Tuberculosis Epidemiological Surveillance Report AFRO 2003

Transcription

1 Tuberculosis Epidemiological Surveillance Report AFRO 2003 TB Case Notification Rates, WHO African Region, 2002 Case Notification Rates (per ) <100 Not Reporting Outside AFRO Division of Disease Prevention and Control WHO OFFICE FOR THE AFRICAN REGION Harare, Zimbabwe

2 Preface: Reducing the high burden of Tuberculosis is still an enormous challenge for the African Region. Even though the Region is home to only 10.1% of the world population, it contributes no less than 20 percent of reported TB cases annually 1. In 2001, the Region contributed 20.1% of total notified TB cases and 23.8% of new smear positive cases globally. Within the region, overall notified cases have continued to rise, and new smear positive cases more so 2. In-spite of the increase in notifications, estimated detection and treatment success rate for new smear positive remain generally low compared to global and regional targets. This is believed to be partly due to insufficient coverage of at risk populations with effective diagnostic and treatment services. The priority for TB Control in the Region must therefore be first and foremost universal adoption of the WHO/IUATLD recommended Directly Observed Therapy Short-course Strategy (DOTS) followed by increasing involvement of all public and private health services in the delivery of those services. Government commitment will need to be maintained and effective control programmes developed in all member states. This is possible through the recently heightened political commitments of African Heads of State and Government and the International community. To facilitate assessment of progress with regard to control efforts, monitoring and evaluation is one of the key elements of the DOTS strategy. This is currently being done through regular surveillance of case finding and treatment outcomes and this report is a product of such routine surveillance undertakings in countries. The report contains a lot of information it is not possible to discuss all of it exhaustively. Countries are therefore encouraged to examine their own data with a view to improving programme performance to the extent possible. Dr A.B Kabore Director Division of Communicable Disease Prevention and Control WHO Office for the African Region Highlands, Harare, Zimbabwe 1 WHO Report 2003: Global Tuberculosis Control Surveillance, Planning, Financing: WHO/CDS/TB/ Regional TB Surveillance Report WHO Office for the African Region. 2

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4 Acknowledgements The principal author of this report is Dr Wilfred Nkhoma, Medical Officer in the TB Unit, Division of the Prevention and Control of Communicable Diseases (DDC), WHO/AFRO. The database used for deriving the report was created and updated in close collaboration with Mrs. Anna Madzongwe, secretary in the TB Unit. Invaluable inputs in preparing the report were received from all professional staff of the TB Unit led by Dr E. Nyarko, the Regional TB Advisor. The others were Ms Vainess Mfungwe, Technical Officer TB Unit, Dr Oumou Bah-Sow, Medical Officer TB Unit, Dr Daniel Kibuga, Medical Officer TB Unit, Dr Coulibaly Doulhourou, Medical Officer TB Unit, Professor Bah-Keita, ICP/TUB West Africa, Dr Robert Makombe, ICP/TUB Southern Africa; and all support staff both at Regional and country level. Special acknowledgement goes to all National TB Control Programme Managers, TB Coordinators at various levels and other programme staff who graciously generated and consolidated the country level surveillance data that was subsequently shared with the WHO both at Regional and Headquarters level. That data constitutes the raw material for this report. We also acknowledge inputs from other WHO/AFRO staff that took time to comment on the initial versions of the report and contributed to its completion. Ms Erica Kufa, data officer with RPA/AFRO did the data mapping and generation of epidemiological maps in the report and is especially recognized for her valuable contribution. The collaboration of Dr Chris Dye and the TME team at Stop TB Department, WHO Headquarters in Geneva in producing the Global data collection form, and sharing available data profiles for countries is also greatly appreciated. We owe it to one and all. Without any one of the above, the contents and quality of the report would not have been the same. 4

5 List of Abbreviations GDF DOTS DRC HIV HIV/AIDS NSN NSP NNSD NEP NON DOTS SADC TB TB/HIV WHO WHO/AFRO Global anti-tb Drug Facility Directly Observed Treatment Short Course Democratic Republic of Congo Human Immunodeficiency Virus Human Immunodeficiency Virus and Acquired Immuno-deficiency Syndrome New Smear Negative New Smear Positive New Smear Not Done New Extra-Pulmonary Not implementing Directly Observed Treatment Short Course Southern African Development Community Tuberculosis Human Immunodeficiency Virus related Tuberculosis World Health Organization World Health Organization Regional Office for Africa 5

6 Table of Contents Section Description Page Table of contents 5 1 Introduction 6 2 Methods 7 3 Results Completeness of reporting Dots Implementation and population coverage TB notifications January to December 2002 Notifications by type of TB and DOTS status Notification rates New smear positive case notification rates Notifications by epidemiologic blocs Notifications from Central Epidemiological Bloc Notifications from Eastern Epidemiological Bloc Notifications from Islands Epidemiological Bloc Notifications from Southern Epidemiological Bloc Notifications from Western Epidemiological Bloc Notification of smear positive TB cases by age group, sex and DOTS implementation status Trend of new smear positive cases and rates Trend of new smear positive cases Treatment outcomes Treatment outcomes for New and retreatment smear positive cases registered in 2001 Conclusions and Discussions Overall notifications Notifications by Epidemiological bloc Central bloc Eastern Bloc Islands bloc Southern bloc Western bloc Notification rates Overall case notification rates in DOTS areas Notification rates for new smear positive cases in DOTS areas Notification of new smear positive cases by age group and sex in DOTS areas Treatment outcomes DOTS areas Non DOTS areas Annexes

7 1: INTRODUCTION The purpose of this Regional Surveillance Report is to provide a synopsis of TB burden and TB Control Programme implementation in the region at a point in time. It provides an analysis of notified TB cases by type, and treatment outcomes for new and retreated TB cases in an annual cohort. This allows tracking of progress towards Global and Regional targets, as well as assessment of programme performance at regional and country levels. The report should allow countries to relate their own Control Programme performance in a particular time period to other countries and regional average, but equally importantly to themselves overtime. While the Global Report discusses in detail only few selected Global TB High Burden countries (HBCs), the regional report also discusses those with low and intermediate burden. This should help to provide a more complete picture of the burden of disease and control performance in the region. In order to relate regional performance to Global targets, reference will be made to WHA TB control targets for 2005 with the aim of highlighting gaps at regional and country levels. In addition to the WHA targets, the report will also make reference to the Millennium Development Goals targets for 2015 as the ultimate goal on a continuum of outcome and impact indicators. Monitoring and Evaluation (M&E) of the epidemic and control activities must of necessity remain an on-going exercise at country and regional levels and include standardized recording and reporting systems to ensure valid comparisons within and between countries. This way of collecting data on a regular basis helps the countries and regional office to monitor trends and program performance useful for country, sub-regional and regional level planning of control strategies, and need for resources. 7

8 2: METHODS As is the case every year, a standard WHO TB data collection form was sent to all countries in the region to report on standardized administrative, epidemiological and financial aspects of their control programmes. The form covered information on registered TB cases for the period January to December 2002 and treatment outcomes for patients registered during the period January to December 2001 inclusive. Completed data collection forms were returned to the Regional Office where a regional database was created and the data therein computerized in Excel software. The data collection form had 6 sections. Section 1 covered programme and country identification information while sections 2 and 3 covered information on policies and strategies of the control program including extent of coverage with services in DOTS and non-dots implementing areas during the period under review. Section 4 of the form covered information on notified TB cases by type (i.e. new pulmonary smear positive (NSP); new pulmonary smear negative (NSN); new pulmonary smear not done (NNSD), new extra-pulmonary (NEP); relapse pulmonary smear positive (RELAPSE); pulmonary smear-positive re-treatment after failure; and other re-treatment cases (OTHER). Section 5 covered breakdown of new smear positive cases reported in section 4 above by age group and sex while section 6 covered information on treatment outcomes for new and retreated smear positive cases registered until 18 months previously. The lag period between the time of registration of cases and assessment of treatment outcomes is to allow countries up to 6 months to collect outcomes on the last cases registered in the cohort under review. Data on case notifications was examined for completeness and consistency between sections while cases evaluated for treatment outcomes were compared with number of cases notified in each relevant category two years previously. Where more cases were evaluated than previously registered, the larger number was adopted as the cases registered. Where necessary, clarification and updating was sought from countries. Under treatment outcomes analysis, cases were evaluated under the intention to treat principle. Cases notified previously or declared in the report, whichever was the greater of the two was taken as the denominator for assessing outcomes. Cases notified earlier but not evaluated were classified under default. In general however, data was entered as declared by the reporting agency. 8

9 3: RESULTS 3.1. COMPLETENESS OF REPORTING: Duly completed WHO TB data collection forms for cases registered between January to December 2002 and treatment outcomes for cases registered during the cohort January to December 2001 were received from forty-two of the forty-six member states in the Region, representing a return rate of 91.3%. This compares favorable to return rates of 82.6% (38 of 46 countries) for the calendar year 2000 and 67.4% (31 of 46 countries) for the calendar year 2001 respectively. Four countries, namely, Comoros, Equatorial Guinea, Liberia and Niger did not submit completed data collection forms. 3.2: DOTS IMPLEMENTATION AND POPULATION COVERAGE Forty-one of the forty-two countries that submitted completed forms reported implementing TB Control services based on the DOTS principle and provided information on estimated population coverage with TB DOTS services. Collectively, countries reported an average geographical DOTS coverage of 78.7% with a range of between %. Nineteen (19) of the forty-one countries (46.3%) reported countrywide DOTS coverage, while Gabon and Cape Verde reported DOTS coverage for the first time. There were also countries that varied the coverage between years. Congo Brazzaville that had hitherto reported 100% this time reported 20% coverage, a figure considered more realistic based on consistency between sections of the DOTS reporting form. Similarly, Angola that had hitherto reported 46% coverage, this time reported 14% coverage. Again this is considered consistent with other pieces of data reported in the data collection form. Table and Figure below show estimated DOTS coverage by country in the African Region as at end December 2002: 9

10 Table 3.2.1: Reported population DOTS coverage by country. Country DOTS coverage (%) Comments on status of coverage Algeria 100 Angola 14 (cf 46.0 in 2001) 69.6% drop compared to previous year s coverage Benin 100 Botswana 100 Burkina Faso 100 Burundi 91 Cameroon 90 (cf 46.0 in 2001) 95.7% increase in coverage from previous year Cape Vert 40 CAR 75 Comoros No report for 2002 Congo Brazzaville 20 (cf 100 in 2001) * 80% drop in coverage from previous year Cote D Ivoire 74 (cf 60.0 in 2001) 23.3%increase in coverage from previous year DRC 70.0 Equatorial Guinea No report for 2002 Eritrea 80.0 (cf 60 in 2001) 33.3% increase in DOTS coverage Ethiopia 95.0 (cf 85 in 2001) 11.8% increase in coverage from previous year Gabon 22 First report in recent times Gambia 100 Ghana 100 (cf 87 in 2001) 13% increase from previous year Guinea Bissau 20 (cf 95 in 2001) 78.9% drop in coverage from previous year Guinea Conakry 100 Kenya 100 Liberia No report for 2002 Madagascar 100 Malawi 100 Mali 68 (cf 95.5 in 2001) 28.8% drop in coverage from previous year Mauritania 53 Mauritius 100 Mozambique 40 (cf 100 in 2001) Namibia 60 (cf 100 in 2001) Niger No report for 2002 (cf 70 in 2001) Nigeria 55 (cf 47.0 in 2001) Rwanda 100 Sao Tome Principe Non DOTS but reported Non DOTS Senegal 100 Seychelles 100 Sierra Leone 93% (cf 50 in 2001) 86% increase in coverage from previous year South Africa 98% (cf 77% in 2001) 27.3% increase in coverage Swaziland 100 (cf 77 in 2001) 29.8% increase in reported coverage Tanzania 100 Tchad 98 Togo 35 Uganda 100 Zambia 55 (cf Non DOTS in 2001) Reported DOTS coverage after 4 years break Zimbabwe 100 * REGION 78.7% (cf 84.7% in 2001) Some drop from 82.0% coverage in previous year 10

11 Figure 3.2.1: Map of DOTS coverage by country. WHO/AFRO DOTS Coverage, WHO African Region, 2002 DOTS Coverage Nationwide Percent Percent Not Implementing DOTS Not Reporting Outside AFRO

12 3.3: TB NOTIFICATIONS JANUARY TO DECEMBER : Notifications by type of TB and DOTS status The 42 countries notified a total of 1,018,499 TB cases of all types for the year Of these, 453,625 (44.5%) were new smear positive, 233,315 (22.9%) were new smear negative, 168,344 (16.5%) were new extra-pulmonary, and 48,129 (4.7%) were smear positive relapse cases. Of the remaining117,086 cases, 90,190 (8.9%) were new cases without sputum smear results at the start of treatment and 26, 896 (2.4%) were other retreatment cases. By origin, the majority of cases were notified from DOTS programmes (984,220 of 1,018,499 cases (96.6%)). Of these, 439,790 (44.7%) were new smear positive, 219,012 (22.3%) were new smear negative, 166,593 (16.9%) were new extra-pulmonary, and 46,446 (4.7%) were smear positive relapses. Another 87,690 cases (8.9%) were new cases that had no sputum smears done at the start of treatment. This includes children. The remaining 24,689 cases were other retreatment cases. On the other hand, non-dots implementing programmes and areas notified a total of 34,279 cases (3.4% of total notified cases). Of these, 13,835 cases (40.3%) were new smear positive while 14,303 cases (41.7%) were new smear negative. This compares with 44.7% and 22.3% respectively for DOTS programmes and areas. Figure below shows the proportion of notified cases by DOTS status. Figure 3.3.1: Proportion of notified cases by DOTS status Proportion of notified cases by type and DOTS status. AFRO Proportion (%) S+ve S-ve No smear NEP Relapse Other Non DOTS DOTS Type of TB

13 Tables 3.3.1, Figures and below, and Annex 1.2 in the Annex respectively show summary notified cases by type and DOTS status, cases by type of disease and country in DOTS areas; in Non-DOTS areas, and maps of notification rates for total cases and new smear positive cases respectively. Table 3.3.1: Summary notified cases by type of disease and DOTS status DOTS areas NSP NSN NNSD NEP Relapse Other Total NON-DOTS areas Regional Total Figure 3.3.2: Notified cases by type of TB and DOTS status DOTS areas NON-DOTS areas Regional Total Notifications (absolute numbers) NSP NSN NNSD NEP Relapse Other Total Type of TB 13

14 Table (a): Notifications by country and type of TB in DOTS areas. WHO/AFRO DOTS Not Rate Est TB CDR rate ** (%)** Country DOTS NSP NSN NNSD NEP Relapse Other Total Population Algeria ,266, Angola ,184, Benin ,558, Botswana ,770, Burkina Faso ,624, Burundi ,602, Cape Vert , CAR ,819, Cameroon ,729, Comoros No Report 747, ? Congo Brazzaville ,633, Cote d'ivore ,365, DRC ,201, Equatorial Guinea No Report 81, ? Eritrea ,991, Ethiopia ,961, Gabon ,306, Gambia ,388, Ghana ,471, Guinea Bissau ,449, Guinea Conakry ,359, Kenya ,540, Lesotho ,800, Liberia No Report 3,239, ? Madagascar ,916, Malawi ,871, Mali ,623, Mauritius ,807, Mauritania ,210, ? Mozambique ,537, Namibia ,961, Niger No Report 11,544, Nigeria ,911, Rwanda ,272, Sao Tome Principe Non DOTS 157, Senegal ,855, Seychelles , Sierra Leone ,764, South Africa ,759, Swaziland ,069, , Tanzania ,276, Tchad ,348, Togo ,801, Uganda ,004, Zambia ,698, Zimbabwe ,635, Regional totals ,035, % OF Regional Total Regional rate ** =Estimated total TB prevalence rate and average overall case detection rate (CDR) adopted from WHO Report Global Tuberculosis Control. Surveillance, Planning and Financing. World Health Organization. 45

15 3.3.2: Notification rates: With an estimated 671 million population, the million cases notified in 2002 translate into an overall notification rate of TB cases per 100,000 population. The rates ranged from 5.0 in Mauritius to per 100,000 in Namibia. The top ten countries with regard to overall notification rates were Namibia (709.6), Swaziland (642.4), Botswana (576.5), Lesotho (561.7), Zimbabwe (508.6), South Africa (493.6), Zambia (390.4), Kenya (260.3), Congo Brazzaville (253.5) and Malawi (223.5). Congo Brazzaville in spite of the currently low DOTS coverage emerges as a clear outlier among countries in her own sub-region. Higher coverage will most probably raise her ranking on the list and calls for intensified support and action to preempt a graver situation. Twenty-one other countries had notification rates between 5 and 100 per 100,000 populations. Figures (a): Map of case notification rates (All forms). AFRO 2002 Case Notification Rates (per ) <100 Not Reporting Outside AFRO

16 3.3.3: New smear positive case notification rates. AFRO 2002 The average notification rate for new smear positive TB cases was 66 per 100,000 populations. However, higher rates were mostly noted in the southern and eastern African sub-regions with blips in central and western sub-regions as well. The pattern of distribution rates is shown in the shaded map below: Figures (b): Map of new smear positive TB case notification rates. AFRO 2002 New Smear Positive Case Notification Rates Not Reporting Outside AFRO 16

17 Notification rates for new smear positive TB cases by country. AFRO 2002 By country, the rates ranged from 3.1 per 100,000 population in Mauritius to per 100,000 population in Namibia. Thus Namibia still has the highest notification rates of all countries in the Region. The top ten notification rates were as follows: Namibia (232.8), South Africa (218.2), Botswana (188.4), Lesotho (175.9), Zimbabwe (137.0), Swaziland (131.9), Angola (131.6), Mauritania (124.0), Congo Brazzaville (115.8) and Zambia (109.3). This is rather similar to the trend of total notification rates in the figures above. However, it must be noted that Mauritania that did not feature among the top ten for overall notifications, has emerged among the top ten for new smear positive cases. TB Notification rates by country. DOTS areas. AFRO Notification rate (per 100,000) Algeria Benin Burkina Faso Cape Vert Cameroon Congo Brazaville DRC Eritrea Gabon Ghana Guinea Conakry Lesotho Madagascar 95.1 Country Mali Mauritania Namibia Nigeria Sao Tome Principe Seychelles South Africa Tanzania Togo Zambia Region 146.7

18 3.4: Notifications by Epidemiological blocs: The 46 countries in the WHO African Region are grouped into five epidemiological blocs for purposes of disease surveillance and response. These are shown in Table below. Table 3.4.1: WHO/AFRO Epidemiological blocs Central Eastern Islands Southern Western 1: Cameroon 1: Burundi 1: Cape Verde 1: Angola 1: Algeria 2: Central African 2: Eritrea 2: Comoros 2: Botswana 2. Benin Republic 3: Ethiopia 3: Mauritius 3: Lesotho 3: Burkina Faso 3: Congo Brazzaville 4:Kenya 4: Sao Tome 4: Madagascar 4. Cote d Ívoire 4: Congo Kinshasa 5: Gabon 6: Chad 7: Equatorial Guinea 5: Rwanda 6: Tanzania 7: Uganda & Principe 5: Seychelles 5: Malawi 6: Mozambique 7: Namibia 5. Gambia 6. Ghana 7. Guinea Bissau 8:.Guinea Conakry 8: South 9: Liberia Africa 10: Mali 9: Swaziland 10: Zambia 11: Zimbabwe 11: Mauritania 12: Niger 13: Nigeria 14: Senegal 15: Sierra Leone 16: Togo Both in terms of absolute numbers and proportion, most cases were notified from DOTS areas of Southern Bloc (46.5%), followed by Eastern Bloc (32.4%), Western Bloc (10.8%) and Central Bloc (10.4%) in that order. See Tables 3.4.1(a) and (b) and Figure below. Table 3.4.1(a): Notifications by type by Epidemiological Bloc. AFRO DOTS areas Bloc DOTS NSP NSN NNSD NEP Relapse Other Total Central Eastern Islands Southern Western Region % of Total

19 Table 3.4.1(b): Notifications by type by Epidemiological Bloc. AFRO Non-DOTS areas Bloc NSP NSN NNSD NEP Relapse Other Total Notified Central Eastern Islands Southern Western Region % of total Figure 3.4.1: Proportion of notified total TB cases by Epidemiological Bloc. AFRO 2002 Proportion of notified TB cases by Epidemiological Bloc. AFRO 2002 Western 11% Central 10% Eastern 32% Southern 47% Islands 0% 19

20 3.4.2: Notifications from Central Epidemiological Bloc Complete TB surveillance data forms were received from all seven countries in the Bloc except Guinea Equatorial. From DOTS areas, a total of 102,780 TB cases of all forms (cf 75,723 cases in 2000) were notified, representing 10.4% of all the cases registered in DOTS areas in the Region. Of these, 63,197 (61.7%) were new smear positive (cf 44,803 in 2000), representing 14.3% (cf 12% in 2000) of all new smear positive TB cases registered in the region. Another 2,283 cases were notified from Non-DOTS areas in this Bloc. Tables (a) & (b) in the Annex show notifications in DOTS and Non-DOTS areas in the Central Epidemiological Bloc : Notifications from Eastern Epidemiological bloc: Dully completed reports were received back from all seven countries in the bloc, all of which are implementing the DOTS Strategy. A total of 313,578 TB cases of all forms (cf 252,417 in 2000) were notified, representing 32% of all cases registered in the Region (cf 34% in 2000). Out of these, 121,495 cases (38.7%) were new smear positive cases (cf 104,799 in 2000) representing 27.1% (cf 28.8% in 2000) of all new smear positive TB cases registered in the Region. The bloc also contributed 100,700 new smear negative cases and 69,910 new extra pulmonary TB cases representing 43.6% and 42.2% of all new smear negative and extra-pulmonary TB cases registered in the Region respectively (cf 44.8% and 39.7% respectively in 2000). The Eastern bloc thus contributed at least a third of the notified TB cases in the region during As expected, the bulk of the cases in the bloc were notified from Ethiopia, Kenya, Tanzania and Uganda. Ethiopia was also responsible for more than half of the new extra-pulmonary cases reported from the bloc (38,798 of 69,910 (55.5%) and 23.3% of all extra-pulmonary cases notified in the region (38,798 of 166,593 cases). See Annex

21 3.4.4: Notifications from Islands Epidemiological bloc: Out of the five countries in this bloc, Comoros did not submit a completed data collection form for the year From the four that submitted reports, a total of 493 TB cases of all forms were notified (cf 300 total cases in 2000) in DOTS and Non-DOTS areas (Sao Tome & Principe). This represents 0.0% (cf 0.1% in 2000) of the total cases notified in the region. See Annex : Notifications from Southern Epidemiological bloc: Countries belonging to the Southern African Development Community (SADC) dominate the southern Epidemiologic bloc. Most of the countries in this bloc are severely affected by the dual TB/HIV epidemic because of a high background prevalence of HIV/AIDS in the general population. In the year under review, all the eleven countries in the bloc submitted completed reports. The countries together notified 477,001 TB cases of all forms, representing about 47% (cf 41.6% in 2000) of regional total notifications. Out of these, 192,350 (41.2%) were new smear positive cases, representing 42.9% (cf 40.6% in 2000) of total new smear positive TB cases notified in the Region. Out of the total cases notified, 460,220 (94.5%) were from DOTS areas. Of these, 195,517 (40.9%) were new smear positive, representing 44.5% (cf 40.6% in 2000) of total new smear positive cases notified in Ninety-one thousand seven hundred and twenty six cases (91,726 (19.3%) ) were new sputum smear negative, 82,434 (17.3%) had no smears at the start of treatment (representing 91.4% of cases without sputum smear at the start of treatment (cf 83.9% in 2000)) and 31,512 (6.6%) were smear positive relapse cases. There were 63,393 new extrapulmonary cases accounting for 13.3% of total cases in the bloc. Annexes (a) and (b) show notifications by type from the Southern Epidemiological Bloc : Notifications from Western Epidemiological bloc: This is the bloc with the most number of countries in the Region. In the year under review, two of the 16 countries did not submit completed reports. These are Liberia and Niger. The fourteen countries that submitted reports notified a total of 122,647 cases (cf 106,902 cases in 2000) representing 12% (cf 14.4% in 2000) of all cases notified in the Region during the year. The distribution of notified cases in DOTS and Non-Dots areas in the Western bloc are shown in Annex (a) & (b). 21

22 3.5: Notification of smear positive TB cases by age group, sex and DOTS implementation status A total of 439,790 new smear positive TB cases were notified from DOTS areas in the Region during However, as in previous years, there were discrepancies between notified cases and those broken down by age group and sex. Even though only 439,790 cases were notified, a total of 448,418 cases were broken down by age and sex (8,628 cases (1.9%) more). The latter are the cases analyzed in this report. The new smear positive cases were made up of 246, 658 males (55.0%) and 201,760 (45%) females. For both males and females, most of the notified new smear positive cases fell in the age group years. Thereafter, the order changed. Among males, the second most affected age groups were the followed by year olds in that order. For females on the other hand, the second most affected age groups were the and year olds in that order. Tables (a) & (b) and Figure below show the proportionate distribution of notified new smear positive TB cases by age group and sex in the African Region in

23 Table 3.5.1(a): Number of new smear positive TB cases by age group and sex. DOTS areas. Females. AFRO, 2002 Country TOTAL Algeria Angola Benin Botswana Burkina Faso Burundi Cape Vert CAR Cameroon Comoros No report Congo Brazaville Cote d'ivore DRC Equatorial Guinea No report 0 Eritrea Ethiopia Gabon Gambia Ghana Guinea Bissau Guinea Conakry Kenya Lesotho Liberia No report Madagascar Malawi Mali Mauritius Mauritania Mozambique Namibia Niger No report Nigeria Rwanda Sao Tome Senegal Seychelles Sierra Leone South Africa Swaziland Tanzania Tchad Togo Uganda Zambia Zimbabwe Regional Total % of Total for females

24 Table 3.5.1(b): Number of notified new smear positive cases by age group and sex. DOTS areas. Males, AFRO 2002 Country TOTAL Algeria Angola Benin Botswana Burkina Faso Burundi Cape Vert CAR Cameroon Cape Verde Non DOTS Comoros No report Congo Brazzaville Cote d'ivore DRC Equatorial Guinea No report 0 Eritrea Ethiopia Gabon Gambia Ghana Guinea Bissau Guinea Conakry Kenya Lesotho Madagascar Malawi Mali Mauritius Mauritania Mozambique Namibia Niger No report 0 Nigeria Rwanda Sao Tome Senegal Seychelles Sierra Leone South Africa Swaziland Tanzania Tchad Togo Uganda Zambia Zimbabwe Regional Total % of total males

25 Figure 3.5.1: Proportion of notified new smear positive cases by age group and sex. AFRO Males Proportion of notified cases by age group and sex. AFRO Proportion of notified cases (%) Males Females Regional Age group Males Females Regional 25

26 4: Trends of cases and rates. 4.1: Trend of new smear positive cases Over the passing years, notified new smear positive TB cases have increased in the region. In 2002, just over 450,000 new cases were notified. Table 4.1 below shows the trend of notified absolute cases between 1995 to 2002, and Figure 4.1 shows the trend of notification rates for total and new notified TB cases for the period Trend of Reported New smear positive TB cases WHO/AFRO , , , , , ,926 Number of cases , ,

27 Figure 4.1: Trend of notification rates. Total and new cases Total andsmear positive Notificationsrates. AFRO Rate per 100, Year Total rate S+verate 27

28 5 TREATMENT OUTCOMES 5.1: Treatment outcomes for New and retreatment smear positive cases registered in 2001 A total of 379,780 new smear positive cases were reported registered in DOTS areas in Out of these, 223,099 cases (58.7%) were cured while 47,099 cases (12.4%) completed treatment without end term smear results, giving a treatment success rate of 71.1% for the region. There was a 7.1% death rate (26,989 deaths with TB), 4,401 (1.2%) treatment failure rate, 39,473 (10.4%) defaulter rate and 25,222 (6.6%) transfer out rate. The remaining 13,497 cases (3.6%) were not evaluated for treatment outcomes. Table 5.1(a), (b) & (c), and Figure 5.1 below show the treatment outcomes for new and retreatment TB cases. Table 5.1(a): Summary outcomes for new and retreatment smear positive TB cases registered in 2001 Category of case Cured Completed Success rate Died Failed Defaulted Transferred Out Not Eva Total New cases Retreatment

29 Table 5.1(b): Treatment outcomes for new smear positive TB cases registered Jan-Dec WHO/AFRO. Country Registered Cured % cure Completed % % Compl success Died % Death Failed % Failed Defaulted %Default T/OUT % T/out Evaluated % Evaluated Algeria Angola Benin Botswana Burkina Faso Burundi Cape Vert CAR Cameroon Comoros No report Congo Brazzaville Cote d'ivore DRC Equatorial Guinea No Report Eritrea Ethiopia Gambia Gabon Ghana Guinea Bissau Guinea Conakry Kenya Lesotho Madagascar Malawi Mali

30 Mauritius Mauritania Mozambique Namibia Niger No Report Nigeria Rwanda No results Sao Tome Non DOTS 0 Senegal Seychelles Sierra Leone South Africa , Swaziland Tanzania Tchad No results 0 Togo Uganda Zambia Zimbabwe Regional Total E ,

31 Table 5.1(c): Treatment outcomes for retreatment smear positive TB cases registered Jan-Dec WHO/AFRO Country Registered Cured % Cured % Completed Complet % Success Died % Died Failed % Failed Defaulted % Default T/OUT % T/Out Total Eva % Eval Algeria Angola No info Benin Botswana Burkina Faso Burundi Cape Vert No info CAR Cameroon Comoros No report Congo Brazzaville No info Cote d'ivore DRC No info Equatorial Guinea No report Eritrea Ethiopia Gabon Gambia Ghana No info Guinea Bissau Guinea Conakry Kenya Lesotho Madagascar Malawi Mali Mauritius

32 Mauritania Mozambique Namibia Niger No report Nigeria Rwanda No info Sao Tome Non DOTS Senegal Seychelles No info Sierra Leone South Africa Swaziland Tanzania Tchad No info Togo Uganda Zambia Zimbabwe Regional Total

33 Figure 5.1: Treatment outcomes for new and retreatment TB cases Treatment outcomes. New and Treatment cases. AFRO 2001 Cohort Proportion (%) Cured Completed Success Died Failed Defaulted Transferred Out Not Eva New cases Retreatment Treatment outcomes New cases Retreatment

34 Figure 5.2: Treatment outcomes by Bloc. AFRO 2001 Cohort Proportion (%) Cured Completed Success Died Failed Defaulted T/out No Eva Total Treatment outcome Central Eastern Islands Southern Western 34

35 Figure 5.3: Trend of Treatment outcomes for new and retreatment TB cases: Treatment success rates. New and retreatment cases. AFRO Treatment success rate (%) Year New cases Retreatment cases 35

36 6: CONCLUSIONS AND DISCUSSIONS 6.1: OVERALL NOTIFICATIONS Between January and December 2002 inclusive, just over a million TB cases were notified to WHO from member states. Over 90% of cases (96.6%) were notified from DOTS programmes and areas within countries. Average population DOTS coverage was estimated at 78.7% with a range of %. Even though reported DOTS coverage during the year was lower than in the previous year, to the extent that approximately 97% of notifications were from DOTS areas and programmes in the region, there is a strong indication of the widespread adoption of the DOTS strategy in the region. Within the DOTS programme, 44.7% were new smear positive, 22.3% were new smear negative, 16.9% were new extra-pulmonary cases and 4.7% were smear positive relapse cases. Another 2.5% were other cases, not falling in any of the major categories in the WHO data collection form. The predominance of new smear positive cases suggests predominant use of sputum microscopy as the primary mode of diagnosis in the majority of countries while a relapse rate of less than 5% strongly argues for high effectiveness of anti-tb drug regimens in use in most countries. This is to be expected if indeed the generally more effective short course chemotherapy regimens are in use in the predominant DOTS programmes. Non-DOTS programmes notified a total of 34,279 cases of all forms. Of these, 40.4% (13,835 cases) were new smear positive, 41.7% (14,303 cases) were new smear negative cases and 4.7% were relapse cases. Other cases accounted for 0.6% of the notifications. The majority of cases from non-dots programmes were reported from the Southern (16,781 cases) and Western (15,106 cases) blocs respectively. In proportion to overall notifications, the Western bloc notified the highest number of cases from non-dots areas (mostly from Nigeria, Cote D Ivoire and Togo). By country, the majority of cases reported from non-dots programmes and areas came from Zambia, Nigeria, Cote D Ivoire, South Africa, Angola and Central African Republic (CAR) in that order. In relation to population at risk, Zambia with a population of just over 11 million made the greatest contribution to the total number notified. This is because Zambia has only recently started to re-establish her DOTS programme after a period of uncertain structure for TB Control. This is already being actively scaled up and Zambia should be able to quickly increase 36

37 population coverage with DOTS services in the short to medium term. In the final analysis, efforts to attain region wide implementation of the DOTS strategy must include these countries, among others. 6.2: NOTIFICATIONS BY EPIDEMILOGIC BLOC 6.2.1: Central epidemiological bloc: The Central Epidemiological bloc contributed 10.4% of the total cases notified from DOTS areas. Of the notified cases in this bloc, 61.7% were new smear positive, 13.8% were new smear negative and 17.9% were new extra-pulmonary cases. Relapse cases accounted for 4.1%. As in the overall regional picture, there is a predominance of new smear positive cases among the notified cases compared to other forms. However, as in previous years, the predominance in this as well as the western and central blocs tends to exceed that observed in southern and eastern sub-regions. Non-DOTS areas in the bloc notified 2,283 cases (6.7% of all cases notified from non-dots areas). Most of the cases in this bloc (57.7%) were from the Central African Republic (1,318 of 2,283 cases). This is not consistent with the reported 75% population coverage with DOTS services in that country and calls for strengthening and scale up of DOTS services to improve quality of services : Eastern epidemiological bloc: The Eastern bloc accounted for 31.9% of the cases notified from DOTS areas in the region. All the countries in the bloc are implementing DOTS countrywide. Of the notified cases 38.7% were new smear positive cases, 32.1% were new smear negative and 2.6% were relapses. New extrapulmonary cases accounted for 22.3%, the highest proportion in any bloc. This has resulted in a relatively low proportion of new smear positive cases compared to all the other blocs including the southern bloc that is known to have a higher prevalence of HIV in the general population and among TB patients. Most of the EP cases (55.5%) were reported from Ethiopia (38,798 of 69,910 EP cases) where the proportion of EP cases among notified cases has overtaken the proportions of both new smear positive and smear negative cases. Tanzania and Kenya were the other countries with significant 37

38 contributions accounting for 17.9% (12,508 cases) and 16.6% (11,578 cases) of the total EP cases for the bloc respectively. There is an urgent need to explain the reversal of proportions, especially in Ethiopia, the only country in the region with this kind of distribution : Islands epidemiological bloc: As has been the case in previous years, the Islands bloc contributed only 0.03% of the total notified cases. New smear positive cases also predominate, as is the case in the other blocs. However, in contrast to other blocs, the proportion of other cases was highest in the Islands, and all these cases were reported from Cape Vert. The occurrence is worthy close scrutiny. A total of 109 cases were reported from non-dots areas in the bloc. All the cases were notified from Sao Tome and Principe, the only country not yet adopted the DOTS strategy in the bloc. It is important to support the adoption of DOTS in that country in the short to medium term in order to further improve the performance of the bloc with regard to regional and global TB control targets : Southern epidemiological bloc The southern bloc continues to be the dominant bloc in terms of regional notifications. During 2002, the bloc accounted for 46.8% of all notified cases in DOTS areas (460,220 of 985,220 cases). This is an indication of a very heavy disease burden and is associated with very high prevalence of HIV/AIDS in the general population and among TB patients. Of the notified cases, 41.1% were new smear positive, 18.6% were new smear negative while a high 13.7% were new cases without smears done at the start of treatment. This is the highest proportion among blocs and is a matter of concern with regard to diagnostic practices. The highest numbers of no smear done were from South Africa (45,047 of 79,948 (56.3%), Zimbabwe (14,831 cases (18.6%), Zambia and Botswana (8.7% and 5.6% respectively). However, the 4,444 cases reported from Botswana are most probably not correct. This number is suspiciously high. 38