NATIONAL TB PREVALENCE SURVEY DESIGN & IMPLEMENTAION

Lessons From the Field Ghana

Frank Bonsu & Survey Team

30th April, 2013, Accra

BURDEN OF DISEASE

• TB prevalence all forms: 92 /100,000 pop/yr (2011)

• TB incidence all forms: 79/100,000 pop/yr (2011)

• TB/HIV co-infection 14.5% ( 2008)

• CDR 78% (2011) • Treatment success : 86.2

% 2011

GHANA: Pop: 26,594,185 (2013)

Lessons From the Field • Do quality survey

Let’s have a better view Ikushi Develop budget more seriously. Don’t swap participant forms

• Training important but by whom and for whom Eveline/ Van

• Real time data entry avoid backlog , 1.5 million data entry points Software for data. Use local expertise Yamada

• Watch missing data (avoid preventable ones) Babis • Be mindful of the little details/plan Marina • Find someone to do the survey Jaap • High precision around estimate Task force • Strong justification for your survey Katherine

OPERATIONAL LESSONS FROM ETHIOPIA & CAMBODIA

– Information – Good luck – God helps those who help themselves. Cambodia

– High staff turn over – microplanning – Transportation/ keep away from rains Ethiopia

Further issues: New tech Data entry in the field and barcode

• Benefits and downsides need to be considered. • Recording in paper forms -> Initial data entry every

evening in the field • Barcode: how to incorporate and print structure of PINs

Slide Shown in Cambodia By Norio Yamada Ikushi has earlier suggested barcode idea to NTP Babis has stressed it is possible from Zamstar project experience But HOW?

Key benefits Digital

Barcoding for unique participant ID yes

High CXR readability/image quality yes

Immediate image availability yes

Picture Archiving & Communication System yes

Electronic Data management & privacy tools yes

Film & chemical elimination yes

Automated data back-up yes

Prevalence survey innovations

Core lessons

• Passion • Effective Leadership • Planning • Communication • Teamwork • Logistics • Quality Staff/Team • Data management

Workload Assumptions • Assumptions:

– Prevalence survey sample size: 64,000 – 98 clusters – 170 images per day per CXR system – Cluster size 650 – 5 working days per week – 3 effective working weeks per month

• Expected survey lead time

– 4 mobile/portable CXR units, 7,200 per month => 11 months

Census

Questionnaire

Film Form/Register

Link Analysis

Prevalence Survey data

Different sources of information

Sputum

Trend of estimated prevalence [Source: Global Plan to

Stop TB 2010-2015]

286 267 246 206

163 92

143

0

100

200

300

400

500

600

700

1990 1995 2000 2005 2010 2015High boundTB prevalence (per 100 000 population)Low bound

MDG/STB target

5/10/2013 Ghana NTP REview

Conclusion: TB Evaluation of surveillance system

• Out of 13 standards for TB surveillance evaluated,

• 3 (B1.1, B1.2, B1.3 & B1.6) were met, • 3 (B1.4 & B2.1) were partially met, • 6 (B1.7, B2.2, B3.1, C1, C2 &C3) were not met,

and • 1 (B1.5) Not

Is the TB Disease burden in Ghana high or not ?

Answer will inform determination of future direction for TB Control Post

2015

PASSION Who is more interested than NTP to have this question answered?

Effective leadership

• Decisive decisions based on good planning: X-ray equipment procured within 8 weeks, lifting of MGIT consumables within 72 hours, Prompt decision to use Xpert, effective solns for potential high staff turn

over eg. finding replacement doctors trained within 2 weeks

Design Concept • Internet Access 50-60% PENETRATION • Power (electricity) 100% guaranteed ( GENERATORS, BATTERIES,

NATIONAL GRID, Torch light) • Local network of computers with its own local server for each team .

Linked to Central server . Use of barcode systems to track individual participants.

• Learn by doing ( after 56 years no skills). Engage local expertise TAB Consult for the experiment.

Support Systems • Intense continous engagement of survey team.( PI, Survey coordinator

(Babis initially) ) • Intense engagement of WHO ( Ikushi & Marina mostly on going Field

support visits, e-mails, phone calls ---Clarifications, study protocols) • Irwin providing data quality feedback

PS: Keep it Simple: less transcription • NATIONAL TB SURVEY REGION: CODE: • NATIONAL TB CONTROL PROGRAMME DISTRICT: CODE: • GHANA HEALTH SERVICE CLUSTER NO: • RURAL/URBAN: • STRUCTURE NO: • • • • ANNEX 2: Individual Survey Card (Symptom Questionnaire) • Interviewer: _____________ • Individual Code Number: __ __ - ___ ___ ___- ___ ___ • Name: ______________________________________ • Sex: 1□ Female, 2□ Male • Age: ___ ____ check if estimated □ • Occupation: __________________________ Category code ______ • Symptom and Duration • 0No

1Yes Duration • days weeks months • 6.1 Cough □ □

__ __ __ • 6.2 Sputum □ □

__ __ __ • 6.3 Blood contained sputum □ □ __

__ __ • 6.4 Chest pain □ □

__ __ __ • 6.5 Body weight loss □ □

__ __ __ • 6.6 Fatigue, malaise □ □

__ __ __ • 6.7 Fever □ □

__ __ __ • 6.8 Other( ) □ □ __

__ __ • 6.9 TB Suspect by symptom(s) 0 No □ 1 Yes□

• Current TB Treatment: 7-1: 0□No, 1□ Yes (Start M, Y; TB No. ) • 7-2: 1□Public Hospital/NTP, 2□Health Center/NTP, 3□ Other hospitals • 4□GP, 5□Pharmacy, 6□ NGOs, 7□Traditional Healers, 8□Other_________ • • 8. Past history of TB Treatment: 0□No, 1□Yes (Year: TB No. ) • 8-2: 1□Public Hospital/NTP, 2□Health Center/NTP, 3□ Other hospitals • 4□GP, 5□Pharmacy, 6□ NGOs, 7□Traditional Healers, 8□Other _________ •

• 9 Behavior toward symptom(s)/ Yes for 8-9 (TB suspect) only: (Example of Optional Question) • 0□ Not applicable, 1□ Not recognized as illness, 2□ Ignored, 3□Self treatment • 4□Consulted • 9.2: When “consulted”: Place of consultation (can choose more than one): • 1□Public Hospital/NTP, 2□Health Center/NTP, 3□ Other hospitals, 4□GP, 5□Pharmacy, 6□NGOs,

7□Traditional Healers, 8□Community Health Worker, 9□Other _________ • 9.3: Examination: • 1. Sputum(0□No, 1□Yes) , .2□ X-ray (0□No, 1□Yes) • • 10 X-ray • 10.1 1□Requested, 2□Exempted (reason:____________________), 3□Rejected • 10.2 Result by field screening • 0□.Normal • 1□ Active TB, 2□ TB suspect, 3□Healed TB, 4□Other lung disease (active), 5□ Other findings in

lung(inactive), 6□ Heart disease, • 7□ Other __________________ 9□. NA _________________ • • 10.3 Sputum Request by X-ray result: 0□ No, 1□ Yes • • 10.4 Result by Central Reading • 0□.Normal • 1□ Active TB, 2□ TB suspect, 3□Healed TB, 4□Other lung disease (active), • 5□ Other findings in lung(inactive), 6□ Heart disease, • 7□ Other __________________ 9□. NA _________________ • • 11 Sputum Examination • 11.1 0□ Not request, 1□ Request • 11.2 Smear: • 11.2.1.1 SP1: 0□ Not collected, 1□negative, 2□positive 3□ＮA • 11.2.1.2 When positive (5□3+, 4□2+, 3□1+, 2□Scanty 3 or more, 1□Scanty <3) • 11.2.2.1 SP2: 0□ Not collected, 1□negative, 2□positive 3□ＮA • 11.2.2.2 When positive (5□3+, 4□2+, 3□1+, 2□Scanty 3 or more, 1□Scanty <3) • 11.3 Culture (AFB): • 11.3.1.1 SP1 1□NA, 2□negative, 3□<5colonies, 4□positive, 5□contaminated • 11.3.1.2 When positive 5□4+, 4□3+, 4□2+, 2□1+, 1□__colonies (5 or more) • 11.3.2.1 SP2: □NA, □negative, □positive, □contaminated • 11.3.2.2 When positive 5□4+, 4□3+, 4□2+, 2□1+, 1□__colonies (5 or more) • 11.4 Identification: • 0□NA, 1□TB, 2□ Non-TB, 3□ Pending • • 12. Final Diagnosis • 12.1. TB: 0□No, 1□Smear Positive TB, 2□Smear negative/Culture Positive TB, • 3□Bacteriological Negative Active TB suggested, 4 □ TB suspect, 5□ Healed TB, • • 12.2. Other findings: 0□No abnormality, 1□ Other lung disease(active)______________, • 2□Other finding(inactive)____________, 3□ heart disease, 4□Other site_______________ • • Remarks:____________________________________________________________________________________

___________________________________________________________________________ •

Form05

SURVEY FORMS

15 FORMS • Form 01 household register • Form 02 survey household # • Form03 survey screening invitation • Form o4 consent form • Form05 individual survey card • Form 06 CXR data sheet • Form 06b CXR register • Form 06 c CXR cluster summary • Form 07sputum collection record sheet • Form 08 sputum examination record • Form 09cluster summary report sheet • First report of TB prevalence survey • Second Report of TB prevalence survey • Third report of TB prevalence survey • Form 13 individual case report • Form 14 individual TB suspect report • Form 15 Central x-ray result

5 FORMS • Form 01 household register • Forms 5/ 5B • Form 05 Individual survey

card (CERTIFICATE OF PARTICIPATION)

• Form 02 (PRE-PRINTED HOUSEHOLD NUMBERS)

• Form 04 Consent forms

Household Registration

(F01)

Field Data Entry

Printing Invitation

Verification (Residential

)

Data Update (F01)

(Reception)

HH Register

Issue Invitation

Card

Register (15yrs+)

Invitation Card

Household Summary

Register (15yrs+) Residential Status

Eligible Participants

Updated Eligible Participants

Printed Barcode

1

2 3

4

6

5 7

TB Prevalence Study Process Flow -1

Household register

No. Surname

First name Age

Sex 1-M 2-F

Occupation

Residential Status 1-Permanent 2-Visitor

Eligibility

residential

criteria

Eligible?

1 –Yes 2 – No

01

02

03

04

05

06

07

Certificate of Participation

Form05

Form05b

Field Lab Register

CLUSTER SUMMARY REPORT

Cluster Daily Summary

TEAM Function Number

Team leader 1

Receptionist, Interviewing group 4 Laboratory 1

X-ray group 2

IT + engineer 2

Data entry clerk 3

Total 13

Driver 4 or 5

Central X-Ray Daily Summary

Challenges

• Adequate funding ( part of operational cost hinged around ORIO) Plan B is to reprogramme part of our GF funds)

• Stigma in the communities • Air lifting specimen ( safety issues biological

specimen) • Full attention of survey support staff.

ACKNOWLEDGEMENT • WHO ( Task force for TB Impact Measurement) - Dr Ikushi - Dr Talidoni - Dr. Irwin - Dr Floyd & Babis - Study Field Directors/Survey Coordinator - NTP Staff/Survey Team Members/Laboratory

staff/Radiologist - USAID/TB Care 1 - Italian/WHO - ORIO GRANT/ Dr Klinkenberg - Study Co-investigators/Steering Committee/TAG

THANK YOU MEDA MO

ASE