Surveillance and Monitoring,

India

What do epidemiological

studies in India tell us about

disease trends & progress

towards MDGs

Prevalence of

bacteriologically positive PTB= 400 / 100 000

population.ICMR Special Report No. 34

Prevalence of

bacteriologically +ve PTB

per 1000 population

Trends in Prevalence of bacteriologically positive PTB, Tumkur

410

444

390

400

410

420

430

440

450

1960 1962 1964 1966 1968 1970 1972

Year

Pre

v/1

00

K

BackI JTB 1979; 26: 121-35

Trends in Prevalence of bacteriologically positive PTB, Madnapalle

681

501 483

0

200

400

600

800

1960 1961 1962 1963 1964 1965

Year

Pre

v/1

00

K

Back1.Indian J Med Res 1981 (suppl); 73: 1-80

Trends in Prevalence of bacteriologically positive PTB, Rural Bangalore

406372

337

393

320

438

0

100

200

300

400

500

1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984

Year

Pre

v/1

00

K

BackBull WHO 1974; 51: 473-88

Trends in Prevalence of bacteriologically positive PTB, Delhi

400

700 700

210280

320360 330

0

100

200

300

400

500

600

700

800

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

Year

Pre

v/1

00

K

BackIJTB 1999; 46: 133

DOTS reduces prevalance of PTB :

Trends in Thiruvellur

0

1000

2000

68-

70

71-

73

73-

75

76-

78

79-

81

81-

83

84-

86

99-

01

01-

03

04-

06

Year

Pre

v / 1

00 K

Male C+

Male S+

Female C+

Female S+

Int J Tuberc Lung

Trends in Prevalence of PTB/ 100 000 population,

Thiruvellur

609

451

311326257

169

0

200

400

600

800

2000 2002 2005

Year

Pre

v /

10

0 k

Culture+, 12.6% decline/Yr

smear+, 12.3% decline/Yr

50% decline in 5 years

Int J Tuberc Lung Dis 2008;12:916-20

Next

Prevalence of bacteriologicallynegative PTB per 1000 population

= prevalence of bacteriologicallypositive PTB X 1.5-4

Limitation: No follow up with antibiotics

1981-83 : 1.1(sm+)

1961-68 : 0.8 -1.3(cul+)

2001-03 : 1.3(sm+)

1968-86 : 1.9-3.5(cul+)

INCIDENCE OF PTB

Bull WHO 1974; 51: 473-88, Tubercle 1995; 76: 190-5, Int J Tuberc Lung Dis 2001; 5:142-57, Int J Tuberc Lung Dis 2006; 10:115-17

Trends in incidence of culture positive PTB -

Rural Bangalore

132

79

99

0

20

40

60

80

100

120

140

1962 1964 1967Year

Incid

en

ce / 1

00 K

Bull WHO 1974; 51: 473-88 Back

Trends in incidence of PTB - Chilglepet, Thiruvellur

352

250 251

207 209189

157142

106 104

127113

126

0

50

100

150

200

250

300

350

400

1972 1974 1977 1980 1982 1985 2002*

Incid

ence / 1

00 K

culture+ cases,

decline=4.3%/Yr

smear+ cases, decline

2.3%/Yr

*Thiruvellur

Int J Tuberc Lung Dis 2001; 5:142-157, Int J Tuberc Lung Dis 2006; 10:115-17

Next

Ratio of Prevelance : Incidence of

PTB (Chenglepet)

2.5

2.8

3.7 3.83.6

3.9

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

1968-70 1971-73 1973-75 1976-78 1979-81 1981-83

Year

Ratio

Int J Tuberc Lung Dis 2001; 5:142-157, Int J Tuberc Lung Dis 2006; 10:115-17

Prevalence : Incidence, smear+cases

3.6

2

0

1

2

3

4

Chingleput, 1968-84 Thiruvellur, 2002-2004

Ra

tio

Int J Tuberc Lung Dis 2001; 5:142-157, Int J Tuberc Lung Dis 2006; 10:115

Tumkur – 1960-73 (2) : 1.5

Bangalore Rural - 1961 – 84 (7) : 0.6 – 1.0

Periurban Bangalore - 1992 – 2006 (2) :0.6-1.0

Doddaballapur – 1974-1979 (2) : 1.0-1.4

Chingleput – 1969 -1979 (3) : 1.7-1.9

Car Nicobar-1986(1) : 1.5

Thiruvananthapuram – 1991-1992 (1) : 0.8

Bikaner – 1992 (1) : 1.3

Morena – 1989 (1) : 3.6

Thiruvallur – 1999-2005(3) : 1.2-1.6

Estimated ARTI in different

parts of INDIA

Zone-wise ARTI Estimates, 2000-03

North

WestEast

South

1.9%

1.3%

1.0%

1.6%

National Average=1.5%

Int J Tuberc Lung Dis 2005; 9: 569-75, Int J Tuberc Lung Dis 2005; 9: 116-18

Back

State level tuberculin surveys

Int J Tuberc Lung Dis. 2004; 8 :545-51, IJTB 2007; 54:177-183

ARTI Trends in India (Pre-RNTCP period)

1

1.4

1.81.9

1.7

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

Years

AR

TI%

Doddaballapur

Chingleput

Tubercle 1992; 73: 213-18, NTI Newsletter 1985; 21: 28, Int J Tuberc Lung Dis 2001; 5:142-57

ARTI Trends in India (Pre-RNTCP period)

0.7

0.9

0.6

0.4

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

Years

AR

TI%

Rural Bangalore

Tubercle 1992; 73: 213-18, NTI Newsletter 1985; 21: 28, Int J Tuberc Lung Dis 2001; 5:142-57

ARTI Trends in India (RNTCP period)

1.6

1.4

1.2

0.9

0.6

2.2

1.5

0

0.5

1

1.5

2

2.5

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Years

AR

TI%

Thiruvellur

Peri-urbanBangaloreBangalore city

Int J Tuberc Lung Dis 2006; 10 (3): 346-348, NTI Bulletin 2006, 42:68-73

TB-specific mortality rate

Rural Bangalore, 1960-68

80 per 100,000 population

Indian J Tuberc 1978; 25:181-86

Epidemiological impact surveys conducted (2)

Mortality surveys

• TB specific mortality surveys using VA conducted in 2 states 2005-06

Drug resistance surveys

• District representative DRS surveys conducted 2002-05

• State representative DRS surveys conducted in 2

states (combined population 160 million), 2005-06

Year Age

group

TB deaths

(%)

Rate/

100000

Delhi 1994-

2004

All

≥15

25

29

58

Chennai City 1995-

1997

≥25 5.2 150-male

(35-69 yr)

43 female

Rural Villupuram

Tamilnadu

1997-

1998

≥25 7.9

Tamilnadu and

Maharashtra

2003 >1

month

4.6

SRS 2001-

2003

30-69 10.8

Verbal Autopsy studies in India

Sensitivity of VA in a study at Chandigarh was estimated at 57%.

Nation wide study – 1 million deaths

Population,

reference

Year n (adults) Follow-up/

tracing

method

TB deaths Adjusted

treatment

outcome

‘died’ %

As recorded

treatment

outcome

Undetected

in defaulters

and

transfers

Bangalore

city

1999 67

defaulters

(25% of 271

new SS+

PTB)

2.5 years

including VA

and death

certificate

review

2.2% 23 (33%) by

end of

follow-up

10.5

Chennai city 2000-2001 241

defaulters

(9.0% of

2674

patients)

Home-based

1-year

followed-up

122 (4.6%) 19 (7.9%) by

12 months

43 (17.8%)

by 20

months

5.3

Rural

Velliyur,

south India

2000-2003 134

defaulters

(15% of

3405

patients)

Home-based

2-7 year

followed-up

176 (5.2%) 10 (7.5%) by

12 months

41 (30.6 %)

by 24

months

6.3

Under reporting of TB deaths in RNTCP

• Vital Registration in India - Incomplete

• Sample registration system (SRS)

- Carried out among 6 to 8 million populations at 6 monthly intervals.

-Census

-Events of deaths registered are investigated for COD by VA.

- Completeness estimated at 86%.

Epidemiological impact surveys conducted (1)ARTI

• Nationwide ARTI survey undertaken over 2000-2003 in 4 zones among children aged 1 to 9 years

• Sample stratified between rural and urban areas

• Overall ARTI estimated at 1.5% at national level (add zonal figures)

• Prevalence of infection and ARTI significantly higher in urban areas compared to rural areas

• State specific ARTI surveys also conducted 2005-06 (Andhra Pradesh, Kerala and Orissa)

Disease prevalence

• Serial prevalence surveys in field research area of TRC Chennai

• Other surveys from NTI and other institutes• National prevalence estimate calculated for 2000 – 3.8

million bacteriological positive cases

Epidemiological studies ~Progress

towards MDGs

� For the first time in history of TB control in India, significant declines observed in prevalence of TB & ARTI, albeit is few areas

� No decline yet demonstrated in incidence of TB,

mortality ~ paucity of data

Prospects of TB Control

• Targets of changes in prevalence & TB mortality to

be met by 2015

• Most incidence cases arise from persons infected in

the distant past

• 30-40% population infected

~new cases to continue emerging for years

• Expected 5% per annum decline in ARTI would lead

to 50% decline in pool of infected people in 15-20 years

• Onset of decline at some point of time

• Risk of infection ~ incidence

• Change in life time risk of TB disease

Prospects of TB Control

• HIV epidemic ~ transmission of infection

• Urbanization & MDRTB to have opposing

influence

• Multiple interacting factors

- Efficiency of control measures

- Epidemiological

- Political

- Economic

- Socio-environmental

On-going sub-

national surveys for

estimating prevalence

On-going Repeat zonal ARTI surveys, 2009-

2010North

WestEast

South

On-going/planned studies

• Nation wide ARTI Survey – 2008-10– Coordinated by NTI, Bangalore in association with: New Delhi TB

Centre (North Zone); MGIMS, Wardha (West Zone); LRS Institute, New Delhi (East Zone); and CMC, Vellore (South Zone)

• Disease prevalence Surveys – 2007-09– 3 sites using symptomatic screening + C-Xray + sputum smear and

culture: TRC Chennai (MDP project); NTI, Bangalore; and MGIMS, Wardha

– 4 sites using symptomatic screening + sputum smear and culture: PGI, Chandigarh; AIIMS, New Delhi; JALMA, Agra; and RMRCT, Jabalpur

• Repeat ARTI and Disease prevalence surveys planned in 2015

• On-going state representative DRS surveys in 3 states

• Mortality will be estimated via the RGI community based health surveys

Programme Routine Surveillance System

Peripheral Health

Institute (DMC and other PHIs)

District TB Centre

Electronic reports)

Central TB Division State TB Cell

Tuberculosis Unit

Monthly PHI Report

Quarterly CF, SC, RT, PM Reports

Quarterly Reports

CF, SC, RT, PM

Additional

Feedback

Quarterly

Feedback

System electronic from district level

upwards

Publication of quarterly and annual performance reports

RNTCP: Records and Reports

Records and reports revised in 2008 – now includes

TB/HIV and MDR-TB data

Reports include Quarterly Reports on Case Finding,

Sputum Conversion and Results of Treatment. In

addition, Report on Programme Management and

Logistics (monthly - Peripheral Health Institution

Level; quarterly -Tuberculosis Unit, District

And State Levels)

EPI-CENTRE:

RNTCP Data processing system

New windows based version has been developed and introduced,

phasing-out of DOS version to be completed by end of 2009

RNTCP “Supervision and

Monitoring strategy”• Strategy document developed and

published in March 2005

• Contains checklists and indicators for monitoring

• All states and districts implementing the strategy

• All state/district programme staff trained in the strategy, including now MIFA trainings

• Mechanism of internal evaluations from the state (2 districts per quarter) and central levels (1 state per month)

• Annual joint donor missions and 6 monthly World Bank mission

• External evaluations by partners & donors once every 3 years since 2000

Trends in prevalence of culture-positive and smear-positive tuberculosis in south India (5 Blocks), 1968-2006

7.0

8.0

9.0

10.0

11.0

1968-70 1971-73 1973-75 1976-78 1979-81 1981-83 1984-86 1987-89 1990-92 1993-95 1996-98 1999-01 2001-03 2004-06

Y ear

256

512

1024

Smear +ve

Culture +ve

128

Pre-SCC treatment era SCC treatment era

RNTCP era

Impact of RNTCP

Progress towards Millennium

Development Goals• Indicator 23: between 1990 and 2015 to halve prevalence of TB disease and

deaths due to TB

• Indicator 24: to detect 70% of new infectious cases and to successfully treat 85% of detected sputum positive patients

– The global NSP case detection rate is 61% (2006) and treatment success

rate is 85%

– RNTCP consistently achieving global bench mark of 85% treatment

success rate for NSP; and case detection rate 72% (2008)

586

283 293

0

200

400

600

800

1990 2007 2015 (MDG-

Target)

Cases p

er 100,000 p

opula

tion

42

28

21

0

20

40

60

1990 2007 2015 (MDG-

Target)

Cases p

er 100,0

00 p

opula

tion

51.7%33.3%

Prevalence rate of TB Mortality rate of TB

Lessons learnt• All epidemiological surveys complex to implement with related

financial, logistical and technical issues• ARTI: 1TU PPD unavailable; challenge to engage with institutes

new to doing TST surveys; difficulty in interpreting results of skin reactions as prevalence of infection / ARTI falls

• Prevalence: which method to use; challenge to engage with institutes new to doing prevalence surveys; which additional factors to add to survey methodology (behavioural factors, HIV status, drug resistance status, etc)

• Mortality: just how to estimate from VA based health surveys in community

• Drug resistance: limited laboratory capacity to undertake the C&DST; need to include SL DST in future surveys; sampling methodology to capture