Tuvalu
National TB Programme
Dr. Nese Ituaso-Conway
Fourth Pacific Stop TB Meeting
11-14 March 2008, Brisbane, Australia
Country Information (2007)
Population
DOTS coverage
9,561 (2002
census)
100%
MDR rate (never treated - previously
treated)
No case yet
HIV prevalence
0.07%
HIV prevalence among TB patients
Not known
Trend of Registered Cases
(2000-2005)
Year
2000
Tot Pop
Tot TB
(est)
Cases
9,043
16
New
PTB
7
ReEPTB
treated
2
7
2001
9,043
16
10
4
2
2002
9,561
6
5
2003
9,561
21 (+3
8
transfer-in
32
17
7
8
2004
9,561
17
11
0
6
2005
9,561
15
8
3
4
Trend of Registered Cases
from 2000-2005
35
30
25
2000
2001
2002
2003
2004
2005
20
15
10
5
0
Tot TB
Cases
New PTB
Retreated
EPTB
Case detection rate
Tuvalu 2004 - 2007
120
CDR all forms (%)
CDR new sm+ (%)
Percentage (%)
100
80
60
40
20
0
2004
2005
2006
2007
Increase of bacteriologically confirmed TB
100%
90%
80%
70%
60%
50%
40%
Sm- PTB & EXPTB
Sm+ PTB
30%
20%
10%
0%
Sm- PTB & EXPTB
Sm+ PTB
2003
2004
2005
2006
2007
32
0
12
5
10
5
5
4
5
14
JanFeb
2008
1
3
Case detection
• CDR was remarkably improved in 2007, especially CDR of new sm+
(102%), compared with the previous year (30-36% between 2004 &
2006).
• Quality of diagnosis has been improved since 2004 with the
continuously increased proportion of the bacteriologically confirmed
cases, from 29% in 2004 to 74% in 2007.
• Case notification rate varies between the islands. The notification (per
100,000 - average during the last 4 years) shows particularly high rate of
TB in some islands: Nanumea (490), Nanunaga (394) and Nakufetau (317) ;
while the rate is relatively low in the main island Funafuti. The very low rate
shown in some other islands suggested limited case finding activities in
Niutao and Nukelaelae.
Treatment Outcomes
Year
2004
2005
2006
New sm+
5
6
4
Cured
Defaulted
5 (100%)
6 (100%)
3 (75%)
1
Treatment Outcomes
Percentage (Cure Rates)
120%
100%
100%
100%
75%
80%
60%
40%
20%
0%
2004
2005
Years
2006
Treatment Outcomes (PTB/EP)
80
70
60
50
40
Treatment Completed
30
20
10
0
2000
2001
2002
2003
Anti-TB drug supply
• TB program obtain TB drugs from GDF and
through the Fiji Pharmaceutical Services (FPS)
and/or NZ.
• In the past years, Tuvalu Government and donor
partner (WHO) pay for the TB drugs.
• No shortage of TB drugs in 2007.
• Stock: GDF drugs have been used for patients.
– 12 boxes (RHE) exp Feb/2010, (RHZE) Aug/2010
– 4000 loose Z 500mg exp Mar/2009
– 3500 loose E 400mg exp Oct/2008
Yield of microscopy
Year
No. patients
tested
No. sm(+)
Positive rate
(%)
2004
73
7
10
2005
65
5
8
2006
65
5
8
2007
39
18
46
2008
11
4
36
Desired positive rate would be around 10%
Laboratory Activities
• Implication of the high positive rate of microscopy in
2007 & 2008:
– The selection of TB suspects, who are referred to lab for TB
microscopy, is too specific (or too late) – more likely of missing
cases
• Number of smear examination for diagnosis:
– In average (2004-2006), 50 patients tested per year, ~ 0.5%
population. This is too low compared with the epi. Estimation of
3-5% population, i.e. 300 – 500 pts/yr in Tuvalu.
• Supplies
– Sputum container:
• Not standard (reuse the antibiotic vials)
• Order placed since Nov 2007 and been followed up
– Reagents, slides and microscope: Good quality & no shortage
Laboratory activities…. contd
Proportion of specimens scored as saliva
1:3
Are control slides used to check performance of ZN stain? No
since
2006
Did your lab(s) participate in blinded rechecking during the No
past year ? (Yes/No)
Did your lab(s) participate in a panel test during the past
year ? (Yes/No)
No
Was there any shortage of laboratory supplies during the
past year ? (Yes/No)
Yes
Progress 2006 Country Action Plan
• Using combination TB drugs
• Supervisory visit to outer islands once last year
and currently on this year
• Lab Assistant to be recruited soon
• Refresher DOTS training for nurses once/twice a
year
• Programmatic reporting to PR, SPC for Global
Fund
Funding for TB control
Source(s)
Duration
Global Fund
WHO
Ministry of
Health
Jan-June 2008 $16,716
Total available
Estimated financial gap for--- (insert period)
Amount
$13,191
ACHIEVEMENTS
WEAKENESSES
• Improvement of CDR
since the introduction of
AFB examination in 2004
• TB activities almost
completed under Global
Fund Rd 2
• Community health
programmes and
education (schools,
women groups, teachers,
etc)
• CME once a week for
health personnel on
Funafuti
• In-patients DOTS is good
in the ward
• Higher default rate noted
when patient returns to
the outer islands
• High turnover of health
personnel (esp in the
nursing & lab services)
• Incomplete TB record
keeping
• Limited regular
communication & visits to
outer islands (due to
telecommunication
breakdown, limited health
personnel & shipping
schedule)
• Delay in lab order for
sputum containers
Recommendations (1)
1. Develop national TB guidelines.
2. Strengthen monitoring and technical support to
TB control in the outer islands.
3. Standardize laboratory performance including
specimen collection; smear preparation;
reading & recording results; and compliance
with the EQA process.
Recommendations (2)
4. Improve quality of diagnosis process by:
•
•
•
•
Broader identification and referral of TB suspects;
Complying with the process for diagnosis of sm(-) PTB
in the WHO guideline
Retraining physicians working at the OPDs and nurses
in the outer islands
Developing IEC materials to improve awareness of the
community on TB symptoms and TB services
Recommendations (3)
5. Improve TB drug management
•
Improve stock management to avoid being
expired and over stock
–
Solve the problems of loose PZA and Ethambutol
tablets before their expiry dates