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EpidemiologicalReviewPhilippines,2019

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ListofAbbreviationsARMM AutonomousRegioninMuslimMindanaoART AntiretroviraltreatmentBC BacteriologicallyconfirmedCAR CordilleraAdministrativeRegionCD ClinicallydiagnosedCNR CasenotificationrateDOH DepartmentofHealthDSSM DirectsputumsmearmicroscopyDSTB Drug-susceptibletuberculosisDRTB Drug-resistanttuberculosisDST DrugsusceptibilitytestingEP ExtrapulmonaryHIV HumanimmunodeficiencyvirusIQR InterquartilerangeIPT IsoniazidpreventivetherapyITIS IntegratedTBInformationSystemLTBI LatenttuberculosisinfectionLPA LineprobeassayNCR NationalCapitalRegionNTPS NationalTuberculosisPrevalenceSurveyNTP NationalTuberculosisControlProgramPICT Provider-initiatedcounsellingandtestingPTR PopulationtestingratePhilSTEP PhilippinesStrategicTBEliminationPlanRR/MDR-TB Rifampicin-/multidrug-resistanttuberculosisTB TuberculosisTSR TreatmentsuccessrateWHO WorldHealthOrganizationXDR-TB Extensivelydrug-resistanttuberculosis

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CONTENTSLISTOFABBREVIATIONS ________________________________________________________ 2

INTRODUCTION _______________________________________________________________ 4

METHODS____________________________________________________________________ 4

ASSESSMENTOFTUBERCULOSISSURVEILLANCESYSTEM______________________________ 5CHARACTERISTICSOFTHETBSURVEILLANCESYSTEM______________________________________ 5TBSURVEILLANCESYSTEMDATAQUALITY _____________________________________________ 5TBSURVEILLANCESYSTEMCOVERAGE________________________________________________ 6SURVEILLANCEOFDRUGRESISTANTTB_______________________________________________ 7SURVEILLANCEOFTB/HIV________________________________________________________ 8SURVEILLANCEOFCHILDHOODTB___________________________________________________ 8STRENGTHS __________________________________________________________________ 8CHALLENGES _________________________________________________________________ 8SUMMARY___________________________________________________________________ 9

TBEPIDEMIOLOGY____________________________________________________________ 10TBBURDENESTIMATES_________________________________________________________ 10

Incidence _______________________________________________________________ 10Mortality _______________________________________________________________ 11

CARECASCADE_______________________________________________________________ 11POPULATIONTESTING__________________________________________________________ 12LABORATORYTESTING__________________________________________________________ 14TBCASENOTIFICATION_________________________________________________________ 16

TBtypeandtreatmenthistory_______________________________________________ 18Ageandsex _____________________________________________________________ 20Referralsource___________________________________________________________ 23

TREATMENTOUTCOMES ________________________________________________________ 25DSTB___________________________________________________________________ 25RR/MDR-TB _____________________________________________________________ 27HIV/TB _________________________________________________________________ 30

LATENTTBANDIPT ___________________________________________________________ 32CHILDHOODTB ______________________________________________________________ 34HIV/TB____________________________________________________________________ 36DETERMINANTSOFTB__________________________________________________________ 37

APPENDICES_________________________________________________________________ 39APPENDIX1:STANDARDSANDBENCHMARKSFORTUBERCULOSISSURVEILLANCEANDVITALREGISTRATIONSYSTEMS___________________________________________________________________ 40APPENDIX2:COMPARATIVEANALYSISBETWEENQ1/Q22018ANDQ1/Q22019________________ 46

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IntroductionThePhilippinesisoneoftop30hightuberculosis(TB)burdencountriesglobally.1TheWorldHealthOrganization(WHO)estimatesthattherewere589,000newTBcasesin2018or552casesper100.000population.Approximately1millionFilipinoshaveTBbutmanymaynotbediagnosedortreated.2Atthetimeoflastepidemiologicalreviewin2016,thePhilippinesTBsurveillancesystemwasatatransitionalphase.Asitwasbeingimplementedacrossthecountry,therewerenotedissuesregardingitscoverage,aswellastheaccuracyandfrequencyofthesubmittedreports.Sincethen,severalkeyinitiativeshaveacceleratedthecountry’sprogresstowardseliminatingTB.First,theNationalTuberculosisPrevalenceSurvey(NTPS)wascompletedin2017.2ThesurveyfoundthattheTBburdenwasmuchhigherthanpreviouslyestimatedandmanyTBpatientsacrossthecountryarenotbeingdiagnosed,treatedornotified.Also,theNationalTuberculosisControlProgram(NTP)ofthePhilippinesDepartmentofHealth(DOH)adoptedthe2017-2022PhilippinesStrategicTBEliminationPlan:Phase1(PhilSTEP1).Thisplanstatesambitiousgoalsthatwillguidetheprogramforthenextfiveyears.In2019,thecountryalsolaunchedanationalcampaign,RacetoEndTB,tocreateawarenessandengageFilipinosinthejourneytocombatthedisease.InordertoendTBinthePhilippines,itiscriticaltohaveanup-to-dateandcomprehensiveunderstandingoftheTBepidemiologyandprogrammaticperformance.ThepurposeofthisreviewistodescribeandassessthecurrentTBsurveillancesystematthenational-andsubnational-levels.Thisreviewalsosummarizesprogrammaticperformanceinkeyareasthatwereidentifiedduringthelastepidemiologicalreviewconductedin2016.3

MethodsThisanalysiswasconductedinJunetoAugust2019undertheleadofWorldHealthOrganizationRegionalandCountryofficewithinputsandassistancefromconsultantsandtheJointProgramReview(JPR)TaskForceaspartofthepreparationsfortheNTPPhilippinesJPRheldinOctober2019.TheprimarydatasourceforthisreviewwastheelectronicTBsurveillancesystemoftheNTP,whichiscalled:IntegratedTBInformationSystem(ITIS).AformalevaluationwasconductedusingtheWHOTBSurveillanceChecklist.4EstimatesonincidenceandmortalitywasprovidedbytheWHOGlobalTBUnit(https://www.who.int/tb/en/).DataonpopulationsizeandHIVtestingwasprovidedbytheDOHEpidemiologyBureau(http://eb.doh.gov.ph).Asthelastepidemiologicalreviewwasconductedin2016,thisreviewfocusedonnewdatasubmittedsince(i.e.from2015onwards).

1WorldHealthOrganization(2018).GlobalTuberculosisReport.2RepublicofPhilippinesDepartmentofHealth(2017).NationalTuberculosisPrevalenceSurvey2016,Philippines.3Yamada,N(2016).ReportonEpidemiologicalReviewofTuberculosisinthePhilippines,2016.4WorldHealthOrganization(2014).StandardandBenchmarksforTuberculosisSurveillanceandVitalRegistrationSystems.

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AssessmentofTuberculosisSurveillanceSystemCharacteristicsoftheTBSurveillanceSystemThePhilippinesusesanelectronic,internet-basedTBsurveillancesystem,ITIS.Thistoolconsistsofstandardizedformsforrecordingcase-basedinformation.TheformsarebasedonNTPguidelinesandmanualofprocedure.5,6TheITIShasreplacedpaper-basedreportingandisusedbyallNTPfacilitiesacrossallregionssince2010.TheNTPnetworkconsistsofallpublicfacilities(e.g.healthcenters,hospitals,prisons/jails)andsomecommunity-basedfacilities.AlimitednumberofprivatepractitionersparticipateinmandatoryTBnotification,asdictatedbyRepublicActionNo.10767.Alllocal-levelfacilitieswithintheNTPnetworkroutinelyenterdataonlaboratorytesting,treatmentenrollmentandtreatmentoutcomesinITIS.Theinformationisthenvalidatedbytheresponsibleprovincialand/orregionalNTPofficeseachquarter.ITISalsohasqualityassuranceproceduresbuiltintothesystemtovalidatedataentry.ThecentralNTPofficesystematicallyreviewsthesurveillancedataandproducesanTBreportonprogrammaticperformanceseachyear.TBSurveillanceSystemDataQualityThecasedefinitionsusedinITISaredetailedintheNTPManualofProcedures5thedition.6TheyareconsistentwiththeWHO2013revisionon“definitionsandreportingframeworkfortuberculosis”.ITISrecordscase-basedinformation.Patientsareidentifiedusingunique,anonymizedregistrationnumbers.TestresultsandtreatmentstatusarerecordedaspatientsmoveinthecontinuumofTBcare,alongwithdataonsociodemographiccharacteristicsandTBdiseasetype(anatomicalsite,treatmenthistory).ITIScapturessurveillanceinformationinreal-time,suchthatdataenteredatlocallevelsareimmediatelyavailableforviewbythehigher-leveloffices.(BenchmarksB1.1-1.4aremet)ITIShasbuilt-inmechanismstopreventpotentialduplicationandrequiresuserstoenterkeyindicators.Surveillancedatawasanalyzedtodetermineinternalandexternalconsistency.Usingtheminimalsetofkeyvariables,

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RatioofpulmonarytoEP

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2015 49.3 1.8 12.3% - -2016 48.9 1.8 14.2% 1.07 1.042017 46.9 1.9 11.9% 0.94 0.922018 50.1 1.8 13.8% 1.16 1.09

Table2ComparisonofkeyindicatorstodetermineinternalconsistencyofITIS.

TBSurveillanceSystemCoverageNotifyingTBcasestotheNTPismandatedbyRepublicActionNo.10767,whichcoversallpublicandprivatehealthcenters,hospitalsandfacilities.However,the2016NTPSestimatedthattheprevalencetonotificationratioforsmear-positivepulmonarycaseswas3.1.2ThisindicatesahighproportionofTBcasesinthecountryareeithernotdiagnosedorarenotnotifiedtotheNTP.Currently,ITISdoesnotcaptureallTBpatientswithinthecountry.OnlyTBpatientsreceivingtreatmentatNTPfacilities(eitherdiagnosedandtreatedataNTPfacilityorreferredfortreatmentataNTPfacilityafterbeingdiagnosedelsewhere)aremonitoredbyITIS.ThenumberoffacilitiesthatreportedTBcaseshasremainedconstantforallregionsexceptNCR,Regions3and4A(Figure1).ThesystembegantoincludemandatorynotificationsfromprivatefacilitiestreatingTBpatientsin2018(Table3).However,onlyselectregionshaveparticipated.(Benchmark1.8notmet)

Figure1NumberofhealthfacilitiesreportedDSTBcases,2015-2018.

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NumberofnotifiedcasesNCR 6,691

RegionI 6RegionIII 16,964RegionIV-A 13,751RegionVI 1RegionVII 4RegionVIII 1RegionIX 135Total 37,553

Table3Mandatorynotificationfromprivatephysiciansin2018.

Overall,accesstohealthcarehassteadilyimprovedovertime,butremainsbelowbenchmarks.Under-5mortalityrateispoor,at28.1per1,000livebirthsin2017.7Furthermore,household-out-of-pocketpayment(OOP)postedPHP372.8billionor54.5percentofcurrenthealthexpendituresin2017.ThiswasfollowedbygovernmentschemesandcompulsorycontributoryhealthcarefinancingschemesatPHP225.9billionor33.0percent.8TheUniversalHealthCareActwassignedin2019.Itaimstoimproveaccesstobasichealthservicesandessentialmedicineacrossthecountry.(BenchmarkB1.9wasnotmet)SurveillanceofDrugResistantTBIn2018,33%ofnewpulmonarycasesweretestedforrifampicinsusceptibilityandhaddocumentedtestresults(Table4).MajorityofnewcaseswerediagnosedwithoutlaboratoryconfirmationdespiteincreasedcoverageofGeneXpert(Xpert)throughadditionalmachinesandsputumtransportnetwork.In2018,therewere323laboratoriesequippedwithatotalof357Xpertmachines.Thishasincreasedto403laboratoriesoperating449Xpertmachines,asofJuly1,2019.(BenchmarkB2.1notmet)

2017 2018Tested 45,399 94,464

%tested 16.4% 29.2%Table4ProportionofnewpulmonaryTBcasestestedforrifampicin-resistance.

7UNInter-agencyGroupforChildMortalityEstimation,20178PhilippineStatisticsAuthority(2017).PhilippineNationalHealthAccounts.

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SurveillanceofTB/HIVTestingforHIVamongallnotifiedTBcaseshasincreasedovertheyears,butremainsbelowthetargetof80%(Table5).LowtestinguptakemaybeattributedtolimitedaccesstoHIVtesting.IndividualswithTBwhoare15yearsorolderareofferedprovider-initiatedcounsellingandtesting(PICT)atanaccreditedHIVtestingcenter.ThegrowthinthenumberofHIVtestingsiteshasnotbeenevenacrossthecountries,leavingsomeregions(

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deviatefromNTPstandards.WhilechildhoodTBcasesincreasedovertime,itremainslowerthanexcepted,particularlyinthe0-4yearsgroup.Thelargenotificationgapremainstobeakeyconcern.WhiletheNTPcontinuestobridgethegapbyincreasingthecoverageofITISandmandatorynotifications,initiativessuchastargetedactivecasefindingarealsoneeded.Moreover,servicesneedtobemodifiedbasedonhealthseekingpatternsfromthe2016NTPStobettersuittheneedsofthesemissingTBpatients,especiallyamongmales.ThoughtheNTPproducesanannualreport,surveillanceinformationremainsunderutilized.Amobileappandwebdashboardisin-developmenttoautomatedataanalysis.TrainingshouldbeprovidedtoNTPstaffatalllevelstoensuredatafromthismobileappandwebdashboardisusedtorefineprogramimplementation.Summary

Benchmarks ResultsB1.1 MetB1.2 MetB1.3 MetB1.4 MetB1.5 MetB1.6 MetB1.7 MetB1.8 NotmetB1.9 NotmetB1.10 NotassessedB2.1 NotmetB2.2 NotmetB2.3 Notmet

Table7ResultsoftheTBsurveillancechecklist.

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TBEpidemiologyTBBurdenEstimatesIncidenceThePhilippinesisoneofthetop30countrieswithhigh-burdenofTBandRR/MDR-TB.In2018,theWHOestimatedincidenceratewas552per100,000populationor589,000newTBcases(Figures2).Atthecurrentstate,thenumberofnewTBcasesisexpectedtosteadilyincrease.Therefore,thePhilippinesmayfailtoreachtheglobaltargettoendTBby2030(Figure2,reddots).

Figure2Notification,projectedincidenceandglobaltargets(number)

WhilemoreTBcaseswerereportedoverthepast10years,alargenotificationgappersists(Figure3).In2018,about216,000newandrelapsecaseswerenotcapturedbytheNTPsurveillancesystem.

Figure3Notification,projectedincidenceandglobaltargets(rateper100000population)

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MortalityAlthoughtheestimatednumberofnewTBcaseshasbeenrelativelyconstantinthepast10years,mortalityamongTBpatientsdecreasedbyapproximately50%between2000to2017(Figure4).In2018,themortalityrateinTBpatientswas24per100,000population.

Figure4EstimatedTBincidenceandmortality2000-2017.

CareCascadeAnanalysisoftheTBpathwayofcareconfirmsthatthemajorbarrierinthePhilippinesisthelargenumberofTBcasesnotnotifiedtotheNTP(Figure5,leftandcenter).OnceaTBpatientisdiagnosedandnotifiedtotheNTP,theyarelikelytoenrolforanti-TBtreatmentandsuccessfullycompletethefullcourseoftreatment.Lookingatthenotificationgapindetail(Figure5,right),majorityofthemissingcasesaremenbetweentheagesof15-54years.ThisisconsistentwiththehealthseekingpatternresultfromtheNTPS,2whereworkingmenarelesslikelytoconsultwithamedicalprofessionaldespiteexperiencingTBsymptoms.TheNTPneedstomodifytheircasefindingapproachestobettercatertotheneedsoftheseindividuals(e.g.clinicswithflexibletime,patient-centeredtreatment)suchthattheycanreceivethecaretheyneedwithouthavingtore-prioritizetheirdailylives.

Figure5TBcarecascade,2017.

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PopulationTestingAcrossthePhilippines,theproportionofpresumptiveTBcasestestedusingeitherdirectsputumsmearmicroscopy(DSSM)orXpertisapproximately1%(Figure6,left).Thisisbelowthetargetof2%setbytheNTP.Therewerenotedvariationinpopulationtestingrate(PTR)acrosstheregions(Figure6,right).ThelowestPTRwasreportedbyRegion8andARMMandthehighestbyNCRandRegion13.

Figure6PopulationtestingratewithDSSMorXpert2016-2018inthePhilippines(L)andbyregion(R).

Figures7and8compare2018populationtestingrate(PTR)andspecimenpositivityrate(SPR)byregionforDSSMandforXpert,respectively.Forbothtestingapproaches,anegativerelationshipwasobserved.Provincesthathavehighpopulationtestingratesreportedlowerspecimenpositivityrate.Thismaysuggestthatintensifiedcasefindingapproachesarebeingused,leadingtoTBpatientsbeingtestedsoonafterdiseaseonset.Conversely,provincesthathavelowpopulationtestingratesandhighspecimenpositivityratesmaybeover-relyingonpassivecasefindingapproaches,andthereforemaybemissingalargeproportionofTBpatients.Theseprovincesneedtointensifytheircase-findingefforts.Thegraphsalsoshowwidevariationsbetweenprovincesinthesameregions.Moreover,therewereoutlierprovincesinARMMwithhighpositivityrateandlowpopulationtestingrateusingXpert,whichindicatethattheymayhaveloworselectiveaccesstoXperttesting.

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Figure7PTRwithDSSMvs.positivityratebyprovincein2018.

Figure8PTRwithXpertvs.positivityratebyprovincein2018.

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LaboratoryTestingThedecreaseinthenumberofTBtestingusingDSSMandincreaseinXpertinbothDSTBandDRTBreflectstheexpansionofXpertacrossthecountry(Figure9,left).Inthelastquarterof2018,thetotalnumberofpresumptiveTBcasestestedwithXpert(136,095;51,898inRR/MDR-TBand84,197inDSTB)exceededthecasestestedwithDSSM(84,197tests)forthefirsttime.AsthenumberofpresumptiveTBcasestestedwitheithermodalitiesincreasedovertime,theproportionoftestedpositivedecreased(Figure9,right).ThedropinthespecimenpositivityrateusingXpertisexpectedasitreplacesDSSMastheinitialdiagnostictestforTB.

Figure9NumberofTBlaboratorytestsandpositivityrateinthePhilippines,byquarter.

TheexpansionofXpertavailabilitywasnotconsistentacrossthecountry.WhileRegions3,4AandNCRreportednotableincreaseincasestestedwithXpertovertime,littletonochangewasobservedinmanyregions,notably,inRegion11,ARMMandCAR(Figure10,left).ARMMhasreportedsteadydecreaseinthenumberofcaseswithlaboratorytestingforbothDSSMandXpert.Thedeclineinpositivityratesovertimeforbothtestingmodalitiesacrossallregionsisconsistentwiththeoveralltrendatthenationallevel.Theslightdeviationsfromthispattern,suchasincreaseinXpertpositivityrateamongDSTBinARMM,couldbeduetothesmallnumberofcasestestedintheregion.

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Figure10NumberofTBlaboratorytestsandpositivityratebyregion,2016-2018.

Table8summarizestheperformanceoflaboratoriesofferingculture,lineprobeassay(LPA)anddrug-susceptibilitytesting(DST)acrossthecountryin2018. New+Relapse Re-treatment Culture LPA DST Culture LPA DSTNumbertested 3,373 3,377 438 1,625 1,788 244

Table8Numberoflaboratorytestsconductedin2018

Testingusingfor1stand2ndlinedrugusingphenotypicDSTdecreasedbetween2017and1stportionof2018while2ndlineLPAincreased(Figure11).Inthe1stportionof2018,1008patients(37%retreatmentorothertreatmenthistorycases)weretestedwith1stlinephenotypicDSTB,146(48%retreatmentorothertreatmenthistorycases)weretestedwith2ndlinephenotypicDSTand1815(75%retreatmentorothertreatmenthistorycases)weretestedwith2ndlineLPA.For1stlinephenotypicDST(Figure11,topleft),68%werefoundMTB+andresistanttobothrifampicinandisoniazidand11%wereresistanttorifampicinalone.For2ndlinephenotypicDST(Figure11,topright),majority(85%)weresusceptibleto2ndlinedrugs,5%resistanttofluoroquinolonesor2ndlineinjectableeach,and1%wereresistanttoboth.2ndlineDSTusingLPAfoundthat68%wereMTB+and83%weresusceptibletobothdrugs(Figure11,bottomleft).

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Figure111stand2ndlinedrugacceptabilitytesting

TBCaseNotificationThenumberofnotifiedDSTBcasestripledfrom2000(128,495casesor168casesper100,000population)to2018(376,277casesor354per100,000population)(Figure12).WhileimprovedeffortstocaptureallTBcaseshasreducedtheincidence-notificationgapovertime,asignificantdifferencebetweenincidenceandnotificationratestillpersists(Figure12,right).ThisindicatesthatITISisstillmissingalargenumberofdiagnosedTBcasesinthecountry,especiallyfromtheprivatesector.Inaddition,thepersistentincidence-notificationgapisalsobecausemanyTBpatientsremainundiagnosed.

Figure12CasenotificationofDSTBinthePhilippines,2000-2018.

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IncreaseinthenumberofnotifiedDSTBcasesovertimewasobservedacrossallregions,withthemostsignificantincreasesinthethree“big”regionsofNCR,Region3andRegion4A(Figure13,left).Thenumberofnotifiedcasesincreasedby25%forNCR,61%forRegion3and55%inRegion4Abetween2015and2018.Accountingforpopulationsize,thesmallerregions(e.g.ARMM,CARandRegion13)reporteddecreasedCNRinrecentyears(Figure13,right).

Figure13CasenotificationofDSTBbyregion,2015-2018.

Between2013and2018,thenumberofnotifiedRR/MDR-TBcasesincreasedby2.6timesreaching6,229casesin2018(Figure14).Majorityofthecaseswerenotifiedfromthethree“big”regions(i.e.,NCR,Regions3and4A).AswithDSTB,thesmallerregionsreportedlownumberofDRTBcases,withminimalchangeovertime.Thismaybeattributedtolimitedavailabilityofdrug-susceptibilitytestingorvariationsinclinicalpractice,whichrequirefurtherinvestigation.

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Figure14CasenotificationofDRTBinthePhilippines(left)andbyregion(right),2013-2018.

TBtypeandtreatmenthistoryTheincreaseinDSTBnotificationhasbeendrivenbyincreaseinclinicallydiagnosed(CD)casesovertime.(Figure15,left).Since2012,thenumberofnotifiedCDcasesexceedthenumberofBCcases.In2018,63%ofallnotifiedcaseswereCD.TheCNRforCD,223per100,000population,wasnearlytwicetheCNRforBCcases,124per100,000population(Figure15,right).

Figure15CasenotificationofDSTBinthePhilippinesbyTBtype,2000-2018.

ThequickriseofnotifiedCDcaseswasobservedacrossallregions(Figure16).ThemainreasonsforthehighproportionofCDcasesarelikelytobe(1)over-relianceonX-rayasa

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diagnostictoolratherthanjustascreeningtooland(2)lackofaccesstosensitivebacteriologicaltestsliketheXpert.

Figure16CasenotificationofDSTBbyTBtypeandregion,2015-2018.

Approximately95%ofnotifiedDRTBcaseswereBCRR/MDR-TBovertime(Figure17,left).TheproportionofBCXDR-TBwas

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Figure18CasenotificationofDSTBbypatienttype,2015-2018.

Thepatternintreatmenthistoryatthenationallevelwasalsoobservedacrossallregionsovertheyears(Figure19).Theproportionofrelapsecaseshaveincreasedovertimeinmanyregions.Theregionswiththehighestproportionofrelapsecasesin2018wereRegion6(16%)andNCR(14%).

Figure19CasenotificationofDSTBbypatienttypeandregion,2015-2018.

AgeandsexMostofthecasenotifications(innumbers)forDSTBcasesweremenbetweentheagesof15-64yearsold(Figure20).ThisisconsistentwiththeresultsfromtheNTPS,2whichfoundthehighestTBburdenamongthissubpopulation.GiventherelativelyyoungageoftheFilipinopopulation,casenotifications(asarate)increaseswithage(Figure20,right).

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Otherthanpediatriccases,thenumberoffemaleswithnotifiedTBwaslessthanhalfofthemaleswithTB.TherewereminimalchangestothisageandsexdistributionamongnotifiedDSTBcasesovertime.

Figure20AgeandsexdistributionofDSTBcasesinthePhilippines,2015-2018.

ThepatternofhighernotificationamongmenofworkingagesandincreasedCNRwithagewasobservedacrossallregions(Figure21).Inregionswithlowcasenotification(e.g.ARMM,CAR),thedifferencebetweennotifiedcasesinmenandwomenwaslessprominent.ThismaysuggestthattherearemoremissingTBcasesamongmenintheseareas.

Figure21AgeandsexdistributionofDSTBbyregion,2015-2018.

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TheageandsexpatternamongnotifiedRR/MDR-TBcasesaresimilartothatofDSTB(Figure22).Majorityareamongmenbetween15-64yearsold.

Figure22AgeandsexdistributionofRR/MDR-TB,2015-2018.

Themedianand25thpercentileageatTBdiagnosiswerelowerinCDcasescomparedtoBCcases(Figure23).ThisisexpectedaspediatriccasesaretypicallyCD.However,themedianageofCDcaseshasincreasedtothatofBCcasesinrecentyears,giventhehighproportionofDSTBcaseswithoutlaboratoryconfirmationoverall.In2018,themedianagewas43yearsold(interquartilerange[IQR]:29-56years)inBCcasesand42yearsold(IQR:21-59years)inCDcases.

Figure23AgedistributionbyTBtypeinthePhilippines(left)andbyregion(right),2015-2018.

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ThemedianageatdiagnosisamongRR/MDR-TBislikethatofDSTB(Figure24).In2018,themedianageatdiagnosiswas43years(IQR:32-54years)forBCRR/MDR-TBand40years(IQR32-53years)forBCXDR-TB.Themedianageatdiagnosiswas41years(IQR:29-54years)forCDDRTBand27years(IQR:21-34years)forEPDRTB.

Figure24AgedistributionofRR/MDR-TBbytype.

ReferralsourceTheproportionofDSTBcaseswhosesourcewastheprivatesectorhasincreasedovertime(Figure25).Thiscouldreflectincreasedeffortstoengagewiththeprivatesector.Notifiedcasesfromtheprivatesector,however,weremainlyCDorEPcases(Figure25,right).ThissuggeststhatphysiciansatprivatefacilitiesmaynotbefollowingtheNTPguidelinesfortestinganddiagnosisbeforereferralfortreatmentatNTPfacilities.

Figure25Casenotificationbysource(left)andTBtype(right),2015-2018.

TheincreaseinprivatesectorcontributiontoDSTBcasenotifications(innumbers)washighestinNCR,Regions3and4A(Figure26).Therewerealsonotedvariationsintheproportionreferredfromcommunitysourcesacrosstheregions.

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Figure26DSTBcasesbyreferralsourceandregion.

ForRR/MDR-TB,mostcaseswerediagnosedinpublicfacilities(Figure27).TheproportionofRR/MDR-TBforwhomthesourcewasprivatesectorwaslowercomparedtothatforDSTB.ThismaysuggestthatpatientswhosesourcewastheprivatesectormayhavelessRR/MDR-TB.Documentationofreferralsourcealsoimprovedovertime,with100%documentationin2018.

Figure27RR/MDR-TBcasesbyreferralsource.

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TreatmentOutcomesDSTBTreatmentsuccessrate(TSR)forDSTBpatientshasbeenconsistentlyhighovertime(Figure28).Forthecohortthatstartedtreatmentin2017,91%weretreatedsuccessfully,thatis,completedtreatmentandwerecured.About28%ofDSTBpatientswerecured.Therewerelimitedchangesinunfavorableoutcomesovertime.Approximately4%ofthecohortwaslosttofollow-up,2%diedwhileontreatmentand

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TSRforBCDSTBcohortswassimilartotheentireDSTBcohorts,buttheproportionthatwerecuredwasmuchhigherintheBCDSTBcohorts(Figure30).Forthe2017BCDSTBcohort,TSRwas89%andcureratewas75%.Theothertreatmentoutcomesweresimilarbetweenthetwogroups.ThissuggestthatphysiciansmaynotbeconductingDSSMattheendoftreatmentandweremerelyrelyingontreatmentcompletiontoinfertreatmentsuccesswithoutbacteriologicalevidence.

Figure30TreatmentoutcomesforBCDSTBcohorts.

TheoutcomesfortheBCDSTBcohortswereconsistentwithnationalpatternsacrossallregions(Figure31).AswiththeentireDSTBcohorts,withandwithoutBC,therewasahighproportionofpatientsnotevaluatedat12monthsinARMM.

Figure31TreatmentoutcomesforBCDSTBcohortsbyregion.

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RR/MDR-TBTreatmentsoutcomesforRR/MDR-TBpatientshavebeenverylow.FortheRR/MDR-TBcohortthatstartedtreatmentin2016,58%successfullycompletedthefullcourseoftreatment(Figure32).One-third(31%)ofthecohortwaslosttofollow-upand9%diedwhileontreatment.Whenanalysiswasdoneforrecentcohorts(2017and2018)afterexcludingthepatientswhoarestillontreatment,thetreatmentoutcomescontinuetobeverylow.Thiswasdespitethewidespreaduseofshorterinjectionregimensin2018.Thissuggeststhatunaddressedsocio-economicbarriersandpoorlymanagedadversedrugreactions,ratherthanthelengthoftreatment,continuetobethemajorreasonsforthehighproportionofdeathsandlost-to-follow-ups.

Figure32TreatmentoutcomeforRR/MDR-TBcohorts.

Comparingoutcomesbetweenregions(Figure33),TSRwasthelowestinNCR(48%)andARMM(43%).EnsuringRR/MDR-TBpatientsremainontreatmentisaconcernforallregions.

Figure33TreatmentoutcomesforRR/MDR-TBcohortsbyregions.

InJan-May2019,11-16%ofRR/MDR-TBpatientsmissedmorethan10%oftheirdosesinamonth.Theyarecalled“patients-in-crisis”bytheNTP(Figure34).Thethree“big”regions(NCR,Region3andRegion4A)reportedthehighestproportionofpatients-in-crisis.Manyregionsareshowingsomeimprovementforthisindicatoroverthepastfewmonths.ThismaybeduetoincreaseintheproportionofRR/MDR-TBpatientswho

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receivehome-basedandcommunity-basedcare(includinguseofdigitaladherencetoolslikevideoDOT).

Figure34RR/MDR-TBtreatmentinterruption.

AsmajorityofnotifiedDRTBcaseswereBC-MDR-TB,thetreatmentoutcomesweresimilartothatoftheoverallDRTBcohortsinFigures31and32.

Figure35TreatmentoutcomesforBCRR/MDR-TBcohorts.

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Figure36TreatmentoutcomesforBCRR/MDR-TBcohortsbyregion.

TheRR/MDR-TBshortcourseregimenwasintroducedinthePhilippinesin2017and44%ofthe2017cohortand22%ofthe2018cohortwasenrolledinit.InterimoutcomeatsixmonthsshowsthatTSRishigheramongthoseonshortcourse(67%in2017and55%in2018)comparedtopatientsonconventionalregimen(Figure37).However,theproportionlosttofollow-upordiedwascomparablebetweenthetwotreatmentregimens.

Figure37InterimtreatmentoutcomesforRR/MDR-TBcohortsonshortcourseregimen.

TSRinRR/MDR-TBcohortsonshortcourseregimenwashighlyvariableacrosstheregions.In2018,TSRrangedfrom39%inRegion12to74%inRegion1(Figure38).Thereweresomeoutliers,suchasmortalityof100%inRegion11in2018andTSRof100%inCARin2017,whichcouldbeattributedtosmallcohortsize.Otheroutcomeswereconsistentwithnationalpattern.

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Figure38InterimtreatmentoutcomesforRR/MDR-TBcohortsonshortcourseregimentbyregion.

HIV/TBTSRforDSTBpatientswithHIVwasabove73%inthepast3years,reaching81%forthe2017cohort(Figure39).Theproportionofpatientswhodiedontreatmenthassteadilydecreasedovertimeandwas8%in2017.Therewerelimitedvariationsintheotherunfavorableoutcomesovertime.

Figure39TreatmentoutcomesHIV/DSTB.

Acrossregionsforthe2017cohort,TSRrangedfrom100%inRegion1andCARto71%inRegion8(Figure40).But,Region1onlyhad2HIV/TBpatientsinthe2017cohort.Regions2,13andARMMdidnotreportanyHIV/TBpatientthatstartedtreatmentin2017.

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Figure40TreatmentoutcomesHIV/DSTBbyregion.

Treatmentsuccessrate(TSR)wassimilarbetweenmenandwomenwithDSTB(Figure41).Itdeclinedinthehigheragegroups.ThisdeclineinTSRamongtheelderlywasmoredrasticamongthosewithRR/MDR-TB.Thismaybeduetohigherproportionofunaddressedadversedrugreactionsandaccessbarriersamongtheelderly.ForHIV/DSTB,womenweremorelikelytobetreatedsuccessfullyforTBcomparedtomen,particularlywomenbetweentheagesof45-54years.

Figure41TreatmentsuccessratebyageandTBtype.

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LatentTBandIPTAsperthe2014ManualofProcedures(2014MOP),under-fivechildrenwhoarehouseholdcontactsofbacteriologicallyconfirmedTBpatientsneedtobegivenisoniazidpreventivetherapy(IPT).However,theproportionofunder-fivechildhouseholdcontactsofbacteriologicallyconfirmedTBcaseswhowereinitiatedonpreventivetreatmentin2018(accordingtotheWHOGlobalTBReport2019)wasonly9.4%(graphnotshownhere).Thissuggestpoorcontacttracingand/orreportingofIPTcoverage.ThenumberofchildrengivenIPTincreasedby43%between2016and2018.In2018,6,611childrenweretreatedwithIPT.Formostregions,thenumberofchildrentreatedremainslow(Figure42,left).In2018,ARMMreportedIPTforjustonecontactandCARreportedforeightcontacts.AmongregionsthatreportedhighnumberofchildrengivenIPT,majorityofreportedcasesdidnotseemtobecontactsofTBpatients(Figure42,right).TheindicationsforIPTamongnon-contactsarenotknown.Also,someolderchildrenandyoungadultsreceivedIPTalthoughthiswasnotpartofthe2014MOP(Figure43).TheMOPiscurrentlybeingrevisedtoincludecontactsofallage-groups(withandwithoutadditionalriskfactors).Moreover,thenumberofchildrenonIPTissignificantlylowerinRegions4Aand6comparedtothenumberofadultTBpatientsnotifiedfromtheseregions(Figure44).

Figure42LatentTBonIPTbyregion

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Figure43LatentTBonIPTbyage,sexandregion.

Figure44AdultcasenotificationandlatentTBonIPT.

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ChildhoodTBThenumberofnotifiedDSTBcasesamongchildrenaged0-14yearsoldincreasedby17%between2015and2018.In2018,45,488pediatricTBcaseswerenotified,whichtranslatestoaCNRof141per100,000population(Figure45).TheproportionofDSTBcasesamongchildrenhasbeensteadyat12%,otherthanaslightincreasein2017.

Figure45ChildrenDSTBinthePhilippines2015-2018.

TherewerelargevariationsinthenumberandrateofnotifiedpediatricTBcasesacrosstheregions(Figure46).In2018,thenumberofpediatricTBcasesrangedfrom337(CNR21per100,000children)inARMMto11,193(CNR332per100,000children)inRegion3.TheproportionofDSTBcasesamongchildrenrangedfrom25%inCARandRegion3to4%inRegion9.

Figure46ChildrenDSTBbyregion,2015-2018.

Inahightransmissionsetting,childrenaged0–4yearsaredisproportionatelyimpactedduetotheirhighriskofprogressiontoactivediseaserelativetoolderchildren.Therefore,theexpectedratioofnotifiedTBcasesamongthoseaged0-4yearsand5-14yearsis1.5–3.0:1.But,thenumberofnotifiedTBcasesamong5-14yearswashigherthanthenotifiedTBcasesamong0-4yearsovertimeandacrossregions,exceptinCAR(Figure47,

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left).ThisindicatethattheremaybemanymissingTBcases(eitherunder-diagnosedornotreported)amongchildren0-4years,orthatTBamongchildren5-14yearsoldisbeingover-diagnosed.Thecasenotificationrates(Figure47,right)among0-4yearoldchildrenarehigherorsimilartothoseamong5-14yearoldchildrenovertimeandacrossregionsbecausethelattergroupisforawiderage-groupandlargerpopulationofchildren.However,asmentionedabove,weexpectmuchhighercasenotificationratesamong0-4yearoldchildren.Nevertheless,someregionsseemtodoingbetterthanothers(e.g.,Region3).However,therearewidevariationsforcasenotificationsofTBamongchildrenacrossprovinceswitheachregion(Figure47).Forexample,Region3hasveryhighcasenotificationsofTBamongchildreninoneprovincecomparedtoitsotherprovinces.

Figure47CasenotificationofchildrenTBbyagegroup.

Figure48Casenotificationinadultsvs.childrenbyprovincein2018.

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HIV/TBMoreTBpatientsarebeingtestedforHIVovertime,thoughtestingrateremainslow(Figure49).In2018,30%ofDSTBpatientsweretested.Lessthan2%ofthosetestedwereHIV+andmorethan80%ofHIV/TBpatientsenrolledonART.ThispathwaydemonstratesthatthemainbarrierisHIVtestinguptake.

Figure49HIV/TBtestingandtreatment,2015-2016.

HIVtestingisofferedonlyinselectcitiesandmunicipalitiesthatthePhilippinesDepartmentofHealthhasprioritizedforHIVintervention(i.e.CategoryAandB)basedonprevalenceofHIVandsizeofat-riskpopulations.Althoughthenumberoftestingsiteshaveincreasedovertime,therewerelargevariationsinHIVtestingrateacrossregions(Figure50).In2018,therewere1TBpatientstestedforHIVinRegion2andARMMdidnotreportany.Regionswhichreportedhighpositivityratealsohadthelowestnumberofcasestested.Forexample,Region2reportedpositivityof100%andonlytested1patient.

Figure50HIVtestingandpositivityrateamongTBpatientsbyregion.

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DeterminantsofTBThepopulationofPhilippinesincreasedfrom77millionin2000to101millionin2015.9Annualpopulationgrowthratehasslowedovertime,from1.9percentbetween2000-2010to1.7in2010-2015.Theagestructureofthepopulationisalsochanging(Figure51).Birthratedeclinedby5%between2012-2017andreached16birthsper1000populationin2017.Alongwithincreasinglifeexpectancy,thepopulationisslowlyageingwiththemajorityofFilipinosbeingworkingageadults.ThissubpopulationalsohasthehighestburdenofTBacrossthecountry.

Figure51Populationchangebyageandsex.

Figure52Trendsinchildmortalityandlifeexpectancyatbirth.

Theeconomyhasimprovedsignificantlyinthepast15years.Asthecountrybecomesmoreprosperous,healthexpenditurehasalsoincreasedovertime.Economicprogress,however,hasnotbeequitableacrossthecountryasreflectedbythehighGINIindex.ManyFilipinoscontinuetoliveinpovertyandcannotaccessessentialhealthservices.

9PhilippinesStatisticsAuthority(2017).CensusofPopulationandHousing.

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Figure53Trendsinkeysocio-economicindicators.

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APPENDICES

APPENDIX1:STANDARDSANDBENCHMARKSFORTUBERCULOSISSURVEILLANCEANDVITALREGISTRATIONSYSTEMS

APPENDIX2:COMPARATIVEANALYSISBETWEENQ1/Q22018ANDQ1/Q22019

Appendix1:Standardsandbenchmarks

40

Appendix1:Standardsandbenchmarksfortuberculosissurveillanceandvitalregistrationsystems

Question Outcome DescriptionA1.HowaredatarecordedforindividualTBcasesattheservicedeliverylevel,e.g.inTBdiagnosticunits,healthcentres,clinics?(Tickallthatapply)

☒Dataarerecordedelectronicallyonanationalinternet-basedsystem☐Dataarerecordedelectronicallyonastate/provincial/regionalinternet-basedsystem☐Dataarerecordedelectronicallyonalocalsystem☐Dataarerecordedonpaper☐Dataarenotrecorded

AllNTP-engagedfacilitiesusetheITIS.

A2.DoallservicedeliverypointssystematicallyusestandardizedTBdatacollectionformsandtools?

☒Yes,completely☐Mostly☐Partially☐No,notatall

AllNTP-engagedfacilitiesusestandardformats.(Butthisisnotsoformanyprivateproviders.)

A3.WhichTBcasesareincludedinthenationalTBsurveillancedata?(Tickallthatapplyanddescribe):

☐AllTBcasesfromallpartsofthecountry☐SomeTBcasesareexcluded☐Somepart(s)ofthecountryareexcluded☐Somecasetypesareexcluded☒Somecareproviders,e.g.non-NTPproviders,prisons,privatepractitioners,areexcluded.☐Others:________________________Describe:_______________________

A4.WhattypesofTBdataareavailableatthenationallevel?(Tickallthatapply)

☐Patient-leveldatathatallowmultipleepisodesofTBinthesamepersontobeidentifiedareavailable☒Case-leveldataareavailableforallofthecountry☐Case-leveldataareavailableforpartsofthecountry☐Aggregateddataareavailable,i.e.summariesforgroupsofcases.

A5.Whatistheexpectedfrequencyofdatatransmissionfromthefirstsub-nationaladministrativeleveltothenationallevel?(Tickallthatapply)

☒Real-time☐Moreoftenthanmonthly☐Monthly☐Quarterly☐Lessoftenthan

A6.AtwhatlevelsofthesystemareTBdatasystematicallyverifiedforaccuracy,timelinessandcompleteness?(Tickallthatapply)

☐Fromtheserviceunitupwards☐Fromthe1stadministrativelevelupwards☒Fromthe2ndadministrativelevelupwards☐Onlyatthenationallevel☐Notatanylevel

A7.Whattypesofqualityassuranceproceduresare

☒Qualitycontrolsareinplacefortheelectronicsurveillancesystem(automatedchecksatdataentry

Appendix1:Standardsandbenchmarks

41

Question Outcome DescriptionsystematicallyundertakenforTBdata?(Tickallthatapply)

andbatchchecking,plusstandardoperatingprocedures(SOPs)☒Dataarereviewedduringsupervisorymonitoringvisitstoserviceunitsandsub-nationallevels(Howoften?_______________)☐DataarereviewedduringmeetingswithTBstaff(Howoften?__Quarterly_________________________)☐Other(Specify:_________________________)

A8.IsfeedbackonTBdataqualitysystematicallyprovidedtoalllowerreportinglevels?

☐Yes,completely☐Mostly☒Partially☐No,notatall

A9.WhenarenationalTBcasedataforagivencalendaryearconsideredreadyfornationalanalysesandreporting?

☒BeforeAprilthefollowingcalendaryear☐BeforeMaythefollowingcalendaryear☐BeforeJunethefollowingcalendaryear☐OnorafterbeginningofJunethefollowingcalendaryear

A10.AretherenationalguidelinesforrecordingandreportingofTBdata,e.g.documentationorinstructions?(Tickallthatapply)

☒Yes.Theyarepostedontheinternet☐Yes.Theyareavailableinamanualorotherreferencedocument,e.g.trainingmaterials☐No

A11.DoesthenationalTBprogrammehaveatrainingplanthatincludesstaffinvolvedindatacollectionandreportingatalllevelsofthereportingprocess?

☒Yes☐No

A12.HowoftendoTBprogrammestaffreceivetrainingspecificallyonTBsurveillance,i.e.recodingandreportingofTBdata?(Tickallthatapply)

☐Trainingisroutinelyreceivedatnationalandsub-nationallevels(Howoften?____________________________)☒Trainingisreceivedonanadhocbasis☐Staffreceivetrainingwhentheyarehired☐Noroutinetrainingisreceived

A13.HowmanystaffworksonTBsurveillanceatthenationallevel?(Tickallthatapply)

☐Epidemiologist:full-time(#)☐Epidemiologist:part-time(#)☐Statistician:full-time(#_)☐Statistician:part-time(#)☐Datamanager:full-time(#)☐Datamanager:part-time(#_)☐Dataqualityofficers:full-time(#)☐Dataqualityofficers:part-time(#_______)

Appendix1:Standardsandbenchmarks

42

Question Outcome Description☐Other(specify:OneM&EOfficerand11officerswhoworkonthecase-based,onlineIntegratedTBInformationSystem)

A14.IsanationalTBsurveillancereportroutinelyproducedanddisseminatedonanannualbasis?

☒Yes☐No

Suchannualreportswereproducedin2016-2018.The2018reportwasdisseminatedinearly2019.

A15.Aretherewrittengoalsofthesurveillancesystem?

☒Yes☐No

A16.Arepoliciesandproceduresinplacetoprotecttheconfidentialityofallsurveillancedatae.g.records,registers?

☒Yes,completely☐Mostly☐Partially☐No,notatall

A17.Istherealong-termfinancialplanandbudgetinplacetosupportTBsurveillanceactivities?

☒Yes☐No

A18.WhenwasthelasttimetheTBsurveillancesystemwasevaluated?

☒Withinthepast5years☐Withinthepast5-10years☐Never

B1.1CasedefinitionsareconsistentwithWHOguidelines

Allbenchmarksshouldbesatisfiedtomeetthisstandard:• Laboratory-confirmedcasesaredistinguished fromclinicallydiagnosedcases10

• Newcasesaredistinguishedfrompreviouslytreatedcases

Pulmonarycasesaredistinguishedfromextra-pulmonarycases.

☒Met☐Partiallymet☐Notmet

B1.2TBsurveillancesystemisdesignedtocaptureaminimumsetofvariablesforallreportedTBcases

DataareroutinelycollectedforatleasteachofthefollowingvariablesforallTBcases:• Ageoragegroup• Sex• Yearofregistration• Bacteriologicalresults• Historyofprevioustreatment• Anatomicalsiteofdisease

Forcase-basedsystems,apatientidentifier

☒Met☐Partiallymet☐Notmet

10i.e.bysmear,cultureorWHO-endorsedmolecularteste.g.GeneXpertMTB/RIF

Appendix1:Standardsandbenchmarks

43

Question Outcome DescriptionB1.3Allscheduledperiodicdatasubmissionshavebeenreceivedandprocessedatthenationallevel

• Forpaper-basedsystems:100%ofexpectedreportsfrom each TB BMU have been received and dataaggregatedatthenationallevel

Fornationalpatient-basedorcase-basedelectronicsystemsthatimportdatafilesfromsub-national(e.g.provincialorregional)electronicsystems:100%ofexpecteddatafileshavebeenimported.

☐Met☐Partiallymet☐Notmet☒Notapplicable

B1.4Datainquarterlyreports(orequivalent)areaccurate,complete,andinternallyconsistent(Forpaper-basedsystemsonly)

Allbenchmarksshouldbesatisfiedtomeetthisstandard:• Sub-totalsofthenumberofTBcasesbyagegroup,sex and case type matches the total number ofreportedTBcases in>95%ofquarterly reports (orequivalent)fromBMUs

• ThenumberofTBcasesin>95%ofquarterlyreports(or equivalent) matches the number of casesrecordedinBMUTBregistersandsourcedocuments(patienttreatmentcardsandlaboratoryregister)

Dataforaminimumsetofvariablesareavailablefor>95%ofthetotalnumberofreportedTBcasesinBMUTBregisters.

☐Met☐Partiallymet☐Notmet☒Notapplicable

B1.5Datainthenationaldatabaseareaccurate,complete,internallyconsistent,andfreeofduplicates(Forelectroniccase-basedorpatient-basedsystemsonly)

Allbenchmarksshouldbemettoreachthisstandard:• Data validation checks are in place at thenationallevel to identify and correct invalid, inconsistentand/ormissingdata in theminimumset (StandardB1.2)

• For each variable in the minimum set (StandardB1.2),≥90%ofcaserecordsarecomplete,validandinternallyconsistentfortheyearbeingassessed

Appendix1:Standardsandbenchmarks

44

Question Outcome Descriptioninternalconsistencyoverthepreviousfiveyearsforthefollowingbenchmarks:2. RatioofnotifiedpulmonarytoextrapulmonaryTB

cases3. RatioofmaletofemaleTBcases4. Proportion of childhood TB cases out of all TB

cases5. Year-to-yearchange in thecasenotificationrate

forallformsofTB6. Year-to-yearchange in thecasenotificationrate

fornewsmear-positiveTB

andifdataareavailable,RatioofthenumberofpeoplewithpresumptiveTBtototalnotificationsofTBcases.

B1.8AlldiagnosedcasesofTBarereported

Bothbenchmarksshouldbesatisfiedtomeetthisstandard:• TBreportingisalegalrequirement

>90%ofTBcasesarereportedtonationalhealthauthorities,asdeterminedbyanational-levelinvestigation(e.g.inventorystudy,conductedinpast10years).

☐Met☐Partiallymet☒Notmet

B1.9Populationhasgoodaccesstohealthcare

Bothbenchmarksshouldbesatisfiedtomeetthisstandard:• Under-fivemortalityrate(probabilityofdyingbyage5per1000livebirths)is

Appendix1:Standardsandbenchmarks

45

Question Outcome Descriptionepidemic state11 or where it is not feasible toimplementroutinesurveillance.

B2.3SurveillancedataforchildrenreportedwithTBarereliableandaccurate,andalldiagnosedchildhoodTBcasesarereported

Bothbenchmarksshouldbesatisfiedtomeetthisstandard:• Ratioofagegroups0–4to5–14yearsisintherange1.5–3.0

>90%ofchildhoodTBcasesarereportedtonationalhealthauthorities,asdeterminedbyanational-levelinvestigation(e.g.inventorystudy,conductedinthepast10years)

☐Met☐Partiallymet☒Notmet

11Low-levelepidemicstate:HIVprevalencehasnotconsistentlyexceeded5%inanydefinedsub-population.

Appendix2:Performancein2018and2019

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Appendix2:ComparativeanalysisbetweenQ1/Q22018andQ1/Q22019ActiveCaseFindinginVulnerablePopulations

1. Massscreeningamongvulnerablepopulations(usingmobileX-ray)Inthethree“big”regionsofNCR,RegionIIIandRegionIV-A,thenumberofindividualsscreenedaspartofmassscreeninginitiativesincreasedby3-foldsbetweenthe1stand2ndhalfof2018(26,629inQ1/Q2of2018vs.108,824inQ3/Q4of2018)andthendecreasedbynearly2/3betweenQ3/Q4of2018andQ1/Q2of2019(16,284in2019).Theproportionscreenedpositivewasrelativelystablebetween2018and2019at13%inQ1/Q2of2018,15%inQ3/Q4of2018and10%inQ1/Q2of2019.Individualswithapositivechestx-raywererecommendedtoundergoXperttesting.However,Xperttestingwasonlyconductedin35%ofthosescreenedpositiveinQ1/Q2of2018,48%inQ3/Q4of2018and27%inQ1/Q2of2019.Byregion,massscreeningeffortsincreaseddrasticallyinthe2ndhalfof2018,butthendecreasedagainin2019(FigureA.1,topleft).ThisrapidchangewasmostnotableinNCR,wherethenumberofindividualsscreeneddroppedby83%betweenQ3/Q4of2018(25,550individuals)andQ1/Q2of2019(4,368individuals).ScreeningyieldinNCRalsodecreasedfrom21%to7%inthesametimeperiod.ThenumberofindividualstestedwithXpertdecreasedbetween2018and2019,eventhoughmoreindividualswerescreened.ThissharpdecreaseinXperttestingwasmostnotableinRegionIV-A(FigureA.1,topright).Xperttestresultswasnotavailableforallthreeregionsinthe2ndhalfof2018.Asaresult,majorityofnotifiedcasesfromthesemassscreeninginitiativeswereclinicallydiagnosed(CD)in2019(91%inNCR,72%inRegionIIIand82%inRegionIV-A)(FigureA.1,bottomleft).InQ1/2of2019,thisformofcasefindingcontributedto0.4%(0.03%BC)ofallnotifiedcasesinNCR,2.2%(0.6%BC)inRegionIIIand2.4%(0.4%BC)inRegionIV-A(FigureA.1,bottomright).

Appendix2:Performancein2018and2019

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FigureA.54Resultsofmassscreeninginvulnerablepopulationsin2018and2019.

2. Massscreeningamongvulnerablepopulations(usingX-rayvouchers)

Anotherformofactivecasefindinginvulnerablepopulationswasbyprovidingchestx-rayvoucherstoeligibleindividuals.ThenumberofindividualsgivenvouchersandscreenedwithchestX-rayincreasedby4-foldsbetweenQ3/Q4of2018andQ1/Q2of2019(1,631in2018vs.8,949in2019).Positivescreeningyieldalsoincreasedfrom12%to19%inthesametimeperiod.WhilethisinitiativewasnotconductedinNCRin2018,NCRscreenedthemostindividuals(5,198individuals,58%)in2019(FigureA.2,topleft).Theproportionscreenedpositivewassimilaracrossregions(21%inNCRandRegionIII,16%inRegionIV-A)(FigureA.2,topleft).SimilartomassscreeningusingmobileX-ray(mentionedabove),mostindividualswhoscreenedpositivewithchestx-raydidnotfollowthroughwithXperttesting.InQ1/Q2of2019,only37%(639individuals)ofthosescreenedpositivewastestedwithXpert(FigureA.2,topright).Inturn,majorityofnotifiedcaseswereCD(70%inQ3/Q4of2018,91%inQ1/Q2of2019).NCRdidnotreportXperttestingdataandall766notifiedcasesin2019wereCDpatients.InQ1/Q2of2019,theproportionofCDamongthenotifiedcaseswas70%inRegionIIIand72%inRegionIV-A.Thismethodofmassscreeningcontributedaminorparttooverallcasefinding(FigureA.2,bottomright).ThiswasanewinitiativeandbaselinedatainQ1/Q2of2018wasnotavailable.

Appendix2:Performancein2018and2019

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FigureA.55ResultsofscreeningwithX-rayvouchersinvulnerablepopulationin2018and2019.

Activecasefindinginjails(usingmobileX-ray)MassTBscreeningwithchestX-raywasalsocarriedoutinjailsinthethree“big”regions.Thisinitiativehasexpandedtootherregionsin2019(FigureA.3).Inthethreeregionswithdatain2018,thenumberofindividualsscreeneddecreasedby21%betweenthe1stand2ndhalfof2018(28,292inQ1/Q2and22,277inQ3/Q4)andthenincreasedby16%betweenQ3/Q4of2018andQ1/Q2of2019(25,791in2019).Thisdrasticchangebetween2018and2019wasmostnotableinNCR(FigureA.3,topleft).Screeningyieldinthesethreeregionschangedinasimilarpattern;24%inQ1/Q2of2018,11%inQ3/Q4of2018and13%inQ1/Q2of2019.WhilethenumberofindividualstestedwithXpertwasslightlyhigherthanthenumberofindividualsscreenedpositivein2018(6,662screenedpositiveand7,430XperttestedinQ1/Q22,446screenedpositiveand3,062XperttestedinQ3/Q4),only67%(2,798individuals)ofthosescreenedpositivewasXperttestedinQ1/Q2of2019(FigureA.3,topright).Theproportiontestedpositivewas6%inQ1/Q2of2018,18%inQ3/Q4of2018and9%inQ1/Q2of2019.Similartootheractivecasefind