Overview of TB Epidemiology in the African Region TUB/AFRO Meeting on TB Surveillance and Epidemiology, Harare August 2003

Magnitude of the TB Problem Approx. 1.6 million new cases estimated to occur per year Approximately 600,000 deaths estimated to occur per year With only 10% of world population AFRO contributes 20-24% of TB cases0yr. Approx. 30-50% of new TB cases in Southern and Eastern Africa is HIV+ Approx. 40% of AIDS deaths due to TB

Global and Regional Targets. Where are we ? Context: Global targets adopted by WHA in 1993 & 1999: By 2005, to attain: Case detection rate of 70% Treatment success rate of 85%2: By 2015: To reduce incidence and mortality by 50%

In 1983, only one country, Tanzania was implementing what later became known as the DOTS Strategy. The number increased slowly at first until the early ninenties when TB control began to receive increased attention culminating in 1993 by the declaration of the the global emergency by WHO. Since then more and more countries have adopted the strategy and the rise was particularly exponential between 1994 and 1999. The number has remained static for two consecutive years since then, and little further movement is expected in the short term. For all intents and purposes, adoption of the strategy could be considered a prerequisite to effective TB Control. This trend in coverage is therefore a significant development for purposes of meeting global and regional targets for TB Control.

By the end of December 2000, about 82 By the end of December 2000, about 82.6% of the Regions population was estimated to have access to DOTS services in the 41 countries. Coverage by country ranged between 40-100% with 20 countries reporting countrywide coverage of their populations. There has also been a significant shift to the right in the number of countries reporting coverage greater than 50%, such that there is currently no country in DOTS coverage category 2 (coverage less than 10% of total population).

REPORTED POPULATION COVERAGE WITH DOTS STRATEGY BY COUNTRY. 2000 Algeria 100 Gambia Nigeria 47 Angola 46 Ghana 87 Rwanda Benin Guinee-Bissau 95 Sao Tome ? Botswana Kenya Seychelles Burkina Faso Lesotho Sierra Leone 50 Cameroon Malawi South Africa 77 Comores Mali 95.5 Swaziland Congo Brazaville 100? Mauritania 40 Tanzania Ivory Coast 60 Mauritius Togo DRC 70 Mozambique Uganda Eritrea 80 Namibia Zambia Ethiopia Niger Zimbabwe

Along with the increasing DOTS coverage, has been an increasing number of notified cases. This is expected. However, within countries, especially in Southern and Eastern blocs, the rises have exceeded what would have been expected just by increased program coverage and population growth. There has generally been more than doubling of cases in many countries in the Region.

As indicated earlier, going by 1999 and 2000 notification figures, Southern and Eastern African blocs contributes the bulk of the Region’s TB cases. From available information these are also the countries with the most severe TB/HIV dual epidemic.

In terms of density of rates, again the picture is one of higher rates in Southern and Eastern and blocs. However, the relatively lower rates in West and Central blocs need to be corrected for program coverage which is also rather low comparatively. The white patch in the middle of the southern bloc is really a mistake as data was available but reported under “no dots”. This shows that the rates are similar to the surrounding neighbouring countries. Note that the countries with the highest rates are in-fact countries with small populations and so not in the global league of High Burden countries. For this reason, however, these countries are among AFR’s 34 High Burden Countries. Incidentally, the detection rates shown here are far below estimated TB prevalence rates in all the countries.

TREND OF TB RATES IN SELECTED MEDIUM TO HIGH HIV PREVALENCE COUNTRIES: 1990-1998

TB IN SELECTED LOW HIV PREVALENCE COUNTRIES: 1990-1998

NOTIFIED NEW SMEAR POSITVE CASES BY AGE GROUP AND SEX: JAN-DEC 2000 0-14 15-24 25-34 35-44 45-54 55-64 65+ TOTAL DOTS Male (N) % Female(N) Total (N) 1,816 1.8% 2,471 3.3% 4,287 2.5% 18,785 18.7% 20,645 27.7% 39,430 22.5% 32,630 32.5% 25,041 33.6% 57,671 32.9% 22,999 22.9% 13,886 18.6% 36,885 21.1% 13,159 13.1% 6,994 9.4% 20,153 11.5% 6,690 6.7% 3,479 4.7% 10,169 5.8% 4,309 4.3% 2,030 2.7% 6,339 3.6% 100,388 100% 74,546 174,934

The rise in notified cases has been matched by increasing notification rates. Between 1995 and 2000, the Regional rates have risen from around 82% to around 164% (and rising!). The rise between 1998 and 2000 has been greater than the rise between the earlier years. This could be attributed to increased program coverage but is also due to increasing incidence as the same has been observed in countries where nationwide coverage had already been attained.

MAJOR OBSERVATIONS Severe and worsening TB epidemic: Case notifications and case notification rates of all cases and smear positive cases have progressively risen in many countries in the Region, especially those in the epicenter of the dual TB/HIV epidemic Apparent higher TB “incidence” among females aged <25 years compared to male counterparts Overall, slow but steady progress in expanding “DOTS”: 41 of 46 countries adopted TB DOTS Strategy and 20 already attained population wide coverage Very slow though increasing progress towards attaining global targets for case detection: In-spite of increasing notifications and notification rates, case detection rates still fall below the global target of 70% of expected new smear positive cases. Still below global targets for treatment success rate even though fair and steady progress being made

MAJOR OBSERVATIONS Regional average treatment success rate still below global target: Even though the average treatment success rate for the region has been increasing steadily since the mid nineties, current levels are still below the Global and Regional targets Completeness and frequency of reporting by country varies violently from year to year. Since 1997, only a maximum of 38 countries have submitted complete annual TB reports to WHO (range 29-38)