ibrahim abubakar, mbbs, msc, phd, ffph · ibrahim abubakar, mbbs, msc, phd, ffph head of section /...
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Ibrahim Abubakar, MBBS, MSc, PhD, FFPH
Head of Section / Consultant EpidemiologistTuberculosis Section
HPA Centre for InfectionsColindale
London UK
Outline
• TB epidemiological situation• UK data collection system • Challenges in TB data reporting
(EuroTB to ECDC) – ETS– Treatment outcome monitoring
0
50
100
150
200
250
300
350
1913 1916 1919 1922 1925 1928 1931 1934 1937 1940 1943 1946 1949 1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000
Year
Not
ifica
tion
rate
per
100
,000
pop
ulat
ion
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
Dea
th ra
te p
er 1
00,0
00 p
opul
atio
n
BCG
Chemotherapy
Pasteurisation
Housing and hygiene
Short course therapy
TB in the UK
EpidemiologyTuberculosis rates, England & Wales, 1982-2007
0
10
20
30
40
50
1982 1987 1992 1997 2002 2007Year
Rat
e (p
er 1
00,0
00))
LondonEngland and Wales excluding London
Place of birth and time since entry, UK, 2007
0
25
50
75
100
UK Born Non-UK Born <2 years ≥2 years
Place of birth Time since entry into the UK to TBdiagnosis
Perc
enta
ge o
f cas
es
Sources: Statutory notifications of infectious diseases (NOIDs) 1982-1998, Enhanced Tuberculosis Surveillance 1999-2007, Office for National Statistics mid-year population estimates, Enhanced Surveillance of Mycobacterial Infections
* Abubakar et al Thorax 2009, Kruijshaar et al BMJ 2008, Abubakar et al Epidemiology and Infection 2008
0
1
2
3
4
5
6
7
8
9
2000 2001 2002 2003 2004 2005 2006 2007
Year
Prop
ortio
n of
cas
es (%
)
Isoniazid resistant M ulti-drug resistant Resistant to any first line drug
XDR – 8 cases from 1995 to 2008*
Epidemiology
0
100
200
300
400
500
600
700
800
900
1000
HIV
Living
in H
ostel/o
n stre
et
Problem
Drug
users
Prison
Blac
k Afric
an
Recent
migran
t (arriv
ed <1
yr)
Chinese
or ot
her
South
Asian
Foreign
Born Male
Black C
aribb
eanOve
rallFem
aleBorn
UK
Whit
e
Risk group
Prev
alen
ce p
er 1
00,0
00
Transferred out2.4%
Outcome unknown0.7%
Treatment stopped1.2%
Reason for non-completion not
reported0.2%
Lost to follow up4.5%
Still on treatment5.7%
Died6.3%
Completed79.0%
59.3
77.3 76.5 72.665.9
80.482.982.5
79.1 77.5 77.7 79.279.2
0102030405060708090
100
Englan
d
Northern
Irelan
dSco
tland
Wales
East M
idlands
East o
f Englan
dLond
onNor
th East
North W
est
South
East
South
West
West M
idlands
Yorks
hire an
d the H
umber
Country/region
Prop
ortio
n (%
)
CMO's target 85%
Risk Groups Treatment outcome, 2007
* Story et al Thorax 2007
# Ditah et al Thorax 2008
#
*
Notification of tuberculosis in England and Wales
• Diagnosing clinician• Notification form• Consultant in Communicable
Disease Control (Proper Officer)• Weekly and quarterly returns• HPA Centre for Infections
History of TB surveillance in England & Wales
• Routine system– Notifications (NOIDS) (1913) HPA– Enhanced surveillance (ETS) (1999) HPA– Treatment outcome monitoring (2002) HPA– Laboratory reports (Mycobnet) (1994) HPA– Tuberculosis Incidents and Outbreaks (TBIOS) HPA– Mortality ONS
– Linkage• ETS and mycobnet HPA• TB and HIV HPA• ETS and HES HPA• ETS and Mortality HPA
• Specific surveys (some examples)– London case load profiling– BPSU paediatric survey
Aims and objectives of TB surveillance
To reduce the burden of morbidity and mortality from tuberculosis
Local• Identification and treatment of cases• Identification and management of contacts
Local, regional and national
Epidemiology Incidence & trends
Risk groups/factorsDrug resistance
Outcome
• Detection of outbreaks• Evaluation of treatment programme• Evaluation of control and prevention• Policy and guidance
Epidemiology…
Risk groups/factors
Drug resistance
Outcome
Incidence & trends
TB Surveillance systems
INCIDENT CASES• ETS• NOIDS
TREATMENT OUTCOMES
ISOLATESMycobNet
Drug resistance
Outcome
Incidence & trends
TB Surveillance systems
INCIDENT CASES• ETS• NOIDS
TREATMENT OUTCOMES
INCIDENTS & OUTBREAKS
FINGERPRINTSNational strain
typing databaseISOLATESMycobNet
Death Registrations
TB surveillance – data flow
Regional Coordinator
HPAnational database
Locallaboratories
Reference Labs
Clinician& nurse:
case of TB
CCDC in HPU
MycobNet
Specimen
Species,sensitivities
Culture
Feedback
Matching
Web-based
MycobNet Reference Laboratories, UK
Wales Centre for Mycobacteriology
HPA Regional Centre for Mycobacteriology, Newcastle
HPA Regional Centre for Mycobacteriology, Birmingham
HPA National Mycobacterium Reference Unit, London
Northern Ireland Public Health Laboratory, Belfast
Scottish MycobacteriaReference Laboratory, Edinburgh
Royal Brompton Hospital, London
Web based TB Surveillance
•Case reporting
•Drug susceptibility data
•Strain typing
•Contact Information
Web based system
Web Interface: Reports
Web Interface: Reports
Cluster Report
UPLOADED RECORD NUMBER 2: ETR-MIRU Profile: 422342642515323: Lab ID: BIR_06.0607303Key: 13701: Date typed in laboratory: 2006-09-29-----------------------------------------------------------------------------------------------------------There are 2 records in the database that match the VNTR profile: 422342642515323
Key Lab ID ISO RIF ETH PYR Date typed8605 BIR_06.0601244 S S S S 2006-02-2712514 BIR_06.0601244 S S S S 2006-02-27
UPLOADED RECORD NUMBER 3: ETR-MIRU Profile: 324332312515324: Lab ID: BIR_06.0607541Key: 13703: Date typed in laboratory: 2006-11-02-----------------------------------------------------------------------------------------------------------**************************************************ACTIVE CLUSTER - (NAME ASSIGNED: Ghaenia)***************************************************There are 14 records in the database that match the VNTR profile: 324332312515324Key Lab ID ISO RIF ETH PYR Date typed13698 BIR_06.0608375 S S S S 2006-10-3013228 BIR_06.0607663 2006-10-0913125 BIR_06.0605682 2006-08-0312368 SCO_MR121719G S S S R 2006-07-25
Challenges in TB data reporting: Routine Surveillance
• Timeline• Content• Treatment Outcome
Timeline for the optimal for reporting to European level
• Annual for the moment• Annual process fairly seamless now
• Future…. Automated web based monthly upload through Tessy
• Automated reported will be the next test
Content of variables
• No major concerns with existing variables
• Some standard Tessy fields may not be collected nationally e.g. travel
• Definition of variables– 'MajorSiteofTBDisease' or MinorSiteofTBDisease'
coded value option for Laryngeal TB? – ‘ResultMicroscopy' – sputum or other smears?– Matching of data – drug resistance / strain typing
• Changes
Challenges in TB data reporting : Treatment outcome monitoring
• Categories clear and consistent with national criteria
• Cured often a difficult category
• Outcome at 24 months only collected for a subset
• Outcome at 36 months not collected
Thank you! www.hpa.org.uk