1. Implementation of Management information system in Ukraine. PATH Project team “TB Control partnership in Ukraine” TBTeam-Kyiv@path.org

2. To provide an overview of management-information systems and show how TB data can be used for appropriate decision making in TB Programs Goal of the presentation

3. Outline 1.TB-epidemiology overview 2.Overview of Ukraine 3.Definitions and examples: –Management information system (MIS) –Monitoring and evaluation (M&E) –Cohort analysis (ChA) 4.Main indicators for TB-program M&E 5.Examples of decision-making in TB program

4.  2 billion the world’s of population are infected by Mycobacterium Tuberculosis (MBT) 8.9 million new TB cases each year – (Every 4 Seconds. = one new TB case) 3.9 million of them are smear+ (highly infectious) 80% of cases are registered in African, South-East Asia, and Western Pacific regions (22 high- burden countries) 8.3 % (741,000) HIV prevalence among new adult TB cases 3.2 % primary MDR prevalence 1.7 million. deaths due to TB (EACH 20 SEC. = ONE DEATH DUE TO TB) Estimated TB Burden in the world, 2004 Ref: Global TB control report, 2006

5. Estimated TB incidence rate, 2004 Ref: Global TB control report, 2006

7. Estimated HIV prevalence among new adult TB cases, 2004

8. Ref: DRS Report 9.4 Estonia Ivanovo (Russia) Latvia Henan (China) Iran Liaoning (China) Domenican Rep 3.1 5 7.8 10.4 9 9.3 12.2 Tomsk (Russia) 13.7 Israel 14.2 6.6 5.3 Ivory Coast 4.9 Ecuador 14.2 Kazakhstan 13.2 Uzbekistan Lithuania MDR-TB is rampant in the former Soviet Union and China Prevalence of primary MDR, 1994-2002 MDR-TB is rampant in the former Soviet Union and China

9. Ukraine- An Overview 2 nd largest country in Europe (603,700 km 2 ) independent from the USSR since 1991 27 regions and 490 districts population – 48 million –67% living in urban areas gross national income per person US$ 5,430 life expectancy 67 years –62 years among male and 73 among female population growth rate = -0.7 %

10. Definition (MIS) Management information system (MIS) is an ongoing process of information collection and analysis with periodical interpretation and dissemination of public-health data Data for decision-making process in controlling the public-health problems “Information for action” Ref: Principle of Epidemiology, second edition, CDC

11. Epidemiological approach of the MIS in public health ProblemAction By surveillance (define burden) what kind of problem? where is the problem? when was happen? among whom? Descriptive epidemiology By operational research (define exposure): why does this happen? how does this happen? Analytic epidemiology By operational research (define efficacy and efficiency of intervention): what works? Prognostic (experimental) epidemiology Implementation : How better to implement interventions? Field epidemiology Supervision, Monitoring and Evaluation

12. PATH!MOH?TBI? Region / Oblast level Quarterly (at data of 10 of first MM of the next Q) District level Structure of TB MIS (by DOTS) in Ukraine implemented by PATH Quarterly (at data of 15 of first MM of the next Q)

13. Standard DOTS recording and reporting forms M&E guidelines IT technologies –Equipment; –Software; –Electronic communication e-mail chat listserv Training Inputs => Process => Output

14. Definition of MONITORING MONITORING is the observation of TB program performance to ascertain whether activities are accomplished as planned. (It aims to identify problems quickly so that they can be solved without delay) –Internal – self-analysis of activities –External - by upper level Direct – field visits Indirect – at distance (examining periodic reports) Is a daily management activity

15. Definition of EVALUATION EVALUATION refers to the periodic assessment of progress towards operational targets and epidemiological objectives. –Includes measurement of indicators, such as percentage of patients cured, to assess progress in achieving targets and objectives. –Is undertaken after some interval (3, 6, or 12 months, or longer), allowing sufficient time to measure program results. –Process evaluation –Outcome (cohort analysis) and impact evaluations (TB-burden evaluation)

16. Definition: COHORT ANALYSIS COHORT ANALYSIS – review and interpretation of patient outcomes using a set cohort, that is, a cohort (or group of individuals) that started treatment during the same time period (usually during the same quarter) KEY MANAGEMENT TOOL FOR EVALUATING THE EFFECTIVENESS OF TB CONTROL PROGRAM Cohort structure is defined by main determinants used for case management Ref: Compendium of indicators for M&E of the NTP, WHO 2004

17. TB determinants and case definitions pericarditis  peritonitis  bilat./extensive  pleural effusion  spinal  intestinal  genito-urinary Smear-Pos. if:  2sputum+ or  1sputum+ and X-ray suspect and physician or  1sputum+ and culture + Pulmonary if: lung parenchyma New = previous treatment lasted less than 1 month Defaulter = stopped treatment after 2 months Relapse = previously received full treatment and was cured Failure = still positive after 5 months of treatment Chronic = positive after full re-treatment course

18. Cohort analysis In a foot race:In a TB programme: A group of people start together a 10 km foot race ➨ A group of TB patients start treatment within one quarter How many people did complete the race and who was the champion (results)? ➨ How many patients did complete their treatment and what was the outcomes?

19. Core package of the TB MIS Lab request/report (TБ-05 and ТБ- 06)  TB case management card (TB-01) Referral/transfer form (TБ-09) Lab register (TB-04 and ТB-04c)  TB cases register (TB-03)  Quarterly report about registration of new cases & relapses (TB-07)  Smear conversion report (TB-10 )  Quarterly report about treatment outcomes (TB-08) For case management For TB program monitoring at district level For TB program evaluation at oblast level

20. Indicators for cohort analysis IndicatorsTargets DiagnosisRate of re-treatments< 30 % Rate of extra-pulmonary TB≈ 10-15 % Rate of S+ among PTB≈ 65 % Rate of S+ among all new TB cases≈ 50 % Primary MDR- HIV prevalence among new TB cases- TreatmentSmear conversion rate>85 % Cure rate (cured + tr. completed) among new PTB+ > 85 % Lethality rate among new PTB+< 5 % Failure rate among new PTB+< 5 % Defaults rate among new PTB+< 3 %

21.  Incidence increasing since 1990 г. – 250 %  Mortality increasing since 1990– 280 % each hour 4 Ukrainians get disease and 1 dies due to TB  Primary MDR * – 0.6 – 11.9%  HIV Prevalence among new TB cases * – 3.5 – 12% Ref: Ukrainian journal of chemotherapy Ukrainian journal of pulmonology TB epidemic in Ukraine

22. Age Distribution of TB Incidence and Risk to acquire TB, Ukraine, 1995-2004

23. Efficiency of case finding system in Ukraine, 2003 WHO estimates Official MOH data  TB Incidence (all cases) 9277.5  TB Incidence (PTB+) 4126.8 Just FYI 53% of Ukraine population receive annual X-rays

24. Registered new PTB + incidence compared with estimates, by PATH Project’s cites

25. TB control targets (detection) Detect 70 % of estimated TB cases

26. Estimated TB cases Real TB cases Cases presented to PHC Cases referred to TB Program Cases correctly diagnosed Reported and treated by DOTS TB cases Structure of TB reservoir and management, where we are losing TB

27. 70 % An onion with a thin hull

28. TB control targets (treatment) Cure 85 % of detected

29. Convergence towards DOTS targets

30. Treatment outcomes among new PTB+ Cohort analysis, Donetska oblast, 2002-2004, by years Source: PATH TB MIS Program failure

31. 0 2 4 6 8 10 EURSEARWPRAFRAMREMR (%) Ref: Global TB control report, 2003 Failures rate in cohorts of 2001, world by regions

32. Lethality rate in cohorts of 2001, world by regions Ref: Global TB control report, 2003 0 2 4 6 8 AFREURAMRSEAREMRWPR (%)

33. Lethality rate among new cases, Ukraine, 1999-2004 Source: medical statistics centre of MOH of Ukraine

34. HIV prevalence among new TB cases, Donetska oblast, 2000-2005 Source: Donetska oblast MIS

35. MDR Prevalence, Donetska oblast, 2005 Source: Donetska oblast TB service

36. Anxiety High level of:  Failure rates (2004 average = 15%)  Defaulter rates (2004 average = 14%)  Lethality (2004 average = 14%)  HIV prevalence among newly detected TB cases (growth up to 9.6 %)  Primary MDR prevalence (10.7%) ? Quality of drugs

37. Suggested solution Social and pecuniary support for previously treated TB cases during continuation phase Building up coordination mechanism among HIV and TB Programs -Joint planning of TB/HIV -Clinical surveillance of TB/HIV Reduction of HIV-burden among TB patients -HIV testing and counseling; HIV prevention -ART for TB/HIV patients Reduction of TB-burden among PLHA -Active TB case detection -Treatment of LTBI (prophylaxis with Isoniazid) ? Implementation of DOTS PLUS (needs assessment of preparedness and detailed implementation plan)

38. Health-seeking of people with TB symptoms to PHC and TB service, Donetsk, 2003 Information campaign Source: health administration

39. Economical TB Burden, Ukraine, 2003 Number of death due to TB, by age groups = 10,421* Life expectancy = 67 years YPLL (years of potential life lost) due to TB –198,389 years Gross national income (GNI) lost per capita –USD 4,800** Financial TB burden = USD 952,267,200 Ref: * medical statistics centre of MOH of Ukraine ** World Bank/WDI-2004

40. TB death and GNI lost, Ukraine, 2003

41. Definition of epidemiological TB burden  Incidence per 100.000  Lethality in cohorts per 100  Prevalence per 100.000  Mortality per 100.000  Invalidity per 10.000

42. TB figures by regions, Ukraine 2003

43. Adjusted TB figures, Ukraine, 2003

44. Epidemiological TB Burden in Ukraine, 2003 Where intervention is more required?

45. 2003-2005 2006   2003 Decision making based on eight unrepresentative rating indicators (system established during WWII) Decision making based on new M&E indicators PATH’s TB Project coverage, Ukraine

46. Increase of TB incidence and mortality rates, Ukraine, 1991-2004 Standardizing of case management by DOTS Stage 1 of DOTS implementation, pilot sitesCentralized TB drugs supplying Stage 3 of DOTS implementation, throughout the country PATH get involved in to TB control in Ukraine

47. Interpretation  Providing task-oriented, efficient technical support to reduce morbidity and mortality in Ukraine

48. Recommendation/Conclusion  TB Burden Evaluation should be performed every 3 to 5 years to determine the extent (prevalence) of the problem  Quarterly Cohort Analysis provides specific and sensitive surveillance data for TB program evaluation and monitoring  MIS is one of the most important components of TB Program, providing information on intervention efficiency