Digital, case-based, real-time surveillance for TB: status of progress

Tuberculosis (TB) surveillance is the continuous and systematic collection, analysis and reporting of data related to TB infection and TB disease in the population. To support countries to implement national surveillance systems for TB in a consistent and comparable way worldwide, the World Health Organization (WHO) has, since the mid-1990s, provided guidance with standardized definitions, forms, registers and reports (1). There were major updates to this guidance in 2006 (2) and 2013 (3).

A new edition of guidance on TB surveillance is in development and will be published in 2022. It will have an expanded scope that covers the full pathway of screening, diagnosis, treatment and care for people with TB infection and TB disease. It also aims to facilitate implementation of digital, case-based, real-time surveillance systems for TB, including the strengthening of systems that already exist and the transition to such systems elsewhere, especially in countries that are using a mixture of paper-based and digital systems or that rely primarily on paper-based systems.

Digital and case-based real-time surveillance systems for TB have several advantages over more traditional paper-based reporting of aggregated data. These include enabling the use of automated data quality checks, timely access to data and the availability of individual-level data for people with TB infection or disease, from the level of health facilities up to national level. These systems also greatly facilitate data analysis (including by age, sex and location) to inform adaptation and targeting of response efforts, both geographically and for specific population groups.

As of August 2021, data on the type of TB surveillance system in place at national level were available for 210 countries and territories (Fig. 1). Of these, 130 reported having in place a digital, case-based surveillance system that covered all people diagnosed and reported with TB (both those with drug-susceptible TB and those with drug-resistant TB [DR-TB]). A further 14 countries, mainly in the WHO regions of Africa, the Americas and South-East Asia, had a case-based surveillance system only for people with DR-TB. Twenty countries reported that they were in the process of transitioning from a paper to digital system. About half of the countries in the WHO African Region still have paper-based systems for the recording and reporting of data.

The WHO Global TB Programme has been working with other WHO departments, the University of Oslo and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) to develop and support country implementation of digital packages for the collection, analysis, visualization and use of data from routine health facility information systems (4). This has built on WHO guidance about case-based digital TB surveillance (5), guidance on the routine analysis and use of TB data (6) and the WHO TB surveillance checklist of standards and benchmarks (7). The packages are based on WHO data standards and have been developed using DHIS2 software (because many countries have already chosen DHIS2 for use within their health information systems) but can be adapted for use with other software. Each package contains a machine-readable DHIS2 configuration, an analysis guide with a core set of indicators and dashboards, and an accompanying exercise book.

A TB-specific package for the digital management, analysis and use of key surveillance data in aggregated format has been available since early 2019 (8),¹ for use by countries that are not yet ready to transition to case-based digital surveillance. The TB package for case-based data, which enables the digital management of data for both drug-susceptible TB and DR-TB in a single system, has been available since late 2020 for download as a digital data configuration package in both English and French (8). Both TB packages are based on the latest WHO recording and reporting framework, and both allow extensive data analysis at different levels of the health system (e.g. health facility and subnational administrative area). The standard dashboards include graphs, tables and maps for core surveillance indicators (e.g. notifications, coverage of testing for drug resistance and HIV, and treatment outcomes) and data quality indicators (e.g. completeness and internal consistency).

The status of implementation and use of the WHO digital package for aggregated TB data is shown in Fig. 2. Historical subnational TB data from 60 countries have been stored and can be analysed and visualized in this package. At national level, the digital package for aggregated data has already been implemented for ongoing collection, analysis, visualization (using standard dashboards) and reporting of data in 18 countries; an additional 12 countries are in the process of doing the same. In a further 22 countries, the package has been used to upload historical data for analysis during a national TB epidemiological review. As of August 2021, piloting of the TB digital package for case-based data was underway in four countries.

The longer term goal is that all countries are able to rely on a unified case-based digital environment for TB surveillance, along the complete pathway of prevention and care for people at risk of TB infection and TB disease; an illustration is shown in Fig. 3. This will be supported by WHO standards for metadata, indicators and analytics (via a software-agnostic digital accelerator kit for TB, for countries that would like to develop the environment in the software of their choice), as well as a fully developed environment in DHIS2 (for countries that are looking for an off-the-shelf solution).

The success of case-based digital surveillance for TB in most countries is not just about the availability of technical products (e.g. digital packages, data standards and guidance). Other prerequisites include the necessary infrastructure, a competent core national health information and surveillance team, sufficient staffing and funding, and political commitment to TB data. WHO is currently developing standardized terms of reference for national assessments of readiness to adopt and implement case-based digital TB surveillance, in collaboration with stakeholders including national and local governments, technical agencies, funding agencies and civil society.

Fig. 1 Countries with national, case-based digital surveillance systems for TB, 2020

Fig. 2 Global status of implementation and use of the WHO TB DHIS2 packages for health facility and case-based data, 2017–2020

Fig. 3 An illustration of a unified, digital environment for TB surveillance, along the pathway of care