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Progress of the Singapore TB Elimination Programme (STEP)

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)

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  1. Progress of the Singapore TB Elimination Programme(STEP) 3.8.07. 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 Residents1960-1997 1997 1,712 new cases Incidence rate: 55 / 100,000

  4. TB incidence rates (new cases) among residents by age and sex1999

  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 centrefor themanagement 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 Treatment Centres Notification Centres

  12. THE STEP SURVEILLLANCE SYSTEM Treatment Surveillance Module Notified case Final Outcome Infectious case Active TB ContactInvestigation 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 OutcomeSingapore 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 National1998-2006

  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 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

  20. 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

  21. Contact Programme Performance2000-2004

  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 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

  25. Incidence of HIV infection in Singapore 1985-2005

  26. Number of TB notifications (New cases) By Residential Status1998 - 2005

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

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