1. Progress of the Singapore TB Elimination Programme (STEP)
IUATLD 1st Asia Pacific Region Conference 2007
Dr Cynthia Chee
TB Control Unit, Department of Respiratory Medicine
Tan Tock Seng Hospital
Deputy Chairman
STEP Committee, Ministry of Health, Singapore

2. Singapore Population 4.35 million
Resident population 3.55 million; 75% Chinese, 14% Malay, 8% Indian

3. TB in Singapore Residents 1960-1997
1,712 new cases
Incidence rate: 55 / 100,000

4. TB incidence rates (new cases) among residents by age and sex 1999

5. STEP
World Health Day
April 1997

6. Singapore TB Elimination Programme
Mission: To eliminate TB in Singapore with the following goals:
to detect and diagnose all infectious (sputum positive) cases in the community
to cure all cases of TB
to detect and treat all infected TB contacts
to prevent the emergence of MDRTB

7. Singapore - 1997 HIV incidence : 55 per million population
Primary INH resistance : < 4%
Primary MDRTB resistance : < 0.5%

8. STEP Components Epidemiological component : STEP Surveillance System
Clinical component : TB Control Unit, TTSH
National referral centre for the management of TB patients, contact investigation and preventive treatment

9. Key STEP Initiatives Nation-wide treatment surveillance module
Directly Observed Therapy (DOT)
Nation-wide policy of preventive therapy for infected close contacts

10. TB NOTIFICATION SYSTEM
TB Labs of Singapore General Hospital & National University Hospital
Tuberculosis Control Unit (TTSH)
Restructured Hospitals
STEP Registry,
Ministry of Health
Private Practitioners
Clinical Laboratories
Registry of Births & Deaths
Singapore Anti-tuberculosis Association

11. TB Notification and Treatment Centres
Notification Centres
Treatment Centres

12. THE STEP SURVEILLLANCE SYSTEM Contact Investigation
Treatment
Surveillance
Module
Notified case
Final Outcome
Infectious case
Active TB
Contact Investigation
Contact
Uninfected
Discharged
Contact with LTBI
advised
INH Preventive
Therapy
If declined
Advised on TB symptoms

13. STEP Treatment Surveillance Module
Implemented in stages, nation-wide coverage from 2001
Treating physician to submit a return for each TB patient at every visit until treatment completion (or other outcome) achieved
Compliance, latest sputum smear result, treatment delivery mode and prescribed regimen captured
“Real-time” tracking of patient’s treatment progress and to provide national data on treatment outcome

14. TB Treatment Outcome Singapore Residents, 2001-2004

15. Treatment defaulters
Real-time tracking of treatment progress enables timely identification of treatment defaulters
Recall measures: phone calls, letters, and home visits by TBCU nurses; Medical social worker
Free long-stay 20-bed ward for defaulters with poor social support and who are unable to adhere to treatment
~ 10 to 20 infectious recalcitrant defaulters each year; since July 2004, the Infectious Diseases Act used on ~ 50 infectious patients

16. DOT in Singapore Outpatient DOT
By nurses at the patients’ nearest public health polyclinic
Daily for intensive phase; thrice weekly for continuation phase
Outreach DOT 2002 – 2004

17. Proportion of TB cases on DOT TBCU and National 1998-2006

18. Contact investigation at TBCU Before 1998
Household / family contacts of all notified TB cases (regardless of infectiousness of index case) invited for CXR screening to detect active TB disease
Tuberculin skin testing (TST) screening and preventive therapy (PT) only for children who were household contacts

19. Contact investigation at TBCU Since 1998
TST to detect LTBI for preventive therapy in close contacts of infectious cases regardless of age
Contact investigation extended beyond household to workplace, schools
Contact screening in congregate settings eg. prisons, drug rehabilitation centres, mental health institute, nursing homes, dialysis centres

20. Preventive Therapy for contacts with LTBI
Contacts with TST >= 15 mm advised PT after exclusion of active disease
Those with TST mm advised on “case-by-case” basis
Preventive therapy regimen:
Isoniazid (6 months in adults, 9 months in children and HIV+)
Rifampicin (4 months) for contacts of INH-resistant cases

21. Contact Programme Performance 2000-2004

22. Incidence rate of All Notified TB and Pulmonary TB Singapore Residents (New Cases) 1991 - 2006

23. TB Incidence Rate in Singapore Residents 1960 -2006
1,256 new cases

24. Thank You Acknowledgments SNO Han Kwee Yin and staff of TBCU
Polyclinic nurses (SingHealth & NHG)
Dr KhinMar K Y and staff of STEP Registry
Dr Irving Boudville, Dr Monica Teleman

26. Incidence of HIV infection in Singapore 1985-2005

27. Number of TB notifications (New cases) By Residential Status 1998 - 2005

28. Drug Resistance in Residents with pTB (New cases) 1998 - 2006