First Ethiopian National Population Based Tuberculosis Prevalence Survey July 2011 Addis Ababa CONTENTS List Figures .......................................................................................II List of Tables ................................................................................... III Acronyms ...........................................................................................IV Acknowledgments ............................................................................V Executive Summary ..........................................................................VIII 1. Introduction ........................................................................1 2. TB Prevalence Survey: rationale and objectives .................9 3. Survey organization ............................................................11 4. Training ...............................................................................15 5. Methodology .......................................................................17 6. Case definitions ..................................................................27 7. Data management and analysis ..........................................29 8. Monitoring and evaluation ...................................................31 9. Results ................................................................................33 10. Discussion ..........................................................................59 11. Programme implications ......................................................65 12. Limitations of the study .................................................... 66 13. References ..........................................................................67 14. Annexes ..............................................................................69 First Ethiopian National Population I Based Tuberculosis Prevalence Survey LIST OF FIGURES Figure 1: Trend of WHO SS+ TB Estimate versus Case Detection Rate (CDR) in Ethiopia-FMoH 1999/00-2009/10 (1992-2002EC) ............ 7 Figure 2: Organizational structure of survey team .................................. 12 Figure 3: Screening Arrangement at Survey Camp Site ........................... 23 Figure 4: Method of Screening ............................................................... 25 Figure 5: Survey Data flow ..................................................................... 30 Figure 6: Comparison of national population with survey population ........................................................................... 34 Figure 7: Summary of census and screening result ................................ 56 First Ethiopian National Population Based Tuberculosis Prevalence Survey II LIST OF TABLES Table 1: Total New TB Cases notified in 2009/10, 14 years old and younger ....................................................................... 5 Table 2: Overview of classifications according to culture and AFB-smear positive results ...................................................... 28 Table 3: Survey census population by sex, age group, place of residence, and eligibility for study ........................................ 34 Table 4: Participation rates .................................................................... 36 Table 5: Occupational status of participants .......................................... 36 Table 6: TB contact history by sex ......................................................... 37 Table 7: Current anti-TB treatment history by sex and residence .......... 37 Table 8: Place of treatment for participants currently on anti-TB treatment ..................................................................... 39 Table 9: Place where previously received TB treatment ......................... 41 Table 10: TB symptom screening outcome ........................................... 42 Table 11: Characteristics of respondents with cough for more than 14 days ................................................................. 43 Table 12: CXR field screening results .................................................... 45 Table 13: Comparison of field and central CXR readings ....................... 46 Table 14: Summary results of the screening: Reasons of eligible for sputum examinations ........................................... 47 Table 15: Screening and CXR results and sputum examinations ........... 49 Table 16: Smear examination results ..................................................... 51 Table 17: Relationship between morning and spot smear ..................... 52 Table 18: Relationship between smear and culture Result ..................... 52 Table 19: Medical Panel review of study cases ...................................... 54 Table 20: Number of prevalent cases (study cases) by interview and CXR results ...................................................... 55 Table 21: Different methods of calculation of Prevalence of TB among age >15 Years ....................................................... 58 Table 22: Survey Budget ........................................................................ 69 Table 23: Source of Funding ................................................................... 69 Table 24: Participant flow, code and number of individuals in each step ........................................................................... 70 Table 25: Prevalence of bacteriologically confirmed pulmonary TB (per 100 000 population) .......................................................... 73 Table 26: Prevalence of smear positive pulmonary TB (per 100 000 population) ............................................................................... 74 Table 27: Prevalence of smear positive results (per 100 000 population) .............................................................................. 74 First Ethiopian National Population III Based Tuberculosis Prevalence Survey ACRONYMS ACSM Advocacy Communication and Social Mobilization AFB Acid Fast Bacilli CXR Chest X-ray CSA Central Statistics Authority DOTS Directly Observed Therapy, Short-course EHNRI Ethiopian Health and Nutrition Research Institute FMOH Federal Ministry of Health HIV Human immunodeficiency virus IPT Isoniazid Preventive Therapy ISN Individual Survey Number IUATLD International Union Against TB and Lung Disease LJ Lowenstein-Jensen MDG Millennium Development Goals MDR TB Multi Drug Resistant Tuberculosis MTB Mycobacterium Tuberculosis NTP National TB Programme PI Principal Investigator PPS Population Proportion to Size SC Steering Committee SCT Survey Coordinating Team TAG Technical Advisory Group TB Tuberculosis WHO World Health Organization ZN Ziehl Neelsen SOPs Standard Operating Procedures First Ethiopian National Population Based Tuberculosis Prevalence Survey IV ACKNOWLEDGMENTS This study was implemented by the Ethiopian Health and Nutrition Research Institute in collaboration with The Federal Ministry of Health of Ethiopia and with the technical support from the World Health Organization. In addition, the following organizations have supported the study in various ways: Global Fund, TBCARE Ethiopia, USAID Ethiopia, GLRA Ethiopia, and Italian Cooperation. First Ethiopian National Population V Based Tuberculosis Prevalence Survey MESSAGE FROM H.E, Dr Kesetebirhan Admasu State Minister, FMOH As Ethiopia is one of the 22 Highest TB burden countries in the world, Federal Ministry of Health of Ethiopia is implementing TB Prevention and control program at all level of the health facility. The implementation of TB prevention and control interventions is guided by the five year TB Strategic plan, prepared in line with the HSDP IV and the STOP TB Strategies. In the last 10 years much effort had been made to control and prevent TB throughout the country. The recent scale up of community TB Care by health extension workers ensured access of DOTS at grass root level in the community. However compared to the previous estimation of TB burden for the country, the program achieved TB case detection rate less than 36% which is much lower than the minimum target (70%). The steady progress in case detection rate raised a question whether the previous estimate was reliable or not. As a result Federal ministry of Health in collaboration with the Ethiopian Health and Nutrition Research Institute conducted the first Ethiopian National TB prevalence survey, which is the first in its kind in the country and also in Africa. Since reliable baseline information is essential for TB control program, the findings of this survey will be of great importance for the overall management of the National TB control Program particularly for planning, policy and decision making. In addition the findings will assist the national TB control program in guiding the efforts of the government and partners towards reaching the millennium Development goal not only national but also regionally and globally. Therefore it is my great pleasure to recommend using this survey finding for planning and decision making of TB prevention and control activity in Ethiopia. First Ethiopian National Population Based Tuberculosis Prevalence Survey VI MESSAGE FROM Dr Amha Kebede, Director General, EHNRI As TB prevalence is one of the indicators of MDGs and the Global Stop TB Plan, the Ethiopian Ministry of Health and the Ethiopian Health and Nutrition Research Institute, EHNRI have conducted this population based National TB Prevalence Survey. The Ethiopian Ministry of Health, which stresses the importance of research for health development, delegated its health research arm, EHNRI to undertake