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TB Notes 1, 2001
International Activities Update
Image 1: Peter Ciegielski, MD, of DTBE's International Activities,
showed his dedication to the cause on Friday, March 23, by adorning
his car and himself with the "STOP TB!" logo. We hope
he was able to raise a bit of awareness about TB on his way to and
from work that day.
Latvian Center of Excellence Established
The International Activities branch of DTBE is involved in an ongoing
project with the National TB Program (NTP) of Latvia to establish
a Center of Excellence for the diagnosis, treatment, and management
of multidrug-resistant TB (MDR TB). Latvia, a former republic of
the Soviet Union, is being challenged with a substantial epidemic
of MDR TB. After the disintegration of the Soviet Union in 1991,
Latvia faced substantially depleted resources for TB control, resulting
in erratic and unreliable supplies of anti-TB drugs. Additionally,
treatment regimens were inadequate and treatment completion rates,
as a rule, were very low. Furthermore, institutional infection control
was inadequate, resulting in high levels of transmission of M.
tuberculosis in prisons and hospitals and high numbers of staff
developing TB and MDR TB. There were major delays in the diagnosis
of drug resistance due to poor laboratory proficiency.
In 1996, Latvia participated in the first global anti-TB drug resistance
survey, which was conducted jointly by the World Health Organization
(WHO) and the International Union Against TB and Lung Disease (IUATLD).
Latvia had the highest level of MDR TB of any of the participating
35 countries; 14.4% of its new TB cases were MDR, or roughly 1 out
of 7. Latvia's neighbor, Estonia, also had high levels, at 10%,
reflecting the regional impact of the disintegration of the Soviet
The Latvian NTP responded as quickly and effectively as possible
with the very limited resources available and with some limited
financial and technical assistance from donor countries. Modeled
on the United States' response to the MDR TB epidemic in New York
City in the early 1990s, the initial steps taken by Latvia included
fully implementing the WHO-defined DOTS strategy, improving the
national laboratory proficiency and capacity, and addressing infection
control issues in hospitals. The Latvian national surveillance system
was also improved by adopting WHO reporting standards. By 1998,
the Latvian NTP started a civilian and prison DOTS-plus program
to treat the roughly 200 MDR TB patients diagnosed each year, which
resulted in a 30% reduction in the level of MDR TB in Latvia.
Given the facts that the Latvians had made great strides and developed
much expertise in mobilizing against MDR TB, yet also needed continued
support to advance their progress in reducing MDR, an idea evolved
to establish the Latvian National TB and Lung Disease Center as
a regional Center of Excellence for the treatment and management
of MDR TB. This collaborative project between CDC and the Latvian
NTP began in late 1999 and is funded by the U.S. Department of State
and the U.S. Agency for International Development (USAID). The specific
objectives of the project are to assist the Latvian NTP in further
reducing the country's MDR TB burden, to establish a sustainable
model of MDR TB management in a resource-limited country, and to
use the Center to train clinicians from other former Soviet republics
that are facing similar issues with MDR TB.
The project consists of several components. The initial component
is centered on continuing to build Latvian clinical expertise for
MDR TB. First, a comprehensive training course taught by U.S. experts
was held in March 2000 for the 22 Latvian physicians who treat MDR
TB. Subsequently, a "telemedicine" (or videoconferencing)
project was launched at the Center in June 2000 for monthly clinical
case review with CDC MDR TB clinical experts. At the most recent
conference, MDR TB experts from Partners in Health at Harvard University
also participated. Additional laboratory upgrades for more rapid
diagnosis of MDR TB are being made. The cost-effectiveness of using
new technologies will be carefully studied. Moreover, continued
improvements are being made regarding infection control. In August
2000, a TB infection control expert from the National Institute
for Occupational Safety and Health (NIOSH) was sent to the Center
to perform a full assessment and develop a comprehensive strategy
and plan for improving infection control throughout the 500-bed
facility. It is hoped that the measures being taken will serve as
an infection control model for TB facilities throughout the region.
Another component of the project involves the development of a
computerized data management and information system for MDR TB patients.
Lorna Thorpe, PhD, International Activities' EIS Officer, began
developing this system in August 2000. The system will be used for
case management, better MDR TB surveillance, and outcome studies.
It will also be exportable for use by other NTPs in the region that
are implementing DOTS-plus programs for MDR TB. Building epidemiologic
capacity is also a component of establishing the Center. This has
involved working with the NTP staff on the design and implementation
of a risk-factors study for MDR TB and also includes staging a basic
epidemiology training course for the staff scheduled for May 2001.
Finally, the first of three 3-week MDR TB training courses planned
for 2001 for physicians from other countries in the region, including
Russia, was held in late January.
Future plans for continued development of the Center as a sustainable
resource for MDR TB training in the region include further expansion
of training capabilities, to meet the growing demand of TB programs
in the region for education of clinicians and program managers.
A study of additional rapid-diagnostic technologies is also slated
for the Center. The analysis of the cost-effectiveness of these
technologies will be critical to determining their feasibility for
use in resource-limited countries such as Latvia. Broadening infection
control efforts to include smaller regional TB facilities, clinics,
and prison facilities within the country is planned. It is hoped
that the measures taken will serve as a model of TB infection control
for the region. Also, given the high level of alcoholism and its
role in the interruption of patient treatment in Latvia, effective
approaches and strategies will be pursued for managing these patients
to increase treatment adherence. This is a great need throughout
the region, where alcoholism is a common problem.
-Reported by Charles D. Wells, MD
Division of TB Elimination
Use of a Computerized TB Register for Automated Generation of
Case Finding, Sputum Conversion, and Treatment Outcome Reports
During the 1990s, sub-Saharan Africa experienced an explosive increase
in TB. Public health workers needed tools to strengthen TB surveillance
activities and TB program management in the region. These tools
had to be tailored to and compatible with local circumstances. For
example, many countries follow the International Union Against TB
and Lung Disease/World Health Organization (IUATLD/WHO) guidelines
for TB recording and reporting. These guidelines recommend the generation
of quarterly reports on the incidence of new cases and on treatment
outcomes for cohorts enrolled 9 to 12 months previously. These reports
serve as an important management tool to assess program performance
and to determine future needs and direction. They also form the
basis of ongoing TB surveillance. Manual generation of such reports
is often extremely time-consuming, which may lead to failure to
complete the reports in a timely fashion. Furthermore, the manual
analysis of data, particularly for the cohort analysis, can be subject
Development of the Electronic TB Register
In response to these issues, a user-friendly, menu-driven computer
program based on EpiInfo version 6.04c was developed1.
The Electronic TB Register, initially known as BOTUSA, was created
in 1995 as part of a collaboration between the Ministry of Health
of Botswana and CDC. The program was designed with three important
principles in mind: 1) it should be capable of generating the standard
case-finding and cohort analysis reports recommended by IUATLD/WHO
guidelines; 2) it should include additional tools for TB program management
and support at the district level (e.g., lists of patients for whom
2-month sputum specimens had not yet been obtained); and 3) it should
be simple and highly user-friendly.
The software was implemented in Botswana in 1995 after training was
provided to the 22 District TB Coordinators, none of whom had previously
had any computer experience. The software was installed on existing
computers in each of the district health offices and, by 1996, was
completely operational in all districts. Use of the software completely
replaced manual compilation at the district level, with each District
TB Coordinator entering the data, maintaining an ongoing electronic
database, and producing district case-finding and cohort analysis
reports. By 1997, data from the districts were being merged at national
level to create a national database and produce national reports;
the software was considered an integral part of the Botswana National
TB Program. Subsequently, the software has been implemented in two
of the nine provinces of South Africa, Lesotho, and three of the 12
districts of Namibia, with plans to extend to an additional two South
African provinces and to Malawi, Tanzania, and Swaziland in the near
Botswana's TB register
In Botswana, the TB register is maintained on paper in a log book
at the facility level, with manual data entry. The TB coordinators
visit all health facilities in their district at regular intervals
to provide program support and supervision, ideally monthly but, at
a minimum, quarterly. During these visits, they review the registers
for accuracy and completeness and hand-copy the information into their
own district registers. Records for patients under treatment are updated
with any new information.
At the district level, the TB coordinators enter information into
the computer as it becomes available from the health facility visits.
At this point, they are expected to have completed and validated
the quality of the data at the end of each quarter so that the quarterly
report and cohort analyses can be performed. In addition to generating
paper reports for district-level management purposes, they send
the data to the national level. The data are expected to arrive
within 1 month of the closing of the quarter, although in reality,
substantial delays may occur.
At national level, the data from the district level are merged
into the national data base as they become available. The data for
each district are examined for quality and completeness. Feedback
is given to the districts, and corrections are requested. Only when
the data from all the districts are available and considered to
be of adequate quality is the final analysis performed. An annual
report is published using the cumulative data for all four cohorts
in the calendar year.
South Africa's TB register
In South Africa, the system functions at the provincial level.
The TB register at the health facility level is based on a four-page
form with autocarbons, with each page a different color. At the
end of the first quarter, the first sheet is detached and sent to
the District TB Coordinator, who enters the data. At the end of
the second quarter, the second page, which contains information
on sputum conversion, is detached and sent to the coordinator for
ongoing data entry. The third page is sent in 9 to 12 months after
the beginning of treatment and contains the treatment outcome data.
The fourth sheet remains in the facility as part of its permanent
register. This recently implemented system differs from the previous
one, in which each facility was responsible for producing aggregate
quarterly and cohort reports. As in Botswana, data are examined
for completeness, entered, and analyzed at district level. They
are then sent to the provincial level, where the combined data are
examined and analyzed. The aggregate hard-copy reports at the provincial
level are then sent to the national level for inclusion in the national
Image 2: Training class for TB Coordinators in South Africa in
the use of the Electronic TB Register.
The Electronic TB Register has a number of patient management and
supervision functions. These include the ability to generate facility-specific
lists of patients who are active or sputum-smear positive and those
who have died, defaulted, transferred out, or not converted their
sputum. In addition, it can provide lists of potential duplicate
patient entries and also permits the TB coordinators to identify
whether patients who have transferred out were followed up in their
As a result of the Botswana experience, a number of important lessons
were learned. Some of these lessons have resulted in further software
enhancements, improved initial orientation for district medical
staff, and modifications in training methods. The process of implementation,
however, also highlighted underlying problems in the paper-based
TB data collection system, which were subsequently addressed.
In Botswana, acceptance by the District TB Coordinators was generally
high, though considerable support was required early in the implementation
process to prevent frustration. Acceptance by the Senior District
Medical Officers was initially more variable, with some reluctant
to allow the District TB Coordinators, who are under their direct
supervision, to use the district computer. This was remedied by
providing demonstrations of the software to the Senior District
Medical Officers, who readily acknowledged and accepted its value
as a management tool in their jobs. In other countries where the
software has been implemented, great efforts are now made to provide
orientation to the supervisory medical officers as well as to health
information systems staff at both district and central levels.
A second important problem was lack of uniformity in the computer
equipment in the various districts, making it highly difficult for
the central TB unit to provide adequate technical guidance and support.
In 1997, an international donor provided all the district health
offices in Botswana with updated computers and printers, which has
greatly improved the performance of the system.
The need for ongoing training emerged as an important issue in
the effective implementation of the software. Although the system
was highly user-friendly, a single training session was insufficient.
Three training sessions, held several months apart, were conducted,
allowing the users to learn from their experience and ask additional
Although the accuracy and completeness of the register improved
after implementation of the software, timeliness of reporting to
the central TB unit did not improve. The delay appears to be due
largely to the inability of the District TB Coordinators to visit
the individual health facilities on a regular basis to collect information
from the facility-based registers.
Another important lesson has been the need for specifically dedicated
central-level staff to provide training and support for the District
TB Coordinators, validate the data coming in from the districts,
and make minor modifications in the software to serve local needs.
A final but extremely important lesson has been that the software
is only a tool for the compilation and analysis of data at the district
level. Improper recording of data in the paper-based register and
failure to transmit information to the district level result in
poor reporting. For example, in Botswana a validation study of data
on diagnostic sputum smears showed that 60% of patients recorded
as having missing smear results actually had sputum collected and
analyzed in the laboratory2. The vast majority of missing
results had simply not been transcribed onto the patients' treatment
card and thus were not in the register. Computerization can only
succeed when adequate paper-based recording systems are in place
at the facility level and where data are routinely compiled and
evaluated for completeness and accuracy at the district level.
The Electronic TB Register has proven to be an acceptable and powerful
tool for TB surveillance and program management in the five sites
where it has been implemented. It functions well at the national
level in Botswana, a country with 1.6 million people and 8000 TB
cases annually; to date it is functioning well in two provinces
of South Africa, the largest of which has more than 16,000 cases
annually. Its feasibility in countries with several hundred thousand
TB cases annually has not been evaluated, although theoretically
it should be able to handle very large numbers of cases if computer
memory is adequate.
-Reported by Peter Vranken
The BOTUSA Project
- Dean AG, Dean JA, Coulombier D, Brendel KA, Smith DC, Burton
AH, Dicker RC, Sullivan K, Fagan RF, Arner TG. Epi Info, Version
6: A Word Processing, Database, and Statistics Program for Epidemiology
on Microcomputers. Centers for Disease Control and Prevention,
Atlanta, Georgia, 1994.
- Alpers A, Chrouser K, Halabi S. et al. Validation of the surveillance
system for tuberculosis in Botswana. Int J Tuberc Lung Dis