Progress%20of%20the%20Singapore%20TB%20Elimination%20Programme%20(STEP)

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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

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Singapore

• Population 4.35 million
• Resident population 3.55 million 75 Chinese,
  14 Malay, 8 Indian

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TB in Singapore Residents1960-1997
1997 1,712 new cases Incidence rate 55 /
100,000
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TB incidence rates (new cases) among residents by
age and sex1999
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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

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Singapore - 1997

• HIV incidence 55 per million population
• Primary INH resistance lt 4
• Primary MDRTB resistance lt 0.5

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STEP Components

• Epidemiological component STEP Surveillance
  System
• Clinical component TB Control Unit, TTSH
• National referral centre for the management of TB
  patients, contact investigation and preventive
  treatment

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Key STEP Initiatives

• Nation-wide treatment surveillance module
• Directly Observed Therapy (DOT)
• Nation-wide policy of preventive therapy for
  infected close contacts

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TB NOTIFICATION SYSTEM
Tuberculosis Control Unit (TTSH)
TB Labs of Singapore General Hospital National
University Hospital
Restructured Hospitals
STEP Registry, Ministry of Health
Private Practitioners
Clinical Laboratories
Registry of Births Deaths
Singapore Anti-tuberculosis Association
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TB Notification and Treatment Centres
Treatment Centres
Notification Centres
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THE STEP SURVEILLLANCE SYSTEM
Treatment Surveillance Module
Notified case
Final Outcome
Infectious case
Active TB
Contact Investigation
Contact Uninfected
Discharged
Contact with LTBI advised INH Preventive Therapy
If declined
Advised on TB symptoms
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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 patients treatment
  progress and to provide national data on
  treatment outcome

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TB Treatment OutcomeSingapore Residents,
2001-2004
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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

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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

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Proportion of TB cases on DOT TBCU and
National1998-2006
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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

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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

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Preventive Therapy for contacts with LTBI

• Contacts with TST gt 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

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Contact Programme Performance2000-2004
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Incidence rate of All Notified TB and Pulmonary
TB Singapore Residents (New Cases)1991 - 2006
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TB Incidence Rate in Singapore Residents 1960
-2006
2006 1,256 new cases
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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
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Incidence of HIV infection in Singapore 1985-2005
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Number of TB notifications (New cases) By
Residential Status1998 - 2005
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Drug Resistance in Residents with pTB(New
cases)1998 - 2006