Tuberculosis Epidemiological Surveillance Report AFRO 2003 TB Case Notification Rates, WHO African Region, 2002 Case Notification Rates (per 100000) 500-999 100-499 <100 Not Reporting Outside AFRO Division of Disease Prevention and Control WHO OFFICE FOR THE AFRICAN REGION Harare, Zimbabwe
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/2003.316 2 Regional TB Surveillance Report 2001. WHO Office for the African Region. 2
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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
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
Table of Contents Section Description Page Table of contents 5 1 Introduction 6 2 Methods 7 3 Results 8 3.1 Completeness of reporting 8 3.2 Dots Implementation and population coverage 8 3.3 3. 3.1 3.3.2 3.3.3 3.4 3.4.1 3.4.2 3.4.3 3.4.4 3.4.5 3.5 4 4.1 5 5.1 6 6.1 6.2 6.21 6.2.2 6.2.3 6.24 6.25 6.3 6.3.1 6.3.2 6.3.3 6.4 6.4.1 6.4.2 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 11 11 14 15 17 19 19 20 20 20 21 25 25 27 27 Annexes 47-79 36 36 37 37 37 38 38 39 40 40 40 40 43 43 46 6
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
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
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 14-100%. 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 3.2.1 and Figure 3.2.1 below show estimated DOTS coverage by country in the African Region as at end December 2002: 9
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
Figure 3.2.1: Map of DOTS coverage by country. WHO/AFRO 2002. DOTS Coverage, WHO African Region, 2002 DOTS Coverage Nationwide 50-89 Percent 10-49 Percent Not Implementing DOTS Not Reporting Outside AFRO
3.3: TB NOTIFICATIONS JANUARY TO DECEMBER 2002 3.3.1: 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 2002. 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 3.3.1 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 2002 45.0 40.0 35.0 30.0 Proportion (%) 25.0 20.0 15.0 10.0 5.0 0.0 S+ve S-ve No smear NEP Relapse Other Non DOTS 40.4 41.7 7.3 5.1 4.9 0.6 DOTS 44.7 22.3 8.9 16.9 4.7 2.5 Type of TB
Tables 3.3.1, Figures 3.3.2 and 3.3.3 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 439790 219012 87690 166593 46446 24689 984220 Regional Total 13835 14303 2500 1751 1683 207 34279 453625 233315 90190 168344 48129 24896 1018499 Figure 3.3.2: Notified cases by type of TB and DOTS status. 1200000 1000000 DOTS areas NON-DOTS areas Regional Total 800000 Notifications (absolute numbers) 600000 400000 200000 0 NSP NSN NNSD NEP Relapse Other Total Type of TB 13
Table 3.3.2 (a): Notifications by country and type of TB in DOTS areas. WHO/AFRO 2002. DOTS Not Rate Est TB CDR rate ** (%)** Country DOTS NSP NSN NNSD NEP Relapse Other Total Population Algeria 100 8246 1076 263 8593 496 380 19054 31,266,000 60.952 114 Angola 14 17345 7359 0 2548 1292 0 28544 13,184,000 216.5335 94 Benin 100 2415 84 0 225 106 193 3023 6,558,000 46.186 98 Botswana 100 3334 816 4444 1387 223 0 10204 1,770,000 576.5657 73 Burkina Faso 100 1544 219 0 507 106 94 2470 12,624,000 19.6157 18 Burundi 91 2791 1138 128 2203 111 24 6395 6,602,000 96.9359 28 Cape Vert 40 111 49 0 17 18 21 216 454,000 47.6178 31 CAR 75 2657 308 0 402 152 0 3519 3,819,000 92.1338 51 Cameroon 90 7365 1682 0 844 450 384 10725 15,729,000 68.2188 64 Comoros No Report 747,000 0.061? Congo Brazzaville 20 4207 2073 0 2619 177 132 9208 3,633,000 253.5395 69 Cote d'ivore 74 7105 1115 0 650 93 278 9241 16,365,000 56.5412 34 DRC 70 44518 8543 201 14181 3182 1440 72065 51,201,000 140.7383 52 Equatorial Guinea No Report 81,000 0.0191? Eritrea 60 646 1171 122 828 38 0 2805 3,991,000 70.3268 14 Ethiopia 95 36541 33308 0 38798 1642 709 110998 68,961,000 161.0370 33 Gabon 22 1033 514 271 137 79 118 2152 1,306,000 164.8248 73 Gambia 100 1035 710 0 80 34 31 1890 1,388,000 136.2230 73 Ghana 100 7732 2694 0 793 504 0 11723 20,471,000 57.3211 41 Guinea Bissau 20 532 465 0 49 67 0 1113 1,449,000 76.8196 72 Guinea Conakry 100 4300 563 1142 194 148 6347 8,359,000 75.9215 54 Kenya 100 34337 31765 0 11578 2503 1931 82114 31,540,000 260.3540 49 Lesotho 100 3167 1513 2919 2083 429 0 10111 1,800,000 561.7726 61 Liberia No Report 3,239,000 0.0247? Madagascar 100 10940 1609 0 2772 761 0 16082 16,916,000 95.1234 62 Malawi 100 7686 10659 0 5378 872 1936 26531 11,871,000 223.5431 36 Mali 68 2757 871 0 622 207 0 4457 12,623,000 35.3334 15 Mauritius 100 86 28 0 23 2 0 139 2,807,000 5.064 25 Mauritania 53 1500 384 67 456 213 0 2620 1,210,000 216.5188? Mozambique 40 15236 6224 0 2936 1148 573 26117 18,537,000 140.9436 45 Namibia 60 4565 4387 1560 1454 825 1125 13916 1,961,000 709.6751 76 Niger No Report 11,544,000 0.0193 63 Nigeria 55 19596 8021 5 1040 983 1383 31028 120,911,000 25.7304 14 Rwanda 100 3956 898 0 876 281 376 6387 8,272,000 77.2389 29 Sao Tome Principe Non DOTS 157,000 0.0130 46 Senegal 100 5796 1274 0 813 483 421 8787 9,855,000 89.2242 54 Seychelles 100 9 20 0 0 0 0 29 80,000 36.342 60 Sierra Leone 93 2938 915 429 338 173 0 4793 4,764,000 100.6405 36 South Africa 98 97656 15023 45047 32716 22174 8296 220912 44,759,000 493.6558 97 Swaziland 100 1410 234 4216 766 122 119 6867 1,069,000 642.41,067 31 Tanzania 100 24136 21959 0 12508 1703 2742 63048 36,276,000 173.8363 43 Tchad 98 3417 1045 0 182 184 0 4828 8,348,000 57.8222 43 Togo 35 421 30 0 96 27 421 995 4,801,000 20.7361 16 Uganda 100 19088 10461 6256 3119 1771 1136 41831 25,004,000 167.3377 47 Zambia 55 11694 19676 6931 1629 1557 278 41765 10,698,000 390.4668 56 Zimbabwe 100 15942 18129 14831 9205 1064 0 59171 11,635,000 508.6683 46 Regional totals 3226 439790 219012 87690 166593 46446 24689 984220 671,035,000 350 % OF Regional Total 78.7 44.7 22.3 8.9 16.9 4.7 2.5 100.0 Regional rate 66 32.6 13.1 24.8 6.9 3.7 146.7 146.7 ** =Estimated total TB prevalence rate and average overall case detection rate (CDR) adopted from WHO Report 2004. Global Tuberculosis Control. Surveillance, Planning and Financing. World Health Organization. 45
3.3.2: Notification rates: With an estimated 671 million population, the million cases notified in 2002 translate into an overall notification rate of 146.7 TB cases per 100,000 population. The rates ranged from 5.0 in Mauritius to 709.6 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 3.3.3 (a): Map of case notification rates (All forms). AFRO 2002 Case Notification Rates (per 100000) 500-999 100-499 <100 Not Reporting Outside AFRO
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 3.3.3 (b): Map of new smear positive TB case notification rates. AFRO 2002 New Smear Positive Case Notification Rates 100-499 50-99 0-99 Not Reporting Outside AFRO 16
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 232.8 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 2002 800.0 700.0 709.6 642.4 Notification rate (per 100,000) 600.0 500.0 400.0 300.0 200.0 100.0 0.0 Algeria 60.9 216.5 Benin 46.1 576.5 Burkina Faso 96.9 92.1 68.2 47.6 19.6 0.0 Cape Vert Cameroon Congo Brazaville 253.5 56.5 DRC 140.7 0.0 Eritrea 70.3 161.0 164.8 136.2 Gabon Ghana 57.3 76.875.9 Guinea Conakry 260.3 Lesotho 561.7 0.0 Madagascar 95.1 Country 223.5 Mali 35.3 5.0 Mauritania 216.5 140.9 Namibia 0.0 25.7 Nigeria Sao Tome Principe 77.2 0.0 89.2 Seychelles 36.3 100.6 South Africa 493.6 Tanzania 173.8 57.8 20.7 Togo 167.3 Zambia 390.4 508.6 Region 146.7
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 3.4.1 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 3.4.1 below. Table 3.4.1(a): Notifications by type by Epidemiological Bloc. AFRO 2002. DOTS areas Bloc DOTS NSP NSN NNSD NEP Relapse Other Total Central 70.6 63197 14165 472 18365 4224 2074 102497 Eastern 92.3 121495 100700 6506 69910 8049 6918 313578 Islands 100.0 206 97 0 40 20 21 384 Southern 76.7 188975 85629 79948 62874 30467 12327 460220 Western 79.3 65917 18421 764 15404 3686 3349 107541 Region 439790 219012 87690 166593 46446 24689 984220 % of Total 44.7 22.3 8.9 16.9 4.7 2.5 100.0
Table 3.4.1(b): Notifications by type by Epidemiological Bloc. AFRO 2002. Non-DOTS areas Bloc NSP NSN NNSD NEP Relapse Other Total Notified Central 759 910 0 278 336 0 2283 Eastern 0 0 0 0 0 0 0 Islands 42 37 10 5 0 15 109 Southern 6542 6097 2486 519 1045 92 16781 Western 6492 7259 4 949 302 100 15106 Region 13835 14303 2500 1751 1683 207 34279 % of total 40.4 41.7 7.3 5.1 4.9 0.6 100.0 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
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 3.4.2 (a) & (b) in the Annex show notifications in DOTS and Non-DOTS areas in the Central Epidemiological Bloc. 3.4.3: 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 2002. 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 3.4.3. 20
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 2002. 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 3.4.4 3.4.5: 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 2002. 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 3.4.5 (a) and (b) show notifications by type from the Southern Epidemiological Bloc. 3.4.6: 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 3.4.6 (a) & (b). 21
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 2002. 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 15-34 years. Thereafter, the order changed. Among males, the second most affected age groups were the 35-44 followed by 15-24 year olds in that order. For females on the other hand, the second most affected age groups were the 15-24 and 35-44 year olds in that order. Tables 3.5.1 (a) & (b) and Figure 3.5.1 below show the proportionate distribution of notified new smear positive TB cases by age group and sex in the African Region in 2002. 22
Table 3.5.1(a): Number of new smear positive TB cases by age group and sex. DOTS areas. Females. AFRO, 2002 Country 0-14 15-24 25-34 35-44 45-54 55-64 65+ TOTAL Algeria 71 1840 730 334 224 217 258 3674 Angola 600 2520 2128 1532 921 503 296 8500 Benin 35 255 298 159 86 47 24 904 Botswana 45 393 566 290 144 54 26 1518 Burkina Faso 12 85 159 104 80 30 25 495 Burundi 48 243 242 324 152 24 23 1056 Cape Vert 2 11 11 12 3 4 4 47 CAR 57 307 389 254 133 79 16 1235 Cameroon 59 950 1053 545 236 140 44 3027 Comoros No report Congo Brazaville 0 0 0 0 0 0 0 0 Cote d'ivore 91 744 1013 535 237 141 96 2857 DRC 874 5378 6230 3939 2262 1055 476 20214 Equatorial Guinea No report 0 Eritrea 15 75 85 52 39 30 20 316 Ethiopia 1614 5607 5692 2685 935 323 136 16992 Gabon 18 125 140 71 32 21 28 435 Gambia 5 71 112 42 40 21 10 301 Ghana 98 489 806 592 325 223 238 2771 Guinea Bissau 2 54 65 30 24 21 5 201 Guinea Conakry 42 399 439 259 109 77 50 1375 Kenya 392 4542 5465 2267 996 445 190 14297 Lesotho 14 304 447 207 125 41 17 1155 Liberia No report Madagascar 163 983 1372 1000 598 234 135 4485 Malawi 64 948 1447 788 339 119 52 3757 Mali 39 141 250 166 190 71 24 881 Mauritius 1 3 8 7 1 2 1 23 Mauritania 13 104 110 75 50 37 21 410 Mozambique 0 0 0 0 0 0 0 0 Namibia 42 355 770 472 171 83 67 1960 Niger No report Nigeria 242 2633 2884 1368 787 420 241 8575 Rwanda 15 98 113 58 22 15 8 329 Sao Tome 0 0 0 0 0 0 0 0 Senegal 61 545 523 317 210 118 86 1860 Seychelles 0 0 0 0 0 0 2 2 Sierra Leone 31 300 382 284 133 48 26 1204 South Africa 3257 7052 11266 6061 2603 1070 600 31909 Swaziland 9 236 274 127 50 13 9 718 Tanzania 241 1927 3511 1706 907 475 304 9071 Tchad 17 21 482 490 175 14 11 1210 Togo 8 81 96 51 28 19 8 291 Uganda 371 1689 3011 1708 765 374 184 8102 Zambia 5005 6087 14881 9153 3664 1637 1338 41765 Zimbabwe 222 914 2185 1095 421 140 65 5042 Regional Total 13895 48509 69635 39159 18217 8385 5164 202964 % of Total for females 6.8 23.9 34.3 19.3 9.0 4.1 2.5 100.0 23
Table 3.5.1(b): Number of notified new smear positive cases by age group and sex. DOTS areas. Males, AFRO 2002 Country 0-14 15-24 25-34 35-44 45-54 55-64 65+ TOTAL Algeria 39 1364 1580 630 406 273 280 4572 Angola 407 2133 2211 1844 1144 592 415 8746 Benin 16 248 489 304 231 125 94 1507 Botswana 17 226 595 517 244 136 84 1819 Burkina Faso 6 123 273 266 156 124 83 1031 Burundi 16 310 470 520 270 97 52 1735 Cape Vert 3 9 29 20 14 1 2 78 CAR 69 255 450 403 145 80 20 1422 Cameroon 66 818 1335 1117 619 258 125 4338 Cape Verde Non DOTS Comoros No report Congo Brazzaville 0 0 0 0 0 0 0 0 Cote d'ivore 69 826 1402 968 532 251 200 4248 DRC 649 4965 7414 4994 3065 1388 791 23266 Equatorial Guinea No report 0 Eritrea 16 85 88 53 41 24 23 330 Ethiopia 1251 6764 5669 3128 1544 821 372 19549 Gabon 10 137 173 148 63 27 40 598 Gambia 2 135 240 160 100 60 37 734 Ghana 80 535 1245 1282 883 507 429 4961 Guinea Bissau 4 70 91 78 37 34 17 331 Guinea Conakry 24 413 958 634 336 139 149 2653 Kenya 299 4445 7708 4306 2023 807 433 20021 Lesotho 10 218 547 535 347 211 80 1948 Madagascar 94 1023 1594 1563 1174 609 398 6455 Malawi 41 599 1359 1008 542 262 118 3929 Mali 20 209 547 447 430 151 72 1876 Mauritius 1 12 6 21 12 7 4 63 Mauritania 11 175 374 259 133 94 83 1129 Mozambique 0 0 0 0 0 0 0 0 Namibia 16 300 1029 723 308 141 88 2605 Niger No report 0 Nigeria 163 2274 3719 2283 1352 696 534 11021 Rwanda 13 96 167 184 79 38 13 590 Sao Tome 0 0 0 0 0 0 0 0 Senegal 58 815 1271 813 488 279 212 3936 Seychelles 0 1 3 1 0 1 1 7 Sierra Leone 23 317 561 427 246 102 58 1734 South Africa 3080 5122 13634 13177 7009 2333 936 45291 Swaziland 1 94 244 182 117 33 10 681 Tanzania 187 2309 4814 3525 2075 1211 944 15065 Tchad 24 79 1015 776 263 32 16 2205 Togo 6 91 155 108 68 36 26 490 Uganda 259 1503 3783 2865 1399 723 465 10997 Zambia 2637 2632 7916 5367 2067 969 890 22478 Zimbabwe 191 600 2548 1662 6744 315 159 12219 Regional Total 9878 42330 77706 57298 36706 13987 8753 246658 % of total males 4.0 17.2 31.5 23.2 14.9 5.7 3.5 100.0 24
Figure 3.5.1: Proportion of notified new smear positive cases by age group and sex. AFRO 2002. Males Proportion of notified cases by age group and sex. AFRO 2002 40.0 35.0 Proportion of notified cases (%) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 0-14 15-24 25-34 35-44 45-54 55-64 65+ Males 4.1 17.2 31.5 23.2 14.9 5.6 3.5 Females 6.9 23.9 34.3 19.3 9.0 4.1 2.5 Regional 5.3 20.3 32.8 21.4 12.2 4.9 3.1 Age group Males Females Regional 25
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 1993-2002. Trend of Reported New smear positive TB cases. 1995-2002. WHO/AFRO 500000 453,625 450000 400000 362,135 350000 298,879 300000 222,078 256,598 245,926 Number of cases 250000 209,039 200000 157,415 150000 100000 50000 1995 1996 1997 1998 1999 2000 2001 2002 0 26
Figure 4.1: Trend of notification rates. Total and new cases 1993-2002 Total andsmear positive Notificationsrates. AFRO1993-2002 160 140 147 120 113 120 121 124 Rate per 100,000 100 80 60 40 78 100 89 38 101 101 46 47 53 56 56 57 66 20 19 22 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year Total rate S+verate 27
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 2001. 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 58.7 12.4 71.1 7.1 1.2 10.4 6.6 3.6 100 Retreatment 45.6 11.8 57.4 8.7 2.1 12.4 9.2 10.1 100 28
Table 5.1(b): Treatment outcomes for new smear positive TB cases registered Jan-Dec 2001. WHO/AFRO. Country Registered Cured % cure Completed % % Compl success Died % Death Failed % Failed Defaulted %Default T/OUT % T/out Evaluated % Evaluated Algeria 8361 4561 54.6 2462 29.4 84.0 165 2.0 46 0.6 378 4.5 424 5.1 8211 98.2 Angola 1191 554 46.5 227 19.1 65.6 28 2.4 315 26.4 40 3.4 27 2.3 1354 113.7 Benin 2298 1257 54.7 558 24.3 79.0 138 6.0 44 1.9 282 12.3 19 0.8 2476 107.8 Botswana 3225 1049 32.5 2291 71.0 103.6 303 9.4 22 0.7 252 7.8 379 11.8 4521 140.2 Burkina Faso 1537 875 56.9 118 7.7 64.6 202 13.1 43 2.8 191 12.4 108 7.0 1695 110.3 Burundi 3465 1447 41.8 1340 38.7 80.4 155 4.5 16 0.5 466 13.4 41 1.2 3644 105.2 Cape Vert 12 5 41.7 0 0.0 41.7 0 0.0 0 0.0 7 58.3 0 0.0 154 1280.6 CAR 2633 784 29.8 809 30.7 60.5 121 4.6 66 2.5 403 15.3 450 17.1 2776 105.4 Cameroon 4695 2586 55.1 317 6.8 61.8 241 5.1 63 1.3 613 13.1 51 1.1 4014 85.5 Comoros No report Congo Brazzaville 4319 2275 52.7 556 12.9 65.5 102 2.4 20 0.5 848 19.6 158 3.7 4113 95.2 Cote d'ivore 6509 3946 60.6 821 12.6 73.2 279 4.3 158 2.4 711 10.9 595 9.1 6674 102.5 DRC 40884 26808 65.6 4740 11.6 77.2 2529 6.2 360 0.9 4223 10.3 1970 4.8 40802 99.8 Equatorial Guinea No Report Eritrea 860 607 70.6 77 9.0 79.5 62 7.2 10 1.2 61 7.1 33 3.8 1025 119.1 Ethiopia 32391 19814 61.2 4718 14.6 75.7 2146 6.6 256 0.8 1938 6.0 1197 3.7 30234 93.3 Gambia 861 563 65.4 50 5.8 71.2 50 5.8 16 1.9 137 15.9 45 5.2 1027 119.3 Gabon 849 363 42.8 52 6.1 48.9 37 4.4 0 0.0 365 43.0 32 3.8 994 117.1 Ghana 7712 2849 36.9 377 4.9 41.8 383 5.0 93 1.2 924 12.0 212 2.7 4940 64.1 Guinea Bissau 513 167 32.6 95 18.5 51.1 14 2.7 2 0.4 127 24.8 108 21.1 643 125.3 Guinea Conakry 4090 2706 66.2 327 8.0 74.2 279 6.8 34 0.8 376 9.2 368 9.0 4255 104.0 Kenya 31307 20703 66.1 4098 13.1 79.2 1577 5.0 105 0.3 2505 8.0 1867 6.0 31027 99.1 Lesotho 2977 2112 70.9 0 0.0 70.9 330 11.1 42 1.4 137 4.6 171 5.7 2951 99.1 Madagascar 9228 5564 60.3 848 9.2 69.5 598 6.5 107 1.2 1672 18.1 439 4.8 9393 101.8 Malawi 8274 5574 67.4 222 2.7 70.1 1584 19.1 140 1.7 492 5.9 259 3.1 8438 102.0 Mali 2430 1007 41.4 401 16.5 57.9 160 6.6 32 1.3 707 29.1 123 5.1 2583 106.3
Mauritius 123 106 86.2 8 6.5 92.7 3 2.4 2 1.6 4 3.3 0 0.0 316 256.7 Mauritania 1490 511 34.3 265 17.8 52.1 8 0.5 1 0.1 327 21.9 320 21.5 1559 104.6 Mozambique 14047 10551 75.1 323 2.3 77.4 1360 9.7 175 1.2 1224 8.7 368 2.6 14175 100.9 Namibia 4532 1856 41.0 1012 22.3 63.3 328 7.2 88 1.9 633 14.0 324 7.1 4391 96.9 Niger No Report Nigeria 17436 11810 67.7 1935 11.1 78.8 997 5.7 364 2.1 2057 11.8 273 1.6 17613 101.0 Rwanda No results Sao Tome Non DOTS 0 Senegal 6094 2646 43.4 555 9.1 52.5 187 3.1 68 1.1 1239 20.3 276 4.5 5101 83.7 Seychelles 12 8 66.7 0 0.0 66.7 2 16.7 0 0.0 0 0.0 2 16.7 162 1350.0 Sierra Leone 2683 1836 68.4 299 11.1 79.6 21 0.8 140 5.2 357 13.3 29 1.1 2860 106.6 South Africa 83233 45791 55.0 8305 10.0 65.0 5764 6.9 1343 1.6 9681 11.6 10,362 12.4 81396 97.8 Swaziland 1586 228 14.4 342 21.6 35.9 161 10.2 2 0.1 129 8.1 142 9.0 1094 69.0 Tanzania 24235 18493 76.3 1054 4.3 80.7 2506 10.3 85 0.4 1018 4.2 1079 4.5 24411 100.7 Tchad No results 0 Togo 982 526 53.6 14 1.4 55.0 90 9.2 10 1.0 72 7.3 23 2.3 862 87.8 Uganda 17291 4832 27.9 4861 28.1 56.1 1052 6.1 89 0.5 2984 17.3 867 5.0 14821 85.7 Zambia 8847 5208 58.9 1446 16.3 75.2 1055 11.9 27 0.3 501 5.7 590 6.7 8995 101.7 Zimbabwe 16568 10521 63.5 1176 7.1 70.6 1972 11.9 17 0.1 1392 8.4 1491 9.0 16731 101.0 Regional Total 379780 2E+05 58.7 47099 12.4 71.1 26989 7.1 4401 1.2 39473 10.4 25,222 6.6 372431 98.1 30
Table 5.1(c): Treatment outcomes for retreatment smear positive TB cases registered Jan-Dec 2001. WHO/AFRO Country Registered Cured % Cured % Completed Complet % Success Died % Died Failed % Failed Defaulted % Default T/OUT % T/Out Total Eva % Eval Algeria 425 238 56 70 16.5 72.5 16 3.8 6 1.4 20 4.7 18 4.2 368 86.6 Angola No info Benin 289 152 52.6 70 24.2 76.8 20 3.8 14 4.8 28 9.7 5 1.7 289 100 Botswana 448 101 22.5 228 50.9 73.4 44 3.8 2 0.4 42 9.4 31 6.9 448 100 Burkina Faso 141 83 58.9 13 9.2 68.1 18 3.8 7 5.0 16 11.3 4 2.8 141 100 Burundi 92 46 50.0 12 13.0 63.0 14 3.8 3 3.3 16 17.4 1 1.1 92 100 Cape Vert No info CAR 250 70 28.0 87 34.8 62.8 25 3.8 7 2.8 25 10.0 36 14.4 250 100 Cameroon 291 144 49.5 22 7.6 57.0 24 3.8 10 3.4 88 30.2 3 1.0 291 100 Comoros No report Congo Brazzaville No info Cote d'ivore 354 158 44.6 43 12.1 56.8 22 3.8 29 8.2 79 22.3 23 6.5 354 100 DRC No info Equatorial Guinea No report Eritrea 57 35 61.4 5 8.8 70.2 3 3.8 1 1.8 3 5.3 1 1.8 48 84 Ethiopia 1505 826 54.9 142 9.4 64.3 103 3.8 46 3.1 85 5.6 37 2.5 1239 82 Gabon 208 23 11.1 48 23.1 34.1 12 3.8 5 2.4 57 27.4 3 1.4 148 71 Gambia 87 62 71.3 2 2.3 73.6 11 3.8 1 1.1 7 8.0 4 4.6 87 100 Ghana No info Guinea Bissau 156 14 9.0 16 10.3 19.2 11 3.8 1 0.6 42 26.9 72 46.2 156 100 Guinea Conakry 350 206 58.9 20 5.7 64.6 30 3.8 13 3.7 50 14.3 31 8.9 350 100 Kenya 2294 1780 77.6 256 11.2 88.8 259 3.8 14 0.6 175 7.6 151 6.6 2635 115 Lesotho 313 199 63.6 0 0.0 63.6 60 3.8 3 1.0 14 4.5 12 3.8 288 92 Madagascar 948 557 58.8 74 7.8 66.6 84 3.8 17 1.8 146 15.4 70 7.4 948 100 Malawi 854 553 64.8 34 4.0 68.7 198 3.8 6 0.7 45 5.3 5 0.6 841 98 Mali 322 143 44.4 36 11.2 55.6 23 3.8 6 1.9 69 21.4 18 5.6 295 92 Mauritius 2 1 50.0 0 0.0 50.0 0 3.8 0 0.0 1 50.0 0 0.0 2 100 31
Mauritania 162 69 42.6 51 31.5 74.1 1 3.8 13 8.0 7 4.3 13 8.0 154 95 Mozambique 1462 1033 70.7 15 1.0 71.7 172 3.8 36 2.5 174 11.9 40 2.7 1470 101 Namibia 766 313 40.9 193 25.2 66.1 95 3.8 40 5.2 92 12.0 43 5.6 776 101 Niger No report Nigeria 1847 1140 61.7 164 8.9 70.6 165 3.8 111 6.0 224 12.1 43 2.3 1847 100 Rwanda No info Sao Tome Non DOTS Senegal 959 352 36.7 61 6.4 43.1 34 3.8 19 2.0 219 22.8 65 6.8 750 78 Seychelles No info Sierra Leone 74 54 73.0 3 4.1 77.0 6 3.8 5 6.8 6 8.1 0 0.0 74 100 South Africa 17869 7740 43.3 1725 9.7 53.0 1576 3.8 406 2.3 3071 17.2 2938 16.4 17456 98 Swaziland 104 6 5.8 30 28.8 34.6 21 3.8 1 1.0 7 6.7 3 2.9 68 65 Tanzania 3847 1782 46.3 1145 29.8 76.1 530 3.8 45 1.2 195 5.1 150 3.9 3847 100 Tchad No info Togo 88 43 48.9 0 0.0 48.9 7 3.8 3 3.4 11 12.5 1 1.1 65 74 Uganda 1653 525 31.8 388 23.5 55.2 150 3.8 17 1.0 266 16.1 85 5.1 1431 87 Zambia 1249 1073 85.9 116 9.3 95.2 5 3.8 15 1.2 23 1.8 17 1.4 1249 100 Zimbabwe 3322 0 0.0 0 0.0 0.0 0 3.8 0 0.0 0 0.0 0 0.0 0 0 Regional Total 42788 19521 45.6 5069 11.8 57.5 3739 3.8 902 2.1 5303 12.4 3923 9.2 38457 90 32
Figure 5.1: Treatment outcomes for new and retreatment TB cases Treatment outcomes. New and Treatment cases. AFRO 2001 Cohort. 80.0 70.0 60.0 50.0 Proportion (%) 40.0 30.0 20.0 10.0 0.0 Cured Completed Success Died Failed Defaulted Transferred Out Not Eva New cases 58.7 12.4 71.1 7.1 1.2 10.4 6.6 3.6 Retreatment 45.6 11.8 57.5 8.7 2.1 12.4 9.2 10.1 Treatment outcomes New cases Retreatment
Figure 5.2: Treatment outcomes by Bloc. AFRO 2001 Cohort 120 100 80 Proportion (%) 60 40 20 0 Cured Completed Success Died Failed Defaulted T/out No Eva Total Treatment outcome Central Eastern Islands Southern Western 34
Figure 5.3: Trend of Treatment outcomes for new and retreatment TB cases: 1994-2001 Treatment success rates. New and retreatment cases. AFRO 1994-2001 80 70 69.6 69 68.2 73 71 Treatment success rate (%) 60 50 40 30 59 53.8 63.5 58 62 55.8 55.7 64 57.5 20 10 0 1994 1995 1996 1997 1998 1999 2000 2001 Year New cases Retreatment cases 35
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 14-100%. 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
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. 6.2.2: 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
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. 6.2.3: 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. 6.2.4: 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