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

2. 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 % of new TB cases in Southern and Eastern Africa is HIV+
Approx. 40% of AIDS deaths due to TB

3. 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%

4. 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 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.

5. 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 % 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).

6. 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

7. 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.

8. 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.

9. 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.

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

11. TB IN SELECTED LOW HIV PREVALENCE COUNTRIES: 1990-1998

13. 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

14. 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.

17. 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

18. 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)