Statistical Analysis of TUBERCULOSIS Data

PROJECT REPORT

Submitted in the summer research program of the INSPIRE Scholarship for higher education

Session: May2013-July2013

Supervisor Submitted by

Dr. Sanjeev Kumar Abhigyan Pandey

Assistant Professor B.Sc.(Hons.) iv Sem.

Dept. of statistics, faculty of science faculty of science

Banaras Hindu University, Varanasi Banaras Hindu University, Varanasi

INSPIRE SHE Reg. no.-4053/2011

CERTIFICATEThis is to certify that the project report entitled as “ Statistical analysis of Tuberculosis data” has been successfully conducted and completed under my supervision and guidance.

The data used in this project report was collected, analyzed and submitted by Abhigyan Pandey. B.Sc.(Hons.) IV sem. During the session 11 May 2013-10 July 2013.

Dated: Dr. Sanjeev Kumar

Assistant Professor

Dept. of Statistics

Banaras Hindu University

Varanasi-221005

ACKNOWLEDGEMENT

On the very outset of this report, I would like to extend my sincere and heartfelt obligation towards all the personages who have helped me in this endeavor. Without their active guidance, help, cooperation and encouragement I would not have made headway in the project.

Especially, I take this opportunity to express my profound gratitude and deep regards to my supervisor Dr. Sanjeev Kumar for his exemplary guidance, monitoring and constant encouragement throughout the course of this project work. The blessing help and guidance given by him time to time shall carry me a long way in the journey of life on which I am about to embark .

I extend my gratitude to Dept. of STATISTICS, BANARAS HINDU UNIVERSITY and INSPIRE SHE Scheme for giving me this opportunity.

Lastly, I thank almighty, my parents, brother, sister and friends for their constant encouragement without which this project work would not be possible.

Dated: Abhigyan Pandey

B.Sc.(Hons.) IV-sem.

Faculty of science, BHU

Varanasi-221005

CONTENTS:1. Introduction

2. Global TB disease burden

2.1 Tables

2.2 Graphs

2.3 Interpretations

3. India TB disease burden

3.1 Tables

3.2 Graphs

3.3 Interpretations

4. TB-HIV Co infection

5. Conclusion

6. References & Abbreviations

IntroductionTuberculosis, or in short TB, is caused by the bacterium Mycobacterium tuberculosis, which can be present as either latent infection or active disease. Latent TB infection means that TB bacteria are living in the body but not causing any symptoms. People with latent TB infection are not sick, do not have symptoms, and cannot spread the disease. TB disease means that the bacteria are multiplying and are destroying body tissues, if not diagnosed and treated properly, it can be fatal. People with TB disease are sick do have symptoms, and can spread the disease. Only TB disease is infectious latent TB infection is not. TB disease of the lungs or airways can be spread from person to person through the air when a person with TB disease coughs, sneezes, speaks.

TB infection can be detected by a skin test or a blood test, if the test is positive, additional tests such as sputum tests and x-rays are needed to determine whether the infection has progressed to TB disease.

The symptoms of active TB of the lung are coughing, sometimes with sputum or blood, chest pains, weakness, weight loss fever and night sweats. Tuberculosis is treatable with a six-month course of antibiotics. The drugs that are taken for the treatment of TB, have the aim of killing all the TB bacteria in the person’s body. However, TB bacteria die very slowly, and so the drugs have to be taken for quite a few months. Even when a patients starts to feel better they can still have bacteria alive in their body, and so the person needs to keep taking the medicine until all the bacteria are dead. All the drugs must be taken for the entire period of treatment. If only one or two drugs are taken then the bacteria may not all be killed and they can become resistant to the drugs which then don’t work. If the person becomes sick again then different drugs may be needed.

TB Treatments the aims:-

The aims of TB treatments are-

To cure the patients and restore quality of life and productivity. To prevent relapse of TB. To reduce the transmission of TB to others. To prevent the development and transmission of drug resistant TB.

Relapse, failure and recurrence:-A patient is said to relapse if they improve whilst on TB treatment, but become ill again after finishing their TB treatment. Patients who experience only a transient improvement whilst on TB drug treatment, or who never respond to treatment, are said to have failed their TB treatment.Recurrence of active TB is usually used to refer to the situation when a person’s first TB treatment appears to have been successful, and there has then been a significant time interval before active develops again. This may either be because of reactivation of the person’shave been reinfected. In any of these situations it must be considered a real possibility that the person has drug resistant TB and their TB drug treatment program must be decided taking this into account.

Tabulation and analysis of Global TB burden

Tables Graphs and charts Interpretations

Global TB disease burdenAs per the WHO Global TB Report2011, there were an estimated 8.8 million incident cases of TB(range,8.5million-9.2million) among HIV-negative cases of TB and an additional 0.35 million deaths(range,0.32million-0.39million) among people who were HIV positive in 2009, there were an estimated 9.7million(range,8.5-11million) children who were orphans as a result of parental deaths caused by Tuberculosis.Globally,the absolute number of incident TB cases per year has been falling since 2006 and the incidence rate(per 1000000 population) has been falling by 1.3%per year since 2002. If these trends are sustained, the MDG target that TB incidence should be falling by 2015 will be achieved.

Pie diagram1:-

The following pie diagram shows the incidence of TB patients throughout the world continents wise-

2300000

260000660000

380000

3500000

1700000

Incidence of TB

AfricaAmericasEastern MediterraneanEuropeAsiaWestern pacific

Table1:-The following table shows the total number of incidence and deaths cases due to TB in various continents.

Continents Deaths due to TB Incidence of TB

Africa 220000 2300000

Americas 21000 260000Eastern

Mediterranean 99000 660000

Europe 45000 380000

Asia 480000 3500000

Western pacific 130000 1700000

Source- "Global Tuberculosis Control 2012, WHO, Geneva

Bar Diagram1:-

The bar diagram1 shows the deaths and incidence of TB patients in various continents.

Africa

Americas

Eastern Mediterranean

Europe

Asia

Western pacific

0 1000000 2000000 3000000 4000000

Incidence of TBDeaths due to TB

Interpretations of TB incidence and deaths in continents:-

There are 35,00,000 estimated incidence cases of TB in Asia which is highest as compared to other continents.

There are 2300000 estimated incidence cases of TB in Africa.

American continents are in good condition.

Europe and other continents are in satisfactory condition.

In Asia India has the maximum number of TB patients, whereas China is the second.

Medical facilities in Asia are in very poor condition almost 48% deaths in Asia out of incidence cases.

TB Statistics for high burden countries:-

Of all the countries that report their TB statistics to WHO. There are 20 countries that are sometimes referred to as the TB “high burden” countries, and they have been prioritized at a global level since 2000. There are 20 of these countries and between them they accounted for 81% of all estimated cases of TB worldwide in 2011.

Table2:- Data for high burden countries

Country Incidence Deaths Population

Afghanistan 61000 13000 32,358,000Bangladesh 340,000 68000 150,494,000Brazil 83,000 5600 196,655,000Cambodia 61,000 9100 14,305,000China 1,000,000 47000 1,347,565,000DR Congo 220,000 36000 67,758,000Ethiopia 220,000 15000 84,734,000India 2,200,000 300000 1,241,492,000Mozambique 130,000 11000 23,930,000Myanmar 180,000 23000 48,337,000Nigeria 190,000 27000 162,471,000Pakistan 410,000 59000 176,745,000Philippines 260,000 28000 94,852,000Russian Federation 140,000 22000 142,836,000South Africa 500,000 25000 50,460,000Thailand 86,000 9800 69,519,000Uganda 67,000 5000 34,509,000UR Tanzania 78,000 6400 46,218,000Viet Nam 180,000 38000 88,792,000Zimbabwe 77,000 6000 12,574,000

Source:- "Global Tuberculosis Control 2012”, WHO, Geneva

Bar Diagram2:-

The following bar diagram shows the fraction of died people over incidence TB cases in high burden countries in year 2011.

Afghan

istan

Bangla

desh Brazil

Cambodia

China

DR Congo

Ethiopia

India

Mozambique

Myanmar

Nigeria

Pakista

n

Philippines

Russian

Federa

tion

South Afri

ca

Thaila

nd

Uganda

UR Tanzan

ia

Viet Nam

Zimbab

we0

0.05

0.1

0.15

0.2

0.25

Fraction of death over incidence TB cases

Interpretations of bar diagram2:-

In high burden countries Afghanistan has highest fraction of deaths over incidence TB cases due to poor medical facilities and insufficient supports from the governments.

China has the largest proportion of population but fraction for deaths over incidence TB cases is very less because TB control has been a part of China’s public health program since the 1950s.

Vietnam, Russian federation, India and Pakistan are also have high fraction of deaths over incidence TB cases.

Bar Diagram3:

The following bar diagram shows the proportion of incidence TB case and proportion of deaths in high burden countries in year 2011.

Afghanistan

Bangladesh

Brazil

Cambodia

China

DR Congo

Ethiopia

India

Mozambique

Myanmar

Nigeria

Pakistan

Philippines

Russian Federation

South Africa

Thailand

Uganda

UR Tanzania

Viet Nam

Zimbabwe

0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45

Proportion of DeathsProportion of Incidence

Bar Diagram4:-

The following bar diagram shows the proportion of incidence and population proportion in high burden countries in year 2011.

Afghan

istan

Brazil

China

Ethiopia

Mozambique

Nigeria

Philippines

South Afri

ca

Uganda

Viet Nam

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

Proportion of Incidencepopulation proportion

Countries

Prop

ortio

n

Interpretations of Bar diagrams 3 and 4:-

In Zimbabwe, UR Tanzania, Uganda, South Africa, Philippines, Mozambique, Ethiopia, China and Brazil proportion of deaths low with respect to proportion of incidence. So by this we draw a conclusion that in these countries medical facilities are good with respect to other high burden countries.

Afghanistan, Bangladesh, DR Congo, India, Pakistan and Vietnam are in very poor condition due to low social level and insufficient medical facilities.

In Thailand proportion of deaths and proportion of incidence both are almost equal.

Afghanistan, Bangladesh, DR Congo, Ethiopia, India, Mozambique, Myanmar, Pakistan, Philippines, Thailand, and Zimbabwe have higher proportion of incidence with respect to population proportion.

South Africa is in very bad condition. It has very low population proportion among high burden countries but it has very high proportion of incidence because South Africa has the highest TB-HIV coinfection in the world,TB is a leading cause of death for people living with HIV.

China is in very good condition. It has very low proportion of incidence with respect to population proportion.

Interpretations of Global TB disease burden:-

There were an estimated 8.7 million incident cases of TB in 2011.

The Africa and Asia continents are in bad condition.

There are 20 of these countries and between them they accounted for 81% of all estimated cases of TB worldwide in 2011.

There were an estimated 1.42 million deaths. Of these 990,000 were among HIV negative people and there were a further 430,000 deaths among HIV positive people.

Medical facilities are in poor condition in Indian subcontinent, Africa, and Vietnam

In high burden country china is in the good condition.

.

Tabulation and analysis of India TB burden

Tables Graphs and charts Interpretations

TB Burden in IndiaThough India is the second-most populous country in the world, India has more new TB cases annually than any other country. In 2009,out of the estimated global annual incidence of 9.4million TB cases, 2million were estimated to have occurred in india, thus contributing to a fifth of the global burden of TB. It is estimated that about 40% of Indian population is infected with TB bacillus.

Bar Diagram5:-

The following bar diagram shows the comparison of India with some other country.

swaziland

Camodia

Bangaladesh

INDIA

Pakistan

China

Russia

Japan

USA

0 100 200 300 400 500 600 700

TB patients per lakhs population of year 2011

Table3:- The following table shows the TB cases notified in India from year 2005-2011.

Year Tb cases notified2005 1,294,550

2006 1,400,340

2007 1,474,605

2008 1,517,363

2009 1,533,309

2010 1,522,147

2011 1,515,872

Source- “TB India 2012 annual report”

Interpretation:-

TB is prevalent even in developed countries. But it is a more serious problem in the developing and populous countries.

Bar Diagram6:-

The following bar diagram shows the total number of TB cases notified during years 2005-2011.

2005 2006 2007 2008 2009 2010 20111,150,000

1,200,000

1,250,000

1,300,000

1,350,000

1,400,000

1,450,000

1,500,000

1,550,000

1,600,000

1,294,550

1,400,340

1,474,605

1,517,3631,533,309 1,522,147 1,515,872

Total TB cases notified

Total TB cases notified

Bar Diagram7:-

The following bar diagram shows the death due to TB in India in the year 2011.

People died from TB in INDIA People infected from Tb0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

300000

1515872

Popu

latio

n

Table4:-

The following table shows the number of TB patients in a year and new TB cases notified in that year

YearTotal TB case notified

New TB case notified

2005 1294550 507089

2006 1400340 554914

2007 1474605 592262

20081517363 616027

2009 1533309 624617

2010 1522147 630165

2011 1515872 642321

Source- “Revised national TB control program”

Interpretations:-

TB patients were increased in a regular manner from the year 2005 to 2009 and slightly decreased in the year 2010 and 2011.

The new TB cases were increased in a regular manner from 2005 to 2011.

Bar Diagram8:-

The following bar diagram shows the comparison of total TB case notified versus new TB case notified in India.

2005 2006 2007 2008 2009 2010 20110

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

Comparison of total TB case notified versus new TB case notified in india

Total TB case notifiedNew TB case notified

Years

Popu

latio

n of

indi

a co

vere

d un

der R

NTC

P

Table5:-

TB retreatment outcome statistics for India

Year Treatment relapse retreatment success

Treatment relapse retreatment death, failure or default

Treatment failure retreatment success

Treatment failure retreatment death,failure or default

Treatment default retreatment success

Treatment default retreatment death,failure or default

2005 73% 26% 59% 40% 67% 32%

2006 73% 26% 58% 41% 66% 31%

2007 74% 23% 60% 38% 68% 30%

2008 75% 24% 59% 39% 68% 29%

2009 75% 24% 58% 41% 68% 29%

2010 75% 24% 57% 41% 68% 30%

Table6:- The following table consists the number of patients and population of every state in India.

States patients population

Andaman & Nicobar 908 400000

Andhra Pradesh111915 84700000

Arunachal Pradesh 2311 1400000

Assam 37841 31200000

Bihar 76484 103800000

Chandigarh 2537 1100000

Chhattisgarh 27118 25500000

Dadar & Nagar haveli 419 300000

Daman & Diu 313 200000

Delhi 51645 16800000

Goa 1982 1500000

Gujrat 74867 60400000

Haryana 37913 25400000

Himachal Pradesh 13501 6900000

Jammu & Kashmir 13473 12500000

Jharkhand38574 33000000

Table6 continued………

Karnataka 70595 61100000

Kerala 26126 33400000

Lakshadweep 17 100000

Madhya Pradesh 90764 72600000

Maharashtra 135281 112400000

Manipur 3080 2700000

Meghalaya 5079 3000000

Mizoram 2304 1100000

Nagaland 3722 2000000

Orissa 48970 41900000

Puducherry 1568 1200000

Punjab 39206 27700000

Rajasthan 112504 68600000

Sikkim 1631 600000

Tamil Nadu 79830 72100000

Tripura 2798 3700000

Uttar Pradesh 285884 199600000

Uttarakhand 14883 10100000

West Bengal 99829 91300000

Source:- “Revised national TB control program”

Bar diagram9:-

The following bar diagram shows the TB patients proportion and population proportion of the states which have the TB patients proportion less than 0.003.

Lakshadweep

Daman & Diu

Dadar & Nagar haveli

Andaman & Nicobar

Puducherry

Sikkim

Goa

Mizoram

Arunachal Pradesh

Chandigarh

Tripura

Manipur

Nagaland

Population proportion TB patients proportion

Bar diagram10:-

The following bar diagram shows the TB patients proportion and population proportion of the states which have the TB patients proportion greater than 0.003 but less than 0.03.

Meghalaya

Jammu & Kashmir

Himachal Pradesh

Uttarakhand

Kerala

Chhattisgarh

Assam

Haryana

Jharkhand

Punjab

0 0.005 0.01 0.015 0.02 0.025 0.03

Population proportion TB patients proportion

Bar diagram11:-

The following bar diagram shows the TB patients proportion and population proportion of the states which have the TB patients proportion greater than 0.03.

Orissa

Delhi

Karnataka

Gujrat

Bihar

Tamil Nadu

Madhya Pradesh

West Bengal

Andhra Pradesh

Rajasthan

Maharashtra

Uttar Pradesh

0 0.05 0.1 0.15 0.2

Population proportion TB patients proportion

Interpretations of bar diagrams 9, 10 and 11:-

Nagaland, Chandigarh, Arunachal Pradesh, Mizoram, Sikkim, Haryana, Himachal Pradesh, Rajasthan and Delhi are in very poor condition. These states have TB patients proportion much higher than the population proportion.

Tripura, Kerala, Lakshadweep and Bihar are in satisfactory condition.

Madhya Pradesh and Gujrat have same population proportion and TB patients proportion.

Table7:- Year wise budget for the 11th five year plan for “Revised national TB control program”

Year Allocation as per Planning commission(in crore)

Actual allocation by the MOHFW*(in crore)

2007-08 267.00 267.00

2008-09 275.00 275.00

2009-10 285.00 312.25

2010-11 300.00 350.00

2011-12 320.00 400.00

Bar diagrams12:-

20072008

20092010

201114400001450000146000014700001480000149000015000001510000152000015300001540000

Total TB case notified

Total TB case notified

20072008

20092010

20110

50100150200250300350400450

Allocation of ru-pees(in crores) for

RNTCP

Allocation of rupees(in crores) for RNTCP

Interpretations:- The allocations of rupees for the RNTCP by the ministry of health and

family welfare are increased in a regular manner every year but the total number of notified cases of TB patients in India is increased from 2007 to 2009 and then slightly decreased.

Table8:- Population attributable fraction- risk factors for progression to disease

Factors Weighted prevalence Population attributable fraction

HIV infection 0.8% 16%

Malnutrition 16.7% 27%

Diabetes 5.4% 10%

Alcohol use 8.1% 13%

Active smoking 26% 21%

Indoor air Pollution 71.2% 22%

Source- “TB India 2012 annual report”

Fitting of curve for the total number of patients in India in various years:-

Equation of Regression curve

y=4.935257841+0.142348x+0.02585976x2

2004 2006 2008 2010 2012 2014 20161150000

1200000

1250000

1300000

1350000

1400000

1450000

1500000

1550000

1600000

Years

patie

nts

Interpretations:-

From the curve estimated number of patients for the year 2012 is 1508883.

Number of patients for the year 2013 is 1516772 Number of patients for the year 2014 is 1525177

TB and HIV Co-infection

TB and HIV co-infection is when people have both HIV infection, and also either latent or active TB disease. In 2011, there are total 430,000 people are estimated to have died of TB and HIV co-infection, in addition to the 990,000 people who died from TB alone. Those people, who have HIV infection as well as TB when they die, are internationally reported as having died of HIV infection. In total an estimated 1.7 million people died of HIV infection in 2011. So this means that the deaths from TB and HIV are:

Deaths* from HIV and TB coinfection:430,000 Deaths* from TB alone:990,000 Deaths* from HIV alone:1,270,000

*in the year2011

So with an estimated 1.42 million people having active TB when they died, of these 30% also had HIV infection. The World health organisation(WHO) reported that in 2010 350,000 people died who had active TB and HIV infection, meaning an increase between 2010 and 2011. Yet despite this in November 2012 UNAIDS reported that there had been a 13% reduction in TB associated HIV deaths in the last two years.

CONCLUSIONTuberculosis was declared a global health emergency in 1993 but it has been growing unchecked. Today, TB is causing millions of deaths every year globally. Like any infectious disease, TB is prevalent even in developed countries. But it is a more serious problem in the developing and populous countries. According to the WHO report, the detection rate for new and relapse cases is almost the same in 1995 and 2011, 58 in 1995 and 59 in 2011. But it was 71 per cent in 2011 among new sputum positive patients alone. But among the populous countries china is in good condition because of the 37 notifiable diseases in china, TB ranks no. 1. The concept of acceptance of the problem, identifying its requirements and the political will of TB eradication has set China on a progressive path. From the above analysis, there are following main points which is

In 2011 total 430,000 people are estimated to have died of TB and HIV co-infection There are 35,00,000 estimated incidence cases of TB in Asia which is highest as compared to other continents.

TB patients were increased in a regular manner from the year 2005 to 2009 and slightly decreased in the year 2010 and 2011.

The new TB cases were increased in a regular manner from 2005 to 2011. The estimated number of patients for the year2014, is 1525177.

Abbreviations:-Abbreviations used in this project are-WHO- World Health organizationRNTCP- Revised national TB control programTB- TuberculosisMOHFW- Ministry of health and family welfare

References:-My major references are-

Global Tuberculosis Control 2012, report WHO, Geneva TB India 2012 report Revised national TB control program The Hindu Wikipedia.org Tbfacts.org