Success and failure in TB surveillance in Hungary Dr. J. Mester, Dr. I. Vadász, Dr. D. Kozma Korányi Natl. Inst. TB and Pulmonology, Budapest, Hungary Tuberculosis Surveillance Centre

New TB cases in Hungary (1950-2001)

Trend of TB incidence in Hungary

Tuberculosis notification rates in Hungary 2002 Czech Republic 15.9 Tuberculosis notification rates in Hungary 2002 Slovakia 22.6 Ukraine 64.9 30.4 43.4 24.9 Austria 14.7 27.9 33.7 Budapest 24.8 38.7 39.1 28.4 Romania 119.9 14.5 33.3 14.7 24.5 16.3 21.4 Slovenia 22.0 29.3 Rate per 100,000 inhabitants 24.6 15.2 22.4 < 20 19.9 20-25 Yugoslavia 28.4 Croatia 39.5 25-35 35-45 > 45

TB incidence by age groups and sex in Hungary, 2002

Risk factors of new TB cases, 2002

Proportion of DST (1999-2001) 67% 65% 35% Not representative!

Initial drug-resistance in 2002 Previously Drug sensitivity test done Resistant to any drugs INH resistant MDR INH+RMPresistant Not treated 678 (70%) 87 (13%) 52 (8%) 13 (2%) Treated 123 (54%) 31 (25%) 20 (16%) 8 (7%) All cases 801 (68%) 118 (15%) 72 (9%) 21 (3%)

Case detection rate in Hungary, 2002 % Estimated real incidence Total notification 3007 100 2684 Bact. confirmed 1254 37 1556 58 Bact. not confirmed 1762 63 1128 42 Case detection rate of bact. conf. cases: 80% Bact. not confirmed cases: 63% (1762) 36% of them is overdiagnosed (643) Real incidence of bact. not confirmed cases: 41% (1128)

Notified afterwards 201 (49%) cases Drug sensitivity tests done in 1197 cases Of them 413 (34%) were not notified by the National TB Surveillance Center (NTSC)  Notified afterwards 201 (49%) cases  No information about 212 (17%) cases

Treatment Outcome Monitoring for Pulmonary Smear-Positive cases, 2001 New Retreated n=584 n=136 Cured 188 (32%) 29(21%) Completed 83 (14%) 14(10%) Died 96 22 Failed 66 33 Defaulted 38 8 Still on treatment 106 (18%) 25(18%) Transferred out 0 0 Unknown 6 5

Treatment Outcome Monitoring for Pulmonary Culture Positive cases, 2001 New Retreated n=810 n=185 Cured 299 (37%) 54 (30%) Completed 135 (16%) 24 (13%) Died 113 24 Failed 77 43 Defaulted 56 11 Still on treatment 125 (15%) 25 (13%) Transferred out 0 0 Unknown 5 4

Initial treatment of pulmonary TB cases in 2002 Smear and culture positive cases Only culture positive cases Bacteriologically not confirmed cases 3 drugs 165 (25%) 175 (36%) 1240 (74%) 4 or more drugs 432 (67%) 200 (41%) 312 (19%)

Outstanding analytical problems High proportion of bacteriologically not confirmed cases (~60%) Possible reasons: Overdiagnosis/misdiagnosis of TB Deficiency in bacteriologic diagnosis

Outstanding analytical problems 1. Békés county: Proportion of bacteriologically not confirmed cases was 80% After individual supervision of cases, 36% of them proved overdiagnosed („inactive” TB) or misdiagnosed (i.e. cancer)

Outstanding analytical problems 2. Number of notified cases in 2002: 3007 Bact. not confirmed: 1882 (63%) Culture negative: 1329 (70%) Culture not done: 553 (30%) Unsatisfactory communication among TB labs-hospitals-chest clinincs  bact. results sometimes disappear Modification of flow of informationTB labs will inform the NTSC NTSC conveys the results to the proper institution

Conclusion To improve the quality of TB control it is necessary To increase the proportion of bacteriologically confirmed cases To diminish the proportion of previously treated cases To increase the proportion of initial drug sensitivity tests To adjust the treatment to national and international guidelines To modify information flow