Delays in health seeking, diagnosis and treatment for tuberculosis patients in Mongolia: an analysis of surveillance data, 2018–2021

@#Early diagnosis and treatment of infectious tuberculosis (TB) is essential to the attainment of global targets specified in the End TB Strategy. Using case-based TB surveillance data, we analysed delays in health seeking, diagnosis and treatment among TB patients in Mongolia from 2018 to 2021. We calculated the median and interquartile range (IQR) for “diagnostic delay”, defined as the time from symptom onset to diagnosis, subdivided into “health-seeking delay” (time from symptom onset to first visit to a health facility) and “health facility diagnostic delay” (time from first health facility visit to diagnosis), and for “treatment delay”, defined as the time from diagnosis to start of treatment. We also calculated “total delay”, defined as the time from symptom onset to treatment start. Based on data for 13 968 registered TB patients, the median total delay was estimated to be 37 days (IQR, 19–76). This was mostly due to health-seeking delay (median, 23 days; IQR, 8–53); in contrast, health facility diagnostic delay and treatment delay were relatively short (median, 1 day; IQR, 0–7; median, 1 day; IQR, 0–7, respectively). In 2021, health-seeking delay did not differ significantly between men and women but was shorter in children than in adults and shorter in clinically diagnosed than in bacteriologically confirmed TB cases. Health-seeking delay was longest in the East region (median, 44.5 days; IQR, 20–87) and shortest in Ulaanbaatar (median, 9; IQR, 14–64). TB treatment delay was similar across sexes, age groups and types of TB diagnosis but slightly longer among retreated cases and people living in Ulaanbaatar. Efforts to reduce TB transmission in Mongolia should prioritize decreasing delays in health seeking.

Epidemiology of and programmatic response to tuberculosis in Solomon Islands: analysis of surveillance data, 2016–2022

@#Objective: To identify progress and challenges in the national response to tuberculosis (TB) in Solomon Islands through an epidemiological overview of TB in the country. Methods: A descriptive analysis was conducted using the national TB surveillance data for 2016–2022. Case notifications, testing data, treatment outcomes and screening activities were analysed. Results: The number of case notifications was 343 in 2022, with an average annual reduction of the case notification rate between 2016 and 2022 of 4.7%. The highest case notification rate was reported by Honiara City Council (126/100 000 population) in 2022. The number of people with presumptive TB tested by Xpert® rapidly increased from zero in 2016 to 870 in 2022. Treatment success rate remained consistently high between 2016 and 2022, ranging from 92% to 96%. Screening for HIV and diabetes mellitus (DM) among TB patients in 2022 was 14% and 38%, respectively. Most patients (97%) were hospitalized during the intensive phase of treatment in 2022; in contrast, during the continuation phase, the proportion of patients treated at the community level increased from 1% in 2016 to 63% in 2022. Despite an increase in household contact investigations, from 381 in 2016 to 707 in 2021, the uptake of TB preventive treatment (TPT) was minimal (7% among eligible child contacts). Discussion: This epidemiological analysis in Solomon Islands reveals both notable achievements and challenges in the country’s TB programme. One major achievement is a potential actual reduction in TB incidence. Challenges identified were potential underdetection of cases in rural areas, suboptimal community-based care, and insufficient contact tracing and uptake of TPT. It is crucial to address these challenges (e.g. by optimizing resources) to advance the national TB response.

Epidemiology of tuberculosis in the Pacific island countries and areas, 2000–2020

@#Objective: Tuberculosis (TB) is one of the most important infectious diseases with an estimated 9.9 million people falling ill globally in 2020. We describe the epidemiology of TB in the Pacific island countries and areas (PICs) to inform potential priority actions to implement the Western Pacific Regional Framework to End TB 2021–2030. Methods: A descriptive analysis was conducted using annual TB surveillance data submitted by national TB programmes to the World Health Organization (WHO) and TB burden estimates (incidence rates and number of deaths) generated by WHO for the PICs, for the period 2000–2020. We also analysed TB case numbers, multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB), recent risk factor indicators and treatment outcomes. Results: The estimated TB incidence rate in the PICs increased between 2000 and 2020 from 62 to 69 per 100 000 population, with an 8% reduction observed since 2015. TB cases increased by 29% during 2000–2020, with 1746 cases in 2020 and a high proportion in children (19%). Bacteriological diagnosis was used for 58% of total TB cases, although some countries reported clinical diagnoses in over 60% of cases. From 2015 to 2019, 52 MDR/RR-TB cases were reported and there were 94 TB/HIV coinfected cases in 2015–2020. Treatment success was 74% in 2019 due to 18% of cases being unevaluated. In 2020, the estimated proportion of TB cases attributable to smoking, malnutrition, alcohol abuse and diabetes was 17%, 16%, 11% and 9%, respectively. Discussion: There was an increasing trend in TB cases, estimated incidence and deaths between 2000 and 2020. Laboratory services were scaled up in some PICs and case-finding activities greatly contributed to the detection of cases. In order to end the incidence of TB, continued efforts on case finding, contact investigation and scaling up TB preventive treatment should be prioritized. At the same time, collaboration with other sectors for risk factor management and decentralized management need to be considered.

Epidemiology of tuberculosis in Mongolia: analysis of surveillance data, 2015–2019

@#Mongolia has a high tuberculosis (TB) burden. Data from routine paper-based surveillance were used to describe the epidemiology of TB in Mongolia; the data included testing presumptive TB cases, TB notifications, drug-resistant cases, treatment outcomes and notifications in prisoners. The proportion of the population tested for TB increased between 2015 and 2019. The number and rate per 100 000 population of TB notifications decreased between 2015 and 2018 and then increased in 2019. Most TB notifications in 2019 were in the capital, Ulaanbaatar (59.3%), followed by the central (16.8%), Khangai (10.4%), east (8.5%) and west (5.0%) regions. About half of TB notifications nationally were bacteriologically confirmed (45.4% in 2015, 48.1% in 2019), with the proportion of bacteriologically confirmed TB per province or district varying from 0% to 66%. High TB notification rates were observed in 2019 for males aged 15–54 years (202 per 100 000 population) and females aged 15–34 years (190 per 100 000 population). Treatment success for all forms of TB was 90% in 2019 but was below the 90% target for bacteriologically confirmed cases. Between 2015 and 2019, the number of RR/MDR-TB notifications ranged from 265 to 211. The Mongolian National Tuberculosis Programme needs to continue its efforts in TB control, to further increase the programmatic impact and reduce the TB burden. It is recommended that Mongolia continue to increase TB screening, the use of Xpert testing, contact investigations and preventive treatments, and targeting interventions to the high-burden areas identified in this subnational analysis.

Financing for tuberculosis prevention, diagnosis and treatment services in the Western Pacific Region in 2005–2020

@#Objective: This paper provides an overview of financing for tuberculosis (TB) prevention, diagnostic and treatment services in the World Health Organization (WHO) Western Pacific Region during 2005–2020. Methods: This analysis uses the WHO global TB finance database to describe TB funding during 2005–2020 in 18 low- and middle-income countries (LMICs) in the Western Pacific Region, with additional country-level data and analysis for seven priority countries: Cambodia, China, the Lao People’s Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam. Results: Funding for the provision of TB prevention, diagnostic and treatment services in the 18 LMICs tripled from US$ 358 million in 2005 to US$ 1061 million in 2020, driven largely by increases in domestic funding, which rose from US$ 325 million to US$ 939 million over the same period. In the seven priority countries, TB investments also tripled, from US$ 340 million in 2005 to US$ 1020 million in 2020. China alone accounted for much of this growth, increasing its financing for TB programmes and services five-fold, from US$ 160 million to US$ 784 million. The latest country forecasts estimate that US$ 3.8 billion will be required to fight TB in the seven priority countries by 2025, which means that unless additional funding is mobilized, the funding gap will increase from US$ 326 million in 2020 to US$ 830 million by 2025. Discussion: Increases in domestic funding over the past 15 years reflect a firm political commitment to ending TB. However, current funding levels do not meet the required needs to finance the national TB strategic plans in the priority countries. An urgent step-up of public financing efforts is required to reduce the burden of TB in the Western Pacific Region.

Progress on diagnosis and treatment of drug-resistant tuberculosis in line with World Health Organization recommendations in six priority countries in the Western Pacific Region

@#Background: Diagnosis and treatment of drug-resistant tuberculosis (DR-TB) have radically changed in accordance with recommendations from the World Health Organization (WHO) in the past decade, allowing rapid and simple diagnosis and shorter treatment duration with new and repurposed drugs. Methods: A descriptive analysis of the status and progress of DR-TB diagnosis and treatment in six priority countries in the Western Pacific Region was conducted using information from interviews with countries and the WHO TB database. Results: Over the past decade, the use of Xpert MTB/RIF has increased in the six priority countries, in parallel with implementation of national policies and algorithms to use Xpert MTB/RIF as an initial diagnostic test for TB and detection of rifampicin resistance. This has resulted in increases in the number of people diagnosed with multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB). Shorter treatment regimens with new and repurposed drugs have also been adopted for MDR/RR-TB cases, alongside a decentralized model of care, leading to improved treatment outcomes. Discussion: The Western Pacific Region has achieved considerable progress in the diagnosis and treatment of DR-TB, in line with the evolving WHO recommendations in the past decade. The continued commitment of Member States is needed to address remaining challenges, such as the impact of the coronavirus disease pandemic, suboptimal management and health system issues.

Tuberculosis outbreaks in schools: Experiences from the Western Pacific Region

@#Reports of tuberculosis (TB) outbreaks among schoolchildren have increased in recent years in countries across the Western Pacific Region. Cases from China, Japan, Mongolia and the Republic of Korea were studied to derive lessons from the challenges and responses to TB outbreaks in schools. Despite differences in the TB burden and outbreak preparedness, the four countries reported similar challenges. These included delayed diagnosis of index cases, lack of experienced health professionals and sustained financial support, and difficulty in responding to intensified media and community attention. Early detection of outbreaks, established resource mobilization networks, coordination among stakeholders and proactive communication were highlights of successful outbreak responses. These principles could be adapted to each context for responses to future TB outbreaks in schools.

Epidemiological review of leprosy in WHO’s Western Pacific Region: 1991–2019

@#Background: Leprosy elimination was achieved in the Western Pacific Region of the World Health Organization (WHO) in the late 1980s. However, cases continue to be reported within the Region. This paper analyses leprosy cases in the Region reported to WHO during 1991–2019. Methods: Descriptive analyses were conducted of data from leprosy surveillance reported in the Region. Key indicators included prevalence, the number and rate of new cases detected, proportions of cases with multibacillary leprosy or grade 2 disability, and the numbers and proportions of cases among children and cases by sex. Results: From 1991 to 2019, the number of registered cases detected in the Region decreased by 94% (from 68 313 in 1991 to 4381 in 2019), and the number of new cases detected decreased by 72.1% (from 15 002 in 1991 to 4004 in 2019). The proportion of cases of multibacillary leprosy increased from 67.4% (8045/11 943) in 1995 to 85.6% (3428/4004) in 2019, and between 1997 and 2019 the number of leprosy cases occurring in children decreased from 1240 to 424. The proportion of new cases with grade 2 disability decreased from 15.4% in 1997 to 6.6% in 2019. With few exceptions, nearly two thirds of reported cases occurred in males. Conclusion: Most countries and areas in the Region have successfully eliminated leprosy, although some pockets remain in countries with hard-to-reach areas. The introduction of multidrug therapy and WHO’s 1991 elimination goals may have prompted the initial decline in leprosy cases. Continued efforts are required in case-finding, care and prevention in areas with a high burden of disease.

Epidemiology of tuberculosis in the Western Pacific Region: Progress towards the 2020 milestones of the End TB Strategy

@#Since 2015, the End TB Strategy and the Regional Framework for Action on Implementation of the End TB Strategy in the Western Pacific 2016–2020 have guided national tuberculosis (TB) responses in countries and areas of the Region. This paper provides an overview of the TB epidemiological situation in the Western Pacific Region and of progress towards the 2020 milestones of the Strategy. A descriptive analysis was conducted of TB surveillance and programme data reported to WHO and estimates of the TB burden generated by WHO for the period 2000–2018. An estimated 1.8 million people developed TB and 90 000 people died from it in the Region in 2018. Since 2015, the estimated TB incidence rate and the estimated number of TB deaths in the Region decreased by 3% and 10%, with annual reduction rates of 1.0% and 3.4%, respectively. With current efforts, the Region is unlikely to achieve the 2020 milestones and other targets of the Strategy. Major challenges include: (1) wide variation in the geographical distribution and rate of TB incidence among countries; (2) a substantial proportion (23%) of TB cases that remain unreached, undiagnosed or unreported; (3) insufficient coverage of drug susceptibility testing (51%) for bacteriologically confirmed cases and limited use of WHO-recommended rapid diagnostics (11 countries reported < 60% coverage); (4) suboptimal treatment outcomes of TB (60% of countries reported < 85% success), of TB/HIV co-infection (79%) and of multidrug- or rifampicin-resistant TB (59%); (5) limited coverage of TB preventive treatment among people living with HIV (39%) and child contacts (12%); and (6) substantial proportions (35–70%) of TB-affected families facing catastrophic costs. For the Region to stay on track to achieve the End TB Strategy targets, an accelerated multisectoral response to TB is required in every country.

Intensified research on tuberculosis in the Western Pacific Region: a bibliometric analysis, 2000-2019

@#“Intensified TB research and innovation” is one of the three pillars of the End TB Strategy. To assess achievements and gaps in tuberculosis (TB) research productivity in countries and areas of the Western Pacific Region quantitatively, a bibliometric analysis was carried out by examining trends in the numbers of publications on TB indexed in PubMed between 2000 and 2019 and by comparing them with trends in publications on other selected major infectious diseases for the same period. The number of publications on TB in the Region increased by 3.2 times during the period, from 534 in 2000–2004 to 1714 in 2015–2019, as compared with 2.9 times each for HIV, hepatitis and malaria. The number increased by 46% in 2005–2009, 79% in 2010–2014 and 23% in 2015–2019, as compared with each previous 5-year period. The average annual growth rate between 2000 and 2018 was 8.8%. China accounted for 34.8% of the total number of publications on TB in the Region. Increases in TB research were observed in most countries and areas in the Region, particularly in those with a high TB burden. The number of publications on TB remained low, however, in the Lao People’s Democratic Republic, Mongolia and Pacific island countries. Countries are encouraged to implement the set of actions proposed in the Global Strategy for TB Research and Innovation to accelerate progress towards ending TB.

Epidemiology of tuberculosis in Papua New Guinea: analysis of case notification and treatment-outcome data, 2008–2016

@#Papua New Guinea has strengthened its surveillance system for tuberculosis (TB) under the National TB Program. This paper provides an overview of TB surveillance data at the national and subnational levels from 2008 to 2016. TB case notification has consistently increased since 2008 with 6184 cases (93 per 100 000 population) in 2008 to 28 598 (359 per 100 000 population) in 2014 and has stabilized since 2014 with 28 244 cases (333 per 100 000 population) in 2016. The population-screening rate for TB rose from 0.1% in 2008 to 0.4% in 2016. Notified cases were dominated by extra-pulmonary TB (EP-TB, 42.4% of all cases in 2016). The proportion of pulmonary TB cases with no sputum test results was high with a national average of 26.6%. The regional variation of case notifications was significant: the Southern Region had the highest number and rate of notified TB cases. Of the nationally reported cases, 26.7% occurred in children. Treatment success rates remained low at 73% for bacteriologically confirmed TB and 64% for all forms of TB in 2016, far below the global target of 90%. For all forms of TB, 19% of patients were lost to follow-up from treatment. An analysis of TB data from the national surveillance system has highlighted critical areas for improvement. A low population-screening rate, a high proportion of pulmonary TB cases without sputum test results and a low treatment success rate suggest areas for improvement in the National TB Program. Our additional subnational analysis helps identify geographical and programmatic areas that need strengthening and should be further promoted to guide the programme’s direction in Papua New Guinea.

Tuberculosis case-finding in Cambodia: analysis of case notification data, 2000 to 2013

The routine tuberculosis (TB) surveillance system in Cambodia has been strengthened under the National TB Programme (NTP). This paper provides an overview of the TB surveillance data for Cambodia at the national level for the period 2000 to 2013 and at the subnational level for 2013. The proportion of the total population that were screened for TB rose from 0.4% in 2001 to 1.1% in 2013, while the smear-positivity rate decreased from 28.9% to 8.1% in the same period. The total number of notified TB cases increased steadily from 2000; this has stabilized in recent years with 39 055 cases notified in 2013. The proportion of all TB cases that were smear-positive decreased from 78% in 2000 to 36% in 2013. Case notification rates (CNRs) for all forms of TB and new smear-positive TB in 2013 were 261 and 94 per 100 000 population, respectively. Higher CNRs were found in the north-west and south-east parts of the country and were higher for males especially in older age groups. The increase in TB screening, decline in the smear-positive rate and decline in notified smear-positive TB cases likely reflect a long-term positive impact of the NTP. A negative correlation between the proportion of the population screened and the smear-positivity rate at the subnational level helped identify where to find undiagnosed cases. Subnational differences in case notification of the elderly and in children provide more specific targets for case-finding and further encourage strategic resource allocation.