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Progress of the Singapore TB Elimination Programme (STEP). 3.8.07. IUATLD 1 st 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. Singapore.

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progress of the singapore tb elimination programme step

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

  • Population 4.35 million
  • Resident population 3.55 million; 75% Chinese, 14% Malay, 8% Indian
tb in singapore residents 1960 1997
TB in Singapore Residents1960-1997


1,712 new cases

Incidence rate: 55 / 100,000



World Health Day

April 1997

singapore tb elimination programme
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
singapore 1997
Singapore - 1997
  • HIV incidence : 55 per million population
  • Primary INH resistance : < 4%
  • Primary MDRTB resistance : < 0.5%
step components
STEP Components
  • Epidemiological component : STEP Surveillance System
  • Clinical component :TB Control Unit, TTSH
      • National referral centrefor themanagement of TB patients, contact investigation and preventive treatment
key step initiatives
Key STEP Initiatives
  • Nation-wide treatment surveillance module
  • Directly Observed Therapy (DOT)
  • Nation-wide policy of preventive therapy for infected close contacts
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

tb notification and treatment centres
TB Notification and Treatment Centres

Treatment Centres

Notification Centres






Notified case

Final Outcome

Infectious case

Active TB





Contact with LTBI


INH Preventive


If declined

Advised on TB symptoms

step treatment surveillance module
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
treatment defaulters
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
dot in singapore
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

contact investigation at tbcu before 1998
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
contact investigation at tbcu since 1998
Contact investigation at TBCUSince 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
preventive therapy for contacts with ltbi
Preventive Therapy for contacts with LTBI

Contacts with TST >= 15 mm advised PT after exclusion of active disease

Those with TST 10 - 14 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

Thank You


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