WHY A SUCCESSFUL TB CONTROL DOES NOT DECREASE DISEASE INCIDENCE?

1. WHY A SUCCESSFUL TB CONTROL DOES NOT DECREASE DISEASE INCIDENCE? Şeref Özkara, Seren Arpaz, Sevtap Keskin, Nejat Sezgin Atatürk Chest Diseases and CSER Hospital, AnkaraNazilli Tuberculosis Dispensary

2. Aim of the study • This dispensary carries out a successful study in case finding and treatment for many years. • In addition, BCG vaccination and preventive therapy is applied • We aimed to evaluate the effect of these practices in TB incidence

3. Introduction • TB incidence decrease in developed countries, • Pre-chemotherapy period, 4-5% annually • Between 1950-1980, 12-13% annually • With case finding and chemotherapy, 8% annually. K. Styblo. Epidemiology of Tuberculosis, 1991

4. Why Nazilli TB Dispensary Region? • We organized 11 regional meetings between 27.2.1997 and 5.6.1997. • First meeting was held in İzmir, 27.02.1997 • Dr. Seren Arpaz presented some information • A letter from Nazilli about their applications

5. Information letter (30 April 1997) • Notifications from pharmacies • Meeting with pharmacies (50% participation) • Second meeting with pharmacies (100% participation) • Notification of the prescriptions • Un-notified cases informed to provincial Health Director • Notifications from Gov. Hospital • Negotiations with the head of the hospital • 2 year part time work in the hospital • A notification protocol with the chest physician • Reports for rest: dispensary ask for, hospital prepares • Notification from Social Security Hospital • A protocol prepared • Prescription written in dispensary • Reports for rest, dispensary ask for, hospital prepares

6. Information letter (30 April 1997) “.. I think we captured all TB cases in Nazilli ...” 8 notifications from pharmacies 10 notifications from Gov. Hospital Regular notification from İzmir Chest Hospital No notification from universities

7. Pioneering in observed treatment • Nazilli TB dispensary, pioneered in DOT in Turkey • Initiation April 2000 • First presentation Thorax Society Annual Congress 2001 • Presentation in most of the regional 11 meetings during 2001 and 2002 • Presentations in all national congresses and some regional meetings.

8. Findings Registered TB cases 1996-2006:Annual mean 98,5 (83-121) REGISTERED CASES IN NAZILLI TB DISPENSARY

9. Nazilli TB Dispensary, All cases during 1996-2006 • Pulm-TB : 74,8% • Extra-Pulm-TB : 25,1% • Smear (+) / all cases : 42,1% • Smear (+) / Pulm-TB : 56,2%

12. Treatment Results • Treatment success rate is over 90%. • Cure rate of smear positives is over 90%. • Defaulter 3 cases in 11 years. • Treatment completed in one at 18 months.

13. %85

14. ALL Wıthout village • Annual mean 250 (132-707) 183 (132-288) Prevent. Tx/ patient 2,54 (1,3-6,5) 1,99 (1,3-2,9)

15. Contact examination • Annual mean : 1.225 (528-1.867) • Contact exam. / patient no. : 12,4 (5,3-20,9)

17. Annual decrease 0.4% (p=0.32)

18. Annual decrease 0.7% (p=0.15)

19. Decrease in case rates: Nazilli • All cases 1996-2006 • Annual 0.4% (p=0.32) • Cases without village • Annual 0.7% (p=0.15)

20. Discussion This dispensary and region • Population was stable. • Notifications done regularly • Bacteriological examinations done routinely • Treatment success rate is high • Contact investigation done regularly • Preventive therapy given in high rates • Support for the patients.

21. Discussion This dispensary region • Is a social and economically developed region.

22. Discussion Reason for the slow decrease in case rates: • Notification and registration increaase We think this is not important for this region. But, With DOT, dispensary became well known in the region, which may result in an increase of patients preferences

23. Discussion Reason for the slow decrease in case rates: 2. Registration of cases from other regions We don’t think this possibility.

24. Discussion Reason for the slow decrease in case rates: 3. Microepidemics a. Microepidemics in one village (1,000 population) 2002-2005, 52 cases in 4 years, annual mean case rate 1,300/100,000 b. Other microepidecis (?)

25. Result • Styblo’s result for the developed countries is a question for our country. We think, operational research is required for this subject.

32. Estimated incidence Gijs Elzinga, 2006 weighted notification rates from selected countries in each region, scaled to the estimated incidence.

33. TB insidans değişimi 2004 Gijs Elzinga, 2006

34. The Netherlands Gijs Elzinga, 2006

35. Mortality 1903 - 1913 3.5%/yr 1920 - 1940 5.7%/yr ARI <world war II 4-5%/yr >world war II 12-13 %/yr The data from the Netherlands Gijs Elzinga, 2006

36. Annual decrease in case ratesStyblo 1984, 1991 Gijs Elzinga, 2006

37. Vietnam Gijs Elzinga, 2006

38. Vietnam is in target zone since 1996 100 Target zone 90 Treatment success (%) 80 Gijs Elzinga, 2006 70 50 60 70 80 90 100 110 120 DOTS detection rate (%)

39. Registered case rates in 100,000 population in Vietnam, 1995-2004 Gijs Elzinga, 2006

40. Thank you.