, the non-ntp providers refer their diagnosed cases to be treated at the NTP. This situation proved to be the most effective intervention to detect almost all cases in the country, especially, in the presence of good community accessibility to public health services. 2/3/2010

9 Methodology of the guide The percentage summation score for each component and all the components was calculated as follows: (Sum of scores obtained/maximum scores that could be obtained) X 100. Then the percentage summation score of the studied component and all the components was expressed as falling between 0 and 100%, with the highest percentage reflecting a better performance related to that component. The 95% confidence interval (CI) around the proportion was calculated. Data analysis was performed using excel. 2/3/2010 9

10 Application of the methodology The model with its indicators was applied in 3 countries of the Region: Jordan, Syria and North Sudan 2/3/

11 1. ACSM Indicators Use of TV, radio, print media as communication tool Target Measurement Wt Score 1 To become the source of information for the community No. of TV or radio announcements, or printed media 1 None printed materials Score 2 Score 3 Score 4 Additiona l media activities Full strategy implemented Knowledge about TB among TB patients and community Improved over time Proportion of individuals with correct knowledge about TB 1 <25% 25-50% 50-75% >75% Level of stigma related to TB among TB patients and community Reduced over time Mean percent score of stigma related to TB 1 >75% 50-75% 25-50% <25% Patient delay Reduced over time (target 2 weeks) Duration between the onset of symptoms and their first visit to health facilities 1 Mean 60day s Mean days Mean days 2 weeks First care-seeking behavior of patients TB centres (TBMUs or PHCs) Proportion of patients that visited TB centres 1 <25% 25-50% 50-75% >75% Civil society Increased over % of patients % 25-50% 50-75% >75% engagement time supported by NGO 2/3/

12 Indicators Use of TV, radio, print media as communication tool Jordan Limited to printed materials Score Syria 2 Limited to printed materials Score North Sudan 2 Limited to printed materials Score 2 Knowledge about TB among TB patients and community Level of stigma related to TB among TB patients and community Patient delay (duration between onset of symptoms till their first visit) 79% of TB suspects in the community had adequate knowledge about TB Mean percent score 71% for TB suspects in the community Mean of 7.4(3.9) days for TB suspects in the community 4 61% of patients had adequate knowledge about TB. 2 High among patients but not yet studied in the community 4 -Mean (SD)=80.4(79.0) % had adequate knowledge about the disease 2 The average score of stigma in the community was 54.7% in (28.1) in First health seeking behavior of patients Civil society engagement (% of patients supported by NGOs) Public health centres for 92% of the community living at >30 km from the TB centre, followed by the private sector 4 Public health centres for 21% of patients 1 Public health centres for 90% of community >75% % 2 <25% 1 2/3/

13 2-3 PPM Indicators Target Measurement Weight Score 1 Score 2 Score 3 Score 4 Presence of PPM focal person, task force and guidelines Yes Present or not 1 None Focal point Focal point and guidelines Focal point, task force and guidelines Non-NTP facilities engaged out of planned 100% No. of non-ntp health facilities participating in TB care (DOTS) / Total no. of targeted (X100) % 25-50% 50-75% >75% % of suspects referred from private and public non-ntp sector Increase over time No. of suspects referred from non-ntp providers / total number of suspects identified by NTP(X100) % 10-25% 25-50% >50% % of TB cases detected by public and private non- NTP provider Increase over time Number of TB cases detected by non-ntp providers/total number of cases (X100) % 10-25% 25-50% >50% Sale of TB Drugs in private pharmacies No Extent of sale of anti-tb drugs in private pharmacies 3 >50% of population 25-50% of population 5-25% of population No or negligible (<5%) No. of training sessions for PPM out of planned 100% No. of training sessions / total planned (X100) % 25-50% 50-75% >75% 2/3/

14 Indicators Presence of PPM focal person or task force and guidelines Jordan Score Syria Score Sudan Yes 4 Yes 4 Yes, newly appointed, guidelines developed in 2009 Score 1 Non-NTP facilities engaged out of planned % of suspects referred from public and private sector % of TB cases detected by public and private non-ntp providers Sale of TB Drugs in private pharmacies No. of training sessions and trained personnel for PPM 100% out of a total of 1540 public health facilities (75%). All the 162 (100%) private health facilities are engaged. 58% out of a total of 12,498 suspects (54.9%) were referred from public and private non-ntp providers 66% 4 66% from private and 19% from public out of a total of public health facilities (41.5%). The private sector engaged is negligible Data not available % from public sector and none from the private sector None 12 None 12 Yes 3 <25% of planned 1 <25% of planned 1 <25% of planned 1 2/3/

15 4 Suspect management Indicators % of suspects that have had sputum smear examination Target Measurement Weight Score 1 Score 2 Score 3 Score 4 100% No. of suspects who had their sputum examined at laboratory / No. of suspects identified at outpatient units (X100) 1 <75% 75-90% 90-95% >95% % of suspects diagnosed as sputum smear positive TB 10% No. of suspects with positive smears / total no. of suspects(x100) 1 >20% 15-20% >10-15% 10% TB suspect register coverage in the outpatient departments (TBMUs and PHCs) (or PAL coverage including the use of suspect register) 100% No. of outpatient departments (TBMUs and PHCs) with suspect registers / all outpatient departments (X100) % 25-50% 50-75% >75% 2/3/

16 Indicators Jordan Score Syria Score Sudan Score % of suspects that have had sputum smear examination 100% 4 95% 4 NA 0 % of suspects diagnosed as sputum smear positive TB 5.1% 4 7% 4 NA 0 % of health facilities with TB suspect register (TBMUs and PHCs) /PAL activity coverage including suspect register 100% 8 in TBMUs only 6 None 0 2/3/

17 5 Laboratory Indicators Target Measurement Weigh t Score 1 Score 2 Score 3 Score 4 Size of population per functioning diagnostic laboratory (microscopy) 1 lab per ,000 populat ion Total population / No. of functioning diagnostic laboratories 1 1 lab per >550,000 pop 1 lab per 300, ,000 pop 1 lab per 250, ,000 pop 1 lab per <250,000 population Extent of EQA coverage for direct smear microscopy 100% No. of diagnostic units submitting slides for EQA / Total no. of diagnostic units (X100) 1 <50% 50-75% 75-99% 100% Proportion of microscopy laboratories that failed to show adequate performance 0% No. of laboratories that reported major error (high false positive (HFP) or high false negative (HFN)) / No. of laboratories covered by the EQA system (X100) 1 >10% 5-10% 1-5% 0% 2/3/

18 5 Laboratory Indicators Target Measurement Weigh t Score 1 Score 2 Score 3 Score 4 Proportion of lab personnel trained out of planned 100% % of lab personnel trained out of planned 1 <50% 50-75% 75-99% 100% % of supervisory visits with feedback reports to lab out of planned 100% No. of supervisory visits conducted / No. of supervisory visits planned (X100) 1 <50% 50-75% 75-99% 100% Primary defaulter rate 0% No. of SS+ cases detected at laboratory) (No. of smear positive TB cases registered for treatment) / No of SS+ cases detected at laboratory (X100) 1 >10% 5-10% 1-5% 0% Proportion of smear positive cases among all pulmonary TB cases 60-70% No. of smear positive TB cases / No. of all pulmonary TB cases (X100) 2/3/ <40% 40-50% 50-60% >60% 18

19 Indicators Laboratory network coverage: Number of population per functioning diagnostic laboratory (microscopy) Extent of EQA coverage for direct smear microscopy Jordan Score Syria 1 per 39, per 300,000 pop 8% 1 14/65 (21.5%) Score Sudan 3 1 lab per 120,372 population Score % 2 Proportion of microscopy laboratories that failed to show adequate performance % of lab personnel trained out of planned 0% 4 22% in % % 2 88% 3 <50% 1 % of laboratories supervisory visits with feedback report 50-75% 2 80% 3 Inadequate (less than 1/lab/year) 1 Primary defaulter rate 0% 4 0% 4 Up to 50% in some centres 1 Proportion of smear positive cases among all pulmonary TB cases 71% 4 62% % 3 2/3/

20 6 Quality of NTP surveillance and case management Target Measurement Weight Score 1 Score 2 Score 3 Score 4 Report completeness 100% Number of submitted reports from TBMU/number of expected reports (X100) Direct observation of treatment (DOT) Adherence to standardized treatment regimens Treatment success rate % of annual supervisory visits with feedback reports out of planned at all levels 2/3/ % No. of patients daily supervised during the entire treatment period/ total no. of cases treated(x100) 100% No. of cases treated with correct treatment regimens / Total no. of cases eligible to the regimen (X100) >85% No. of smear positive TB patients successfully treated / No. of patients registered (X100) 100% No. of supervisory visits with feedback reports at all levels/total No. of planned visits at all levels(x100) 1 <50% 50-75% 1 <50% 50-75% 1 <50% 50-75% 2 <75% 75-80% 1 <50% 50-75% 75-99% 75-99% 75-99% 80-85% 75-99% 100% 100% 100% >85% 100% 20

21 6 Quality of NTP surveillance and case management % household contact evaluated for TB (all ages) % household contact evaluated for TB (under 5 years of age) No. & % of household contacts given INH preventive therapy (under 5 years of age) No and % of TB patients tested for HIV % of TB patients subjected to drug susceptibility testing (DST) out of eligible ones Target Measurement Wt Score 1 Score 2 Score 3 Score 4 100% No. of household contacts evaluated for TB/ total No. of household contacts (X100) 100% No. of household contacts under 5 evaluated for TB/ total No. of household contacts under 5 years of age 100% No. of under 5 years old household contacts given INH preventive therapy / No of under 5 years old household contacts (X100) Yes No of TB patients tested for HIV/ total no. of TB patients (X100) 100% No of TB patients DST tested /total no. of eligible TB patients (X100) 1 <50% 50-75% >75-95% 1 <50% 50-75% >75-95% 1 <50% 50-75% >75-95% 1 <50% 50-75% >75-95% 1 <50% 50-75% >75-95% 2/3/ % % % % %

22 Indicators Jordan Score Syria Score Sudan Report completeness 100% 4 70% in % in Score Treatment supervision & support DOT in place 4 DOT in place 4 DOT is rarely implemented 1 Adherence to standardized treatment regimens Yes 4 Yes 4 Yes 4 Treatment success rate 71% 2 86% 8 81% 6 %of annual supervisory visits with feedback reports out of planned from central to intermediate and from intermediate to peripheral levels 75-99% % 3 Only 7 states out of 15 were subjected to one supervisory visit per year from central level 2/3/

23 Indicators % household contact evaluated for TB (all ages) Jordan Score Syria Score Sudan % 4 42% 1 NA 0 Score % household contact evaluated for TB (under 5 years of age) NA 0 NA 0 NA 0 No. & % of household contacts given INH preventive therapy (under 5 years of age) 100% 4 135/396 (34%) 1 Not in place 0 No and % of TB patients tested for HIV % of TB patients DST tested out of eligible ones 100% in Q3, 2008, in 8 states out of 15 only 100% 4 100% 4 None 0 1 % of MDR-TB under treatment 100% 4 23/41 (56% in 2008) 2 None 0 2/3/

24 Summary table on the implementation of the Stop TB strategy in the different countries Components (Domains) No of indicators % weight Max score Jordan Syria N Sudan Score % Score % Score % ACSM PPM Suspect management Laboratory network Treatment and quality of NTP surveillance Total % CI 2/3/ (78-91%) (61-79%) (22-48%)

25 Correlation between CDR and Summation Score in 9 EMR countries 110 Yemen 100 syria 90 Pakistan 80 Oman 70 N Sudan Jordan 40 Iran 30 Egypt CDR (%) Afghanis Rsq = % summation score 2/3/

26 2/3/

27 Descriptive Statistics CDR SCORE Mean Std. Deviation N Correlations CDR SCORE CDR Pearson Correlation * Sig. (2-tailed)..025 N 9 9 SCORE Pearson Correlation.731* Sig. (2-tailed).025. N 9 9 *. Correlation is significant at the 0.05 level (2-tailed). 2/3/

28 Trend in TB notification in Jordan 14 TB notification rate (per population) New and relapse New smear-positive 2/3/

29 Trend in TB notification in Syria TB notification rate (per population) New and relapse New smear-positive 2/3/

30 Trend in TB notification in North Sudan TB notification rate (per population) New and relapse New smear-positive 2/3/

31 Interpretation of the model The national TB control programmes are encouraged to use this model to evaluate the case finding processes in their countries and identify areas of weaknesses which should be targeted in future interventions. The summary table shows that the NTP performance scores in Jordan and Syria were 84% and 70%, respectively. This is consistent with the Case Detection rate these countries that exceeded 70% in 2007, with the quality of their surveillance system and with the smooth annual decline (almost plateau phase) in their notifications Similarly, Sudan NTP reported a percent summation score of 35%, which is also consistent with the low Case detection rate of 31% in 2007, and with the increase in the annual trend of the disease due to inadequate TB control. 2/3/

32 Conclusion Countries are advised to use this tool to evaluate whether the situation is consistent with the case detection rate estimated for the country. For instance, if the evaluation showed that few gaps were identified while the estimated case detection rate is very low, they would conclude that the country case detection rate needs to be revisited. In such situation, it is recommended to approach WHO with the collected evidence to obtain the necessary technical assistance in carrying out one of the WHO recommended methods to estimate TB incidence in order to revisit the case detection rate and TB burden in that country. 2/3/