TB in Singapore by jizhen1947

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									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
                                                 1960-1997

                                                       1997
Rate per 100,000 population




                              400                      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

                      500
TB ratesper 100,000




                      400

                      300

                      200

                      100

                        0
                                           14


                                                     19


                                                               29


                                                                         39


                                                                                   49


                                                                                             59


                                                                                                       69


                                                                                                                 79
                            o4


                                 o9




                                                                                                                      +
                                                                                                                      80
                                       to


                                                 to


                                                           to


                                                                     to


                                                                               to


                                                                                         to


                                                                                                   to


                                                                                                             to
                            0t


                                 5t

                                      10


                                                15


                                                          20


                                                                    30


                                                                              40


                                                                                        50


                                                                                                  60


                                                                                                            70
                                                                         Age
                                                     Males           Females
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                     Tuberculosis           Restructured
  Singapore                      Control Unit            Hospitals
General Hospital                   (TTSH)
  & National
  University
   Hospital                 STEP Registry,
                                                           Private
                           Ministry of Health           Practitioners
    Clinical
  Laboratories


                   Registry of            Singapore Anti-
                    Births &              tuberculosis
                    Deaths                Association
      TB Notification and Treatment
                 Centres
           SATA                            SATA

Private Chest                   Private chest
                                 physicians
 Physicians            TBCU


                                                   TBCU
                                Public
                               Hospitals

       Public
      Hospitals


        Notification Centres         Treatment Centres
      THE STEP SURVEILLLANCE SYSTEM

                                       Treatment
              Notified case           Surveillance            Final Outcome
                                         Module


Active TB    Infectious case



                                            Contact
            Contact Investigation                               Discharged
                                           Uninfected




            Contact with LTBI       If declined
                                                        Advised on TB symptoms
                advised
             INH Preventive
                Therapy
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          2002         2003            2004

       Completed    Died   Defaulted   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    1999     2001     2003        2005

              TBCU     National (including TBCU)
     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 of All Notified TB and Pulmonary TB
                                                Singapore Residents (New Cases)
                                                            1991 - 2006
Incidence rate per 100,000 population




                                        60

                                        50

                                        40

                                        30

                                        20

                                        10

                                         0
                                          1991   93   95    97     99   2001    2003   2005

                                                       All TB    Pulmonary TB
           TB Incidence Rate in Singapore Residents
                          1960 -2006
Rate per 100,000 population




                              400
                                                              2006
                                                              1,256 new cases
                              300


                              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
       Cases per million population

19




        10
        20
        30
        40
        50
        60
        70
        80
        90
       100




         0
  85
19
  87
19
  89
19
  91
19
  93
19
  95
19
  97
                                                    1985-2005




19
  99
20
  01
20
  03
20
  05
                                      Incidence of HIV infection in Singapore
 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
             20

             15
% of cases




             10

             5

             0
                    1998 1999 2000 2001 2002 2003 2004 2005 2006

                  New, single drug resistance   New, > 1 drug resistance   MDRTB

								
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