NATIONAL TB PREVALENCE SURVEY DESIGN &

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NATIONAL TB PREVALENCE SURVEYDESIGN & IMPLEMENTAIONLessons From the FieldGhanaFrank Bonsu & Survey Team30th April, 2013, Accra

GHANA: Pop: 26,594,185 (2013) TB prevalence all forms:92 /100,000 pop/yr(2011) TB incidence all forms:79/100,000 pop/yr (2011) TB/HIV co-infection14.5% ( 2008) CDR 78% (2011) Treatment success : 86.2% 2011BURDEN OF DISEASE

Lessons From the Field Do quality surveyLet’s have a better viewIkushiDevelop budget more seriously. Don’t swap participant forms Training importantbut by whom and for whomEveline/ Van Real time data entry avoid backlog , 1.5 million data entrypointsSoftware for data. Use local expertiseYamada Watch missing data (avoid preventable ones) Babis Be mindful of the little details/planMarina Find someone to do the surveyJaap High precision around estimateTask force Strong justification for your surveyKatherine

OPERATIONAL LESSONS FROMETHIOPIA & CAMBODIA– Information– Good luck– God helps those who help themselves. Cambodia– High staff turn over– microplanning– Transportation/ keep away from rainsEthiopia

Further issues: New techData entry in the field and barcode Benefits and downsides need to be considered. Recording in paper forms - Initial data entry everyevening in the field Barcode: how to incorporate and print structure of PINsSlide Shown in Cambodia By Norio YamadaIkushi has earlier suggested barcode idea to NTPBabis has stressed it is possible from Zamstar projectexperienceBut HOW?

Prevalence survey innovationsKey benefitsDigitalBarcoding for unique participant IDyesHigh CXR readability/image qualityyesImmediate image availabilityyesPicture Archiving & Communication SystemyesElectronic Data management & privacy toolsyesFilm & chemical eliminationyesAutomated data back-upyes

Core lessons PassionEffective ality Staff/TeamData 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 11months

Prevalence Survey Different sources of informationAnalysis

Trend of estimated prevalence [Source: Global Plan toStop TB 2010-2015]700600500400300286200267246206100MDG/STB target16392143019905/10/20131995200020052010High boundTB prevalence (per 100 000 population)Low boundGhana NTP REview2015

Conclusion: TB Evaluation ofsurveillance system Out of 13 standards for TB surveillanceevaluated, 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 Ghanahigh or not ?Answer will inform determination offuture direction for TB Control Post2015PASSIONWho is more interested than NTP tohave 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 turnover eg. finding replacement doctors trainedwithin 2 weeks

Design ConceptInternet Access 50-60% PENETRATIONPower (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 individualparticipants. Learn by doing ( after 56 years no skills). Engage local expertise TABConsult 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 Fieldsupport visits, e-mails, phone calls ---Clarifications, study protocols) Irwin providing data quality feedback

PS: Keep it Simple: less transcription NATIONAL TB SURVEYNATIONAL TB CONTROL PROGRAMMEGHANA HEALTH SERVICEREGION:DISTRICT:CLUSTER NO:RURAL/URBAN:STRUCTURE NO:ANNEX 2: Individual Survey Card (Symptom Questionnaire)Interviewer:Individual Code Number: - -Name:Sex: 1 Female, 2 MaleAge: check if estimated Occupation:Symptom and Duration1Yesdays weeks months6.1 Cough6.2 Sputum6.3 Blood contained sputum6.4 Chest pain6.5 Body weight loss6.6 Fatigue, malaise6.7 Fever6.8 Other()6.9 TB Suspect by symptom(s)CODE:CODE: Category code0NoDuration 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 hospitals4 GP, 5 Pharmacy, 6 NGOs, 7 Traditional Healers, 8 Other8. Past history of TB Treatment: 0 No, 1 Yes (Year: TB No. )8-2: 1 Public Hospital/NTP, 2 Health Center/NTP, 3 Other hospitals4 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 treatment4 Consulted9.2: 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 Other9.3: Examination:1. Sputum(0 No, 1 Yes) , .2 X-ray (0 No, 1 Yes)10 X-ray10.110.21 Requested, 2 Exempted (reason: ), 3 RejectedResult by field screening0 .Normal1 Active TB, 2 TB suspect, 3 Healed TB, 4 Other lung disease (active), 5 Other findings inlung(inactive), 6 Heart disease,7 Other 9 . NA10.3Sputum Request by X-ray result: 0 No, 1 Yes10.4Result by Central Reading0 .Normal1 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 . NA11 Sputum Examination11.10 Not request, 1 Request11.2 Smear:11.2.1.1 SP1: 0 Not collected, 1 negative, 2 positive 3 NA11.2.1.2When 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 NA11.2.2.2When positive (5 3 , 4 2 , 3 1 , 2 Scanty 3 or more, 1 Scanty 3)11.3 Culture (AFB):11.3.1.1SP1 1 NA, 2 negative, 3 5colonies, 4 positive, 5 contaminated11.3.1.2 When positive 5 4 , 4 3 , 4 2 , 2 1 , 1 colonies (5 or more)11.3.2.1 SP2: NA, negative, positive, contaminated11.3.2.2 When positive 5 4 , 4 3 , 4 2 , 2 1 , 1 colonies (5 or more)11.4Identification:0 NA, 1 TB, 2 Non-TB, 3 Pending12. Final Diagnosis12.1.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 siteRemarks:

Form05

SURVEY FORMS15 FORMS Form 01 household registerForm 02 survey household #Form03 survey screening invitationForm o4 consent formForm05 individual survey cardForm 06 CXR data sheetForm 06b CXR registerForm 06 c CXR cluster summaryForm 07sputum collection record sheetForm 08 sputum examination recordForm 09cluster summary report sheetFirst report of TB prevalence surveySecond Report of TB prevalence surveyThird report of TB prevalence surveyForm 13 individual case reportForm 14 individual TB suspect reportForm 15 Central x-ray result5 FORMSForm 01 household registerForms 5/ 5BForm 05 Individual surveycard (CERTIFICATE OFPARTICIPATION) Form 02 (PRE-PRINTEDHOUSEHOLD NUMBERS) Form 04 Consent forms

TB Prevalence StudyProcess Flow -11HouseholdRegistration(F01)2Field DataEntryHH Register3PrintingInvitationRegister (15yrs ential)Register (15yrs )Residential StatusPrinted Barcode7UpdatedEligible ationCardEligible Participants

Household FResideEligiblntiale?OccupStatus Eligibilation1 –Yes1ity2 – NoPerma residenentntial2criteriaVisitor

Certificate of Participation

Form05

Form05b

Field Lab Register

CLUSTER SUMMARY REPORT

Cluster Daily Summary

FunctionTEAMNumberTeam leader1Receptionist, Interviewing group4Laboratory1X-ray group2IT engineer2Data entry clerk3Total13Driver4 or 5

Central X-Ray Daily Summary

Challenges Adequate funding ( part of operational costhinged around ORIO) Plan B is toreprogramme part of our GF funds) Stigma in the communities Air lifting specimen ( safety issues biologicalspecimen) Full attention of survey support staff.

ACKNOWLEDGEMENT -WHO ( Task force for TB Impact Measurement)Dr IkushiDr TalidoniDr. IrwinDr Floyd & BabisStudy Field Directors/Survey CoordinatorNTP Staff/Survey Team Members/Laboratorystaff/RadiologistUSAID/TB Care 1Italian/WHOORIO GRANT/ Dr KlinkenbergStudy Co-investigators/Steering Committee/TAG

THANK YOUMEDA MOASE

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

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