Transcript TB in Singapore

Progress of the Singapore TB
Elimination Programme
(STEP)
3.8.07.
IUATLD 1st Asia Pacific Region Conference 2007
Dr Cynthia Chee
TB Control Unit, Department of Respiratory Medicine
Tan Tock Seng Hospital
Deputy Chairman
STEP Committee, Ministry of Health, Singapore
Singapore
• Population 4.35 million
• Resident population 3.55 million; 75% Chinese, 14%
Malay, 8% Indian
TB in Singapore Residents
Rate per 100,000 population
1960-1997
400
1997
1,712 new cases
Incidence rate: 55 / 100,000
300
200
100
0
1960 1964 1968 1972 1976 1980 1984 1988 1992 1996
Year
TB incidence rates (new cases) among
residents by age and sex
1999
400
300
200
100
Age
Males
Females
+
80
79
70
to
69
60
to
59
50
to
49
40
to
39
30
to
29
20
to
19
15
to
14
to
10
o9
5t
o4
0
0t
TB ratesper 100,000
500
STEP
World Health
Day
April 1997
Singapore TB Elimination Programme
Mission: To eliminate TB in Singapore with the
following goals:
 to
detect and diagnose all infectious (sputum
positive) cases in the community
 to cure all cases of TB
 to detect and treat all infected TB contacts
 to prevent the emergence of MDRTB
Singapore - 1997
• HIV incidence : 55 per million population
• Primary INH resistance : < 4%
• Primary MDRTB resistance : < 0.5%
STEP Components
• Epidemiological component : STEP
Surveillance System
• Clinical component : TB Control Unit,
TTSH
• National referral centre for the
management of TB patients, contact
investigation and preventive treatment
Key STEP Initiatives
• Nation-wide treatment surveillance
module
• Directly Observed Therapy (DOT)
• Nation-wide policy of preventive therapy
for infected close contacts
TB NOTIFICATION SYSTEM
TB Labs of
Singapore
General Hospital
& National
University
Hospital
Tuberculosis
Control Unit
(TTSH)
Restructured
Hospitals
STEP Registry,
Ministry of Health
Private
Practitioners
Clinical
Laboratories
Registry of
Births &
Deaths
Singapore Antituberculosis
Association
TB Notification and Treatment
Centres
SATA
Private Chest
Physicians
SATA
TBCU
Private chest
physicians
Public
Hospitals
TBCU
Public
Hospitals
Notification Centres
Treatment Centres
THE STEP SURVEILLLANCE SYSTEM
Notified case
Active TB
Treatment
Surveillance
Module
Final Outcome
Infectious case
Contact Investigation
Contact with LTBI
advised
INH Preventive
Therapy
Contact
Uninfected
If declined
Discharged
Advised on TB symptoms
STEP Treatment Surveillance Module
• Implemented in stages, nation-wide coverage from
2001
• Treating physician to submit a return for each TB
patient at every visit until treatment completion (or
other outcome) achieved
• Compliance, latest sputum smear result, treatment
delivery mode and prescribed regimen captured
• “Real-time” tracking of patient’s treatment progress
and to provide national data on treatment outcome
TB Treatment Outcome
Singapore Residents, 2001-2004
80
70
60
50
40
30
20
10
0
2001
Completed
2002
Died
2003
Defaulted
2004
Still on Rx
Treatment defaulters
• Real-time tracking of treatment progress enables timely
identification of treatment defaulters
• Recall measures: phone calls, letters, and home visits
by TBCU nurses; Medical social worker
• Free long-stay 20-bed ward for defaulters with poor
social support and who are unable to adhere to
treatment
• ~ 10 to 20 infectious recalcitrant defaulters each year;
since July 2004, the Infectious Diseases Act used on ~
50 infectious patients
DOT in Singapore
• Outpatient DOT
– By nurses at the patients’ nearest public health
polyclinic
– Daily for intensive phase; thrice weekly for
continuation phase
Outreach DOT 2002 – 2004
Proportion of TB cases on DOT
TBCU and National
1998-2006
100
80
60
40
20
0
1995
1997
TBCU
1999
2001
2003
National (including TBCU)
2005
Contact investigation at TBCU
Before 1998
• Household / family contacts of all notified TB
cases (regardless of infectiousness of index case)
invited for CXR screening to detect active TB
disease
• Tuberculin skin testing (TST) screening and
preventive therapy (PT) only for children who were
household contacts
Contact investigation at TBCU
Since 1998
• TST to detect LTBI for preventive therapy in close
contacts of infectious cases regardless of age
• Contact investigation extended beyond household to
workplace, schools
• Contact screening in congregate settings eg. prisons,
drug rehabilitation centres, mental health institute,
nursing homes, dialysis centres
Preventive Therapy for contacts with
LTBI
Contacts with TST >= 15 mm advised PT after
exclusion of active disease
Those with TST 10 - 14 mm advised on “case-by-case”
basis
• Preventive therapy regimen:
– Isoniazid (6 months in adults, 9 months in children
and HIV+)
– Rifampicin (4 months) for contacts of INH-resistant
cases
Contact Programme Performance
2000-2004
100
80
60
40
20
0
2000
2001
2002
2003
2004
% smear + case with at least one contact screened
% contacts who completed screening
% eligible contacts who started PT
% completed PT
Incidence rate per 100,000 population
Incidence rate of All Notified TB and Pulmonary TB
Singapore Residents (New Cases)
1991 - 2006
60
50
40
30
20
10
0
1991
93
95
97
All TB
99
2001
Pulmonary TB
2003
2005
Rate per 100,000 population
TB Incidence Rate in Singapore Residents
1960 -2006
400
300
2006
1,256 new cases
200
100
0
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
Thank You
Acknowledgments
SNO Han Kwee Yin and staff of TBCU
Polyclinic nurses (SingHealth & NHG)
Dr KhinMar K Y and staff of STEP Registry
Dr Irving Boudville, Dr Monica Teleman
19
85
19
87
19
89
19
91
19
93
19
95
19
97
19
99
20
01
20
03
20
05
Cases per million population
Incidence of HIV infection in Singapore
1985-2005
100
90
80
70
60
50
40
30
20
10
0
Number of TB notifications (New cases)
By Residential Status
1998 - 2005
2000
1800
1600
1400
1200
1000
800
600
400
200
0
1998 1999 2000 2001 2002 2003 2004 2005
Residents
Non-residents
Drug Resistance in Residents with pTB
(New cases)
1998 - 2006
% of cases
20
15
10
5
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
New, single drug resistance
New, > 1 drug resistance
MDRTB