NATIONAL TB PREVALENCE SURVEY DESIGN & IMPLEMENTAION
Lessons From the Field Ghana
Frank Bonsu & Survey Team
30th April, 2013, Accra
BURDEN OF DISEASE
• TB prevalence all forms: 92 /100,000 pop/yr (2011)
• TB incidence all forms: 79/100,000 pop/yr (2011)
• TB/HIV co-infection 14.5% ( 2008)
• CDR 78% (2011) • Treatment success : 86.2
% 2011
GHANA: Pop: 26,594,185 (2013)
Lessons From the Field • Do quality survey
Let’s have a better view Ikushi Develop budget more seriously. Don’t swap participant forms
• Training important but by whom and for whom Eveline/ Van
• Real time data entry avoid backlog , 1.5 million data entry points Software for data. Use local expertise Yamada
• Watch missing data (avoid preventable ones) Babis • Be mindful of the little details/plan Marina • Find someone to do the survey Jaap • High precision around estimate Task force • Strong justification for your survey Katherine
OPERATIONAL LESSONS FROM ETHIOPIA & CAMBODIA
– Information – Good luck – God helps those who help themselves. Cambodia
– High staff turn over – microplanning – Transportation/ keep away from rains Ethiopia
Further issues: New tech Data entry in the field and barcode
• Benefits and downsides need to be considered. • Recording in paper forms -> Initial data entry every
evening in the field • Barcode: how to incorporate and print structure of PINs
Slide Shown in Cambodia By Norio Yamada Ikushi has earlier suggested barcode idea to NTP Babis has stressed it is possible from Zamstar project experience But HOW?
Key benefits Digital
Barcoding for unique participant ID yes
High CXR readability/image quality yes
Immediate image availability yes
Picture Archiving & Communication System yes
Electronic Data management & privacy tools yes
Film & chemical elimination yes
Automated data back-up yes
Prevalence survey innovations
Core lessons
• Passion • Effective Leadership • Planning • Communication • Teamwork • Logistics • Quality Staff/Team • Data management
Workload Assumptions • Assumptions:
– Prevalence survey sample size: 64,000 – 98 clusters – 170 images per day per CXR system – Cluster size 650 – 5 working days per week – 3 effective working weeks per month
• Expected survey lead time
– 4 mobile/portable CXR units, 7,200 per month => 11 months
Census
Questionnaire
Film Form/Register
Link Analysis
Prevalence Survey data
Different sources of information
Sputum
Trend of estimated prevalence [Source: Global Plan to
Stop TB 2010-2015]
286 267 246 206
163 92
143
0
100
200
300
400
500
600
700
1990 1995 2000 2005 2010 2015High boundTB prevalence (per 100 000 population)Low bound
MDG/STB target
5/10/2013 Ghana NTP REview
Conclusion: TB Evaluation of surveillance system
• Out of 13 standards for TB surveillance evaluated,
• 3 (B1.1, B1.2, B1.3 & B1.6) were met, • 3 (B1.4 & B2.1) were partially met, • 6 (B1.7, B2.2, B3.1, C1, C2 &C3) were not met,
and • 1 (B1.5) Not
Is the TB Disease burden in Ghana high or not ?
Answer will inform determination of future direction for TB Control Post
2015
PASSION Who is more interested than NTP to have this question answered?
Effective leadership
• Decisive decisions based on good planning: X-ray equipment procured within 8 weeks, lifting of MGIT consumables within 72 hours, Prompt decision to use Xpert, effective solns for potential high staff turn
over eg. finding replacement doctors trained within 2 weeks
Design Concept • Internet Access 50-60% PENETRATION • Power (electricity) 100% guaranteed ( GENERATORS, BATTERIES,
NATIONAL GRID, Torch light) • Local network of computers with its own local server for each team .
Linked to Central server . Use of barcode systems to track individual participants.
• Learn by doing ( after 56 years no skills). Engage local expertise TAB Consult for the experiment.
Support Systems • Intense continous engagement of survey team.( PI, Survey coordinator
(Babis initially) ) • Intense engagement of WHO ( Ikushi & Marina mostly on going Field
support visits, e-mails, phone calls ---Clarifications, study protocols) • Irwin providing data quality feedback
PS: Keep it Simple: less transcription • NATIONAL TB SURVEY REGION: CODE: • NATIONAL TB CONTROL PROGRAMME DISTRICT: CODE: • GHANA HEALTH SERVICE CLUSTER NO: • RURAL/URBAN: • STRUCTURE NO: • • • • ANNEX 2: Individual Survey Card (Symptom Questionnaire) • Interviewer: _____________ • Individual Code Number: __ __ - ___ ___ ___- ___ ___ • Name: ______________________________________ • Sex: 1□ Female, 2□ Male • Age: ___ ____ check if estimated □ • Occupation: __________________________ Category code ______ • Symptom and Duration • 0No
1Yes Duration • days weeks months • 6.1 Cough □ □
__ __ __ • 6.2 Sputum □ □
__ __ __ • 6.3 Blood contained sputum □ □ __
__ __ • 6.4 Chest pain □ □
__ __ __ • 6.5 Body weight loss □ □
__ __ __ • 6.6 Fatigue, malaise □ □
__ __ __ • 6.7 Fever □ □
__ __ __ • 6.8 Other( ) □ □ __
__ __ • 6.9 TB Suspect by symptom(s) 0 No □ 1 Yes□
• Current TB Treatment: 7-1: 0□No, 1□ Yes (Start M, Y; TB No. ) • 7-2: 1□Public Hospital/NTP, 2□Health Center/NTP, 3□ Other hospitals • 4□GP, 5□Pharmacy, 6□ NGOs, 7□Traditional Healers, 8□Other_________ • • 8. Past history of TB Treatment: 0□No, 1□Yes (Year: TB No. ) • 8-2: 1□Public Hospital/NTP, 2□Health Center/NTP, 3□ Other hospitals • 4□GP, 5□Pharmacy, 6□ NGOs, 7□Traditional Healers, 8□Other _________ •
• 9 Behavior toward symptom(s)/ Yes for 8-9 (TB suspect) only: (Example of Optional Question) • 0□ Not applicable, 1□ Not recognized as illness, 2□ Ignored, 3□Self treatment • 4□Consulted • 9.2: When “consulted”: Place of consultation (can choose more than one): • 1□Public Hospital/NTP, 2□Health Center/NTP, 3□ Other hospitals, 4□GP, 5□Pharmacy, 6□NGOs,
7□Traditional Healers, 8□Community Health Worker, 9□Other _________ • 9.3: Examination: • 1. Sputum(0□No, 1□Yes) , .2□ X-ray (0□No, 1□Yes) • • 10 X-ray • 10.1 1□Requested, 2□Exempted (reason:____________________), 3□Rejected • 10.2 Result by field screening • 0□.Normal • 1□ Active TB, 2□ TB suspect, 3□Healed TB, 4□Other lung disease (active), 5□ Other findings in
lung(inactive), 6□ Heart disease, • 7□ Other __________________ 9□. NA _________________ • • 10.3 Sputum Request by X-ray result: 0□ No, 1□ Yes • • 10.4 Result by Central Reading • 0□.Normal • 1□ Active TB, 2□ TB suspect, 3□Healed TB, 4□Other lung disease (active), • 5□ Other findings in lung(inactive), 6□ Heart disease, • 7□ Other __________________ 9□. NA _________________ • • 11 Sputum Examination • 11.1 0□ Not request, 1□ Request • 11.2 Smear: • 11.2.1.1 SP1: 0□ Not collected, 1□negative, 2□positive 3□NA • 11.2.1.2 When positive (5□3+, 4□2+, 3□1+, 2□Scanty 3 or more, 1□Scanty <3) • 11.2.2.1 SP2: 0□ Not collected, 1□negative, 2□positive 3□NA • 11.2.2.2 When positive (5□3+, 4□2+, 3□1+, 2□Scanty 3 or more, 1□Scanty <3) • 11.3 Culture (AFB): • 11.3.1.1 SP1 1□NA, 2□negative, 3□<5colonies, 4□positive, 5□contaminated • 11.3.1.2 When positive 5□4+, 4□3+, 4□2+, 2□1+, 1□__colonies (5 or more) • 11.3.2.1 SP2: □NA, □negative, □positive, □contaminated • 11.3.2.2 When positive 5□4+, 4□3+, 4□2+, 2□1+, 1□__colonies (5 or more) • 11.4 Identification: • 0□NA, 1□TB, 2□ Non-TB, 3□ Pending • • 12. Final Diagnosis • 12.1. TB: 0□No, 1□Smear Positive TB, 2□Smear negative/Culture Positive TB, • 3□Bacteriological Negative Active TB suggested, 4 □ TB suspect, 5□ Healed TB, • • 12.2. Other findings: 0□No abnormality, 1□ Other lung disease(active)______________, • 2□Other finding(inactive)____________, 3□ heart disease, 4□Other site_______________ • • Remarks:____________________________________________________________________________________
___________________________________________________________________________ •
Form05
SURVEY FORMS
15 FORMS • Form 01 household register • Form 02 survey household # • Form03 survey screening invitation • Form o4 consent form • Form05 individual survey card • Form 06 CXR data sheet • Form 06b CXR register • Form 06 c CXR cluster summary • Form 07sputum collection record sheet • Form 08 sputum examination record • Form 09cluster summary report sheet • First report of TB prevalence survey • Second Report of TB prevalence survey • Third report of TB prevalence survey • Form 13 individual case report • Form 14 individual TB suspect report • Form 15 Central x-ray result
5 FORMS • Form 01 household register • Forms 5/ 5B • Form 05 Individual survey
card (CERTIFICATE OF PARTICIPATION)
• Form 02 (PRE-PRINTED HOUSEHOLD NUMBERS)
• Form 04 Consent forms
Household Registration
(F01)
Field Data Entry
Printing Invitation
Verification (Residential
)
Data Update (F01)
(Reception)
HH Register
Issue Invitation
Card
Register (15yrs+)
Invitation Card
Household Summary
Register (15yrs+) Residential Status
Eligible Participants
Updated Eligible Participants
Printed Barcode
1
2 3
4
6
5 7
TB Prevalence Study Process Flow -1
Household register
No. Surname
First name Age
Sex 1-M 2-F
Occupation
Residential Status 1-Permanent 2-Visitor
Eligibility
residential
criteria
Eligible?
1 –Yes 2 – No
01
02
03
04
05
06
07
Certificate of Participation
Form05
Form05b
Field Lab Register
CLUSTER SUMMARY REPORT
Cluster Daily Summary
TEAM Function Number
Team leader 1
Receptionist, Interviewing group 4 Laboratory 1
X-ray group 2
IT + engineer 2
Data entry clerk 3
Total 13
Driver 4 or 5
Central X-Ray Daily Summary
Challenges
• Adequate funding ( part of operational cost hinged around ORIO) Plan B is to reprogramme part of our GF funds)
• Stigma in the communities • Air lifting specimen ( safety issues biological
specimen) • Full attention of survey support staff.
ACKNOWLEDGEMENT • WHO ( Task force for TB Impact Measurement) - Dr Ikushi - Dr Talidoni - Dr. Irwin - Dr Floyd & Babis - Study Field Directors/Survey Coordinator - NTP Staff/Survey Team Members/Laboratory
staff/Radiologist - USAID/TB Care 1 - Italian/WHO - ORIO GRANT/ Dr Klinkenberg - Study Co-investigators/Steering Committee/TAG
THANK YOU MEDA MO
ASE