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

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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

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in H

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et

Problem

Drug

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Prison

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Recent

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ed <1

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Chinese

or ot

her

South

Asian

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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