david sm chapter 2 ppt by fred r david stategic management concepts and cases 13th edition
Cases and Rates in 1991 Table 6 Population: ? New SM +: N = 8,507 All Cases: N = 10,903 Table 8...
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Transcript of Cases and Rates in 1991 Table 6 Population: ? New SM +: N = 8,507 All Cases: N = 10,903 Table 8...
![Page 1: Cases and Rates in 1991 Table 6 Population: ? New SM +: N = 8,507 All Cases: N = 10,903 Table 8 Population: ? New SM +: N = 8,835 All cases: N = 10,872.](https://reader036.fdocuments.in/reader036/viewer/2022062517/56649e745503460f94b75247/html5/thumbnails/1.jpg)
Cases and Rates in 1991
Table 6
Population: ?• New SM +: N = 8,507• All Cases: N = 10,903
Table 8
Population: ?• New SM +: N = 8,835• All cases: N = 10,872
Table 7
Population: 8,904,395• New SM +: N = 8,103• Rate = 91/100,000• All Cases: N =11,036• Rate = 123/100,000
Rate SM + : 220 - 20
Rate All : 276 - 26
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Cases and Rates in 2009
• N SM +: N = 17,863
• Rate N SM + = 133/100,000
• All forms: N = 38,770
• Rate All forms: 289/100,000
• Source cases: Page 9 R10 proposal
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NOTIFICATIONS ASIAM 1982-2008
ALL FORMS
SMEAR POSITIVE (N+R)
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NOTIFICATIONS/100,000 ASIAM 1982-2006
ALL FORMS
SMEAR POSITIVE (N+R)
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NOTIFICATIONS/100,000 ASIAM 1982-2008
ALL FORMS
SMEAR POSITIVE (N+R)
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Average Prevalence 1981-1989
Table 5:
• Survey population: N = 71,398
• Smear-positive cases: N = 374
• Prevalence smear-positive cases
= 520/ 100,000 population
Note:
Table 4: ARI in 1970 between 4.7 and 2.7 !!
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Prevalence in 2001
• SM+: 270/100,000
• Cult+: 902/100,000
• CDR SM +: 124/270 = 46%
• Trend of prevalence:
520 (81-89) > 270 (01)
True decline or unreliable survey data?
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Conclusions
The TB problem is still serious as:• Notification rate SM+ = 91/100,000 in 1991
(74% of all cases are new smear-positive)• Notification rate SM+ = 141/100,000 in 2000• Prevalence rate of SM+ 81-89 = 520/100,000• Prevalence rate of SM+ 2001 = 270/100,000 • HIV + TB: 2.5% in 95 > 8.9% in 2000 > 10.3 in
2001
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Observations
• Trend of notifications 82-91 is inconclusive
• New SM+ notification rate in 1991< 20% of SM + prevalence rate (1981-1989)
• Rate SM+ ranges from 220/100,000 in province 1 to 17/100,000 in province 17
• 20% of cases are registered in the capital
• 36% of cases in the capital are > 54
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Observations
• Trend of notifications 92-2004 steady increase
• DOTS introduced in 1994
• In 2004 ~ 50% of prevalent cases detected
• Still considerable differences between provinces
• TB problem increasing due to HIV
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Final Conclusions
• The TB problem in Asiam is serious
• The NTP in Asiam detects only 50% of the prevalent cases
• Case-detection in a number of provinces is very low
• How to increase coverage and detection?
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Problem description and Situational analysis
• TB prevalence survey data
• Tuberculin survey data: prevalence of infection with M.tuberculosis
• Case notifications recent and past years
• Age, Gender, Area differences
• Rates and trend
• Drug resistance survey data
• HIV prevalence, incidence and trend
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Conclude:
• Size of TB problem: High, medium, low?
High: > 50 new sm+ cases/100,000 per yr.
Low: < 10 new sm+ cases/100,000 per yr.
• Trend: Increase, decrease, stable?
• Program coverage: % of districts?
Estimate number of expected TB notifications
for each year during plan period! (3 to 5years)
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Block 5
1. 8,507/38,868 = 22% (see table 6, set I)3. 93/171 centers = 53% (see table 10, set I)4. 38,868 x 3 = 116,604 : 260 = 448 : 93 = ~ 5
(4.8)5. 9,000,000 : 100,000 = 90 x 520 = 46,800 x 35%
= 16,380 x 30 = 491,400 : 260 = 1,890 : 93 = 20,3
Yes the number is sufficient
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Block 5
6. Positive suspects 33.6% (2002 review, 18)
7. 141 microscopy centers (2002 review, 14)
8. 15,640 : 33.6 x 100 = 46,548 x 3 = 139,642 : 260 = 537 : 141 = ~ 4 (3.8)
9. 12,014,000 : 100,000 x 270 = 32,438 x 70% = 22,706 x 30 = 681,194 : 260 = 2,620 : 141 = 18,6
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suspects
sputum positivity rate
smear positive cases
% population examined
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0.1
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sputum positivity rate
proportion of population examinedby direct microscopy
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Population examined and positive suspects 1980-1991 (table 6, data set I)
00.10.20.30.40.50.60.7
1980 1982 1984 1986 1988 1990
0
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% of population examined % of suspects positive
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year Suspects examined
Positive suspects
% positive suspects
% of population examined
Positive suspects
per 100,000
population 1997 80 22 27.5 0.12 33.8 1998 172 32 18.6 0.27 50.2 1999 230 24 10.4 0.35 36.4 2000 580 20 3.5 0.82 28.2 2001 393 24 6.1 0.56 34.2
RESULTS OF DIRECT MICROSCOPY IN DISTRICT X FROM 1997 TILL 2001
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0.1
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suspects examined
positive suspects
positivity rate
% population examined
Relation between positivity rate and %
population examined
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PARAMETERS FOR PLANNING THE MICROSCOPY NETWORK
• Expected number of smear-positive cases • As a rule one centre per 100,000 population
if case-notification rate of smear + cases =
50/100,000• 3 smears per suspect• Number of smears per technician per day:
Not more than 20• Minimum requirement one positive case per
week per reader in view of proficiency
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PARAMETERS FOR PLANNING THE MICROSCOPY NETWORK
• Workload and smear-positivity rate (SPR):
SPR 20% = 1 positive case per 5 suspects = 15 smears to diagnose one sm+ case
SPR 5% = 1 positive case per 20 suspects = 60 smears to diagnose one sm+ case
• Screening of suspects by X-ray?
• Number of existing microscopy centres
• Available technicians and available time for direct microscopy per centre
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Conclude:
• Number of microscopy centres sufficient or not? If not how many more needed?
• Available technicians and time sufficient or not? If not train and employ more or ensure more time of available technicians
• Calculate need for microscopes, slides, cups, reagents, slide boxes, laboratory equipment, immersion oil, etc.
![Page 23: Cases and Rates in 1991 Table 6 Population: ? New SM +: N = 8,507 All Cases: N = 10,903 Table 8 Population: ? New SM +: N = 8,835 All cases: N = 10,872.](https://reader036.fdocuments.in/reader036/viewer/2022062517/56649e745503460f94b75247/html5/thumbnails/23.jpg)
External Factors Influencing Smear-Positivity Rate
• Prevalence of Tuberculosis in community
• Prevalence of other conditions causing a chronic cough
• Patients delay/doctors delay
• Selection of suspects
• Active CF surveys
Duration of cough as criteria
Screening of suspects by X-ray
![Page 24: Cases and Rates in 1991 Table 6 Population: ? New SM +: N = 8,507 All Cases: N = 10,903 Table 8 Population: ? New SM +: N = 8,835 All cases: N = 10,872.](https://reader036.fdocuments.in/reader036/viewer/2022062517/56649e745503460f94b75247/html5/thumbnails/24.jpg)
Laboratory Factors Influencing Smear-Positivity Rate
False Positive Results
Acid Fast Particles other than TB bacilli
Food particles
Precipitated stains (filter, use fresh stains)
Saprophytic acid-fast bacilli (distilled water)
Spores, fibers, pollen
Scratches on slide (always use new slides)
Contamination
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Laboratory Factors Influencing Smear-Positivity Rate
False Negative Results
Inadequate sputum collection
Selection of particles from sputum
Inadequate storage of sputum specimens and stained smears
Inadequate preparation of smears or staining of slides
Inadequate examination of the smear
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Laboratory Factors Influencing Smear-Positivity Rate
False Negative Results
Administrative errors
Reading errors
Time spend on reading
Work load
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Labserialnumber
Diagnosis Follow up 1 2 3
x + +
x Neg Neg Neg
x Neg
x +
x Neg + +
![Page 28: Cases and Rates in 1991 Table 6 Population: ? New SM +: N = 8,507 All Cases: N = 10,903 Table 8 Population: ? New SM +: N = 8,835 All cases: N = 10,872.](https://reader036.fdocuments.in/reader036/viewer/2022062517/56649e745503460f94b75247/html5/thumbnails/28.jpg)
Indicators to evaluate microscopyusing the laboratory register
• % of population in the district examined per year by direct microscopy =
suspects in the register (one year)
-------------------------------------------- x 100
population of the district in that year
• Value: 0.6 to 0.9 (Note:Vietnam data)
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Indicators to evaluate microscopyusing the laboratory register
• Distribution of positive smear results
80-85% of positive cases show positive in the first smear
Few (~ 5%) positive cases show positive in the third smear only
This distribution should normally appear in
the laboratory register, if not this should be
investigated
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Indicators to evaluate microscopyusing the laboratory register
• Smear-positivity rate:
N suspects with positive smear
result(s) during a quarter or year
--------------------------------------- x 100
N suspects examined during
a quarter or year
• Value usually observed: 5 to 15%
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Indicators to evaluate microscopyusing the laboratory register
• % of suspects with three smear results
N suspects with 3 smear result(s) during a quarter or year --------------------------------------- x 100N suspects examined during a quarter or year
• Value: Target 100%. Observed in good programs 85-90%
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Further use of laboratory register
• Calculation of proportions of suspects by
Gender
Age-groups
Distance to microscopy centre• Time between first examination and diagnosis• Number of examinations per day/ month• Requirements of slides and materials
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Link with TB register
• Serial number of laboratory book in TB register and TB registration number in laboratory register
• Are all diagnosed SM + cases (new and previously treated) put on treatment?
• Average time between diagnosis and start of treatment
• % of negative suspects put on treatment
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Case of tuberculosis
• A definite case of TB, or one in which a clinician has diagnosed TB and has decided to treat the patient with a full course of TB treatment
• Note: Any person given treatment for tuberculosis should be recorded
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A definite case of tuberculosis
• Patient with positive culture or positive LPA test for the Mycobacterium tuberculosis complex
• In countries where culture is not routinely available a patient with one or more initial sputum smears positive for acid fast bacilli (AFB+) is also considered a definite case
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Smear positive pulmonary case
• At least one initial sputum smear examination (direct smear microscopy) with at least one AFB provided that there is a functional EQA system with blind rechecking
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STAG 2007
New definition of smear-positive PTB
One smear
with at least
one AFB
in 100 fields
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Smear-negative pulmonary case
Sputum smear-negative, but culture positive
At least 2 sputum specimens at the start of treatment with functional EQA, high workload and limited human resources
Sputum culture should be performed in settings where HIV > 1% in pregnant women or > 5% in TB patients
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Smear-negative PTB case (B)
Decision by a clinician to treat with a full course of anti-TB therapy
X-ray suggestive for active TB and patient is HIV+ (laboratory or clinical evidence)
X-ray suggestive for active TB and no improvement after antibiotics in HIV-negative patients
![Page 40: Cases and Rates in 1991 Table 6 Population: ? New SM +: N = 8,507 All Cases: N = 10,903 Table 8 Population: ? New SM +: N = 8,835 All cases: N = 10,872.](https://reader036.fdocuments.in/reader036/viewer/2022062517/56649e745503460f94b75247/html5/thumbnails/40.jpg)
STAG 2007
New definition of smear-negative PTB
When two smears are negative follow algorithm
for the diagnosis of
smear-negative tuberculosis
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Extra-pulmonary case
• Patient with tuberculosis of organs other than the lungs e.g. pleura, lymph nodes, abdomen, genito-urinary tract, skin, joint and bones, meninges
• Note: a patient diagnosed with both pulmonary and extra-pulmonary tuberculosis should be classified as a case of pulmonary tuberculosis
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EPTB
• Diagnosis of EPTB should be based on one culture positive specimen, or histological or strong clinical evidence consistent with active extra-pulmonary disease, followed by a decision by a clinician to treat with a full course of anti-tuberculosis chemotherapy
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New Case
• Patient who has never had treatment for tuberculosis, or who has taken anti-tuberculosis drugs for less than one month
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Previously treated case
• Received 1 month or more anti-TB drugs
• May be smear-positive or –negative
• May have TB at any site
• Further defined by treatment outcome:
• Relapse, Failure and Default
• Note: classification “Chronic” stopped
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Indicators for quality of Diagnosis
• Proportions of New SM +, SM - and EPTB depend on efficiency of CF and diagnostic methods used
• Proportions reported by well organised NTP’s are:
60-70% New smear-positive PTB
20-30% New smear-negative PTB
10-20% New EPTB
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Indicators for quality of Diagnosis
• Ratio New SM +/New SM- PTB
N new smear-positive TB cases
---------------------------------------
N new smear-negative TB cases
• Value: normally 2 to 2.5, but often lower in high HIV prevalence countries
• Minimum acceptable level 1 to 1.5
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Indicators for quality of Diagnosis
• In high HIV-prevalence countries the proportion of EPTB may be higher due to a higher frequency of Pleural Effusions and miliary TB
• Diagnosis of EPTB depends further on clinical capacity, preferences of clinicians and focus on childhood TB
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Indicators for quality of Diagnosis
• A SM+/SM- PTB ratio of <1 may indicate that SM- cases are diagnosed without microscopy (X-ray and clinical diagnosis)
• The proportion of relapses: should be < 5-7% of all cases reported or less than <10% of new smear-positive cases reported
• A high proportion of previously treated cases is an indication of poor program and/or poor private sector performance
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Block 8: Strategies for DOT• Population 2000: 12,014,000 (table 3. set II)• Cases detected: 18,892 (table 3. set II)• HC’s: 90% x 632 = 569 (table 7. set II)• Area Asiam: 181,035 sq.km. (table 1. Set II)• Area 5 km radius = 3.14 (π) x 5 km² = 78,5
x 569 = 44,667 : 181,035 x 100 = 25% (30% if 115 hospitals also provide A-Dots)
• Beds: 18,892 x 75% = 14,169 : 6 = 2,362• (19 to 21 beds per hospital: 2,362 : 115)
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Advantages of SCC
• Lower case-fatality (high sterilising effect)
• Lower relapse rate (role of pyrazinamide)
• Lower default rate (shorter duration)
• Intermittent (3 x per week or on alternating days) as effective as daily treatment
• Effective in HIV+ TB cases (only daily!)
• DOT is essential to prevent R resistance
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Intensive phase
• Sterilizing phase to reduce the bacillary load as quick as possible
• Always treat with combination of at least 3 drugs to prevent development of resistance
• Recommended by WHO: 2EHRZ
• EHRZ FDC tablets have been developed in recent years
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Continuation phase
• Maintenance phase to take care of dormant bacilli (persisters)
• Always treat with at least 2 drugs
• Duration defined by relapse rate in sensitive patients
• 2RH > 15% relapse rate
• 4RH < 5% relapse rate
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Consider how to ensure DOT
• Hospitalise patients during intensive phase?
Consider costs for health service, patients and availability of beds
• Ambulatory treatment at PHC facilities?
Consider feasibility in view of access
• Community based DOT?
Consider presence of volunteers and costs of training and supervision of volunteers
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Decide:
• Using Fixed Dose Combination tablets
(ERHZ) or (RHZ) instead of loose formulations?
• Using blister packs?
• Consider costs, logistics, training of staff and revision of guidelines
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What is cohort analysis?• A cohort: A group of patients diagnosed and
registered for treatment during a given time period usually one quarter of a year
• Cohorts are defined by: period, type of TB, type of treatment, age, gender, income, etc
• Cohort analysis: Evaluation of treatment outcome when all patients in the cohort have finished treatment and results are collected
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Treatment outcome: Cure rate• Initially smear-positive patient who has a
smear negative result in the last month of treatment, and on at least one previous occasion
• Value: > 85% in low HIV prevalence countries, > 80% in high HIV prevalence countries
• A high cure rate is the result of a combination of low other outcome rates!!
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Treatment outcome: Treatment completion rate
• Patient who completed treatment but does not meet the criteria for cure or failure
• Depends essentially on the proportion of patients producing sputum during the last month of treatment and the efficiency of sputum collection.
• Value: Not well established!
• Observed: 5-15% of patients, which finish treatment
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Treatment outcome: Treatment success rate
• Total of cure and treatment completion rate
• WHO: “Successfully treated”: Essentially a rate showing the effectiveness of case-holding
• Operational indicator: At least 85-90% of cases, which complete treatment should have a final smear result shown in the register (Indicate no sputum obtained in cases which can not produce sputum!)
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Treatment outcome: Death rate• Proportion of patients who die while on
treatment, irrespective of the cause
• Factors: Severity of disease at time of diagnosis (diagnostic delay!), initial resistance, type of regimen, age, immunity, HIV status, adherence to treatment.
• Value: with SCC 1-3% , but in high HIV prevalence countries 5-15%!!
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Treatment outcome: Failure rate• Smear-positive patient who remained
smear-positive, or became smear-positive again, at least 5 months after the start of treatment
• Factors: Initial resistance, type of regimen, treatment adherence
• Value: In new patients on SCC < 1-2%. In relapse case on retreatment < 3-5%. Other previously treated cases on retreatment?
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Treatment outcome:Default rate
• Interrupted treatment rate: Patient who did not collect drugs for 2 months or more at any time after registration
• Most important case-holding indicator!
• Influenced by multiple factors!
Accessibility and acceptability of DOT services: distance, clinic hours, attitude of staff, waiting time, privacy, support, control
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Treatment outcome: Default rate
• Patient perspective: convenience, costs, loss of income, side effects, well being after initial treatment, awareness about treatment, availability of drugs, duration of treatment, support, attitude of community, intercurrent events
• Value: Target 0%!
• Good performance < 5%
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Treatment outcome:Transferred out rate
• Patient who was transferred to another reporting unit and from whom treatment results are not know
• Depends essentially on mobility of patients and capacity of NTP to retrieve results of transferred patients
• Value: Not defined! Preferably < 5%
• Future: Electronic register?