1. TB epidemiological reviews: baseline to setting country-level targets 9 th Technical Advisory Group and National TB Programme Managers' Meeting Manila, 10 December 2014 Charalampos (Babis) Sismanidis Philippe Glaziou GLOBAL TB PROGRAMME

2. WHO Global Task Force on TB Impact Measurement www.who.int/tb/advisory_bodies/impact_measurement_taskforce National TB Programmes of many countries & key technical and funding agencies

3. What is the aim of a TB epidemiological review? To offer a country-level, systematic and standardised assessment of: – The strengths & gaps of the quality & coverage of the TB surveillance system as well as direct measurement of disease burden – The best estimates of the level of, and trends in, TB disease burden – A plausible interpretation of how TB disease burden is influenced by prevention and treatment interventions implemented by NTP and partners? To inform programme reviews, "epidemiological stage" of Concept Note submission to the Global Fund and target setting (at least short-, but also useful for longer-term)

4. What is the aim of a TB epi review? (cont.) Standardised terms of reference (available since early 2013) Four objectives, with suggested analytical tasks per objective: 1.Assessing quality & coverage of the surveillance system 2.Understanding the level of, and trends in, TB burden 3.Plausible interpretation of how various factors drives TB burden (control activities and risk factors) 4.Development of investment plan to address gaps identified Used in about 21 countries globally so far

5. Objective 1 assessing quality and coverage of surveillance Describe and assess current national TB surveillance and vital registration systems, with particular attention to their capacity to measure the level of and trends in TB disease burden (incidence and mortality). http://www.who.int/tb/publications/ standardsand-benchmarks/en/

9. Summary results: 21 countries (Jan 13-Jul 14) Systematically assess quality of paper-based TB data (Service Availability & Readiness Assessment) Move from paper to electronic case-based system Inventory study to measure under-reporting, mandatory reporting of TB, PPM expansion Advocate for use of VR system Improve surveillance data for burden in MDR-TB, TB/HIV, children

10. Where has the checklist been used? 3 WPRO countries: Fiji, the Philippines, Viet Nam

11. Objective 2 understanding the level of, & trends in, TB burden Assess the level of, and trends in, TB disease burden (incidence, prevalence, mortality) through systematic collation and compilation of available surveillance, survey, programmatic and other data. http://www.who.int/tb/publications/ understanding_and_using_tb_data/en/

12. Do case notification rates in China reflect incidence? TB notifications

13. Evidence that prevalence declined in China (1990 – 2010) Wang, L. et al. (2014). Lancet, 383(9934), 2057–64.

14. Notifications // incidence? … probably not TB notifications TB Mortality 3 rd national survey DSP

15. Evidence of TB under-reporting in China before the SARS epidemic Reporting reform following SARS epidemic Notification rate Estimated incidence rate TB Mortality

16. Time trends in case notifications (national) do trends in notification reflect trends in incidence? Contribution of active case finding (e.g. contact tracing), PPM over time? DOTS expansion

17. Quantifying gap between incidence and case notification: under-reporting in India 46% of cases on treatment not known to NTP PloS One, 2011; 6(9): e24160.

18. Objectives 1.To explain and promote the role and value of inventory studies to TB care and control 2.To explain (i) major alternative study design & (ii) key issues concerning the implementation and analysis of inventory studies 3.To facilitate the development of a draft protocol outline for a TB inventory study Design and protocol development workshop: TB inventory studies to measure under-reporting of TB cases 24-26 September, 2014

19. Getting to the non-NTP & closing gap in surveillance Under-reporting: (199+99+9)/1980 = 16% An estimated additional cases 473 (394 – 565)

20. First protocol development workshop for TB inventory studies (Bali, September 2014): summary of key design aspects, timelines and requirements China Indonesia Pakistan Philippines ThailandViet Nam Objectives Under- reporting (retrospective) Under- reporting (prospective) Under- reporting (prospective) Data quality assessment (NTP and non-NTP) Under- reporting (retrospective & continuous) Under- reporting & incidence (prospective) Case definitions Bact-conf (all ages) All-form TB Bact-conf Children All-form TB Bact-conf Children All-form TB Bact-conf Children All-form TB Bact-conf Children Timelines Protocol Study end Q1 2015 Q4 2015 Q4 2014 Q4 2015 Q4 2014 Q4 2015 Q2 2015 Q4 2016 Q4 2014 Q4 2015 Q4 2014 Q4 2015 Support required TA Funding TA Funding TA Funding TA Funding TA Funding

21. Time trends in case notifications (sub-national) geographical heterogeneity or diagnostic capacity?

22. Age-specific time trends in case notifications who are we notifying?

23. Age- & sex-specific trends in TB prevalence rates identifying higher at risk groups

24. Ratio of prevalence to notification rates identifying case detection differentials

25. TB surveillance data internal consistency

26. Objective 3 How do determinants influence TB burden? Assess whether recent trends in TB disease burden indicators are plausibly related to changes in TB-specific interventions taking into account external factors including economic or demographic trends. Which are the upward and which the downward drivers?

27. TB determinants HIV disease burden

28. TB determinants economic growth

29. TB determinants inequalities in health service provision

30. TB determinants proxies for performance of health system

31. TB determinants proxies for performance of health system (cont.)

32. TB determinants age and sex structure of general population

33. Putting it all together programmatic implications (& target definition)

34. Disease burden due to TB time trends in incidence

35. Disease burden due to TB time trends in prevalence

36. Disease burden due to TB time trends in mortality

37. Objective 4 investment plan: the example of Indonesia Define the investments needed and define associated targets to: (i) strengthening surveillance and (ii) directly measuring trends in TB disease burden

38. Objective 4 DRAFT investment plan: the example of Myanmar Improve case detection Expand PPM with private hospitals, specialists (e.g. paediatricians) and pharmacies (target: xx% of private hospitals linked with NTP by xxxx) Improve M&E capacity and data quality Enhancing capacity on good data management and analytical practices (target: xx number of epidemiology and statistics workshops/courses, xx number of staff in M&E team) Advocate for the transition from a paper to an electronic case-based recording and reporting system (target: electronic case-based pilot by xxxx) Improve direct measurement of disease burden Supporting the development of a high-quality national vital registration system with standard coding of cause of death (target: liaison officer to report on TB deaths from VR, xx number of staff trained on ICD-10) Conduct studies to improve direct measurement of TB disease: repeat TB prevalence survey in 2016/2017 (target: repeat prevalence survey by xxxx)

39. Conclusion & next steps Epidemiological and impact reviews offer a unique opportunity to: – conduct a baseline assessment of the strengths and weaknesses of the surveillance system (repeat review in some years t monitor progress); – understand, use & improve the quality of TB, & other relevant, data; – identify data gaps for direct measurement of TB burden; – set targets on improving: (i) quality and coverage of surveillance, and (ii) direct measurement of disease burden. Next steps: – Discussion with technical partners on revision of ToR's of epidemiological reviews (e.g. include projections on key indicators) – Enhance global and regional capacity to conduct epidemiological reviews (e.g. model examples, train a small roster of consultants) – Promote the wide use of handbook on "understanding and using TB data" (e.g. workshops)

40. Acknowledgements National TB Control Programmes (particularly Indonesia, Myanmar & Nigeria) Katherine Floyd Ikushi Onozaki Irwin Law Hazim Timimi Emily Bloss Suzanne Verver Eveline Klinkenberg Norio Yamada Chikwe Ihekweazu Ananta Nanoo Global Fund USAID UNITAID TB CARE